Brain Fog Case Study In Pots

[davecom]

The Neuropsychological Profile of Postural Orthostatic Tachycardia Syndrome: Sibling Case Study

Ashlee R. Loughan^a*, Jeremy Hertza^a & Robert Perna^a

June 14, 2013

http://www.tandfonline.com/doi/abs/10.1080/09084282.2012.753075#.Uc48_hYc2aQ

Can anyone get access to the full PDF and report back on the details?

[corina]

I'm very interested in this article as over the years my cognitive skills have decreased strikingly. It's one of the things I find very difficult to accept.

[Foggy01]

Nice that someone is actually paying attention to brain fog now. Back before it was "all in your head". You were "just anxious" or something.

[Hope]

Just the little bit that you can read there looks like ADD. Interesting since ADD is so very common in my family. I don't think anybody ever addressed what might be causing it. Now that I know more about dysautonomia, I can see where many family members could have different levels of it. Just an observation.

[AshleyPooh]

I remember the brain fog starting with my thyroid disease, got a good bit better after my medications, then I started getting it again with the blood pressure drops. Problem is my blood pressure isn't just dropping sometimes, but quite often, so it's daily brain fog At 26, I wonder if my best 'brain' days are behind me...

[Foggy01]

I remember the brain fog starting with my thyroid disease, got a good bit better after my medications, then I started getting it again with the blood pressure drops. Problem is my blood pressure isn't just dropping sometimes, but quite often, so it's daily brain fog At 26, I wonder if my best 'brain' days are behind me...

Yeah it's terrible to not have a brain in tip top shape. It's like the most important thing to have.

[blueskies]

Brain fog became a problem for me about 10 years ago. Up until 5 years ago I was teaching over the internet and could write a decent letter, email, post etc. I used to write to a pen friend -- constructing these really long and interesting letters -- we use to swap ideas about the different societies we lived in. I was still 'sharp" enough. Now I find it hard just to write a post that makes sense if I have more than one thought I want to express.

I've just started tying to write 'opinion' pieces -- to myself. Imagining I'm writing for a paper on a political or feminist issue. It's my form of soduku or crosswords. Forcing my self to think. Not having much success yet but hopefully, if I persist I will get my ability back to write coherent pieces. Enough, hopefully, that I'll be able to write long letters again. I equate it to exercising my body for strength to cope with standing/walking problems - which works, to a point.

blue

[GlenGrail]

I do have access to the journal, but I'm afraid my online access is delayed by a year, so that's not much help. I might request it through interlibrary loan; it looks like a fascinating article. Cognitive dysfunction is definitely my most frustrating problem, and anything that can start to shed some light on it is welcome. Plus it's nice to see that, even in the abstract, the authors acknowledge that the cognitive symptoms can be severe, even when they don't necessarily match up with objective tests.

[Chaos]

My access is only available to this journal up to April of this year. Will keep an eye out to see if the June one becomes available.

[GlenGrail]

I found a library nearby that apparently has access, so hopefully I should be able to get ahold of it in a couple of days. Very much looking forward to it, since this is the only publication I know of that specifically addresses cognitive dysfunction and POTS. The research on brain fog and CFS is helpful, but it's hard to know to what extent it applies to POTS, especially considering that the relationship between these two conditions is not entirely clear.

[Guest maia]

There are 500 thousand of us?!

[blueskies]

There are 500 thousand of us?!

HI maia,

That struck me too. And that's only in the U.S? I'm in Australia and by that percentage I should at least know one other person with pots/dys

blue

[Chaos]

I think that may actually be an old statistic. I thought I'd seen more current estimates between 500,000- 1 million. As more docs become more familiar with the diagnosis, I suspect that number has been rising.

[magentastardust]

Thank you for posting this. The brain fog and cognitive issues are just awful with this. I have to write everything down or I forget, and I often lose track of what I am talking about/doing if I get interrupted. I can relate to those of you that stated that you have trouble composing writings. I used to be so good at that (loved writing poetry and short stories). Now, you can forget it. It's like that part of my brain got sucked away into a black hole and is gone. It makes me so sad.

[GlenGrail]

All right, I found the article. Unfortunately, I found it somewhat disappointing, and I suspect many of you will concur. I will summarize it at some length. First, it is quite a brief article--only about eight pages, one containing a bibliography and several others taken up by tables and ancillary matter. The author, judging from her other publications, is not primarily a POTS researcher, but a neuropsychologist. The description of POTS is drawn from standard sources dating from the early 1990's. POTS is defined as "a mild form of orthostatic palpitations." Considering that this appeared in a journal (a relatively marginal one) targeted at neuropsychologists, the few paragraphs that actually describe the condition are probably insufficient to inform a clinician not already familiar with it. On the other hand, the article does not seem to be targeted at a broad audience; judging by the view count, I was the second person to download it.

