Metacognitive functioning in bipolar disorder versus controls and its correlations with neurocognitive functioning in a cross-sectional design.

INTRODUCTION: Metacognition is an important factor in the development and persistence of bipolar disorder. One of the most striking examples of impairment in metacognitive functioning in bipolar disorder is the lack of insight these patients have in their disorder. Despite its importance, research regarding metacognition in bipolar disorder is scarce. Furthermore, the neurocognitive basis of metacognitive functioning is unknown. METHODS: The current study included 29 patients with bipolar disorder and 29 age, educational level and gender matched healthy controls. All the participants filled in a metacognition questionnaire that examined their metacognitive beliefs. In addition, it was tested how well they estimated their performance on a neurocognitive test-battery beforehand (metacognitive knowledge) and afterwards (metacognitive experience). RESULTS: Bipolar disorder patients showed maladaptive metacognitive beliefs in comparison with the healthy controls. They also showed impaired metacognitive knowledge and experience. That is, they overestimated their own cognitive performance. However, the latter result was also true for the healthy controls. In addition, metacognition had neurocognitive correlates. However, for the bipolar patients, depressive symptomatology had an important effect on this relationship and on metacognition in general. CONCLUSION: Maladaptive metacognitive skills are related to depression in bipolar disorder. A more healthy metacognitive thinking should be promoted. An effective training for this could be a therapy that includes various elements, from basic cognitive- to higher order metacognitive training.

The Effect of Electroconvulsive Therapy on Hypoperfusion in Psychotic Bipolar Depression: A Case Study.

The pharmacological treatment of bipolar depression has low response rates. Twenty percent to 30% of patients have an insufficient response to medication. The guidelines suggest that electroconvulsive therapy (ECT) is the next step. The aim of this case study is to evaluate the effect of ECT on the perfusion of the brain in bipolar depression, while monitoring effects on mood and cognition. We present a case study of 56-year-old female patient who suffered from a psychotic depression and cognitive impairment. Before ECT, she took several antidepressants and atypical antipsychotics, but there was no improvement in her symptoms. By using single-photon emission computed tomography, we obtained the status of the regional cerebral blood flow and found a decreased perfusion in the anterior part of the left temporal lobe, the posterior part of the right temporal lobe, and in the left gyrus frontalis inferior. This is consistent with previous findings. Electroconvulsive therapy resulted in a resolution of the patient's depression and an improvement in her neurocognitive performance. Markedly, this was only in visual learning and working memory, domains in which the patient was already relatively stronger pre-ECT treatment. A new single-photon emission computed tomography, 4 weeks after the last ECT course, showed normalization of the regional cerebral blood flow.

How self-reflection and self-certainty are related to neurocognitive functioning: an examination of cognitive insight in bipolar disorder.

INTRODUCTION: The pattern of associations between clinical insight, cognitive insight, and neurocognitive functioning was assessed in bipolar disorder patients. METHODS: Data from 42 bipolar disorder patients were examined. Cognitive insight was measured using the Beck Cognitive Insight Scale (BCIS). The BCIS is a 15-item self-report instrument consisting of two subscales, self-reflectiveness and self-certainty. Clinical insight was measured by the use of the item G12 of the Positive and Negative Syndrome Scale. Neurocognitive functioning was assessed using the International Society for Bipolar Disorders-Battery for Assessment of Neurocognition. RESULTS: Correlation analyses revealed significant positive associations between self-reflectiveness and speed of processing, attention, working memory, visual learning, and reasoning and problem solving. The subscale self-certainty was negatively correlated to working memory, however, this correlation disappeared when we controlled for confounding variables. No correlations between clinical insight and neurocognition were found. In addition, there was no association between cognitive insight and clinical insight. CONCLUSION: Better neurocognitive functioning was more related to higher levels of self-reflectiveness than to diminished self-certainty.

The longitudinal course of cognitive insight and mood in bipolar disorder.

