Higher Cortical Functions: Attention and Vigilance

| January 21, 2011 | 0 Comments

by Paulette Marie Gillig, MD, PhD, and Richard D. Sanders, MD

Dr. Gillig is Professor of Psychiatry and Faculty of the Graduate School, Department of Psychiatry, Wright State University, Dayton, Ohio; and Dr. Sanders is Associate Professor, Departments of Psychiatry and Neurology, Boonshoft School of Medicine, Wright State University, and Dayton VA Medical Center, Dayton, Ohio.

Innov Clin Neurosci. 2011;8(1):43–46

Series Editor: Paulette M. Gillig, MD, PhD, Professor of Psychiatry, Department of Psychiatry, Boonshoft School of Medicine, Wright State University, Dayton, Ohio

Funding: No funding was received for the development of this article.

Financial Disclosures: The authors have no conflicts of interest relevant to the content of this article.

Key words: Attention, attention and borderline personality disorder, attention and anxiety disorders, attention and posttraumatic stress disorder, attention and depression, higher cortical functions

Abstract: The ability to sustain attention over time (vigilance) is a cognitive function that often is impaired in patients with psychiatric disorders. Attention has been found to be disordered in a number of psychiatric conditions, including attention deficit disorder, schizophrenia, antisocial personality disorder, and the impulse control disorders. Less widely known is the finding that attention also is affected in patients suffering from anxiety disorders, posttraumatic stress disorder, mood disorders, and borderline personality disorder. In this article, the significance of attention deficits with regard to the mood disorders, anxiety disorders, posttraumatic stress disorder, and borderline personality disorder, is described.

In this series, Drs. Sanders and Gillig explain how aspects of the neurological examination can aid in differential diagnosis of some common (and some uncommon) disorders seen in psychiatric practice.

What is attention?

Attention refers to being able to focus on a specific thing without being distracted. It is different from simply being alert, because alertness refers to basic arousal. An alert person is simply awake. An alert but inattentive patient will be attracted to any novel stimulus in the environment, but will not be able to screen out irrelevant stimuli.

The ability to sustain attention over time (vigilance) must be present before more complex functions can be evaluated.[1] It may be surprising to see how many problems that are attributed by others and by the patient to memory loss are in fact due to the person not being able to attend to material and, therefore, being unable to assimilate the information in the first place.

Testing Attention

Basic level of attention can be tested by asking a patient to repeat some numbers from a short numerical series. Most people (of average intelligence) can repeat five to seven digits without difficulty.

Attention tasks can be made progressively more complicated, at which point the tasks can be used to assess executive functioning, global intelligence, and general educational level. One widely used test of attention is the serial sevens task from the Mini-mental State Exam.[2] This is routinely interchanged with backwards spelling, although such tasks are not interchangeable[3–5] and are influenced by educational level and abilities outside of attention.[3,5]

Vigilance can be tested by reading a patient a series of random letters and asking the person to indicate whenever a certain letter is spoken. Problems with vigilance are reflected by the omission of a letter, by signaling even when the letter is not presented, or by continuing to indicate a letter several times even though new letters are being presented, called perseveration. Perseveration is particularly likely to be present in patients who are having executive problems in shifting their “set.” As presented in a previous article in this series,[6] the Go–No Go test is a popular format for testing vigilance and perseveration. Impersistence in certain motor exam tests, such as the test for motor drift and the Romberg, are also indicative of attentional impairment.

Psychiatric disorders affecting attention

Attention has been found to be disordered in a number of psychiatric conditions, including attention deficit disorder, schizophrenia, antisocial personality disorder, and the impulse control disorders.[7] Less widely known is the finding that attention also is affected in patients suffering from anxiety disorders, posttraumatic stress disorder, the mood disorders, and borderline personality disorder.[7]

Emotions can bias the focus of a person’s attention. People suffering from anxiety or depression are more likely to notice negative stimuli even if they try to ignore these stimuli. People who tend to ruminate and brood about things notice sad faces more, and this bias persists even after the current depressive state has resolved. Stimuli that could be interpreted as rejecting (“threat-related”) are noticed more by patients with social anxiety and generalized anxiety disorders, and by other people who are high in rejection sensitivity or suffer from insecure attachment, such as traumatized children.[7]

