Review article
Impaired theory of mind and emotion recognition in pediatric bipolar disorder: A systematic review and meta-analysis

https://doi.org/10.1016/j.jpsychires.2021.04.011Get rights and content

Highlights

  • Theory of Mind (ToM) and Emotion Recognition (ER) were impaired in pediatric bipolar disorder (PBD).

  • Social cognitive impairments in PBD yielded moderate to large effect sizes.

  • The impairments in social cognition (SC) were independent of the presence of manic symptoms.

  • Meta-regression did not yield a significant moderator of the deficits in SC.

Abstract

Background

Social cognition is impaired in patients with severe mental disorders. We aimed to investigate impairments in social cognition in youth with pediatric bipolar disorder (PBD) through a systematic review of the literature and the meta-analysis.

Method

Following the PRISMA guidelines, we searched in PubMed, Scopus, and Cochrane CENTRAL for studies reporting on the theory of mind (ToM) and emotion recognition (ER) abilities of patients with PBD compared to healthy controls (HC). We conducted a random-effects model meta-analysis for the contrast between PBD and HC. Subgroup and meta-regression analyses were conducted for demographic and clinical variables as appropriate.

Results

A total of thirteen studies involving 429 patients with PBD and 394 HC were included. Patients with PBD had significantly poorer social cognitive abilities (Hedges’ g for ER, g = −0.74, CI = −0.91, −0.57; and for ToM, g = −0.98, CI = −1.41 to −0.55). Subgroup analysis also revealed significant impairment in ER for patients in a euthymic state (g = −0.75). Age, gender, sample size, the severity of mood symptoms, estimated IQ, the frequencies of bipolar-I disorder, attention-deficit hyperactivity disorder, medications, study quality and euthymia did not moderate the difference in meta-regression. Heterogeneity was low in all analyses and there was no evidence for publication bias.

Conclusion

The results of this meta-analysis supported the notion that PBD is associated with a deficit in social cognitive abilities at a medium to a large level. Impairments in social cognition could be an illness-related trait of PBD. Meta-regression results did not find a moderator of the deficits in social cognition.

Introduction

Bipolar disorder (BD) is a chronic psychiatric disorder that usually begins in the early stages of life, with a first mood episode often occurring in childhood or adolescence (Lish et al., 1994; Perlis et al., 2004; Stepanova and Findling, 2017). BD is considered the fourth leading cause of disability in individuals between the ages of 10 and 24 (Gore et al., 2011; Stepanova and Findling, 2017). Pediatric Bipolar Disorder (PBD) is an early-onset form of the illness, manifesting itself under the age of 18 and affecting up to 2% of the young population (Frias et al., 2015; Merikangas et al., 2011; Van Meter et al., 2011). Compared to adulthood-onset BD, young patients with PBD can suffer from more severe symptoms and a worse prognosis (Goldstein and Birmaher, 2012; Stepanova and Findling, 2017). PBD is associated with multiple negative outcomes, such as academic failure, difficulties in interpersonal relationships, and high rates of suicide attempts (Goldstein et al., 2009; Hauser et al., 2013; Merikangas et al., 2007). The disability associated with the disease is not fully explained with acute mood episodes, given that only 40% of patients are able to return to their premorbid functioning levels during disease-free intervals (DelBello et al., 2007).

Recent research focused on the relationship between severe mental illnesses and social cognition. Social cognition covers the understanding of the relationship between oneself and others and the ability to use this information when acting in social circumstances (Green et al., 2015). A variety of different domains have been conceptualized under the heading of social cognition (Green et al., 2015; Savla et al., 2013). Among these, emotion recognition (ER) and the theory of mind (ToM) have been most extensively investigated (Savla et al., 2013). ER is considered as the capability to identify other people's facial expressions and emotions properly (Guarnera et al., 2015). ToM is defined as the correct identification of mental states of ourselves and others in a given social context and plays a key role during social interactions (Harrington et al., 2005). It also involves the ability to realize that other people have different mindsets, understandings, and mental states, such as intentions, beliefs, and desires (Harrington et al., 2005). Some studies have divided ToM into social-cognitive and social-perceptual components (Sabbagh, 2004; Tager-Flusberg and Sullivan, 2000). Social-cognitive ToM is the ability of a person to predict or explain the actions of others based on perceived information about others' intentions, feelings, beliefs, or desires (Sabbagh, 2004; Tager-Flusberg and Sullivan, 2000). Social-perceptual ToM is the person's capacity to perceive other people's mental state based on directly observable information (Sabbagh, 2004; Tager-Flusberg and Sullivan, 2000).

