The Art of Drawing a Blank: Fibromyalgia and Memory
ImmuneSupport.com
01-09-2002
Reprinted from Fibromyalgia
Frontiers (Vol. 8, #1, 2000), the official quarterly publication of the
National Fibromyalgia Partnership. Website: www.fmpartnership.org.
Okay, so you're still
looking for that slip of paper with your doctor's new phone number on it. And
you have yet to recover from the embarrassment of driving around town with the
grocery bag perched on top of your car. And you still worry that your new boss
will never forgive you for "blanking" on his name when you tried to
introduce him to an important client.
In short, it's hard to
deny that your memory just isn't what it used to be. Does that mean you have a
problem? If so, is fibromyalgia (FM) the cause? Or is there some other culprit?
Or both? The answers to these questions may surprise you. What probably won't
surprise you is that to date very little research has been done on the subject
of memory and FM. This article will explore available findings and offer
insights which will at the very least help you make peace with yourself. First,
a few basics on how memory works (and when it doesn't).
As is widely known, there
are two types of memory: short-term and long-term. Short-term memory, also known
as active or working memory, consists of the day-to-day details that people
consciously pay attention to at any one time: the physical objects that surround
them, the conversations or sensory information they are taking in, and the
activities or projects in which they are engaged.
In contrast, long-term
memory is a permanent storage area where factual information, recollections of
personal experiences, and knowledge of particular skills (i.e., riding a bike or
driving a car) are retained. Psychologist Kenneth Higbee, Ph.D., compares
short-term memory to the in-basket on an office desk which has a limited
capacity to hold information and must therefore be "emptied" regularly
before new material can be placed there. [1]
Information which is
emptied is either discarded permanently (i.e., the phone number of a local
carryout restaurant that you look up but don't need to remember) or is sent on
to long-term memory, a series of filing cabinets used for permanent storage.
Unlike short-term memory, long-term memory has virtually unlimited capacity and
is not easily disrupted by environmental "noise". It also changes very
little with age. It is helpful to think about memory as consisting of three
stages: (1) the acquisition of information, (2) the storage of information, and
(3) the retrieval of information when it is needed. When we forget things, we
tend to blame our retrieval powers.
However, according to
Cynthia Green, Ph.D., of the Memory Enhancement Program at Mt. Sinai (NY) School
of Medicine, the most common reason that healthy adults have problems with
memory is because of their failure to focus on new information. [2 ] In other
words, they aren't paying very good attention in the first place so they never
actually learn the new material they will later try to remember. Of course,
people often fail to pay proper attention to things that aren't particularly
interesting to them or have little emotional impact.
However, there are also a number of factors which simply get in the way of memory and can cause even "healthy" people significant problems. Many of these factors are also relevant to people with FM.
Factors Which Interfere
With Memory
Multiple Tasks: Many
people suffer from information overload. They may have many competing tasks to
perform during a given period of time or have pressing demands from a wide
variety of sources (work, family, friends, etc.). As a result, they must process
an amazing amount of information, some of which comes at them with a speed or
complexity which makes remembering difficult.
Ironically, simple things
that should be easily recalled (like the location of car keys or even the car
itself) are frequently forgotten because they involve routine activities (i.e.,
parking the car) which are done quickly and often unconsciously amidst a maze of
other involvements.
Emotional State:
Depression and anxiety are two variables which have been a central focus in the
study of memory. Depression is of interest because it can cause problems with
attention, perception, speed of cognitive response, problem-solving, and memory
and learning. [3]
People who are depressed
tend to be preoccupied with other concerns and find it difficult to concentrate
on new tasks, particularly those requiring prolonged attention or the complex
processing of information. The good news is that when depression gets better,
either with time or with medical treatment, memory usually improves as well. [4]
The term "stage
fright" is already familiar to most people. Many comic sketches have
portrayed actors or comedians fumbling desperately for lines they have spent
hundreds of hours memorizing. Thus, it is no surprise to learn that anxiety can
be a formidable foe to the acquisition, storage, and retrieval of information,
though it can be beneficial in boosting performance in small doses. [5]
Fatigue: Whether from lack
of restful sleep, overdoing it, or conditions like sleep apnea, fatigue can have
significant effects on memory because it often impedes attention and
concentration. Some researchers also believe that it makes retrieving
information from long-term memory difficult, even familiar or easy-to-remember
items. [6]
Likewise, stress in
general (particularly chronic stress) can have a negative effect on memory
because it is a powerful distraction and contributes to fatigue.
