Post-acute COVID-19 Syndrome: Brain Fog Phenotype, Patient-Centric Understanding, and Biopsychosocial-Oriented Treatment

Abstract

Post-acute COVID-19 syndrome (PACS), a term used to describe ongoing symptoms after SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2) (COVID-19) infection, includes prominent neuropsychological sequela, such as a subjective sense of brain fog. Brain fog can be persistent and interfere with quality of life and daily functioning across multiple domains. Rehabilitation professionals can comprehensively address PACS-related brain fog through a biopsychosocial framework of chronic illness. Through emphasizing a patient-centric perspective, rehabilitation practitioners can understand lifestyle protective factors, as well as the reciprocal relationships between emotional processing and behaviors that potentially maintain symptomology manifesting as brain fog. However, current practice models do not fully address the biopsychosocial components for adults suffering from PACS-related brain fog. To address gaps in the literature, we present a biopsychosocial framework for PACS-related brain fog and provide treatment strategies based on evidence from current literature of neuropsychiatric sequela of mild traumatic brain injury. These recommendations will provide practice guidance to rehabilitation professionals in (1) identifying common protective factors that can be optimized in the context of persistent PACS-related brain fog and (2) addressing these symptoms via integrative interventions, considering the biopsychosocial presentation of brain fog.

Keywords

Biopsychosocial model; Brain fog; Patient-centered treatment; Rehabilitation

List of Abbreviations

  • mTBI: mild traumatic brain injury
  • PACS: post-acute COVID-19 syndrome
  • TBI: traumatic brain injury

Brain Fog Overview

Brain fog is a constellation of subjective symptoms influenced by reactive emotions and mood factors, which include variable attentional and working memory, slowed processing speed, and mental and physical fatigue.1,2 This phenomenon has been reported in many medical conditions involving chronic neuroinflammation and has been associated with chronic fatigue syndrome, mild traumatic brain injury (TBI), and treatments that affect immune system functioning (ie, chemotherapy).3,4 Brain fog has also been identified as a core component of post-acute COVID-19 syndrome (PACS), a term used to describe ongoing symptoms after SARS-CoV-2 (COVID-19) infection. Although the literature is still in its relative infancy, up to 81% of those with “long haul COVID” endorse brain fog as a core residual complaint.5–8 Li et al9 employed a machine learning analysis of heterogeneous symptoms of PACS to identify a brain fog subphenotype characterized by diminutions in cognitive performance, pain, psychological distress, headaches, and sleep and mood disorders.

Improved understanding of brain fog as a core feature of PACS could facilitate the development of more precise multidisciplinary rehabilitation interventions, ultimately leading to improved functioning for individuals with this brain fog subtype.6,10 From a patient perspective, improved awareness of the often cyclical relationship between the physical symptoms of brain fog, coupled with frequent, unpredictable shifts in cognitive capability, can foster patient awareness and promote a deeper understanding of a broader clinical context, thereby enhancing patient engagement and collaboration in care. Moreover, a patient’s experiential perspective of brain fog can further guide the clinical understanding of cardinal elements of brain fog and be used to identify treatment targets.

Risk Factors for PACS-Related Brain Fog

Preexisting physical and demographic risk factors have been identified for PACS-related neurocognitive dysfunction, including respiratory, gastrointestinal, psychiatric, and autoimmune disease.11,12 In a meta-analysis involving 41 papers and 860,783 participants, additional factors such as female sex, age, high body mass index, and smoking were also noted.13 According to Asadi-Pooya et al,6 other risk factors potentially associated with PACS-related “brain fog” include sex (female), age, length of hospital stay, respiratory problems at onset, neurologic problems at onset, gastrointestinal problems at onset, preexisting chronic medical problems, and ICU (intensive care unit) admission. Older age at the time of infection (>60), chronic preexisting conditions, SARS-CoV-2 RNA, Epstein–Barr virus, increased levels of inflammatory markers, and specific autoantibodies are additional risk factors for psychiatric-related PACS.14 Based on health records of 1,180,948 participants, preexisting mood disorders such as bipolar or psychotic disorders and substance use disorders were revealed as risk factors for the development of PACS-related psychiatric disorders.15 Consistently, preexisting mental health diagnoses were independently associated with subjective neurocognitive impairment, specifically brain fog, at 8 months postinfection.16

Genetic risk factors for developing PACS, including a specific set of 73 genes mostly associated with neurologic and cardiometabolic conditions, have also been identified.17 There is an overlap at the molecular level between PACS and the pathophysiological mechanisms associated with age-related neurodegenerative conditions such as Alzheimer disease.18 Given that treatment responses in Alzheimer disease are often modulated by apolipoprotein E genotype, particularly the apolipoprotein E ε4 allele, it is beneficial to account for genetic factors such as apolipoprotein E ε4 in the development and evaluation of therapeutic strategies for PACS.19

Although less is known regarding specific biomarkers of PACS-related brain fog, higher levels of the protein S100β within the blood–brain barrier have been identified, implying that a “leaky” blood–brain barrier may be present in those with PACS-related brain fog.20,21 Furthermore, distinct biomarker profiles predict cognitive outcomes in PACS, including elevated fibrinogen relative to C-reactive protein.22 Increased understanding of the role of genetic and environmental risk factors in PACS-related brain fog will facilitate the development and testing of new therapeutic biologics.