Social cognition is related to disrupted psychosocial functioning in many psychiatric disorders (Fett et al., 2011; Vlad et al., 2018; Weightman et al., 2019). Impairments in social cognitive abilities also have negative effects on increased symptom severity and decreased functioning of patients with serious mental illnesses (Henderson, 2013; Hoertnagl and Hofer, 2014; Weightman et al., 2014). On the other hand, studies also have shown impairments in the social cognition of adults with BD (Bora et al., 2016; Cusi et al., 2012; de Siqueira Rotenberg et al., 2020; Samame et al., 2012). Previous studies revealed deficits in social cognition of adult patients with BD were also detectable during remission periods (Samame et al., 2012; Varo et al., 2019). In a systematic review conducted by Cusi et al. (2012) investigating the impairments in ToM and ER in patients with BD and major depressive disorder, the evidence-synthesis also suggested ToM deficits were also present during symptom-free intervals among patients with BD (Cusi et al., 2012). In a meta-analysis involving 46 studies by Samamé and colleagues (2012), both ToM and ER were impaired in euthymic adult patients with BD (Samame et al., 2012). Moreover, Bora et al. (2016) suggested a worse ToM performance during mood episodes; however, it lasted during euthymic periods to a lesser extent, which seems a trait-marker of BD (Bora et al., 2016). In a recent meta-analysis by Rotenberg and colleagues (2020), results also confirmed impairments in ToM during euthymia, leading to the hypothesis that ToM deficits might be a possible endophenotype for BD (de Siqueira Rotenberg et al., 2020). In the same meta-analysis, patients yielded more severe deficits in the Faux Pas test and the Hinting test than those in ER abilities (de Siqueira Rotenberg et al., 2020). Yet, it is still unknown whether these impairments exist before the illness-onset or are a consequence of the disease.

To date, no meta-analysis specifically explored the social cognitive deficits of patients with PBD. Previous efforts provided an evidence-synthesis of other cognitive domains (Elias et al., 2017); nevertheless, the impairments in the social cognition of patients with PBD remained an unmet need. Given the potential impact of social cognition on clinical and functional outcomes, we aimed to investigate deficits in ToM and ER by comparing subjects with PBD to healthy controls (HC). To answer this research question, we conducted a systematic review of the literature and a meta-analysis of the current evidence.

Section snippets

Search strategy and study selection

PRISMA guidelines were followed while conducting this meta-analysis (Liberati et al., 2009). The PRISMA checklist is presented in Supplementary Material (Table S1). Our study also adhered to a study protocol, upon the agreement of authors, even if not pre-published. The study protocol can be found in the Supplementary material (Supplementary material: Study Protocol). We searched several databases (PubMed, Scopus, and Cochrane CENTRAL) to identify eligible studies up to March 2020 (last updated

Search results

A detailed description of the study selection process is described in Fig. 1. A total of 3068 records were identified through systematic database searching and 126 records were identified from other sources. After removing duplicates, 2673 records were screened for eligibility. Thirteen studies met all our eligibility criteria and were finally included in the quantitative analysis. The list of excluded studies together with their reasons is reported in Supplementary Material (Table S3).

Characteristics of the included studies and participants

The

Discussion

According to the best of our knowledge, this study is the first meta-analysis investigating deficits in social cognition among children and adolescents with PBD. Patients with PBD had significant impairments in the ToM and ER domains of social cognition compared to healthy children. The magnitude of the differences for pooled ToM (Hedges' g = −0.98), and ER abilities (Hedges’ g = −0.74) were medium to large. This finding indicated similar degrees of impairment in both domains. Moreover, data

Conclusion

The findings of this meta-analysis proposed a significant impairment in social cognition among children and adolescents with BD. Deficits in the ER domain seemed to be a trait-marker of the illness, detectable regardless of the mood state. No demographic or clinical data were found to be predictive for ToM and ER abilities. Large-scale observational studies precisely reporting clinical and treatment data are suggested to confirm and expand these results.

Authorship contribution statement

EH, CE and ROC designed and conceptualized the study. EH, FE and ST screened titles and abstracts. CE and ROC resolved the disagreements in the inclusion. EH and CE conducted data extraction. CE and ROC performed the statistical analysis. EH, CE and ROC prepared the first draft of the manuscript. SR also contributed to the data analysis and the interpretation of the results. All authors significantly contributed to and approved the final manuscript.

The role of funding source

None to be reported.

Declaration of competing interest

None to be reported.

Acknowledgments

None.

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      We examined moderators related to the biological characteristics of individual participants, including demographic and illness-related features. All tested demographic moderators, such as mean age, sex distribution and education level, failed to demonstrate a significant association with the effect estimate, which accords with a prior meta-analysis that assessed the impaired emotion recognition in BD (Halac et al., 2021). Our finding of non-significant age effect contrasts the claims that aging is accompanied with an overall decrease of APR accuracy (Demenescu et al., 2015) or a better performance in facial emotion perception (Kohler et al., 2011), though other research similarly reported a non-significant effect of age and sex on social cognition in BD patients (de Siqueira Rotenberg et al., 2020).

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