Medications: If you take
medications regularly for fibromyalgia, you already know that they can cause
grogginess or other side effects which make concentration and recall difficult.
Antihistamines, anti-anxiety drugs, painkillers, beta blockers, and some
anti-depressants are particular culprits in this regard. Drug interactions can
be problematic as well. While it may be imprudent for FM patients to discontinue
medications which happen to impair memory, knowing that such side effects exist
can also provide peace of mind. Maybe your memory isn't so faulty after all!
Illness: There is no
question that illness or disease can interfere with memory. Not only can a cold
or the flu impair one's ability to retain or recall information, but many
chronic conditions like diabetes, hypertension, endocrine imbalance, and
multiple sclerosis can also worsen memory. [7] There is also mounting evidence
that chronic fatigue syndrome, a medical condition which overlaps with
fibromyalgia, can cause difficulties with recall. In many chronic health
conditions, impairment often improves as the underlying illness is treated.
Research on FM &
Memory
So what about fibromyalgia?
Many with FM complain about difficulties with memory, particularly short-term
memory. Some link such difficulties to "fibro-fog", a term defined by
FM researcher Stuart Donaldson, Ph.D., as "decreased ability to
concentrate, decreased immediate recall, and an inability to multi-task".
[8] Does this mean that there is something intrinsically wrong with the memory
centers in the brain, or do certain FM symptoms or environmental factors simply
get in the way of learning or recall?
Although fibromyalgia
research is now exploring such issues as cerebral blood flow, abnormal levels of
certain brain chemicals, and various neuroendocrine anomalies in fibromyalgia
patients, the emphasis is frequently on the origins of pain or the behavior of
specific hormones and not on the function of memory systems per se. Thus, there
is not yet much hard, empirical evidence on possible biophysiological origins of
memory impairment in the brain.
However, a few recent
studies in the fields of chronic pain and FM do consider the issue of memory in
fibromyalgia. Their results are mixed and somewhat conflicting. In an article
published in 1995, Canadian researchers Schnurr and MacDonald reported on their
study of the effect of chronic pain on memory in 134 subjects. [9] They compared
the memory complaints reported by two groups of chronic pain patients (i.e.,
those who had received whiplash injuries in an automobile accident and those who
had suffered lower back or repetitive strain injuries in a work-related
accident) to two control groups of medical/dental and psychotherapy patients who
had no pain symptoms.
The researchers chose two
distinct pain groups because they had noticed that many chronic pain patients
had cognitive symptoms and pain behaviors similar to persons who had sustained a
mild, closed-head brain injury. They chose whiplash sufferers because they were
persons who might have had an underlying head trauma. None of the pain group
with work-related accidents had sustained head injuries, so they served as a
comparison pain group. The researchers subsequently found that both of the
chronic pain groups reported significantly more memory problems than the two
control groups even when the effects of depression (another common deterrent to
concentration and memory) was statistically removed.
In addition, they found no
differences between the two chronic pain groups in terms of amount of memory
impairment and concluded that "mild head injury did not appear to be the
sole contributing factor to memory complaints in chronic pain patients".
[10] They also recommended that future studies include neuropsychological
testing to determine actual memory and cognitive functioning rather than
perceived problems as had been reported in this study by subjects.
In an article also
published in 1995, Norwegian researchers Sletvold, Stiles, and Landro compared
the scores of a group of patients with fibromyalgia to a group of patients with
depression on a battery of information processing tests. [11] Both groups'
scores were then compared to those of a control group. While as predicted,
patients with depression were found to have an information processing deficiency
compared to controls, the investigators were surprised to find a similar
deficiency in fibromyalgia patients.
Moreover, when they tested
a subset of the fibromyalgia patients who did not have any history of major
depression, they found that group still significantly different from controls in
their information processing capacity. There was, however, an interesting
difference between the patients with depression and those with fibromyalgia.
