Brain Fog Causes and Interventions | Counselor Education Training

I'd like to welcome everybody to today's presentation on brain fog, causes, impacts, and interventions. I'm your host, Dr. Donna Lee Snipes. Have you ever had a client that seems to be using all the cognitive tools, but just not making progress? You know, they're kind of they're going through the motions, but they still seem to be stuck. Or maybe a client that professes to want to make a change and in in session they're saying, "Yes, I'm going to do that." and they just don't follow through. Or maybe a client that doesn't seem to internalize the skills and tools. You talk about something this week and by the time they come back next week, you're repeating the same thing again. It's like you're stuck in a perpetual loop. There are a lot of reasons that that could be happening and check out the video on the different causes of resistance. Um if you want to look into some of those. But one of them and for a lot of people is brain fog and that's why we're going to talk about that today. We're going to define brain fog, explore how to assess it, discuss various causes of it, and identify interventions to address it. We're not going to go into the deep scientific nitty-gritty about what's going on. Y'all know about a lot of the different causes of inflammation. What I really want to focus on today is helping you identify some of the co-occurring issues that might be going on with your clients that are impairing their ability to move forward and strategies to support them while they're struggling with brain fog. Oops. Brain fog is characterized by mental fatigue, memory loss, confusion, anxiety, decreased concentration, tiredness, injury, and impaired cognitive functions that have long-term effects on psychosocial, physiological, and socioeconomic levels. All right, that's the boilerplate definition. When we think of brain fog, and I think most of us have experienced brain fog at one time or another, whether it was during a period where we were grieving, or if we were getting over an illness, or we had a new baby in the house, there are a lot of periods where something may be happening in our lives that may contribute to the development of brain fog. Common symptoms, and if you click on the link in the in the PDF of the PowerPoint, it will take you to the brain fog assessment scale. Great, we've got this wonderful scale that's out there. Ultimately, a lot of the symptoms are what many of our clients complain about. They have their mood symptoms over here, but they also complain about difficulty thinking clearly, concentrating, impaired problem-solving, and making decisions. Those are criteria for major depressive disorder. A lot of our clients who have major depressive disorder, or I'll give you a hint, hypothyroid, uh may have some of these symptoms. They have problems organizing thoughts, cognitive slowing, it they get information in and it just sits there for a second before it finally processes, or cognitive racing, where their mind is just all over the place and it feels overwhelming. They can't kind of grab onto a thought. They may be easily confused, have problems finding the right words, or forgetting words like the names of objects. If you've ever been watching a TV show and you see an actor that you know you've seen them before. You know their name, but you it's on the tip of your tongue. It's so frustrating. And I don't know about you. I've gotten really dependent on Google in order to figure out that person's name. But the same thing happens with people who have brain fog. I remember when my kids were little, I would get kind of overwhelmed with stuff and instead of I've trying to think of their name, I can't think of their name. I'm like, "Boy child, boy child, you come here." >> [clears throat and laughter] >> It is what it is, but it's frustrating. And for people who have persistent brain fog and overwhelming brain fog, it's more than just some little episode somewhere where their stress response is activated and they're not thinking clearly. It's most of the day, most days. They may have difficulty processing what is read and or following what others are saying. They read the same thing on the page two, three, four times and they're like, "I have no idea what the stink I just read." Or they're listening to someone or talking to someone and the words are coming at them, but they're just not registering. And they may feel lost, spacey, or mentally absent. People describe brain fog very differently, uh just like they describe depression and anxiety, etc. very differently. You don't have to have all of these symptoms, but it's important to recognize when people do have these symptoms, how it might be impacting their quality of life, the other issues that are contributing to their presenting issue. Um if I've got brain fog and anxiety and I'm being and depression and I'm being seen in therapy and one of the things that um is causing me distress in my life is difficulty in my relationships, well, if I've got brain fog, maybe I'm not communicating well. Maybe I am spaced out. Maybe I'm forgetting things all the time and that's going to add additional stress. But I got ahead of myself. Physical consequences of brain fog. It's stressful. A lot of people, when you're trying to find that word, your stress response gets amped up. When you can't find that word, then you get frustrated in acceptance and commitment therapy, um Hayes calls this dirty discomfort. You're getting angry about this situation that's causing you frustration and the more frustrated you get, the harder it is to access that knowledge. Why? Because when our stress response kicks off, that's fight or flight, brain's not interested in thinking, problem-solving, doing all that stuff. Energy is diverted from the prefrontal cortex over