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Feeling forgetful, unfocused, or scatterbrained? Bipolar disorder affects cognition in different ways, but effective strategies can help.
“I’m the PhD down the hall whose memory fails during critical discussions at the office,” says Debra.
In her early sixties, Debra is a behavioral scientist with the Centers for Disease Control and Prevention (CDC) in Atlanta. She leads research and oversees a team of data analysts in the Division of Violence Prevention.
Before her bipolar diagnosis, she sometimes had trouble keeping focused. Now, recall is a bigger problem, especially if she’s expected to dredge updates or statistics during a meeting or keep track of details after an impromptu encounter.
“I ask people to schedule meetings rather than have these hallway conversations when we need to make decisions,” she says.
In meetings, she takes copious notes to jog her memory.
“I scribble as fast as I can … sometimes so fast I can’t read my own notes,” she describes. “I just have to chuckle when, ‘This research should move ahead,’ turns into, ‘This rabbit should go to bed.’”
Understanding the Brain’s Response to Bipolar Disorder
Psychiatrists and researchers are coming to appreciate that memory lapses and other neurocognitive problems — disorganization, groping for words, difficulty learning new information — can go hand in hand with the more obvious mood and behavioral symptoms that characterize bipolar.
Joseph Goldberg, MD, a psychiatrist and clinical professor of psychiatry at the Mount Sinai School of Medicine in New York City, helped put these “thinking” problems on the bipolar map. He’s co-editor of Cognitive Dysfunction in Bipolar Disorder: A Guide for Clinicians, a book he says builds on “literally hundreds of studies” analyzing aspects of cognition in individuals with bipolar disorder.
He mentions an older but influential Spanish study published in the American Journal of Psychiatry. In every phase of the illness (depression, mania, and remission), researchers found marked deficits in verbal memory and what’s known as “frontal executive tasks.”
Think of it this way: The brain is organized like a big office with specific departments designated to complex tasks such as decision-making, attention, verbal memory, spatial memory, motor speed and skill, and logical reasoning.
RELATED: The Link Between Bipolar and Memory Problems
The frontal lobes of the brain contain circuitry that acts, in essence, like a hardworking executive secretary. Information comes into the frontal lobe, and the secretary notes it, organizes it, and sends out messages to the brain’s different departments to get things done.
Faulty processing in this executive center can lead to cognitive deficits that affect awareness, perception, reasoning, and judgment, Dr. Goldberg explains.
The Role of Bipolar Disorder in Memory Issues
The hippocampus, meanwhile, serves as a kind of file clerk for recording new memories and sending them on to permanent storage. Bipolar disorder has been associated with shrinkage of the hippocampus, which may explain difficulties in acquiring and accessing various kinds of data.
Goldberg notes that many aspects of intellectual functioning carry on just fine in people with bipolar — sometimes even better than in the general population. The glitches seem limited to specific areas: verbal memory, executive organization, “processing speed” and attention.
Navigating Life With Cognition Issues
Bipolar brain fog can complicate everything from succeeding in school to paying the bills. Rick of Saskatchewan, Canada is less confident behind the wheel these days because of “near misses and some dents.” He blames poor concentration and slowed motor skills.
“I used to pride myself on being an excellent driver,” says Rick, a boomer who crisscrossed the continent during his 25 years as a communications specialist in the Canadian Forces. “I didn’t even get any tickets.”
Rick says predominantly high moods helped him succeed socially, in sports, and his career. With time, however, he began to notice it was harder to follow a train of thought. Loud talking and other noises made it tough to focus on what he was doing.
His coordination also deteriorated, leaving him with a tendency to lose his balance on a ladder, stumble while walking, or nick himself when working with tools. Escalating mood shifts led to his bipolar 2 diagnosis.
RELATED: Bipolar and Memory: Real-Life Tips and Tricks
Rick still captains the car on local errands, but it helps to have his spouse on board as navigator, noting where to turn or when to slow down. As a military wife, she managed the family and handled all the relocations; now more than ever, Rick says, she’s “the decision-maker and my assistant.”
In addition to checking in daily with his wife to ensure he hasn’t overlooked any obligations or appointments, Rick follows a routine that includes activities in the morning when he feels most alert, a nap in the afternoon when energy and attention flag, and a strictly regimented bedtime.
