Exploring praxia deficits in bipolar disorder: A cross-sectional analysis of functionality and quality of life

Praxia in bipolar disorder



apraxia, bipolar disorder, functioning, occupational therapy, quality of life


Background/Aim: Patients with bipolar disorder often experience praxia deficits, which might impede their functionality and quality of life. This study sought to delve into praxis defects in these patients, contrasting their praxia performance with healthy controls and illuminating the interrelation between praxia performance, functionality, and quality of life.

Methods: In this cross-sectional study conducted from February to July 2023, we enrolled 203 patients diagnosed with bipolar disorder 1. Participants were recruited from the Ibni Sina and Sifa Community Mental Health Centers, both of which are affiliated with the Istanbul Tuzla State Hospital. Additionally, 201 healthy controls (HC) were recruited, primarily from the friends and relatives of the hospital staff. Patients diagnosed with bipolar disorder 1, between 18 and 65 years of age, were included based on their diagnosis as determined by the Structured Clinical Interview for DSM-5 Clinical Version (SCID-5-CV). Their right-handedness was ascertained via the Edinburgh Handedness Inventory. To minimize the confounding effects of acute mood episodes on praxia deficits, patients were required to score below 5 on the Young Mania Rating Scale (YMRS) and 7 or lower on the 17-item Hamilton Depression Rating Scale (HDRS). This criterion ensured the exclusion of individuals experiencing an active mood episode. Additionally, participants needed to have been in remission for at least six months. Healthy controls, aged 18-65 and confirmed as right-handed, were included, provided they had no personal or familial history of psychiatric conditions. A detailed interview using SCID-5-CV confirmed that the healthy controls had no history or suspicion of bipolar disorder (BD) or any other psychiatric disorder and no relatives with a psychiatric disorder. All participants (203 bipolar disorder patients and 201 healthy controls) underwent evaluations using the Test for Upper Limb Apraxia (TULIA), while the bipolar cohort received the Global Functioning Assessment-Functioning (GAF-F)  and the World Health Organization Quality of Life-Brief Version (WHOQOL-BREF). Statistical analyses were conducted using SPSS 22.0.

Results: We identified a critical TULIA score threshold of 217, which differentiates bipolar patients from healthy individuals with a sensitivity of 79.3% and a specificity of 77.1% (area under the curve (AUC) 0.799, P<0.001). TULIA scores in bipolar patients were significantly positively correlated with functionality (GAF-F; r=0.502, P<0.001) and quality of life-general health (WHOQOL; r=0.389, P<0.001). TULIA pantomime subscores (OR=0.92, 95% CI 0.86-0.99, P=0.022) and CPZ use of more than 250mg per day (OR=2.24, 95% CI 1.19-4.21, P=0.012) were independent predictors of impairment in functioning in bipolar patients.

Conclusion: Praxia deficits in bipolar disorder patients may be intricately tied to specific clinical features that influence both their functionality and life quality. Comprehensive praxia deficit assessments can pave the way for devising tailored interventions, enhancing praxia and, by extension, the quality of life of bipolar patients.


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Bonnín, CDM, Reinares M, Martínez-Arán A, Jiménez E, Sánchez-Moreno J, Solé B, et al. Improving functioning, quality of life, and well-being in patients with bipolar disorder. Int J Neuropsychopharmacol. 2019;22(8):467-77. DOI: https://doi.org/10.1093/ijnp/pyz018

Léda‐Rêgo G, Bezerra‐Filho S, Miranda‐Scippa Â. Functioning in euthymic patients with bipolar disorder: A systematic review and meta‐analysis using the Functioning Assessment Short Test. Bipolar Disord. 2020;22(6):569-81. DOI: https://doi.org/10.1111/bdi.12904

Fornaro M, Carvalho AF, Fusco A, Anastasia A, Solmi M, Berk M, et al. The concept and management of acute episodes of treatment-resistant bipolar disorder: a systematic review and exploratory meta-analysis of randomized controlled trials. J Affect Disord. 2020;276:970-83. DOI: https://doi.org/10.1016/j.jad.2020.07.109

