Attachment styles are used to describe patterns of attachment in relationships. Adults with a secure attachment style tend to have good self-esteem, they share their feelings with partners and friends, and have trusting, lasting relationships. Insecure attachment styles include anxious attachment style (also known as ambivalent or preoccupied), which involves reluctance to become close to others, worry about the security of relationships, a reduced sense of autonomy, and increased dependence on others. Avoidant attachment style is another insecure style. It involves problems with intimacy, over-regulation of emotions, and unwillingness to share thoughts and feelings. Fearful attachment style is represented by an inconsistent sense of self and an inability to regulate one’s emotions.

While attachment style in adulthood is thought to be based on early experiences with primary care givers, life’s experiences can also impact on attachment style in adults. Children described as ambivalent or avoidant can become securely attached as adults, while those with a secure attachment in childhood can show insecure attachment patterns in adulthood.

What is the evidence for attachment styles in people with bipolar disorder?

Moderate to high quality evidence finds a large effect of more insecure attachment styles in people with bipolar disorder compared to controls. This effect was similar to that seen in people with depression or schizophrenia. It was also similar across all three disorders for anxious attachment style. However, for avoidant attachment style, it was small for schizophrenia, medium-sized for bipolar disorder, and large for depression.

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Aspects of attention can be affected in bipolar disorder. These include selective attention, which is the ability to focus on relevant stimuli and ignore irrelevant stimuli. Sustained attention is the ability to maintain a consistent focus. Selective and sustained attention involve ‘alerting’ (achieving and maintaining an alert state); ‘orienting’ (directing attention); and ‘executive control’ (choosing suitable responses).

Several tasks have been developed to assess attention performance. The most common tasks include the Continuous Performance Test (CPT) that uses both visual and auditory stimuli and requires participants to respond to targets and ignore distractors. The Trail Making Test (TMT), requires participants to connect, in order, letters and/or numbers as quickly as possible. The Stroop Colour Word Test (SCWT), presents colour names printed in an ink congruent to the colour name (e.g. blue), or incongruent to the colour name (e.g. blue). Participants are asked to either read the word or name the ink colour. Any impairment in attention disrupts other cognitive functions. Information processing, for example, requires selective attention to retrieve relevant information, and dismiss irrelevant information. Working memory requires sustained attention in order to maintain concentration on information temporarily being stored. Therefore, tasks that have been developed to measure attention also measure other cognitive constructs.

What is the evidence regarding attention in people with bipolar disorder?

Moderate to high quality evidence suggests a medium-sized effect of poorer attention in people with bipolar disorder compared to controls, with no significant changes over time (3-5 years). The effect was similar in people with bipolar I or bipolar II disorder, in people with first-episode bipolar disorder, and in elderly patients who were matched to controls for age and education. The effect was not significant in children with bipolar disorder who were matched to controls for age (mean age 13 years) and IQ (mean IQ score 104).

High quality evidence suggests a small association between poorer attention and poorer general functioning in people with bipolar disorder.

Moderate quality evidence suggests people with first-episode bipolar disorder showed a medium-sized effect of better performance on some attention tasks (TMT-A and B) compared to people with first-episode schizophrenia. However, high quality evidence showed no differences in attention between people with bipolar disorder and a history of psychotic symptoms and people with bipolar disorder and no history of psychotic symptoms.

Moderate quality evidence found no differences in attention between people with bipolar disorder and people with major depression, in both euthymic and depression phases.

In people of any age with a first-degree relative with bipolar disorder, moderate to high quality evidence found no differences in attention compared to controls, or compared to first-degree relatives of people with schizophrenia. However, in youth aged 10 to 25 years with a first-degree relative with bipolar disorder, there was a small to medium-sized effect of poorer attention compared to controls.

September 2021

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Bipolar disorder is characterised by episodes of depression and mania, which can include psychosis. A major depressive episode is a period of at least two weeks in which a person has at least five of the following symptoms (including one of the first two): intense sadness or despair; feelings of helplessness, hopelessness or worthlessness; loss of interest in activities once enjoyed; feelings of guilt, restlessness or agitation; sleeping too little or too much; slowed speech or movements; changes in appetite; loss of energy; difficulty concentrating, remembering or making decisions; and/or thoughts of death or suicide.

A manic episode is a period of at least one week when a person is high spirited or irritable in an extreme way most of the day for most days. It involves changes in normal behaviour such as showing exaggerated self-esteem or grandiosity, less need for sleep, talking more than usual, talking more loudly and quickly, being easily distracted, doing many activities at once, scheduling more events in a day than can be accomplished, embarking on risky behaviour, uncontrollable racing thoughts, and/or quickly changing ideas or topics. Psychotic symptoms such as hallucinations and delusions most commonly occur during manic episodes.

