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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 38  |  Issue : 3  |  Page : 147-153

Association of executive dysfunctions and symptoms in a sample of bipolar affective disorder patients


1 Department of Psychiatry, Faculty of Medicine, Seuz Canal Universiy, Ismalia, Egypt
2 Ministry of Health, Egypt

Date of Submission19-Jan-2017
Date of Acceptance12-Jun-2017
Date of Web Publication25-Oct-2017

Correspondence Address:
Mona Elsayed
Department of Psychiatry, Faculty of Medicine, Seuz Canal University, Ismailia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ejpsy.ejpsy_7_17

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  Abstract 

Background
Executive functions are defined as the higher-level cognitive functions that are necessary to plan and execute goal-directed behaviors and may include cognitive flexibility, creativity, planning ability, abstract thinking, concept formation, and response inhibition. Recently, it has been shown that those with schizophrenia, as well as those with bipolar disorder, exhibit deficits in executive functions relative to controls. Executive function capability is an important predictor of the treatment, prognosis, and functional outcomes of these disorders.
Patients and methods
This cross-sectional study was carried out in Suez Canal University Outpatient Psychiatric Clinic. It included 60 patients with bipolar disorder type 1 (male and female). All studied patients were subjected to assessment of the manic symptoms using the total scores of Young’s Mania Rating Scale and the depressive symptoms using the total scores of the Hamilton Depression Rating scale by researcher. Assessment of cognitive functions was carried out by an expert psychologist using the Wechsler Adult intelligence Scale, Wechsler Memory Scale-III-Revised Hayling Sentence Completion Test, Trail Making Test, and the Wisconsin Card-Sorting Test.
Result
The results showed worsening in the executive function associated with manic than with depressive symptoms.
Conclusion
Manic symptoms had a significant effect on cognitive functions.

Keywords: bipolar disorder, depression, executive functions, manic


How to cite this article:
Fahmy M, Hagagg W, El Moez KA, Elsayed M, Elsayes S. Association of executive dysfunctions and symptoms in a sample of bipolar affective disorder patients. Egypt J Psychiatr 2017;38:147-53

How to cite this URL:
Fahmy M, Hagagg W, El Moez KA, Elsayed M, Elsayes S. Association of executive dysfunctions and symptoms in a sample of bipolar affective disorder patients. Egypt J Psychiatr [serial online] 2017 [cited 2018 Jan 16];38:147-53. Available from: http://new.ejpsy.eg.net/text.asp?2017/38/3/147/217213


  Introduction Top


Executive functions are a highly complex structure consisting of several internal mental processes designed to solve mental and environmental complex problems in an efficient and acceptable way to the person and the society (Papazian et al., 2006).

Generally, executive function is defined as the higher-level cognitive functions that are necessary to plan and execute goal-directed behaviors and may include cognitive flexibility, creativity, planning ability, abstract thinking, concept formation, and response inhibition (Jurado and Rosselli, 2007). Recently, it has been shown that those with schizophrenia, as well as those with bipolar (BP) disorder, exhibit deficits in executive function relative to controls. Executive function capability is an important predictor of the treatment, prognosis, and functional outcomes of these disorders (Ritsner et al., 2006).

Sweeney et al. (2000) observed widespread cognitive disturbances during manic and mixed affective states, which contrasted with less extended deficits in depression. Similarly, Murphy et al. (1999) found suboptimal decision-making, reduced accuracy, and decreased ability to inhibit responses in an affective shifting task, in manic, but not depressed, BP patients. The latter were impaired in their ability to reverse the focus of attention.

The present study compared the associations of symptom pattern with executive functions in BP I disorder patients with manic and depressive symptoms.


  Patients and methods Top


This cross-sectional study was carried out in Suez Canal University Outpatient Psychiatric Clinic. It included 60 patients with BP disorder type 1 (male and female). Patients were divided into two subgroups according the predominant current clinical symptoms, either with predominant manic symptoms or with predominant depressive symptoms. Consequently, all patients who met the inclusion and exclusion criteria were included in the study.

Inclusion criteria

  1. Age between 18 and 45 years to minimize the influence of aging on cognitive functions.
  2. Diagnosis of BP type 1 according to American Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV), Text Revision).
  3. Both sexes.
  4. Duration of last hospitalization less than 6 months.
  5. Duration of the disorder of at least 1 year.
  6. No electroconvulsive therapy during the last 6 months.
  7. Having symptoms in the stabilizing or the maintenance phase.


