Development of the Development of the Mental Clutter ScaleMental Clutter Scale

Robert S. Katz Robert S. Katz 1,31,3 Frank Leavitt Frank Leavitt 2,3 2,3 Serene Francis Serene Francis 44

Rush University Medical CenterRush University Medical Center11Rheumatology Associates, Department Internal Medicine, Rheumatology Associates, Department Internal Medicine,

22Department of Behavioral SciencesDepartment of Behavioral Sciences3 Rush University Medical Center3 Rush University Medical Center

4 Lutheran General Hospital4 Lutheran General Hospital

OVERVIEWOVERVIEW

FIBROFOG FIBROFOG

DEFINITIONDEFINITION

MEASUREMENT – MENTAL CLUTTER SCALEMEASUREMENT – MENTAL CLUTTER SCALE

MEASUREMENT – NEUROCOGNITIVE TESTINGMEASUREMENT – NEUROCOGNITIVE TESTING

THEORETICAL CONSIDERATIONSTHEORETICAL CONSIDERATIONS

FibrofogFibrofog

““Fibrofog” Fibrofog” (Leavitt & Katz 2003)(Leavitt & Katz 2003) forgetfulness forgetfulness a lack of mental claritya lack of mental clarity

Memory loss in those without FMS: Memory loss in those without FMS: only 8.8% reported diminished only 8.8% reported diminished mental clarity mental clarity (Leavitt & Katz 2002)(Leavitt & Katz 2002)

PurposePurpose A new scale was developed to A new scale was developed to

capture the varying appreciation of capture the varying appreciation of disturbances in the cognitive state of disturbances in the cognitive state of people with fibromyalgia. people with fibromyalgia.

SamplesSamples Sample 1. Sample 1. 88 FMS females with memory complaints 88 FMS females with memory complaints    Sample 2. Sample 2. first replication: 128 FMS subjects withfirst replication: 128 FMS subjects with memory complaintsmemory complaints

Sample 3. Sample 3. second replication: 592 subjects with second replication: 592 subjects with memorymemory complaints completed Web complaints completed Web based version of the scalebased version of the scale

MethodsMethods

Over 800 subjects Over 800 subjects

Mental Clutter Scale: Mental Clutter Scale:

Seven items relating to skillsSeven items relating to skills Six items relating to mental claritySix items relating to mental clarity

StatisticsStatistics These data were subjected to factor These data were subjected to factor

analysis with varimax rotation. analysis with varimax rotation.

The criteria of Eigenvalue greater than one combined with a The criteria of Eigenvalue greater than one combined with a visual inspection of the Scree Plot were used in identifying visual inspection of the Scree Plot were used in identifying the number of factors to be extractedthe number of factors to be extracted

ResultsResults Seven variables cover a broad range of cognitive Seven variables cover a broad range of cognitive

skills and formed the Cognition Factor (I). Six skills and formed the Cognition Factor (I). Six variables associated mainly with intrinsic qualities variables associated mainly with intrinsic qualities of the brain relating to clear headedness formed of the brain relating to clear headedness formed the Mental Clarity Factor (II). The two factors the Mental Clarity Factor (II). The two factors explained 82.4% of the total variance.explained 82.4% of the total variance.

As expected, individuals with fibromyalgia As expected, individuals with fibromyalgia presented the highest level of disturbance in both presented the highest level of disturbance in both cognitive skills and mental clarity.cognitive skills and mental clarity.

Mental Clutter Scale

Table 1. Comparison of factor loadings across 3 studiesTable 1. Comparison of factor loadings across 3 studies

Table 2. Group differences in the presentation of cognitive Table 2. Group differences in the presentation of cognitive difficulties on the basis of a two dimensional framework difficulties on the basis of a two dimensional framework

involving cognitive skills and mental clutter.involving cognitive skills and mental clutter.

The culprit of poor recall in The culprit of poor recall in

fibromyalgia appears to be a weak fibromyalgia appears to be a weak memory trace brought on by slow memory trace brought on by slow processing time, and exacerbated by processing time, and exacerbated by distraction, that prevents the distraction, that prevents the rehearsal of relevant information.rehearsal of relevant information.