to the rest of the brain. Your your hypothalamus, your um uh threat response system, basically. And it makes it more difficult to think clearly. And that's why again, with when I would get stressed out with my kids and I'm like, "Boy child, come here." I needed to get something across and it was stressing me out. Once I got that message across, I was able to down regulate. Uh So, physically, it's stressful on the sympathetic nervous system and the parasympathetic nervous system. When people have persistent brain fog and they're constantly struggling to process, to think, to concentrate. That uses a lot of energy. It's exhausting. And it can contribute to the development of what we've called sympathetic dominance, where the stress response is much more hyperactive, and the relaxation or the parasympathetic response, you can't get it kicked into gear. Interpersonally, when people have brain fog, other people can feel ignored or disrespected because the person with brain fog's not remembering what you said or not focusing and asking you to repeat things or seeming to be spaced out in their own world. Uh there are a lot of different ways brain fog, difficulty thinking clearly, processing, interacting impacts our ability to maintain supportive relationships, especially when people don't understand. When my kids were young, and you know, during that postpartum period, I had wicked postpartum depression, and I had a lot of brain fog. My husband was aware, and he was very supportive in slowing things down. We were writing things down. There were a lot of supportive uh strategies that we used because I was doing my very best, but the brain just wasn't working. And there's also a lot of people who got sick with the virus, and I'm not going to say the word because YouTube still blacklists it when you do that. Um >> [laughter] >> but and they ended up with long-term brain fog. My husband got sick, and [snorts] it was 6 months before he was back to his cognitive functioning as he thought he should be. And I've known other people who've had long-term effects from getting that particular virus or other viruses, chronic fatigue syndrome. Uh recognizing the how that impacts your relationships with others, the people in your own household, as well as people at work, etc. You're not going to tell your office mate or the client that's coming in, "Okay, slow down. I got some brain fog today, blah." You're not going to do that. But how hard is it for you as a therapist if you've got brain fog to sit there and focus and empathize and be present for 50 minutes? It's exhausting. Intrapersonally or our self-esteem is impacted when we can't think clearly, when we can't function like we think we should be functioning, when we're forgetful, when we know we have dropped the ball on things. Emotionally, it contributes to anxiety about, you know, when is this going to get any better? It's exhausting. It can start to develop people can start to develop symptoms of depression. They start feeling hopeless and helpless cuz it doesn't feel like the fog is ever going to clear. Cognitively, and obviously brain fog cognitive, this is where we first see it showing up. It makes it more difficult to do daily activities, whether it's remembering what you need to get at the grocery store or completing a project at work or even just participating in problem-solving with your family. From a clinical standpoint, when we have people with brain fog, we have to recognize that it's a lot harder for them to receive the information, encode the information, and use the information. I worked for the better part of my career in residential co-occurring disorders treatment. When you have people that are 2 days or even 2 months out of detox, they often still have very persistent uh brain fog. Now, by 2 months, it started to get a little bit better, but it always struck me odd when I first started working in the field that people were coming out of detox, and we were putting them in groups all day, every day, and my thought was we were expecting them to learn something and get something out of it before they were discharged. One of my mentors finally clued me in, and they're like, "No, a lot of what we're doing in this first 28 days is just getting them to get up and show up, reset their circadian rhythms. We recognize they're probably not going to internalize a lot of what is going on." The things that they do, great. But the progress in therapy really doesn't begin until that fog starts to lift and they can start processing and understanding and applying what they're learning. Environmentally, when people have difficulty thinking, completing tasks, especially if they have oppressive brain fog that keeps them from doing their job, they may start experiencing job instability and consequently housing instability. Brain fog has no single cause, but generally, it can be distilled down into a few underlying concepts. Sympathetic nervous system dominance. When we are in fight or flight for whatever reason, trauma, pain, sleep deprivation, whatever, our blood glucose and energy is being diverted over to the hypothalamus and the amygdala, away from executive functioning in the prefrontal cortex. Brain fog. Neurotransmitter alterations or um perturbations, if you want to call it that. Some people, um especially for example, people with ADHD, struggle with brain fog a lot because they have different neurotransmitter balance than we do. But, in a lot of other people, um you may have this baseline neurotransmitter balance that is your healthy or non-foggy baseline, and then something happens that causes alterations in your gonadal hormones, your thyroid hormones, and consequently, your neurotransmitters. Poor oxygenation contributes to brain fog. Um if you're not getting oxygen throughout your body and you're not getting oxygen