So, on to the meat of it, which is where the problems appear. The article is structured as a case study of two sisters, 19 and 22, who both have POTS. While this case study may be interesting from a neuropsychological standpoint, it is, I think, almost entirely irrelevant as applied to POTS. The problem is that both of these patients have a number of comorbidities and complicating factors. Sister A has been diagnosed with bipolar disorder, severe depression, agoraphobia, social anxiety, and obsessive-compulsive tendencies. Both sisters have been previously diagnosed with ADHD (though, as the authors point out, it is possible that the attention deficits were caused by then-undiagnosed POTS). Both have a chronic pain syndrome; one of them uses narcotic analgesics daily. Sister B also has a complicated psychological history, including suicidal ideation, self-multilation, panic attacks, anorexia, and post-traumatic stress syndrome related to a sexual assault.

As the abstract suggests, the full-scale IQ score is preserved in both sisters. One has quite a high score of 132, and the other has a very good score of 118. Each, however, shows a number of deficits in certain specific subtests. For the purposes of the article, a significant deficit was a subtest score more than 1.5 standard deviations (23 points or so) below the general FSIQ. By this measure, Ms. A had 16 scores significantly below FSIQ, and Ms. B had 10. The impairments were related to working memory, processing speed, visual memory and recognition, category fluency, and inhibition. The authors contend that this pattern is "suggestive of prefrontal cortical cerebral dysfunction."

The immediate concern is the large number of comorbidities, and the associated psychiatric conditions. Not only does this create the impression that psychiatric conditions are regularly compresent with, or worse, inseparable from, POTS (which studies like Raj 2009 have shown is not the case), it means that the case studies chosen for the article are not representative of the general patient population. The specific cognitive problems that these sisters are experiencing could have other causes from POTS. Cognitive deficits, of course, are also associated with some of their psychiatric conditions and some of the medications they are taking. Again, this doesn't invalidate the case study by any means, but it does seem to limit its usefulness for commenting on POTS in general.

In addition, the article does not spend much time describing the cognitive symptoms these women are experiencing. I had hoped for a fairly robust phenomenological account of what those cognitive symptoms are like, subjectively; this does not occur. One sister left college because she found it "too stressful"; the other left for the same reason, though she elaborates, "stressing about getting things done on time, being late with assignments, and then getting more stressed." These are understandable responses to cognitive difficulties, as far as it goes, but these are the only sentences in the article that actually describe the sisters' subjective and functional sense of their cognitive problems. And given the psychiatric components, this concern with stress could just as easily be attributed to anxiety. It seems extremely dangerous to equate cognitive dysfunction with stress.

The authors are aware of these limitations. The conclusion notes that "the two individuals have comorbidities that complicate test interpretations." Specifically, the diagnosis of ADHD, the presence of treated hypothyroidism, and the anxiety and affective disorders really muddy the waters in these cases. It is impossible to say which deficits are attributable to other causes and which arise from the POTS. In fact, the specific cases of POTS are not discussed at all: it is not mentioned what form of POTS the sisters have, how they were diagnosed, how severe their symptoms are, etc. Some of this seems like extremely basic footwork, and I can't help but thinking that the authors should have covered these bases more thoroughly.

It is an interesting article, but these problems make it unsuitable for drawing any conclusions. Anyone looking for enlightenment regarding their own cognitive symptoms (which was my hope) will probably be disappointed. At worst, the article will suggest to uninformed readers that POTS is intimately bound up with psychological problems. On the bright side, I think Vanderbilt is working on an extended study of cognitive dysfunction in a more homogeneous set of patients, and their results ought to be a little more meaningful.

[davecom]

Thanks for reading it and reporting back. Yes, it does sound pretty disappointing, and not at all useful.

[Guest Alex]

Here are 3 more free access articles along the same lines:

http://www.frontiersin.org/Integrative_Physiology/10.3389/fphys.2013.00113/full

Cognitive impairments associated with CFS and POTS

http://ajpheart.physiology.org/content/302/5/H1185.full

Postural neurocognitive and neuronal activated cerebral blood flow deficits in young chronic fatigue syndrome patients with postural tachycardia syndrome

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3368269/?report=classic

Increasing orthostatic stress impairs neurocognitive functioning in chronic fatigue syndrome with postural tachycardia syndrome

They seem to deal with overlapping CFS and POTS, but the first one is actually talking about CFS and POTS as separate entities.

Alex

[GlenGrail]

Thanks, Alex, these look like far better articles. The connection between CFS and POTS is also an interesting point.