Insight and neuropsychological functions in bipolar outpatients in remission

O insight no transtorno bipolar: uma revisão sistemática

Objetivos Realizar uma revisão sistemática para compreender que fatores estão relacionados a uma maior ou menor consciência de morbidade no transtorno bipolar (TB), como o insight varia em função do estado afetivo e estabelecer uma comparação com outros transtornos mentais. Métodos Realizou-se uma revisão sistemática da literatura científica sobre o insight em pacientes com TB. Foram buscados estudos clínicos originais sobre o tema nas bases de dados Medline, ISI e SciELO. Os termos de busca empregados foram: “insight” OR “awareness” AND “bipolar” OR “mania” OR “manic”. Resultados Foram selecionados 55 artigos. O insight no TB parece ser mais prejudicado do que na depressão unipolar, porém menos do que na esquizofrenia. Com relação ao TB, um menor nível de insight está relacionado à presença de sintomas psicóticos e de alterações cognitivas. Além disso, um comprometimento do insight está associado a uma menor adesão ao tratamento. Por outro lado, uma maior preservação do insight pode estar associada a maior ideação suicida. Finalmente, a fase maníaca cursa com um nível inferior de insight quando comparada à fase depressiva ou de eutimia. Conclusão No TB, o insight está significativamente prejudicado, especialmente na mania. Diversos fatores clínicos parecem influenciar o nível de insight.

The reliability of self-assessment of affective state in different phases of bipolar disorder

Some studies have indicated that the capacity of self-assessment of affective state is more compromised during mania than during depression. In the present study, we investigated whether the reliability of self-assessment in bipolar disorder varies as a function of actual affective state (i.e., euthymia, mania, or depression). Sixty-five patients with a diagnosis of type I and type II bipolar disorder were evaluated with regard to the occurrence of an affective syndrome using the Clinical Global Impressions Scale for use in bipolar illness, the Positive and Negative Syndrome Scale, and the Global Assessment of Functioning scale. In parallel, we applied the Analog Visual Mood Scale, a self-assessment tool to evaluate mood changes. The same individual prospectively completed the self-assessment scale in different affective states. During depression, the patients' evaluation was significantly different from when they were in manic or euthymic mood states. However, when in mania, the patients evaluated their mood state similarly to when they were euthymic. The bipolar patients in mania but not in depression did not reliably evaluate themselves with regard to their affective state.

Insight in bipolar disorder

Although there has been interest in insight in bipolar disorder, research has not been as developed as in schizophrenia. The Medline, Embase, and PsychInfo data bases were searched. The key words used in the search were "bipolar", "mania", "manic", "awareness", and "insight". Books, editorials, letters, and reports on pediatric subjects were excluded. Abstracts or full texts were screened for relevance. Better insight is associated with better adherence to treatment and better outcomes. Impairments of executive functions and memory, as well as higher severity of psychotic symptoms, are associated with impairments of insight. Insight is more impaired during an illness episode than during remission, in mixed than in pure manic episodes, in bipolar II than in bipolar I patients, in pure mania than in bipolar or unipolar depression. Psychosocial treatments improve insight and outcomes. There is a need for integration of quantitative assessment methods and their introduction into research and clinical practice.

Insight in bipolar disorder: associations with cognitive and emotional processing and illness characteristics

OBJECTIVE

To investigate the multifactorial relationship between illness insight, cognitive and emotional processes, and illness characteristics in bipolar disorder patients.

METHODS

Data from 85 euthymic or mildly to moderately depressed bipolar disorder patients were evaluated. Insight was measured using the Mood Disorder Insight Scale (total score and subscale scores: awareness of illness, symptom attribution, and need for treatment). Cognitive and emotional functioning was measured in four domains (processing speed, memory, executive functioning, and emotional learning) in addition to premorbid IQ. Illness characteristics were assessed using the Mini-International Neuropsychiatric Interview, the Questionnaire for Bipolar Disorder, and the Inventory of Depressive Symptomatology-self rating scale. Regression analyses were performed for the whole sample. Post-hoc, interactions with lifetime psychotic features (LPF) were statistically tested and if significant, analyses were repeated for patients with (n = 36) and without (n = 49) LPF separately.