into the cells and getting that up to your brain, it makes it harder to to think clearly. And so, we see a lot of brain fog in people with anemia, for example. Which takes us to nutrient deficiencies. Whether it's calories or particular nutrients like B12, when there are imbalances or inadequate nutrients, the body doesn't have the building blocks to make the hormones and neurotransmitters that help keep the system functioning and help us think clearly. And finally, inflammation. Inflammation can be caused by chronic stress, chronic sympathetic nervous system dominance. It can be caused by illness. It can be caused by a variety of things. But inflammation, especially when it travels up into the brain and becomes neuroinflammation, contributes to brain fog. Well, that's all well and good, but we are not doctors. So, what Why did I just go through all that? Because we need to screen and refer. Many of the factors contributing to brain fog symptoms are prevalent in people experiencing mental health and or substance abuse issues, and will not respond to CB cognitive behavioral therapy. You can do cognitive behavioral therapy until the cows come home, but if somebody is anemic, hypothyroid, and um postmenopausal, they're really going to struggle to make progress because the body is unable. The body factory is unable to process the cognitions um as effectively. Behavioral health clinicians must screen for possible underlying factors, make referrals, and provide supportive interventions for these co-occurring issues that are outside of our scope. We'll start out with POTS. It's a common co-occurring issue in brain fog, and you know this one is near and dear to my heart because my daughter has it. 90% of POTS cases occur in females, which averages out to be 1 in 62 girls, 1 in 62 adolescent women, young women. Uh so, think about a high school. When you have, say, a thousand people in the high school and 600 of them, or 620 of them, make the math easy for me, are female, then you're going to have at least 10 of them that have that are struggling with POTS and brain fog. And unfortunately, especially in females, POTS often initially gets misdiagnosed as anxiety. And people can go years before they get an accurate diagnosis. It just started being talked about in um common medical circles about 3 to 5 years ago. Um But it it is a thing, and it is a real diagnosis, and there are clinical trials on it. It's not just some, you know, fly-by-night diagnosis, just like fibromyalgia was not a thing until suddenly it was. The medical community is starting to accept it. However, um it's not well known even among physicians, and unfortunately, even among pediatricians. Generally, POTS sets in 1 to 2 years after puberty. And it often starts uh after a some sort of viral illness that causes inflammation. Some of the things that people with POTS can do to help with the brain fog. This doesn't help the POTS necessarily, but to help with the brain fog. Avoid long sitting. A lot of people with POTS, once they've been sitting for 15 or 20 minutes, their blood starts pooling in their feet, not getting to their brain, and guess what? Brain fog. Shorten work periods. A lot of people with POTS, um, have difficulty with extended cognitive activity. So, chunking it. Working during your best times of day. For some people it's the morning, some people it's at night. And improving vagal tone. One of the key factors in POTS is when people stand up, their blood pressure goes way up, and their heart rate goes way up. And helping people, that's obviously hyperactivation of the sympathetic nervous system. Helping people down regulate as quickly as possible, and strengthen that vagal tone has been shown to be somewhat effective. Again, it's not going to make it go away, it's not a magic bullet, but in terms of reducing the excess energy spend as much as possible, and providing strategies to help them feel and and remain functional longer. These are some strategies that work for some people. People who've had cancer and or chemotherapy. We see brain fog in people with cancer who don't have chemotherapy, and we see brain fog in people who have chemotherapy. Um, 75% of cancer patients and survivors may have persistent brain fog. Again, when we have persistent brain fog, it's frustrating, it increases our stress, which subsequently increases inflammation, disregulates the immune system, not what you want in somebody with cancer or a cancer survivor. Encouraging people to educating them about what brain fog is and helping them examine what they can do to support themselves in moving toward what's important in their rich and meaningful life despite or and having brain fog. Fibromyalgia is not an autoimmune disorder because a lot of people with fibro don't have systemic inflammation, but they have some wicked chronic pain. Chronic pain often disrupts sleep, uses a lot of energy, contributes to brain fog. Chronic fatigue syndrome the main variables correlating with cognitive performance in cognitive fatigue chronic fatigue syndrome were anxiety symptoms and physical fatigue. The more tired somebody felt the more um cognitive dysfunction they had. There was just no energy to fuel the body or the brain. And the more anxiety they had, the more energy was being spent over here in fight or flight and not over here in executive functioning. Dysbiosis, which is a disruption of the gut microbiome uh has a strong correlation with brain fog. A lot of our neurotransmitters are made in our gut. And when for whatever reason our gut gets out of balance it contributes to leaky gut, it contributes to systemic and neuroinflammation. And it may contribute to an imbalance in the creation of the neurotransmitters we need to function. With dysbiosis, we want to encourage people to potentially talk it over with their doctor, talk it