The Role of Cognitive Function in Substance Abuse Treatment Sara L. Dolan, Ph.D. Baylor University Department of Psychology and Neuroscience Baylor Addiction

The Role of Cognitive The Role of Cognitive Function in Function in

Substance Abuse Substance Abuse TreatmentTreatmentSara L. Dolan, Ph.D. Sara L. Dolan, Ph.D.

Baylor University Department of Psychology and NeuroscienceBaylor University Department of Psychology and NeuroscienceBaylor Addiction Research CenterBaylor Addiction Research Center

Baylor UniversityBaylor UniversityOne Bear Place #97334One Bear Place #97334Waco, TX 76798-7334Waco, TX 76798-7334

[email protected](254) 710-2573(254) 710-2573

TIPSS 6/2010

OverviewOverview

DSM-IV Alcohol-Related DisordersDSM-IV Alcohol-Related Disorders History and BackgroundHistory and Background Review of neuropsychological, neuroimaging, Review of neuropsychological, neuroimaging,

and neuropathological correlates of alcohol and neuropathological correlates of alcohol related disordersrelated disorders

Review of evidence-based treatments for Review of evidence-based treatments for alcohol dependencealcohol dependence

Neuropsychological function and treatmentNeuropsychological function and treatment

DSM-IV Alcohol-Related DSM-IV Alcohol-Related Disorders - TemporaryDisorders - Temporary

Alcohol Intoxication Delirium Alcohol Intoxication Delirium

Alcohol Withdrawal Delirium (With Alcohol Withdrawal Delirium (With Perceptual Disturbances)Perceptual Disturbances)

DSM-IV Alcohol-Related DSM-IV Alcohol-Related Disorders – Persisting Disorders – Persisting

Alcohol-Induced Persisting DementiaAlcohol-Induced Persisting Dementia Learning/memory impairment AND 1 +:Learning/memory impairment AND 1 +:

Aphasia, Apraxia, Agnosia, Executive Aphasia, Apraxia, Agnosia, Executive dysfunctiondysfunction

Alcohol-Induced Persisting Amnestic Alcohol-Induced Persisting Amnestic DisorderDisorder Learning/memory impairment (Wernicke-Learning/memory impairment (Wernicke-

Korsakoff’s)Korsakoff’s)

Background/History Background/History Beyond thiamine-deficiency (i.e., Wernicke Beyond thiamine-deficiency (i.e., Wernicke

– Korsakoff’s), alcoholism researchers – Korsakoff’s), alcoholism researchers have focused on models based on brain have focused on models based on brain systems vulnerabilitiessystems vulnerabilities

Three predominant theories on the pattern Three predominant theories on the pattern of consequences of alcoholism on the brainof consequences of alcoholism on the brain

1.1. Premature aging / whole brainPremature aging / whole brain2.2. Right brainRight brain3.3. Frontal lobesFrontal lobes

Parsons, Butters, and Nathan, 1987

The Human BrainThe Human Brain

Targets of Alcohol and Targets of Alcohol and Other DrugsOther Drugs

Cerebellum

Premature Aging / Whole Premature Aging / Whole BrainBrain Alcoholism accelerates brain agingAlcoholism accelerates brain aging

Findings only support premature aging in Findings only support premature aging in older alcoholics (i.e., age 50 +) older alcoholics (i.e., age 50 +) (Oscar-Berman, (Oscar-Berman, 2000)2000)

Alcohol leads to mild generalized Alcohol leads to mild generalized dysfunction of the brain dysfunction of the brain (Parsons, 1996)(Parsons, 1996)

Right BrainRight Brain Right hemisphere is more vulnerable to Right hemisphere is more vulnerable to

the effects of alcoholism than the left the effects of alcoholism than the left hemispherehemisphere Impairments in visuospatial functioning and Impairments in visuospatial functioning and

emotional processing emotional processing (Oscar-Berman, 2000)(Oscar-Berman, 2000)