RESULTS

In the whole group, better insight was associated with lower processing speed, better memory performance, increased emotional learning, higher level of depressive symptoms, and longer duration of illness. Patients with LPF had worse awareness of illness, but better symptom attribution than patients without LPF. No group differences for need for treatment and overall insight were found. Finally, processing speed significantly predicted subscores for symptom attribution in patients with LPF only.

CONCLUSIONS

Cognitive functioning as well as impairments in emotional learning and psychotic features independently contributes to impaired insight in bipolar disorder. Processing speed seems to be a key variable in the prediction of insight in patients with LPF and not in patients without LPF.

Lack of insight may predict impaired decision making in manic patients

OBJECTIVES

The tendency to engage in risky behaviours is a core feature of the manic episodes of bipolar disorder. The aim of this study was to establish whether this characteristic can be quantified with a laboratory measure of decision making [the Iowa Gambling Task (IGT)] and to determine clinical correlates of the IGT performance in mania.

METHODS

Inpatients with acute mania (n = 45) and healthy volunteers (n = 45) were assessed on the IGT. Affective symptomatology was assessed with the Young Mania Rating Scale and Hamilton Depression Rating Scale, and item scores were subjected to factor analysis. Multivariate regression was used to assess clinical predictors of impaired decision making in the manic patients.

RESULTS

On the IGT, manic patients selected more cards from the risky decks than healthy controls, and showed little capacity to learn from incurred losses. In a multivariate analysis, impaired decision making ability in the manic patients was significantly predicted by a symptom factor associated with lack of insight.

CONCLUSIONS

Manic patients clearly show defects in decision making, which are strongly related to their lack of insight. Neural circuitry supporting effective decision making, including the ventromedial prefrontal cortex and somatosensory cortex, may be implicated in the pathophysiology of acute mania.

Insight, quality of life and cognitive functioning in euthymic patients with bipolar disorder

INTRODUCTION

The relationship between insight, quality of life and cognition in bipolar disorder has not been clearly established.

METHOD

A neuropsychological battery assessing attention, mental control, perceptual-motor skills, executive functions, verbal fluency, abstraction and visuo-spatial attention was administered to 70 remitted bipolar patients and 50 healthy controls. Insight was assessed using the Scale to Assess Unawareness of Mental Disorder; Quality of Life was assessed using the Portuguese version of the WHO Quality of Life Assessment--Abbreviated version (WHOQOL-BREF-PT).

RESULTS

No differences in QoL and cognitive performance were observed between bipolar patients with 'impaired' and 'preserved' insight. Insight was found to be correlated with poorer psychological and environmental QoL. A multiple regression model showed that depressive symptoms were significant predictors of physical, psychological and environmental QoL.

CONCLUSION

The present study adds to the notion that depressive symptoms, even of low intensity, are strong predictors of QoL. The present study suggests that the impact of insight on self-reported QoL may be subtle during remission and may be more substantially affected in the presence of manic symptoms.

Clinical and neurocognitive correlates of insight in patients with bipolar I disorder in remission

OBJECTIVE

The relationship between insight and neurocognition in bipolar disorder has not been clearly established.

METHOD

A neuropsychological battery assessing attention, mental control, perceptual-motor skills, executive functions, verbal fluency and abstraction, and visuo-spatial attention was administered to 50 bipolar remitted patients and 50 healthy controls. Insight was assessed with the Scale to Assess Unawareness of Mental Disorder.

RESULTS

Patients presented significantly worse neurocognitive performance. Insight was impaired in 60% of patients, and age, educational level, manic symptoms, age of disease onset, number of admissions, and performance on several neurocognitive tests correlated significantly with insight. A regression model revealed that age and Trail Making Test part B (TMT-B) performance accounted for 32% of the variance in overall illness awareness, while performance on the TMT-B alone accounted for 28% of the variance.

CONCLUSION

Impaired insight and neurocognitive dysfunction seem to be present in euthymic bipolar patients. Insight in bipolar disorder may be partially dependent on intact neurocognition.