The Biopsychosocial Approach to Brain Fog

Once the patient’s risk factors (ie, medical, demographic, psychiatric, genetic, presence or absence of key biomarkers, if available) and individualized symptom profile have been established, a patient’s lived experience of brain fog can also be used by clinicians to identify treatment targets addressed via a multidisciplinary team approach.23 Application of a biopsychosocial conceptual framework in this manner facilitates an improved, comprehensive understanding of the interaction between neuroinflammation, cognitive variability, emotional responses, and external stressors, which contributes to symptom severity and persistence. Specifically, in the context of PACS-related brain fog, the biopsychosocial cycle highlights the presence of mental fatigue contributing to diminished attention and processing, thereby adversely impacting work capacity and increasing errors.2 In turn, the patient’s subjective, lived experience of these cascading effects contributes to a diminished sense of self, reduced engagement, and increased anxiety, thereby exacerbating physical discomfort and sleep difficulties.2 Using a consistent biopsychosocial approach in the treatment of PACS-related brain fog by multiple providers (ie, psychologists, physical therapists, speech therapists, occupational therapists) aimed at disrupting this negative feedback loop can shift patients’ perspectives from an externally focused, disease-based model toward an internally empowered, actionable framework for improving functioning.

Self-report questionnaires allow the assessment of a patient’s perception of neurocognitive insufficiency and, by extension, provide the opportunity to address cognitive distortions.24 Depressive responses to one’s own health challenges (eg, self-blame, perceived stigma, felt loss of professional identity, loss of relationships) can limit engagement in all aspects of life, regardless of the condition’s etiology.25 These challenges exacerbate stress and anxiety, which can, in turn, increase behavioral avoidance and social isolation. Both neurocognitive and affective dysfunction should ideally be addressed in terms of patients’ lived experiences in personal, social, and occupational contexts.25 This patient-centered approach serves as a precedent for the care of patients with PACS-related brain fog.

It is also critical to examine a patient’s specific manifestations of brain fog through the lens of other central nervous system disorders that share overlapping cognitive and psychiatric features, such as mild traumatic brain injury (mTBI), in order to facilitate evidence-driven care for individuals with PACS-related brain fog.4,26 While PACS involves distinct pathophysiological mechanisms, including immune dysregulation and chronic inflammation not typical in mTBI, comparing and contrasting the psychological experience and sequelae central to this latter diagnosis may be useful in deriving a conceptual framework to understand the lived experience and functional consequences of PACS-related brain fog, enhancing interdisciplinary treatment planning and the utilization of rehabilitation strategies.

Comparative Discussion: mTBI and PACS

To illustrate, acute symptom awareness or hypervigilance, coupled with negative interpretation of physiological concerns, is a commonality across patients with mTBI and PACS. Extant mTBI literature reveals that patients often retain greater self-awareness of their cognitive difficulties, which can heighten emotional distress.27 By contrast, individuals with more severe TBI may have diminished insight because of structural brain injury, leading to underreporting of symptoms. Symptom awareness and negative interpretation of cognitive fluctuations may contribute to emotional distress and functional impairment, though such occurrences may be secondary to biological factors such as inflammation and blood–brain barrier disruption in PACS.28,29

Moreover, in both mTBI and PACS, there is a complex interplay between a variety of illness-related and contextual factors.30 While some patients present with objective deficits on standardized cognitive testing, others report cognitive challenges that may not be captured by formal metrics. Both profiles are valid and require specialized clinical understanding and tailored clinician responses. To this end, it is critical to garner the patient’s perspective on the drivers of cognitive dysfunction arising from brain fog when setting collaborative treatment goals.29 In case studies, this collaborative approach yielded individualized goals that were meaningful to patients through the inclusion of both self-reported deficits and objective test findings.4 Furthermore, the lived experience of patients with PACS should be accepted and validated by clinicians as a point of entry into a treatment relationship, thereby providing a motivating and validating foundation for subsequent treatment sessions. This general approach has been used with success in treating persons with persistent symptoms after mild TBI. Given the important effect of psychosocial factors on recovery in this population, a collaborative interdisciplinary approach—incorporating both psychosocial and medical dimensions—has been shown to enhance treatment outcomes.31,32

