Skip to main content
    • Aa
    • Aa

Processing efficiency and sustained attention in bipolar disorder

  • DAVID E. FLECK (a1), PAULA K. SHEAR (a1) (a2) and STEPHEN M. STRAKOWSKI (a1) (a2)

We hypothesized that patterns of sustained attention performance in bipolar disorder were consistent with processing efficiency theory—a theory of the relationship between central processing capacity and performance. We predicted (1) sustained attention deficits during mania because symptoms interfere with limited-capacity executive control processes resulting in decreased performance effectiveness; and (2) decreased processing efficiency during euthymia, as indicated by speed/accuracy tradeoffs, consistent with a stable phenotypic abnormality. Twenty-five manic bipolar, 23 euthymic bipolar, and 28 healthy comparison participants were compared on a continuous performance task and administered symptom-rating scales. The manic group was significantly impaired on overall perceptual sensitivity and demonstrated a significant linear decrease in performance over time, consistent with impaired sustained attention. The euthymic group evidenced significantly slower overall hit reaction time (RT), but when RT was controlled they performed similarly to the healthy group over time. Two discriminant functions combined to separate the groups on manic symptom severity and on-task effort/strategy use. These findings are consistent with processing efficiency theory. They suggest that euthymic patients sustain attention through effortful control at the expense of processing efficiency, while acute mania reduces the capacity for control and impairs sustained attention. Problems with processing efficiency are viewed as trait characteristics of bipolar disorder that may be overlooked by traditional error-based assessments. (JINS, 2005, 11, 49–57.)

Corresponding author
Reprint requests to: David E. Fleck, Ph.D., Department of Psychiatry, University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH 45267-0559. E-mail:
Linked references
Hide All

This list contains references from the content that can be linked to their source. For a full set of references and notes please see the PDF or HTML where available.

Ackenheil, M. (2001). Neurotransmitters and signal transduction processes in bipolar affective disorders: A synopsis. Journal of Affective Disorders, 62, 101111.

Addington, J. & Addington, D. (1997). Attentional vulnerability indicators in schizophrenia and bipolar disorder. Schizophrenia Research, 23, 197204.

Adler, C.M., Sax, K.W., Holland, S.K., Schmithorst, V., Rosenberg, L., & Strakowski, S.M. (2001). Changes in neuronal activation with increasing attentional demand in healthy volunteers: An fMRI study. Synapse, 42, 266272.

Bearden, C.E., Hoffman, K.M., & Cannon, T.D. (2001). The neuropsychology and neuroanatomy of bipolar affective disorder: A critical review. Bipolar Disorders, 3, 106150.

Corkum, P.V. & Siegel, L.S. (1993). Is the continuous performance task a valuable research tool for use with children with attention-deficit-hyperactivity disorder?Journal of Child Psychology and Psychiatry, 34, 12171239.

Eysenck, M.W. & Calvo, M.G. (1992). Anxiety and performance: The processing efficiency theory. Cognition and Emotion, 6, 409434.

Fleck, D.E., Sax, K.W., & Strakowski, S.M. (2001). Reaction time measures of sustained attention differentiate bipolar disorder from schizophrenia. Schizophrenia Research, 52, 251259.

Fleck, D.E., Shear, P.K., Zimmerman, M.E., Getz, G.E., Corey, K.B., Jak, A., Lebowitz, B.K., & Strakowski, S.M. (2003). Verbal memory in mania: Effects of clinical state and task requirements. Bipolar Disorders, 5, 375380.

Hamilton, M. (1960). A rating scale for depression. Journal of Neurology, Neurosurgery and Psychiatry, 23, 5661.

Huynh, H. & Feldt, L.S. (1976). Estimation of the Box correction for degrees of freedom from sample data in randomized block and split-plot designs. Journal of Educational Statistics, 1, 6982.

Liu, S.K., Chiu, C.-H., Chang, C.-J., Hwang, T.-J., Hwu, H.-G., & Chen, W.J. (2002). Deficits in sustained attention in schizophrenia and affective disorders: Stable versus state-dependent markers. American Journal of Psychiatry, 159, 975982.

Mauchly, J.W. (1940). Significance test for sphericity of a normal n-variate distribution. Annals of Mathematical Statistics, 11, 204209.

Nuechterlein, K.H., Dawson, M.E., Ventura, J., Miklowitz, D., & Konishi, G. (1991). Information processing anomalies in the early course of schizophrenia and bipolar disorder. Schizophrenia Research, 5, 195196.

