Comparación del funcionamiento cognitivo en pacientes con trastorno bipplar tipo II en eutimia vesus trastorno bippolar tipo I en eutimia y controles / Comparison of Cognitive Functioning in Bipolar Disorder Type II Patientes in Euthymia vs. Bippolar Disorder Type I in Euthymia and Controls

Introducción. El trastorno bipolar (TBP) se encuentra clasificado dentro de los trastornos del estado del ánimo, se trata de una enfermedad común, recurrente y severa que causa un impacto considerable en el bienestar del paciente y una significativa carga económica para el individuo y la sociedad. Según el DSM IV el TBP se puede clasificar en Tipo I y II, el TBP I se caracteriza por la presencia de un episodio de manía o mixto que se alterna con episodios de depresión. El TBP II se presenta con episodios de depresión y al menos un episodio de hipomanía. Se ha estimado que 30 a 50% de los pacientes con TBP en remisión fracasan en alcanzar el nivel premórbido de funcionamiento psicosocial y esta discapacidad puede estar asociada a alteraciones cognitivas. Varios estudios han reportado que estas alteraciones se presentan fundamentalmente durante los episodios, las principales están relacionadas con la memoria verbal y funciones ejecutivas, y estas deficiencias persisten aún cuando el paciente se encuentra en eutimia. Existen pocos estudios que comparen las diferencias en el funcionamiento cognitivo entre pacientes con TBP I y II, el conocer estas diferencias y su repercusión en la calidad de vida de los pacientes, nos permitirá desarrollar nuevas estrategias de tratamiento que se enfoquen en rehabilitar estas funciones acorde al perfil neuropsicológico de cada grupo. Objetivo. Comparar el funcionamiento cognitivo en pacientes con TBP I y II en eutimia y sujetos controles y determinar si existe relación con la calidad de vida percibida por los pacientes. Material y métodos. Estudio comparativo, transversal, homodémico Muestra: Pacientes del sexo masculino y femenino, edad 18-60 años con diagnóstico TBP II en eutimia los últimos 4 meses, con un puntaje <7 en la Escala de Depresión de Hamilton y <6 en la Escala de manía de Young. (n=18) Se excluyó: Pacientes con dependencia a alcohol y otras sustancias o antecedente de terapia electroconvulsiva ...

Bipolar Disorder (BPD) is classed among mood disorders. It is a common, recurrent and severe disease which causes considerable impact on the patient's wellbeing and an economic burden for the individual an society. According to the DSM IV, BPD can be classified into Type I and II. BPD Type I is characterized by the presence of a manic or mixed episode which alternates with depression episodes. BPD II is accompanied with depression episodes and at least one hypomanic episode. It has been estimated that 30 to 50 % of patients with remitting BPD fail to achieve the premorbid level of psychosocial functioning and this impairmet may be associated to congnitive alterations. Several studies have reported that these alterations mostly occur during the occurrence of the episodes. The main alterations are related to verbal memory and executive functions, and these deficiencies still persist when the patient is experiencing euthymia. Few studies have compared the differences in cognitive functioning between BPD I and BPD II patients. Knowing these differences and their impact on the patients' quality of life will enable us to develop new treatment strategies focused on adapting such strategies to the neuropsychological profile of each group of patient. Purpose: to compare the cognitive functioning between BPD I and BPD II patients with euthymia and control subjects, and to determine whether it is related with the patients' quality of life as perceived by them. Materials and methods: comparative, longitudinal, homodemic study. Sample: Male and female patients aged 18-60 years-old who had been diagnosed with BPD II in euthymia during the last 4 months, with a < 7 score in the Hamilton Rating Scale for Depression and a < 6 score inthe Young Mania Rating Scale (n=18). Exclusion criteria: Patients with alcohol and other substances abuse, or with a history of electroconvulsive therapy during the previous year. Patients with a history of CVA or CET were also excluded ...