The test results also
suggested that the patients with depression had cognitive abnormalities
suggestive of a dysfunction of the right hemisphere of the brain. No such
abnormality was found in the FM patients, and the researchers concluded that
"FM and depression are biologically different conditions". [12]
In 1997, the same group of
researchers used the identical three study groups to look specifically at memory
impairment (rather than the more general information processing skills studied
previously). In this later, small, exploratory study, when the fibromyalgia
patients were divided into two groups containing those with and those without a
history of major depression, only the "depression sub-group" showed
memory impairment compared to controls. [13] Most recently, researchers have
looked at the problem of memory impairment and cognitive performance not only in
terms of pain and depression but also in terms of sleep quality, level of
anxiety or emotional distress, and the patients' own assessment of their
performance. In an innovative study reported in 1997, Canadian researchers Cote
and Moldofsky compared patients with fibromyalgia to healthy controls in terms
of sleep patterns, their speed and accuracy in completing complex cognitive
tests (i.e., grammatical reasoning, serial addition/subtraction, and a simulated
multi-task office procedure), and their assessment of their own accuracy in
responding to test questions. [14]
The researchers found that
the FM group spent more time in stage 1 sleep than the controls and also
reported more sleepiness, pain, negative mood, and lower (perceived) accuracy on
complex cognitive tests over a 14-hour day. However, while the FM group was in
fact slower in test-taking speed, their accuracy and performance was not
significantly different from the control group. In 1999, the Canadian
investigative team of Gloria Grace reported on a study of memory performance in
fibromyalgia patients versus controls on a battery of tests. They also measured
pain severity, trait anxiety, and depression in FM patients. [15] What they
found was that while the FM group as a whole performed within normal limits
across all of the tests, some individuals had significant impairments on
particular memory-related tasks. This was thought to be a result of difficulties
with attention rather than "primary memory processes". [16]
Such patients tended to
score poorly on arduous tasks requiring either sustained concentration or the
recall (either immediate or delayed) of material presented only once. In fact,
many subjects were so anxious about the more prolonged tests that the latter had
to be discontinued before completion. In contrast, when engaged in less taxing
memory tasks involving attention/concentration or where items to be recalled
were repeated several times, the same subjects performed normally.
The authors concluded that
"as a group, patients with FS [fibromyalgia syndrome] had good basic
attentional skill; only when significantly challenged to sustain their attention
did they show worse performance than the control group". [17] They also
noted that "objective memory deficits in FS are more related to anxiety
levels and subjective pain intensity than to either quality of sleep or
depressed mood". [18] Like Cote and Moldofsky, Grace et al., found in their
study that the FM group greatly underestimated their performance on the tests
administered. At the 1999 Annual Scientific Meeting of the American College of
Rheumatology, University of Michigan psychologist Denise Park, a specialist in
the field of cognition in the aging, reported on a new study of cognitive
functioning in fibromyalgia patients that was funded by the Arthritis Foundation
and the NIH National Institute of Arthritis and Musculoskeletal and Skin
Diseases (NIAMS). [19]
Park and her
co-investigators wondered if persons with FM had cognitive function similar to
adults 20-30 years their senior. They selected a sample containing three groups
of twenty subjects each: (1) FM patients with an average age of 47, (2)
age-matched, healthy controls, and (3) adult controls 20 years older than the
patient group. It should be noted that none of the patient group suffered from
major depression or any other rheumatoid condition. In addition, all subjects
were well educated.
The researchers
administered a variety of tests designed to measure cognitive function and
memory. What they found was that in speed of processing (i.e., how fast
information could be handled), FM patients were similar to the healthy controls
and therefore normal. Park considered this an extremely important finding as
speed of processing is considered a very reliable measure of overall
neurological intactness. Where the FM patients seemed to have problems, however,
was with memory processes governed largely by the brain's pre-frontal cortex.