In both mTBI and PACS-related brain fog, patients’ engagement with treatment is shaped by the personal meaning they assign to their perceived cognitive impairment. Venkatesan and Ramanathan-Elion26 conceptualized that, for patients with mTBI, initial treatment should not focus solely on the head injury but rather on their historical accumulations of negative beliefs and their effect on affective and physiological states. To this end, clinical relationships emphasizing personalized psychoeducation or individually tailored “myth-busting” that explicitly elucidates the patient’s relationship between belief systems and behavior patterns represent a critical first step in the treatment process.26

Patients with PACS-related brain fog frequently express catastrophic or inflexible beliefs such as “I’ll never get better,” “This symptom means I have permanent brain damage,” or “I can’t trust my mind anymore.” These statements, anecdotally described by the authors (H.A.B., N.A.W., J.M.B., F.C., F.M.B., T.B., Y.B., E.C., J.R., A.D.L., A.S-Z.), reflect core beliefs that influence behavioral engagement, emotional responses, and functional outcomes. Highlighting the connection between belief systems, interpretation of symptoms, and behaviors in this population is a primary treatment target. Further, these authors recommend that psychoeducation include guidance toward evaluating progress gradually in relation to the weakest postinfection or postinjury functioning, rather than premorbid functioning. Such psychoeducation can help address the effects of comparing pre- and post-illness functioning and mood on symptom perception and recovery, as has been found in individuals with persistent symptoms after mild TBI.33,34

Likewise, patient perception of neurocognitive symptoms such as brain fog or cognitive fatigue has a substantial effect on treatment engagement, influencing motivation, adherence to clinical recommendations, and therapy participation post–COVID-19 infection.35 By extrapolating clinical treatment elements used in mTBI—where neurocognitive insufficiency is a key element—an empirically informed treatment protocol can begin to be derived for PACS-related brain fog.

Lifestyle and Protective Factors

Preexisting healthy lifestyle behaviors (eg, weight, diet, exercise, sleep) reduce the risk of developing long COVID in general and, by extension, PACS-related brain fog.36 Although research specific to PACS has yet to be completed, individuals with greater happiness, life satisfaction, balanced affect, a sense of meaning and purpose, and positive social relationships may be more likely to exhibit resilience in the face of challenges, thereby reducing susceptibility to brain fog.37 Stress-alleviating coping mechanisms also foster resilience. For example, individuals with premorbid robust executive functioning, innate optimism, and effective emotional regulation may demonstrate positive coping through adaptive stress appraisal and response selection, contributing to cognitive resilience, better health, and improved quality of life in the context of PACS-related brain fog.38

Once again, drawing from the literature on persons with mTBI, there is a complex interplay between medical condition and personality traits impacting symptom maintenance and persistence. Interestingly, some personality factors often viewed positively—such as being highly motivated, self-disciplined, efficient, hard-working, and organized—may correlate with stronger negative reactions, potentially contributing to PACS-related brain fog and diminished functionality.39 The unexpected relationship between these traits and poorer outcomes suggests that the interplay among preexisting lifestyle behaviors, personality, and psychosocial attributes on symptom manifestation and functional status remains poorly understood. The relationship between psychological factors and recovery outcomes also warrants further refinement, both in mTBI and other medical conditions.40

In addition to unique personality characteristics, an individual’s premorbid repertoire of cognitive strategies (ie, organizational, cognitive/behavioral, and emotion-focused) may inform coping responses to brain fog. For example, the use of organizational strategies such as maintaining written notes can help prioritize daily responsibilities, manage time, offset memory deficits, improve concentration, and identify symptom patterns over time.41 These strategies are also recommended by the International Interdisciplinary Special Interest Group–Post Infectious Conditions Task Force (formerly known as the COVID-19 Task Force) of the American Congress of Rehabilitation Medicine for managing the cognitive and emotional effects of COVID-19 across the recovery continuum. Implementing these strategies early in the course of PACS-related brain fog may increase a patient’s internal locus of control and potentially ameliorate chronic symptom effects.42

For rehabilitation professionals, leveraging an individual’s preexisting strengths and baseline characteristics—while eliciting their sense of purpose and sources of meaning and positivity—can inform and personalize treatment targets, enhancing overall therapy engagement and outcomes.