What is the evidence for the relationship between cognition and symptoms of bipolar disorder?

High quality evidence finds small effects of greater impairment in global cognition, verbal and working memory, processing speed, and executive functioning in people with bipolar disorder and a history of psychosis compared to people with bipolar disorder with no history of psychosis. Moderate to high quality evidence also finds greater impairment in social cognition in people with a history of psychosis. There were no differences in visual memory or attention.

Moderate to low quality evidence finds an association between poorer overall cognitive functioning and more mood episodes, more hospitalisations, and longer duration of illness.

September 2021

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Bipolar disorder is characterised by episodes of depression and mania. A major depressive episode is a period of at least two weeks in which a person has at least five of the following symptoms (including one of the first two): intense sadness or despair; feelings of helplessness, hopelessness or worthlessness; loss of interest in activities once enjoyed; feelings of guilt, restlessness or agitation; sleeping too little or too much; slowed speech or movements; changes in appetite; loss of energy; difficulty concentrating, remembering or making decisions; and/or thoughts of death or suicide. A manic episode is a period of at least one week when a person is high spirited or irritable in an extreme way most of the day for most days. A manic episode involves changes in normal behaviour such as showing exaggerated self-esteem or grandiosity, less need for sleep, talking more than usual, talking more loudly and quickly, being easily distracted, doing many activities at once, scheduling more events in a day than can be accomplished, embarking on risky behaviour, uncontrollable racing thoughts, and/or quickly changing ideas or topics. These changes in behaviour are significant and clear to friends and family and are severe enough to cause major dysfunction.

The difference between bipolar I disorder and bipolar II disorder is determined by the existence of mania in bipolar I and hypomania in bipolar II, which is a less severe form of mania. People with bipolar I disorder are also more likely to have psychotic symptoms. As people with psychotic disorders show cognitive deficits, they may be more apparent in people with bipolar I disorder.

What is the evidence for cognition in different types of bipolar disorder?

Moderate to high quality evidence suggests small effects of greater cognitive impairment in global cognition, verbal memory, processing speed, executive functioning, and language fluency in people with bipolar I disorder compared to bipolar II disorder, with no differences in working or visual memory, attention, inhibition, or social cognition.

September 2021

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Functional outcomes refer to aspects of general life and day-to-day functioning that may be impacted as a consequence of illness-related impairments. Impaired cognition may impact on such functional outcomes, and may vary across different cognitive domains and functional indicators. Interventions to improve cognitive impairments may have additional benefit for general functional outcomes.

What is the evidence for the relationship between cognition and functional outcomes?

High quality evidence suggests poor cognitive ability across multiple domains is associated with poor general functioning. Moderate to low quality evidence suggests a relationship between poor emotion identification and regulation and poor general functioning, particularly in people with more severe depressive symptoms. There was no relationship found between general functioning and mania symptoms.

September 2021

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Bipolar disorder is characterised by intermittent periods of mania and depression, while people with major depression do not experience mania. Mania involves elevated or irritable mood, which is often accompanied by inflated self-esteem or grandiosity, decreased need for sleep, distractibility, psychomotor agitation or excessive involvement in pleasurable activities. Manic episodes may involve psychotic symptoms including grandiose delusions. Depression is characterised by extended periods of sadness, a loss of interest in activities, loss of appetite, decreased energy, feelings of worthlessness, and difficulty concentrating. Suicidal thoughts may also be present.

Neurocognitive deficits are a feature of bipolar disorder and may also be present in people with major depression. Domains of intelligence, memory, executive functioning, language, information processing and attention can all be affected. Identifying any differences in these cognitive domains may assist correct diagnosis and treatment of the two disorders.

What is the evidence for cognition in bipolar disorder compared to major depression?

Moderate quality evidence suggests a medium-sized effect of better verbal memory (list learning) in people with major depression than in people with bipolar disorder, but only during euthymic phases, as there were no differences during depression phases. There were no significant differences between people with major depression or bipolar disorder on tasks assessing attention, processing speed, and executive functioning.

September 2021

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Neurocognitive deficits are a core feature of both schizophrenia and bipolar disorder. People with either disorder may perform poorly on cognitive tasks assessing intelligence, memory, executive functioning, language, information processing and attention. Establishing differences in these cognitive domains may assist correct diagnosis and treatment of the two disorders.

What is the evidence for cognition in bipolar disorder compared to schizophrenia?