When it came to short-term
memory, long-term memory, and verbal fluency, the FM patients scored worse than
the healthy controls and more like the older controls. The researchers were also
surprised to discover that the FM group scored worse than both control groups on
vocabulary measures, a finding which reinforced patient reports of difficulties
with word-finding and vocabulary. Dr. Park suggested that future studies should
take advantage of functional neural imaging technology which measures cerebral
blood flow in patients who are performing particular cognitive tasks while
undergoing an MRI scan.
Because younger adults
tend to show different patterns of brain function in these tests than older
adults, knowing how FM patients compare with those the same age as themselves
and older may shed some light on the cognitive brain function of individuals
with FM. [20]
Memory Assistance
Techniques
Clearly, more research
will need to be done to better define the variables which effect memory in
individuals with FM. Also, fatigue, exertion, and other elements will need to be
factored into the equation. In the meantime, what can persons with FM do to
improve their memories? Aside from minimizing information overload, excessive
fatigue, and other factors known to interfere with concentration and memory, are
there techniques available that can help? Absolutely! Visit any bookstore, and
you will find a variety of books and tapes offering a wide range of strategies,
some of them very intricate, for battling memory woes. Approaches like the Loci,
Peg, and Phonetic systems, for example, can help train you to learn staggering
lists of words or numbers. However, there are some simple approaches which
anyone can use to improve his/her memory skills. In addition, an innovative new
lifestyle technique known as "neurobics" has been developed which
works by exercising the mind in specific ways that keep it fit and prevent its
deterioration. Both of these approaches will be described below.
As was noted earlier, the
majority of memory problems which occur in healthy adults are a result of
problems with focus or attention, problems which can be improved. In his book,
Your Memory: How It Works & How to Improve It, Dr. Kenneth Higbee suggests
that people make a conscious effort to be more aware. Firmly reminding yourself
that you need to pay attention to something (and then doing it) is a great
start. Thus, if you tend to be absent-minded and forget whether you have turned
off the burner on the stove, then you will need to make a conscious effort to
say to yourself, "I am turning off the stove" when you do so. Your
chances of remembering whether you did later on will improve. Similarly, if you
tend to walk into another room and then realize that you have forgotten why you
were going there, you will need to say to yourself as you start out, "I am
going in the other room to get a pencil". [21] What can you do when you
really need to commit something to memory? Among the techniques most often
recommended by psychologists are the following:
Rehearsal:
Repeating new material several times (verbally and/or in writing) and then
reviewing it until it is committed to memory. This is a technique with which
most of us are already familiar.
Sequencing/Categorizing:
Arranging material in ways that will organize it, thereby making it easier to
remember. For example, if you are memorizing the 50 states in the U.S., you
might learn them in alphabetical order or by geographic location. Or you might
learn the states in categories: Mid-Atlantic states, New England states, Rocky
Mountain states, etc.
Visualization:
Picturing the word(s) or concept(s) you are trying to memorize. For example,
imagine the face of a person whose name you are trying to learn so that your
brain learns to associate the face with the name. Or, picture an image that goes
with a particular name or word (i.e., a road painted green for the name
Greenstreet) or some distinctive aspect of a person's appearance or voice (i.e.,
a bow-tie for Mr. Boden who always wears such an item). Visual images are very
powerful, and when associated with words help memory considerably.
Linking:
Relating one word in a list to the next word, and so on down the list. For
example, if you need to remember to purchase cat food, potatoes, and butter at
the grocery store, you might imagine your cat eating a dish of mashed potatoes
with melted butter on them. Interestingly, bizarre images like this one are
frequently easier to remember. [22]
Association:
Connecting a new piece of information with something you already know. For
example, most people learn that Italy is shaped like a boot or that an atomic
blast looks like a mushroom. Alternatively, to help yourself remember a word or
name that is on the tip of your tongue, you might also use an association
technique which Dr. Higbee calls "thinking around it", meaning that
you remember the context in which you learned a given word/name, where you were,
what was going on at the time, etc. [23] Students can sometimes recall material
when taking an exam by remembering where a particular concept was described in
their textbook.
Creating a Story or
Rhyme: Making up a
story or verse which includes all of the items you are trying to commit to
memory. To remember the email address "bostoncop@mailnet.com", you
might think of a Boston police officer calmly throwing a net over the local
mailman. The story contains all of the elements of the phrase you are trying to
commit to memory. To learn their numbers, most young children learn the rhyme,
"One, two, buckle my shoe....".
