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Abstract
There is a growing consensus that persistent cognitive deficits are common in patients with bipolar disorders even when they are euthymic. Apart from certain exceptions, studies of remitted patients have generally reported deficits in several cognitive domains. However, many of these studies have not controlled for residual affective symptoms, which would have a substantial bearing on their results. When this has been done enduring deficits have been observed in either memory or executive functions, or a combination of these areas. Precisely what characteristics best define the prodromal phase of bipolar disorder remain at issue, and the extent to which cognitive manifestations of illness may be evident before, or alongside, the first emergence of affective signs in high risk individuals is largely unknown. Furthermore, the direction of causality is unclear, mood episodes may adversely affect neuropsychological performance, or impaired cognitive function may contribute to the development and exacerbation of mood symptoms.
Some of the evidence suggests that recurring episodes of bipolar disorder are associated with greater cognitive disturbance. It has been proposed that successive episodes cause subtle damage to key brain areas leading to the neurological and cognitive impairment observed in bipolar disorder. However, the evidence linking cognitive deficits with indicators of severity, progression of the illness is not always consistent. The most direct approach to determine the course of cognitive abnormalities in bipolar disorder would be a longitudinal follow up of first episode subjects with repeated assessment of their cognitive functioning. This is usually difficult and expensive. Alternatively, cognitive functions of patients in their first episodes could be compared with patients who have already experienced multiple episodes. Such strategy has been successfully used in schizophrenia. Unlike other areas of medicine, psychiatry at present has no biochemical markers or laboratory tests on which to base its diagnosis. Instead subjective assessments form the basis of both clinical and research psychiatric diagnosis. Furthermore, family studies of bipolar disorders reveals that individuals with genetic predisposition for the illness do not necessarily manifest the illness, when in fact they do carry genetic risk (genotype) variants linked with the disorder. Similarly, a clinical diagnosis may include subjects whose outward symptoms may resemble those of bipolar disorder (known as phenocopies) but who in fact lack the true bipolar genotype. Such misclassification resulted into diagnostic confusion and lead to a new approach which is the use of an endophenotype which describes the hidden traits of the illness. It is an indicator of biological processes mediating between genotype and phenotype. Using endophenotype markers may be adventitious because they are generally less complex than their associated phenotype. Two endophenotype considered for bipolar disorder are the neuropsychological assessment, the main concern of our study, and the neuroimaging of bipolar disorder.
Cognitive impairment can have several adverse consequences for patients of BAD in terms of disability, quality of life, and outcome. Individuals with bipolar disorder are at risk for an addiction, they are also at risk of committing suicide or homicide when acting on their delusions. Therefore, this must be a priority area for future research.
So we assessed cognitive functions of a group of euthymic and stable bipolar patients after a single episode. Compared and contrast cognitive profiles of those patients with those who had experienced multiple episodes, both while in remission. The results were compared with a cross matched control group.
The cases were selected from the out patient clinic in the institute of psychological medicine (Ain Shams University). The institute is located in Eastern Cairo, and serves a catchments area of about the third of Greater Cairo. It serves both urban and rural areas, including areas around Greater Cairo as well, which represents a true random sample of the Egyptian population. There are three outpatient general psychiatry clinics (A, B, and C), working four days per weak.
Two random samples of bipolar disorder patients were chosen one after the first manic episode and the other after multiple episodes. Each group consisted of 50 patients. A cross matched Control group selected consisted of 50 Egyptian individuals with no apparent physical or neuropsychiatric morbidity. They were matched for age, sex, and other demographic variables as far as possible with the patient group. They have no family history of any psychiatric disorder. The control group was selected randomly from workers and employers working in Ain Shams University Hospitals. A semi structured sheet was done for the entire sample including sociodemographic factors to ensure that sample was matched. ICD-10 symptoms check list to diagnose bipolarity, Hamilton and Young mania scale was given to ensure absence of residual affective symptoms followed by neurocognitive assessment including the following trail A (attention and concentration), trail B, WCST-CV (executive functions), WAIS to exclude any patient who are mentally subnormal, and WMS-R (memory assessment) to the patient groups. Regarding the control group a general health questionnaire was given to ensure that they are free from any illness which was followed by the same battery done for the patient group.
The main findings in the study were
There was no statistical significant difference among the three groups regarding the occupational level and socioeconomic status, which ensures that the three groups were matched.
Regarding the demographic data the sample of our study consisted of 150 subjects. Fifty diagnosed as multiple episode BAD in remission. (Thirty were males=60% 20 females=40%). fifty diagnosed as having first episode BAD in remission (33 males=66%, 17 females=34%) and 50 cross matched healthy control subjects 29 males=58%, 21 females=42%).
The mean age of the multiple episode bipolar groups was 36.1+/-7.8, for the first episode bipolar patients was 26.4 +/- 4.7 and the control group was 38.6+/-7.8.
By the end of our study we came up with the following conclusions:
Results show that there was no difference between male and female bipolar patients regarding attention, executive functions and total memory score. Yet, there was statistical difference in verbal memory favoring female patients.
Patients with single manic episode showed impairment in attention, executive function and total memory score compared to healthy control. The presence of such impairment in bipolar patients as early as the first episode and their continuous presence even in remission indicate that these cognitive deficits are trait markers and could be used as an endophenotype for the illness. However, regarding the temporal evolution, it is still not clear whether they occurred prior to the illness or accompanying the illness.
Patients with bipolar disorder with multiple episodes in remission performed worse than those with single episode patients’ in attention, executive function which indicates that there is progressive nature of the illness.
Results show that bipolar patients with positive family history of psychiatric illness did not differ in the cognitive impairments compared to those with negative family history.
Results show that the earlier age of onset is associated with more declines in executive functions and attention.
Results show that duration of illness is inversely proportionate to attention and executive functions.
Results show that number of episodes is inversely related to executive functions.