Tag: brain fog

The Functional Lab Testing Revolution
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What if the very hormone designed to help you survive is actually the reason you’re struggling to thrive?

My mother relentlessly saved and sacrificed so that she could enjoy her life in retirement. But two years into retirement, she was diagnosed with early onset Alzheimer’s.

Here’s what I’ve learned since becoming a Functional Diagnostic Nutrition Practitioner: she didn’t just “get” Alzheimer’s two years after retirement. It was building and building for years before that. She was making it worse with lifestyle choices: the over-exercising that women in their 40s and 50s often do, eating trans fats during the low-fat craze of the 80s and 90s.

Had I known what I know now, her outcome might have been different.

This is why I’m passionate about functional health. This is why thousands of practitioners are learning to identify and address the root causes of dysfunction before they become disease. If we can reach people in that gray space (when things are out of balance but before they become diagnosable conditions), we can change their trajectory. We can save lives.

As functional health practitioners, we see it every day: clients who’ve tried everything, followed every protocol, cleaned up their diet, and taken all the right supplements, yet they’re still stuck in that frustrating place of “I’m okay, but I’m not great.”

The missing piece? Understanding cortisol and its profound impact on every system in the body.

If you’ve ever wondered why some clients get amazing results while others plateau, or why you yourself might be experiencing symptoms that doctors dismiss as “normal aging,” this deep dive into cortisol will change everything.

What Is Wellness, Really?

Before we dive into cortisol, let’s get clear on what we’re actually working toward. At FDN, we don’t believe in “fine” or “okay.” We believe in abundant vitality.

Picture this as a spectrum:

The Right Side (The Medical Model): Symptoms → Sickness → Disease → Death

The Middle (Neutral Health): No symptoms, but no energy either. This is the “I’m fine, I guess” zone where most people live.

The Left Side (True Wellness): High energy, optimal function, metabolic fire, abundant vitality, joy for life.

Here’s the thing: neutral health equals a neutral life. When you’re operating from “I’m okay, I don’t have any complaints,” you’re not building empires, writing books, raising joyful kids, or showing up as your best self in relationships.

Good health, abundant vitality, is your birthright. It’s not just for the lucky few.

The Body’s Incredible Healing Power (And What’s Limiting It)

Your body is a self-healing machine. You know this because when you get a cut, it heals. When you break a bone, it mends. When you catch a cold, you recover.

But this healing ability isn’t infinite. If it were, we’d never age or die.

So what’s the difference between what your body can heal and what it can’t?

It’s a savings versus spending problem.

Think of your body as having a bank account called “Vital Reserve.” This is your innate intelligence: your body’s natural ability to function at 100% and fix imbalances before they become problems.

Where do you spend this precious currency? On your environment.

This has always been the case. Our paleolithic ancestors spent their Vital Reserve on not knowing if food would be available, dealing with harsh weather, avoiding predators, and navigating tribal conflicts.

Today? We spend it on mental-emotional stress, environmental toxins, and poor lifestyle habits that are constantly draining our account.

The main spender of Vital Reserve is stress.

The Modern Stress Problem: It’s Not What You Think

When most people think of stress, they picture this: work deadlines, traffic, relationship conflicts, financial pressure. And yes, these mental-emotional stressors are huge.

But there are two other categories most people completely miss:

Physical Stressors:
- Sitting too long
- Blue light exposure from screens
- Too much coffee
- Not exercising enough (or exercising too much)
- Needing wine to fall asleep
- Poor sleep quality
Environmental Stressors:
- Depleted soils
- EMF exposure
- Chemicals in food, water, and air
- Toxins our paleolithic ancestors never encountered
Plus, there’s the existential stress of modern life: What’s my purpose? How do I make my life meaningful when I’ll likely be forgotten in 100 years?

All of these are constantly withdrawing from your Vital Reserve account.

Meet Cortisol: Your Body’s “Energy on Credit” System

Cortisol is your primary stress hormone, and it’s actually designed to help you survive. When your environment throws stressors at you, cortisol says, “We need to put internal spending on hold and take all available resources to deal with this external threat.”

Cortisol breaks the body down for quick energy. We call this “catabolic.”

Why would your body have a mechanism for breaking itself down? Because sometimes you need energy RIGHT NOW. When your boss says, “This project is actually due in 30 minutes,” you can’t drive to the store, buy food, cook it, eat it, digest it, and then produce energy. You need quick fuel immediately.

So cortisol reaches for easy-to-break-down tissues like cartilage, tendons, connective tissue, and muscle, converting them to blood sugar.

Here’s the kicker: Cortisol is also a natural painkiller and anti-inflammatory. It masks the damage it’s doing, which is why it makes you feel amazing in the moment: clear thinking, quick reactions, pain-free movement.

Think of cortisol as your body’s credit card. You’re borrowing energy now and promising to pay it back later through rest, recovery, and healing.

When “Energy on Credit” Becomes a Problem

Throughout history, humans dealt with stress that was intense but occasional and short-lived. A wild animal attack, a natural disaster, a tribal conflict: these were serious but temporary.

Take a moment to think about this: Does this describe the stress in your life?

For most of us, stress is intense, constant, and never-ending. We wake up stressed, work stressed, drive home stressed, and lie in bed stressed about tomorrow’s stress.

This creates what we call “catabolic debt”: you’re constantly running up charges on your cortisol credit card without ever paying it back.

Chronic stress is not within our biological design.

Consider this: Anthropological studies show paleolithic humans worked only 15-20 hours per week. How many of you work only 15-20 hours per week? (And remember, “work” includes housework, childcare, and all the other responsibilities that don’t stop when you leave the office.)

They lived in close communities with cooperative resource sharing and had each other’s backs. Think about your own life: Do you know your neighbors? If you do, would they really have your back if things got serious?

Most of us are duplicating resources instead of sharing them. We’re all figuring out our own childcare, making our own meals, maintaining our own everything. There’s no interdependence, no shared load.

The cost of modern life is enormous:
- 70-80% of doctor visits are for stress-related illnesses
- People with high anxiety are 4-5 times more likely to die from heart attack or stroke
- Stress contributes to 50% of all illnesses
The Stress Response Curve: Your Roadmap to Understanding Where You Are

This is where it gets really interesting. Understanding this curve will change how you see your health (and your clients’ health) forever.

We all start in the green zone: Homeostasis. When you experience occasional stressors, cortisol and adrenaline spike, you handle the situation, then return to baseline to rest and repair.

But when stress becomes chronic, you move into the orange zone: Acute Stress. You’re constantly producing cortisol and adrenaline, never returning to homeostasis.

Here’s the thing: on your way up this curve, you feel AMAZING. Remember when you could pull all-nighters and still ace exams? When you could eat junk food without consequences? When you had laser focus for 12-16 hours straight?

