Cognitive Deficits
Cognitive Deficits
Understanding potential changes involved in cognition associated with people with bipolar disorder
One of the most overlooked aspects of people with bipolar disorder is the potential for developing a degree of cognitive deficit as part of the illness. This omission reflects the reality that mainstream medias portrayal of someone with bipolar disorder mostly focuses on the cycling of elevated and/or depressed moods which are the benchmark features of the disorder.
What we typically read are descriptions of mood elevation that reflect symptoms of higher energy, a lessened need for sleep, feelings of euphoria or happiness, grandiosity or narcissism, impulsivity, elevated libido, etc. Similarly, on the depressed end of the spectrum, we read descriptions of lowered energy, lowered self esteem , feelings of sadness, loss or emptiness, suicidal ideation, extreme pessimism , lowered motivation, and all the other symptoms we associate with feeling depressed. Moods typically receive the bulk of our attention when it comes to its descriptions and discussions of bipolar disorder; however, its common to hear concerns about their lessened cognitive capacities. Im referring to the experience of decreased cognitive capacity relative to the period of time before any sustained bipolar mood symptoms arrived on the scene.
Examples of the kinds of deficits reported are difficulties with word retrieval, difficulties with planning, executive functioning, problems with retaining whats been read or listened to, as well as the experience of mildly dulled or slowed thought processes. For some with bipolar disorder, its like theyve experienced a gradual and continual decline of brain power from their previous baseline level of function.
The key word in the preceding sentence is some. The research literature poses a wide range of figures pertaining to cognitive deficit in bipolar disorder, with studies showing incidence rates between 15% on the low end and 60 % on the high end. Granted, this broad a range doesnt tell us much. Research samples that vary widely in relation to the subjects age, symptom acuity, presence of comorbidity and differences in prior treatment backgrounds do offer different findings.
A key conclusion supported by numerous research articles is that there appears to be a positive connection between the presence of cognitive deficit and higher acuity bipolar symptoms. This means that those with a history of more severe bipolar mood symptoms are more likely to experience aspects of cognitive deficit. There are also important findings that point to the reality that individuals whose symptoms have been well-managed over the years will be less likely to experience cognitive impairment. Those who have experienced a more difficult course of their disorder due to treatment resistant symptoms, treatment non-compliance, and/or unhealthy lifestyle choices suffer more cognitive impairments.
A related question is whether the phenomenon of cognitive deficit symptoms are mood-specific or do they represent some degree of impairment that persists and is independent of cycles of mania, hypomania and depression
Most would agree that cognition is negatively impacted when one is suddenly depressed. When severely depressed, individuals often find that the alertness and incisiveness of their cognition feels like its been toned down a few notches. Recall of written or spoken words can also become compromised. Consider the depressed student whose trying to complete a reading assignment the night before class. He reaches the end of the chapter and realizes he is unable to recall most of what hes just read over the last 10 to 15 pages. The same can apply to the retaining of material that was transmitted during a class lecture. The student truly attempts to understand whats being said, but the material being taught in the lecture just doesnt stay with the person. .
Hypomania and mania also bring about a broad range of cognitive modifications. Racing thoughts is a common symptom during mood elevation, and the consequence of racing can again manifest as faulty memory and impaired focus. The individuals thought content progresses so fast that it becomes difficult to hold onto specific thoughts or to maintain clear awareness of what he thought only a few minutes ago.
In addition to racing thoughts, an unusually large amount of thoughts can flood a persons awareness during hypomanic/manic states. Too much happening at the same time in ones mind makes it difficult to select or to prioritize effective responses. The hypomanic/manic individual may find that everything feels important, while at the same time new and even more important thoughts keep emerging. The experience is that of too much mental activity and the consequence becomes manifest through behavioral responses that are poorly planned, prioritized and executed.
A different dilemma that sometimes comes along with mood elevation is the experience of becoming too focused. An example would be the individual who becomes locked on to an idea, a plan, or a project and continues with sustained focus far beyond what would likely occur in mid-range or even depressed mood. This sometimes yields an amazing burst of sustained focus and productivity in a short span of time. The problem is that the experience of being hyper-focused, or the loss of cognitive flexibility and adaptability, can also result in the individuals failure to attend to important matters that really need attention.
