Neuropsychological task performance in bipolar spectrum illness: genetics, alcohol abuse, medication and childhood trauma

Association between childhood trauma, cognition, and psychosocial function in a large sample of partially or fully remitted patients with bipolar disorder and healthy participants

BACKGROUND

Childhood trauma (CT) are frequently reported by patients with bipolar disorder (BD), but it is unclear whether and how CT contribute to patients' cognitive and psychosocial impairments. We aimed to examine the impact of CT on cognition and psychosocial functioning in a large sample of 345 patients with BD and 183 healthy control participants (HC) using the Childhood Trauma Questionnaire, neurocognitive tests and ratings of mood symptoms and functioning.

RESULTS

Patients showed broad cognitive impairments across memory, attention and executive function and functional disability despite being in partial or full remission and had higher levels of CT than HC. Higher levels of CT correlated with impairments across almost all cognitive domains and lower psychosocial functioning across BD patients and HC. Of these, the associations between CT and poorer working memory and lower psychosocial functioning, respectively, prevailed after adjusting for clinical and demographical variables. Diagnosis of BD and estimated verbal intelligence did not moderate these associations. Analysis of CT sub-categories showed that working memory impairments were related particularly to childhood physical and emotional abuse, while psychosocial difficulties were related to physical and emotional neglect.

CONCLUSIONS

CT may have negative implications for working memory and psychosocial functioning across both BD and healthy populations. If the findings are replicated, this would suggest that early interventions that reduce the frequency of CT in vulnerable families may aid children's cognitive and psychosocial development.

Status of Type II vs. Type I Bipolar Disorder: Systematic Review with Meta-Analyses

LEARNING OBJECTIVES AFTER PARTICIPATING IN THIS CME ACTIVITY, THE PSYCHIATRIST SHOULD BE BETTER ABLE TO

• Analyze and compare the different bipolar disorder (BD) types.• Identify markers that distinguish BD types and explain how the DSM-IV defines the disorder.

ABSTRACT

Since the status of type II bipolar disorder (BD2) as a separate and distinct form of bipolar disorder (BD) remains controversial, we reviewed studies that directly compare BD2 to type I bipolar disorder (BD1). Systematic literature searching yielded 36 reports with head-to-head comparisons involving 52,631 BD1 and 37,363 BD2 patients (total N = 89,994) observed for 14.6 years, regarding 21 factors (with 12 reports/factor). BD2 subjects had significantly more additional psychiatric diagnoses, depressions/year, rapid cycling, family psychiatric history, female sex, and antidepressant treatment, but less treatment with lithium or antipsychotics, fewer hospitalizations or psychotic features, and lower unemployment rates than BD1 subjects. However, the diagnostic groups did not differ significantly in education, onset age, marital status, [hypo]manias/year, risk of suicide attempts, substance use disorders, medical comorbidities, or access to psychotherapy. Heterogeneity in reported comparisons of BD2 and BD1 limits the firmness of some observations, but study findings indicate that the BD types differ substantially by several descriptive and clinical measures and that BD2 remains diagnostically stable over many years. We conclude that BD2 requires better clinical recognition and significantly more research aimed at optimizing its treatment.

Association of childhood trauma with cognitive domains in adult patients with mental disorders and in non-clinical populations: a systematic review

Although the association between cognitive performances and the onset of psychiatric disorders has been widely investigated, limited research on the role of childhood trauma or early life stress (CT/ELS), and whether this role differs between clinical and non-clinical cohorts is available. This systematic review aims at filling this gap, testing whether the occurrence of CT/ELS and its subtypes are associated with cognitive domains (general cognitive ability, executive functions, working memory, attention, processing speed, verbal/visual memory) in patients with psychiatric disorders and in non-clinical populations. This study followed the PRISMA 2020 guidelines and the Newcastle-Ottawa scale for quality assessment. The search was performed until May 2022. Seventy-four studies were classified as eligible. The graphical representations of the results reported an association between exposure to CT/ELS and worse general cognitive ability, verbal/visual memory, processing speed and attention in patients affected by anxiety, mood and psychotic disorders, and that specific CT/ELS subtypes (physical neglect, physical/sexual abuse) can differentially influence specific cognitive abilities (executive functions, attention, working memory, verbal/visual memory). In non-clinical cohorts we found associations between CT/ELS exposure and impairments in executive functions, processing speed and working memory, while physical neglect was related to general cognitive ability and working memory. Concerning the emotional abuse/neglect subtypes in both populations, the results indicated their involvement in cognitive functioning; however, the few studies conducted are not enough to reach definitive conclusions. These findings suggest an association of CT/ELS with specific cognitive deficits and psychopathology.

Childhood trauma relates to worse memory functioning in bipolar disorder

BACKGROUND

Childhood trauma is commonly experienced by individuals diagnosed with bipolar disorder (BP). In BP, childhood trauma is related to a more severe clinical course, but its association with cognition remains unclear.

METHODS

This study evaluated 405 adult participants diagnosed with BP and 136 controls. Participants completed the Childhood Trauma Questionnaire and a comprehensive neuropsychological battery. High versus low childhood trauma was defined with one standard deviation above the control participant's mean Childhood Trauma Questionnaire score. Neuropsychological data was transformed into eight cognitive factors, including four executive functioning, auditory and visual memory, fine motor, and emotion processing. Multivariate analysis of covariance evaluated group differences in cognition, while adjusting for covariates.

RESULTS

There were significant differences among the three groups, F(16, 968) = 4.05, p < .001, Wilks' Λ = 0.88, partial η² = 0.06. Comparing the high and low trauma BP groups, high trauma was related to lower auditory and visual memory factor scores (p < .05). As compared to controls, the BP high trauma group had lower scores on six of eight factors (all p < .01), while the BP low trauma group had lower scores on four of eight factors (all p < .01).

LIMITATIONS

Analyses of factor score do not address which aspect of the memory process is affected and biomarkers may help guide interventions addressing underlying biological process.

CONCLUSIONS

Adults diagnosed with BP with higher childhood trauma have worse memory functioning, beyond the lower childhood trauma BP group, highlighting the importance of understanding the long-term cognitive outcomes of childhood trauma.

Child maltreatment and victimization

It is estimated that up to 25% of all children growing up worldwide experience child maltreatment, making it a global emergency with substantial individual and public health consequences. This chapter addresses one of the most societally pervasive consequences of child maltreatment which is known as the "cycle of victimization." This concept depicts the increased risk of maltreated individuals to victimize others later in life, both within and outside the family environment. To understand the architecture of this victimization cycle, the chapter further sheds light on neurocognitive mechanisms aiding different forms of victimization and the buffering role of social support that could help break the cycle of victimization. Advancing our understanding of these complex and interrelated mechanisms will ultimately facilitate the design and implementation of more targeted early treatments and (preventive) interventions and support a move toward a safer society.

The impact of substance use disorder comorbidity on cognition of individuals with bipolar disorder: A systematic review

The aim of this study is to describe whether Bipolar Disorder (BD) with Substance Use Disorder (SUD) comorbidity is associated with an increased cognitive impairment as compared to BD without SUD comorbidity. This is a systematic review. The literature search was conducted in three databases: PubMed, PsycINFO and Embase. A total of 2032 studies were screened after removing duplicates. 29 articles were included for full text screening, and a total of 14 articles were included in the systematic review. Multiple cognitive domains were assessed, including verbal, spatial and visual memory, and psychomotor and executive functioning. Over half the articles (64.3%, n=9) identified cognitive impairments in individuals with BD+SUD comorbidity as compared to individuals with BD without SUD comorbidity. In addition, individuals with the comorbidity exhibited more severe impairments on tests of executive functioning, and greater impairments in verbal and visual memory. The studies included in this systematic review reinforce that individual with comorbidity of BD and SUD have increased cognitive impairment as compared to individuals with BD without SUD comorbidity. Executive functioning was the most impaired cognitive domain found across the studies included in this review. Intervention strategies focused on executive functioning would be beneficial for this specific population.

Association between Childhood Maltreatment and Suicidal Ideation: A Path Analysis Study

Epidemiological studies have suggested that childhood maltreatment increases suicidal ideation, and dissociative symptoms and hopelessness are involved in this relation. To better address this issue, we used a path analysis model to examine the role of different types of childhood maltreatment on suicidal ideation, investigating whether hopelessness and dissociative symptoms mediated this relation. A sample of 215 adult psychiatric inpatients was enrolled between January 2019 and January 2020, at the psychiatric unit of Sant’Andrea Medical Center in Rome, Italy. The Childhood Trauma Questionnaire (CTQ), Beck Hopelessness Scale (BHS), Dissociative Experiences Scale (DES-II), and Columbia-Suicide Severity Rating Scale (C-SSRS) were used to test the hypotheses. Results revealed that the presence of sexual abuse directly affected suicidal ideation (β = 0.18, SE = 0.8, p < 0.05), while emotional abuse and neglect indirectly increased suicidal ideation via dissociation (β = 0.05, SE = 0.02, 95% C.I. 0.01/0.09) and hopelessness (β = 0.10, SE = 0.03, 95% C.I. = 0.04/0.16). Professionals working with children should be aware of the long-term consequences of childhood maltreatment, particularly suicide risk. Furthermore, professionals working with adults should inquire about past childhood maltreatment.

