Discussing Bipolar Related Cognitive Impairment
Importance of appropriate timing for discussion of bipolar cognitive impairment
Posted May 28, 2018
In December, 2014, I published a blog titled Cognitive Deficit in Bipolar Disorder. If you’ve not previously done so, it might be helpful to review the piece as its content will provide useful background information pertaining to this blog installment.
Cognitive deficit can be one of the more difficult long-term outcomes of living with bipolarity. Examples of the kinds of deficits experienced by individuals are difficulties with linguistic working memory (word retrieval), difficulties with planning, prioritizing and organizing of behavior (executive functioning), problems with retention of what’s been read or listened to as well as the experience of mildly dulled or slowed thought processes (Federman, 2014)
The experience of bipolar-related cognitive deficit will vary greatly from one individual to the next, just as will the impact of the illness on people’s lives. Cognitive deficit that endures over time will range from mild, almost imperceptible impairment to the opposite end of the continuum where social and occupational limitations create functional difficulties consistent with long-term disability. Indeed, for those new to the bipolar diagnosis, the possibility of illness-related cognitive decline is a frightening possibility.
The best we can do with regards to prediction of cognitive deficit is to understand that there’s a positive correlation between higher acuity bipolar symptoms and the development of cognitive deficit. This means that those with histories of more acute bipolar mood symptoms are more likely to experience aspects of cognitive deficit. Conversely, individuals with milder symptom acuity over the course of their illness will be less likely to experience cognitive impairment.
The idea of cognitive deficit is very concerning to the newly diagnosed, particularly for those whose bipolar onset occurs between the late teens and the mid-twenties when so much is occurring with identity consolidation and preparation for one’s future. The bipolar diagnosis itself is difficult enough for the young adult to accept, let alone the possibility that the illness may be accompanied by some degree of cognitive decline. Thus, the specific question I’m posing in this blog is: To what extent should the issues of potential cognitive impairment be discussed with the late adolescent or young adult who has just received the diagnosis of bipolar disorder?
My answer … gradually, carefully and in due time.
Consider Julia, a 19-year-old female hospitalized for five days in mid-April of her college freshman year due to rapid onset manic symptoms. She took incompletes in her courses and returned home with a plan to finish her coursework over the summer and take exams by late July. However, by late May she had progressed into a strong depressive episode. She was still taking some low-dose antipsychotics as well as a mood stabilizer and her thought process felt blunted from the drugs as well as from the effects of her depression. She had no idea how she was going to pull herself together in time to tackle her remaining school work. But looming much larger was her fear of facing the reality of life with bipolar disorder.
A psychiatric diagnosis didn’t fit well with Julia’s narrative. She had been a consistent “A” student in high school – had always been motivated to do well. She would become anxious during times of high stress, but for the most part, it was manageable and not something that got in her way. She had a good relationship with both parents. Dad was a math professor at a northeastern university. He could get gloomy during the winter months, but by early March, a lot of people in the Northeast were tired of the dreary grey. Mom was a high school librarian also prone towards anxiety. Julia had a younger brother, age 14, who was dealing with normal adolescent junior high concerns. In other words, most things about her life felt pretty normal. Julia did have a maternal first cousin with bipolarity, but since they lived on the West Coast, she didn’t see her cousin that often and the diagnosis just wasn’t on her radar as anything to be concerned about.
But at age 19, there it was. She felt flattened by it and she wasn’t close to getting back up on her feet.
Julia’s experience is not that atypical for the recently diagnosed young adult with bipolar disorder. It truly feels like it’s too much to take in. It’s too large of an identity modification to adapt to over a brief period of time.
In Julia’s second year at school, following an additional semester where she remained out of enrollment, she learned the hard way that drugs and alcohol didn’t work well with bipolarity. Fortunately, she was able to rescue the semester by dropping two courses after a bumpy start. She also got some good help from a university-based counselor who had done a fair amount of work with bipolar students.
In Julia’s junior year, she saw a brief hypomanic spike after her sleep cycle became disrupted during a spring break trip abroad with family. Fortunately, she had some if-needed emergency, antipsychotic medications with her. She also had a psychiatrist who did an excellent job helping her avert another manic episode by being responsive by phone for medication adjustments during several sleep-deprived, mood-elevated days in Ireland.
By the time Julia graduated college with a degree in computer science she had little doubt about the presence of her bipolarity. She lived with a revised version of self that included medication, bi-monthly visits with her psychiatrist and realistic expectations that, even with appropriate meds, her mood intensity could still derail her from time to time. She wasn’t happy about this, but she was in an entirely different place than when she first encountered the mania that took her into bipolarity.
I first saw Julia when she was 26. Her last two years had been relatively stable. She had completed a master’s in applied computer programming and was working at a start-up software company. She was seeking help for two reasons: 1) she had recently relocated and wanted to establish an ongoing supportive connection with a psychologist, and 2) she was concerned about her cognitive capacity to do the work in her chosen field.
Julia had never doubted her intellectual capacities. With the exception of how she functioned during depressive episodes, her learning, memory, analytic thinking and information retrieval had always come easily to her. But in her current working environment, Julia consistently felt she was around others who reached coding solutions more rapidly than she did. She acknowledged that she was only two years post masters and she was working with some colleagues who had been in the field for a couple of decades. But even in relation to her similar age cohort, she perceived they had a grasp on their work demands that somehow felt beyond her, regardless of how much extra time she put in. She was beginning to feel that what used to come easily to her was now taking a lot more effort. And this wasn’t just limited to the workplace.
