Development of the Mental Clutter Scale

1. Development of the Mental Clutter Scale Robert S. Katz 1,3 Frank Leavitt 2,3 Serene Francis 4 Rush University Medical Center 1Rheumatology Associates, Department Internal Medicine, 2Department of Behavioral Sciences 3 Rush University Medical Center 4 Lutheran General Hospital

2. OVERVIEW • FIBROFOG • DEFINITION • MEASUREMENT – MENTAL CLUTTER SCALE • MEASUREMENT – NEUROCOGNITIVE TESTING • THEORETICAL CONSIDERATIONS

3. Fibrofog • “Fibrofog” (Leavitt & Katz 2003) forgetfulness a lack of mental clarity • Memory loss in those without FMS: only 8.8% reported diminished mental clarity (Leavitt & Katz 2002)

4. Purpose • A new scale was developed to capture the varying appreciation of disturbances in the cognitive state of people with fibromyalgia.

5. Samples • Sample 1. 88 FMS females with memory complaints • Sample 2. first replication: 128 FMS subjects with memory complaints • Sample 3. second replication: 592 subjects with memorycomplaints completed Web based version of the scale

6. Methods • Over 800 subjects • Mental Clutter Scale: Seven items relating to skills Six items relating to mental clarity

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

8. Results • Seven variables cover a broad range of cognitive skills and formed the Cognition Factor (I). Six variables associated mainly with intrinsic qualities of the brain relating to clear headedness formed the Mental Clarity Factor (II). The two factors explained 82.4% of the total variance. • As expected, individuals with fibromyalgia presented the highest level of disturbance in both cognitive skills and mental clarity.

9. Mental Clutter Scale

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

11. Table 2. Group differences in the presentation of cognitive difficulties on the basis of a two dimensional framework involving cognitive skills and mental clutter.

12. Fibrofog • The culprit of poor recall in fibromyalgia appears to be a weak memory trace brought on by slow processing time, and exacerbated by distraction, that prevents the rehearsal of relevant information.

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

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

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

17. CONCLUSION • Cognitive loss was accompanied by changes in mental clarity to a much higher degree in fibromyalgia. A new Mental Clutter Scale was developed to measure this construct.

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

21. Results Study 1. • The factor analysis produced a two-factor solution (Eigenvalues = 9.6 and 1.1 respectively) with 7 variables loading highly (0.7) on the first factor and six variables loading highly on the second factor (Table 1). Factor loadings of (0.7) indicate a close association of variables with a factor and formed the basis for inclusion of variables in Factors. • Seven variables cover a broad range of cognitive skills and formed the Cognition Factor (I). They are shown in bold in Table 1. Six variables associated mainly with intrinsic qualities of the brain relating to clear headedness formed the Mental Clarity Factor (II). The two factors explained 82.4% of the total variance.

22. Results (Con’t) • Next, we examined group differences in the presentation of cognitive difficulties on the basis of this two dimensional framework. As can be seen in Table 2, groups with and without memory complaints differed on both factor scales. Those with memory complaints on average produced significantly higher scores on both cognitive skills and mental clutter. Higher scores represent increased disturbance in cognitive skills and mental clarity. • As expected, individuals with fibromyalgia presented the highest level of disturbance in both cognitive skills and mental clarity

23. Results (cont.) Studies 2 and 3 • Confirmatory factor analysis in studies 2 and 3 produced highly similar 2 factor solutions, with 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 accounting for 70.7% of the variance. • The two -factor solution across studies 2 and 3 displays a high degree of overlap with the original 2 factor inventory of variables indicating a high amount of factor stability.

24. Naming speed is used to measure the time course of word processing, a crucial stage in stimulus identification (Kello 2004). It reflects the amount of time consumed in accessing the vocabulary (lexical) system (Wagner & Torgerson 1987). • If more time is needed to access the stock of vocabulary traces, then less time is available for the later processing of this information (Ericsson 1985).

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

26. The extra time needed to access entries in the lexical stage shortens the time available to process this information to enter the short term memory stage. Like a slow runner in the 100 yard dash, this delay changes the flow of information from one stage to the next. • The presumption is that built-in delays operate to shorten processing time, causing individuals with fibromyalgia to lay down weaker memory traces.