over with a dietitian. There are a lot of ways to improve gut health and we can't as social workers, as mental health counselors, et cetera. We can't recommend, you know, take this probiotic or do make this dietary change, but we can educate people that eating colorful whole fruits and vegetables and fermented foods and things like yogurt, kimchi, kefir can help support the gut microbiome. Additionally, stress reduction helps support the gut microbiome. When we get stressed, our microbiome changes and not in a good way. When we take antibiotics, that drug goes in there and may wipe out the bad thing that's causing us to be sick, but it wipes out everything else, too. Some more than others, whether it's a gram positive, gram negative, or broad spectrum. Either way, it's taking out a whole group of microbes in our gut that we really need and they've shown in studies that people who take antibiotics after one course, their gut microbiome is not exactly the same for up to 2 years later. I was like, wow. Um now, I don't those were people who weren't actively trying to intervene and heal their microbiome, but it still was interesting. I know when I was little, this was back before antibiotics were you know, hard to come by. Um every time I would start to get an ear infection or something, they'd be giving me antibiotics. I think I was on antibiotics probably more months a year than I was off of them. Uh which, you know, probably had some long-term effects on my gut microbiome. Hormone changes. Menopause and postpartum have been most closely studied. I did not find any articles that actually looked at andropause and how that affects uh um brain fog. We do know that people who have low low levels um of testosterone do have some cognitive dysfunction. But in andropause, generally, people are still within that um scale. They're still within that range that the doctor considers normal for your age. Um the studies that look at cognitive dysfunction in people regarding their testosterone levels were looking at people who had really, really low T, way outside of that range. Anyhow, understanding that changes in estrogen and um progesterone can significantly impact our ability to think clearly, especially for people who are as- assigned female at birth. Uh That's really important. Estrogen is sort of bimodal. If you don't have enough, you got problems. If you've got too much, you're going to have a lot of anxiety. You've got problems. It's that sweet spot that's just right. And estrogen in the female body is neuroprotective and anti-inflammatory. So, when we go through menopause, oh my gosh, all of a sudden that anti-inflammatory, neuroprotective agent is pretty much gone. During the postpartum period, hormones are all over the place and it's variable protection, which we often see people who have who are in the postpartum phase but do not have postpartum depression, they have variable cognition. There are some days they're clear and some days they're kind of foggy. People who develop postpartum depression almost always, not always but almost always, evidence pretty significant brain fog. Autoimmune issues, which by their very nature involve inflammation and sometimes neuroinflammation, are associated with brain fog. How many of your patients have some autoimmune issue? There are a lot of them out there. Educate yourself about autoimmune issues. Educate yourself about or just pay attention to your clients and recognize when they're postpartum, when they are going through menopause. And for men, you know, even though the research isn't there, I would still be alert to the fact that older men have lower levels of DHEA and testosterone and may also struggle with cognition. We know that cognitive slowing, they call it, very euphemistically, is really common in older adults. Why? Well, in large part, um because of hormone changes. People who have chronic pain, we see decreased activation of the prefrontal cortex in people with chronic pain. Why? The body registers pain as a stressor. So, it's taking energy from the prefrontal cortex, the thinking area, and putting it over to the vigilance area. We also see decreased oxygen hemo- hemoglobin flow, um which may contribute to some cognitive deficits. So, not only is the prefrontal cortex not getting blood glucose, it's also not getting the oxygen and hemoglobin or the oxygen that's attached to the hemoglobin going to that area of the brain, which is kind of interesting. Pain management, guided imagery for pain, um helping advocating for people to talk with their pain management physician to about massage, about um heat, about cold, about you know, there are a lot of non-pharmacological interventions that can be very helpful. From a therapist standpoint, guided imagery is one of those tools we can teach. We can also teach acceptance and commitment therapy for pain. Recognizing that yeah, I've got pain and I can still move toward my rich and meaningful life. Noticing that my pain is not a 10 every single day. Embracing those days that my pain is a six and say, "Hey, it's going to be a good day." And getting over the expectation that I should be pain-free. Most of us, especially as we get older, but most of us frequently have some sort of ache or pain somewhere, especially if you work out or do things that are physically active. It's going to happen. You're going to occasionally have a headache or a kink in your neck or, you know, right now I was doing a lot of work in the garden, so my low back is kind of sore. Okay, it is what it is. It does it not so bad that it's going to impair my ability to move forward. Does it slow me down a little bit? Yes. Is that frustrating? Well, it could be, but I've decided not to get stressed out about it. Helping people develop strategies to live with things that they can't get rid of are huge. People