Fibro fog or losing your marbles: the effect of chronic pain on everyday executive functioning

There are days when I think I’m losing the plot! When my memory fades, I get distracted by random thin—-ooh! is that a cat?!

We all have brain fades, but people with chronic pain have more of them. Sometimes it’s due to the side effects of medication, and often it’s due to poor sleep, or low mood – but whatever the cause, the problem is that people living with chronic pain can find it very hard to direct their attention to what’s important, or to shift their attention away from one thing and on to another.

In an interesting study I found today, Baker, Gibson, Georgiou-Karistianis, Roth and Giummarra (in press), used a brief screening measure to compare the executive functioning of a group of people with chronic pain with a matched set of painfree individuals. The test is called Behaviour Rating Inventory of Executive Function, Adult version (BRIEF-A) which measures Inhibition, Shift, Emotional Control, Initiate, Self-Monitor, Working Memory, Plan/Organize, Task Monitor, and Organization of Materials.

Executive functioning refers to “higher” cortical functions such as being able to attend to complex situations, make the right decision and evaluate the outcome. It’s the function that helps us deal with everyday situations that have novel features – like when we’re driving, doing the grocery shopping, or cooking a meal. It’s long been known that people living with chronic pain experience difficulty with these things, not just because of fatigue and pain when moving, but because of limitations on how well they can concentrate. Along with the impact on emotions (feeling irritable, anxious and down), and physical functioning (having poorer exercise tolerance, limitations in how often or far loads can be lifted, etc), it seems that cognitive impairment is part of the picture when you’re living with chronic pain.

Some of the mechanisms thought to be involved in this are the “interruptive” nature of pain – the experience demands attention, directing attention away from other things and towards pain and pain-related objects and situations; in addition, there are now known to be structural changes in the brain – not only sensory processing and motor function, but also the dorsolateral prefrontal cortex which is needed for complex cognitive tasks.

One of the challenges in testing executive functions in people living with chronic pain is that usually they perform quite well on standard pen and paper tasks – when the room is quiet, there are no distractions, they’re rested and generally feeling calm. But put them in a busy supermarket or shopping mall, or driving a car in a busy highway, and performance is not such an easy thing!

So, for this study the researchers used the self-report questionnaire to ask people about their everyday experiences which does have some limitations – but the measure has been shown to compare favourably with real world experiences of people with other conditions such as substance abuse, prefrontal cortex lesions, and ADHD.

What did they find?

Well, quite simply they found that 50% of patients showed clinical elevation on Shift, Emotional Control, Initiate, and Working Memory subscales with emotional control and working memory the most elevated subscales.

What does this mean?

It means that chronic pain doesn’t only affect how uncomfortable it might be to move, or sit or stand; and it doesn’t only affect mood and anxiety; and it’s not just a matter of being fogged with medications (although these contribute), instead it shows that there are clear effects of experiencing chronic pain on some important aspects of planning and carrying out complex tasks in the real world.

The real impact of these deficits is not just on daily tasks, but also on how readily people with chronic pain can adopt and integrate all those coping strategies we talk about in pain management programmes. Things like deciding to use activity pacing means – decision making on the fly, regulating emotions to deal with frustration of not getting jobs done, delaying the flush of pleasure of getting things completed, having to break a task down into many parts to work out which is the most important, holding part of a task in working memory to be able to decide what to do next. All of these are complex cortical activities that living with chronic pain can affect.

It means clinicians need to help people learn new techniques slowly, supporting their generalising into daily life by ensuring they’re not overwhelming, and perhaps using tools like smartphone alarms or other environmental cues to help people know when to try using a different technique. It also means clinicians need to think about assessing how well a person can carry out these complex functions at the beginning of therapy – it might change the way coping strategies are learned, and it might mean considering changes to medication (avoiding opiates, but not only these because many pain medications affect cognition), and thinking about managing mood promptly.

The BRIEF-A is not the last word in neuropsych testing, but it may be a helpful screening measure to indicate areas for further testing and for helping people live more fully despite chronic pain.


Baker, K., Gibson, S., Georgiou-Karistianis, N., Roth, R., & Giummarra, M. (2015). Everyday Executive Functioning in Chronic Pain The Clinical Journal of Pain DOI: 10.1097/AJP.0000000000000313

Decision making and cognitive psychology iii

OK, I said yesterday that I’d discuss debiasing, and I didn’t – so I will today!

