Cognitive Dysfunction in Psychiatric Disorders: Characteristics, Causes and the Quest for Improved Therapy
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REVIEWS Cognitive dysfunction in psychiatric disorders: characteristics, causes and the quest for improved therapy Mark J. Millan1, Yves Agid2, Martin Brüne3, Edward T. Bullmore4, Cameron S. Carter5, Nicola S. Clayton6, Richard Connor7, Sabrina Davis8, Bill Deakin9, Robert J. DeRubeis10, Bruno Dubois11, Mark A. Geyer12, Guy M. Goodwin13, Philip Gorwood14, Thérèse M. Jay14, Marian Joëls15, Isabelle M. Mansuy16, Andreas Meyer-Lindenberg17, Declan Murphy18, Edmund Rolls19, Bernd Saletu20, Michael Spedding21, John Sweeney22, Miles Whittington23 and Larry J. Young24 Abstract | Studies of psychiatric disorders have traditionally focused on emotional symptoms such as depression, anxiety and hallucinations. However, poorly controlled cognitive deficits are equally prominent and severely compromise quality of life, including social and professional integration. Consequently, intensive efforts are being made to characterize the cellular and cerebral circuits underpinning cognitive function, define the nature and causes of cognitive impairment in psychiatric disorders and identify more effective treatments. Successful development will depend on rigorous validation in animal models as well as in patients, including measures of real-world cognitive functioning. This article critically discusses these issues, highlighting the challenges and opportunities for improving cognition in individuals suffering from psychiatric disorders. Cognition Historically, philosophers have subdivided the study relevant dimension of psychiatric disorders that cuts A suite of interrelated of the human mind and behaviour into two broad across traditional diagnostic boundaries, and improved conscious (and unconscious) categories: the cognitive (how we know the world) and treatment should be a major goal in efforts to enhance mental activities, including: the affective (how we feel about it). This division is, how- quality of life for patients. pre-attentional sensory cognition gating; attention; learning and ever, arbitrary as — a highly complex construct memory; problem solving, (FIG. 1) — and emotion interact; cognitive status can Cognitive dysfunction in psychiatric disorders planning, reasoning and colour the processing of emotions, and changes in mood Challenges of defining and characterizing cognitive judgment; understanding, affect cognitive function1,2. deficits. Alzheimer’s disease is characterized by poor knowing and representing; learning memory creativity, intuition and It is therefore surprising that changes in emotion are and , Parkinson’s disease by motor insight; ‘spontaneous’ thought; universally recognized as being inherent to psychiatric impairment, depression by melancholy, and schizophre- introspection; as well as mental disorders and their classification, whereas cognitive nia by delusions; however, these and related diagnoses time travel, self-awareness and impairment — which has an equally disabling effect on are also accompanied by a range of symptoms involving meta-cognition (thinking and patients — has been comparatively neglected. Despite alterations in mood, motor behaviour, appetite, sleep, knowledge about cognition). this close interrelationship between cognition and diurnal rhythms and, most pertinently, cognitive func- mood, the cognitive deficits of psychiatric disorders are tion. For example, psychosis is common in Alzheimer’s not just a secondary consequence of perturbed affect, disease, depression can be just as debilitating as motor and their underlying neurobiological substrates differ. deficits in Parkinson’s disease, and perturbed cognition 1Institut de Recherche Servier, Although certain symptoms of psychiatric disorders — is a characteristic of both psychiatric and neurological 78290 Croissy/Seine, France. such as depression, delusions and anxiety — are allevi- disorders (TABLE 1). Correspondence to M.J.M. e-mail: ated by current drugs, cognitive deficits are not usually Defining the precise nature of changes in cognition 3,4 [email protected] improved, and may even be worsened . Cognitive is challenging. Specificity relative to generalized changes doi:10.1038/nrd3628 dysfunction is, therefore, a poorly controlled and highly in overall intelligence remains under discussion, in NATURE REVIEWS | DRUG DISCOVERY VOLUME 11 | FEBRUARY 2012 | 141 © 2012 Macmillan Publishers Limited. All rights reserved REVIEWS 12 Author addresses in obsessive compulsive disorder (OCD) and recurrent, unwanted recall (flashbacks) in post-traumatic stress dis- 2ICM, Pitié-Salpétrière University Hospital, 47 boulevard de l’Hôpital, 75013 Paris, France. order (PTSD)13,14. The latter state represents a form of 3 Research Department of Cognitive Neuropsychiatry and Psychiatric Preventive ‘hyper-memory’ resulting from defective processes of Medicine, LWL University Hospital, Ruhr-University Bochum, Alexandrinenstr. 