uh who eat gluten, not only people with celiac disease, but people with gluten sensitivity, they found that gluten-induced neurocognitive impairment is common and may be severe in both individuals with celiac disease and non-celiac gluten sensitivity. You don't have to have celiac disease to be to be sensitive to gluten. Some people are sensitive to it when they eat it, it causes um inflammation in their gut. And I forgot to put FODMAPs on here, too, but FODMAP f o d m a p. Those are other um molecules in food that can sometimes irritate someone's gut um and when people are eating something, like for me, eating raw green peppers will tear my stomach up, and I know that. Um do I like raw green peppers? Well, I used to, but I can't eat them anymore. And recognizing some of those triggers for chronic pain, whether it's celiac or exposure to certain pesticides or certain FODMAPs, um is important, and people can work with a dietitian to do this. People can also just keep a log of what they're eating and notice if their symptoms increase after they eat a particular food. Um Dehydration impairs cognitive performance through autonomic dysregulation and neurochemical alterations with effects detectable even at mild levels of fluid deficit 2% or less. This is really important, especially for our older adults or our patients who have a job where they work outside, where they sweat a lot, or our patients who are really intense exercisers. When they get dehydrated it can contribute to uh cognitive impairment. And 2% dehydration, you don't even really notice. You're not really starting to feel parched until you get to 3% dehydration. So, you're starting to experience brain fog. Older adults, as we get older, our receptors that tell us, "Hey, you're thirsty." They start to fritz out a little bit, which is why older adults often don't drink enough and are often highly at risk of being dehydrated. Um and I'll add on to that uh um they may also be more at risk for developing urinary tract infections. They're not flushing things out. They're not going to the bathroom enough, so things can build up, maybe. Either way, we do know that dehydration contributes to cognitive impairment. Uh we also know, and this isn't on the slide, but I'll share with you anyway, more than 30% of older adults that are taken to the ER for symptoms of delirium don't have anything wrong up here. They have a urinary tract infection causing systemic inflammation and potentially dehydration. Once their hydration and infection are taken care of, cognition improves straight away. Calorie deficits. We need calories to fuel our body. Whether it's a calorie deficit because somebody's doing a cleanse for an extended period of time, or they're on a diet, or they've got anorexia, or bulimia, or they're on a weight loss medication. Significant calorie impairment not only deprives the body of energy it needs to function, cuz it takes a lot of energy to think. The brain is one of the heaviest users of blood glucose. In the absence of blood glucose, it'll use fatty acids. But ultimately, we start seeing um impairments in cognitive functioning in people who are at a persistent calorie deficit. One study showed that 22% of GLP-1 patients develop nutritional deficiencies within 12 months because they're typically only eating 800 to maybe 1200 calories a day. >> [snorts] >> And it's impossible to get your adequate nutrients from real foods only eating that many calories per day. Now, there are workarounds, but it's important if somebody is on a GLP-1, if they've had um bypass surgery, anything that may impair their food intake or food absorption, that they work closely with a dietitian to prevent side effects. PAWS, which is post-acute withdrawal syndrome. The This is a syndrome that goes on for up to 2 years after somebody gets clean while their body heals. Addiction is really hard on the body. It's hard on the liver. It's hard on the nervous system. It rewires everything. It's hard on the the uh dopaminergic system. It's hard on everything. And the body doesn't just rebound like that. It doesn't just rebound in a week or a month. For a lot of people, they will have ongoing PAWS symptoms, which get better over time, but they're not completely resolved for up to 2 years. And one of those symptoms is often brain fog. As I mentioned, addiction is stressful on the body. When people ingest a toxin, the body registers a stressor, triggers the stress response. When the the toxin leaves the body and all of a sudden the brain's going, "Hey, what happened to that? I I just got used to it." And they're in withdrawal, the body registers that as a stressor. >> [snorts] >> So that stress response, that HPA axis, is regularly being triggered, which contributes to ongoing neuroinflammation. And it takes the brain a while. It takes those receptors a while. It takes the circuits a while to rewire and rebuild. And when I say a while, I mean, you know, up to 2 years. Helping people reduce their stress and develop strategies to manage their PAWS symptoms during the first 2 years is important. Other things we see in people with PAWS are include anhedonia and fatigue and difficulty with getting motivated and concentration. What are those things all associated with? Dopamine. And we know that dopamine fries. I'm [clears throat] sorry that addiction fries that dopaminergic system. It takes a while to get rebalanced. Hypothyroid. When the body slows down because the thyroid is for whatever reason conserving energy. Whether it's autoimmune hypothyroid or stress-induced hypothyroid or whatever. When the thyroid is hypoactive the heart's not beating as fast, the blood's not circulating as fast, the oxygen's not getting where it needs to as fast, which is why people develop significant brain fog, fatigue, listlessness. B12 deficiency occurs in approximately 