Fibrofog

Adding verbal rehearsal seemingly Adding verbal rehearsal seemingly makes up for losses in processing makes up for losses in processing time, and creates a more durable time, and creates a more durable memory trace that is a available for memory trace that is a available for later recalllater recall. .

Neurocognitive TestingNeurocognitive Testing We suggest that all rheumatic We suggest that all rheumatic

disease and non-rheumatic disease disease and non-rheumatic disease patients concerned about memory patients concerned about memory decline or mental fogginess should be decline or mental fogginess should be tested for the effect of distraction tested for the effect of distraction through the (Auditory Consonant through the (Auditory Consonant Trigram) and for naming speed using Trigram) and for naming speed using the (Stroop test). the (Stroop test).

Time Delay in the Transmission of Information in the Fibromyalgia

Neural Network

Processing Processing DelayDelay

3 seconds of 3 seconds of sensory sensory Information.Information.

Time in Time in Lexicon Lexicon StorehouseStorehouse

Time in Time in Short Term Short Term MemoryMemory

FibromyalgiaFibromyalgia 620 msec620 msec 2 sec 380 2 sec 380 msecmsec

NormalNormal 417 msec417 msec 2 sec 583 2 sec 583 msecmsec

The average deficiency in word naming speed in fibromyalgia is approximately 200 The average deficiency in word naming speed in fibromyalgia is approximately 200 msec. (Leavitt & Katz 2008).msec. (Leavitt & Katz 2008).

CONCLUSIONCONCLUSION Cognitive loss was accompanied by changes Cognitive loss was accompanied by changes

in mental clarity to a much higher degree in in mental clarity to a much higher degree in fibromyalgia. fibromyalgia. A new Mental Clutter Scale A new Mental Clutter Scale was developed to measure this construct. was developed to measure this construct.

Adding a source of distraction following a 3 Adding a source of distraction following a 3 second presentation of the word stimulus second presentation of the word stimulus prevents rehearsal of the primary prevents rehearsal of the primary information, sending weaker memory traces information, sending weaker memory traces into long term memory.into long term memory.

ResultsResults Study 1.Study 1.

The factor analysis produced a two-factor solution The factor analysis produced a two-factor solution (Eigenvalues = 9.6 and 1.1 respectively) with 7 (Eigenvalues = 9.6 and 1.1 respectively) with 7 variables loading highly (0.7) on the first factor and variables loading highly (0.7) on the first factor and six variables loading highly on the second factor six variables loading highly on the second factor (Table 1). Factor loadings of (0.7) indicate a close (Table 1). Factor loadings of (0.7) indicate a close association of variables with a factor and formed the association of variables with a factor and formed the basis for inclusion of variables in Factors. basis for inclusion of variables in Factors.

Seven variables cover a broad range of cognitive Seven variables cover a broad range of cognitive skills and formed the Cognition Factor (I). They are skills and formed the Cognition Factor (I). They are shown in bold in Table 1. Six variables associated shown in bold in Table 1. Six variables associated mainly with intrinsic qualities of the brain relating to mainly with intrinsic qualities of the brain relating to clear headedness formed the Mental Clarity Factor clear headedness formed the Mental Clarity Factor (II). The two factors explained 82.4% of the total (II). The two factors explained 82.4% of the total variance.variance.

Results (Con’t)Results (Con’t)

Next, we examined group differences in the presentation of Next, we examined group differences in the presentation of cognitive difficulties on the basis of this two dimensional cognitive difficulties on the basis of this two dimensional framework. As can be seen in Table 2, groups with and without framework. As can be seen in Table 2, groups with and without memory complaints differed on both factor scales. Those with memory complaints differed on both factor scales. Those with memory complaints on average produced significantly higher memory complaints on average produced significantly higher scores on both cognitive skills and mental clutter. Higher scores on both cognitive skills and mental clutter. Higher scores represent increased disturbance in cognitive skills and scores represent increased disturbance in cognitive skills and mental clarity. mental clarity.

