Cognitive and Focus Issues

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Difficulties with cognition and focus are almost universal in folks with moods. In the scientific literature there have been attempts to distinguish between mood related problems and problems that tend to persist regardless of mood state.

There is probably nothing that can more profoundly affect our brain’s ability to focus than an episode of depression or mania.

These functional brain images (functional meaning that they show brain activity rather than brain structure) show the kind of changes in brain function that can take place with depression. On the right you see normal brain activity and on the left you see brain activity during an episode of depression. Yellow represents normal levels of activity and green and blue represent abnormally low levels of activity. As you can see, depression lowers activity throughout the brain. It is literally like a dimmer switch for the brain.

These changes are much greater than the effects of medications. Most people who9-19-2013 7-05-34 AM are getting treated with medications tend to assume that it is the medications that are causing cognitive problems. In our clinical experience, in the absence of severe sedation (bumping into things, having trouble staying awake), medications never cause as severe an effect on brain function as a mood episode.

There is also evidence to suggest that the brain effects of a mood episode persist much longer than the mood episode itself. A study of patients hospitalized for a manic episode found that cognitive impairment took up to six months to return to its usual level after mood was back to normal.

If you are noticing trouble thinking clearly and you are feeling either unusually energized or depressed, the change that is most likely to improve this is not reducing medications, it is making sure that you are getting the most effective treatment for your moods.

Bipolar Cognitive Issues

People with bipolar mood swings have three kinds of cognitive problems. Here we are going to talk about two of these – problems that are related to a mood episode (either being manic or energized, or depressed), and problems that tend to persist when the person is not energized or depressed. We are not going to talk about the adverse effects of medications on cognition, mostly because these are specific to individual medications and there are so many medications and combinations of medications that it is not really useful to talk about medication effects in general.

Mood Related Cognitive Issues

As noted above, depression has major effects on overall brain function. Energized or manic states have effects that can be no less problematic, although, as we will see, they are harder for the person who is in an energized state to notice.

Whereas there seems to be an overall dimmer switch effect with depression, with energized states the effect is more specific. Overall brain activity may be increased, but the area of the brain involved in assessing risk (midline prefrontal cortex) is gradually turned off.

One of the reasons being manic can seem so attractive is that these areas seem to be overactive in depression (scanning for potential problems) with the result that almost any decision or action becomes fraught with potential bad outcomes, and paralysis sets in. So it is a relief when this obsessive focus on negative consequences lightens up. But the effect is not just a reduction to a normal level, it continues until the person is not able to see real and imminent hazards in an action.

In mild states of being energized, the result is that the person feels they are cognitively “at their best” even though they are actually making more mistakes than they usual do, because the monitoring for errors process is turned off.

These neuropsychological tests illustrate the effect.

Picture 123 combined


The first set of tests was done when he was feeling depressed. In fact we did the tests because he felt sure that he had suddenly become demented. The tests show broad reductions in cognitive function in a number of areas.

The second set of tests was done when he was feeling almost normal (perhaps slightly depressed). They show that his cognitive function was much improved (depression is sometimes called “pseudo-dementia” because its effects look like dementia, but they are reversible). However, at this point he still felt that his cognitive function was impaired.

The last set of tests were done when he was energized or hypomanic. At this point he felt that he was functioning at his best cognitively. However you can see that in fact he was not doing as well as when he was very slightly depressed.

More specifically, when he was hypomanic he made a kind of mistake that is ordinarily very unusual, he “remembered” items from a list that had not actually been on the list in the first place. This is the opposite of the effect of depression, where people usually report that they “don’t know” the answer even when, if they are encouraged to “guess” it turns out that they do.

[For those of you with sharp eyes you might notice that there are some consistent problems across these tests, it turns out that this person has had long standing issues with visual processing and visual memory that have nothing to do with bipolar].

Mood Independent Cognitive Issues

Finally, let’s talk about cognitive problems that tend to be relatively persistent, even when the person is not depressed or energized.

There are two types of problems that we often see –

  • Problems with sustained attention. There is usually a mild problem with sustained attention (the same problem that people with attention deficit disorder (ADD) which can affect the ability to do things like read a book or concentrate on a complicated problem.
  • Problems with processing speed. There is often a slowing down of overall processing speed that affects time dependent tasks like doing standardized tests, or solving urgent problems. Again, this problem tends to be mild.

Readers who are interested in more information on this topic may want to find this review article by Goldberg and Chengappa in the journal Bipolar Disorder. It is a bit technical but summarizes many somewhat confusing studies on this topic.