Exclusion criteria

  1. Mental retardation (Intelligence Quotient less than 70).
  2. History of head trauma.
  3. Severe general medical conditions, which can interfere with test performance, such as hepatic precoma, renal failure, and delirium.
  4. Moderate-to-severe sensory defect such as hearing or visual defect.
  5. History of alcohol or substance abuse during the past year.
  6. Comorbidity of other axis one psychiatric disorders for both schizophrenia and BP patients.


Sample size

The sample size was calculated using the following equation:



where:
  1. zα/2 (confidence level)=1.96,
  2. zβ (power of the study)=0.84,
  3. P1 (prevalence of executive dysfunction among schizophrenic patients)=65%,
  4. P2 (prevalence of executive dysfunction among BP I patients)=30%,
  5. n (sample size)=60 patients per group.



  Methods Top


All studied patients were subjected to the following:
  1. Detailed history taking and mental status examination performed by researcher through a semistructured interview (Firstet al., 1996).
    History taking included the following:
    1. Age at illness onset.
    2. Duration of illness.
    3. Type of medications.
    4. Family history and consanguinity.
  2. Complete physical and neurological examination to exclude neurological or organic comorbidities.
  3. Assessment by researcher of the manic symptoms in BP I patients using the total scores of Young’s Mania Rating Scale (YMRS) (Younget al., 1978).
  4. Assessment by researcher of the depressive symptoms in BP I patients using the total scores of the Hamilton Depression Rating scale (Hamilton, 1960).
  5. Assessment of cognitive functions by an expert psychologist included the following:
    1. Assessment of IQ using the Wechsler Adult intelligence Scale, Arabic version (Wechsler, 1955).
    2. Assessment of memory (verbal, visual, and working memory) using the Wechsler Memory Scale-III-Revised (WMS-R) Wechsler (1997).
    3. Assessment of the executive functions for the patient and control groups included the following:
      1. Assessment of response initiation and inhibition using the Hayling Sentence Completion Test (Burgess and Shallice, 1996).
      2. Assessment of cognitive flexibility using the Trail Making Test (Retain and Wolfson, 1985).
      3. Assessment of reasoning, decision-making, and strategic planning using the Wisconsin Card-Sorting Test (Berg and Grant, 1948).


Ethical considerations

Along the procedures of the present study, the following ethical considerations taken:
  1. A brief explanation of the aim of the study to patients and their families, stressing the importance of data they are going to offer.
  2. Obtaining informed consent before the start of the study from patients and their families based on information given about the nature of the study.
  3. No obligation to participate.
  4. Ensuring the confidentiality of the collected data.
  5. Results of this study used for the benefit of patients.
  6. During the study, participants were not exposed to any harm.


Ethical committee of the Faculty of Medicine, Suez Canal University approved the ethical consideration of the study.


  Result Top


This cross-sectional study was carried out in Suez Canal University Outpatient Psychiatric Clinic. It included 60 patients with BP I disorder (26 male and 34 female) with a mean of age 34.364±9.012 years. [Table 1] shows a statistically significantly lower working memory score in BP I group with predominant manic symptoms compared with BP I group with predominant depressive symptoms.
Table 1: Comparison between bipolar I patients as regards Wechsler Memory Scale-III

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[Table 2] shows a statistically significantly lower overall scaled score in the BP I group with predominant manic symptom compared with the BP I group with predominant depressive symptoms. There was statistically significantly higher A errors-connected errors in the BP I group with predominant manic symptoms compared with the BP I group with predominant depressive symptoms.
Table 2: Comparison between bipolar I patients as regards Hayling Sentence Completion Test

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[Table 3] shows a statistically significant prolonged MT-B part in the BP I group with predominant manic symptoms compared with the BP I group with predominant depressive symptoms.
Table 3: Comparison between bipolar I patients as regards Trial Making Task

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[Table 4] shows a statistically significantly lower TC in the BP I group with predominant manic symptoms compared with the BP I group with predominant depressive symptoms. There was a statistically significantly higher preservative error (PE) in the BP I group with predominant manic symptoms compared with the BP I group with predominant depressive symptoms.
Table 4: Comparison between bipolar I patients as regards the Wisconsin Card-Sorting test