2 to 3% of adults in the United States. B12 is one of those vitamins that comes from animal products. If you have somebody who is a vegan um or even a vegetarian, but more so in vegans. If people are lacto-ovo vegetarians or they eat um fish, they're getting some B12. But people who are strict vegans need to be cognizant and ensure they're getting enough B12. Doesn't mean they can't stay vegan. I'm not dissing veganism. I'm pointing out though that a B12 deficiency has a lot of side effects. B12 is one of those um nutrients we have that helps us have energy. Risk factors for B12 deficiency include malabsorption. If you're stressed and your gut's inflamed, you're not going to absorb it as well. If you're not taking enough in because you're not eating enough animal-based products or if you're using certain medications. Now, hold up here. Metformin, which is a diabetes medication, or proton pump inhibitors, which are antacids. How many of your clients are either on diabetes medications or proton pump inhibitors? Those patients are at risk of B12 deficiency, which may be contributing to their brain fog. And older age. As we age, our body just doesn't absorb stuff through our digestive tract nearly as well, even if we're eating a healthy diet with lots of animal protein. Um our body's just not able to break it down and absorb it as efficiently. Blood tests, super easy to identify nutrient deficiencies, hypothyroid, hormone um alterations, gonadal hormone alterations, B12 deficiency, deficiency in vitamin D, and um deficiency in iron. Now, both B12 deficiency and iron deficiency can contribute to anemia. What is anemia? Anemia is when your red blood cells aren't able to carry oxygen as efficiently. We don't get enough oxygen to the brain, what happens? Brain fog. Other issues, sleep impairment. How many of your clients have sleep apnea? There is a significant increase in the proportion of people who have sleep apnea who also have PTSD. So again, I ask you, how many of your clients have sleep apnea? Maybe they didn't have it before and then they experienced trauma, they may have developed sleep apnea incident to that. If they're snoring and they snore themselves awake, if their partner says, "You're peeling the paint off the walls, you're snoring so loudly." Or they move to another room. 25% of couples don't even sleep in the same room because one partner snores so loudly. Or if the person just has poor sleep hygiene. My son, God bless him, um just refuses to go to bed at a reasonable hour. And you know, he's 26 years old. I quit harping on that a long time ago, but he's still um not prioritizing his sleep hygiene, which can be really problematic. Additionally, people with ADHD have been shown to have more difficulty getting to sleep and poorer sleep architecture leading to overall poorer sleep. They may be in bed for as many hours as a non-ADHD person, but their sleep quality is significantly reduced. Working with people to um maximize their sleep hygiene to the extent possible is super important. When we sleep, when we're in deep sleep, our brain gets rid of the toxins that uh build up throughout the day, and that contributes which contribute to brain fog. If we don't clear out those toxins, then all the works are gummed up. Uh when we start to get sleepy, there is a um I think it's a hormone. It's called adenosine, and it attaches in our brain to cause us to feel sleepy and sleep pressure. If we don't get enough deep sleep, that adenosine doesn't get dislodged. So, we feel foggy and well, foggy the next day. Sleep is huge. And And I know I harp on this probably every week because it's that important. Shift work and circadian misalignment also contribute to brain fog. Every cell in your body has a circadian clock. And that includes your hormones, that includes your melatonin secretion, that includes your cortisol secretion, your everything. Everything is on a circadian clock. If you're constantly doing shift work, maybe you're working overnight shift 3 days a week, and then the other 4 days a week, you switch your shift back so you can be awake with the kids. Oh my gosh, your brain doesn't know when to secrete what. Your gut doesn't know when to have which microbes on duty. It starts creating a lot of problems. But even minor shift changes, for example, going from the 8:00 a.m. to 4:00 p.m. shift to the 12:00 p.m. to 8:00 p.m. shift changes the circadian alignment. It may alter when you eat, it may alter when you go to bed, it may alter when you get up in the morning. And anytime those things are altered, it changes your circadian rhythms. It changes your hormone secretions. Can it be stabilized? Yes. But it takes some diligence to do it, and it usually takes at least 28 days, and most people say it's more like 2 months of being on the same schedule every single day. Now, your firefighters, they can't help when they get called out. You know, there are some nights they're just not going to sleep at night. What can you do? And our job is to help people figure out how to mitigate the issues that may be contributing to the brain fog even if we can't completely eliminate them. How can we help you mitigate this? Melatonin hangover. Now, this is really interesting. There's no evidence that melatonin can cause brain fog the next day. But people who take supratherapeutic doses, big doses, of melatonin may have persistent fatigue the next day. Um this is especially true with extended release melatonin or higher doses of melatonin, 5 mg and up. And a lot of you are going, "5 mg, that's nothing." Well, the Sleep Foundation recommends if you're going to use melato- melatonin to use an immediate release kind cuz that's what happens in our body. It's not an extended release. The body just goes squirt melatonin. An immediate release kind of 0.1 to 0.5 mg and to take it 1 to 3 