Emotional processing deficits also may be Emotional processing deficits also may be due to abnormalities in other brain regions due to abnormalities in other brain regions (e.g., limbic system, frontal lobes; (e.g., limbic system, frontal lobes; Colson & Dolan, Colson & Dolan,

2010; 2010; Oscar-Berman & Schendan, 2000Oscar-Berman & Schendan, 2000))

Frontal LobesFrontal Lobes Frontal lobes show increased susceptibility Frontal lobes show increased susceptibility

to alcoholism-related damageto alcoholism-related damage Evidence from post-mortem neuropathological Evidence from post-mortem neuropathological

studies studies (Harper, 1998)(Harper, 1998) and neuroimaging of living and neuroimaging of living patients patients (Sullivan, 2000)(Sullivan, 2000)

Also behavioral and neuropsychological Also behavioral and neuropsychological deficits in executive functioning seem to be deficits in executive functioning seem to be prominent in both currently-drinking and prominent in both currently-drinking and recently-detoxified alcoholics recently-detoxified alcoholics (e.g., Bechara et al., 2001)(e.g., Bechara et al., 2001)

Neuropsychological Neuropsychological Impairment in Substance Impairment in Substance AbusersAbusers

Approximately 33-75% of patients Approximately 33-75% of patients admitted to VA outpatient substance admitted to VA outpatient substance abuse treatment programs have abuse treatment programs have measurable cognitive impairmentmeasurable cognitive impairment Mostly in the mild to moderate rangeMostly in the mild to moderate range

(Eckardt & Martin, 1986; Meek et al., 1989; Parsons & Leber, 1981; Tabakoff & Petersen, 1988)

Neuropsychological Deficits Neuropsychological Deficits in Substance Abusersin Substance Abusers

Alcoholics have deficits in:Alcoholics have deficits in: Memory (anterograde worse than Memory (anterograde worse than

retrograde)retrograde) Visual worse than verbalVisual worse than verbal

Visuospatial functionsVisuospatial functions Executive functionsExecutive functions

Problem‑solving, abstractionProblem‑solving, abstraction Cognitive efficiency Cognitive efficiency

((Page, 1983; Page, 1987; Parsons Page, 1983; Page, 1987; Parsons et al., 1987; et al., 1987; Ratti et al., 2002; Wilson, 1987Ratti et al., 2002; Wilson, 1987))

Executive FunctionExecutive Function

A disruption of processes thought to:A disruption of processes thought to: MonitorMonitor DirectDirect Organize Organize Regulate behavior…Regulate behavior…

……to enable persons effectively to achieve to enable persons effectively to achieve desired goals while minimizing adverse desired goals while minimizing adverse consequencesconsequences

Mediated by the prefrontal cortex((Lezak, 1995Lezak, 1995))

Neuropsychological Neuropsychological FunctioningFunctioning

Early studies suggested that sober alcoholics Early studies suggested that sober alcoholics demonstrate impairment on demonstrate impairment on neuropsychological tests that is similar to that neuropsychological tests that is similar to that of patients with diagnosed mild-to-moderate of patients with diagnosed mild-to-moderate brain injury brain injury (Parsons, 1986).(Parsons, 1986).

Neuropsychological Neuropsychological FunctioningFunctioning

15 studies examining performance 15 studies examining performance between alcoholic patients and control between alcoholic patients and control peers revealed poorer performance on a peers revealed poorer performance on a variety of tests variety of tests (Parsons & Farr, 1981)(Parsons & Farr, 1981)

Neuropsychological Neuropsychological FindingsFindings

Compromised fronto-cortico-cerebellar circuits Compromised fronto-cortico-cerebellar circuits underlie cognitive deficits underlie cognitive deficits (Scheurich, 2005)(Scheurich, 2005)

Patterns of correlations between cortical and Patterns of correlations between cortical and subcortical volume deficitssubcortical volume deficits

