Feeling scatterbrained? Can’t remember a thing? It may be “bipolar brain fog”—and you can manage it.
Managing Bipolar Complicated by Cognition Problems
“I’m the PhD down the hall whose memory fails during critical discussions at the office,” says Debra.
Debra, 48, is a behavioral scientist with the Centers for Disease Control and Prevention in Atlanta. She leads research and oversees a team of data analysts in the Division of Violence Prevention.
Before her bipolar diagnosis six years ago, she sometimes had trouble keeping focused. Now recall is a bigger problem, especially if she’s expected to dredge up dates or statistics during a meeting or keep track of details after an impromptu encounter.
“I ask people to schedule meetings rather than have these hallways conversations when we need to make decisions,” she says.
In meetings, she takes copious notes to jog her memory.
“I scribble as fast as I can … sometimes so fast I can’t read my own notes,” she reports. “I just have to chuckle when, ‘This research should move ahead,’ turns into, ‘This rabbit should go to bed.’”
Psychiatrists and researchers are coming to appreciate that memory lapses and other neurocognitive problems—disorganization, groping for words, difficulty learning new information—can go hand in hand with the more obvious mood and behavioral symptoms that characterize bipolar.
Joseph Goldberg, MD, a psychiatrist and associate clinical professor of psychiatry at the Mount Sinai School of Medicine in New York City, helped put these “thinking” problems on the bipolar map. He’s co-editor of Cognitive Dysfunction in Bipolar Disorder: A Guide for Clinicians, which came out in 2008.
Goldberg says the book builds on “literally hundreds of studies” analyzing aspects of cognition in patients with bipolar disorder.
He mentions an influential Spanish study, published in the American Journal of Psychiatry in February 2004. In every phase of the illness (depression, mania and remission), researchers found marked deficits in verbal memory and what’s known as “frontal executive tasks.”
Think of it this way: The brain is organized like a big office with specific departments designated to complex tasks such as decision-making, attention, verbal memory, spatial memory, motor speed and skill, and logical reasoning.
The frontal lobes of the brain contain circuitry that acts, in essence, like a hardworking executive secretary. Information comes into the frontal lobe and the secretary notes it, organizes it, and sends out messages to the brain’s different departments to get things done.
Faulty processing in this executive center can lead to cognitive deficits that affect awareness, perception, reasoning and judgment, Goldberg says.
The hippocampus, meanwhile, serves as a kind of file clerk for recording new memories and sending them on to permanent storage. Bipolar has been associated with shrinkage of the hippocampus, which may explain difficulties in acquiring and accessing various kinds of data.
Goldberg notes that many aspects of intellectual functioning carry on just fine in people with bipolar—sometimes even better than in the general population. The glitches seem limited to specific areas: verbal memory, executive organization, “processing speed” and attention.
Daily Cognitive Difficulties with Bipolar
Attention—the ability to focus on a task or conversation, tune out distractions, and, ultimately, filter information into working memory—is the gateway to learning, memory and other higher cognitive processes, says Frederick Goodwin, MD, a leading clinical researcher on bipolar disorder who is now based at George Washington University.
All of those functions can go haywire during depression and mania, of course. In fact, manic symptoms can mimic attention deficit hyperactivity disorder (ADHD).
Their treatment recommendations, published in the February 2012 issue of the Annals of Clinical Psychiatry, note the importance of accurate diagnosis and careful pharmacotherapy, since some ADHD medications can trigger mania. Mood stabilization should come first, they write, before addressing ADHD symptoms.
But what about scattered attention, memory glitches and other cognitive deficits that practitioners never hear about from their patients with bipolar?
Goodwin notes a change in thinking since Manic-Depressive Illness, the now-classic textbook he wrote with Kay Redfield Jamison, came out in 1990. Not more than a decade ago, he says, professionals checked off a host of mood and behavioral symptoms and didn’t pay much mind to cognitive factors.
It didn’t help that the problems can be subtle and unlikely to show up in an office interview—especially when verbal ability remains sharp.
Cognitive deficits can be subtle or severe, but studies show that as many as a third of people with bipolar I have cognitive problems that disrupt their lives.