hours before bed, not right before bedtime. Those are some mistakes that people commonly make. They're trying to do the right thing. They're trying to use this melatonin. They're trying to get their sleep improved, but they're working against themselves. Antihistamines. Acutely, if you've taken Benadryl, I know, I take half the adult dose of Benadryl and I'm like drooling on myself. But antihistamines have a long history and well-documented evidence of contributing to brain fog and cognitive disruption. Um They also have shown that people who use antihistamines like Benadryl or the other one that I can never remember the name of um in order to get as as a sleep aid often have brain fog the next day. Sometimes it's just the next morning. Sometimes it's ongoing. Recognizing that and by the way Dramamine actually has an antihistamine component to it. So some people who take Dramamine for seasickness or motion sickness may also have experience brain fog. Encourage people to pay attention. When is your brain fog worse? Let's look backwards, do some backward chaining. Figure out what did you do? What did you ingest? What was different last night that contributed to you having worse brain fog today as opposed to a different day. Here's another big one, overtraining or overreach. I have when I was in high school, when I was in college, I was a personal trainer, I taught spin, you know, I love working out. I love exercising. I love exercising hard and it's taken me a long time to recognize that I was actually overreaching. I was actually pushing my body too hard. Yes, when you're preparing for a race or something, you're going to increase the amount that you train, but you have to have some recovery time in there. Um and depending on the person, some people may be able to really ramp it up quite a bit. Other people may start experiencing overreach when they only increase their workout by one day a week. Anyhow, the ACSM joint consensus statement explicitly notes that brain fog is a characteristic feature of overtraining syndrome with symptoms requiring weeks to months of rest to resolve. It's not weeks to months of backing off a little bit. It's weeks to months of rest. Encouraging people not to get to the point where they're all the way at overtraining. Overreach is when you're starting to push your body too much. Overtraining syndrome is basically like physiological burnout. Studies have found that consecutive days of high-intensity exercise led to persistently worsened executive functioning. Brain fog, slower choice reaction times, and increased ratings of mental fatigue as early as day two. So, doing two back-to-back really intense activities started to have on evidence ongoing impairment in cognitive functioning. Four to five days a week of high-intensity training will produce functional overreaching within one to two weeks in most individuals. And I want you to think about this. There are certain places now that Well, I'll call it out. Orange Theory Fitness encourages people to do I think it's 20 minutes um in the red zone four to five days a week. And by this very definition, that is going to produce functional overreaching in a lot of people. The general consensus is that you can do two intense days a week. 20% of your workout can be intense, you know, really pushing it, and the other 80% of your workout days should be easier. People who did CrossFit um, and runners who are preparing for a marathon, for example, because you don't prepare for a marathon in 2 weeks, are very susceptible to overtraining syndrome, which can contribute to brain fog, worsen mood, irritability. Reduce high-intensity sessions to two to three per week and replace the other days with low-intensity, zone one, zone two training. So, somewhere around 60% target heart rate, maybe 65%, which is really hard for a lot of us to be that restrained. Ensuring at least one complete rest day per week from all structured exercise, avoiding consecutive days of high-intensity training, so you alternate your hard and easy days, and that includes lifting, and maintaining adequate carbohydrate intake and overall energy balance. Now, these are guidelines, obviously, unless you are a, um, certified personal trainer or a medical doctor. We can't prescribe these things, but we can educate people what the guidelines are and encourage them strongly to talk with their, uh, physician about what the best steps are for training. Depression and anxiety use an abundance of cognitive resources, potentially overwhelming and prohibiting typical cognitive functioning. People often come to our office and they are experiencing depression and anxiety. Most of the time, in almost 30 years of practice, they've also got a lot of other stuff going on that's contributing to physiological, interpersonal, or emotional, or cognitive stress. Uh, however, the depression and anxiety uses a lot of energy, makes it harder to think clearly. When they can't think clearly, it's frustrating, which uses more energy, which may contribute to worsening depression and anxiety and worsening neurochemical imbalances. As I mentioned earlier, ADHD brain fog can be a symptom for a lot of people with ADHD, having difficulty concentrating, making decisions, interpreting, taking in information. Not everybody with ADHD has this, but it is not an uncommon symptom. People with PTSD and/or CPTSD, people who are still in that state of feeling unsafe and disempowered are chronically hypervigilant, are chronically stressed, if you will. So, that energy, it may not be all of it, but it they have a some undercurrent of energy that's constantly being diverted away from the prefrontal cortex over to the fight or flight. Helping people feel safe, helping people feel empowered, helping people process their trauma. We can do that. That's in our in our scope. Um and once