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How can we “clear the fog” surrounding brain fog? Experts addressed the cognitive dysfunction, or “brain fog,” observed in patients with long COVID—as well as those with fibromyalgia, with chronic fatigue syndrome, and undergoing chemotherapy treatment—at the 2022 American Psychiatric Association (APA) Annual Meeting.

Maria Tiamson-Kassab, MD, of the Moores Cancer Center at UC San Diego introduced the presidential session, which was delivered on behalf of the Academy of Consultation-Liaison Psychiatry. Durga Roy, MD, FACLP, of Johns Hopkins Bayview Neuropsychiatry Clinic and Johns Hopkins University School of Medicine discussed symptoms and pathophysiology of brain fog in long COVID, plus some ways clinicians can manage patients with brain fog after long COVID. Additional speakers included Jon Levenson, MD, of Columbia University Irving Medical Center and Susan Abbey, MD, FRCPC, of the University of Toronto.

Tiamson-Kassab explained that “brain fog” is a nonmedical term used to describe what patients feel in any condition that causes confusion, memory loss, inability to concentrate or focus, and difficulty with word-finding or multitasking. It is found in many conditions, including long COVID, fibromyalgia, chronic fatigue syndrome, pregnancy, multiple sclerosis, and systemic lupus erythematosus, as well as in cancer treatments and certain medications. Neurocognitive domains affected in brain fog include planning; decision-making; processing speed; complex, divided, and selective sustained attention; free and cued recall; and working, procedural, and autobiographical memory.

Cognitive dysfunction is a particular concern in long COVID, as many patients have reported symptoms such as brain fog weeks or months after SARS-CoV-2 infection, Roy explained. Current definitions of long COVID differ. The National institute for Health and Care Excellence defines it as a constellation of symptoms that develop during or following SARS-CoV-2 infection persisting for 12 weeks or more; the World Health Organization defines it as persistent symptoms occurring 3 months from onset in individuals with past confirmed or probable SARS-CoV-2 infection and persisting for at least 2 months; and the Centers for Disease Control and Prevention defines it as a range of symptoms that can last weeks or months after initial SARS-CoV-2 infection, which can appear weeks after infection. In all cases, the symptoms cannot be sufficiently explained by any alternative diagnosis, and they can present even if the initial SARS-CoV-2 infection was mild or asymptomatic.

Although a range of symptoms may present, “fatigue and cognitive impairment appear to be the most debilitating symptoms of long COVID,” Roy said. The exact cause of brain fog and other symptoms in long COVID is not yet clear, however: “We have to be cognizant of the fact that, potentially, anxiety and depression could be factors that are driving the fatigue and cognitive impairment,” Roy said. “And pathophysiology can stem from numerous hypotheses, neuroinflammation, or neurotropism, but the idea is that the frontal limbic pathway seems to consistently be something that we’re hearing about when it comes to cognitive problems in long COVID.”

In terms of treatment, Roy recommended both pharmacologic and nonpharmacologic interventions targeting mental fatigue and cognition. Pharmacologic interventions may include medications such as methylphenidate, donepezil, modafinil, luteolin, nicotinamide riboside, vitamin C or probiotic supplementation, monoclonal antibodies, or adaptogens. Suggested nonpharmacologic interventions include cognitive behavioral therapy, graded exercise therapy, pacing, and rehabilitation.

With studies on brain fog in long COVID still new and in development, however, Roy emphasized a need for more research to improve treatment and patient quality of life. “This is definitely a syndrome that we don’t know very much about,” Roy said. “It’s something that we really need to study more in order to get a better grasp on what’s going on.”

Articles

Experts address cognitive dysfunction found in patients with long COVID at the 2022 APA Annual Meeting.

Clearing the ‘Brain Fog’ in Long COVID

John J. Miller, MD, shares why he's so excited to be back live at not only conferences, but also in the everyday clinical setting. According to Dr Miller, there's so much you miss over Zoom when evaluating patients, as he discusses in his editorial from the 2022 May issue of Psychiatric Times™, 

For more from the conference, check out the 

is medical director, Brain Health, Exeter, New Hampshire; Editor in Chief,

; staff psychiatrist, Seacoast Mental Health Center, Exeter; Consulting Psychiatrist, Exeter Hospital, Exeter; consulting psychiatrist, Insight Meditation Society, Barre, Massachusetts.