Funcionamiento neuropsicológico de adolescentes con trastorno bipolar / Neuropsychological functioning of adolescents with bipolar disorder

Persistent neuropsychological deficits have been reported in adult bipolar affective disorder, and impairments in executive functions, attention, verbal learning and memory, are postulated as neurocognitive endophenotypes. However, there is a lack of information about the neuropsychological functioning in Pediatric Bipolar Disorder (PBD). Hence, it is important to study this pediatric disorder because it could help, in first place, to clarify if children and adolescents with this disorder have neurocognitive impairments and secondly to analyze if the neuropsychological impairments in PBD are alike to those reported in adults. Neuropsychological characterization of PBD has been complicated because it has a 60%-90% comorbidity with Attention Deficit Hyperactivity Disorder (ADHD). Several studies have reported ADHD neuropsychological impairment in executive functions, sustained attention and working memory. Meanwhile, few studies in PBD have reported impairments in vigilance, working memory, interference control, speed processing, abstract problem solving and verbal learning. Yet, it is unknown if these deficiencies are distinct to the ones reported in ADHD or if they are a more severe manifestation of the same deficits. The objective of the present study was to assess the neuropsychological functioning of PBD by means of a battery of tests to analyze the capacities of complex problem solving, abstract reasoning and planning. We seeked if PBD presents other neuropsychological impairments beyond executive functions, verbal learning and memory, and attention that have been reported in adults with this disorder. Two groups were assessed, the first one included fourteen adolescent patients with PBD in euthimic phase, the other group consisted of eleven asyntomatic adolescents selected by means of absence of bipolar, affective, psychotic or neurodevelopmental disorders. Each participant was evaluated by certified neuropsychologists during three sessions of one hour each. As study variables we considered the general capacity for complex problem solving measured by subtest of the Intelligence Scales of Wechsler (WAIS or WISC-R) that were administered and qualified according to Lezak's proposals. We also assessed abstract reasoning, cognitive flexibility and planning measured by the Wisconsin Card Sorting Test (WCST) and Tower of London Drexel University (TOL DX). Results were analized with SPSS 11 program using U Mann-Whitney test with statistic significance at p <0.05 and <0.01. The results obtained, showed that adolescents with PBD had impairments in neuropsychological functioning. Some of the deficits are alike the impairments reported in adults with bipolar disorder, specially in tasks that involve executive funcioning like working memory and planning. Besides, we detected impairments in other neuropsychological measures that are associated with complex problem solving capacities that no other studies have reported, suggesting that PBD show neuropsychological impairments that go beyond those reported in adult patients. Capacities for complex problem solving were related to diminished scores for Wechsler's subtests of information, vocabulary, similarities, comprehension, picture completion, block designs and digit symbol. These subtests are associated with language abilities, concept formation, verbal reasoning, visual reasoning and speed of information processing. Although in our study adolecents with PBD scored within the normal range on Intellectual Quotient (IQ) full, verbal and executive scales, analysis showed statistical differences when compared to control group, suggesting a potentially more insidious impact of the early onset of the disorder on overall cognitive functioning. This impact can directly affect through disease evolves, or indirectly disrupting academic functioning. PBD group also differed from control group on variables that measured executive functions like planning and working memory as could be seen in Digit Span Wechsler's subtests and TOL 's total move, total rule violation and total execution time variables. Explanation of deficits could involve problems with speed processing, given the lower scores obtained on Wechsler's digit-symbol substitution subtest; or with executive deficits, such as organization and problem solving ruled out by working memory and language reasoning. Whatever the explanation could be, our data contributes to the possibility of a continuity of domains of neuropsychological impairment in people with early and later onset of bipolar disorder, although direct comparison of such groups is necessary in future studies. As such, these neuropsychological findings also could provide support for the validity of the differential diagnosis in children and adolescents with bipolar disorder. The neuropsychological impairments found in our research are consistent with the behavioral dyscontrol, poor frustration tolerance and impulsive aggression that are characteristic of PBD. It is proposed that the ability to regulate attention has implications for emotional regulation, meanwhile verbal reasoning deficits may reflect difficulties with effortful semantic processing, and impairments in executive functions such as working memory and planning, contribute to self-control and completion of goal-directed behavior. Together, deficits in these domains may impair the ability of PBD to attend to cues in the environment that assist the regulation of emotion and arousal, and to limit the ability for identifying and implementing novel and prosocial options for behavior by processing efficiently cues that are presented and ignore emotionally salient or distracting stimuly. It is important to point out that not all capacities for complex problem solving were impaired in PBD. There were no differences in Wechsler's subtests of object assembly, picture arrangement or arithmetic, neither differences were observed in TOL's variables of total correct, total time violation, total problem-solving or none of WCST variables. These findings can be associated with preserved capacities for set shifting, abstract reasoning, interference control, arithmetic reasoning, sequencing thinking, interpretation of socio-emotional clues and visuo-spatial planning. However, more work is needed to elucidate the meaning of this preserved capacities and how they interact with the impairments already discussed. In this sense, it is possible to speculate that although the impairments already described can influence on academic functioning, the preserved capacities might exert an important role in the regulation of adaptive behavior. As a conclusion, our data indicate neuropsychological deficits in youth with PBD in domains of executive functioning and capacities for general problem solving. These findings add to a growing body of work documenting the presence of neurocognitive underpinnings of bipolar disorder in adolescents. Data suggests that measures of verbal reasoning, visual reasoning, speed processing, working memory and planning might be explored further in future functional neuroimaging studies of PBD.