RAISE study protocol: a cross-sectional, multilevel, neurobiological study of resilience after individual stress exposure

INTRODUCTION

This paper describes the protocol for an ongoing project funded by the Royal Society, the Resilience After Individual Stress Exposure (RAISE) study; which aims to examine the factors and mechanisms that facilitate resilient functioning after childhood adversity (CA).

METHODS AND ANALYSIS

We aim to recruit up to 200 participants. We will use dimension reduction techniques (principal component analysis) on standard-normally transformed individual parameters of mental health, social functioning and CA to calculate a composite measure of adaptive (ie, 'resilient') psychosocial functioning. To examine the neuroimmune responses to stress and their relationship with the brain and social environment, we will use a well validated functional MRI task; the Montreal imaging stress task and venepuncture. We will run group or dimensional comparisons in multiple levels of biological and psychological outcomes, as well as mediation and moderation analyses to study how key biological systems (ie, the hypothalamic-pituitary-adrenal axis and the immune system) interrelate and interact with brain function and social influences in order to facilitate resilient functioning after CA. We hypothesise that resilient functioning will be facilitated by reduced morning cortisol and cytokine levels before and after the stressor and improved neural responses to such stress, as well as increased gray matter volume in the hippocampus and prefrontal cortex, enhanced inhibitory control and emotion regulation, and more friendship and family support.

ETHICS AND DISSEMINATION

This study has been reviewed and given favourable opinion by the National Research Ethics Service, NRES Committee East of England-Cambridge Central and external reviewers from the Royal Society (RGF\R1\180064 and RGF\EA\180029). The results of the RAISE study will be disseminated through (1) publications in scientific peer reviewed journals, (2) presentations on relevant scientific conferences and meetings, (3) publications and presentations for the general public and (4) through social media.

The Impact of Childhood Trauma on Developing Bipolar Disorder: Current Understanding and Ensuring Continued Progress

Childhood trauma (CT) has been repeatedly linked to earlier onset and greater severity of bipolar disorder (BD) in adulthood. However, such knowledge is mostly based on retrospective and cross-sectional studies in adults with BD. The first objective of this selective review is to characterize the short-term effects of CT in the development of BD by focusing on studies in young people. The second objective is to describe the longer-term consequences of CT by considering studies with adult participants. This review first outlines the most prominent hypotheses linking CT exposure and the onset of BD. Then, it summarizes the psychological and biological risk factors implicated in the development of BD, followed by a discussion of original studies that investigated the role of CT in young people with early-onset BD, youths at increased risk of developing BD, or young people with BD with a focus on subclinical and clinical outcome measures. The review considers additional biological and psychological factors associated with a negative impact of CT on the long-term course of BD in later adulthood. Finally, we discuss how the integration of information of CT can improve ongoing early identification of BD and mitigate severe clinical expression in later adulthood.

A systematic review of research on neuropsychological measures in psychotic disorders from low and middle-income countries: The question of clinical utility

INTRODUCTION

Several studies of neuropsychological measures have been undertaken in patients with psychotic disorders from low- and middle-income countries (LMICs). It is, however, unclear if the measures used in these studies are appropriate for cognitive screening in clinical settings. We undertook a systematic review to determine if measures investigated in research on psychotic disorders in LMICs meet the clinical utility criteria proposed by The Working Group on Screening and Assessment.

METHODS

Preferred Reporting Items for Systematic Reviews and Meta-Analyses were employed. We determined if tests had been validated against a comprehensive test battery, the duration and scope of the tests, the personnel administering the tests, and the means of administration.

RESULTS

A total of 31 articles were included in the review, of which 11 were from Africa. The studies included 3254 participants with psychosis and 1331 controls. 3 studies reported on the validation of the test against a comprehensive cognitive battery. Assessments took 1 h or less to administer in 6/31 studies. The average number of cognitive domains assessed was four. Nonspecialized staff were used in only 3/31 studies, and most studies used pen and paper tests (17/31).

CONCLUSION

Neuropsychological measures used in research on psychotic disorders in LMICs typically do not meet the Working Group on Screening and Assessment clinical utility criteria for cognitive screening. Measures that have been validated in high-income countries but not in LMICs that do meet these criteria, such as the Brief Assessment of Cognition in Schizophrenia, therefore deserve further study in LMIC settings.

The complex neurobiology of resilient functioning after childhood maltreatment

BACKGROUND

Childhood maltreatment has been associated with significant impairment in social, emotional and behavioural functioning later in life. Nevertheless, some individuals who have experienced childhood maltreatment function better than expected given their circumstances.

MAIN BODY

Here, we provide an integrated understanding of the complex, interrelated mechanisms that facilitate such individual resilient functioning after childhood maltreatment. We aim to show that resilient functioning is not facilitated by any single 'resilience biomarker'. Rather, resilient functioning after childhood maltreatment is a product of complex processes and influences across multiple levels, ranging from 'bottom-up' polygenetic influences, to 'top-down' supportive social influences. We highlight the complex nature of resilient functioning and suggest how future studies could embrace a complexity theory approach and investigate multiple levels of biological organisation and their temporal dynamics in a longitudinal or prospective manner. This would involve using methods and tools that allow the characterisation of resilient functioning trajectories, attractor states and multidimensional/multilevel assessments of functioning. Such an approach necessitates large, longitudinal studies on the neurobiological mechanisms of resilient functioning after childhood maltreatment that cut across and integrate multiple levels of explanation (i.e. genetics, endocrine and immune systems, brain structure and function, cognition and environmental factors) and their temporal interconnections.

CONCLUSION

We conclude that a turn towards complexity is likely to foster collaboration and integration across fields. It is a promising avenue which may guide future studies aimed to promote resilience in those who have experienced childhood maltreatment.

Severe childhood trauma and clinical and neurocognitive features in schizotypal personality disorder

OBJECTIVE

Literature suggests that childhood trauma increases vulnerability for schizophrenia-spectrum disorders, including schizotypal personality disorder (SPD). Yet, it remains unexplored whether childhood trauma predicts symptom load and the level of neurocognitive functioning in SPD.

METHOD

We included 225 individuals with SPD and 127 healthy controls. Childhood trauma was evaluated using the Childhood Trauma Questionnaire, and schizotypal traits were assessed using the Schizotypal Personality Questionnaire. Standard neurocognitive assessments covered six cognitive domains.

RESULTS

All types of reported childhood trauma were significantly associated with SPD, in a linear fashion. Severe sexual abuse showed the greatest magnitude of association with higher cognitive-perceptual load (e.g., ideas of reference, odd belief or magical thinking); severe emotional neglect was associated with interpersonal scores (e.g., excessive social anxiety, constricted affect) within the SPD group. SPD individuals who reported severe trauma showed worse cognitive functioning (i.e., working memory, verbal/visual learning and memory, as well as verbal fluency).

CONCLUSIONS

Particular severe childhood trauma types were associated with higher cognitive-perceptual and interpersonal symptoms in SPD, along with worse cognitive functioning. These findings highlight the need for clinicians to enquire about childhood trauma in SPD patients, since unaddressed early adverse experiences may carry long-term negative consequences.

Objective and biological markers in bipolar spectrum presentations

INTRODUCTION

Subthreshold presentations of bipolarity (BSPs) pose a diagnostic conundrum, in terms of whether they should be conceptualized and treated similarly as traditionally defined bipolar disorders (BD). While it has been argued that BSPs are on a pathophysiologic continuum with traditionally defined BDs, there has been limited examination of biological and objective markers in these presentations to validate this assertion. Areas covered: The authors review studies examining genetic, neurobiological, cognitive and peripheral markers in BSPs, encompassing clinical and non-clinical populations with subthreshold hypo/manic symptoms. Results are placed in the context of previously identified markers in traditionally defined BDs. Expert commentary: There have been few studies of objective and biological markers in subthreshold presentations of BD, and results are mixed. While abnormalities in brain structure/functioning, peripheral inflammatory, and cognitive markers have been reported, it is unclear whether these findings are specific to BD or indicative of broad affective pathology. However, some studies suggest that increased sensitivity to reward and positive stimuli are shared between subthreshold and traditionally defined BDs, and may represent a point of departure from unipolar major depression. Further examination of such markers may improve understanding of subthreshold bipolar presentations, and provide guidance in terms of therapeutic strategies.

