For a diagnosis of PTSD, there needs to be at least two “negative alterations in cognitions and mood”. These include negative thoughts or feelings that began or worsened after the trauma, an inability to recall key features of the trauma, overly negative thoughts and assumptions about oneself or the world, exaggerated blame of self or others for causing the trauma, negative affect (e.g., fear, horror, anger, guilt, or shame), decreased interest in activities, feeling isolated, and difficulty experiencing positive affect.

What is the evidence for negative thoughts and mood in PTSD?

Moderate to high quality evidence found a strong relationship between increased dysfunctional appraisals of the trauma and increased PTSD symptoms in children and adolescents. Increased shame was related to increased PTSD symptoms in adults. There was also a relationship between increased symptoms and increased guilt, particularly feelings of wrongdoing and self-blame. In veterans, poor mental health in general, poor social functioning, more substance use and more aggression were related to more emotional numbing. However, more treatment initiation and better treatment retention were also related to more emotional numbing in veterans.

Moderate to low quality evidence found decreased reward functioning in people with PTSD, being a reflection of an inability to feel pleasure. There was less anticipation and approach reward functioning, and also decreased hedonic responses.

Moderate to low quality evidence finds five clusters of items relating to negative alterations in cognition and mood. These are;

Decreased interest items

I lost interest in activities which used to mean a lot to me. I lost interest in my usual activities. I lost interest in free time activities that used to be important to me. I lost interest in social activities. I lost interest in activities that I used to enjoy.

Detachment items

I felt distant or cut off from people. No one, not even my family, understood how I felt.

Restricted affect items

I was not able to feel normal emotions. It seemed as if I have no feelings. I felt emotionally numb. I felt unemotional about everything. I was unable to have loving feelings for people who are close to me.

Foreshortened future items

I felt as if my plans for the future would not come true. I felt that I had no future. Making long term plans seemed meaningless to me. I felt as if I don’t have a future. I felt as if my future would somehow be cut short.

Guilt items

I felt guilty. I felt ashamed of the traumatic events that happened to me. I blamed myself. I felt guilt over things I did around the time of the event. I felt guilty for having survived.

August 2021

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Overall cognitive functioning may be disrupted in people with PTSD. Intelligence quotient (IQ) is derived from standardised tests used to measure general cognitive functioning. IQ is most commonly measured using the Wechsler Adult Intelligence Scale (WAIS). The WAIS is designed to measure all aspects of cognitive functioning and is divided into subtests measuring verbal IQ (verbal comprehension and working memory) and non-verbal IQ (perceptual organisation and processing speed). Other tests used to assess IQ include the Mini-Mental State Examination (MMSE), which assesses cognitive impairment; the National Adult Reading Test (NART), which assesses premorbid intelligence; the Wide Range Achievement Test (WRAT), which assesses both verbal and mathematic ability; and the Raven’s Progressive Matrices, which assesses general intelligence.

What is the evidence for general cognition in people with PTSD?

High quality evidence finds a medium-sized effect of poorer general intelligence in people with PTSD than people without PTSD. Moderate quality evidence finds a large effect of poorer general intelligence in traumatised children with PTSD compared to non-traumatised children, and a small effect when compared to traumatised children without PTSD.

August 2021

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Cognitive failures or “slips” are experienced by everyone from time to time and represent a brief lapse in concentration in real world settings. They are influenced by factors such as personality, mood, stress, and time of day. People with psychological disorders are thought to be more vulnerable to cognitive failures, possibly due to increased problems with related cognitive processing such as attention.

Several self-report tools have been developed to measure cognitive failures. One common tool is the Cognitive Failures Questionnaire (CFQ), which requires individuals to indicate how frequently they have experienced a list of minor perceptual, memory, and action failures in everyday life.

What is the evidence for cognitive failures in people with PTSD?

Moderate quality evidence finds increased severity of PTSD symptoms is related to more cognitive failures.

August 2021

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Antecedents, including cognitive anomalies, are usually subtle deviations in development that may become evident during childhood or adolescence. The presence of these deviations may foreshadow the later development of bipolar disorder, however most children who exhibit deviations do not develop the disorder. Studies exploring antecedents are ideally based on representative, population-based samples that follow the group from birth through childhood and adolescence to adulthood.

What is the evidence from long-term studies on cognitive anomalies as antecedents of bipolar disorder?

Moderate to low quality evidence suggests a medium-sized effect of low IQ in childhood, particularly measured on attention and working memory scales, in people who developed bipolar disorder or mania in adulthood. However, this finding is not consistent across studies, and there is also evidence of a large association between high childhood IQ and mania in adulthood.

October 2021

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Cognitive symptoms in people with bipolar disorder may be apparent in many cognitive domains, including executive function, memory, and attention, and may develop prior to the core mood symptoms of bipolar. Cognitive symptoms are highly disabling and may predict poor functional outcomes

What is the evidence for pharmaceutical treatments for cognitive symptoms?

Low quality evidence is unclear of the benefits of pharmaceutical treatments for cognition in people with bipolar disorder. Review authors conclude that the findings are disappointing due to study methodological issues.

November 2021

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Intelligence quotient (IQ) is derived from standardised tests used to measure general cognitive functioning. IQ is most commonly measured using the Wechsler Adult Intelligence Scale (WAIS). The WAIS is designed to measure all aspects of cognitive functioning. It is divided into subtests measuring verbal comprehension and working memory and non-verbal perceptual organisation and processing speed. Other tests used to assess IQ include the Mini-Mental State Examination (MMSE), which assesses cognitive impairment; the National Adult Reading Test (NART), which assesses premorbid intelligence; the Wide Range Achievement Test (WRAT), which assesses both verbal and mathematic ability; and the Raven’s Progressive Matrices, which assesses general intelligence.