Bipolar brain fog can complicate everything from succeeding in school to paying the bills. Rick of Saskatoon, Saskatchewan, is less confident behind the wheel these days because of “near misses and some dents.” He blames poor concentration and slowed motor skills.
“I used to pride myself on being an excellent driver,” says Rick, 62, who crisscrossed the continent during his 25 years as a communications specialist in the Canadian Forces. “I didn’t even get any tickets.”
Rick says predominantly high moods helped him succeed socially, in sports and in his career. With time, however, he began to notice it was harder to follow a train of thought. Loud talking and other noise made it tough to focus on what he was doing.
His coordination also deteriorated, leaving him with a tendency to lose his balance on a ladder, stumble while walking, or nick himself when working with tools. Escalating mood shifts led to his bipolar II diagnosis a few years ago.
Rick still captains the car on local errands, but it helps to have his spouse on board as navigator, noting where to turn or when to slow down. As a military wife, she managed the family and handled all the relocations; now more than ever, Rick says, she’s “the decision-maker and my assistant.”
In addition to checking in daily with his wife to make sure he hasn’t overlooked any obligations or appointments, Rick follows a routine that includes activities in the morning when he feels most alert, a nap in the afternoon when energy and attention flag, and a strictly regimented bedtime.
“It’s a long journey,” he says of learning how to manage his fluctuating symptoms, “but I believe that hope is the best car to drive in.”
Complicated Causes of Neurocognitive Concerns with Bipolar
The fact that neurocognitive problems linger after symptoms subside—and can be present before a bipolar diagnosis is made—makes scientists think that these disturbances are a core and consistent feature of the illness.
A Canadian study that appeared in the Journal of Clinical Psychiatry in September 2010 found that attention, recall, and several aspects of executive functioning were compromised even at onset of the first manic episode.
Researchers are trying to learn more about what areas of the brain are vulnerable to the disease process and what role the course of illness plays.
Moira A. Rynn, MD, an associate professor of clinical psychiatry at Columbia University Medical Center, is involved in a multi-center study on pharmacological treatment for adolescents that includes a detailed cognitive battery given at baseline and again every two years.
Rynn says it can be difficult to assess cognitive impairment in a “snapshot” evaluation because individuals come with their own set of cognitive strengths and weaknesses. A “longitudinal” study such as she is doing can reveal whether each participant’s learning difficulties get better or worse, and shed light on why.
“There is a need to do careful standardized assessments over time, controlling for the type of treatments given,” she says. “We do need to know whether the severity and frequency of episodes make cognitive problems more severe, and what is the impact of medication treatment over time.”
Goodwin says that while the pathological underpinnings of the disease itself may play a role in cognitive problems, there are a number of other explanations to consider. All kinds of medications can affect the brain regions that control cognitive function. So can medical illnesses such as fibromyalgia and cancer, drug and alcohol use, anxiety, and stress.
Sue Marsh (not her real name) is a walking example of that interplay. Marsh, 59, recalls that learning was difficult for her as a kid. She was diagnosed with adult attention deficit disorder in her 30s. Still, she was driven to excel right through graduate school, then as a speech pathologist, and later in medical sales. She made good money and balanced a busy career with raising a family.
Her divorce in 2002 led to depression. When she went through therapy for breast cancer three years later, the treatment apparently triggered bipolar symptoms. Her diagnosis and treatment changed accordingly.
Now, seven years later, she frequently gets lost when she leaves the house. She can’t get out the door without reading dozens of slips of paper that line a path from her bathroom to the kitchen to the door that will send her out into the world. Some of the notes read: Brush teeth. Take pills. Find keys. Find phone. Put coat on. Lock door.
“I just can’t function the way other people do,” says Marsh. Without the notes throughout her house, “I don’t know how I would even get out in the morning.”
Every brain scan and neuropsychiatric report spits out the same result: problems with executive function. She is now on disability. Three words on a note card by the door remind her: Keep it simple.
“I’ve had to revamp my dreams,” she says.
Working through Cognitive Difficulties
Those who remain employed may have to work a little harder. Kyle, 33, says friends used to call him Superman because, “I could do a million things at once and do it well.”