A systematic review on neuropsychological function in bipolar disorders type I and II and subthreshold bipolar disorders-something to think about

Neuropsychological dysfunction is a well-established finding in individuals with bipolar disorder type I (BP-I), even during euthymic periods; however, it is less clear whether this also pertains to bipolar disorder type II (BP-II) or those with subthreshold states (SBP; subthreshold bipolar disorder), such as bipolar not otherwise specified (BP-NOS). Herein, we compare the literature regarding neuropsychological performance in BP-II vs BP-I to determine the extent of relative impairment, and we present and review all related studies on cognition in SBP. After systematically searching PubMed, Medline, PsycINFO, and The Cochrane Library, we found 17 papers that comprise all the published studies relevant for this review. The areas that are consistently found to be impaired in BP are executive function, verbal memory, visual spatial working memory, and attention. More studies than not show no significant difference between BP-I and BP-II, particularly in euthymic samples. Preliminary evidence suggests that patients experiencing major depressive episodes who also meet criteria for SBP show similar profiles to BP-II; however, these results pertain only to a depressed sample. SBP were found to perform significantly better than both MDD and healthy controls in a euthymic sample. A consensus on mood state, patient selection, and neuropsychological testing needs to be agreed on for future research. Furthermore, no studies have used the most recent DSM-5 criteria for SBP; future studies should address this. Finally, the underlying bases of cognitive dysfunction in these diagnostic groups need to be further investigated. We suggest recommendations on all of the above current research challenges.

Schizotypal personality traits and social cognition are associated with childhood trauma exposure

OBJECTIVES

Childhood trauma is a common risk factor for adult psychiatric disorders, such as schizophrenia (SZ) and bipolar-I disorder (BD). However, its association with schizotypal personality traits, as well as cognitive and social cognitive abilities, is less well studied in these populations.

METHODS

In a cohort of 79 SZ cases, 84 BD cases, and 75 healthy controls (HCs), clinically significant levels of childhood trauma exposure (according to scores on the Childhood Trauma Questionnaire; CTQ) were evident in 54 SZ, 55 BD, and 26 HC individuals. Trauma-exposed and non-exposed groups were compared on schizotypal personality features (schizotypy) measured with the Schizotypal Personality Questionnaire (SPQ). Cognitive assessments included executive function, working memory, attention, and immediate and delayed memory. Social cognitive measures assessed facial emotion processing and theory-of-mind abilities.

RESULTS

Trauma-exposed participants showed higher levels of schizotypy, especially suspiciousness, relative to non-exposed individuals, regardless of clinical or HC status. Furthermore, trauma-exposed individuals showed deficits specifically in social cognitive, but not general cognitive abilities, regardless of clinical or HC status. These trauma-related results were found in the context of higher schizotypy levels in both SZ and BD relative to HC, and lower cognitive and social cognitive performance in SZ, relative to BD and HC groups.

CONCLUSIONS

These findings suggest that childhood trauma exposure impacts long-term schizotypy outcomes, especially paranoid ideation (suspiciousness), as well as complex social cognitive abilities in both healthy and psychotic populations. However, cognitive deficits associated with psychotic illness may not be distinguishable from those related to trauma exposure in previous studies.

PRACTITIONER POINTS

Findings Childhood trauma exposure is associated with increased schizotypal features (in particular paranoid ideation) and complex social cognitive abilities, independently of the diagnosis of psychotic disorder. Cognitive and social cognitive deficits were larger in schizophrenia compared to bipolar-I cases and healthy controls, but increased schizotypal features were observed in both schizophrenia and bipolar-I disorder relative to healthy controls. Limitations We were unable to distinguish the specific effects of particular childhood trauma exposures due to the high rate of exposure to more than one type of maltreatment. Retrospective assessment of childhood trauma in adulthood cannot be externally validated, and associations with behavioural traits in later life may be confounded by other factors not studied here.

The effects of social exclusion on response inhibition in borderline personality disorder and major depression

It is a prevalent notion that borderline personality disorder (BPD) is characterized by deficits in executive functions (EF) like inhibition. Yet experimental studies yield inconsistent results. However, despite emotional dysregulation being a core feature of BPD, most paradigms did not control for emotional state or comorbid mental disorders. In the present study, subjects with BPD and comorbid MDD (BPD+MDD), with major depression (MDD) and healthy controls (HC) partook in a social exclusion paradigm combined with an inhibition task. We expected inhibition to be more strongly impaired in BPD+MDD than in depression and HC when experiencing negative emotions. Respecting inhibition, depressed patients performed best while (BPD+MDD) patients performed worst. Surprisingly, MDD & HC participants' performance improved during social exclusion, but this was not the case for BPD+MDD. Inhibition deficits were correlated with childhood trauma. These results challenge the hypothesis that an induction of negative emotion results in inferior inhibition in (BPD+MDD). Instead, patients with (BPD+MDD) seem to suffer from a more general inhibitory dysfunction. Importantly, (BPD+MDD) patients were not able to improve their performance during social exclusion like HC and MDD patients did. These findings need to be investigated further, particularly regarding the efficiency of neural networks regulating inhibition and effects of trauma.

Neurocognitive features in clinical subgroups of bipolar disorder: A meta-analysis

OBJECTIVE

There is a significant cognitive heterogeneity in bipolar disorder (BD). The aim of this systematic review was to examine the potential distinctive neuropsychological of features of clinical subgroups of BD. A literature search investigating cognitive differences between potential subtypes of BD was conducted.

METHODS

It was possible to conduct a meta-analysis of studies investigating the relationship between cognitive deficits and subgroups of DSM-IV BD (type I (BD-I) and type II (BD-II)), subgroups based on history of psychosis (PBD and NPBD). The cognitive domains investigated in this meta-analysis included verbal memory, visual memory, processing speed, executive functions speed (EF-speed), EF-accuracy, attention, working memory, social cognition. Current meta-analysis included 48 reports and compared cognitive performances of 1211 BD-I and 836 BD-II patients. It also compared cognitive functioning in 1017 PBD and 744 NPBD patients.

RESULTS

Both history of psychosis (d = 0.19) and BD-I (d = 0.17) diagnosis were associated with modestly more pronounced global cognitive impairment. In specific domains, BD-I significantly underperformed BD-II in verbal memory, processing speed, EF-speed, EF-accuracy (d = 0.15-0.26). PBD was associated with significantly impaired cognition compared to NPBD in verbal memory, processing speed, EF-speed, EF-accuracy, working memory and social cognition (d = 0.12-0.28).

CONCLUSION

In BD, history of psychosis and full-manic episode are modestly associated with increased cognitive deficits. Neurocognitive differences between clinical subtypes of BD are quite subtle and are not distinctive. Furthermore, other factors reflecting differences in illness severity can explain observed between-group differences. Most of the cognitive heterogeneity in BD cannot be explained by proposed subtypes of BD.

Cognitive Impairment In Treatment-Naïve Bipolar II and Unipolar Depression

Cognition dysfunction may reflect trait characteristics of bipolarity but cognitive effects of medications have confounded previous comparisons of cognitive function between bipolar II and unipolar depression, which are distinct clinical disorders with some overlaps. Therefore, we examined the executive function (WCST), attention, cognitive speed (TMT-A) and memory (CAVLT, WMS-Visual reproduction) of 20 treatment-naïve bipolar II patients (BPII), 35 treatment-naïve unipolar depressed (UD) patients, and 35 age/sex/education matched healthy controls. The subjects were young (aged 18–35), and had no history of psychosis or substance use, currently depressed and meeting either RDC criteria for Bipolar II Disorder or DSM-IV-TR criteria for Major Depressive Disorder. The patients were moderately depressed (MADRS) and anxious(HAM-A), on average within 3.44 years of illness onset. Sociodemographic data and IQ were similar between the groups. UD patients had significantly slower cognitive speed and cognitive flexibility (WCST perseverative error). BPII depressed patients showed relatively intact cognitive function. Verbal memory (CAVLT List A total) correlated with illness chronicity only in BPII depression, but not UD. In conclusion, young and treatment-naïve BPII depressed patients differed from unipolar depression by a relatively intact cognitive profile and a chronicity-cognitive correlation that suggested a stronger resemblance to Bipolar I Disorder than Unipolar Depression.