That’s the acute phase. You’re running on cortisol, and it feels like superpowers.

Then you hit Peak Production. Your body says, “We’ve put way too much on the cortisol credit card. We have to cut back.”

Now you fall into the Compensatory Phase. Your cortisol numbers might look normal to a doctor, but the distribution is all wrong. Maybe you have too much in the morning and crash by afternoon, or you spike at night and can’t sleep.

Plus, you have a relativity problem. You’re used to feeling like Superman from the acute phase, so normal cortisol levels feel terrible by comparison.

Continue down this path, and you reach the Exhaustive Phase. Like a phone on low battery mode, everything still works but at 30% capacity and not for long. You’re devoting everything to just getting through the day.

The Hidden Cost: What Happens to Your Body’s Core Systems

At FDN, we focus on six foundational systems that chronic stress systematically shuts down. We call them the H-I-D-D-E-N systems, and understanding what happens to each one under chronic stress is crucial for practitioners:

H – Hormones DHEA is your anabolic hormone: the one responsible for building you back up after cortisol breaks you down. This is how you pay off your cortisol credit card. But when stress is constant, DHEA steps back and says, “I’ll come back when it’s safe to focus internally, but right now we need to keep spending on the environment.” DHEA becomes chronically low, which means your healing potential becomes chronically low.

Then sex hormones get the message: “We don’t have enough resources to fund fertility right now.” Sex hormones plummet, taking motivation and joy for life with them. This is when you get to that neutral state where you’re thinking, “I have dreams I want to pursue, but it’s just too much effort. I’ll just watch Netflix instead.”

I – Immune Your immune system is expensive to run. Under chronic stress, it says, “I cost a ton of money, so I’m going to operate at 30% capacity and not for very long.” Now you’re getting sick often, it takes forever to heal, you can’t shake that cough, and if anyone around you is sick, you know you’re going down.

D – Digestion Digestion costs a lot of energy to function properly. When you’re spending everything on stress, digestion goes into low-power mode. Now you’re only digesting at 30% capacity. Even if you’re eating the cleanest diet in the world, you can’t use it. You’re not getting the building blocks to repair or the nutrients your body needs to power metabolic functions at full capacity.

D – Detoxification Detoxification is another huge system that’s expensive to run. When your body’s bank account is overdrawn from cortisol debt, detox says, “I don’t have enough money to find these toxins, bind them up, and effectively remove them. So I’ll put them in storage instead.” Your body shoves toxins into fat cells, brain tissue, and bones, creating a toxic backlog that makes you feel slow, gives you acne, throws off digestion, and impairs hormone production.

E – Energy Production Your mitochondria can’t function optimally when all resources are diverted to stress response. This leads to that “tired but wired” feeling where you’re exhausted but can’t actually rest.

N – Nervous System Sleep, mood, and cognitive function all suffer. This is where we see the brain fog, insomnia, anxiety, and depression that so many people struggle with.

The fundamental principle of FDN: These systems don’t operate in isolation. You can’t just say, “Oh, you have classic hormone symptoms, so let’s run a hormone test.” You miss immunity, digestion, detoxification: all the other systems contributing to what we call “Metabolic Chaos.”

This is why the “take this supplement for that symptom” approach rarely works long-term. You’re not dealing with isolated problems: you’re dealing with systemic dysfunction where multiple systems are compromised simultaneously.

Real-Life Case Studies: The Stress Curve in Action

Let’s look at three real clients to see how this plays out. As FDN practitioners, we use what we call “clinical correlation,” which means we never look at lab numbers in isolation. We always consider how someone feels alongside their test results.

Case Study 1: Adam – The Acute Phase Crash

Profile: 35-year-old male, broker at a mid-size investment firm, former athlete still crushing CrossFit workouts

Symptoms: Weight gain, trouble concentrating, loss of muscle mass despite rigorous workouts, headaches

Doctor’s Assessment: “Your results are unremarkable. This is normal aging.”

Lab Results:
- Cortisol sum: 9 (acute phase)
- Four-point pattern: Way too high in morning, drops low at noon, crashes severely in afternoon, bounces back up at night
- DHEA: 2 (low end of normal range)
- Clinical correlation: Catabolic debt despite “normal” DHEA
The Reality: How do we know Adam isn’t on the left side of the stress curve going up into acute phase? His symptoms tell us everything. If he were on the way up, he’d feel amazing and wouldn’t be in our office. Instead, he’s on the right side coming down from peak production.

His cortisol pattern explains everything: sky-high morning cortisol makes him feel wired and anxious, the afternoon crash leaves him unable to concentrate (not ideal for an investment broker), and the nighttime spike disrupts his sleep.

Even though his DHEA looks “normal,” when we compare it to his cortisol level of 9, he’s clearly catabolic dominant. He’s breaking down faster than he’s building up, which explains why his intense CrossFit sessions aren’t building muscle: they’re just adding more stress to an already overloaded system.

Case Study 2: Caitlyn – The Compensatory Struggle

Profile: 48-year-old court stenographer, recently divorced

Symptoms: Insomnia, fatigue, joint pain

Doctor’s Assessment: “Your results are fine. Everything’s in normal range.”

Lab Results:
- Cortisol sum: Compensatory phase (appears “normal” to doctors)
- Four-point pattern: Way too low in morning, slightly higher at noon, drops severely in afternoon, spikes at night
- DHEA: Low
- Clinical correlation: Cortisol dominant, catabolic debt
The Reality: Caitlyn’s cortisol sum looks normal, but the distribution is completely dysfunctional. She can barely drag herself out of bed in the morning, crashes hard in the afternoon (imagine trying to accurately record legal proceedings when your cortisol is plummeting), and lies awake at night because her cortisol spikes just when it should be lowest.

She also has a relativity problem. When she was in the acute phase, she felt like Superman. Now that she’s in compensatory with “normal” cortisol levels, she feels terrible by comparison. Her DHEA is low, confirming she’s still in catabolic debt despite the lower cortisol numbers.

Case Study 3: Maggie – The Exhaustive Phase Crisis

Profile: 43-year-old chef at a popular five-star restaurant, diagnosed with hypothyroid

Symptoms: Weight gain in hips and belly, trouble keeping up at work, depression, irregular menstrual cycle

Lifestyle: Working 60+ hours per week, consistently sleeping only 5 hours per night

Medical Status: Seeing a counselor, considering antidepressant medication

Lab Results:
- Cortisol sum: 3.1 (exhaustive phase)
- Four-point pattern: Way too low in morning, drops low at noon, slight bounce in afternoon, drops again at night
- DHEA: Very low
- Clinical correlation: Still catabolic dominant despite low cortisol
The Reality: Maggie’s body is operating like a phone on low battery mode: everything still works, but at 30% capacity and not for long. Her thyroid has downregulated because there’s literally not enough energy in the system to maintain normal function.