“It’s a long journey,” he says of learning how to manage his fluctuating symptoms, “but I believe that hope is the best car to drive in.”
Complicated Causes of Neurocognitive Concerns With Bipolar
The fact that neurocognitive problems linger after symptoms subside — and can be present before a bipolar diagnosis is made — makes scientists think that these disturbances are a core and consistent feature of the illness.
Researchers are trying to learn more about what areas of the brain are vulnerable to the disease process and what role the course of illness plays. While the pathological underpinnings of the disease itself may play a role in cognitive problems, there are a number of other explanations to consider, according to an article published in World Psychiatry.
Comorbid mental and physical health conditions, such as substance abuse, anxiety, attention deficit hyperactivity disorder (ADHD), obesity, type 2 diabetes, high blood pressure, and thyroid problems, can also impact thinking abilities. Medication given to people with bipolar — like anticholinergic drugs, anticonvulsants, antipsychotics, benzodiazepines, and lithium — can all have negative effects on cognition.
Living With Executive Function Problems
Sue M. recalls that learning was difficult for her as a kid. She was diagnosed with ADHD in her thirties. Still, she was driven to excel right through graduate school, then as a speech pathologist, and later in medical sales. She made good money and balanced a busy career with raising a family.
Her divorce led to depression. When she went through therapy for breast cancer three years later, the treatment apparently triggered or unmasked bipolar symptoms. Her diagnosis and treatment changed accordingly.
RELATED: How to Overcome Bipolar Focus Problems and Sharpen Your Memory
Seven years after her diagnosis, Sue frequently gets lost when she leaves the house. She can’t get out the door without reading dozens of slips of paper that line a path from her bathroom to the kitchen to the door that will send her out into the world. Some of the notes read: Brush teeth. Take pills. Find keys. Find phone. Put coat on. Lock door.
“I just can’t function the way other people do,” says Sue, now in her seventies. Without the notes throughout her house, “I don’t know how I would even get out in the morning.”
Every brain scan and neuropsychiatric report spits out the same result: problems with executive function. She had to go on disability. Three words on a note card by the door remind her: Keep it simple.
“I’ve had to revamp my dreams,” she says.
Managing Bipolar Disorder at Work
Those who remain employed may have to work a little harder. Kyle L. says friends used to call him Superman because “I could do a million things at once and do it well.”
He discovered the hard way that he needs to stay on medication to stave off psychosis and extreme behavior. He was fired from his previous job during a bout of unrecognized mania — although to this day, he can’t remember anything that happened during the episode.
Now the effortless multitasking of hypomania is a thing of the past. He’s made accommodations to handle his responsibilities as a production engineer at a small medical device company in Bloomington, Indiana.
“I’ve learned I can focus on one thing and do that,” he explains. “I have to consciously think, ‘This is what I’m doing, this is what I’ve done, and this is what I’m going to do when I get back to it.’”
Because he can’t keep all the balls juggling in his head anymore, he makes sure to note appointments on his calendar and jot down reminders about important tasks.
Embracing Strengths While Managing Cognitive Challenges at Work
Kyle says he was upfront about his altered abilities when he was hired, but he’s done well enough to win his supervisors’ support. During a recent psychiatric hospitalization, he says, the firm’s owner came by to let him know his job was waiting.
Debra, the CDC scientist, is also happy with the feedback from her superiors. In any event, she says, her bipolar diagnosis at 43 was a life-saving discovery — a fair swap for the slowdown of a few brain cells.
“It’s one of those side effects I have to deal with,” she says, “because I’m not going to stop taking the medication.”
Despite her positive evaluations, Debra admits to feeling incompetent at times because of her quirky memory. Still, she says, living with bipolar disorder also has its advantages. For her, lifelong traits such as creativity and increased productivity far outweigh the downside of her lapses.
“It’s about finding your strengths,” she says, “and capitalizing on them.”
Seeking Solutions for Memory Problems
As new evidence emerges about cognitive deficits associated with bipolar disorder, clinicians are more apt to take such problems into consideration during evaluation and treatment.