Julie was concerned about this. She also knew that since her mood wasn’t elevated or depressed, the difficulties she was experiencing were not likely due to interference from acute mood symptoms interfering with her functioning. She had also been talking about these issues with her psychiatrist and both were relatively sure that her medications were providing therapeutic benefit with minimal side effects. And besides, the medications she was currently taking were no different than what she had been taking over the last year and a half. The problem was her experience of self was changing.
About six weeks into our therapy relationship, I began talking with Julia about the possible presence of some early cognitive deficit related to her bipolarity. This came as a shock as she hadn’t previously had similar discussions with her previous mental health providers. She wasn’t aware the risk existed. To assist Julia in beginning to face the possibility, I encouraged her to review some of the scientific literature about cognitive deficit and bipolarity that she was able to access online.
She did, and in tandem with our sessions, the reality of what she as facing hit her hard, just as we might expect it would. What did this all mean in relation to her current and future career issues? If her contemporary struggles did represent cognitive deficit, how bad would things continue to get? What might things look like in 10 or 15 years?
So, back to my original question - what extent should these issues have been discussed with Julia early on in the course of her emerging illness? If I had seen Julia during college years I would not likely have approached the issues, partly due to the fact that she wasn’t experiencing any cognitive difficulties at the time. She already was facing enormous adjustments to her identity, lifestyle and self-care. She was appropriately struggling to integrate the new reality of living with bipolarity. We also could not have known if Julia would develop any cognitive deficit, nor when it might appear on the scene. Would it have made sense to further intensify the extent to which she was feeling overwhelmed and distressed as a young adult college student? Probably not.
On the other hand, if I had been seeing Julia during her college years and she had posed specific questions to me about potential cognitive implications of her disorder, I absolutely would have been truthful with her. The key difference here is that she would have initiated the discussion with me signaling some readiness to take in the information.
My point is that it’s important to assess an individual’s readiness to receive and integrate information about bipolarity, particularly since we’re talking about something that’s uncertain and indeterminate for a newly diagnosed young adult with bipolar disorder. I also find that the symptoms of cognitive deficit are difficult to discern from similar presenting issues which might reflect medication side effects or cognitive interference from mood intensity. The last thing I’d want would be a patient arriving at unwarranted negative conclusions about self before having had enough experience with the illness to know how they’d be impacted.
I want to clarify that I’m not advocating a broader delay pertaining to the introduction of psychoeducational material to people early in the course of dealing with their bipolarity. I think it’s very important to provide substantial psychoeducational information as part of the early treatment approach with bipolarity. The caveat I’m suggesting is that issues of cognitive deficit be approached more gradually and not at the outset of a young adult’s diagnosis.
Interesting side note here - I often find that young adults are resistant to learning much about bipolarity. During my early sessions with bipolar college students I usually direct them towards online resources about bipolar disorder and it’s not uncommon that when I circle back to my suggestion and inquire about their reactions, I learn that they haven’t done the reading, or have only given the material cursory review. Again, this is further illustration of the fact that most newly diagnosed young adults are not ready to integrate even the most basic information about their bipolarity.
Let’s look at another example where the approach was very different than what unfolded with Julia. A third-year college student named Greg who had been diagnosed with bipolar disorder at age 13. He had struggled with emotional volatility since childhood and been on psychiatric meds since age 10. Greg also had three hospitalizations in the past five years. Despite the challenges of his illness, he had managed to complete high school with a strong grade point. However, by his junior year in college, he was having increasing difficulty with his academics.
His reading comprehension and information recall seemed to be declining and by completion of fall semester junior year, he had only attained a 2.6 GPA. At the point of intake there were a number of different possible explanations for Greg’s academic struggles. They were: 1) negative impact of lifestyle and psychosocial stress, 2) interference upon cognitive functioning from concomitant mood symptoms, 3) cognitive difficulties due to medication side effects, 4) early manifestation of cognitive deficit, or 5) a combination of several of these factors. Once I got to know Greg within psychotherapy and after conferring with his psychiatrist on several occasions, it became clear to me that the first three possibilities were not strong factors contributing to his current difficulties. I subsequently referred Greg for some neurocognitive testing assessment and his assessment results did reveal significant areas of enduring cognitive impairment.
As Greg and I processed this outcome, he understood the implications, even acknowledging it had been one of his fears. He was distressed by the findings, but given his early bipolar onset, strong symptom acuity and high relapse frequency, Greg already knew that his life was being profoundly affected by his bipolar disorder. It was not such a stretch for him to learn that his bipolarity was affecting his cognitive functions and he was therefore able to receive and process the information more readily than did Julia. Essentially, he was farther along in his acceptance and integration of the limitations brought about through his bipolarity. In some respects, he had to be since the course of his illness had been more severe than Julia’s.
I also want to be clear that there are individuals who live with bipolar disorder who will never experience enduring cognitive deficit. There are also those for whom the onset of cognitive difficulties is quite gradual and may not begin to manifest until well into middle adulthood. The presence of sustained cognitive deficit is not ubiquitous within the bipolar population and the extent to which cognitive symptoms manifest and become problematic will vary for each individual. As a clinician, my role is to ask - when is it appropriate to introduce the issue to each patient for further discussion and exploration? The answer will be unique to each individual and my guiding principal will be to remain sensitive to the extent of information that each person is ready to receive and capable of integrating.
For those seeking further information about bipolar cognitive deficit, I’ve provided some open access links from recent scientific literature below:
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Russ Federman, Ph.D., ABPP is in private practice in Charlottesville, VA. He specializes in work with individuals diagnosed with bipolar disorder.