The depression isn’t just psychological: it’s physiological. Her body can’t afford to fund optimal brain function. Even though her cortisol is very low and her DHEA is very low, she’s still cortisol dominant and in catabolic debt.

This is why understanding the stress curve is so crucial. Three people, three different phases, three different approaches needed.

The Path Forward: Why Understanding Cortisol Changes Everything

Here’s why this matters for you as a health practitioner:

1. It explains why some clients plateau. If you’re not addressing the stress component, you’ll hit a ceiling on healing no matter how perfect the diet or supplement protocol.

2. It validates your clients’ experiences. When someone says, “I used to be able to handle so much more,” or “I don’t feel like myself anymore,” you now understand the physiology behind it.

3. It gives you a roadmap for intervention. Different phases require different approaches. Someone in the acute phase needs different support than someone in the exhaustive phase.

4. It highlights the importance of comprehensive testing. A single cortisol measurement tells you almost nothing. You need the full pattern plus clinical correlation.

The FDN Approach: Test, Don’t Guess

At FDN, we don’t just talk about stress: we measure it. We use what we call “clinical correlation,” which means we never look at lab numbers in isolation. We always consider how someone feels alongside their test results.

We look at:
- Four-point cortisol patterns throughout the day (not just a single measurement)
- DHEA levels and the cortisol-to-DHEA ratio
- How stress is affecting all the H-I-D-D-E-N systems
- The complete picture of metabolic chaos
- Progress tracking with tools like the Metabolic Chaos Scorecard
Then we address it systematically through our DRESS protocol:

D – Diet: Personalized nutrition based on lab findings, not generic “healthy eating” advice

R – Rest: Sleep optimization and recovery strategies tailored to your stress phase

E – Exercise: Right-sized movement for your current capacity (over-exercise is just as harmful as under-exercise)

S – Stress Reduction: Targeted techniques for your specific stressors: mental/emotional, physical, environmental, and lifestyle factors

S – Supplementation: Targeted support based on actual lab results, not guesswork

This isn’t about generic protocols. It’s about understanding exactly where someone is on the stress curve and what their body needs to heal.

Key Takeaways for Health Practitioners

Cortisol isn’t the enemy. A lot of people talk about cortisol as if it’s the villain—commercials make it sound like cortisol just makes you “old and fat.” That’s not what cortisol does. Cortisol is a vital hormone for navigating stress. The problem is chronic stress disrupting its natural rhythm.

Understanding the stress curve is diagnostic gold. It explains why clients feel the way they do and gives you a framework for intervention. Different phases require different approaches.

Clinical correlation is everything. You can’t just look at lab numbers in isolation. A cortisol sum of 5 might be “normal” to a doctor, but if your client feels terrible and the distribution is dysregulated, that tells you the real story.

You can’t ignore stress and expect lasting results. No matter how perfect your diet protocol or how targeted your supplements, chronic stress will cap healing potential. There’s a ceiling you’ll never break through if you don’t address the stress component.

The body’s systems are interconnected. You can’t just “fix hormones” without addressing how stress is affecting immunity, digestion, detoxification, and all the other H-I-D-D-E-N systems. This is why comprehensive testing and systematic protocols are crucial.

Metabolic Chaos requires a systematic approach. When multiple systems are compromised simultaneously, you need a framework like DRESS that addresses all aspects of healing, not just isolated symptoms.

Your Next Steps

If you’re ready to master functional lab testing and learn how to identify and address cortisol dysregulation in your practice, FDN provides the training, community, and ongoing support you need.

Because here’s the truth: your clients deserve more than “fine.” They deserve abundant vitality. And you deserve the confidence that comes from knowing exactly how to help them achieve it.

When you understand cortisol (really understand it), you hold the key to unlocking transformation for every client who walks through your door.

Ready to become the practitioner who always knows what to do next?

The answer lies in data-driven functional health. The answer lies in understanding that robust health isn’t just about the absence of symptoms: it’s about the presence of vitality.

And it starts with the hormone you can’t ignore: cortisol.

Want to learn more about becoming a Functional Diagnostic Nutrition Practitioner?

Discover how our comprehensive training program gives you the tools to master cortisol testing, interpretation, and protocols that get results. Because when you know how to test, you never have to guess. View an indepth case study here.
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Elizabeth Gaines

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July 23, 2025
America’s Concussion Problem Is Way Bigger Than Sports

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The months of haze began in an instant, when the horse I was riding stumbled at the exact moment I was shifting my seat. I don’t remember falling, though I do remember the feeling of the leather reins moving through my hand. I hit my thigh on the ground. Then the flat of my back hit the wall of the indoor arena so hard it felt like I’d popped every vertebrae in my spine. After a few minutes, I got back on the horse (everyone always asks if I got back on the horse), but I haven’t ridden since.

Only on the way home did my thoughts begin to feel sluggish, like a fog was rolling across my brain. I heard ringing in my ears when I tried to think. Everything became too bright and too loud. I slept 17 to 20 hours each of the next three days. I woke up, ate, used the bathroom, and then wandered back to bed, exhausted.

I suspected I had a concussion as soon as the brain fog began. Just the week before, I had heard on a podcast that people could get one without hitting their head. The day after the accident, my doctor confirmed my suspicion. The force of my back against the wall had given me whiplash, my neck jerking forward and back after the collision. My brain, jostling around in my skull, had been injured too.

In my mind, the dangers of concussions were most acute for people who got too many of them—football players, boxers, military veterans, and others who underwent repeated trauma to the brain and had chronic traumatic encephalopathy. A single bump on the head? That was no big deal—except when it was.

For months, a five-minute phone call made me exhausted, as though I’d been swimming laps for an hour. I couldn’t drive, and even as a passenger, looking out the window made me nauseous. Observing anything felt like work; my eyes skipped, as though the world was a slowed-down film reel. My real work—the writing I got paid to do—was impossible. Fun, too, was out of the question. Trying to retrieve thoughts felt like rummaging through one empty file cabinet after another. My self, that person who exists in the wiring in my brain, had gone missing. I worried that she might be gone for good.

During that time, I started to rage against a system that leaves people suffering from concussions or “mild traumatic brain injuries” wading through bad or outdated advice. Studies keep showing that getting targeted rehabilitation for concussion symptoms can lead to a faster recovery, but that’s not what the average patient hears. Many people are still being told by doctors to simply wait a concussion out, when early treatment can make a big difference.

My doctor told me to rest—that most concussion symptoms resolve within a few days. Three days later, the doctor said not to worry until it had been seven to 10 days. Later she updated that range to a month.