A number of neuropsychological tests are proving helpful in identifying problems that can make everyday functioning difficult. Some tests are designed to pick up misfires in memory and attention, while others measure planning skills and “response initiation” — that is, how quickly and appropriately someone responds to stimuli.
Ivan Torres, PhD, a registered clinical neuropsychologist and clinical professor of psychiatry at the University of British Columbia whose research focuses on cognition in bipolar, says that cognitive test scores correlate with how well people with bipolar are able to function in the real world.
What to do with the information is less clear.
“We are just in the beginning stages of identifying ways to help patients with these cognitive problems,” Dr. Torres says.
Some research explores the possible benefits of certain medications, cognitive remediation therapy, and rehabilitation interventions used with brain injury and stroke patients.
“At the very least,” says Torres, “we are in a position to provide education to patients about the cognitive difficulties that they may experience, and to come up with strategies for working around these problems in daily life.”
Torres gives these quick tips:
- Break complex tasks into smaller units.
- Make your environment less distracting.
- Create structure around daily duties to counteract deficits in focus and organization.
- Cues, prompts, reminders, and repetition can help with learning and memory problems.
In his work with individuals with bipolar whose memory is unreliable, Goldberg recommends similar tactics: sticky notes, appointment calendars, and a technique called “chunking” — splitting information into bite-size pieces that are easier to remember.
Some evidence suggests that impaired cognition is linked to higher inflammation and decreased neuroprotection. And poor lifestyle habits like not getting enough sleep, eating poorly, not exercising, smoking, and misusing substances or alcohol can make inflammation worse and harm brain health, according to a review published in Bipolar Disorders in 2019.
The Power of Lifestyle Changes in Boosting Cognitive and Mental Health
Fortunately, these habits can be changed. More and more research shows that programs focusing on exercise, good nutrition, and overall wellness can successfully improve both physical and mental health in people with bipolar disorder. But surprisingly, there hasn’t been much research into how these lifestyle factors relate to thinking abilities.
Improving your sleep is crucial, especially if it’s a struggle. Research links sleep issues to poorer thinking skills in people with bipolar disorder. A study published in a 2019 issue of Psychological Medicine demonstrated this, showing clear differences in thinking abilities between those with and without sleep issues — even outside of mood episodes. Interestingly, those sleeping well performed similarly to people without bipolar disorder, underlining sleep’s key role in cognitive function.
Aging and Cognitive Challenges
Betty of Port McNicoll, Ontario, relies on her cell phone. Her son originally gave her a phone with a keyboard so she could save money by texting him rather than calling. She discovered other benefits.
“My phone has a calendar in it, so I just started using my phone to set off a reminder that I had to do something or go somewhere. I even use it to wake me up in the morning,” she says.
After two decades of disabling depression and untreated hypomanic symptoms, Betty got a new doctor in 2010 who gave her a bipolar diagnosis. Now in her seventies and stable, she says she’s “always had problems with my cognitive abilities. It’s just gotten worse as I’ve got older.”
Betty also adopted a counterintuitive therapy: the game of bridge, which favors players who can keep track of which cards have been put down. Somehow, the mental exercise strengthens her erratic memory, she reports.
Her involvement with the game has been so successful, she says, “I not only play it, I teach it.”
Editorial Sources and Fact-Checking
- Martínez-Arán A, Vieta E, Reinares M, Colom F. Cognitive Function Across Manic or Hypomanic, Depressed, and Euthymic States in Bipolar Disorder. American Journal of Psychiatry. February 2004.
- McIntyre RS, Alda M, Baldessarini RJ, Bauer M. The Clinical Characterization of the Adult Patient With Bipolar Disorder Aimed at Personalization of Management. World Psychiatry. September 2022.
- Van Rheenen TE, Lewandowski KE, Bauer IE, Kapczinski F. Current Understandings of the Trajectory and emerging Correlates of Cognitive Impairment in Bipolar Disorder: An Overview of Evidence. Bipolar Disorders. August 2019.
- Bradley AJ, Anderson KN, Gallagher P, McAllister-Williams RH. The Association Between Sleep and Cognitive Abnormalities in Bipolar Disorder. Psychological Medicine. January 2019.
Adapted and updated from “The Cognitive Connection,” Summer 2012