As expected, individuals with fibromyalgia presented the As expected, individuals with fibromyalgia presented the highest level of disturbance in both cognitive skills and mental highest level of disturbance in both cognitive skills and mental clarityclarity

Results (cont.)Results (cont.) Studies 2 and 3Studies 2 and 3

Confirmatory factor analysis in studies 2 and 3 Confirmatory factor analysis in studies 2 and 3 produced highly similar 2 factor solutions, with produced highly similar 2 factor solutions, with eigenvalues of 11.0 and 1.5 in study 2 accounting for eigenvalues of 11.0 and 1.5 in study 2 accounting for 77.7% of the variance, and 10.1 and 1.2 in study 3 and 77.7% of the variance, and 10.1 and 1.2 in study 3 and accounting for 70.7% of the variance. accounting for 70.7% of the variance.

The two -factor solution across studies 2 and 3 displays The two -factor solution across studies 2 and 3 displays a high degree of overlap with the original 2 factor a high degree of overlap with the original 2 factor inventory of variables indicating a high amount of inventory of variables indicating a high amount of factor stability.factor stability.

Naming speed is used to measure the time Naming speed is used to measure the time course of word processing, a crucial stage course of word processing, a crucial stage in stimulus identification (Kello 2004). It in stimulus identification (Kello 2004). It reflects the amount of time consumed in reflects the amount of time consumed in accessing the vocabulary (lexical) system accessing the vocabulary (lexical) system (Wagner & Torgerson 1987). (Wagner & Torgerson 1987).

If more time is needed to access the stock If more time is needed to access the stock of vocabulary traces, then less time is of vocabulary traces, then less time is available for the later processing of this available for the later processing of this information (Ericsson 1985). information (Ericsson 1985).

In support of this hypothesis, we turn In support of this hypothesis, we turn to a timing deficit uncovered among to a timing deficit uncovered among people with fibromyalgia; namely, people with fibromyalgia; namely, slow naming speed. slow naming speed.

The extra time needed to access entries in The extra time needed to access entries in the lexical stage shortens the time available the lexical stage shortens the time available to process this information to enter the to process this information to enter the short term memory stage. Like a slow short term memory stage. Like a slow runner in the 100 yard dash, this delay runner in the 100 yard dash, this delay changes the flow of information from one changes the flow of information from one stage to the next. stage to the next.

The presumption is that built-in delays The presumption is that built-in delays operate to shorten processing time, causing operate to shorten processing time, causing individuals with fibromyalgia to lay down individuals with fibromyalgia to lay down weaker memory traces. weaker memory traces.

The implication is that 3 seconds of The implication is that 3 seconds of incoming information is actually processed incoming information is actually processed as a 2.8 second stimulus. Without a built-in as a 2.8 second stimulus. Without a built-in delay of 200 msec, processing takes place delay of 200 msec, processing takes place over the full 3 seconds in short term over the full 3 seconds in short term memory. memory.

Presumably another way to support recall in Presumably another way to support recall in FMS is to make lexical processing work FMS is to make lexical processing work more quickly. more quickly.

Your TalkYour Talk

INTRODUCTIONINTRODUCTION ““Fibrofog” derives from the common description Fibrofog” derives from the common description

of mental fogginess in the short term memory of mental fogginess in the short term memory loss of people with fibromyalgia. It represents a loss of people with fibromyalgia. It represents a combination of forgetfulness and a perception of combination of forgetfulness and a perception of a lack of a mental clarity (Leavitt & Katz 2003). a lack of a mental clarity (Leavitt & Katz 2003).

The great majority of cognitively-compromised The great majority of cognitively-compromised patients without fibromyalgia who report memory patients without fibromyalgia who report memory loss do so in a state of good mental clarity, with loss do so in a state of good mental clarity, with only 8.8% of a non-FMS sample connecting only 8.8% of a non-FMS sample connecting memory disturbance to diminished mental clarity memory disturbance to diminished mental clarity (Leavitt & Katz 2002). (Leavitt & Katz 2002).