Cognitive deficits in bipolar disorders: Implications for emotion

Prominent cognitive deficits have been documented in bipolar disorder, and multiple studies suggest that these deficits can be observed among non-affected first-degree relatives of those with bipolar disorder. Although there is variability in the degree of cognitive deficits, these deficits are robustly relevant for functional outcomes. A separate literature documents clear difficulties in emotionality, emotion regulation, and emotion-relevant impulsivity within bipolar disorder, and demonstrates that these emotion-relevant variables are also central to outcome. Although cognitive and emotion domains are typically studied independently, basic research and emergent findings in bipolar disorder suggest that there are important ties between cognitive deficits and the emotion disturbances observed in bipolar disorder. Understanding these relationships has relevance for fostering more integrative research, for clarifying relevant aspects related to functionality and vulnerability within bipolar disorder, and for the development of novel treatment interventions. Bipolar disorder (BD) is a severe psychiatric illness that has been ranked as one of the 20 leading medical causes of disability (WHO, 2011). BD has been shown to be the psychiatric disorder with the highest rates of completed suicide across two major cohort studies (Ilgen et al., 2010; Nordentoft, Mortensen, & Pedersen, 2011). In a cross-national representative sample, one in four persons diagnosed with bipolar I disorder reported a suicide attempt (Merikangas et al., 2011). Rates of relapse remain high despite available treatments (Gitlin, Swendsen, Heller, & Hammen, 1995), and in the year after hospitalization for manic episode, two-thirds of patients do not return to work (Strakowski et al., 1998). Poverty, homelessness, and incarceration are all too common (Copeland et al., 2009). Despite the often poor outcomes, there is also evidence for outstanding accomplishments and creativity among those with milder forms of the disorder and their family members (Coryell et al., 1989; Jamison, 1993; Murray & Johnson, 2010). Some individuals appear to achieve more than the general population, suggesting the importance of understanding the variables that predict differential outcome within bipolar disorder. Within this paper, we focus on two key predictors of outcomes within bipolar disorder: cognition and emotionality. We review evidence that problems in cognition and emotionality are prominent among those diagnosed with the disorder, are not artifacts of symptom state, and relate substantively to poorer outcomes. Although traditionally studied separately, new work points toward the idea that cognition and emotionality are intricately linked within bipolar disorder. Drawing from research within bipolar disorder as well as outside of bipolar disorder, we build a model of how cognition and emotionality might be tied within bipolar disorder. We then provide suggestions for future research. Before considering findings, it is worth noting that there are several forms of the disorder, defined by varying degrees and duration of manic symptoms (APA, 2013; WHO, 1993). Manic episodes are defined by abnormally elevated or irritable mood, accompanied by increased activity and at least three symptoms (four if mood is only irritable) such as decreased need for sleep, increased self-confidence, racing thoughts or flight of ideas, rapid speech, distractibility, goal-directed activity, and engagement in pleasurable activities without regard to potential negative consequences. To meet criteria for mania, these symptoms must persist for at least one week or require hospitalization, and must lead to difficulties with functioning. If functional impairment is not more than mild and duration is between 4 and 6 days, the episode is considered a hypomanic episode. Bipolar I disorder (BD I) is diagnosed on the basis of at least one lifetime manic episode within the DSM-5 and by at least two episodes within the ICD, whereas bipolar II disorder is diagnosed on the basis of at least one hypomanic episode (and no manic episodes) as well as major depressive episodes. Cyclothymic disorder is defined by chronic but milder fluctuations between manic and depressive symptoms. Most research focuses on BD I. In addition to diagnosed samples, research has focused on those at high risk for bipolar disorder, including first-degree relatives of those with BD. This work draws on the evidence for extremely high heritability of BD I, with estimates from community-based twin studies of 0.85 (Kieseppä, Partonen, Haukka, Kaprio, & Lönnqvist, 2014). Other research has considered high risk for BD by virtue of lifetime subsyndromal symptoms, as measured by scales such as the Hypomanic Personality Scale (Eckblad & Chapman, 1986) or the General Behavior Inventory (Depue, Krauss, Spoont, & Arbisi, 1989). The study of high-risk individuals provides a way to decipher whether deficits are present before the onset of the disorder, of importance given models suggesting that episodes of the disorder may change brain function (Chang, Steiner, & Ketter, 2000; Strakowski, 2012) as well as individuals' perceptions of their emotion regulation. Beyond defining BD, it is worth defining some of the many different neuropsychological tasks that have been widely studied in BD. Perhaps no area has received more attention than executive function. Executive function is related to three core functions: 1) inhibition, the ability to suppress irrelevant information in working memory in order to accomplish an established goal; 2) working memory, the ability to hold and manipulate information in mind; and 3) cognitive flexibility, the ability to shift strategies in response to feedback (Diamond, 2013; Miyake et al., 2000). Attention (defined as the process of selecting information reception from internal or external cues) is implicated in all three of these aspects of executive function. Much of the literature we will discuss focuses on response inhibition, or the ability to suppress a prepotent response, which is considered a subtype of inhibition. Some tests measure multiple facets of executive function; for example the Trails B test likely requires working memory and cognitive flexibility (Sánchez-Cubillo et al., 2009). Aside from executive function, multiple other facets of cognition have been widely studied in bipolar disorder. Verbal and non-verbal memory are related to the ability to register, store and retrieve verbal or visual information (Lezak, 1995). Verbal fluency is measured as the number of verbal responses a person can generate to a given target, such as a specific semantic category (e.g., animals, furniture) or phonetic category (e.g., words that begin with letter F) (Diamond, 2013). Although cognitive tasks have been designed to evaluate these specific functions, it is important to note that most measures are highly inter-correlated and may assess multiple overlapping functions to some extent (for example, the Trails B test is often described as an "executive function" task, although this task likely involves both working memory and cognitive flexibility. Not surprisingly, then, some authors label the function of certain tests differently, and this is particularly evident in meta-analyses of cognition. As we describe findings in this paper, we will use the terms proposed by the authors but will also identify key tests used to define a cognitive construct. With this background in mind, we turn to a discussion of cognitive deficits, then of emotion-related traits. Our hope is that those concise summaries provide evidence for the importance of both domains, but also specificity regarding the facets of emotion and cognition that are most impaired in BD. This specificity then guides our consideration of models that integrate cognition and emotion.

Executive functioning deficits among adults with Bipolar Disorder (types I and II): A systematic review and meta-analysis

BACKGROUND

Executive functioning (EF) deficits contribute to a significant proportion of the burden of disease associated with bipolar disorder (BD). Yet, there is still debate in the literature regarding the exact profile of executive functioning in BD. The purpose of the present project was to assess whether EF deficits exist among adults suffering BD, and whether these deficits (if apparent) differ by BD subtype.

METHODS

A systematic search identified relevant literature. Randomised controlled trials that used neuropsychological assessment to investigate EF among adults 16-65 years) with a remitted DSM diagnosis of BD (type I or II) were included. Studies were published between 1994 and 2015. A systematic review and meta-analysis were undertaken. For individual studies, standardised mean differences (Cohen's d) and 95% confidence intervals were calculated and represented in forest plots to illustrate differences in executive performance between groups. Summary effects were produced and tests of heterogeneity employed to assess the dispersion and generalisability of results.

RESULTS

Thirty-six studies met criteria for inclusion. Six domains of EF were identified: Set-shifting (SS), inhibition (INH), planning (PLA), verbal fluency (VF), working memory (WM), and attention (ATT). BD1s performed worse than HCs in all domains. BD2s demonstrated impairment in VF, WM, SS, and ATT. The results were mixed for comparisons between BD1s and BD2s, but revealed that BD2s can experience similar (or sometimes greater) EF impairment.

LIMITATIONS

Only a limited number of studies that included BD2 samples were available for inclusion in the current study. Subgroup analysis to elucidate potential moderators of within-study variance was not undertaken.

CONCLUSION

This is the first systematic review and meta-analysis to have compared the EF of remitted BD1s, BD2s, and HCs. The results provided useful insight into the EF profile of patients with BD, and offered commentary as to some of the contradictory results reported in the literature. A standardised methodological protocol for assessment of EF in BD was proposed. The information in this review could enhance our understanding of EF impairment inherent in BD, and the methods and efficacy with which clinicians assess and treat this population.

Neural correlates of childhood trauma with executive function in young healthy adults

The aim of this study was to investigate the relationship among childhood trauma, executive impairments, and altered resting-state brain function in young healthy adults. Twenty four subjects with childhood trauma and 24 age- and gender-matched subjects without childhood trauma were recruited. Executive function was assessed by a series of validated test procedures. Localized brain activity was evaluated by fractional amplitude of low frequency fluctuation (fALFF) method and compared between two groups. Areas with altered fALFF were further selected as seeds in subsequent functional connectivity analysis. Correlations of fALFF and connectivity values with severity of childhood trauma and executive dysfunction were analyzed as well. Subjects with childhood trauma exhibited impaired executive function as assessed by Wisconsin Card Sorting Test and Stroop Color Word Test. Traumatic individuals also showed increased fALFF in the right precuneus and decreased fALFF in the right superior temporal gyrus. Significant correlations of specific childhood trauma severity with executive dysfunction and fALFF value in the right precuneus were found in the whole sample. In addition, individuals with childhood trauma also exhibited diminished precuneus-based connectivity in default mode network with left ventromedial prefrontal cortex, left orbitofrontal cortex, and right cerebellum. Decreased default mode network connectivity was also associated with childhood trauma severity and executive dysfunction. The present findings suggest that childhood trauma is associated with executive deficits and aberrant default mode network functions even in healthy adults. Moreover, this study demonstrates that executive dysfunction is related to disrupted default mode network connectivity.