Firstly, researchers have identified that ‘experts’ are typically over confident about their decisions.
(Henrion & Fischhoff, 1986)

One solution has been to ‘motivate’ clinicians to be accountable for their decisions, for example, by providing them with a total capped budget for treating all the patients in their area. The reasoning is that poor decisions will be less likely to be made if an error costs. Schwab finds three problems arising from this argument –
1. Methods that increase cognitive effort are useful only when the original decisions were made in a superficial way.
2. Accountability can actually exacerbate biases when judgments are based on the wrong information or when the judgment easiest to rationalize is biased.
3. Accountability has no effect when the biases result from inadequate training on how to make decisions and simply ‘trying harder’ won’t teach how to do this effectively.

Another possible solution is been to provide clinicians with feedback on their accuracy. It’s evident from many studies that good feedback given regularly helps improve the whole process – but how often do clinicians get this? Schwab says ‘when patients get better, it may or may not have been caused by the intervention. ‘Hindsight bias’ – the view that what has already happened was inevitable and, if they had taken the time, they would have predicted it all along – may limit the clarity of any … feedback.’ (more…)

Decision making and cognitive psychology ii

Yesterday I discussed several systematic biases that are known to influence decision making.  Today I want to look at two more – and briefly some thoughts about ‘debiasing’ (if that’s a word!).

Imagining the consequences of a decision is a really influential part of making that decision – cognitive psychologists call this ‘affective forecasting’.  What this means is that people imagine how it will feel emotionally if they make a certain choice. While it seems that humans are pretty good at identifying whether they’ll feel good or bad about their choice, what they don’t do so well is estimate how long they’ll feel this way, or how intense that feeling will be.  Wilson and Gilbert are researchers who look at this area of decision making, and call this effect ‘impact bias’, identifying seven influences on the accuracy of this bias…misconstrual, framing effects, recall/affective theories, correction for unique influences, expectation effects, actual unique influences, and underestimation of sense-making processes. (Wilson & Gilbert, 2003, cited in Schwab, 2008).


Decision making and cognitive psychology

How do we make decisions about treatment? What errors are we likely to make and can we counter those errors?

These are really important questions to ask ourselves as clinicians if we want to avoid leaping into decisions that won’t stand up to scrutiny. Unfortunately it does mean we need to learn a bit about our human fallibility – oh and something about cognitive psychology. And the latter means reading some fairly intense material! Thankfully the paper I’m discussing to day helps to unpack some of the cognitive psychology literature into a form that I can make sense of…

This is a paper by Abraham Schwab, who is based in the Philosophy Department of Brooklyn College. That in itself is interesting – philosophy being about reasoning…
Anyway, he has summarised some of the material that has an influence on how we make decisions in complex situations – and there is no doubt that sifting through the information we collect during an assessment is a complex situation, confounded by the fact that these are real people with problems that will affect their real lives. And emotions surely influence our decisions – think about the effectiveness of advertising if you don’t believe me! (more…)

Revelation: I’m experimenting on patients!!

Actually, the heading should read ‘I’m experimenting on with patients!

Does that not help?  Sorry, perhaps I should unpack what I mean!

Chronic pain, or actually, chronic disability associated with pain, is multifactorial.  What that means is there are many different factors that influence how and why a person has chronic pain and disability.  It also means that each person is likely to have a different set of factors that is contributing to why they are having this set of problems in this specific situation.

And the implications of this are that it’s highly unlikely that any one single treatment will ‘work’ to ‘fix’ the problem! In fact, the only time we can be certain about our treatments is when the following conditions are met:

  • a reliable and valid diagnosis
  • with a well-defined explanation for the cause of the pain
  • and known patient selection criteria
  • that predict a positive response to treatment
  • with known mechanisms of response

This doesn’t happen often, especially with chronic low back pain – and as a result, we’re probably using a working hypothesis when we’re choosing a treatment.  And guess what? That’s exactly what an experiment is – following a systematic process to establish whether the results support a specific hypothesis.

Oooops.  Are you guilty too? (more…)