Videos

Our Editor in Chief is thrilled to be live and in person at the 2022 APA Annual Meeting in New Orleans. Here's why. 

The Benefits of Being in Person at the 2022 APA Annual Meeting 

Frank A. Clark, MD, shares how excited he is to be back in person and able to embrace his colleagues at the 2022 APA Annual Meeting in New Orleans.

is an outpatient psychiatrist at Prisma Health-Upstate and clinical associate professor at the University of South Carolina School of Medicine, Greenville. He served on the American Psychiatric Association’s Task Force to Address Structural Racism Throughout Psychiatry, and he currently serves as the Diversity and Inclusion section editor and advisory board member for

"When we embrace humanity, everyone wins."

Embracing Humanity at the 2022 APA Annual Meeting

John J. Miller, MD, briefly discusses how disruptions in social life can cause change in primary symptoms. Psychosocial stressors have been key talking point at the 2022 APA Annual Meeting in New Orleans.

How do social stressors contribute to patient symptoms? 

The Importance of Psychosocial Stress Explored at the 2022 APA Annual Meeting

In a first-of-its-kind study, researchers looked at the effect of practice sparring on possible brain changes in mixed martial arts (MMA) fighters. The results were presented at the 

2022 American Psychiatric Association Annual Meeting 

by study author Aaron I. Esagoff, a medical student at Johns Hopkins University School of Medicine.

Although previous studies have looked at other sports that involve 

, the real risk for MMA fighters occur during practice sessions, explained Esagoff. Fights/matches only happen a few times per year, but individuals can spend hundreds of hours sparring and practicing. MMA is a hybrid combat sport that includes moves from boxing, wrestling, karate, judo, and jujitsu.

“With MMA and a lot of combat sports, you are going to get hit in the head a good amount. And when you get hit a lot of times, that can lead to damage and disease,” Esagoff noted. The increasing awareness of repetitive brain trauma and its relationship to 

 inspired Esagoff and colleagues to study MMA fighters.

To better understand the effects, the investigators conducted a cross-sectional study of 92 active professional MMA fighters, looking at the relationship between customary sparring practice rounds per week on white matter hyperintensity volume and regional brain volumes.

In doing so, Esagoff and colleagues found customary sparring practice rounds per week were significantly associated with increased white matter hyperintensity volume, which he noted may be indicative of damage (eg, axonal injury, vascular damage, etc). However, the customary sparring practice rounds per week were also associated with increased relative size of the left and right caudate nucleus. The authors hypothesized that practice may help protect from injuries during official fights that damage the caudate.

“The one takeaway would be that sparring and practice is not all good or all bad, as there are some good effects, some not-as-good effects,” concluded Esagoff. “But it's all an association for now; we're not able to conclude anything with confidence.”

Esagoff’s co-authors included Michael J.C. Bray, MS; Andres A. Pasuizaca; Matthew E. Peters, MD; Bharat R. Narapareddy, MD; and Charles B. Bernick, MD.

Are you attending the 2022 American Psychiatric Association Annual Meeting? We want to hear your thoughts! Share recaps, reflections, and experiences with us at PTEditor@mmhgroup.com. Be sure to visit us at booth 1852.

What are the neuropsychiatric effects of sparring in mixed martial arts? New research presented at the 2022 APA Annual Meeting elucidates the issues.     

More Than a Knockout: Structural Brain Effects in MMA Sparring 

Helen Lavretsky, MD, MS, gives a short overview on some topic highlights from the 2022 APA Annual Meeting, including the topic she presented on. 

To see more about her presentation, watch 

Pharmacogenetics: Clinical Applications and Cases Across the Lifespan. 

is a professor in-residence in the Department of Psychiatry at the University of California, Los Angeles. Her work on geriatric depression and integrative mental health using mind-body interventions has received national attention, and she has won numerous grants supporting that work. A distinguished fellow of the American Psychiatric Association and of the American Association for Geriatric Psychiatry, and a fellow of the American College of Neuropsychopharmacology, she is also on the board of 

What are the Psychiatric Times™ Editorial Board Members talking about at the 2022 APA Annual Meeting in New Orleans? 