Impact of childhood trauma on cognitive profile in bipolar disorder

OBJECTIVES

Bipolar Disorder (BD) is associated with cognitive impairment even during remission periods. Nonetheless, this impairment seems to adjust to different profiles of severity. Our aim was to examine the potential impact of childhood trauma (CT) on cognitive performance and, more specifically, on neurocognitive profile membership.

METHODS

Using a data-driven strategy, 113 euthymic bipolar patients were grouped according to their cognitive performance using a hierarchical clustering technique. Patients from the three resulting clusters, the so-called "low", "average", and "high performance" groups, were then compared in terms of main sociodemographic, clinical and functioning variables, including CT measures. One-way ANOVA, a chi-square test and partial correlations were used for this purpose, as appropriate. A multinomial logistic regression model was used to determine which variables contributed to neurocognitive clustering membership.

RESULTS

Patients from the three neurocognitive clusters differed in terms of sociodemographic, clinical, functioning and CT variables. Scores on the Childhood Trauma Questionnaire (CTQ), especially on the physical negligence subscale, were also associated with a poor cognitive performance. The multinomial regression model indicated that CTQ total scores and the estimated intelligence quotient (IQ) significantly contributed to differentiation among the three neurocognitive groups.

CONCLUSIONS

Our results confirmed that CT significantly impacts on cognitive performance during adulthood in BD. The data obtained suggest that a history of CT could act as a liability marker for cognitive impairment. A higher estimated IQ may act as a protective factor against cognitive decline in this group of patients.

Differences in cognitive deficits in individuals with subthreshold syndromes with and without family history of bipolar disorder

Little is known about the development of cognitive deficits prior to the official onset of bipolar disorder (BP). The aim of this study was to investigate neurocognitive performance in two early stages of BP. This high-risk design study recruited a group of offspring of parents with BP (n = 58), aged 8-28 years. Based on the subthreshold syndromes, the "unaffected" offspring were further divided into high-risk (HR) and ultra-high-risk (UHR) stages. For comparison, a group of individuals with subthreshold symptoms but without family history of psychiatric disorder (n = 17) and 48 healthy controls (HCs) were included. The MATRICS Consensus Cognitive Battery (MCCB) and Tower of London task were applied to assess neuropsychological performance. The HR offspring performed significantly poorer on verbal learning and memory when compared with HCs, indicating that the deficits may serve as neurocognitive endophenotypes for BP. Deficits in working memory, visual-spatial memory, and cognitive planning were observed in the UHR offspring when compared with HCs, suggestive of risk of developing BP. The deficits observed in the UHR offspring were absent in the individuals with subthreshold symptoms without psychiatric family history. Our data suggest that cognitive deficits become apparent prior to the official onset of BP, with specific deficits observable in different early stages. These results nonetheless are based on small sample size and a cross-sectional design. Given this and the heterogeneity of bipolar disorders, these findings should be interpreted cautiously and require replication.

Disentangling Working Memory Functioning in Mood States of Bipolar Disorder: A Systematic Review

Working memory (WM) deficits are often reported in patients with Bipolar Disorder (BD). However, it is not clear about the nature of these WM deficits (update or serial order processes) and their association with each BD states (euthymic, mania, and depressive). This review investigated the association between BD patient's states and the functioning of WM components. For this purpose, we carried out a systematic review fulfilling a search in the databases Medline, Scopus, SciELO, and Web of Science using specific terms in the abstracts of the articles that generated 212 outcomes in the restricted period from 2005 to 2016. Twenty-three papers were selected, completely read, and analyzed using PICOS strategy. The mood episodes predicted deficits in different components of WM in BD patients (the phonological loop or visuospatial sketchpad) and were associated with different WM processes (updating and serial recall). Lower cognitive scores persist even in remission of symptoms. This result suggests that WM deficit apparently is stage-independent in BD patients. Furthermore, findings suggest that the neutral point on Hedonic Detector component of WM could be maladjusted by BD.

Lithium and cognition in those with bipolar disorder

Although a percentage of patients report cognitive side-effects when taking lithium, it can be difficult to determine from the literature whether any cognitive changes reflect lithium itself, the lithium serum level, residual mood symptoms, the underlying nature of bipolar disorder, or biological alterations such as hypothyroidism. This review was carried out to synthesize and evaluate relevant literature examining any cognitive impact of lithium in those with bipolar disorder. The effect of lithium in those with bipolar disorder was examined across the cognitive domains of attention, psychomotor speed, processing speed, working memory, intellectual functioning, verbal memory, visual memory, and executive functioning by reviewing the published empirical literature. Any impact of hypothyroidism and lithium toxicity was also examined. The literature supports the conclusion that lithium has a distinct impact on psychomotor speed in participants with bipolar disorder. In contrast, there appears to be no impact on attention. Any impact of lithium on memory in patients with bipolar disorder is unclear as the literature is contradictory and any such effect may be overshadowed by the greater impact of residual mood symptoms. The impact on processing speed, intellectual abilities, and executive functioning also remains unclear. Several clinical management strategies are recommended.

Deconstructing Bipolar Disorder and Schizophrenia: A cross-diagnostic cluster analysis of cognitive phenotypes

BACKGROUND

Bipolar disorder (BD) and schizophrenia (SZ) show substantial overlap. It has been suggested that a subgroup of patients might contribute to these overlapping features. This study employed a cross-diagnostic cluster analysis to identify subgroups of individuals with shared cognitive phenotypes.

METHOD

143 participants (68 BD patients, 39 SZ patients and 36 healthy controls) completed a battery of EEG and performance assessments on perception, nonsocial cognition and social cognition. A K-means cluster analysis was conducted with all participants across diagnostic groups. Clinical symptoms, functional capacity, and functional outcome were assessed in patients.

RESULTS

A two-cluster solution across 3 groups was the most stable. One cluster including 44 BD patients, 31 controls and 5 SZ patients showed better cognition (High cluster) than the other cluster with 24 BD patients, 35 SZ patients and 5 controls (Low cluster). BD patients in the High cluster performed better than BD patients in the Low cluster across cognitive domains. Within each cluster, participants with different clinical diagnoses showed different profiles across cognitive domains.

LIMITATIONS

All patients are in the chronic phase and out of mood episode at the time of assessment and most of the assessment were behavioral measures.

CONCLUSIONS

This study identified two clusters with shared cognitive phenotype profiles that were not proxies for clinical diagnoses. The finding of better social cognitive performance of BD patients than SZ patients in the Lowe cluster suggest that relatively preserved social cognition may be important to identify disease process distinct to each disorder.

Leveling and abuse among patients with bipolar disorder at psychiatric outpatient departments in Ethiopia

INTRODUCTION

The World Health Organization (WHO) clearly states the importance of psychological well-being in the definition of health as "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity". However, in the community, the lives of people with bipolar disorders are often harsh and abusive. Till now, the rate and related information concerning verbal or physical abuse among patients with bipolar disorder at psychiatric outpatient clinics have not been well addressed in Ethiopian settings.

METHODS

Data were collected by interviewing 411 systematically selected participants at outpatient department of Amanuel Mental Specialized Hospital. For analysis, logistic regression and adjusted odds ratios (AOR) with 95% confidence intervals (CI) were used, and P  < 0.05 was considered statistically significant.

RESULTS

The prevalence of abuse (verbal/physical) was 37.7%. Having two or more episodes [AOR 1.70, 95% CI (1.06, 2.74)], a history of aggression [AOR 3.06, 95% CI (1.63, 5.75)] and comorbid illness [AOR 2.21, 95% CI (1.25, 3.90)] were significantly associated.

CONCLUSION

The prevalence of reported abuse is high among patients with bipolar disorder, and it is important to remember the rights of patients during treatment.

Relationship between childhood adversity and bipolar affective disorder: systematic review and meta-analysis

BACKGROUND

The relationship between childhood adversity and bipolar affective disorder remains unclear.

AIMS

To understand the size and significance of this effect through a statistical synthesis of reported research.

METHOD

Search terms relating to childhood adversity and bipolar disorder were entered into Medline, EMBASE, PsycINFO and Web of Science. Eligible studies included a sample diagnosed with bipolar disorder, a comparison sample and a quantitative measure of childhood adversity.

RESULTS

In 19 eligible studies childhood adversity was 2.63 times (95% CI 2.00-3.47) more likely to have occurred in bipolar disorder compared with non-clinical controls. The effect of emotional abuse was particularly robust (OR = 4.04, 95% CI 3.12-5.22), but rates of adversity were similar to those in psychiatric controls.

CONCLUSIONS

Childhood adversity is associated with bipolar disorder, which has implications for the treatment of this clinical group. Further prospective research could clarify temporal causality and explanatory mechanisms.