Cognitive insight or the ability to be self-reflective and to retain from being over-confident in own beliefs is an upcoming topic in research regarding psychiatric disorders. In bipolar disorder investigations are scarce and an important lacuna is the unexamined longitudinal relationship between cognitive insight and mood. Therefore, in this study the level of cognitive insight, mania and depression were assessed in a total of 56 patients with bipolar disorder at baseline, four months and eight months follow-up. In addition, the cognitive insight of 35 healthy controls was assessed at baseline and at four months follow-up. The current research shows that self-reflectiveness and self-certainty remained stable over time in bipolar disorder. The improvement of mood did not affect the course of cognitive insight. However, at baseline higher levels of depression were correlated with more self-reflectiveness. In addition, self-reflectiveness was higher for bipolar disorder patients in comparison with the healthy controls. Our results could imply that higher levels of self-reflectiveness are a specific characteristic in bipolar disorder that is independent from an improvement in mood.

Cognitive insight: A systematic review.

Cognitive insight is the ability to re-evaluate thoughts and beliefs in order to make thoughtful conclusions. It differs from clinical insight, as it focuses on more general metacognitive processes. Therefore, it could be relevant to diverse disorders and non-clinical subjects. There is a growing body of research on cognitive insight in individuals with and without psychosis. This review has summarised the current state of the art regarding this topic. We conclude that while cognitive insight in its current form seems valid for use in individuals with psychosis, it is less so for individuals without psychosis. Additionally, higher cognitive insight not always leads to better psychological functioning. For instance, higher levels of self-reflection are often associated with depressive mood. We therefore recommend the sub-components of cognitive insight to be studied separately. Also, it is unclear what position cognitive insight takes within the spectrum of metacognitive processes and how it relates to other self-related concepts that have been defined previously in literature. Combining future and past research on cognitive insight and its analogue concepts will help in the formation of a uniform definition that fits all subjects discussed here.

Repetition priming in the stop signal task: the electrophysiology of sequential effects of stopping.

Inhibition of a response affects the processing of subsequent stimuli. When a response has to be made to a stimulus to which a response was previously inhibited, response time increases. In this study, we investigated the neurophysiological underpinnings of this repetition priming phenomenon. We aimed at distinguishing between two possible mechanisms. Firstly, it could be that slowing after a successful inhibition trial originates at the response execution level and is due to the reactivation of the system responsible for motor inhibition interfering with execution of the go response. The second possibility is that interference occurs at the more abstract level of conflicting action goals or plans (i.e. "stop" and "go") that are activated prior to response execution. We analyzed activity over primary motor cortices and the parietal cortex in a stop signal task. Stimulus repetition led to a decrease in activity over primary motor cortices but irrespective of history of stopping. Stopping on the previous trial did affect the stimulus-locked parietal P300 only on repetition of the stimulus, mimicking the behavioral pattern. Furthermore, the P300 was lateralized and affected by both stimulus onset and response time, suggesting that the interference caused by inhibition priming is situated between stimulus perception and response execution. Taken together, these findings show that the prolonged response times to a stimulus that was previously successfully inhibited to, do not originate from reactivated suppression of motor output, but are caused by interference between a stop and a go goal in parietal cortex that hampers translation from stimulus to response.

Brain regions involved in the learning and application of reward rules in a two-deck gambling task.

Decision-making involves the ability to choose between competing actions that are associated with uncertain benefits and penalties. The Iowa Gambling Task (IGT), which mimics real-life decision-making, involves learning a reward-punishment rule over multiple trials. Patients with damage to ventromedial prefrontal cortex (VMPFC) show deficits learning these rules, although this performance deficit is not exclusively associated with VMPFC damage. In this study, we used functional Magnetic Resonance Imaging (fMRI) to study the roles of prefrontal cortex regions involved in rule learning and rule application in healthy adults using an adapted version of the Iowa Gambling Task. Participants (N=20) were asked to infer rules over series of 16 trials in a two-deck card game. Rewards were given on each trial and punishment was unpredictable. For half of the series, those decks that gave high rewards were also better decks in the long run. For the other half of the series, the decks that gave low rewards were better decks in the long run. Behaviorally, participants started to differentiate between advantageous and disadvantageous decks after approximately four/six trials, and learning occurred faster for high-reward decks. Lateral PFC (lat-PFC) and Anterior Cingulate Coretex (ACC)/pre-supplementary motor area (pre-SMA) were most active for early decisions, whereas medial orbital frontal cortex (med-OFC) was most active for decisions made later in the series. These results suggest that lat-PFC and ACC/pre-SMA are important for directing behavior towards long-term goals, whereas med-OFC represents reward values towards which behavior should be directed.