Patient-Centered Treatment Approach of PACS-Related Brain Fog

PACS-related brain fog requires the identification of specific treatment targets aimed at enhancing the efficacy of neurorehabilitation. While much of this can be informed by existing evidence-based treatment literature for mild traumatic brain injury (mTBI), the commonalities and differences with PACS must first be identified and appreciated.43 Broadly, psychoeducation is often the first step to guide patient understanding within a medicalized context and to foster a shift toward a biopsychosocial conceptualization of symptom—and treatment—management.

Psychoeducation forms the foundation of the patient-centered treatment approach for PACS-related brain fog, reframing symptoms within a biopsychosocial model. Patients are introduced to the idea that cognitive symptoms arise from the interaction of biological, psychological, and behavioral factors, helping to reduce stigma and promote a comprehensive understanding of their condition.44,45 Because brain fog is multidimensional and often intensified by emotional factors, early psychoeducation should empower patients to become active agents of change in their own recovery. Treatment anchored in the biopsychosocial model—particularly in early stages—should involve a patient’s understanding of experiential factors, emotional triggers, and the relationship between emotions and physical symptomology.

Table 1. Sequence of Patient-Centered Treatment Strategies for Post-Acute COVID-19 Syndrome–Related Brain Fog

Sequence of Patient-Centered Treatment Strategies Examples
First – Psychoeducation Educate the patient regarding how biological, psychological, and behavioral factors interact to influence brain fog to normalize symptoms, encourage a proactive role in treatment, and frame compensatory tools and pacing techniques as evidence-informed strategies to support brain function and reduce disability.
Second – Examination of Thought Patterns Identify negative thought patterns regarding sense of self, neurocognitive functioning, and interpretation of symptoms contributing to avoidance.
Third – Thought Modification Use active questioning and modification of thought patterns that contribute to beliefs of permanency and consistency of neurocognitive insufficiency.
Fourth – Attentional Control and Metacognitive Strategies Use predesigned templates or task sequencing prior to engagement to facilitate task performance “through” brain fog episodes.
Fifth – Behavioral Strategies Create action plans of scheduled activities with pacing across weeks and predetermined “brain breaks” throughout the day.

Concurrent treatment elements such as self-monitoring, self-understanding, and experience-driven neuroplasticity are all key components. Experience-driven neuroplasticity—the nervous system’s capacity to reorganize itself through practice, learning, and environmental engagement—can be enhanced through behavioral activation and targeted interventions designed to strengthen cognitive domains commonly affected by brain fog, such as attention and memory retrieval.46,47

Once a patient-centered locus of control is established, awareness and modification of maladaptive thought patterns and belief systems can reduce avoidance behaviors and functional disability. Systematic questioning through thought modification can mitigate patients’ perceptions of chronic, unpredictable neurocognitive insufficiency. Maintaining a focus on desired outcomes and framing compensatory strategies as “strategic tools” rather than indicators of impairment can lessen self-blame and improve treatment adherence. Behavioral action plans that incorporate consistent, meaningful activity—independent of cognitive fluctuation—encourage pacing, endurance, and recovery consistency.

Future research is needed to isolate and evaluate specific active components of patient-centered treatment, as well as to determine optimal sequencing and duration for each module. A multidisciplinary rehabilitation team—composed of physical therapists, occupational therapists, speech–language pathologists, and psychologists—should collaborate to align therapeutic approaches based on biopsychosocial principles. For example, if a psychologist identifies anxiety as a factor contributing to brain fog, a speech therapist or physical therapist might provide breathing and mindfulness exercises to modulate stress and enhance attention. Regular team meetings allow shared evaluation findings and coordinated treatment progress, a model promoted by Waldron-Perrine et al,48 to optimize outcomes.

Advances in patient-specific communication channels further enable integrated team-based goal setting grounded in the biopsychosocial model. This coordinated approach encourages consistent reinforcement of cognitive awareness, behavioral pacing, and emotional regulation across all disciplines—creating a cohesive and holistic treatment plan. Ultimately, multidisciplinary rehabilitation fosters acceptance of baseline changes due to PACS while supporting self-compassion and functional adaptation.

Conclusion

While implementing sequential and comprehensive biopsychosocial treatment plans presents challenges—such as limited resources, clinician training gaps, and patient readiness—this model has the potential to become a standard of care. By promoting interdisciplinary cross-training, establishing efficient clinical communication systems, and developing standardized clinical protocols rooted in the biopsychosocial model, clinicians can empower patients to understand and address modifiable factors contributing to their brain fog.

As a future direction, the International Interdisciplinary Special Interest Group proposes the development of a standardized treatment reference manual to support clinicians practicing this model across diverse health care settings. Once established, such a protocol for PACS-related brain fog could serve as a foundation for addressing brain fog in other postinfectious syndromes, further advancing rehabilitation science and patient-centered recovery.

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