When I was awake, I ate and used the little mental energy I had to search for information about concussions online and send emails to specialists. I wanted to know what was actually happening in my brain and if I could do anything to speed the recovery process along. I learned that a helmet can’t completely protect against a concussion because simply accelerating and decelerating quickly can exert enough force on the brain to injure it.

Then I took a nap.

I learned that researchers were working on blood tests that could detect a concussion by measuring protein fragments from damaged nerve fibers. (The first commercial product got FDA approval in March.) Douglas Smith, the director of the Center for Brain Injury and Repair at the University of Pennsylvania, describes these nerve fibers as the electrical grid for the city that is the brain. “Having a concussion is like having a brownout,” he told me. The brain’s connections aren’t gone, “but the signals aren’t going through.” And long-term symptoms after a single concussion aren’t uncommon. They happen to roughly 20 percent of concussion patients, Smith said.

I rested again.

I read books about concussions, a few chapters at a time. Most described people being told that, because their CT scan showed nothing, nothing could be done for them. (Concussions rarely show up on imaging.) Or they described people being discharged from hospitals while their brains felt so broken, they could hardly speak. Conor Gormally, the executive director of Concussion Alliance, told me that he believes concussions are treatable injuries that just aren’t being treated by the average medical professional. “The biggest problem people face are barriers to the care that they need, which is out there,” he said.

I closed my eyes in the dark room.

Every time I would spend a little while awake and active, a sensation of pressure would build up behind my ears, in a way that made me feel like my brain was swelling. I’d always been able to push through feeling tired and keep working. Now I couldn’t. When I reached my limit, I’d hear buzzing, as though a bug was stuck inside my eardrums.

I rested again.

This went on for weeks. I started looking up treatments for concussions in my area and found page after page of listings for chiropractors or special centers that didn’t always take insurance but promised that they’d be able to fix my brain. I joined support groups on Facebook where patients shared what had and hadn’t worked for them. Sometimes the posts were hopeful—people got better—but many of the people who remained in the groups did so because years had gone by and they still had problems. What if I never recovered?

After five weeks with no answers, I started sobbing in the middle of the day. I’m a journalist who believes in evidence-based medicine, yet I found so few resources that I started looking into alternative therapy. At a particularly low point, I went to see a doctor whose website looked like it hadn’t been updated since the early 2000s. Over the phone, he’d made multiple mentions of “clean eating” and similar things that gave me pause. I ignored my misgivings because he’d also all but promised he could make me better. I wanted so badly to be myself again. He sold tablets that promised to fight 5G radiation at the front desk. I considered walking away then but didn’t. His alternative treatments, which included wearing tinted glasses and a blanket that blocked electric radiation, didn’t help. They did cost $500.

I went back to bed.

No one really knows how many people get mild traumatic brain injuries every year. Emergency- room data don’t capture everybody, Elizabeth Sandel, a brain-injury-medicine specialist and the author of Shaken Brain, told me, because “a lot of people just go to their primary-care doctor.” The statistic of 3.8 million Americans a year gets bandied about, sometimes linked to mild head injuries from sports and other times to brain injuries of all kinds. Falls, recreational activities, car crashes, and domestic violence all can cause head trauma.

One of the reasons a concussion is so hard to treat is that every brain injury is a little bit different. There are more than 30 concussion symptoms, Smith told me: Some people get severe headaches; others have troubles with cognition, balance, vision, and so on. The treatment might be different for each of these symptoms.

Until recently, Sandel said, doctors often recommended that people with a brain injury spend the first days “cocooning,” or resting in a dark room. Now experts better understand that, for some patients, resting may be beneficial, but for others activities that don’t overly exacerbate symptoms might speed healing. The latest guidelines for concussion recovery, which came out in October 2022, continue to shift toward suggesting better rehab, sooner. If dizziness, neck pain, or headaches persist after 10 days, the guidelines now recommend “cervicovestibular rehabilitation”—exactly the kind of therapy that ultimately helped me recover. It’s a combination of manual therapy on key muscles and rehab for the vestibular, or balance, system. Multiple studies have shown the benefits of this type of rehab, including a 2014 study that found that 73 percent of treated patients recovered after eight weeks, compared with 7 percent in the control group.

By the time I got an appointment at a multidisciplinary brain-injury-rehab center near where I lived, more than two months had passed. After a lot of phone calls with my eyes closed—I could focus longer if I limited external stimulation—I found a vestibular therapist. This kind of therapy focuses on restoring the balance system through a combination of physical and eye exercises. My eyes not working in tandem was a classic sign that this area needed rehab.

The therapist gave me exercises where I tracked my finger with my eyes to help them get back in sync. At my first appointment with him, I could hardly stand on one leg with my eyes open without falling over. After practicing the balance exercises he gave me for a few weeks, I could once again stand on one leg with my eyes closed.

Manual physiotherapy, especially for the back and neck, can help restabilize and strengthen muscles after an accident. For me, this meant targeted physical therapy, strengthening exercises, and visits to a specialized chiropractor who used X-rays and gentle adjustments to put my neck back where it belonged.

Some of the things I’d found through trial and error, like using a stationary bike for an hour each day, the brain-rehab center would have been recommended for me anyway. But long waitlists to get into places like that aren’t uncommon—and having the right doctors made a significant difference.

Soon I noticed my stamina increasing every day. The neighbor’s dog didn’t seem so loud anymore. I could drive for 20 minutes, and then a full hour. I could even talk on the phone with friends and family whom I hadn’t been able to connect with for months. I read or went outside and did not need to nap. I wasn’t recovered but, finally, I was recovering.

After three months, I began taking some writing assignments again. I’d been struggling to hold more than one thought in my head at a time, but now it was like my brain had rebooted. I was again the person I remembered.

Six months after falling off the horse, my final, lingering symptom—the feeling of pressure in my head when I’d been working for too long—went away. I recovered but was left wondering why it had taken so much time for me to be routed to the care that I needed. I’ll never know if I would have gotten better without it, but I suspect recovery would have, at the very least, taken much longer. Why had I—a patient with a brain injury—been the one sifting through scientific papers and online support groups rather than getting these referrals from my doctor? In our American health-care system, many patients are expected to be their own advocates, but in this case, when a better, clearer path to recovery is so well established, it seems like that should have been unnecessary.

I often think wistfully about returning to riding, but then think again of that one moment when I slipped from the saddle and the months it took to recover. We brush off the dangers of a single concussion, but sometimes one fall or bad knock to the head is all it takes to turn your life upside down.

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Tove Danovich

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October 6, 2023
Is It Long COVID, or Dementia, or Both?

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Nov. 28, 2022 – In early September, about a week after recovering from COVID-19, Barri Sanders went to the bank to pay a bill. But by mistake, she transferred a large amount of money from the wrong account.

