Deconstructing Bipolar - Cognitive Control

Patient Expert

This post is about cognitive control, which is part of an involved series that investigates what is going on in our brains when we think and react and behave. There are no definitive answers, but the questions are intriguing.

We kicked off the series in early May with a piece that reported on a provocative blog by Thomas Insel, head of the NIMH. In his blog, Dr Insel referred to the DSM as a "dictionary" rather than the commonly acknowledged "bible." In short, the DSM is a compendium of labels with definitions, little more. The danger to a DSM mindset is that it can seriously undermine our attempts to understand the brain.

Accordingly, the NIMH is setting its own research agenda along five distinct but overlapping domains: positive emotions, negative emotions, cognition, social processes, and arousal and regulatory systems.

Coincidentally, a few weeks ago, the American Psychiatric Association released the DSM-5. The bad news is that the new DSM does nothing to move forward discussion on why we get depressed and crazy, much less guide clinicians in making a correct diagnosis. The good news is that few people are paying attention to it. In short, the DSM-5 was dead on arrival.

But if the DSM is dead, our understanding of the brain is far from mature. At best, we are operating on inspired guesswork. An earlier version of the previous sentence contained the phrase, "a yawning lacuna of ignorance," which brings us to the topic at hand:

Naturally, I fell in love with "yawning lacuna of ignorance," but as much as I wanted to leave it in this piece, it didn't fit. I'm not sure what was going on in my brain when I came up with the phrase, but I can take a reasonable guess at the series of neural processes that ultimately involved my hitting "delete."

Okay, so here I was, experiencing the thrill of "yawning lacuna of ignorance." My pleasure center lit up. Just to show you how writers think, my first thought was to change it to "yawning lacunae of ignorance," but let's not go there. Suffice to say, what the experts loosely refer to as the pleasure center involves a complex array of dopamine-powered circuitry that appears to center on the nucleus accumbens and ventral tegmental area in the midbrain, the amygdala in the limbic system, and the ventral medial prefrontal cortex. Pleasure can be a very good thing. Indeed, the brain science is coming in loud and clear that our emotions are vital in our decision making. We are guided but what "feels right" and "feels wrong" to us.

Not only that, feelings of pleasure (and reward) are directly related to motivation. In my case, coming up with the likes of "yawning lacuna of ignorance" does to me what jumping out of a plane or trying on a pair of shoes does to someone else. This is the very opposite of depression. I have a reason to get out of bed in the morning. Not only that, you can say my choice of a career as a writer has been driven by the preferences of my nucleus accumbens.

But there is a catch. Giving into our pleasurable impulses can have serious consequences. It is no coincidence that all drugs of abuse increase dopamine in the nucleus accumbens and ventral tegmental area. Fortunately, if things work right, the brain can deal with the situation. That's why we have brains, or - more specifically - the prefrontal cortex, which appears to be charged with the responsibility of making sense of all our sensory inputs and taking charge. The NIMH has this gobbledygook way of putting it:

Cognitive control involves multiple subcomponent processes, including the ability to select, maintain, and update goal representations and performance monitoring and other forms of adaptive regulation. The implementation of these processes includes mechanisms such as response selection and inhibition or suppression.

So here was the rational part of my brain trying to reason with the emotional part of my brain. At stake was "yawning lacuna of ignorance." Ha - but it is very easy dupe the rational end of the brain, which is why trying to talk sense to opinionated or emotionally-charged individuals is highly problematic.

My rational brain had no intention of throwing a wet blanket over the emotional part of my brain. Rather, it was looking for a way to justify my emotions. To keep "yawning lacuna of ignorance" in the piece. That way, my pleasure center would go through the roof.

Are you getting the picture? The prospect of a major pleasure hit if my thinking brain could come up with a way to justify my previous pleasure hit. It's crazy, I know, but that's really how we think. Alas - ironically - my rational brain let me down. It failed to come up with a credible justification for my literary excess. So I took the only rational option left and hit "delete." How did I feel about it? Terrible, of course, just terrible.

You might say that a good deal of our condition amounts to a failure in our cognitive circuitry to meet the special challenges posed by our emotional circuitry. But don't expect to find any "bipolar" circuits, much less "bipolar" genes. As I have heard numerous experts explain, the brain is not organized with the DSM in mind. Diagnostic labels help us to a point. In a crude way, they tell us "what." But the object of our search is "what really."

Stay tuned: "Bridging the lacuna of Ignorance."

Previous posts in this series:

DSM-5 Bipolar: Not Much Difference from DSM-IV Bipolar

The DSM-5 Debacle - Same Old Bipolar

Attention and Perception: Two Pieces in the Bipolar Puzzle

Understanding Behavior and Emotions - Let's Look at the Circuitry

Beyond the DSM: Thomas Insel and Understanding Mental Illness