Nuechterlein, K.H., Parasuraman, R., & Jiang, Q. (1983). Visual sustained attention: Image degradation produces rapid sensitivity decrement over time. Science, 220, 327.

Riccio, C.A., Reynolds, C.R., Lowe, P., & Moore, J.J. (2002). The continuous performance test: A window on the neural substrates of attention?Archives of Clinical Neuropsychology, 17, 235272.

Sax, K.W., Strakowski, S.M., McElroy, S.L., Keck, P.E.Jr., & West, S.A. (1995). Attention and formal thought disorder in mixed and pure mania. Biological Psychiatry, 37, 420423.

Sax, K.W., Strakowski, S.M., Zimmerman, M.E., DelBello, M.P., Keck, P.E.Jr., & Hawkins, J.M. (1999). Frontosubcortical neuroanatomy and the continuous performance test in mania. American Journal of Psychiatry, 156, 139141.

Strakowski, S.M., Adler, C.M., & DelBello, M.P. (2002a). Volumetric MRI studies of mood disorders: Do they distinguish unipolar and bipolar disorder?Bipolar Disorders, 4, 8088.

Strakowski, S.M., DelBello, M.P., Zimmerman, M.E., Getz, G.E., Mills, N.P., Ret, J., Shear, P.K., & Adler, C.M. (2002b). Ventricular and Periventricular structural volumes in first- versus multiple-episode bipolar disorder. American Journal of Psychiatry, 159, 18411847.

Strakowski, S.M., Adler, C.M., Holland, S.K., Mills, N.P., & DelBello, M.P. (2004). A preliminary FMRI study of sustained attention in euthymic, unmedicated bipolar disorder. Neuropsychopharmacology, 29, 17341740.

Strakowski, S.M., DelBello, M.P., Sax, K.W., Zimmerman, M.E., Shear, P.K., Hawkins, J.M., & Larson, E.R. (1999). Brain magnetic resonance imaging of structural abnormalities in bipolar disorder. Archives of General Psychiatry, 56, 254260.

Strakowski, S.M., Wilson, D.R., Tohen, M., Woods, B.T., Douglass, A.W., & Stoll, A.L. (1993a). Structural brain abnormalities in first-episode mania. Biological Psychiatry, 33, 602609.

Strakowski, S.M., Woods, B.T., Tohen, M., Wilson, D.R., Douglass, A.W., & Stoll, A.L. (1993b). MRI signal hyperintensities in mania at first hospitalization. Biological Psychiatry, 33, 204206.

Strauss, M.E., Prescott, C.A., Gutterman, D.F., & Tune, L.E. (1987). Span of apprehension deficits in schizophrenia and mania. Schizophrenia Bulletin, 13, 699.

Stuss, D.T. & Benson, D.F. (1984). Neuropsychological studies of the frontal lobes. Psychological Bulletin, 95, 328.

Swayze, V.W., Andreasen, N.C., Alliger, R.J., Ehrhardt, J.C., & Yuh, W.T.C. (1990). Structural brain abnormalities in bipolar affective disorder: Ventricular enlargement and focal signal hyperintensities. Archives of General Psychiatry, 47, 10541059.

Tellegen, A. (1965). The performance of chronic seizure patients on the General Aptitude Battery. Journal of Clinical Psychology, 21, 180184.

Wilder-Willis, K.E., Sax, K.W., Rosenberg, H.L., Fleck, D.E., Shear, P.K., & Strakowski, S.M. (2001). Persistent attentional dysfunction in remitted bipolar disorder. Bipolar Disorders, 3, 5862.

Yamasaki, H., LaBar, K.S., & McCarthy, G. (2002). Dissociable prefrontal brain systems for attention and emotion. PNAS, 99, 1144711451.

Young, R.C., Biggs, J.T., Ziegler, V.E., & Meyer, D.A. (1978). A rating scale for mania: Reliability, validity, and sensitivity. British Journal of Psychiatry, 133, 429435.

Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

Journal of the International Neuropsychological Society
  • ISSN: 1355-6177
  • EISSN: 1469-7661
  • URL: /core/journals/journal-of-the-international-neuropsychological-society
Please enter your name
Please enter a valid email address
Who would you like to send this to? *



Full text views

Total number of HTML views: 2
Total number of PDF views: 11 *
Loading metrics...

Abstract views

Total abstract views: 62 *
Loading metrics...

* Views captured on Cambridge Core between September 2016 - 23rd May 2017. This data will be updated every 24 hours.