What is the evidence for IQ and global cognition in bipolar disorder?

Moderate to high quality evidence finds a small effect of poorer global cognition in people with bipolar disorder compared to controls without the disorder. This was found prior to the onset of the disorder when assessments were conducted retrospectively, but not prospectively. After illness onset, there was a medium-sized effect of poorer global cognition in people with bipolar disorder compared to controls, with no changes over time (3-7 years). The effect was smaller in people with first-episode patients than in chronic patients.

Moderate quality evidence finds a large impairment in global cognition in youth with bipolar disorder aged ~13 years who were matched to controls for age and IQ. There were no differences in global cognition in elderly people with bipolar disorder and controls matched for age and education.

High quality evidence finds a small effect of poorer global cognition in people with bipolar disorder and a history of psychotic symptoms compared to people with bipolar disorder with no history of psychotic symptoms. This effect was also found in people with bipolar I disorder compared to people with bipolar II disorder. There was also poorer global cognition in overweight people with bipolar disorder compared to normal weight people with bipolar disorder.

Moderate to high quality evidence finds no differences in IQ between first-degree relatives of people with bipolar disorder and controls. When the analysis included only relatives aged 10 to 25 years, high quality evidence shows a small effect of lower IQ in relatives. Moderate to high quality evidence finds a small to medium-sized effect of higher IQ in relatives of people with bipolar disorder than in relatives of people with schizophrenia.

October 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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Key features of the symptoms of disorganisation include disorganised speech and behaviour, as well as inappropriate affect. Severely disorganised speech is difficult to follow, being incoherent, irrelevant and/or illogical. These symptoms are sometimes called positive formal thought disorder symptoms. Disorganised speech may also be deprived of content, which is sometimes called negative formal thought disorder symptoms. Disorganised behaviour includes bizarre or inappropriate behaviour, actions or gestures. Inappropriate (incongruous) affect involves exhibiting incorrect emotional responses for a given context. Symptoms of disorganisation have been identified as risk factors for poor illness outcome, and have a significant negative effect on a person’s day-to-day functioning and quality of life. There is evidence to suggest that disorganisation symptoms may be associated with impaired cognition.

What is the evidence for disorganised symptoms in people with bipolar disorder?

Moderate to high quality evidence suggests a small to medium-sized effect of less formal thought disorder in people with bipolar disorder than in people with schizophrenia. This effect is significant only in non-acute, stable patients.

October 2021

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Cognitive symptoms of schizophrenia have been found in all cognitive domains, including executive function, memory, and attention, and often develop prior to the other symptoms of schizophrenia. They are highly disabling and predict poor functional outcomes.

What is the evidence for treatments for cognitive symptoms?

Overall, moderate to high quality evidence suggests second-generation antipsychotics are associated with small improvements in processing speed, verbal fluency, learning, motor skills, long-term memory, and global cognition when compared to first generation antipsychotics, but have no benefit over first generation antipsychotics for improving attention, cognitive flexibility, working memory, delayed recall, or visuospatial processing. High quality evidence shows a small benefit of first-generation antipsychotics over placebo for general cognitive functioning.

For specific antipsychotics, moderate to high quality evidence shows haloperidol is associated with small improvements in global cognition (low haloperidol dose only), verbal learning (low and high dose), delayed recall (low and high dose), and attention (low dose only) when compared to second generation antipsychotics, with no differences in executive function, verbal fluency, motor skills, or processing speed. Sertindole may be superior to; clozapine, quetiapine, and first generation antipsychotics for general cognitive ability; clozapine, quetiapine, and olanzapine for memory; clozapine, quetiapine, olanzapine and ziprasidone for executive functioning; and quetiapine for processing speed. Olanzapine may be superior to clozapine and first generation antipsychotics for visuospatial skills and verbal fluency.

Moderate quality evidence finds small improvements in overall cognition after treatment with clozapine, olanzapine, quetiapine, risperidone, and ziprasidone, particularly on measures of memory, attention, processing speed, and executive functioning. Fluency was improved with clozapine, olanzapine, and quetiapine only. There were no significant improvements in visuospatial skills, language, or motor functioning.

For other agents, moderate to high quality evidence suggests small benefits of antidepressants over placebo for global cognition and executive functioning. There was a small improvement in verbal learning with adjunctive anti-dementia medications compared to placebo, with no improvements in overall cognition, memory, speed of processing, attention, problem solving, executive functioning, social cognition or visual learning. There were no differences in adverse events between anti-dementia medications and placebo. There were no benefits of varenicline compared to placebo for cognition, and varenicline may cause more nausea.

October 2020

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Cognitive deficits are core features of both schizophrenia and bipolar disorder. Establishing differences in cognition between these disorders may be useful for identifying differences in the underlying illness pathologies, and may provide potential targets for individual treatments.

What is the evidence for cognitive functioning in schizophrenia and bipolar disorder?

Moderate to high quality evidence shows small to medium-sized effects of poorer global cognition, executive functioning, social cognition, processing speed, attention, reasoning and problem solving, learning, and memory in people with schizophrenia (including early onset schizophrenia) compared to bipolar disorder (including paediatric bipolar disorder).

There was a medium-sized effect of poorer pre-illness onset cognitive functioning and a large effect of poorer post-illness onset cognitive functioning in people with schizophrenia compared to controls without a mental illness. In people with bipolar disorder compared to controls without a mental illness, there was a small effect of poorer pre-illness onset cognitive functioning and a medium-sized effect of poorer post-illness onset cognitive functioning. People with schizoaffective disorder showed poorer cognitive performance than people with bipolar disorder, but better cognitive performance than people with schizophrenia.

March 2022

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