“I’m talking about $20,000,” she says. “I had to go back [later] and fix it.”

Sanders, 83, had not had confusion like that before. Suddenly, the Albuquerque, NM, resident found herself looking up from a book and not remembering what she had just read. She would stand up from her chair and forget what she meant to do.

“I kind of thought it was just the aging process,” she says. Combined with sudden balance issues, insomnia, and a nagging postnasal drip, the overall effect was “subtle, but scary,” she says.

After 5 days of this, she went to bed and slept the whole night through. She woke up in the morning to find her balanced restored, her sinuses clear, and the mental fog gone. What she’d had, she realized, wasn’t a rapid start of dementia, but rather a mercifully short form of long COVID.

Somewhere between 22% and 32% of people who recover from COVID-19 get “brain fog,” a non-scientific term used to describe slow or sluggish thinking. While this is disturbing at any age, it can be particularly upsetting to older patients and their caregivers, who fear they’re having or witnessing not just an after-effect of a disease, but the start of a permanent loss of thinking skills. And some scientists are starting to confirm what doctors, patients, and their families can already see: Older patients who have had COVID-19 have a higher risk of getting dementia or, if they already have mental confusion, the illness may worsen their condition.

British scientists who studied medical records from around the world reported in the journal The Lancet Psychiatry in August that people who recovered from COVID-19 had a higher risk of problems with their thinking and dementia even after 2 years had passed.

Another 2022 study, published in the journal JAMA Neurology, looked at older COVID-19 patients for a year after they were discharged from hospitals in Wuhan, China. Compared with uninfected people, those who survived a severe case of COVID-19 were at higher risk for early onset, late-onset, and progressive decline in their thinking skills. Those who survived a mild infection were at a higher risk for early onset decline, the study found.

Eran Metzger, MD, an assistant professor of psychiatry at Beth Israel Deaconess Medical Center in Boston, says he’s noticed that COVID-19 makes some older patients confused, and their brains don’t regain their former clarity.

“We see a stepwise decline in their cognition during the COVID episode, and then they never get back up to their baseline,” says Metzger, medical director at Hebrew SeniorLife.

New research is beginning to back up such findings.

People who got COVID-19 were twice as likely to receive a diagnosis of Alzheimer’s disease in the 12 months after infection, compared to those who didn’t get COVID, according to a study published in the journal Nature in September, which analyzed the health care databases of the U.S. Department of Veterans Affairs.

Joshua Cahan, MD, a cognitive neurologist at Northwestern University, advises caution about applying such a specific label simply from a patient’s medical chart. After all, he notes, few patients get tested to confirm that they have the proteins linked to Alzheimer’s.

“Probably the most appropriate conclusion from that is that there’s an increased risk of dementia after a COVID infection,” he says, “but we don’t know whether it’s truly Alzheimer’s disease or not.”

There could be a number of reasons why COVID-19 triggers a decline in thinking skills, says Michelle Monje, MD, a neuroscientist and neuro-oncologist at Stanford University.

In a paper published in October in the journal Cell, Monje and her co-author, Akiko Iwasaki, PhD, a professor of immunobiology at Yale University, propose six possible triggers for brain fog caused by COVID: inflammation in the lungs and respiratory passages that leads to inflammation and dysregulation of the central nervous system; autoimmune reactions that damage the central nervous system; brain infection directly caused by the coronavirus (though, they note, this appears rare); a re-activation of a Epstein-Barr virus, which can lead to neuro-inflammation; triggered by the coronavirus; and/or complications from severe cases of COVID-19, possibly involving periods of low blood oxygen and multi-organ failure.

Scientific understanding of brain fog is “part of an emerging picture that inflammation elsewhere in the body can be transmitted to become inflammation in the brain,” Monje says. “And once there’s inflammation in the brain … that can dysregulate other cell types that normally support healthy cognitive function.”

One issue with the concept of brain fog is that, like the term itself, the condition can be tough to define for doctors and patients alike and hard, if not impossible, to capture on common cognition tests.

These days, patients often arrive at the Center of Excellence for Alzheimer’s Disease, in Syracuse, NY, complaining that they “don’t feel the same” as they did before contracting COVID-19, says Sharon Brangman, MD, the center’s director and the chair of the Geriatrics Department at Upstate Medical University.

But the evidence of diminished cognition just isn’t there.

“There’s nothing that we can find, objectively, that’s wrong with them,” she says. “They’re not severe enough to score low on mental status testing.”

But specialized, directed testing can find some probable signs, says Cahan, who evaluates patient cognition in a long COVID clinic at Northwestern University.

He often finds that his long COVID patients score in the low normal range on cognitive testing.

“Patients do have a complaint that something’s changed, and we don’t have prior testing,” he says. “So it’s possible that they were maybe in the high normal range or the superior range, but you just don’t know.”

He says he has seen very high-performing people, like lawyers, executives, PhDs, and other professionals, who have tests that might be interpreted as normal, but given their level of achievement, “you would expect [higher scores].”

Like Sanders, many of those who do have muddled thinking after a COVID infection return to their former mental status. A study published in the journal Brain Communications last January found that people who had recovered from COVID-19, even if they had a mild illness, were significantly more likely to have memory and other cognition issues in the months after infection. But after 9 months, the former COVID patients had returned to their normal level of cognition, the team at Britain’s University of Oxford reported.

Notably, though, the average age of the people in the study was 28.6.

At the Northwestern clinic, Cahan treats patients who have struggled with COVID-induced cognition issues for months or even years. A rehabilitation program involves working with patients to come up with ways to compensate for cognitive deficits – such as making lists – as well as brain exercises, Cahan says. Over time, patients may achieve a 75% to 85% improvement, he says.

Monje hopes that one day, science will come up with ways to fully reverse the decline.

“I think what is likely the most common contributor to brain fog is this neuro-inflammation, causing dysfunction of other cell types,” she says. “And, at least in the laboratory, we can rescue that in mouse models of chemotherapy brain fog, which gives me hope that we can rescue that for people.”

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November 28, 2022
Long COVID Experts: ‘So Incredibly Clear What’s at Stake’

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It’s estimated that more than a third of people who have had COVID-19 experience neurological complications such as brain fog that persist or develop 3 months after infection. And two thirds of so-called long haulers still have neurological symptoms after 6 months.

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October 18, 2022
Epidemic of Brain Fog? Long COVID’s Effects Worry Experts

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Oct. 11, 2022 – Weeks after Jeannie Volpe caught COVID-19 in November 2020, she could no longer do her job running sexual assault support groups in Anniston, AL, because she kept forgetting the details that survivors had shared with her. “People were telling me they were having to revisit their traumatic memories, which isn’t fair to anybody,” the 47-year-old says.

