Cognitive Deficit in Bipolar Disorder

One of the more overlooked aspects of bipolar disorder is the potential for developing a degree of cognitive deficit as part of the illness. This omission reflects the reality that mainstream print media’s portrayal of bipolar disorder mostly focuses upon the cycling of elevated and/or depressed moods which are the hallmark features of the disorder.

What we typically read are descriptions of mood elevation that reflect symptoms of high energy, lessened need for sleep, feelings of euphoria, grandiosity, impulsivity, elevated libido, etc. Similarly, on the depressed end of the mood spectrum, we read descriptions of low energy, low self-esteem, feelings of sadness, loss or emptiness, suicidal ideation, pervasive pessimism, low motivation, and all the other experiences we associate with feeling depressed.

Mood typically receives the bulk of our attention when it comes to descriptions and discussion of bipolar disorder; however, in my sessions with individuals living with the disorder, it’s common to hear concerns about their lessened cognitive capacities. To be more specific, I’m 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 linguistic working memory (word retrieval), difficulties with planning, prioritizing, and organizing of behavior (executive functioning), problems with retention of what’s been read or listened to, as well as the experience of mildly dulled or slowed thought processes. For some with bipolar disorder, it’s like they’ve experienced a gradual decline of brain power from their previous baseline level of function.

Before I scare many readers, 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 percent on the low end and 60 percent on the high end.

Granted, this broad range doesn’t tell us much. Research samples that vary widely in relation to subjects’ age, symptom acuity, presence of comorbidity, and differences in prior treatment backgrounds do yield different findings.

A key conclusion supported by numerous research articles is there appears to be a positive correlation between the presence of cognitive deficit and higher acuity bipolar symptoms. This means that those with histories of more acute 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 salient question is whether the manifestations of cognitive deficit symptoms are mood-phase-specific or if they represent some degree of impairment that persists and is independent of cycles of mania, hypomania, and depression.

Most would agree that cognition is adversely impacted when one is acutely depressed. When acutely depressed, individuals often find that the alacrity and sharpness of their cognition feels like it’s been dialed down a few notches. Recall of written or spoken words can also become compromised.

Consider the depressed student who is 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 he’s just read over the last 10 to 15 pages. The same can apply to retention of material that was conveyed during a class lecture. The student truly attempts to track what’s being said, but the material conveyed in the lecture just doesn’t stick.

Hypomania and mania also generate a broad range of cognitive alterations. Racing thought is a common experience during mood elevation, and the consequence of accelerated thought can again manifest as faulty memory and impaired focus. The individual’s thought content progresses so rapidly 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 volume of thoughts can flood a person’s awareness during hypomanic/manic states. Too much happening concurrently in one’s consciousness makes it difficult to select or to prioritize effective responses. The hypomanic/manic individual may find that everything feels important, while concurrently new and even more important thoughts keep emerging. The experience is that of excessive 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 a 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 individual’s failure to attend to important matters that really need attention.

There are multiple other examples of mood’s impact upon cognition, but at this point, it should be clear that the polarities of mood elevation and depression have an 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 evokes anxiety for those with the disorder. I recall a young adult patient recently saying, “You mean, in addition to all of my mood craziness, I now have to worry about gradual loss of cognitive capacity? My best answer at this point is: Maybe.

There are many complex 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 decicit with bipolar disorder. The salient piece is that those with a history of more acute instability are more likely to encounter some enduring cognitive difficulties whereas those on the lower end of the acuity continuum are less likely to struggle with sustained 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 post.

Let’s shift now to some of more pragmatic implications of what I’ve been saying.

First, how do you know if you do have any enduring cognitive deficit? The key here entails determining whether any of your difficulties with memory, language recall, attention, and concentration, and/or executive functioning (planning, organization and prioritization) are present during mid-range mood (when you’re not up or down) and/or during a sustained period of partial remission (mood state 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 you’re back to baseline, then it’s 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.

It’s also necessary to rule out the presence of neurologically-based diagnoses such as Attention Deficit Disorder (ADD). If you have bipolar disorder and you’re unsure about the presence of ADD, I suggest you see a professional who is knowledgeable about the overlap of these two entities. One of my previous blog posts, “Misdiagnosis of Bipolar Disorder” (February 2013), also speaks to the diagnostic distinctions between attention deficit and bipolar disorder.

If you do already know that you carry both diagnoses of ADD and bipolar disorder, then you’re faced with the complex 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 you’re ADD, then you’ve already lived a life where you’ve 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 you’re 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 you’ll be less prone to experience enduring adverse effects of the medication. Conversely, if you’ve been taking an antipsychotic on a daily basis over extended periods of time, the risks of enduring cognitive deficit 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 one’s dosing are important factors as is one’s 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 lamotrigene tends to be an outlier as it has a fairly low side effect profile, but that’s not to say it comes without any cognitive impact. It’s 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.

What if you’re thinking that all the distinctions I’m referring to still seem fuzzy, and even after psychiatric consultation, you remain uncertain as to whether you suffer from bipolar-related cognitive deficit? I’d recommend you meet with a neuropsychologist who has a good grasp on the neurocognitive symptom profile associated with bipolar disorder. Undergoing a thorough neuropsychological assessment may help you to concretely identify whether you do have any enduring areas of deficit related to your bipolar disorder.

Another consideration in this discussion entails where you are with the course of your disorder. If you’re 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 (7½ 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 your chances are of having a positive stabilizing impact upon your disorder.

Let’s move beyond assessment and prophylaxis and discuss the prospect that you’re sure that bipolar disorder has left you with areas of cognitive deficit consistent with what’s been discussed in this blog post. What are your options?

Unfortunately, I don’t have any “fix-it” responses. Deficits brought on from abnormal brain activity (mania, acute depression, rapid cycling, etc.) are similar to mild brain injuries. They don’t 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 you’re faced with some degree of limitation that’s 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 don’t 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 don’t, 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 didn’t anticipate before being diagnosed. The process of acceptance and adaptation has already begun earlier in the lifecycle than is the case for the majority of the population.

If there’s any good news in what I’m discussing, it’s the extent to which our technology-oriented culture is increasingly focused upon personal “apps” that help us to manage life’s 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 you’re finding you don’t 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. We’re even seeing an increasing presence of apps that assist with self-monitoring of bipolar mood, energy, activity, sleep cycles, and medication use. And they’re getting better each year.

Now, do you really want to have to rely on technology to compensate for internal deficits? Of course not; you’d rather be on top of things. But that doesn’t mean it’s not a good strategy when “being on top” seems out of reach.

Sometime 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 individual’s current capacities. If one doesn’t attain doesn't the career goals established in one's early adulthood, it doesn’t mean there aren’t 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 a failure.

Cognitive deficit stemming from bipolar disorder is no more your fault than impairment brought about by brain trauma. You don’t want it, you didn’t choose it and you can’t make it go away. That said, when a shift in your life’s activities represents a healthy adaptive choice, the new endeavor can still be an integral component of an overall picture of satisfaction and fulfillment.

Last, I encourage you not to 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, there’s the old adage that tells us “we grow wiser as we grow older.” It’s true. The role of maturation across the lifespan provides us with more potential for growth and healthy adaptation than most would ever imagine.

Russ Federman, Ph.D., ABPP is in private practice in Charlottesville, VA.