1, fear extinction — an active process for suppressing nega- 44791 Bochum, Germany. 4University of Cambridge and GlaxoSmithKline, Cambridge Biomedical Campus, tive emotional memories — rather than just the decay of 14,15 Cambridge CB2 0SZ, UK. the mechanisms involved in storage and recall (FIG. 2). 5University of California, Davis, Sacramento, California 95817, USA. Phobias and social anxiety disorder are likewise typi- 6Department of Experimental Psychology, University of Cambridge, Cambridge fied by blunted fear extinction16,17. Comparatively little CB2 3EB, UK. cognitive disturbance has been documented for gen- 7Department of Biology, University of Massachusetts Dartmouth, 02747 North eralized anxiety disorder, despite some subtle changes Dartmouth, USA. and a negative cognitive bias to threatening stimuli16,17 8 Centre National de la Recherche Scientifique, University of Paris-Sud, 91400 Orsay, (TABLE 1). Cognitive dysfunction in panic disorders is France. mainly confined to excessive attention and hyperreactivity 9Neuroscience and Psychiatry Unit, University of Manchester, Manchester M13 9PT, UK. to threatening — but not emotionally neutral — stimuli. 10University of Pennsylvania, 19104 Philadelphia, USA. processing speed 11Institut du Cerveau et de la Moelle Epinière (ICM), Université Pierre et Marie Curie, Interestingly, may actually be acceler- 16,18 Paris 6, UMR-S975 Paris, France. ated in panic disorders . Schizophrenia is charac- 12University of California San Diego, La Jolla, California 92093‑0804, USA. terized by a broad pattern of cognitive deficits, from 13University of Oxford, Warneford Hospital, Oxford OX3 7JX, UK. attention and working memory to social cognition and 14INSERM; Université Paris, Descartes, Centre de Psychiatrie et Neurosciences U894, language7,19–22 (BOX 1). Impairments in bipolar disorder, 75014 Paris, France. which shares certain genetic risk factors with schizo 15Department of Neuroscience and Pharmacology, Rudolf Magnus Institute, University phrenia (Supplementary information S1 (figure)), are Medical Center Utrecht, 3584 CG Utrecht, The Netherlands. similar but generally less severe19,23,24 (TABLE 1). 16 Brain Research Institute, University of Zürich and ETHZ, 8057 Zürich, Switzerland. Cognitive impairment is not traditionally associated 17Central Institute of Mental Health, Heidelberg University, Medical Faculty Mannheim, with depression but it is common, broad-based and D‑68159 Mannheim, Germany. 4,19,25,26 18Institute of Psychiatry, King’s College London, Denmark Hill, London SE5 8AF, UK. often debilitating . Poor performance in certain 19Oxford Centre for Computational Neuroscience and Department of Computer tasks reflects reduced reward, low motivation and/or Science, University of Warwick, Coventry CV4 7AL, UK. an incapacity for sustained effort — possibly owing to 20Department of Psychiatry and Psychotherapy, Medical University of Vienna, disruption of limbic dopaminergic signalling4,10. This Waehringer Gürtel 18‑20, A‑1090 Vienna, Austria. does not, however, provide a satisfactory explanation 21Les Laboratoires Servier, 50 Rue Carnot, 92284 Suresnes Cedex, France. for overall cognitive impairment. For example, the bias 22 University of Texas Southwestern, Dallas 75235, Texas, USA. of patients suffering from depression towards affectively 23Newcastle University, Newcastle NE2 4HH, UK. negative — and even ambiguous — stimuli (such as 24 Yerkes National Primate Research Center, Emory University, 954 Gatewood Rd, facial expressions) involves diminished top-down fronto- Atlanta, Georgia 30329, USA. cortical cognitive control of emotional processing2,27. Deficits in attention deficit hyperactivity disorder (ADHD) are not restricted to attention; they affect Learning particular for schizophrenia and autism spectrum dis- several other cognitive domains, including an inter- The active, experience- and/or orders (ASDs), in which development is abnormal5–8. related impairment in working memory and process- training-driven acquisition of Furthermore, the precise interrelationship between ing speed28,29. Among the deficits characterizing OCD, information or behaviour. The alterations in cognition and changes in mood, reward, impairment of procedural learning is of particular note12,30. term ‘conditioning’ is usually used in an experimental context motor performance and effort can be difficult to estab- Finally, although disrupted social cognition is a cardi- 9,10 of associative learning. Learning lish . Finally, apart from treatment, various other factors nal symptom of ASD, several other domains are also necessitates complementary modify cognitive performance and its measurement in affected9,31,32