Volpe has been diagnosed with long-COVID autonomic dysfunction, which includes severe muscle pain, depression, anxiety, and a loss of thinking skills. Some of her symptoms are more commonly known as brain fog, and they’re among the most frequent problems reported by people who have long-term issues after a bout of COVID-19.

Many experts and medical professionals say they haven’t even begun to scratch the surface of what impact this will have in years to come.

“I’m very worried that we have an epidemic of neurologic dysfunction coming down the pike,” says Pamela Davis, MD, PhD, a research professor at Case Western Reserve University’s School of Medicine in Cleveland.

In the 2 years Volpe has been living with long COVID, her executive function – the mental processes that enable people to focus attention, retain information, and multitask – has been so diminished that she had to relearn to drive. One of the various doctors assessing her has suggested speech therapy to help Volpe relearn how to form words. “I can see the words I want to say in my mind, but I can’t make them come out of my mouth,” she says in a sluggish voice that gives away her condition.

All of those symptoms make it difficult for her to care for herself. Without a job and health insurance, Volpe says she’s researched assisted suicide in the states that allow it but has ultimately decided she wants to live.

“People tell you things like you should be grateful you survived it, and you should; but you shouldn’t expect somebody to not grieve after losing their autonomy, their career, their finances.”

The findings of researchers studying the brain effects of COVID-19 reinforce what people with long COVID have been dealing with from the start. Their experiences aren’t imaginary; they’re consistent with neurological disorders – including myalgic encephalomyelitis, also known as chronic fatigue syndrome, or ME/CFS – which carry much more weight in the public imagination than the term brain fog, which can often be used dismissively.

Studies have found that COVID-19 is linked to conditions such as strokes; seizures; and mood, memory, and movement disorders.

While there are still a lot of unanswered questions about exactly how COVID-19 impacts the brain and what the long-term effects are, there’s enough reason to suggest people should be trying to avoid both infection and reinfection until researchers get more answers.

Worldwide, it’s estimated that COVID-19 has contributed to more than 40 million new cases of neurological disorders, says Ziyad Al-Aly, MD, a clinical epidemiologist and long COVID researcher at Washington University in St. Louis. In his latest study of 14 million medical records of the U.S. Department of Veterans Affairs, the country’s largest integrated health care system, researchers found that regardless of age, gender, race, and lifestyle, people who have had COVID-19 are at a higher risk of getting a wide array of 44 neurological conditions after the first year of infection.

He noted that some of the conditions, such as headaches and mild decline in memory and sharpness, may improve and go away over time. But others that showed up, such as stroke, encephalitis (inflammation of the brain), and Guillain-Barre syndrome (a rare disorder in which the body’s immune system attacks the nerves), often lead to lasting damage. Al-Aly’s team found that neurological conditions were 7% more likely in those who had COVID-19 than in those who had never been infected.

What’s more, researchers noticed that compared with control groups, the risk of post-COVID thinking problems was more pronounced in people in their 30s, 40s, and 50s – a group that usually would be very unlikely to have these problems. For those over the age of 60, the risks stood out less because at that stage of life, such thinking problems aren’t as rare.

Another of study of the veterans’ system last year showed that COVID-19 survivors were at a 46% higher risk of considering suicide after 1 year.

“We need to be paying attention to this,” says Al-Aly. “What we’ve seen is really the tip of the iceberg.” He worries that millions of people, including youths, will lose out on employment and education while dealing with long-term disabilities – and the economic and societal implications of such a fallout. “What we will all be left with is the aftermath of sheer devastation in some people’s lives,” he says.

Igor Koralnik, MD, chief of neuro-infectious disease and global neurology at Northwestern University in Chicago, has been running a specialized long COVID clinic. His team published a paper in March 2021 detailing what they saw in their first 100 patients. “About half the population in the study missed at least 10 days of work. This is going to have persistent impact on the workforce,” Koralnik said in a podcast posted on the Northwestern website. “We have seen that not only patients have symptoms, but they have decreased quality of life.”

For older people and their caregivers, the risk of potential neurodegenerative diseases that the virus has shown to accelerate, such as dementia, are also a big concern. Alzheimer’s is already the fifth leading cause of death for people 65 and older.

In a recent study of more than 6 million people over the age of 65, Davis and her team at Case Western found the risk of Alzheimer’s in the year after COVID-19 increased by 50% to 80%. The chances were especially high for women older than 85.

To date, there are no good treatments for Alzheimer’s, yet total health care costs for long-term care and hospice services for people with dementia topped $300 billion in 2020. That doesn’t even include the related costs to families.

“The downstream effect of having someone with Alzheimer’s being taken care of by a family member can be devastating on everyone,” she says. “Sometimes the caregivers don’t weather that very well.”

When Davis’s own father got Alzheimer’s at age 86, her mother took care of him until she had a stroke one morning while making breakfast. Davis attributes the stroke to the stress of caregiving. That left Davis no choice but to seek housing where both her parents could get care.

Looking at the broader picture, Davis believes widespread isolation, loneliness, and grief during the pandemic, and the disease of COVID-19 itself, will continue to have a profound impact on psychiatric diagnoses. This in turn could trigger a wave of new substance abuse as a result of unchecked mental health problems.

Still, not all brain experts are jumping to worst-case scenarios, with a lot yet to be understood before sounding the alarm. Joanna Hellmuth, MD, a neurologist and researcher at the University of California, San Francisco, cautions against reading too much into early data, including any assumptions that COVID-19 causes neurodegeneration or irreversible damage in the brain.

Even with before-and-after brain scans by University of Oxford researchers that show structural changes to the brain after infection, she points out that they didn’t actually study the clinical symptoms of the people in the study, so it’s too soon to reach conclusions about associated cognitive problems.

“It’s an important piece of the puzzle, but we don’t know how that fits together with everything else,” says Hellmuth. “Some of my patients get better. … I haven’t seen a single person get worse since the pandemic started, and so I’m hopeful.”

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October 11, 2022
One of Long COVID’s Worst Symptoms Is Also Its Most Misunderstood

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On March 25, 2020, Hannah Davis was texting with two friends when she realized that she couldn’t understand one of their messages. In hindsight, that was the first sign that she had COVID-19. It was also her first experience with the phenomenon known as “brain fog,” and the moment when her old life contracted into her current one. She once worked in artificial intelligence and analyzed complex systems without hesitation, but now “runs into a mental wall” when faced with tasks as simple as filling out forms. Her memory, once vivid, feels frayed and fleeting. Former mundanities—buying food, making meals, cleaning up—can be agonizingly difficult. Her inner world—what she calls “the extras of thinking, like daydreaming, making plans, imagining”—is gone. The fog “is so encompassing,” she told me, “it affects every area of my life.” For more than 900 days, while other long-COVID symptoms have waxed and waned, her brain fog has never really lifted.