To compensate for deficient task performance, To compensate for deficient task performance, alcohol-dependent patients require the use of alcohol-dependent patients require the use of additional and higher-order executive functions additional and higher-order executive functions (Scheurich, 2005)(Scheurich, 2005)

Structural NeuroimagingStructural Neuroimaging

In recently detoxified alcoholics, CT findings In recently detoxified alcoholics, CT findings show widened sulci, ventricular dilation, and show widened sulci, ventricular dilation, and cerebellar atrophy cerebellar atrophy (Grant, 1987)(Grant, 1987)

MRI: Reductions in cortical and subcortical MRI: Reductions in cortical and subcortical gray and white matter gray and white matter (Jernigan et al, 1992; Schmidt et al., (Jernigan et al, 1992; Schmidt et al., 2005)2005) Reduction in brain weight and volume Reduction in brain weight and volume

associated with reduction in white matter associated with reduction in white matter volume volume (Harper et al., 2003)(Harper et al., 2003)

Reduction in total hippocampus volumeReduction in total hippocampus volume (Arciniegas et al., 2006)(Arciniegas et al., 2006)

Functional NeuroimagingFunctional Neuroimaging

Functional MRI studies: Functional MRI studies: Decreased prefrontal cortical function in chronic Decreased prefrontal cortical function in chronic

substance abusers (for a review, see substance abusers (for a review, see London et al., London et al., 20002000))

Additional recruitment of brain areas (Additional recruitment of brain areas (Scheurich, Scheurich, 20052005))

Cerebral glucose metabolism (PET studies): Cerebral glucose metabolism (PET studies): Decreased regional cerebral blood flow to frontal Decreased regional cerebral blood flow to frontal regions, ranging from a 75% (regions, ranging from a 75% (Nicolas et al., 1993Nicolas et al., 1993) to ) to 86% (86% (Erbas et al., 1992Erbas et al., 1992) reduction in chronic alcoholics ) reduction in chronic alcoholics

SPECT: decreased blood flow in frontal lobes and SPECT: decreased blood flow in frontal lobes and cerebellum (latter appears to persist even after a cerebellum (latter appears to persist even after a period of abstinence)period of abstinence)

Functional Brain Changes Functional Brain Changes in Problem Drinkersin Problem Drinkers

Etiology of Progressive Cognitive Etiology of Progressive Cognitive DeclineDecline

Wernicke’s Encephalopathy (B1 Wernicke’s Encephalopathy (B1 deficiency)deficiency)

Characterized by nystagmus, abducens and Characterized by nystagmus, abducens and conjugate gaze palsies, ataxia, and mental conjugate gaze palsies, ataxia, and mental disturbance (confusional state)disturbance (confusional state)

Etiology of Progressive Etiology of Progressive Cognitive DeclineCognitive Decline

Wernicke-Korsakoff Syndrome (aka Wernicke-Korsakoff Syndrome (aka Korsakoff psychosis or Korsakoff Korsakoff psychosis or Korsakoff amnesic state; DSM-IV=Alcohol-Induced amnesic state; DSM-IV=Alcohol-Induced Persisting Amnestic Disorder)Persisting Amnestic Disorder)

Retentive memory impaired out of proportion to Retentive memory impaired out of proportion to other cognitive functions (chronic manifestation other cognitive functions (chronic manifestation of Wernicke disease)of Wernicke disease)

With treatment, recovery occurs in less than 20% With treatment, recovery occurs in less than 20% of patients of patients

Alcohol and DementiaAlcohol and Dementia

Association between alcohol use (especially heavy use Association between alcohol use (especially heavy use or dependence) and the development of dementia or dependence) and the development of dementia (Oslin et al., 1998)(Oslin et al., 1998) Heavy alcohol use contributes to the emergence of Heavy alcohol use contributes to the emergence of

dementia in more than 20% of patients diagnosed dementia in more than 20% of patients diagnosed with dementia with dementia (cited in Kapaki et al., 2005)(cited in Kapaki et al., 2005)