Moderate to high quality evidence found large effects of better overall cognition, attention, and social cognition, and medium-sized effects of better speed of processing, working memory, learning, reasoning, and problem solving in people with bipolar disorder. A small effect was found of better overall cognition in people with bipolar disorder compared to people with schizoaffective disorder (particularly depressive type), which remained across different cognitive domains, bipolar disorder type (I or I and II mixed), age, sex, duration of illness, antipsychotic use or no use, and symptom severity.

Moderate to high quality evidence found a medium-sized effect of higher premorbid IQ, and moderate to low quality evidence found a medium-sized effect of higher current IQ in people with first-episode bipolar disorder compared to people with first-episode schizophrenia. There were also medium-sized effects of better verbal memory and verbal fluency, and small effects of better working memory and processing speed in people with first-episode bipolar disorder.

Compared to controls without a mental illness, moderate to high quality evidence found a small effect of poorer pre-illness-onset cognitive functioning, and a medium-sized effect of poorer post-illness-onset cognitive functioning in people with bipolar disorder. In people with schizophrenia compared to controls, there was a medium-sized effect of poorer pre-illness-onset cognitive functioning and a large effect of poorer post-illness-onset cognitive functioning. Moderate quality evidence found similar, medium to large effects of poor semantic inhibition in people with bipolar disorder and in people with schizophrenia when compared to controls.

A medium-sized effect was found of better social cognition in people with bipolar disorder on Theory of Mind and negative facial emotion recognition tasks, particularly in male patients, but no differences between bipolar disorder and schizophrenia on positive (happy) facial emotion recognition tasks.

September 2021

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Deficits across various cognitive domains are a common feature of bipolar disorder. These are strongly associated with difficulties in activities of daily living. Early age at onset of the illness is associated with more severe symptoms and poor prognosis than later age at onset. Identifying cognitive deficits in children contributes to the development of specific treatments and rehabilitation approaches.

What is the evidence regarding cognition in children with bipolar disorder?

Moderate quality evidence finds large impairments in global cognition, verbal and visual learning and memory, and working memory in youth with bipolar disorder, compared to youth without the disorder that are of similar age (average 13 years) and IQ (average 104). There were no differences in attention, reasoning, problem solving, and processing speed.

High quality evidence finds a medium to large effect of reduced emotion recognition in youth with bipolar disorder. Moderate quality evidence finds a large effect of reduced theory of mind, which is the ability to infer the mental states of other people.

Moderate quality evidence finds a medium to large effect of poorer accuracy on emotion recognition in youth with bipolar disorder compared to age-matched controls. There was a smaller, non-significant effect of poorer response time. Unmedicated youth showed longer response times than medicated youth. Caucasian youth with bipolar disorder showed both longer response times and poorer accuracy than non-Caucasian youth.

October 2021

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Cognitive dysfunction is a common feature of bipolar disorder that exists across a number of cognitive domains and usually persists in remission. It is unclear whether cognitive deficits are apparent prior to the onset of bipolar disorder or whether they develop during the course of the illness. Assessing cognitive ability in people with a first-episode of bipolar disorder helps determine whether cognitive deficits were apparent prior to illness onset.

What is the evidence for cognition in first-episode bipolar disorder?

Compared to people without bipolar disorder (controls), high quality evidence shows medium-sized effects of poorer global cognition and processing speed, and small effects of poorer premorbid IQ, working memory, fluency and reasoning in people with first-episode bipolar disorder. Moderate to high quality evidence also suggests a large effect of poorer attention, and medium-sized effects of poorer current IQ, verbal memory, and visual memory in people with first-episode bipolar disorder.

Compared to people with first-episode schizophrenia, moderate to high quality evidence shows medium-sized effects of better verbal memory, verbal fluency, and premorbid IQ in people with first-episode bipolar disorder. Moderate quality evidence also shows small effects of better working memory and processing speed. Moderate to low quality evidence shows a medium-sized effect of better current IQ. There were no differences in attention or reasoning between people with first-episode bipolar disorder and first-episode schizophrenia.

September 2021

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Cognitive deficits across various domains are a common feature of bipolar disorder, and are strongly related to persistent difficulties in activities of daily living. Such deficits may be more pronounced in people with bipolar disorder who are aged over 60 years than in younger patients. Identifying cognitive deficits in elderly people contributes to the development of specific treatments and rehabilitation approaches.

What is the evidence for cognition in elderly people with bipolar disorder?

Moderate to high quality evidence suggests a large effect of poorer executive functioning, and medium-sized effects of poorer memory, attention, and fluency in older people with bipolar disorder compared to controls who were matched for age and education. Moderate to low quality evidence also suggests a medium-sized effect of poorer learning ability in older people with bipolar disorder.

No reviews were identified that directly compared cognition in older versus younger people with bipolar disorder.

September 2021

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