Of long COVID’s many possible symptoms, brain fog “is by far one of the most disabling and destructive,” Emma Ladds, a primary-care specialist from the University of Oxford, told me. It’s also among the most misunderstood. It wasn’t even included in the list of possible COVID symptoms when the coronavirus pandemic first began. But 20 to 30 percent of patients report brain fog three months after their initial infection, as do 65 to 85 percent of the long-haulers who stay sick for much longer. It can afflict people who were never ill enough to need a ventilator—or any hospital care. And it can affect young people in the prime of their mental lives.

Long-haulers with brain fog say that it’s like none of the things that people—including many medical professionals—jeeringly compare it to. It is more profound than the clouded thinking that accompanies hangovers, stress, or fatigue. For Davis, it has been distinct from and worse than her experience with ADHD. It is not psychosomatic, and involves real changes to the structure and chemistry of the brain. It is not a mood disorder: “If anyone is saying that this is due to depression and anxiety, they have no basis for that, and data suggest it might be the other direction,” Joanna Hellmuth, a neurologist at UC San Francisco, told me.

And despite its nebulous name, brain fog is not an umbrella term for every possible mental problem. At its core, Hellmuth said, it is almost always a disorder of “executive function”—the set of mental abilities that includes focusing attention, holding information in mind, and blocking out distractions. These skills are so foundational that when they crumble, much of a person’s cognitive edifice collapses. Anything involving concentration, multitasking, and planning—that is, almost everything important—becomes absurdly arduous. “It raises what are unconscious processes for healthy people to the level of conscious decision making,” Fiona Robertson, a writer based in Aberdeen, Scotland, told me.

For example, Robertson’s brain often loses focus mid-sentence, leading to what she jokingly calls “so-yeah syndrome”: “I forget what I’m saying, tail off, and go, ‘So, yeah …’” she said. Brain fog stopped Kristen Tjaden from driving, because she’d forget her destination en route. For more than a year, she couldn’t read, either, because making sense of a series of words had become too difficult. Angela Meriquez Vázquez told me it once took her two hours to schedule a meeting over email: She’d check her calendar, but the information would slip in the second it took to bring up her inbox. At her worst, she couldn’t unload a dishwasher, because identifying an object, remembering where it should go, and putting it there was too complicated.

Memory suffers, too, but in a different way from degenerative conditions like Alzheimer’s. The memories are there, but with executive function malfunctioning, the brain neither chooses the important things to store nor retrieves that information efficiently. Davis, who is part of the Patient-Led Research Collaborative, can remember facts from scientific papers, but not events. When she thinks of her loved ones, or her old life, they feel distant. “Moments that affected me don’t feel like they’re part of me anymore,” she said. “It feels like I am a void and I’m living in a void.”

Most people with brain fog are not so severely affected, and gradually improve with time. But even when people recover enough to work, they can struggle with minds that are less nimble than before. “We’re used to driving a sports car, and now we are left with a jalopy,” Vázquez said. In some professions, a jalopy won’t cut it. “I’ve had surgeons who can’t go back to surgery, because they need their executive function,” Monica Verduzco-Gutierrez, a rehabilitation specialist at UT Health San Antonio, told me.

Robertson, meanwhile, was studying theoretical physics in college when she first got sick, and her fog occluded a career path that was once brightly lit. “I used to sparkle, like I could pull these things together and start to see how the universe works,” she told me. “I’ve never been able to access that sensation again, and I miss it, every day, like an ache.” That loss of identity was as disruptive as the physical aspects of the disease, which “I always thought I could deal with … if I could just think properly,” Robertson said. “This is the thing that’s destabilized me most.”

Robertson predicted that the pandemic would trigger a wave of cognitive impairment in March 2020. Her brain fog began two decades earlier, likely with a different viral illness, but she developed the same executive-function impairments that long-haulers experience, which then worsened when she got COVID last year. That specific constellation of problems also befalls many people living with HIV, epileptics after seizures, cancer patients experiencing so-called chemo brain, and people with several complex chronic illnesses such as fibromyalgia. It’s part of the diagnostic criteria for myalgic encephalomyelitis, also known as chronic fatigue syndrome, or ME/CFS—a condition that Davis and many other long-haulers now have. Brain fog existed well before COVID, affecting many people whose conditions were stigmatized, dismissed, or neglected. “For all of those years, people just treated it like it’s not worth researching,” Robertson told me. “So many of us were told, Oh, it’s just a bit of a depression.”

Several clinicians I spoke with argued that the term brain fog makes the condition sound like a temporary inconvenience and deprives patients of the legitimacy that more medicalized language like cognitive impairment would bestow. But Aparna Nair, a historian of disability at the University of Oklahoma, noted that disability communities have used the term for decades, and there are many other reasons behind brain fog’s dismissal beyond terminology. (A surfeit of syllables didn’t stop fibromyalgia and myalgic encephalomyelitis from being trivialized.)

For example, Hellmuth noted that in her field of cognitive neurology, “virtually all the infrastructure and teaching” centers on degenerative diseases like Alzheimer’s, in which rogue proteins afflict elderly brains. Few researchers know that viruses can cause cognitive disorders in younger people, so few study their effects. “As a result, no one learns about it in medical school,” Hellmuth said. And because “there’s not a lot of humility in medicine, people end up blaming patients instead of looking for answers,” she said.

People with brain fog also excel at hiding it: None of the long-haulers I’ve interviewed sounded cognitively impaired. But at times when her speech is obviously sluggish, “nobody except my husband and mother see me,” Robertson said. The stigma that long-haulers experience also motivates them to present as normal in social situations or doctor appointments, which compounds the mistaken sense that they’re less impaired than they claim—and can be debilitatingly draining. “They’ll do what is asked of them when you’re testing them, and your results will say they were normal,” David Putrino, who leads a long-COVID rehabilitation clinic at Mount Sinai, told me. “It’s only if you check in on them two days later that you’ll see you’ve wrecked them for a week.”

“We also don’t have the right tools for measuring brain fog,” Putrino said. Doctors often use the Montreal Cognitive Assessment, which was designed to uncover extreme mental problems in elderly people with dementia, and “isn’t validated for anyone under age 55,” Hellmuth told me. Even a person with severe brain fog can ace it. More sophisticated tests exist, but they still compare people with the population average rather than their previous baseline. “A high-functioning person with a decline in their abilities who falls within the normal range is told they don’t have a problem,” Hellmuth said.

This pattern exists for many long-COVID symptoms: Doctors order inappropriate or overly simplistic tests, whose negative results are used to discredit patients’ genuine symptoms. It doesn’t help that brain fog (and long COVID more generally) disproportionately affects women, who have a long history of being labeled as emotional or hysterical by the medical establishment. But every patient with brain fog “tells me the exact same story of executive-function symptoms,” Hellmuth said. “If people were making this up, the clinical narrative wouldn’t be the same.”