Mezes B, Lobban F, Costain D, Hillier L, Longson D, Varese F, et al. Recovery beyond clinical improvement-Recovery outcomes measured for people with bipolar disorder between 1980 and 2020. J Affect Disord. 2022;309:375-92. DOI: https://doi.org/10.1016/j.jad.2022.04.075

Vieta E, Torrent C . Functional remediation: the pathway from remission to recovery in bipolar disorder. World Psychiatry. 2016;15(3):288-9. DOI: https://doi.org/10.1002/wps.20351

Bonnín CdM, González-Pinto A, Solé B, Reinares M, González-Ortega I, Alberich S, et al. Verbal memory as a mediator in the relationship between subthreshold depressive symptoms and functional outcome in bipolar disorder. J Affect Disord. 2014;160:50-4.

Walther S, Mittal VA, Stegmayer K, Bohlhalter S. Gesture deficits and apraxia in schizophrenia. Cortex. 2020;133:65-75. DOI: https://doi.org/10.1016/j.cortex.2020.09.017

Walther S, Stegmayer K, Sulzbacher J, Vanbellingen T, Muri R, Strik W, et al. Nonverbal social communication and gesture control in schizophrenia. Schizophr Bull. 2015;41(2):338–45. DOI: https://doi.org/10.1093/schbul/sbu222

Walther S, Vanbellingen T, Muri R, Strik W, Bohlhalter S. Impaired gesture performance in schizophrenia: particular vulnerability of Meaningless pantomimes. Neuropsychologia. 2013;51(13):2674–8. DOI: https://doi.org/10.1016/j.neuropsychologia.2013.08.017

Walther S, Eisenhardt S, Bohlhalter S, Vanbellingen T, Müri R, Strik W, et al. Gesture performance in Schizophrenia predicts functional outcome after 6 months. Schizophr Bull. 2016;42(6):1326-33. DOI: https://doi.org/10.1093/schbul/sbw124

Viher PV, Stegmayer K, Bracht T, Federspiel A, Bohlhalter S, Strik W, et al. Neurological soft signs are associated with altered white matter in patients with schizophrenia. Schizophr Bull. 2022;48(1):220-30. DOI: https://doi.org/10.1093/schbul/sbab089

Ünal IÖ, Berkol TD. Investigation of Apraxia in Patients with Schizophrenia and Bipolar Disorder Type I. Psychiatr Danub. 2023;35(1):47-55. DOI: https://doi.org/10.24869/psyd.2023.47

Fountoulakis KN. Neurocognitive impairment and evidence-based treatment options in Bipolar disorder. Ann Gen Psychiatry. 2020;19(1):1-11. DOI: https://doi.org/10.1186/s12991-020-00304-4

Çeğil T. Turkish standardisation, validity, and reliability of TULIA (An Apraxia Test for Upper Limbs) (Master's thesis) İstanbul Medipol University Institute of Health Sciences; 2019

Karadağ F, Oral ET, Yalçın AF, Erten E. Turkish validity and reliability of Young Mania Rating Scale (Young Mani Derecelendirme Ölçeğinin Türkiye’de Geçerlilik ve Güvenilirliği) Türk Psikiyatri Derg. 2001;13:107-14.

Akdemir A, Örsel S, Dağ İ, Türkçapar HM, İşcan N, Özbay H. Turkish validity and reliability of Hamilton Depression Rating Scale (Hamilton Depresyon Derecelendirme Ölçeği’nin geçerliği, güvenirliği ve klinikte kullanımı) Psikiyatri Psikoloji Psikofarmakoloji Dergisi. 1996;4(4):251-9.

Bonnín, CDM, Martínez-Arán A, Reinares M, Valentí M, Solé B, Jiménez E, et al. Thresholds for severity, remission and recovery using the functioning assessment short test (FAST) in bipolar disorder. J Affect Disord. 2018;240:57-62. DOI: https://doi.org/10.1016/j.jad.2018.07.045

Eser S, Saatli G, Eser E, Baydur H, Fidaner C. The reliability and validity of the Turkish Version of the World Health Organization Quality of Life Instrument-Older Adults Module (WHOQOL-Old). Turk Psikiyatri Derg. 2010;21(1):37-48.