Los estudios neuropsicológicos del trastorno bipolar en adultos han señalado alteraciones en las funciones ejecutivas, mnésicas y atencionales como endofenotipos neurocognitivos del trastorno. Sin embargo, se conoce poco sobre la caracterización neuropsicológica del Trastorno Bipolar Pediátrico (TBPP), misma que ha sido complicada dado que existe una comorbilidad del 60%-90% con el Trastorno por Déficit de Atención con Hiperactividad (TDAH). Así, desde la perspectiva neuropsicológica, el TBPP ha sido poco estudiado. Existen algunas investigaciones que no reportan alteraciones neurocognitivas, y otras reportan deficiencias en tareas de vigilancia, memoria de trabajo, control de interferencia, velocidad de procesamiento, solución de problemas abstractos y aprendizaje verbal. Sin embargo, aún se desconoce si estas deficiencias son distintas a las observadas en el TDAH, o si son formas más severas de las mismas alteraciones del TDAH. Por lo tanto, el objetivo del presente estudio fue evaluar el funcionamiento neuropsicológico del TBPP por medio de una batería de pruebas integrada para analizar las capacidades en la solución de problemas complejos, razonamiento abstracto y habilidades de planeación. Esto con la finalidad de valorar si el TBPP cursa con otras alteraciones neuropsicológicas, más allá de la esfera de la atención, memoria y del funcionamiento ejecutivo, como se han descrito hasta el momento en adultos con trastorno bipolar. Así, se comparó el funcionamiento neurocognitivo en un grupo de 14 pacientes adolescentes con diagnóstico de TBPP en fase de eutímia y un grupo control de 11 adolescentes asintomáticos. Además, se consideraron como variables del estudio la capacidad general para solucionar problemas, medida por medio de las subpruebas de las Escalas de Inteligencia de Wechsler, así como las habilidades de razonamiento abstracto, flexibilidad cognoscitiva y planeación, medidos con el Test de Clasificación de Tarjetas de Wisconsin y la Torre de Londres Drexel University. Los resultados señalaron que los adolescentes con TBPP presentan alteraciones en el funcionamiento neuropsicológico. Algunas de las deficiencias encontradas son parecidas a las alteraciones reportadas en adultos, especialmente ante tareas que involucran funciones ejecutivas como la memoria de trabajo y la planeación. Además de esto, se detectaron alteraciones en otras mediciones neuropsicológicas que implican la capacidad para solucionar problemas complejos y que no han sido reportadas en estudios previos. Al evaluar la capacidad general para solucionar problemas, se encontraron alteraciones en las habilidades de lenguaje, formación de conceptos, razonamiento verbal, razonamiento visual práctico/ conceptual, análisis-síntesis visual y velocidad de procesamiento. También se observaron deficiencias en las funciones ejecutivas que involucran la planeación y la memoria de trabajo. De tal manera, que nuestros datos ofrecen la posibilidad de plantear una continuidad en la alteración de las funciones ejecutivas en el trastorno bipolar tanto de inicio temprano como en el tardío. Estos hallazgos también pueden considerarse un apoyo para la validez del diagnóstico diferencial del trastorno bipolar en adolescentes. Como conclusión, podemos señalar que nuestros resultados son consistentes con la bibliografía en general al indicar que existen deficiencias neuropsicológicas en adolescentes con TBPP, al tiempo que se mencionan otras alteraciones no descritas con anterioridad. Estas deficiencias involucran el funcionamiento ejecutivo y otros dominios cognitivos que influyen sobre la capacidad general para solucionar problemas. Además, se sugiere que las mediciones que involucran el razonamiento verbal, razonamiento visual, velocidad de procesamiento, memoria de trabajo y planeación podrían examinarse con mayor detenimiento en futuros estudios de neuroimagen funcional en el TBPP.