Earlier this year, a team of British researchers rendered the invisible nature of brain fog in the stark black-and-white imagery of MRI scans. Gwenaëlle Douaud at the University of Oxford and her colleagues analyzed data from the UK Biobank study, which had regularly scanned the brains of hundreds of volunteers for years prior to the pandemic. When some of those volunteers caught COVID, the team could compare their after scans to the before ones. They found that even mild infections can slightly shrink the brain and reduce the thickness of its neuron-rich gray matter. At their worst, these changes were comparable to a decade of aging. They were especially pronounced in areas such as the parahippocampal gyrus, which is important for encoding and retrieving memories, and the orbitofrontal cortex, which is important for executive function. They were still apparent in people who hadn’t been hospitalized. And they were accompanied by cognitive problems.

Although SARS-CoV-2, the coronavirus that causes COVID, can enter and infect the central nervous system, it doesn’t do so efficiently, persistently, or frequently, Michelle Monje, a neuro-oncologist at Stanford, told me. Instead, she thinks that in most cases the virus harms the brain without directly infecting it. She and her colleagues recently showed that when mice experience mild bouts of COVID, inflammatory chemicals can travel from the lungs to the brain, where they disrupt cells called microglia. Normally, microglia act as groundskeepers, supporting neurons by pruning unnecessary connections and cleaning unwanted debris. When inflamed, their efforts become overenthusiastic and destructive. In their presence, the hippocampus—a region crucial for memory—produces fewer fresh neurons, while many existing neurons lose their insulating coats, so electric signals now course along these cells more slowly. These are the same changes that Monje sees in cancer patients with “chemo fog.” And although she and her team did their COVID experiments in mice, they found high levels of the same inflammatory chemicals in long-haulers with brain fog.

Monje suspects that neuro-inflammation is “probably the most common way” that COVID results in brain fog, but that there are likely many such routes. COVID could possibly trigger autoimmune problems in which the immune system mistakenly attacks the nervous system, or reactivate dormant viruses such as Epstein-Barr virus, which has been linked to conditions including ME/CFS and multiple sclerosis. By damaging blood vessels and filling them with small clots, COVID also throttles the brain’s blood supply, depriving this most energetically demanding of organs of oxygen and fuel. This oxygen shortfall isn’t stark enough to kill neurons or send people to an ICU, but “the brain isn’t getting what it needs to fire on all cylinders,” Putrino told me. (The severe oxygen deprivation that forces some people with COVID into critical care causes different cognitive problems than what most long-haulers experience.)

None of these explanations is set in stone, but they can collectively make sense of brain fog’s features. A lack of oxygen would affect sophisticated and energy-dependent cognitive tasks first, which explains why executive function and language “are the first ones to go,” Putrino said. Without insulating coats, neurons work more slowly, which explains why many long-haulers feel that their processing speed is shot: “You’re losing the thing that facilitates fast neural connection between brain regions,” Monje said. These problems can be exacerbated or mitigated by factors such as sleep and rest, which explains why many people with brain fog have good days and bad days. And although other respiratory viruses can wreak inflammatory havoc on the brain, SARS-CoV-2 does so more potently than, say, influenza, which explains both why people such as Robertson developed brain fog long before the current pandemic and why the symptom is especially prominent among COVID long-haulers.

Perhaps the most important implication of this emerging science is that brain fog is “potentially reversible,” Monje said. If the symptom was the work of a persistent brain infection, or the mass death of neurons following severe oxygen starvation, it would be hard to undo. But neuroinflammation isn’t destiny. Cancer researchers, for example, have developed drugs that can calm berserk microglia in mice and restore their cognitive abilities; some are being tested in early clinical trials. “I’m hopeful that we’ll find the same to be true in COVID,” she said.

Biomedical advances might take years to arrive, but long-haulers need help with brain fog now. Absent cures, most approaches to treatment are about helping people manage their symptoms. Sounder sleep, healthy eating, and other generic lifestyle changes can make the condition more tolerable. Breathing and relaxation techniques can help people through bad flare-ups; speech therapy can help those with problems finding words. Some over-the-counter medications such as antihistamines can ease inflammatory symptoms, while stimulants can boost lagging concentration.

“Some people spontaneously recover back to baseline,” Hellmuth told me, “but two and a half years on, a lot of patients I see are no better.” And between these extremes lies perhaps the largest group of long-haulers—those whose brain fog has improved but not vanished, and who can “maintain a relatively normal life, but only after making serious accommodations,” Putrino said. Long recovery periods and a slew of lifehacks make regular living possible, but more slowly and at higher cost.

Kristen Tjaden can read again, albeit for short bursts followed by long rests, but hasn’t returned to work. Angela Meriquez Vázquez can work but can’t multitask or process meetings in real time. Julia Moore Vogel, who helps lead a large biomedical research program, can muster enough executive function for her job, but “almost everything else in my life I’ve cut out to make room for that,” she told me. “I only leave the house or socialize once a week.” And she rarely talks about these problems openly because “in my field, your brain is your currency,” she said. “I know my value in many people’s eyes will be diminished by knowing that I have these cognitive challenges.”

Patients struggle to make peace with how much they’ve changed and the stigma associated with it, regardless of where they end up. Their desperation to return to normal can be dangerous, especially when combined with cultural norms around pressing on through challenges and post-exertional malaise—severe crashes in which all symptoms worsen after even minor physical or mental exertion. Many long-haulers try to push themselves back to work and instead “push themselves into a crash,” Robertson told me. When she tried to force her way to normalcy, she became mostly housebound for a year, needing full-time care. Even now, if she tries to concentrate in the middle of a bad day, “I end up with a physical reaction of exhaustion and pain, like I’ve run a marathon,” she said.

Post-exertional malaise is so common among long-haulers that “exercise as a treatment is inappropriate for people with long COVID,” Putrino said. Even brain-training games—which have questionable value but are often mentioned as potential treatments for brain fog—must be very carefully rationed because mental exertion is physical exertion. People with ME/CFS learned this lesson the hard way, and fought hard to get exercise therapy, once commonly prescribed for the condition, to be removed from official guidance in the U.S. and U.K. They’ve also learned the value of pacing—carefully sensing and managing their energy levels to avoid crashes.

Vogel does this with a wearable that tracks her heart rate, sleep, activity, and stress as a proxy for her energy levels; if they feel low, she forces herself to rest—cognitively as well as physically. Checking social media or responding to emails do not count. In those moments, “you have to accept that you have this medical crisis and the best thing you can do is literally nothing,” she said. When stuck in a fog, sometimes the only option is to stand still.

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Ed Yong

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September 12, 2022