Topic Highlights from the 2022 APA Annual Meeting With Helen Lavretsky, MD, MS

“In a disaster, we naturally tend to pay attention toward the most immediate victims, so people who are impacted physically and with physical injuries and damages,” Gaëlle Rached, MD, MSc, said in a new research presentation at the 2022 American Psychiatric Association Annual Meeting. But what about the family members who live thousands of miles away?

Rached, Research Postdoctoral Fellow at Northwestern University, shared details about the events of August 4, 2020, when the residents of Beirut experienced a massive explosion as a result of improperly stored ammonium nitrate at the port. More than 200 individuals were killed, and many more were injured and left homeless. Although Rached was in the city and saw firsthand the devastation and trauma, she found herself taken aback by the reports from expat friends and colleagues. 

“They heard about the blast from social media, and they tried reaching out to their families, but they weren't able to reach them,” she said. “The lines weren't connecting. They spent hours trying to reach them and thinking and imagining the worst… Can you imagine sitting at home looking at these headlines and wondering what your family is going through? Can you imagine seeing these videos shared over on social media and being stuck abroad due to COVID, not being able to help?”

As she talked with her colleagues about these experiences, she realized that the traumatic experiences were similar, “but somehow a little bit different.”

In general, expatriates are exposed to stressful living conditions, which makes them more susceptible to developing mental health problems, Rached noted. Yet their general mental health is not well studied, and even less is known about such in the context of traumatic events. Thus, Rached and colleagues conducted a 7-month study to examine the impact of the Beirut explosion on expats.

The study consisted of 670 Lebanese citizens or first generation from Lebanese descent who were residing abroad (not in Lebanon) and at least 18 years old. Of that population, 268 experienced the explosion and/or had close family members physically impacted by it. The median age was 31, and the majority (62.2%) were female. Participants came from all over the world, with the highest percentages coming from the United States and France. Study co-authors included Muriel Slim; Dimitri Fiani, MD; Margarita Abi Zeid Daou, MD; and Souraya Torbey, MD.

Participants were screened using the Hopkins Symptoms Checklist and the PTSD Checklist for DSM-5. Preliminary analysis found almost 60% of the 268 who had more personal experience had scores on the PTSD Checklist indicative of PTSD. Furthermore, about 41% of participants screened higher than the threshold for anxiety and depression on the Hopkins Symptom Checklist. Both younger age and female sex were associated with higher scores, even months after the event occurred.

Rached explained their results show expatriates’ mental health are negatively affected by traumatic events in their home countries:

- Regardless of how long the expat has been away from their home country

- Regardless of if they experienced the event or witnessed it firsthand

“My simple message would be that there are 200 million expats around the world right now. Look out for expats in your life—your friends, your coworkers, your colleagues—especially when the country is going through traumatic events,” Rached concluded.

Research explored how a traumatic explosion affected individuals around the world. 

New Data Shows Trauma’s Ripple Effects

Groups such as the Clinical Pharmacogenetics Implementation Consortium and the US Food and Drug Administration (FDA) have developed guidelines supporting the implementation of pharmacogenetics into practice. However, many mental health clinicians are either unfamiliar with or uncertain about these guidelines, the evidence supporting their development, or the circumstances in which they should be employed.

 Board Member Helen Lavretsky, MD, MS, and colleagues Daniel J. Mueller, MD, and Chad Bousman, PhD, for “

Pharmacogenetics: Clinical Applications and Cases Across the Lifespan

American Psychiatric Association Annual Meeting

 on Tuesday, May 24, 2022, at 10:30am. The presentation will feature an overview of the current guidelines; the pharmacogenetic evidence connected to common psychiatric medications; and some recent clinical cases and studies supporting the efficacy of pharmacogenetics in psychiatric care delivery across the lifespan.

What are the current dosing guidelines for the implementation of pharmacogenetics into practice?

“I think until we really understand the underlying neurobiology of PTSD, we’re stuck with a situation where the patient gets better, but they don’t get well.”

Charles B. Nemeroff, MD, PhD, Matthew P. Nemeroff Endowed Chair and professor in the University of Texas at Austin (UT Austin) Dell Medical School Department of Psychiatry & Behavioral Sciences, discussed the neurobiology of posttraumatic stress disorder (PTSD) at the 2022 American Psychiatric AssociationAnnual Meeting. In the session—moderated by Edmond Hsin T. Pi, MD—Nemeroff described the diagnosis, epidemiology, and pathophysiology of PTSD, along with notable risk factors and some current and emerging treatments for PTSD.

