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At the mood disorders clinic not long ago, I was seeing a young woman with bipolar disorder. She was doing generally well and was back at work, but felt that she wasn’t able to retain information as well as she used to. I’d had a number of similar discussions with patients in the past, and I thought myself well able to provide some practical strategies. However, a casual remark at the end of our appointment gave me pause; as she was stepping out, she wryly commented: “sometimes I feel like bipolar has given me brain damage.”
Closing the door behind her, I couldn’t help but wonder if I had missed the full import of her concerns. It was said jokingly, but did this bright and articulate young woman actually feel her abilities to be so altered as to question whether her brain was actually damaged? And if she felt this way, how many others were grappling with the same, awful question: “has bipolar disorder damaged my brain? – my ability to think and understand and interact with the world?” And by extension: “is it going to get worse?” and “what does this mean for me and my ability to succeed?”
Cognition: the process of acquiring, understanding and manipulating information about the world around us.
Difficulties with attention, memory, planning and problem solving are very commonly cited concerns amongst individuals with bipolar disorder. These functions fall under the umbrella of ‘cognition:’ the process of acquiring, understanding and manipulating information about the world around us. Cognition is made up of a number of individual domains such as memory, attention, planning, problem solving and processing speed (the speed at which one can understand and respond to information).
Cognition does appear to be impacted in bipolar disorder. Groups with bipolar disorder on average score lower on cognitive tests compared to groups without a psychiatric diagnosis, even if they are not currently experiencing mood symptoms (Bora et al. 2009). This is seen across multiple domains, including memory, attention, processing speed and planning/problem solving. Studies have also shown that cognition is a significant contributor to real-world functioning in individuals with mood disorders. Large MRI (magnetic resonance imaging) analyses have also found evidence of thinning of the cortex in a number of brain regions known to contribute to cognition (Hibar et al. 2018). All this would suggest that: 1) bipolar disorder is associated with cognitive deficits and corresponding changes in the brain’s structure, 2) these deficits may persist even when mood is stable, and 3) they may impact a person’s functional abilities.
…not at all patients with bipolar meet an accepted threshold of cognitive ‘impairment’, while a sizeable proportion have normal to above-normal cognitive abilities.
However, while we need to be cognizant of the importance of cognitive symptoms in bipolar disorder, we also need to guard against adopting too bleak an outlook. First, not at all patients with bipolar meet an accepted threshold of cognitive ‘impairment’, while a sizeable proportion have normal to above-normal cognitive abilities (Lima et al. 2019; Burdick et al. 2014). So while bipolar disorder may be associated with cognitive deficits on a group level, many individuals with it are cognitively ‘well.’ Additionally, a bipolar disorder diagnosis does not consign you to a lifetime of progressive cognitive decline. If well treated, long term studies in bipolar disorder show improvements over time in memory, working memory and processing speed (Bora and Ozerdem, 2017; Torres et al. 2019).
What can we do about it?
So how would you know if you’re experiencing cognitive deficits? The ‘gold-standard’ assessment is a battery of standardized tests administered by a trained neuropsychologist. Unfortunately, such testing is costly and difficult to access. There are validated computerized testing programs that are simpler to administer – you may be able to access these through specialized mood disorder clinics.
If well treated, long term studies in bipolar disorder show improvements over time in memory, working memory and processing speed.
There are few treatments specifically targeting cognition in people with bipolar disorder. No medication has yet shown reliable enough cognitive-enhancing effects to be routinely recommended. Group functional remediation programs, which address common cognitive deficits, have been shown to improve real-world functioning, but again are not widely available (Torrent et al. 2013).
The most practical advice is to try to maintain mood stability and a healthy lifestyle. Though individuals with bipolar disorder who are not experiencing mood symptoms may still experience cognitive difficulties, on average these deficits are less pronounced compared to individuals with current mood symptoms. Also, a healthy diet, regular sleep and exercise may lower inflammation and enhance neurotrophic factors specialized proteins in the brain that promote the growth and function of neurons (Gomez-Pinilla, 2011).
- Some mood stabilizing medications may have cognitive side effects. If you are wondering about this, make sure to discuss the possibility with your clinician.
- If you are connected with a mental health team, they may have an occupational therapist (OT) on staff who can help you develop strategies for work/school. Alternatively, OT services may be covered by extended health or disability plans.