Evidence-based guidelines for treating bipolar disorder: Revised third edition recommendations from the British Association for Psychopharmacology

The British Association for Psychopharmacology guidelines specify the scope and targets of treatment for bipolar disorder. The third version is based explicitly on the available evidence and presented, like previous Clinical Practice Guidelines, as recommendations to aid clinical decision making for practitioners: it may also serve as a source of information for patients and carers, and assist audit. The recommendations are presented together with a more detailed review of the corresponding evidence. A consensus meeting, involving experts in bipolar disorder and its treatment, reviewed key areas and considered the strength of evidence and clinical implications. The guidelines were drawn up after extensive feedback from these participants. The best evidence from randomized controlled trials and, where available, observational studies employing quasi-experimental designs was used to evaluate treatment options. The strength of recommendations has been described using the GRADE approach. The guidelines cover the diagnosis of bipolar disorder, clinical management, and strategies for the use of medicines in short-term treatment of episodes, relapse prevention and stopping treatment. The use of medication is integrated with a coherent approach to psychoeducation and behaviour change.

Die Bedeutung kognitiver Beeinträchtigungen bei depressiven Patienten

Zusammenfassung. Beeinträchtigungen der Exekutivfunktionen, der Aufmerksamkeit und des Gedächtnisses sind einige der häufigsten und hartnäckigsten Symptome depressiver Störungen. Bisher konnte allerdings kein eindeutiges Profil dieser Defizite identifiziert werden, wahrscheinlich auch deshalb, weil die Defizite von verschiedenen klinischen und demografischen Faktoren, wie dem Depressionssubtypus, Grübeln, Komorbiditäten und Alter beeinflusst werden. Die kognitiven Beeinträchtigungen verbessern sich mit der Remission der Störung, häufig findet jedoch keine vollständige Rückbildung statt. Sie sind klinisch sehr relevant und gehen einher mit Suizidalität, reduzierten Therapieeffekten und negativen Auswirkungen auf Alltagsaktivitäten. Aus diesen Gründen ergibt sich für betroffene Patienten die Notwendigkeit einer neuropsychologischen Behandlung. Erste Ergebnisse lassen hoffen, dass die kognitiven Beeinträchtigungen mithilfe neuropsychologischer Therapie, Achtsamkeitstraining, psychopharmakologischer Therapie und weiteren neurobiologischen Behandlungen, wie z. B. der repetitiven transkraniellen Magnetstimulation, erfolgreich behandelt werden können.

Deficient inhibitory control as an outcome of childhood trauma

Childhood trauma has been linked to the development and severity of psychiatric disorders as well as deficits in cognitive functioning. This study aimed to investigate the performance of bipolar disorder (BD) patients and healthy controls (HC), with or without a history of childhood trauma, on a parametric Go/No-Go (PGNG) task measuring important aspects of executive functions, namely attention and inhibitory control. Two hundred and thirty-three individuals with BD and 90 HC completed diagnostic interview, childhood trauma questionnaire (CTQ), symptom severity scales, and a PGNG task. Four comparison groups were created using a 1.0 standard deviation cut-off of the mean of the HC total CTQ score: BD-trauma, BD-normative, HC-trauma and HC-normative. We assessed interactions between diagnosis and trauma on Go/No-Go levels of interest by using a two-way multivariate analysis of covariance. Results showed a significant main effect of trauma on inhibitory control accuracy, as the trauma group exhibited significantly poorer accuracy on inhibition trials compared to the normative group. There was also a main effect of diagnosis on response time. These findings suggest that early trauma might adversely impact the development of cognitive systems and brain circuits that support inhibitory aspects of executive functioning in individuals with a history of trauma.

The role of childhood trauma in bipolar disorders

This review will discuss the role of childhood trauma in bipolar disorders. Relevant studies were identified via Medline (PubMed) and PsycINFO databases published up to and including July 2015. This review contributes to a new understanding of the negative consequences of early life stress, as well as setting childhood trauma in a biological context of susceptibility and discussing novel long-term pathophysiological consequences in bipolar disorders. Childhood traumatic events are risk factors for developing bipolar disorders, in addition to a more severe clinical presentation over time (primarily an earlier age at onset and an increased risk of suicide attempt and substance misuse). Childhood trauma leads to alterations of affect regulation, impulse control, and cognitive functioning that might decrease the ability to cope with later stressors. Childhood trauma interacts with several genes belonging to several different biological pathways [Hypothalamic–pituitary–adrenal (HPA) axis, serotonergic transmission, neuroplasticity, immunity, calcium signaling, and circadian rhythms] to decrease the age at the onset of the disorder or increase the risk of suicide. Epigenetic factors may also be involved in the neurobiological consequences of childhood trauma in bipolar disorder. Biological sequelae such as chronic inflammation, sleep disturbance, or telomere shortening are potential mediators of the negative effects of childhood trauma in bipolar disorders, in particular with regard to physical health. The main clinical implication is to systematically assess childhood trauma in patients with bipolar disorders, or at least in those with a severe or instable course. The challenge for the next years will be to fill the gap between clinical and fundamental research and routine practice, since recommendations for managing this specific population are lacking. In particular, little is known on which psychotherapies should be provided or which targets therapists should focus on, as well as how childhood trauma could explain the resistance to mood stabilizers.

The neurocognitive profile of mood disorders - a review of the evidence and methodological issues

OBJECTIVES

Cognitive abnormalities are an established part of the symptomatology of mood disorders. However, questions still exist regarding the exact profile of these deficits in terms of the domains most affected, their origins, and their relationship to clinical subtypes. This review aims to examine the current state of the evidence and to examine ways in which the field may be advanced.

METHODS

Studies examining cognitive function in bipolar disorder (BD) and unipolar major depression (MDD) were examined. Given the number and variability of such studies, particular attention was paid to meta-analyses and to meta-regression analyses which examined the possible mediators of cognitive impairment.

RESULTS

Meta-analyses are available for MDD and BD in both depression and euthymia. Several analyses examine mediators. Results do not support the presence of domain specific deficits but rather a moderate deficit across a range of domains in BD and in MDD. The data on clinical mediators is inconsistent, even with regard to the effect of mood state.

CONCLUSIONS

A two-tiered approach, with the broad-based application of standardized measures on a large-scale, and the refined application of theoretically driven experimental development would significantly further our understanding of neurocognitive processing in mood disorder.

The association between childhood trauma and facial emotion recognition in adults with bipolar disorder

Many patients with bipolar disorder (BD) have difficulties in facial emotion recognition, which may also be impaired in maltreated children and in subjects who have a positive history of childhood traumatic experiences. Childhood trauma is reported with a high prevalence in BD and it is considered a risk factor for the disorder. As the relationship between facial emotion recognition and childhood trauma in BD has not yet been directly investigated, in this study we examined whether the presence of a childhood trauma in affectively stable BD patients was associated with poorer performance in emotion recognition. Seventy-five BD I and II participants completed the Childhood Trauma Questionnaire retrospectively assessing five types of childhood trauma (emotional, physical and sexual abuse, and emotional and physical neglect) and the Emotion Recognition Task evaluating the ability to correctly identify six basic facial emotions (happiness, sadness, anger, disgust, fear and surprise). Our results suggest that the presence of childhood trauma in participants with BD is associated with a more severe clinical presentation (earlier onset, longer duration of illness, and higher depressive symptom ratings) and that BD patients with a positive childhood history of emotional neglect perform worse than those without such a history in recognizing anger.

Childhood abuse and neglect may induce deficits in cognitive precursors of psychosis in high-risk children

BACKGROUND

Millions of children are born to parents affected by major psychoses. Cognitive dysfunctions seen in patients are already detectable in these children. In parallel, childhood maltreatment increases the risk of adult psychoses through unknown mechanisms. We investigated whether high-risk offspring exposed to abuse/neglect displayed more cognitive precursors of adult psychoses in childhood and adolescence than nonexposed offspring.

METHODS

We used a stepwise selection strategy from a 25-year follow-up of 48 densely affected kindreds including 1500 adults (405 patients with schizophrenia or bipolar disorder) to select high-risk offspring aged 6-22 years for inclusion in our study. All offspring were assessed for childhood trauma from direct interviews with the offspring, parents and relatives and from the review of lifetime medical records of parents and children and administered a neuropsychological battery including IQ and 4 of the most impaired neuropsychological domains in psychoses.

RESULTS

Our study included 66 high-risk offspring. Those who were exposed to abuse/neglect had significantly lower IQ (effect size [ES] = 0.61) than nonexposed offspring and displayed poorer cognitive performance in visual episodic memory (ES = 0.67) and in executive functions of initiation (ES = 1.01). Moreover, exposed offspring presented more combinations of cognitive deficits that were associated with lower Global Assessment of Functioning scores.