According to Nemeroff—who is also director of the Institute for Early Life Adversity Research and co-director of the Center for Psychedelic Research & Therapy at UT Austin Dell Medical School—PTSD is the only diagnosis in DSM-5 that is dependent on an external event, and the traditional view is that most individuals who develop PTSD eventually recover from it. However, there are several preexisting conditions and risk/vulnerability factors for PTSD that play a role in its development and course, including female sex; childhood or adolescent trauma exposure; family or personal history of anxiety or mood disorder; stressful life events in the prior and following year; and either panicked reactions (eg, shaking, sweating) or dissociative reactions (eg, tunnel vision, slow motion) at the time of the trauma.

Nemeroff also cited several pathophysiology studies using PTSD as the prototype gene X environment interaction disease, with a special focus on candidate genes such as FKBP5 and CRHR1, which have been shown to be predictive of PTSD development. These, along with preexisting conditions and risk/vulnerability factors for PTSD, are important because “psychiatry needs to focus on identifying people who are at risk for psychiatric disorders and intervening before the breaking point (the first psychotic episode, etc),” he stated.

Nemeroff discussed multiple options for psychosocial and pharmacological PTSD treatments, all with the general goals of reducing core symptoms, improving function and quality of life, strengthening resilience, relieving comorbid disorders, preventing relapse, and providing rehabilitation. For psychosocial treatments, he discussed exposure therapy, anxiety management, desensitization, hypnotherapy, and cognitive behavioral therapy (CBT). He added that CBT is a particularly notable psychosocial treatment, stating that “There’s no doubt that either a cognitive processing therapy or trauma-focused CBT should be a component of the treatment.”

In terms of pharmacological PTSD treatments, Nemeroff cautioned that “PTSD takes much longer to respond to medication than depression. You have to stick with it.” He did, however, discuss the efficacy of selective serotonin reuptake inhibitors (SSRIs) sertraline (Zoloft) and paroxetine (Paxil)—the only 2 drugs approved by the US Food and Drug Administration (FDA) for the treatment of PTSD—as well as 3,4-methyledioxymethamphetamine (MDMA)-assisted therapy. Recent research has highlighted the potential of MDMA-assisted therapy as a potential breakthrough treatment for PTSD. “This is the most exciting finding in the PTSD world,” Nemeroff stated. “I believe there will be a role for MDMA in the treatment of PTSD.”

How can we more effectively help patients with PTSD? Charles B. Nemeroff discusses the diagnosis, epidemiology, and pathophysiology of PTSD, along with current and emerging treatments, at the 2022 APA Annual Meeting.

Understanding the Neurobiology of PTSD

Dr Hassan and colleagues Karen B. Rosenbaum, MD; Susan Hatters-Friedman, MD; Ryan C. Hall, MD; and Cathleen Cerny-Suelzer, MD, share more about these issues in their session, “

The BITE of Cults in Our Culture in the Age of COVID

 on Sunday, May 22, 2022. The presentation features an explanation of the BITE Model of Authoritarian Control and why it is particularly important in the COVID era for psychiatrists to take an active role in helping individuals under undue influence or authoritative/exploitative control.

What is undue influence? How do cults and predators operate? And how can clinicians help individuals who are under undue influence or authoritative control, or in exploitative situations? In this episode of 

™, interviews Steven Hassan, PhD, about the importance of effectively evaluating undue influence in the law and clinical settings, and how the 

BITE (Behavior, Information, Thought, and Emotion) Model of Authoritarian Control

is a mental health professional and expert working for over 45 years in the field of destructive authoritarian control (undue influence) in relationships, organizations, and belief systems. He is the author of 4 books including 

Combating Cult Mind Control and Freedom of Mind

. He founded the Freedom of Mind Resource Center. He is the developer of the BITE Model of Authoritarian Control, the Influence Continuum Model, and the Strategic Interactive Approach. All are instrumental in helping empower individuals to exit authoritarian cults, trafficking, extremist groups, conspiracy theories, and controlling relationships.

How can we help individuals who are under undue influence or authoritative control?

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