Bonnín CdM, González-Pinto A, Solé B, Reinares M, González-Ortega I, Alberich S, et al. Verbal memory as a mediator in the relationship between subthreshold depressive symptoms and functional outcome in bipolar disorder. J Affect Disord. 2014;160:50-4. DOI: https://doi.org/10.1016/j.jad.2014.02.034

Pascual-Sanchez A, Jenaro C, Montes-Rodríguez JM. Quality of life in euthymic bipolar patients: A systematic review and meta-analysis. J Affect Disord. 2019;255:105-15. DOI: https://doi.org/10.1016/j.jad.2019.05.032

Frisch S, Grünwald F, Friedrichs B. Cognitive sequelae of lithium intoxication: a case report. Int Psychogeriatr. 2017;29:1747-51. DOI: https://doi.org/10.1017/S1041610217000540

Wingo AP, Wingo TS, Harvey PD, Baldessarini RJ. Effects of lithium on cognitive performance: a metaanalysis. J Clin Psychiatry. 2009;70:1588-97. DOI: https://doi.org/10.4088/JCP.08r04972

Taylor DM, Barnes TR, Young AH. The Maudsley prescribing guidelines in psychiatry, 13th edition. Hoboken, NJ: John Wiley & Sons; 2019

Dutschke LL, Stegmayer K, Ramseyer F, Bohlhalter S, Vanbellingen T, Strik W, et al. Gesture impairments in schizophrenia are linked to increased movement and prolonged motor planning and execution. Schizophr Res. 2018;200:42-9. DOI: https://doi.org/10.1016/j.schres.2017.07.012

Wüthrich F, Viher PV, Stegmayer K, Federspiel A, Bohlhalter S, Vanbellingen T, et al. Dysbalanced Resting-State Functional Connectivity Within the Praxis Network Is Linked to Gesture Deficits in Schizophrenia. Schizophr Bull. 2020;46:905-15. DOI: https://doi.org/10.1093/schbul/sbaa008

Devrımcı Özgüven H, Kir Y. Long Acting Injectable Antipsychotics in the Treatment of Schizophrenia and Bipolar Disorder. Noro Psikiyatr Ars. 2021;58(Suppl 1):47-52. doi: 10.29399/npa.27480. PMID: 34658635; PMCID: PMC8498817. DOI: https://doi.org/10.29399/npa.27480

Fleischhacker WW. Second-generation antipsychotic long-acting injections: systematic review. Br J Psychiatry. 2009;52:29-36. DOI: https://doi.org/10.1192/bjp.195.52.s29

Gharabawi GM, Bossie CA, Zhu Y, Mao L, Lasser RA. An assessment of emergent tardive dyskinesia and existing dyskinesia in patients receiving long-acting, injectable risperidone: results from a long-term study. Schizophr Res. 2005;77:129-39. DOI: https://doi.org/10.1016/j.schres.2005.03.015

Franco-Urbano MS, Rodríguez-Martínez MDC, García-Pérez P. The Impact of Depression on the Functional Outcome of the Elderly Stroke Victim from a Gender Perspective: A Systematic Review Healthcare. 2022;10(10):2110. DOI: https://doi.org/10.3390/healthcare10102110

Chou WH, Ko YL, Huang XY. Design of occupational therapy interventions for middle-aged and elderly family caregivers. Healthcare. 2021;9(3):275. DOI: https://doi.org/10.3390/healthcare9030275






Research Article

How to Cite

Özönder Ünal İpek. Exploring praxia deficits in bipolar disorder: A cross-sectional analysis of functionality and quality of life: Praxia in bipolar disorder. J Surg Med [Internet]. 2023 Oct. 13 [cited 2023 Nov. 29];7(10):682-9. Available from: https://jsurgmed.com/article/view/7967