There are multiple other examples of moods impact upon cognition, but at this point it should be clear that the polarity of mood elevation and depression have adverse impact upon memory, focus, thinking and planning. This should come as no surprise. In fact, it would be more surprising if mood intensity had little to no bearing upon cognition.
There seems to be a fairly broad consensus in the research literature that for some with bipolar disorder, the presence of cognitive deficit is not just a reflection of mood intensity, but an enduring element of the illness itself. The specific cognitive difficulties that present for an individual can be present during mid-range mood or even during sustained periods of remission. This is where the discussion potentially brings about periods of anxiety for those with the disorder.
There are many complicated factors that need to be thoroughly explored and assessed in order for one to develop a clearer sense regarding his/her potential for developing cognitive deficit with bipolar disorder. The arresting piece is that those with a history of more severe instability are more likely to encounter some living with cognitive difficulties whereas those on the lower end of the spectrum are less likely to struggle with continued deficits. And with all of this, there is no guarantee either way. No doubt we will find examples of individuals with bipolar disorder whose experience is inconsistent with the trends being addressed in this blog.
First, how do you know if you are living with any cognitive deficit? The key here entails determining whether any of your difficulties with memory, language, recall, attention, and concentration, and/or planning, organization and prioritization are present when youre not up or down and/or during a mood state that has remained fairly stable. If neither is the case, if your cognitive difficulties are present only during periods of mood intensity and then resolve once youre back to baseline, then its safe to assume that your current status reflects cognitive issues that are mostly mood-phase specific. This is normal for most who live with bipolar disorder.
Its also necessary to rule out the presence of neurologically-based diagnoses such as Attention Deficit Disorder. If you have bipolar disorder and youre unsure about the presence of ADD, I suggest you see a professional who is knowledgeable about the overlap of these two entities.If you already know that you carry both diagnoses of ADD and Bipolar Disorder, then youre faced with the difficult task of figuring out what deficits come from what disorder as well as what degree of overlap may exist between the two. Frankly, these are tough differential diagnostic calls to make and doing so would require consultation from a neuropsychologist who is expert at assessing both. I guess the good news here is that if you already know youre ADD, then youve already lived a life where youve had to adapt to some aspects of cognitive deficit. The cognitive deficits stemming from bipolar disorder are not going to present you with an entirely new set of challenges that are different from what youre already used to living with and adapting to.
The next issue to consider is whether any symptoms of cognitive deficit may possibly be related to the medications you are prescribed. This too is difficult to sort out, as different people react to medications differently. Many who take one of the atypical antipsychotic medications often experience some cognitive dulling from the medication. But if your use of an antipsychotic was episode specific, prescribed during mania and discontinued once stabilization was achieved, or has been continued only on an as needed basis then youll be less prone to experience enduring adverse effects of the medication. Conversely, if youve been taking an antipsychotic on a daily basis over extended periods of time, the risks of enduring cognitive deficits are higher. That said, I also want to strongly caution readers that taking antipsychotic medication on a daily basis does not mean that cognitive deficit symptoms are inevitable. The amount and frequency of ones dosing are important factors as is ones susceptibility to medication side effect reactions. Ultimately, these matters should be raised and explored with your prescribing psychiatrist..
The same issues are applicable to the use of lithium as well as most of the other more commonly used mood stabilizers (anti-seizure medications). Lamictal or lamotrigine tends to be an outlier as it has a fairly low side effect profile; but thats not to say it comes without any cognitive impact. Its more that relative to the atypical antipsychotics as well as the other mood stabilizers typically used for bipolar disorder, its impact on cognitive functioning tends towards the lower end of the side-effect continuum.
Determining if your medications may be responsible for changes in your cognition should begin with an in-depth discussion of the issues with your prescribing physician. If he or she does not know the material with sufficient depth, it would be worthwhile to get a second opinion, particularly from a psychiatric professional that specializes in the treatment of bipolar disorder.