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[Table 5] shows that the very severe YMRS score exhibited significant negative associations with WMS-III Working memory (r=−0.239; P=0.04). There were nonsignificant correlations between different severity YMRS scores and different WMS-III scores.
Table 5: Correlations between the severities of Young’s Mania Rating Scale and cognitive functions using Wechsler Memory Scale-III

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[Table 6] shows that the very severe YMRS score exhibited significant positive associations with PE in Wisconsin Card-Sorting Test (WCST) (r=337; P=0.04).
Table 6: Correlations between the severity of Young’s Mania Rating Scale and cognitive functions using Hayling Sentence Completion Test, Trial Making Task, and Wisconsin Card-Sorting Test

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[Table 7] shows a nonsignificant correlation between different severity Hamilton Depressive Rating Scale (HDRS) scores and different WMS-III scores.
Table 7: Correlations between the severities of Hamilton Depressive Rating Scale and cognitive functions by Wechsler Memory Scale-III

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[Table 8] shows a nonsignificant correlation between different severity HDRS score and different Hayling Sentence Completion Test, Trial Making Task (TMT), and WCST scores.
Table 8: Correlations between the severity of Hamilton Depressive Rating Scale and cognitive functions using Hayling Sentence Completion Test, Trial Making Task, and Wisconsin Card-Sorting Test

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  Discussion Top


Results of the current study showed a statistically significantly lower working memory score in the BP I group with predominant manic symptoms (n=32) compared with the BP I group with predominant depressive symptoms (n=28). Thus, there was poor working memory performance in BP patients with manic symptoms compared with BP patients with depressive symptoms.

Similar to our results, Martínez-Arán et al., (2000) found a poorer performance in the BP manic group as regards executive function and verbal and working memory compared with the BP depressive group.

Our results are in agreement with those of Sweeney et al. (2000), who observed widespread cognitive disturbances during manic and mixed affective states, which contrasted with less extended deficits in depression. Similarly, Murphy et al. (1999) found suboptimal decision-making, reduced accuracy, increased working memory impairments, and decreased ability to inhibit responses in an affective shifting task, in manic, but not depressed, BP patients.

Our results are not in agreement with those of Hoda et al. (2015), who conducted a study in El Maamora Mental Hospital over a 6-month period; they found that BP patients in the three groups (manic, depressive, and euthymic) showed significant cognitive deficits compared with controls. Both manic and depressive patients showed impairment in attention, working memory, and executive functions. Euthymic patients showed a significant impairment in working memory and executive functions. This may be attributed to the difference in patients’ groups division, study design, and psychological tools used.

Results for the BP I group show a statistically significantly lower overall scaled score in the BP I group with predominant manic symptom compared with the BP I group with predominant depressive symptoms. There was statistically significantly higher A errors-connected errors in the BP I group with predominant manic symptoms compared with the BP I group with predominant depressive symptoms.

Thus, executive function performance in BP I patients with manic symptoms is lower than that in BP I with depressive symptoms. BP I patients with positive symptoms exhibited longer average response latency for response suppression and demonstrated an increased rate of response errors compared with BP I with depressive symptoms.

Similar to our results, Stoddart et al. (2007) and Dixon et al. (2004) found that BP patients during manic phase make more errors on HSCT performance.

Similar to our results, Sweeney et al. (2000) and Murphy et al. (1999) found widespread executive function impairments during manic state of BP, which contrasted with less extended deficit in depression state. They found reduced accuracy, increased error intrusion, and decreased ability to inhibit responses in manic, but not depressed BP patients.

Our results are not in agreement with the results of Joshua et al. (2009), who found no difference between the BP group and healthy controls on HSCT performance, and Arts et al. (2008), who found that there is no difference in executive functions, mainly response inhibition between BP patients with euthymic, mania, and depression. This discrepancy may be attributed to differences in the sample number, sample design, patient group arrangement, and psychological tests used.

Results of the current study showed that there was a significantly prolonged TMT-B in the BP 1 group with predominant manic symptoms compared with the BP 1 group with predominant depressive symptoms.

Thus, the cognitive flexibility (part B) performance is impaired in BP 1 patients’ predominant manic symptoms compared with the BP 1 group with predominant depressive symptoms.