He discovered the hard way that he needs to stay on medication to stave off psychosis and extreme behavior. He was fired from his previous job during a bout of unrecognized mania—although to this day, he can’t remember anything that happened during the episode.
Now the effortless multitasking of hypomania is a thing of the past. He’s made accommodations to handle his responsibilities as a production engineer at a small medical device company in Bloomington, Indiana.
“I’ve learned I can focus on one thing and do that,” he explains. “I have to consciously think, ‘This is what I’m doing, this is what I’ve done, and this is what I’m going to do when I get back to it.’”
Because he can’t keep all the balls juggling in his head anymore, he makes sure to note appointments on his calendar and jot down reminders about important tasks.
Kyle says he was upfront about his altered abilities when he was hired nearly two years ago, but he’s done well enough to win his supervisors’ support. During a recent psychiatric hospitalization, he says, the firm’s owner came by to let him know his job was waiting.
Debra, the CDC scientist, is also happy with the feedback from her superiors. In any event, she says, her bipolar diagnosis at 43 was a life-saving discovery—a fair swap for the slowdown of a few brain cells.
“It’s one of those side effects I have to deal with,” she says, “because I’m not going to stop taking the medication.”
Despite her positive evaluations, Debra admits to feeling incompetent at times because of her quirky memory. Still, she says, living with bipolar disorder also has its advantages. For Debra, lifelong traits such as creativity and increased productivity far outweigh the downside of her lapses.
“It’s about finding your strengths,” she says, “and capitalizing on them.”
• • • • •
SEEKING SOLUTIONS FOR MEMORY PROBLEMS WITH BIPOLAR
As new evidence emerges about cognitive deficits associated with bipolar disorder, clinicians are more apt to take such problems into consideration during evaluation and treatment.
A number of neuropsychological tests are proving helpful in identifying problems that can make everyday functioning difficult. Some tests are designed to pick up misfires in memory and attention, while others measure planning skills and “response initiation”—that is, how quickly and appropriately someone responds to stimuli.
Ivan Torres, PhD, a clinical associate professor of psychiatry at the University of British Columbia whose research focuses on cognition in bipolar, says that cognitive test scores correlate with how well people with bipolar are able to function in the real world.
What to do with the information is less clear.
“We are just in the beginning stages of identifying ways to help patients with these cognitive problems,” Torres says.
Current research is looking at the possible benefits of certain medications, cognitive remediation therapy, and rehabilitation interventions used with brain injury and stroke patients.
“At the very least,” says Torres, “we are in a position to provide education to patients about the cognitive difficulties that they may experience, and to come up with strategies for working around these problems in daily life.”
Breaking complex tasks into smaller units, making the environment less distracting, and creating structure around daily duties can counteract deficits in focus and organization, he says.
Cues, prompts, reminders, and repetition can help with learning and memory problems.
In his work with patients whose memory is unreliable, psychiatrist Joseph Goldberg recommends similar tactics: sticky notes, appointment calendars, and a technique called “chunking”—splitting information into bite-size pieces that are easier to remember.
Betty of Port McNicoll, Ontario, relies on her cell phone. Her son originally gave her a phone with a keyboard so she could save money by texting him rather than calling. She discovered other benefits.
“My phone has a calendar in it, so I just started using my phone to set off a reminder that I had to do something or go somewhere. I even use it to wake me up in the morning,” she says.
After two decades of disabling depression and untreated hypomanic symptoms, Betty got a new doctor in 2010 who gave her a bipolar diagnosis. Now 65 and stable, she says she’s “always had problems with my cognitive abilities. It’s just gotten worse as I’ve got older.”
In her low-tech days, she says, she would miss appointments and forget that she was supposed to meet someone or pick something up—even with “my pieces of paper to remind me” and a calendar in her purse.
“The phone works a whole lot better,” she says.
Betty also adopted a counterintuitive therapy: the game of bridge, which favors players who can keep track of which cards have been put down. Somehow the mental exercise strengthens her erratic memory, she reports.
Her involvement with the game has been so successful, she says, “I not only play it, I teach it.”
Jamie Talan, a freelance writer based in New York and Idaho, specializes in neuroscience and writes regularly for Neurology Today. She is the author of Deep Brain Stimulation and coauthor of The Death of Innocents.
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