LIMITATIONS

Exposure to abuse/neglect was not assessed in the control group, thus the study could not test whether the effect of childhood maltreatment occurred only in a high-risk setting and not in the general population.

CONCLUSION

In high-risk youths, maltreatment in childhood/adolescence may negatively impact cognitive domains known to be impaired in adults with psychoses, suggesting an early mediating effect in the association between abuse/neglect and adult psychoses. This finding provides a target for future developmental and preventive research.

Cognitive enhancing agents in schizophrenia and bipolar disorder

Cognitive dysfunction is a core feature of schizophrenia and is also present in bipolar disorder (BD). Whereas decreased intelligence precedes the onset of psychosis in schizophrenia and remains relatively stable thereafter; high intelligence is a risk factor for bipolar illness but cognitive function decreases after onset of symptoms. While in schizophrenia, many studies have been conducted on the development of cognitive enhancing agents; in BD such studies are almost non-existent. This review focuses on the pharmacological agents with putative effects on cognition in both schizophrenia and bipolar illness; specifically agents targeting the dopaminergic, cholinergic and glutamatergic neurotransmitter pathways in schizophrenia and the cognitive effects of lithium, anticonvulsants and antipsychotics in BD. In the final analysis we conclude that cognitive enhancing agents have not yet been produced convincingly for schizophrenia and have hardly been studied in BD. Importantly, studies should focus on other phases of the illness. To be able to treat cognitive deficits effectively in schizophrenia, patients in the very early stages of the illness, or even before - in the ultra-high risk stages - should be targeted. In contrast, cognitive deficits occur later in BD, and therefore drugs should be tested in BD after the onset of illness. Hopefully, we will then find effective drugs for the incapacitating effects of cognitive deficits in these patients.

Toward the identification of neurocognitive subtypes in euthymic patients with bipolar disorder

BACKGROUND

Cross-sectional and meta-analytic studies showed that patients with bipolar disorder (BD) had neurocognitive impairments even during periods of euthymia. The aim of this study was to estimate the prevalence of BD patients with and without clinically significant cognitive impairments, as well as to analyze clinical and functional variables in these subgroups.

METHODS

Hundred patients with BD and 40 healthy controls were assessed with an extensive neurocognitive assessment. Soft (some cognitive domain with a performance below 1.5 SD of the mean) and hard (at least two domains with values below 2 SD of the mean) criteria were utilized to define clinically significant cognitive impairments.

RESULTS

Using both soft and hard criteria, the prevalence of clinically significant cognitive impairments was higher in people with BD than in healthy controls. 70% of patients only showed failures of small effect (d=0.21-0.35) in 2 measures of executive functions. Moreover, 30% of patients were indistinguishable from healthy subjects in terms of both neurocognitive and psychosocial functioning. On the contrary, 30% of the sample showed more severe cognitive deficits than those usually reported in literature and had the worst psychosocial functioning.

CONCLUSIONS

The fact that cognitive impairments are very heterogeneous among euthymic patients with BD could contribute to understanding differences in functional outcome. Theoretical and practical implications of these findings are discussed.

Glycogen synthase kinase-3 as a therapeutic target for cognitive dysfunction in neuropsychiatric disorders

The serine/threonine kinase glycogen synthase kinase-3 (GSK-3) is involved in a broad range of cellular processes including cell proliferation, apoptosis and inflammation. It is now also increasingly acknowledged as having a role to play in cognitive-related processes such as neurogenesis, synaptic plasticity and neural cell survival. Cognitive impairment represents a major debilitating feature of many neurodegenerative and psychiatric disorders, including Alzheimer's disease, mood disorders, schizophrenia and fragile X syndrome, as well as being a result of traumatic brain injury or cranial irradiation. Accordingly, GSK-3 has been identified as an important therapeutic target for cognitive impairment, and recent preclinical studies have yielded important evidence demonstrating that GSK-3 inhibitors may be useful therapeutic interventions for restoring cognitive function in some of these brain disorders. The current review summarises the role of GSK-3 as a regulator of cognitive-dependent functions, examines current preclinical and clinical evidence of the potential of GSK-3 inhibitors as therapeutic agents for cognitive impairments in neuropsychiatric disorders, and offers some insight into the current obstacles that are impeding the clinical use of selective GSK-3 inhibitors in the treatment of cognitive impairment.

The neurocognitive functioning in bipolar disorder: a systematic review of data

BACKGROUND

During the last decades, there have been many different opinions concerning the neurocognitive function in Bipolar disorder (BD). The aim of the current study was to perform a systematic review of the literature and to synthesize the data in a comprehensive picture of the neurocognitive dysfunction in BD.

METHODS

Papers were located with searches in PubMed/MEDLINE, through June 1st 2015. The review followed a modified version of the recommendations of the Preferred Items for Reporting of Systematic Reviews and Meta-Analyses statement.

RESULTS

The initial search returned 110,403 papers. After the deletion of duplicates, 11,771 papers remained for further evaluation. Eventually, 250 were included in the analysis.

CONCLUSION

The current review supports the presence of a neurocognitive deficit in BD, in almost all neurocognitive domains. This deficit is qualitative similar to that observed in schizophrenia but it is less severe. There are no differences between BD subtypes. Its origin is unclear. It seems it is an enduring component and represents a core primary characteristic of the illness, rather than being secondary to the mood state or medication. This core deficit is confounded (either increased or attenuated) by the disease phase, specific personal characteristics of the patients (age, gender, education, etc.), current symptomatology and its treatment (especially psychotic features) and long-term course and long-term exposure to medication, psychiatric and somatic comorbidity and alcohol and/or substance abuse.

The impact of past direct-personal traumatic events on 12-month outcome in first episode psychotic mania: trauma and early psychotic mania

OBJECTIVE

Past traumatic events have been associated with poorer clinical outcomes in people with bipolar disorder. However, the impact of these events in the early stages of the illness remains unclear. The aim of this study was to investigate whether prior traumatic events were related to poorer outcomes 12 months following a first episode of psychotic mania.

METHODS

Traumatic events were retrospectively evaluated from patient files in a sample of 65 participants who had experienced first episode psychotic mania. Participants were aged between 15 and 28 years and were treated at a specialised early psychosis service. Clinical outcomes were measured by a variety of symptomatic and functioning scales at the 12-month time-point.

RESULTS

Direct-personal traumatic experiences prior to the onset of psychotic mania were reported by 48% of the sample. Participants with past direct-personal trauma had significantly higher symptoms of mania (p=0.02), depression (p=0.03) and psychopathology (p=0.01) 12 months following their first episode compared to participants without past direct-personal trauma, with medium to large effects observed. After adjusting for baseline scores, differences in global functioning (as measured by the Global Assessment of Functioning scale) were non-significant (p=0.05); however, participants with past direct-personal trauma had significantly poorer social and occupational functioning (p=0.04) at the 12-month assessment with medium effect.

CONCLUSIONS

Past direct-personal trauma may predict poorer symptomatic and functional outcomes after first episode psychotic mania. Limitations include that the findings represent individuals treated at a specialist early intervention centre for youth and the retrospective assessment of traumatic events may have been underestimated.

Childhood trauma in bipolar disorder

OBJECTIVE

There has been little investigation of early trauma in bipolar disorder despite evidence that stress impacts on the course of this illness. We aimed to compare the rates of childhood trauma in adults with bipolar disorder to a healthy control group, and to investigate the impact of childhood trauma on the clinical course of bipolar disorder.

METHODS

Retrospective assessment of childhood trauma was conducted using the Childhood Trauma Questionnaire (CTQ) in 60 outpatients with bipolar disorder being treated for a depressive episode and 55 control participants across two centres in north-east England and New Zealand.

RESULTS

Significantly higher rates of childhood trauma were observed in patients with bipolar I and bipolar II disorder compared to controls. Logistic regression, controlling for age and sex, identified emotional neglect to be the only significant CTQ subscale associated with a diagnosis of bipolar disorder. Childhood history of sexual abuse was not a significant predictor. Associations with clinical severity or course were less clear.

CONCLUSIONS

Childhood emotional neglect appears to be significantly associated with bipolar disorder. Limitations include the relatively small sample size, which potentially increases the risk of type II errors. Replication of this study is required, with further investigation into the neurobiological consequences of childhood trauma, particularly emotional neglect.

12-month longitudinal cognitive functioning in patients recently diagnosed with bipolar disorder

OBJECTIVES

Although cognitive deficits are observed in the early stages of bipolar disorder, the longitudinal course of neuropsychological functioning during this period is unknown. Such knowledge could provide etiologic clues into the cognitive deficits associated with the illness, and could inform early treatment interventions. The purpose of the present study was to evaluate cognitive change in bipolar disorder in the first year after the initial manic episode.