First Letter
Association:
Forming words or acronyms consisting of the first letter of a series of related
words. For example, the acronym NIH stands for the National Institutes of
Health. The word "HOMES" is a compilation of the first letters of the
names of the Great Lakes (i.e., Huron, Ontario, Michigan, Erie, and Superior).
You might also take the opposite approach and use an acrostic to create a
distinctive phrase whose first letters will help you remember. For instance, the
acrostic, "Every Good Boy Deserves Fun", reminds beginning musicians
of the notes on the lines in the treble clef in music (EGBDF). First letter
associations are helpful because they provide hints that help get your memory
started, and they tell you how many items you need to remember.
Neurobics
Thanks to new scientific
breakthroughs, scientists now have a much better general understanding of how
memory works. As a result, it is now possible to design fitness exercises for
the mind just as you might choose aerobic exercises to maintain physical
fitness. In their book, Keep Your Brain Alive (Workman Publishing, 1999),
neurobiologist Lawrence Katz, Ph.D., and writer/communications specialist
Manning Rubin introduce the concept of "neurobics", a system of
lifestyle changes which helps "maintain a continuing level of mental
fitness, strength, and flexibility as you age". [24]
Neurobics is based on the
premise that the brain is not the static entity it was previously thought to be
which ceases to evolve and change as people grow older. Katz and Rubin note that
in 1998 a team of American and Swedish researchers demonstrated that new brain
cells are generated in adult humans. [25] As a result, it is now known that
people are able to (mentally) grow and adapt to changing environments even as
they age.
Similarly, the human
memory isn't a monolithic, unchanging cavern where memories are stored. Rather,
it is a highly complex and changing information network which stores information
picked up by all of the senses and by the emotions. Hence, as the authors state:
"Because each memory is represented in many different areas of the cerebral
cortex of the brain, the stronger and richer the network of associations or
representations you have built in your brain, the more your brain is protected
from the loss of any one representation". [26]
Katz and Rubin remind us
that young babies are experts at building associations. They experience their
environment in a multi-sensory fashion by looking at, touching, tasting,
smelling, and hearing everything around them. Adults, on the other hand, tend to
rely more on sight and sound and ignore other powerful senses. The authors note
that only the sense of smell is directly connected to the cortex, hippocampus,
and other parts of the limbic system involved in storing memories. It is for
that reason that just the smell of a particular type of industrial cleaner might
remind you of the newly cleaned and polished halls of your childhood elementary
school. Katz and Rubin also argue that adults tend to engage in routine
activities which do not challenge the mind nor make full use of its sensory
equipment. They refer to passive activities like watching television and being a
spectator to others' activities as "brain deadening". By using the
senses and emotions in fun and unexpected ways, they maintain that it is
possible to enhance the brain's natural drive to form associations between
different kinds of information, feed its hunger for novelty, and increase
"mental range of motion". [27]
Neurobics has two rules:
(1) experience the unexpected, and (2) enlist the aid of all of the senses in
the course of a day. [28] In their book, Katz and Rubin offer some interesting
examples of neurobic exercises:
Get dressed or eat a meal
with eyes closed.
Vary your normal
routine--take a new route through the grocery store or choose a magazine you've
never seen before at a newsstand.
Brush your teeth with your
non-dominant hand (including applying the toothpaste) or use only one hand to
get dressed.
Fill a jar with many small
objects which have different shapes and textures (i.e., paper clips, buttons,
screws, coins, etc.), mix them up, and with your eyes closed identify each of
the objects by touch.
Master a new gadget that
intrigues you, or learn a new hobby or skill.
If you are serious about
learning neurobics, it is highly advisable to consult the book as it contains a
wide range of examples of exercises you can try. Ultimately, fibromyalgia
patients may well have to endure some level of memory dysfunction that is
brought on by pain, poor sleep, or general stress. Nevertheless, a number of
strategies are available to help you train yourself to learn and recall things
better. If you take the initiative to keep your mind active and interested in
the world around you, who knows what benefits you may reap?
References