Brain fog

By Marcello Cherchi, MD PhD

For patients

“Brain fog” is not really a disease in itself, but people sometimes use the phrase “brain fog” to refer to problems with thinking and behavior. It can occur along with other diseases. Treatment of “brain fog” usually should be treating the other disease with which it occurs.

For clinicians

Overview

“Brain fog” has no universally accepted definition. It often consists of a constellation of cognitive, psychological and physiological symptoms occurring in the context of some other diagnosis, and has been reported in association with a broad range of diseases. The mechanism of “brain fog” is not understood, and it has no confirmatory test. Practically, treatment should be aimed at the disease in whose context “brain fog” is occurring. Other interventions (such as cognitive-behavioral therapy, neurofeedback, pharmacologic, etc.) are investigational.

Introduction

In clinical practice, English-speaking patients frequently use the colloquial phrase “brain fog.” Despite the absence of any clear definition, this phrase has found its way out of the vernacular into the medical literature, and as of this writing, a PubMed search for “brain fog” gets several hundred hits.

It is difficult to study a phenomenon if, in the absence of a clear definition, it cannot be consistently identified. Efforts to define the meaning of the phrase “brain fog” have included strategies such as scraping social media (McWhirter et al. 2023). More controlled approaches have attempted to define this phrase as it is used by patients suffering from a specific medical condition, such as celiac disease (Knowles et al. 2024), while others cast a broader net by surveying patients with a wide variety of diagnoses (Atik and Inel Manav 2023). Attempts at “re-tooling” other cognitive scales (such as the Montreal Cognitive Assessment) to identify “brain fog” have been unsatisfactory (Lynch et al. 2022).

Some analyses suggest that patients complaining of “brain fog” usually describe symptoms that fall under several broad categories. For example, Atik and Manav (Atik and Inel Manav 2023) suggest cognitive, physiological and psychological categories, as shown in the Table below.

Table: Cognitive, physiological and psychological manifestations of "brain fog." From Atik and Manav (2023).
Table: Cognitive, physiological and psychological manifestations of “brain fog.” From Atik and Manav (2023).

This approach has its merits, but since each subjective symptom has its own rather large differential diagnosis, the discriminatory power is limited. For example, a patient endorsing a subset of these symptoms would also easily meet the DSM-5tr criteria for clinical depression (American Psychiatric Association 2022), as shown below.

  • Depressed mood
    • “I feel detached”
    • “I feel worried”
    • “I have difficulty controlling my emotions”
  • Loss of interest/pleasure
    • “I do not enjoy doing things I have to do”
  • Weight loss or gain
    • N/A
  • Insomnia or hypersomnia
    • “I want to sleep more lately”
    • “I have difficulty falling asleep”
  • Psychomotor agitation or retardation
    • “I feel like my thinking process slows down”
  • Fatigue
    • “I always feel tired”
  • Feeling worthless or excessive/inappropriate guilt
    • N/A
  • Decreased concentration
    • “I am easily distracted”
    • “I have difficulty concentrating”
  • Thoughts of death/suicide
    • N/A

Epidemiology

“Brain fog” has been described in association with an impressive range of illnesses and conditions, including:

  • Neurological disorders
    • Traumatic brain injury (Bell et al. 2023; Elliott et al. 2023)
    • Multiple sclerosis (Atik and Inel Manav 2023)
    • Neurosarcoidosis (Atik and Inel Manav 2023)
    • Mild cognitive impairment (Atik and Inel Manav 2023)
  • Cardiovascular disorders
    • Postural orthostatic tachycardia syndrome (Koch et al. 2023; Rodriguez et al. 2022; Ross et al. 2013; Wells et al. 2020)
    • Dehydration (Atik and Inel Manav 2023)
  • Gastrointestinal and hepatobiliary disorders
    • Celiac disease (Croall et al. 2020; Knowles et al. 2024; Lebwohl and Ludvigsson 2014; Yelland 2017)
    • Hepatitis C (Atik and Inel Manav 2023)
    • Cirrhosis (Atik and Inel Manav 2023)
  • Endocrinological disorders and hormonal states
    • Hypothyroidism (Ettleson et al. 2022; Haskard-Zolnierek et al. 2022; Samuels and Bernstein 2022)
    • Hypoparathyroidism (Elliott et al. 2023)
    • Menopause (Hobson and Dennis 2024; Jaff and Maki 2021; Maki and Jaff 2022; Zhu et al. 2023)
    • Pregnancy (Atik and Inel Manav 2023)
  • Disorders of nutrition and metabolism
    • Disorders of sodium metabolism (Atik and Inel Manav 2023)
    • Vitamin B12 deficiency (Atik and Inel Manav 2023)
    • Iron deficiency (Atik and Inel Manav 2023)
  • Rheumatologic or autoimmune disorders
    • Rheumatoid arthritis (Atik and Inel Manav 2023; Elliott et al. 2023)
    • Chronic fatigue syndrome (Ocon 2013)
    • Systemic lupus erythematosus (Kalim et al. 2020; Mackay 2015)
    • Fibromyalgia (Elliott et al. 2023)
  • Infectious disorders
    • COVID-19 ([No authors] 2024; Aghajani Mir 2023; Antar et al. 2023; Asadi-Pooya et al. 2022; Asadi-Pooya et al. 2023; Babiloni et al. 2024; Bowen and Arany 2023; Bulla et al. 2023; Callan et al. 2022; Chasco et al. 2022; Chatys-Bogacka et al. 2022; Chatys-Bogacka et al. 2023; Chatys-Bogacka et al. 2024; Del Brutto 2022; Delgado-Alonso et al. 2023; Fernández-de-Las-Peñas et al. 2023; Finsterer 2022; Finsterer and Mehri 2023; Graham 2022, 2024; Gross et al. 2023; Hagiya et al. 2024; Hassan et al. 2023; Hugon 2022; Hugon et al. 2022; Ishikura et al. 2023; Jennings et al. 2022; Kavanagh 2022; Kazama 2023; Kopańska et al. 2022; Krishnan et al. 2022; Lam et al. 2023; Lanz-Luces et al. 2022; Lynch et al. 2022; Masuko and Sasai-Masuko 2024; Matias-Guiu et al. 2021; Menichetti 2023; Nordvig et al. 2023; Nouraeinejad 2022, 2023; Orfei et al. 2022; Rabaiotti et al. 2023; Reinfeld 2023; Sfera et al. 2023; Sia et al. 2023; Sklinda et al. 2021; Stefano et al. 2021; Taube 2023; Theoharides et al. 2021; Tsuchida et al. 2023; van der Feltz-Cornelis et al. 2024; Wang and Gandy 2022; Wojcik et al. 2023)
  • Psychiatric disorders
    • Depression (Atik and Inel Manav 2023)
    • Anxiety (Atik and Inel Manav 2023)
    • Autistic spectrum disorders (Atik and Inel Manav 2023)
  • Miscellaneous
    • Renal disease (Atik and Inel Manav 2023)
    • Allergies (Atik and Inel Manav 2023)
    • Chemotherapy (Atik and Inel Manav 2023)

Pathophysiological mechanism of disease

It is difficult to discern a pattern among these. Perhaps the most parsimonious (though not very useful) observation is simply that “brain fog” can occur in association with primary neuropsychiatric disease, and as a neuropsychiatric manifestation of the adverse neurological impact from the biochemical consequences of other medical conditions (cardiovascular, renal, metabolic, nutritional, endocrinological, autoimmune, rheumatologic, infectious, etc.).

Clinical presentation

See the section titled, “Introduction” (above).

Testing

There is not yet any serum marker, imaging study or other “test” for “brain fog.”

Differential diagnosis

See the section entitled, “Epidemiology” (above).

Treatment

Given how poorly understood “brain fog” is, it is hardly surprising that there is a dearth of literature on its treatment. In view of the broad array of diseases and states with which “brain fog” has been associated, it is probably unrealistic to view this as a single uniform disorder that might be treated or managed by a single intervention (Kverno 2021).

Practically:

  • Since “brain fog” occurs in the context of other illnesses, it is reasonable to treat those other illnesses, if such treatment is available.
  • Other interventions, usually aimed at “brain fog” occurring in the context of specific diseases, have been described in case reports and small case series, and should be viewed as investigational, including neurofeedback (Masuko and Sasai-Masuko 2024), cognitive-behavioral therapy (Muthumuni et al. 2023), “photobiomodulation” (Bowen and Arany 2023) and other non-invasive brain stimulation (Linnhoff et al. 2022), and psychiatric medications (Reinfeld 2023).

Prognosis

The prognosis is variable, and is likely to be partly dependent on the disease in whose context the “brain fog” is occurring.

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Page first published on April 26, 2024. Page last updated on April 26, 2024

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