SamplesSamples Sample 1. The sample comprised Sample 1. The sample comprised 88 females with memory 88 females with memory

complaints who met ACR criteria for fibromyalgiacomplaints who met ACR criteria for fibromyalgia. They . They had a mean age of 50.3±10.5 years and a mean level of had a mean age of 50.3±10.5 years and a mean level of education of 15.0±3.7 years. education of 15.0±3.7 years.

    Sample 2. The sample of the Sample 2. The sample of the first replicationfirst replication was roughly was roughly

comparable to sample 1 and comprised comparable to sample 1 and comprised 128 FMS subjects 128 FMS subjects with memory complaints drawn from the same clinical with memory complaints drawn from the same clinical settingsetting. They had a mean age of 49.5±11.7 years and a . They had a mean age of 49.5±11.7 years and a mean level of education of 14.3±2.0 years. The gender mean level of education of 14.3±2.0 years. The gender breakdown was 93.7% female and 6.3% male. breakdown was 93.7% female and 6.3% male.

Sample 3. The sample of the Sample 3. The sample of the second replicationsecond replication consisted consisted of of 592 subjects with memory complaints who completed a 592 subjects with memory complaints who completed a Web based version of the scale over the InternetWeb based version of the scale over the Internet. The . The gender breakdown was 88.3% female, and 11.7% males. gender breakdown was 88.3% female, and 11.7% males. The median age of the sample was 48 years. The median age of the sample was 48 years.

METHODSMETHODS Three studies involving a sample of Three studies involving a sample of over 800 over 800

subjectssubjects were carried out to determine the structure were carried out to determine the structure and stability of the new scale, and stability of the new scale, the Mental Clutter the Mental Clutter ScaleScale. .

An initial item pool of An initial item pool of 13 items was formulated from 13 items was formulated from

self-statements of patients presenting with a history self-statements of patients presenting with a history of memory complaints and a review of the literature.of memory complaints and a review of the literature.

Seven items relating to problems with cognitive Seven items relating to problems with cognitive

skillsskills were rated on a 10-point likert scales from were rated on a 10-point likert scales from 1=no problem to 10=severe problem. 1=no problem to 10=severe problem. Six items Six items relating to the frequency of diminished mental relating to the frequency of diminished mental clarityclarity were rated on a 10-point likert scale from were rated on a 10-point likert scale from 1=not at all to 10=all the time.1=not at all to 10=all the time.

MethodsMethods

The 13 item measure was administered to The 13 item measure was administered to a sample of 88 patients who met the ACR a sample of 88 patients who met the ACR criteria for FMS. criteria for FMS.

These data were subjected to factor These data were subjected to factor analysis with varimax rotation. analysis with varimax rotation. The The criteria of Eigenvalue greater than one criteria of Eigenvalue greater than one combined with a visual inspection of the combined with a visual inspection of the Scree Plot were used in identifying the Scree Plot were used in identifying the number of factors to be extracted. number of factors to be extracted.

FIBROFOG BY FIBROFOG BY NEUROCOGNITIVE TESTINGNEUROCOGNITIVE TESTING

Fibrofog can be assessed through neurocognitive testing, Fibrofog can be assessed through neurocognitive testing, using using distraction techniquesdistraction techniques (such as counting from 100 by (such as counting from 100 by 3's) during the 3's) during the Auditory Consonant TrigramAuditory Consonant Trigram. Adding a . Adding a source of distraction caused the majority of patients with source of distraction caused the majority of patients with FMS to lose information at a rate that was 44% greater FMS to lose information at a rate that was 44% greater than an age matched group presenting with memory than an age matched group presenting with memory problems and almost three times greater than the problems and almost three times greater than the normative sample (Leavitt & Katz 2004). normative sample (Leavitt & Katz 2004).