Posttraumatic stress disorder

In persons with posttraumatic stress disorder (PTSD), one may observe one of two disordered attentional responses after the person first orients him or herself toward any perceived threat of rejection or harm: the person will either 1) maintain a persistent vigilance toward the rejecting material and not be able to ignore it, or 2) show a “vigilant-avoidant” pattern of response with abnormally quick disengagement from the situation.[7] Either response interferes with the person’s ability to engage in meaningful interpersonal relations and/or to remain safe. The first response does because it prevents the patient from noticing others in the environment who are nonthreatening, and the second because it results in danger to the person’s safety when truly threatening information is defensively ignored.

Depression and Anxiety

Persons with depression or a history of depression attend to negative words and sad faces more than other stimuli. Depressed people require a higher intensity of “happiness” in a facial expression before they are able to correctly identify the face as happy, and there is some evidence that this tendency may be genetically inherited. Not only do depressed patients have difficulty disengaging their attention from any negative stimulus, this pattern of focusing attention on negative stimuli may pre-date the development of depression.[8–19]

Patients with anxiety disorders may be particularly accurate about angry facial expressions. Persons with social phobia who are high in rejection sensitivity or who have a history of being abused are able to correctly identify angry facial expressions better than people without these disorders.[12,20–24]

Attention and Memory Functions

Memory is affected by attention and emotional arousal, and anatomically there is close spatial proximity between the hippocampus (particularly significant for memory function) and the amygdale (significant for emotional arousal). The memory function of the hippocampus is affected by the amygdala, and persons who have been shown “emotional” pictures later can remember the emotional details of those pictures even though they may have forgotten nonemotional details. The physiological arousal mediated by the amygdala that accompanies emotion-laden details is not present when attention is focused on nonemotional details, and emotion-laden information is processed via different neurological pathways for both storage and retrieval.[25–27]

Attention, distraction, and the ability to delay gratification

Normally, irrelevant or distracting stimuli are inhibited at multiple levels. They are not processed as strongly by the sensory cortex and so they produce less effect on memory storage. They are also actively inhibited during storage. Active inhibition of distracting stimuli and inappropriate responses requires focused attention and is more difficult and slower than emotionally-based responses or impulse-driven behavior.[28]

The inability to delay gratification is a prominent problem for many psychiatric patients. Delay of gratification is an executive function but it requires the function of attention. A person delays gratification by disengaging attention away from emotional information that would otherwise induce a here-and-now focus, and instead switches to a more recently learned, less impulse-driven response.[7]

The ability to delay gratification is an important aspect of resiliency to trauma.[29] It also protects a person with social anxiety disorder when forming interpersonal relationships. The person who is better able to delay immediate gratification can wait and see whether an initial ambiguous encounter with someone may turn out more positively in the end, if a relationship will deepen over time, or if another person’s intentions initially were misunderstood. Even persons with high-rejection sensitivity have been found to be relatively protected against negative self-image, drug use, and educational underachievement if they scored high on the ability to delay gratification at ages 3 to 4 years.[30–33]

Neurocognitive functions and attention

Better neurocognitive function helps protect trauma-exposed individuals from developing PTSD.[34] Neurocognitive impairments exacerbate the negative effect of trauma because of their effects on processes such as attention, self-reflection, and perspective taking. Neurocognitive function is impaired in many psychiatric patients who display inability to delay gratification, including some patients who develop borderline personality disorder.[35–37]

Conclusion

The ability to sustain attention over time is a cognitive function that often is impaired in patients with psychiatric disorders.[7] The neurological function of attention has been shown to be disordered in a number of psychiatric conditions in attention deficit disorder, schizophrenia,38 antisocial personality disorder, and the impulse control disorders.[39] Less widely known is the finding that attention also is affected in patients suffering from anxiety disorders, posttraumatic stress disorder, the mood disorders, and borderline personality disorder.

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Category: Anxiety Disorders, Mood Disorders, Neurologic Systems and Symptoms, Neurology, Past Articles, Personality Disorders, Psychiatry

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