METHODS

From an initial pool of 65 newly diagnosed patients with bipolar disorder (within three months of the end of the first manic or mixed episode) and 36 demographically similar healthy participants, 42 patients [mean age 22.9 years, standard deviation (SD) = 4.0] and 23 healthy participants [mean age 22.9 years (SD = 4.9)] completed baseline, six-month, and one-year neuropsychological assessments of multiple domains including processing speed, attention, verbal and nonverbal memory, working memory, and executive function. Patients also received clinical assessments, including mood ratings.

RESULTS

Although patients showed consistently poorer cognitive performance than healthy individuals in most cognitive domains, patients showed a linear improvement over time in processing speed (p = 0.008) and executive function (p = 0.004) relative to the comparison group. Among patients, those without a history of alcohol/substance abuse or who were taken off an antipsychotic treatment during the study showed better improvement.

CONCLUSIONS

The early course of cognitive functioning in bipolar disorder is likely influenced by multiple factors. Nevertheless, patients with bipolar disorder showed select cognitive improvements in the first year after resolution of their initial manic episode. Several clinical variables were associated with better recovery, including absence of substance abuse and discontinuation of antipsychotic treatment during the study. These and other factors require further investigation to better understand their contributions to longitudinal cognitive functioning in early bipolar disorder.

Childhood maltreatment and corpus callosum volume in recently diagnosed patients with bipolar I disorder: data from the Systematic Treatment Optimization Program for Early Mania (STOP-EM)

Childhood trauma (CT) has been associated with abnormalities in the corpus callosum (CC). Decreased CC volumes have been reported in children and adolescents with trauma as well as adults with CT compared to healthy controls. CC morphology is potentially susceptible to the effects of Bipolar Disorder (BD) itself. Therefore, we evaluated the relationship between CT and CC morphology in BD. We using magnetic resonance imaging in 53 adults with BD recently recovered from their first manic episode, with (n = 23) and without (n = 30) CT, defined using the Childhood Trauma Questionnaire (CTQ) and 16 healthy controls without trauma. ANCOVA was performed with age, gender and intracranial volume as covariates in order to evaluate group differences in CC volume. The total CC volume was found to be smaller in BD patients with trauma compared to BD patients without trauma (p < .05). The differences were more pronounced in the anterior region of the CC. There was a significant negative correlation between CTQ scores and total CC volume in BD patients with trauma (p = .01). We did not find significant differences in the CC volume of patients with/without trauma compared to the healthy subjects. Our sample consists of patients recovered from a first episode of mania and are early in the course of illness and reductions in CC volume may occur late in the course of BD. It might mean there may be two sources of CC volume reduction in these patients: the reduction due to trauma, and the further reduction due to the illness.

Relationship between frontostriatal morphology and executive function deficits in bipolar I disorder following a first manic episode: data from the Systematic Treatment Optimization Program for Early Mania (STOP-EM)

OBJECTIVES

Executive function impairments are a core feature of bipolar I disorder (BD-I), not only present during acute episodes but also persisting following remission of mood symptoms. Despite advances in knowledge regarding the neural basis of executive functions in healthy subjects, research into morphological abnormalities underlying the deficits in BD-I is lacking.

METHODS

Patients with BD-I within three months of sustained remission from their first manic episode (n = 41) underwent neuropsychological testing and a 3T magnetic resonance imaging scan and were compared to healthy subjects matched for age, sex, and premorbid IQ (n = 30). Group dorsolateral prefrontal cortex (DLPFC; Brodmann areas 9 and 46) and caudate volumes were examined and analyzed for relationships with the average score from three computerized tests of executive function: Spatial Working Memory, Stockings of Cambridge, and Intradimensional/Extradimensional Shift.

RESULTS

Right caudate volumes were enlarged in patients (z = 3.57, p < 0.05 corrected). No differences in DLPFC volumes were found. Patients showed large deficits in executive function relative to healthy subjects (d = -0.92, p < 0.001). While in healthy subjects, a larger right (r = +0.39, p < 0.05) and left (r = +0.44, p < 0.05) caudate was associated with better executive function score, in patients, larger right (r = -0.36, p < 0.05) and left (r = -0.34, p < 0.05) volumes correlated with poorer performance.

CONCLUSIONS

Although the etiology of gray matter changes is unknown, volume increases in the right caudate may be an important factor underlying executive function impairments during remission in patients with BD-I.

Initial evidence for sex-specific effects of early emotional abuse on affective processing in bipolar disorder

PURPOSE

This study investigates the effect of sex and childhood trauma on affective processing in bipolar disorder (BPD) patients.

METHODS

In a sample of fifty-six BPD patients, we administered the Childhood Trauma Questionnaire (CTQ), and the Iowa Gambling Task (IGT) and the Affective Go/No-Go (AGNG) to measure affective processing. Analysis of Variance (ANOVA) was used to evaluate the effect of sex and childhood trauma on IGT; Repeated-Measures ANOVAs to measure accuracy and bias measures across conditions on the AGNG.

RESULTS

In the context of childhood abuse, females evidenced a more conservative cognitive style than males by selecting fewer cards from the disadvantageous decks [F(1, 49)=14.218; P<0.001] and showed an improvement throughout the task, as noted in a normal learning curve [F(1.49)=4.385; P=0.041)]. For the AGNG, an interaction specific to the negative valence stimuli on response bias measures was found. Abused females scored higher (mean=8.38; SD=6.39) than abused males (mean=0.69; SD=1.19) [F(1.46)=6.348; P=0.015].

CONCLUSION

Severity of childhood trauma was significantly different between sexes. In the context of a history of emotional abuse, male bipolar patients tended toward a more risk-taking behavior compared to female. Further investigations are needed to elucidate potential pathophysiological mechanisms underlying this interaction.

Failure to find association between childhood abuse and cognition in first-episode psychosis patients

This study investigated the relationship between severe childhood abuse and cognitive functions in first-episode psychosis patients and geographically-matched controls. Reports of any abuse were associated with lower scores in the executive function domain in the control group. However, in contrast with our hypothesis, no relationships were found amongst cases.

The impact of childhood trauma on cognitive functioning in patients recently recovered from a first manic episode: data from the Systematic Treatment Optimization Program for Early Mania (STOP-EM)

BACKGROUND

Both bipolar disorder (BD) and childhood trauma are associated with cognitive impairment. People with BD have high rates of childhood trauma, which confer greater overall disease severity, but, it is unknown if childhood trauma is associated with greater neurocognitive impairment in BD patients early in the course of their illnesses. In this study, we investigated the impact of childhood trauma on specific cognitive dysfunction in patients who recently recovered from their first episode of mania.

METHODS

Data were available for 64 patients and 28 healthy subjects matched by age, gender and pre-morbid IQ, recruited from a large university medical center. History of childhood trauma was measured using the Childhood Trauma Questionnaire. Cognitive function was assessed through a comprehensive neuropsychological test battery.

RESULTS

Trauma was associated with poorer cognitive performance in patients on cognitive measures of IQ, auditory attention and verbal and working memory, and a different pattern was observed in healthy subjects.

LIMITATIONS

We had a modest sample size, particularly in the group of healthy subjects with trauma.

CONCLUSIONS

Childhood trauma was associated with poorer cognition in BD patients who recently recovered from a first episode of mania compared to healthy subjects. The results require replication, but suggest that the co-occurrence of trauma and bipolar disorder can affect those cognitive areas that are already more susceptible in patients with BD.

Relationship between neurocognitive functioning and episode recurrences in bipolar disorder

BACKGROUND

The relationship between neurocognitive impairment and clinical course in bipolar disorder (BD) is inconclusive. The aim of this study was to compare time to recurrence between patients with and without clinically significant cognitive impairment.

METHODS

Seventy euthymic patients with BD were included. Based on baseline neurocognitive performance, patients were divided into those with (n=49) and those without (n=21) clinically significant cognitive impairment. Both groups of patients were prospectivelly assessed by a modified life chart method during a mean of 16.3 months.

RESULTS

Patients with some cognitive domain compromised had an increased risk of suffering any recurrence (HR: 3.13; CI 95%: 1.64-5.96), hypo/manic episodes (HR: 2.42; CI 95%: 1.13-5.19), or depressive episodes (HR: 3.84, CI 95%: 1.66-8.84) compared with those patients without clinically significant cognitive impairment. These associations remained significant after adjusting for several potential counfounders such as number of previous episodes, time since last episode, clinical subtype of BD, exposure to antipsychotics, and subclinical symptoms.

LIMITATIONS

We classified patients as with or without clinically significant cognitive impairment, although deficits in different cognitive domains may not be equivalent in terms of risk of recurrence.

CONCLUSIONS

The results did not support the hypothesis that the experience of successive episodes is related to a progressive neurocognitive decline. On the contrary, cognitive impairment could be the cause more than the consequence of poorer clinical course. Alternatively, a specific subgroup of patients with clinically significant cognitive impairment and a progressive illness in terms of counts of recurrence and shortening of wellness intervals might explain the association showed in this study.