A recent article in the prestigious journal Nature summarized a study that suggested that a computer application might have the ability to reverse the reductions in sustained attention seen in patients with aging. Follow the link for more on this tantalizing finding.

Stress and Focus

Stress has a major affect on our bodies and our brain. The release of catecholamines (adrenaline and related chemicals) and cortisol causes significant changes throughout our body that are designed to prepare us for “fight or flight.” By shutting down all non-essential functions the stress response system prepares us for a life and death struggle.

Nowadays there are no life or death struggles, and the non-essential functions that get shut down are pretty essential to navigating our busy and complex world and include our brain’s ability to think clearly.

I recently ran across an excellent review of the scientific literature on the effects of stress on brain function. This post is a summary of that article.

The effect of stress on brain function is fairly dramatic. In particular, the functioning of the prefrontal cortex (the newest part of the brain, and the part that does most of what we consider “thinking”) is severely impaired by stress.

One way of thinking about why this happens is that, in the past, stress implied the presence of a significant threat. Facing such a threat it was often better to rely on instinct rather than careful analysis (when you are facing a saber-tooth tiger you don’t really have time to think about why the tiger is there).

Nowadays, when we experience stress there is usually no acute threat… we are just dealing with a pressure to perform better at work… or perhaps lose a job. In those situations our thinking ability is essential and so the stress response of the body becomes a problem rather than a solution.

The best studied impairment in brain function is a dramatic decrease in what is called “working memory.” Working memory refers to the brain’s ability to hold many pieces of information in awareness at the same time, without relying on external reminders. A good example of working memory is being able to remember a number (a phone number for instance) without relying on repetition (many people may have to say the number over and over while they dial it, “415-555-8099… 415-555-8099….”).

That is a fairly trivial example of the role of working memory. Working memory is also essential in deciding what the best solution is to a problem with many options (“should I marry Joe or should I go off with Jim… what are the pros and cons?”). With impaired working memory the ability to consider a range of options is reduced and the likelihood of engaging in “black and white thinking” is increased.

Dopamine is a chemical which is involved in many brain functions, including motivation. As an example, most drugs that are abused activate the dopamine system in the emotional or limbic part of the brain which is why there is such an overwhelming motivation (or craving) for drugs.

In the prefrontal cortex, a particular dopamine receptor (dopamine one) plays a key role in allowing us to focus on important information. With too little dopamine one brain cells in the prefrontal cortex aren’t able to turn on when important information comes in (the brain can’t focus because it isn’t active enough).

Too much dopamine one overwhelms the ability of the brain to turn off when irrelevant information comes through (it overwhelms the cooling down function of a key set of receptors called the HCN receptors). The result is that lots of dopamine one also makes it hard to focus, because the brain is over-stimulated by unimportant information.

Stress also overactivated norepinephrine (noradrenaline) circuits and this further reduces the ability of the brain to selectively focus attention.

In summary, there are at least two different ways that neurotransmitters (brain chemicals) that are released by stress causes a non-selective (not just in response to important information) activation of the prefrontal cortex that makes it much harder to focus only on the important information and thus reduces working memory.

Cortisol (the main stress hormone released in the body) plays a role in these effects. It reduces working memory, while at the same time increasing vivid memory. Think of it this way, when you are facing that saber-tooth tiger you better remember everything that happens, your brain shuts down the thinking function (instincts are faster than thoughts) and at the same time turns on a real time recorder of everything that takes place (so that you can learn the important lessons of the encounter).

There is some evidence that we can undo the effects of stress activation in daily life – for example prazosin (a blocker of excessive norepinephrine activation) and guanfacine (an activator of the circuits that help with selective attention) have been shown to help with attention deficit disorder and posttraumatic stress disorder, both conditions with impaired attention.

However, for now these kinds of interventions are experimental. And the best solution to the harmful effects of stress on the brain is to retrain yourself to not activate stress systems when dealing with everyday stressors… Mindfulness and meditation are two of the most effective ways of doing that.

The Power of Concentrationimages-1

A number of people called my attention to the December 15 NY Times The Power of Concentration article written by Maria Konnikova on the topic of mindfulness.

In this article, Maria Konnikova mentions that “Though the concept originates in ancient Buddhist, Hindu and Chinese traditions, when it comes to experimental psychology, mindfulness is less about spirituality and more about concentration: the ability to quiet your mind, focus your attention on the present, and dismiss any distractions that come your way.

The formulation dates from the work of the psychologist Ellen Langer, who demonstrated in the 1970s that mindful thought could lead to improvements on measures of cognitive function and even vital functions in older adults.”