And by evaluating cognitive And by evaluating cognitive processing speedprocessing speed through the through the Stroop testStroop test for numbers and colors. Fibromyalgia patients for numbers and colors. Fibromyalgia patients have a selective processing speed deficit, specifically in have a selective processing speed deficit, specifically in the area of the area of naming speednaming speed. In fact, the average deficiency . In fact, the average deficiency in word naming speed in fibromyalgia is approximately 200 in word naming speed in fibromyalgia is approximately 200 msec. (Leavitt & Katz 2008). msec. (Leavitt & Katz 2008).

Processing Processing DelayDelay

3 seconds of 3 seconds of sensory sensory Information.Information.

Time in Time in Lexicon Lexicon StorehouseStorehouse

Time in Time in Short Term Short Term MemoryMemory

FibromyalgiaFibromyalgia 620 msec620 msec 2 sec 380 2 sec 380 msecmsec

NormalNormal 417 msec417 msec 2 sec 583 2 sec 583 msecmsec

THEORETICAL THEORETICAL CONSIDERATIONSCONSIDERATIONS

Naming speed is used to measure the time Naming speed is used to measure the time course of word processing, a crucial stage course of word processing, a crucial stage in stimulus identification (Kello 2004). It in stimulus identification (Kello 2004). It reflects the amount of time consumed in reflects the amount of time consumed in accessing the vocabulary (lexical) system accessing the vocabulary (lexical) system (Wagner & Torgerson 1987). (Wagner & Torgerson 1987).

If more time is needed to access the stock If more time is needed to access the stock of vocabulary traces, then less time is of vocabulary traces, then less time is available for the later processing of this available for the later processing of this information (Ericsson 1985). information (Ericsson 1985).

Presumably, distraction is more disruptive Presumably, distraction is more disruptive to individuals with fibromyalgia because to individuals with fibromyalgia because their memory traces haven’t built sufficient their memory traces haven’t built sufficient velcro to stick in memory on their own velcro to stick in memory on their own (Dalenoort 1985; Peterson & Peterson (Dalenoort 1985; Peterson & Peterson 1959). 1959).

Adding verbal rehearsal seemingly makes Adding verbal rehearsal seemingly makes up for losses in processing time, and up for losses in processing time, and creates a more durable memory trace that creates a more durable memory trace that is a available for later recallis a available for later recall. .

Neurocognitive Neurocognitive TestingTesting

Auditory Consonant Trigram-distractionAuditory Consonant Trigram-distraction Adding a source of distraction caused the majority of Adding a source of distraction caused the majority of

patients with FMS to lose information at a rate that was patients with FMS to lose information at a rate that was 44% greater than an age matched group presenting with 44% greater than an age matched group presenting with memory problems and almost three times greater than the memory problems and almost three times greater than the normative sample (Leavitt & Katz 2004normative sample (Leavitt & Katz 2004).).

Stroop TestStroop Test Fibromyalgia patients have a selective processing speed Fibromyalgia patients have a selective processing speed

deficit, specifically in the area of naming speed. In fact, the deficit, specifically in the area of naming speed. In fact, the average deficiency in word naming speed in fibromyalgia is average deficiency in word naming speed in fibromyalgia is approximately 200 msec. (Leavitt & Katz 2008). approximately 200 msec. (Leavitt & Katz 2008).

CONCLUSIONSCONCLUSIONS Traditional neurocognitive tests for Traditional neurocognitive tests for

assessing dementia miss abnormalities in assessing dementia miss abnormalities in naming speed and the effect of distraction, naming speed and the effect of distraction, which are likely common in the populationwhich are likely common in the population ofof those reporting memory complaints.those reporting memory complaints.

We suggest that all rheumatic disease and We suggest that all rheumatic disease and non-rheumatic disease patients concerned non-rheumatic disease patients concerned about memory decline or mental fogginess about memory decline or mental fogginess should be tested for the effect of distraction should be tested for the effect of distraction through the (Auditory Consonant Trigram) through the (Auditory Consonant Trigram) and for naming speed using the (Stroop and for naming speed using the (Stroop test). test).