Similar to our results, Martínez-Arán et al. (2000), Murphy et al. (1999), and Arts et al. (2008) found impaired executive functions, cognitive flexibility decision-making, decreased ability to shifting task in manic, but not depressed, BP patients.

Different from our results, Hoda et al. (2015) found both manic and depressive BP patients showed impairment in attention, working memory, and executive functions. Murphy et al. (1999) found impaired ability to reverse the focus of attention in depressed BP 1 patients. This discrepancy may be attributed to the difference in the symptom classification, severity of symptoms, and study design.

There was a statistically significantly lower total correct in the BP I group with predominant manic symptoms compared with the BPI group with predominant depressive symptoms. There was statistically significantly higher PE in the BP I group with predominant manic symptoms compared with the BP I group with predominant depressive symptoms.

Thus, the executive function performance (decision-making, reasoning. and strategic planning) more affected in the BP 1 group with predominant manic symptoms compared with the BP 1group with predominant depressive symptoms.

Similar to our results, Stoddart et al. (2007) and Dixon et al. (2004) found reduced accuracy of decision-making and increased error intrusion in manic, but not depressed BP patients.

Our results are not in agreement with those of Arts et al. (2008), who found no difference between BP manic and depressive on WCST performance. This discrepancy may be attributed to differences in symptom arrangement, severity of symptoms, and psychological tests used.

The current results show that very severe YMRS score exhibited significant negative associations with WMS-III Working memory (r=−0.239; P=0.04) and no significant correlation between different severity YMRS score and different WMS-III scores.

The current results showed a nonsignificant correlation between different severity HDRS score and different WMS-III scores.

Thus, in BP patients, only the manic symptoms have inverse relation with working memory.

The current results show that very severe YMRS score exhibited a significant positive associations with PE in WCST (r=337; P=0.04) and no significant correlation between different severity YMRS score and different HSCT and TMT scores.

The current results showed a nonsignificant correlation between different severities of HDRS score and different WMS-III scores.

Thus, in BP patients, only the manic symptoms have a direct relation with executive dysfunctions (decision-making).

Similar to our results, Stoddart et al. (2007), Dixon et al. (2004), Murphy et al. (1999), Sweeney et al. (2000), and Martínez-Arán et al. (2000) found a relation between executive dysfunction (suboptimal decision-making, increased working memory impairments, and decreased ability to inhibit responses in an affective shifting task) and manic symptoms, not depressed, in BP patients.

Our results are not in agreement with the findings of Hoda et al. (2015), who found that both manic and depressive symptoms of BP patients have a relation with impairment in attention, working memory, and executive functions. This discrepancy may be attributed to differences in the sample number, symptom arrangement, and psychological tests used.

Limitations

  1. It is a cross-sectional study and not longitudinal study, which is better in studying cognition.
  2. Small sample size.
  3. Lack of information on premorbid cognitive functions.
  4. The effects of medications on cognitive function are unclear.



  Conclusion Top


Manic symptoms had a significant effect on cognitive functions. [19]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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Arts B, Jabben N, Krabbendam L, van Os J (2008). Meta-analyses of cognitive functioning in euthymic bipolar patients and their first-degree relatives. Psychol Med 38:771–785.  Back to cited text no. 1
    
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Joshua N, Gogos A, Rossell S (2009). Executive functioning in schizophrenia: a thorough examination of performance on the Hayling Sentence Completion Test compared to psychiatric and non-psychiatric controls. Schizophr Res 114:84–90.  Back to cited text no. 8
    
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Jurado MB, Rosselli M (2007). The elusive nature of executive functions: a review of our current understanding. Neuropsychol Rev 17:213–233.  Back to cited text no. 9
    
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Martínez-Arán A, Vieta E, Colom F, Reinares M, Benabarre A, Gasto C, Salamero M (2000). Cognitive dysfunctions in bipolar disorder: evidence of neuropsychological disturbances. Psychother Psychosom 69:2–18.  Back to cited text no. 10
    
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Sweeney J, Kmiec J, Kupfer D (2000).Neuropsychological impairments in bipolar and unipolar mood disorders on the CANTAB Neurocognitive Battery. Biol Psychiatry 48:674–685.  Back to cited text no. 16
    
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]



 

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