Another consideration in this discussion entails where you are with the course of your disorder. If youre a young adult with relatively recent onset of symptoms (last few years), I imagine you may find this blog post to be concerning. That can be a good thing if it further promotes your resolve to make healthy lifestyle choices that can mitigate the destabilizing influences of your bipolar illness. Consistent sleep (7 to 9 hrs./night), a stable sleep schedule, reliance upon a consistent daily schedule, consistent exercise, healthy diet and abstaining from psychoactive substances are all key elements which, if given sufficient priority, can make a positive difference in your capacity to manage your bipolar symptoms. The crucial implication here is that the sooner you can be successful with healthy lifestyle management the better are your chances of having a positive stabilizing impact upon your disorder.
Lets move beyond assessment and prophylaxis and discuss the prospect that youre sure that bipolar disorder has left you with areas of cognitive deficit consistent with whats been discussed in this blog post. What are your options?
Deficits brought on by abnormal brain activity (mania, acute depression, rapid cycling, etc.) are similar to mild brain injuries. They dont just self-correct. Instead the brain learns to adapt and compensate such that the injury is no longer evident through functional impairment. But, when the brain dysfunction occurs repeatedly over time, the extent of damage may not be adequately ameliorated through adaptation and compensation.
This is where acceptance becomes crucial. If youre faced with some degree of limitation thats not readily changeable, then you do what you can to accept what is. I know this sounds trite as well as much easier said than done. But the truth is there are some aspects of decline that we really do have to figure out how to live with and accept – all of us, bipolar or not. It certainly is the case with aging – we dont have a lot of choice.
Is this different for the thirty-something individual with bipolar disorder who recognizes cognitive decline from the point when he or she first entered college? Yes and no.
The no entails the reality that the bipolar individual at age 33 may still be struggling with issues of acceptance in relation to his/her disorder, whereas the older individual who is primarily wrestling with age appropriate decline has had more experience with acceptance and adaptation.
Most of us typically do get better with acceptance and adaptation as we age. If we dont, life gets a lot harder. And with regard to the yes – the bipolar individual has already had to accept and adapt to many things he or she probably didnt anticipate before being diagnosed. The process of acceptance and adaptation has already begun earlier in the life cycle than is the case for the majority of the population.
If theres any good news in what Im discussing, its the extent to which our technology-oriented culture is increasingly focused upon personal apps that help us to manage lifes complexities. Forgetfulness or planning difficulties can be lessened by the use of good scheduling apps, to-do apps and even more sophisticated project management apps. When writing and struggling to find the elusive but perfectly fitting word, you can allow a good thesaurus app to become your friend. If youre finding you dont always grasp the verbal content from classes or meetings, there are excellent non-obtrusive, user-friendly digital recorders that can serve as your back-up when your mind is drawing a blank. Were even seeing increasing presence of apps that assist with self-monitoring of bipolar mood, energy, activity, sleep cycles, and medication use. And theyre getting better each year.
Now, do you really want to have to rely on technology to compensate for internal deficits? Of course not; youd rather be on top of things. But that doesnt mean its not a good strategy when being on top seems out of reach.
Sometimes the process of accepting decline may even necessitate some significant life changes such as shifting employment roles or altering long term career goals that may require a higher level of functioning than an individuals current capacities. If one doesnt attain doesn't the career goals established in one's early adulthood, it doesnt mean there arent other viable options that can provide a high degree of satisfaction. Even if, further on down the road. one needs to step away from his or her high-level employment position and shift towards something more manageable, it is doable. The difficult aspect of this kind of downshift is being able to make the adjustment while not perceiving it as failure. Cognitive deficit stemming from bipolar disorder is no more your fault than impairment brought about by brain trauma. You dont want it, you didnt choose it and you cant make it go away. That said, when a shift in your lifes activities represents a healthy adaptive choice, the new endeavor can still be an integral component of an overall picture of satisfaction and fulfillment.
Last, it is encouraged that you not lose sight of the fact that scientific based aspects of bipolar treatment are ongoing and evolving. Research is currently being conducted on cognitive remediation approaches for bipolar disorder. Newer intervention strategies are always in the research pipeline. And even in the absence of dazzling research outcomes, theres the old adage that tells us we grow wiser as we grow older. Its true. The role of maturation across the lifespan provides us with more potential for growth and healthy adaptation than most would ever imagine.
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