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When your brain is expending all its energy keeping your balance, there isn’t a lot left over for other cognitive processes. As a result, many vestibular patients struggle with attention, concentration, and memory, and may feel disoriented and confused. Activities that were automatic, that you never had to even think twice about, now have to be meticulously focused on and thought about. Thankfully, there are ways to combat and overcome these difficulties and improve functioning.
These disorders are variable not only in their physical manifestation, but in their psychological manifestation as well. And while it is important to understand physical symptoms, it is equally important to understand the cognitive symptoms of vestibular disorders and their impacts on physical symptoms.
Cognitive is just a fancy word for thinking. When I use the phrase cognitive aspects of vestibular disorders I am referring to how your vestibular disorder affects your ability to think, specifically to pay attention and concentrate, to remember, to reason and to problem solve.
Disorientation and confusion are common during the acute states of vestibular disorders. In these very frightening and disturbing moments, knowing who and where you are, the time of day, etc. may not be readily available to you. Fortunately, these moments are relatively short-lived. As the physical symptoms fade, clarity and comprehension return.
Cognitive energy is finite for everyone. If you are using a great deal of this energy to maintain equilibrium and stay steady (something that is normally done automatically), it is unlikely that you will have very much left over for other activities. As a result, cognitive fatigue sets in. Activities that you used to be able to perform with ease and very little effort now require much more effort, leaving you drained of energy and requiring rest/naps. Spontaneity goes right out the window.
Vestibular disorders interfere with your ability to pay attention and concentrate. You may find that it is difficult to sustain focus for a significant length of time. You may find you are easily distracted – both by external stimuli (the noise of other people talking, the TV) and internal stimuli (your thoughts and feelings). Multi-tasking, the ability to do and keep track of two processes at the same time can also be compromised. Another area of attention/concentration that is often affected in people that have vestibular disorders is sequencing. For example: you may find yourself mixing up sounds while speaking, or reversing numbers or letters when speaking or writing. You may have trouble following directions, filling out forms, following a recipe, or tracking conversation or plot in a movie.
Due to the intricate link between the vestibular system and the visual system, problems with visual-spatial tasks are common in people suffering from vestibular disorders. Eye-hand coordination may not be very coordinated, depth perception may also be thrown off-course.
The most common cognitive complaint I have heard in my clinical experience working with people suffering from vestibular disorders has been difficulties with memory. And the problem seems to be more with short-term memory (remembering what you had for breakfast this morning) rather than long-term memory (recalling the name of your best childhood friend). Often, but not always, what is perceived as a memory problem is really a problem with attention. I like to use a bank model of memory to explain this phenomenon. In order to deposit money into your bank account, there are a series of steps that you need to execute in order to ensure your money is properly deposited so that at some later date, it will be there for you to withdraw. The same is true for your brain and processing information to be stored in memory. There are specific steps it goes through to ensure that information gets “deposited” so that it is available for retrieval or “withdrawal” at some later point. At the bank as well as in your brain, if the steps are not followed properly, the money/information gets lost and thus is not available for future use. The cognitive strain of a vestibular disorder can interfere with this “depositing” or encoding process of information. As such, if the information is never properly encoded, there is no way it will be available at some later date for retrieval.
Imagine that sitting just inside your forehead is a very important person sitting at a very large desk. This person is the executive of your brain, the person in charge of managing, overseeing and coordinating all the functions of your brain. Specifically, this person is responsible for organization, problem-solving, decision-making and self-monitoring. In addition, this person provides you with a sense of internal certainty, that thoughts get organized and plans get executed, seemingly automatically. These abilities are referred to as executive functioning. Unfortunately, in the presence of a vestibular disorder, your executive functioning may not be functioning very well. This person is asleep under the desk! Overworked, under-resourced, he/she is just too overwhelmed, and this automaticity that you so readily rely on is gone. Plans, even the simplest ones, such as getting yourself dressed in the morning may be completely disorganized…and disorganizing. You may find it difficult deciding what to have for breakfast. Activities that were automatic, that you never had to even think twice about, now have to be meticulously focused on and thought about.
The difficulties described above can, and unfortunately often do, significantly interfere with day-to-day life. In response to these cognitive changes you may feel that your abilities have diminished, both at home and at work. However, it is not your abilities that are diminished. It is your cognitive stamina that is depleted because it is being used for a function that, prior to having a vestibular disorder, it didn’t need to be used for in the past. Reading is laborious, using the computer is painful and frustrating, balancing your checkbook is near impossible. Or if it is possible, you are doing things very differently than you did before. For example, you may find you operate at a slower pace, needing a lot more time to accomplish tasks than you used to, or with help from others. You may have found a more simplistic approach to accomplishing tasks, one that gets the job done but not nearly as satisfactorily. You may also have trouble navigating large supermarkets or department stores.
Thankfully, there are ways to combat and overcome these difficulties and improve functioning. The chart below pairs each problem area discussed above with a variety of coping skills you can utilize to minimize and/or compensate for these difficulties. Rest, proper nutrition and appropriate exercise are also key components to managing areas of cognitive difficulty.
Participating in treatment offers individualized attention to your specific problem areas while also providing normalization, validation and support. Sometimes professional help begins with a neuropsychological evaluation. This evaluation can provide detailed information about your cognitive functions. It identifies your strengths and weaknesses, areas in which you are functioning normally and areas in which you are having problems. With the results of this evaluation, treatment recommendations are made, usually for a course of cognitive rehabilitation. Cognitive rehabilitation can be done by an occupational therapist, a speech therapist or a psychologist. A first step is increasing awareness and self-monitoring of difficulties. Once problems are clearly identified and understood, there are two routes available: (1) cognitive retraining (a physical therapy for the brain) to remediate problem areas and (2) learning compensatory strategies. In cognitive retraining, skills (such as attention and concentration) are practiced and strengthened through a variety of exercises. Learning compensatory strategies involves utilizing strengths to overcome weaknesses, and developing a “bag of tricks” that you can employ to get around problem areas.
Author: Dr. Rachel Bilgrei, PsyD
Vertigo and Psychological Disturbances by Vestibular Expert Dr. Timothy C. Hains, MD
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