they start to feel that safety and empowerment and relief from the trauma, then they may find that their brain fog starts to remit. And sympathetic nervous system dominance from chronic stress in any piece of life. Dirty discomfort, as I mentioned earlier, is defined as distress about distress. One of the best things we can do is help clients recognize that distress about brain fog or things that may happen as a result of brain fog are only going to worsen the brain fog. Help them develop tools to live a rich and meaningful life and have brain fog. Okay, you've got brain fog right now. You've got a new baby at home. All right. Well, so what can we do to help you live your richest, most meaningful life and reduce as much unnecessary stress as possible? What other things might we need to refer out for for an evaluation? I think the statistic is something like 20% may not be quite that high, but it's a big number of women develop hypothyroid postpartum. They didn't have hypothyroid before they had a baby, but once they have that baby, they may develop hypothyroid. If we've got somebody who's evidencing symptoms of postpartum depression or postpartum baby blues, postpartum fatigue, can't hurt to have a blood test run just to see what's going on under the hood. Get the doctor involved, multidisciplinary treatment. Supportive interventions, encourage people to write things down, use push notifications, eliminate distractions. If they're trying to listen to somebody, probably best to not do that in the middle of a busy restaurant if they're easily distracted. Want to have a one-on-one in a quiet room. Or if they're trying to read or process something, may not be helpful to have the television on and the kids running around behind them. Try to create low-stress environments so they're not constantly feeling on edge, constantly feeling hypervigilant. Help them develop distress tolerant and down regulation skills. When they start feeling themselves amp up, how can they down regulate? When they down regulate, then the energy, the oxygen is going to be able to flow back over to that thinking part of the brain. Help them notice changes in an intensity of brain fog and possible correlations. Educate their significant others about brain fog and the need to slow down. They're not trying to ignore you. They're not trying to be rude. They're not trying to be disrespectful. They just can't keep up right now. And encouraging them to um help help them understand it's neurochemical. It's not something that they can will themselves to change right away. Encourage them to maintain proper hydration, nutrition, and blood sugar, and prioritize sleep. Brain fog is common and can worsen mental health issues. Behavioral health clinicians can make appropriate referrals for what I call under-the-hood screening including dieticians and medical providers. Address affective, behavioral, cognitive, and environmental issues that are maintaining their distress and nervous system activation. What's keeping them from feeling safe and empowered and relaxed. We can educate the patients and their significant others about the physiological underpinnings of brain fog. So again, they get out of this it's a weakness, it's a will, I can just I can think harder. No, no, not maybe not. And help them address anxieties about dementia. Some people really start getting worried that they're never going to be able to think like they used to and they might be developing dementia which is almost never the case. And empower clients to develop supportive interventions so they can work smarter, not harder. They can't work harder and suddenly start thinking clearly again. The harder they try, the more stress they're putting on themselves, actually the worse it's going to get. >> [gasps and sighs] >> Are there any questions for me? And it's important to recognize that carbohydrates are an essential macronutrient and carbohydrates themselves are not necessarily bad. Highly processed carbohydrates, those are bad. Those are inflammatory. But carbohydrates, for example, from beans, from legumes, from broccoli, um help nourish some of that gut bacteria. Fiber helps nourish that gut bacteria and produce short-chain fatty acids that help produce energy and fuel the system. Unfortunately, chemo, because it is so destructive to the body, some people continue to struggle with brain fog. I would encourage you to work with your physician to evaluate um anything else that may be going on under the hood contributing to inflammation. Look at your C-reactive protein. Look at your um nutrient levels. Look at your hormone levels. Um I don't know what kind of cancer you had, but some cancers are hormone dependent. So, you may have altered hormone levels that are contributing to it. May not be able to fix that because you can't take hormone replacement therapy. Okay. Um what suggestions might they have that can help you compensate to live your richest and most meaningful life? >> Oh, and Tyrone, you brought up a good point. I didn't even mention the fact that a lot of people who don't have good air conditioning make it dehydrated during the summer just because of the heat. And people who were on psychotropic medications, whether it's antipsychotics or antidepressants, anti-anxiety medications, it alters our body's ability to cool itself and sometimes alters our hydration levels or those medications may be sensitive to changes in hydration levels. I have an entire video on um the impact of heat on mental health, but you're right. I mean, there's a lot to consider. For those of you who are interested in additional um hours, we do have a uh survey on the LCEUs website. We're trying to get information about how many people would be interested and would attend to determine if it's something that we can um theoretically do and uh I'm running that