Besides the research that shows that only 5 minutes a day of mindfulness can help to regulate moods by creating a happier outlook, she also references University of Washington research that examined the effects of meditation training on multi-tasking in a real-world setting with human resources professionals. They found that those people who had received mindfulness training reported fewer negative emotions after the multi-tasking assignment and said that their concentration improved significantly. They were able to stay on a task longer and worked more efficiently. Improved moods and concentration are not the only benefits.

Ms. Konnikova goes on to describe a 2012 University of Emory study that showed how mindfulness improves connectivity inside our brain’s attentional networks that help to save us from distraction, and help us to monitor our feelings, thoughts and external environment. Mindfulness gives you the resources you need to speed up your thinking, and practicing attentional control, your brain becomes more efficient at coordinating multiple tasks, no matter what your age. Maria Konnikova: “The implications are tantalizing. Mindfulness may have a prophylactic effect: it can strengthen the areas that are most susceptible to cognitive decline. When we learn to unitask (…) we may be doing more than increasing our observational prowess. We may be investing in a sounder mental future — no matter how old we are.”

images-2Learned Helplessness

Behavior falls into a pattern that is very hard to interrupt. Even when the circumstances that triggered the state could be avoided.

Now add to this explanation the fact that we have evolved a brain that is always trying to understand and predict how the world is going to work (see “You Can’t Fool Yourself” on this site). That brain has to make sense of things.

There is no way of stopping it from trying to make sense of things, trying to make things predictable. In fact, it will try to make things predictable even when the only way to do that is self-destructive (creating a fight with a partner just to prove what bastards all men are).

It can do something similar in a therapy session… prove to itself that yes, it understands the world and the world is uncaring… in fact, it says to itself, depression is a rational response to the situation.

In other words, a biological state of learned helplessness is triggered, likely the trigger is something of a false alarm (in fact the situation wasn’t as bad as it might have seemed).

Still, the brain goes about “proving” that it understands what is going on. The world is a terrible place and no one is going to help… and by sitting in the session and repeatedly saying to itself, and the therapist, that no one (even you my therapist) can help, it “proves” that its theory is correct. And as horrible as the theory is there is relief in at least “understanding” how things really are.

How do you break out of this?

It isn’t easy. Usually the solution involves doing things to try to break out of the biological state of depression (medications, exercise, sleep, light, etcetera) and things to try to break out of the habit of “proving” that depression is a rational response to the world… which begins with seeing how that therapy session might have gone differently, for example.

What if that young woman, feeling sad and alone, focused her attention a bit more on what the therapist was trying to do and say, rather than being so completely stuck in her own belief that there wasn’t anything that could help?

With lots of effort, it is possible to shift attention and to become a bit more aware of other possibilities

Mood affects Attention

One morning, while I was riding a bike, I got to thinking about how mood affects attention and how that, in turn, creates a different reality for us depending on what mood we’re in. To think all these thoughts were sparked by my reaction to the image of a dead squirrel…

Several weeks ago, it had been an especially dark and rainy week, and I had a very large number of folks calling me with problems of severe depression. All of this had an affect on my own mood.

As is my habit, I got up and went out for a bike ride along a road that I ride pretty much every day. In other words, what I saw that day was almost certainly no different than what I saw any other day.

On this particular day, I remember bicycling by a dead squirrel and finding myself struck with how sad life was and how ultimately tragic it is that all of us die and that death is everywhere that we look. In fact, that thought stayed with me through the entire remaining half hour of my bicycle ride.

I’m usually more of an optimist, and, also, this past week I got to go out skiing at my favorite cross country ski resort.

For this and several other reasons, I started out this morning’s bicycle ride in a good mood. As I was riding, I happened to see that a dog had been killed the day before and was still lying on the side of the road. However, because my mood was better, my mind naturally skipped past the dead dog to think about how beautiful the morning really was and how clean the air was and just what a generally wonderful feeling it is to be healthy enough to go out for a bicycle ride.

This is how mood affects what we observe and think about. It draws our attention to certain things in the environment that are thematically related to that mood. In fact, it does the same thing with our memories. When we are sad, we remember the sad things (when that dead squirrel of dead birds I saw earlier).

Never-the-less, mood is not something that we have to give into. If we are vigilant, we can notice the direction that our thoughts are going and then search around for something different. For instance, the next day, when I was out biking, after I saw the dead squirrel, I was better prepared. Rather than let the sight preoccupy me, I was able to turn my attention to something that was inspiring or beautiful on the ride.

I hope you are feeling good today, but if you’re not, try to pay attention to how your focus turns to things that are sad and, consciously, look for something inspiring or beautiful to focus on instead.