27. The implication is that 3 seconds of incoming information is actually processed as a 2.8 second stimulus. Without a built-in delay of 200 msec, processing takes place over the full 3 seconds in short term memory. • Presumably another way to support recall in FMS is to make lexical processing work more quickly.

28. Your Talk

29. INTRODUCTION • “Fibrofog” derives from the common description of mental fogginess in the short term memory loss of people with fibromyalgia. It represents a combination of forgetfulness and a perception of a lack of a mental clarity (Leavitt & Katz 2003). • The great majority of cognitively-compromised patients without fibromyalgia who report memory loss do so in a state of good mental clarity, with only 8.8% of a non-FMS sample connecting memory disturbance to diminished mental clarity (Leavitt & Katz 2002).

30. Samples • Sample 1. The sample comprised 88 females with memory complaints who met ACR criteria for fibromyalgia. They had a mean age of 50.3±10.5 years and a mean level of education of 15.0±3.7 years. • Sample 2. The sample of the first replication was roughly comparable to sample 1 and comprised 128 FMS subjects with memory complaints drawn from the same clinical setting. 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 breakdown was 93.7% female and 6.3% male. • Sample 3. The sample of the second replication consisted of 592 subjects with memory complaints who completed a Web based version of the scale over the Internet. The gender breakdown was 88.3% female, and 11.7% males. The median age of the sample was 48 years.

31. METHODS • Three studies involving a sample of over 800 subjects were carried out to determine the structure and stability of the new scale, the Mental Clutter Scale. • An initial item pool of 13 items was formulated from self-statements of patients presenting with a history of memory complaints and a review of the literature. • Seven items relating to problems with cognitive skills were rated on a 10-point likert scales from 1=no problem to 10=severe problem. Six items relating to the frequency of diminished mental clarity were rated on a 10-point likert scale from 1=not at all to 10=all the time.

32. Methods • The 13 item measure was administered to a sample of 88 patients who met the ACR criteria for FMS. • These data were subjected to factor analysis with varimax rotation. The criteria of Eigenvalue greater than one combined with a visual inspection of the Scree Plot were used in identifying the number of factors to be extracted.

33. FIBROFOG BY NEUROCOGNITIVE TESTING • Fibrofog can be assessed through neurocognitive testing, using distraction techniques (such as counting from 100 by 3's) during the Auditory Consonant Trigram. Adding a source of distraction caused the majority of patients with FMS to lose information at a rate that was 44% greater than an age matched group presenting with memory problems and almost three times greater than the normative sample (Leavitt & Katz 2004). • And by evaluating cognitive processing speed through the Stroop test for numbers and colors. Fibromyalgia patients have a selective processing speed deficit, specifically in the area of naming speed. In fact, the average deficiency in word naming speed in fibromyalgia is approximately 200 msec. (Leavitt & Katz 2008).

34. Processing Delay

35. THEORETICAL CONSIDERATIONS • Naming speed is used to measure the time course of word processing, a crucial stage in stimulus identification (Kello 2004). It reflects the amount of time consumed in accessing the vocabulary (lexical) system (Wagner & Torgerson 1987). • If more time is needed to access the stock of vocabulary traces, then less time is available for the later processing of this information (Ericsson 1985).

36. Presumably, distraction is more disruptive to individuals with fibromyalgia because their memory traces haven’t built sufficient velcro to stick in memory on their own (Dalenoort 1985; Peterson & Peterson 1959). • Adding verbal rehearsal seemingly makes up for losses in processing time, and creates a more durable memory trace that is a available for later recall.

37. Neurocognitive Testing • Auditory Consonant Trigram-distraction Adding a source of distraction caused the majority of patients with FMS to lose information at a rate that was 44% greater than an age matched group presenting with memory problems and almost three times greater than the normative sample (Leavitt & Katz 2004). • Stroop Test Fibromyalgia patients have a selective processing speed deficit, specifically in the area of naming speed. In fact, the average deficiency in word naming speed in fibromyalgia is approximately 200 msec. (Leavitt & Katz 2008).

38. CONCLUSIONS • Traditional neurocognitive tests for assessing dementia miss abnormalities in naming speed and the effect of distraction, which are likely common in the populationofthose reporting memory complaints. • We suggest that all rheumatic disease and non-rheumatic disease patients concerned about memory decline or mental fogginess should be tested for the effect of distraction through the (Auditory Consonant Trigram) and for naming speed using the (Stroop test).