- Educating yourself is important. Most psychoeducation programs for bipolar disorder devote at least one session to cognition. The ‘cognition’ section of CREST.BD’s Bipolar Wellness Centre explores the relationship between cognition and quality of life in people with bipolar disorder
- With some exceptions, workplaces must provide accommodations for employees with health conditions. The Job Accommodation Network provides some practical accommodations to consider depending on your difficulties.
So, what’s the take-home message here? Cognitive symptoms in people with bipolar disorder are real, but they manifest very differently (if at all) in each individual, and tend to improve with time. Additionally, although we clearly have a long way to go, research and knowledge in this area is growing.
- This guest blog post is brought to you by Dr. Trisha Chakrabarty. Trisha works as a psychiatrist at the UBC Mood Disorders Centre. She also does clinical research, with a focus on cognition in mood disorders.
** We have a number of studies involving CREST.BD members at UBC aimed at understanding and developing treatments for cognitive symptoms in bipolar disorder. If you’d like to learn more about ongoing research studies investigating cognition in bipolar disorder, please visit the link below:
If you are interested in the UBC Mood Disorder Centre’s bipolar
psychoeducation group, please contact the clinic at 604 822 7512 for dates, availability and referral information.
Bora et al. (2009). Cognitive Endophenotypes of Bipolar Disorder: A Meta-Analysis of Neuropsychological Deficits in Euthymic Patients and Their First-Degree Relatives. Journal of Affective Disorders: 113(1-2), 1 – 20.
Bora and Ozerdem et al. (2017). Meta-analysis of Longitudinal Studies of Cognition in Bipolar Disorder: Comparison with Healthy Controls and Schizophrenia. Psychological Medicine: 47(16), 2753 – 2766.
Burdick et al. (2014). Empirical Evidence for Discrete Neurocognitive Subgroups in Bipolar Disorder: Clinical Implications. Psychological Medicine: 44(14), 3083-3096.
Gomez-Pinilla (2011). Collaborative Effects of Diet and Exercise on Cognitive Enhancement. Nutrition and Health: 20(3-4), 165-169.
Hibar et al. (2018). Cortical Abnormalities in Bipolar Disorder: An MRI Analysis of 6503 Individuals from the ENIGMA Bipolar Disorder Working Group. Molecular Psychiatry: 23(4), 932-942.
Lima et al. (2019). Identifying Cognitive Subgroups in Bipolar Disorder: A Cluster Analysis. Journal of Affective Disorders: 246, 252-261.
Torrent et al. (2013). Efficacy of Functional Remediation in Bipolar Disorder: A Multicenter Randomized Controlled Study. American Journal of Psychiatry: 170(8), 852-859.
Torres et al. (2019). Three-year Longitudinal Cognitive Functioning in Patients Recently Diagnosed with Bipolar Disorder. Acta Psychiatrica Scandinavica; 141(2), 98-109.
There is total ignorance of this subject in psychiatrists outside of tertiary specialist centres, in the UK anyway.
Absolutely it does . I can’t remember things the way I used to or think as straight anymore .
I was in a car accident in 2017 that caused a second TBI that was labeled as a concussion so no imaging was done. Then, in relation to poorly handled countertransference by my then providing neuropsychologist I had a full manic episode. A year after that incident a neurologist finally decided to do an MRI because of new and worse symptoms from the car accident. There was damage found to my right pre-frontal cortex. It is assumed that this was due to the car accident and I believe this is likely partially true. However, much like the subject in your leading anecdote, I feel like and wonder if some or all of the damage may have been a result of the mania that was misdiagnosed.
Initially the mania was instead diagnosed by the ex-neuropsychologist to be an issue of romantic transference and countertransference, but he latter denied that along with the mania which prevented me from getting accurate treatment for at least 9 months.
While I exhibit some deficits, I test high on IQ and other tests and I know many people with bipolar who have high intelligence. But it does feel like the mania has caused brain damage as I feel even worse off in some areas than I had been prior to it after the car accident. I think the possibility you present of mania/bipolar actually being the cause of brain damage, needs to be researched and explored more with actual imaging. It is possible that the general lower cognitive functioning you are explaining in this article is due to the effects of bipolar and especially untreated or under-treated bipolar. It is worth examining.
One of the first jokes I made with the malpracticing neuropsychologist was “you should have seen me prior to TBI” when he commented on how I was “one smart cookie,” in response to how well I preformed on my neuropsychological eval only 6 months after the TBI and when I was still exhibiting symptoms of TBI (they labeled it post-concussive syndrome). Now I wonder how different my cognitive performance would be after the manic episode he triggered 6 months later.