May be most apparent among men and those with May be most apparent among men and those with ApoE4 allele ApoE4 allele (Mukamal et al., 2003)(Mukamal et al., 2003)

Cortical and subcortical pathology Cortical and subcortical pathology (Schmidt et al, 2005)(Schmidt et al, 2005)

ReversibilityReversibility

Recovery of function is supported in the Recovery of function is supported in the neuropsychological and neuroradiological neuropsychological and neuroradiological literature literature (Grant, 1987)(Grant, 1987)

Some studies report only partial recovery Some studies report only partial recovery (Oslin & Cary, 2003)(Oslin & Cary, 2003)

ReversibilityReversibility

Cognitive functioning improves with Cognitive functioning improves with extended abstinenceextended abstinence Much improvement over first 21-30 days of Much improvement over first 21-30 days of

abstinenceabstinence Can take as long as 1 yearCan take as long as 1 year

How does recovery occur?How does recovery occur? Glial regenerationGlial regeneration Synaptic plasticitySynaptic plasticity

Range of ImpairmentRange of Impairment

Mild (subtle) = may or may not evidence Mild (subtle) = may or may not evidence impairment in daily lifeimpairment in daily life ““Social” drinkers (6+ drinks per day; Social” drinkers (6+ drinks per day; Parsons, 1998Parsons, 1998))

Moderate = more likely show some impairment in Moderate = more likely show some impairment in daily lifedaily life

Severe = Wernicke’s Encephalopathy (acute), Severe = Wernicke’s Encephalopathy (acute), Korsakoff’s Disease, Alcohol-Induced Persisting Korsakoff’s Disease, Alcohol-Induced Persisting Dementia (chronic)Dementia (chronic)

No Impairment Mild Moderate Severe

Prevalence of ImpairmentPrevalence of Impairment

33 – 75% of alcoholics entering treatment 33 – 75% of alcoholics entering treatment display neuropsychological deficits, most display neuropsychological deficits, most in the mild to moderate rangein the mild to moderate range Problem-solvingProblem-solving Abstract thinkingAbstract thinking Concept shiftingConcept shifting Learning / MemoryLearning / Memory

Eckardt & Martin, 1986; Meek et al., 1989; Parsons & Leber, 1981; Tabakoff & Petersen, 1988

Prevalence of ImpairmentPrevalence of Impairment

Categories = 50%Categories = 50% Abstract thinkingAbstract thinking

COWA = 50%COWA = 50% Verbal fluencyVerbal fluency

Trails-B = 17%Trails-B = 17% Cognitive flexibilityCognitive flexibility

Stroop = 12%Stroop = 12% Response inhibitionResponse inhibition

Shipley Vocabulary = 13%Shipley Vocabulary = 13% Verbal skillsVerbal skills

Morgenstern & Bates, 1999Morgenstern & Bates, 1999

Specific Neuropsychological Specific Neuropsychological Deficits and Substance Abuse Deficits and Substance Abuse Treatment ProcessTreatment Process Attention / Learning / MemoryAttention / Learning / Memory

Patients can’t learn or remember new skills Patients can’t learn or remember new skills taught in treatment taught in treatment (Sanchez-Craig & Walker, (Sanchez-Craig & Walker, 1982)1982)

Specific Neuropsychological Specific Neuropsychological Deficits and Substance Abuse Deficits and Substance Abuse Treatment ProcessTreatment Process Executive function – patients can’t apply new Executive function – patients can’t apply new

skills after treatment skills after treatment (Morgenstern & Bates, 1999)(Morgenstern & Bates, 1999)

Abstract thinkingAbstract thinking Generalizability of skills outside of treatmentGeneralizability of skills outside of treatment

Cognitive flexibilityCognitive flexibility Switching tracksSwitching tracks

Verbal FluencyVerbal Fluency Producing alternative strategiesProducing alternative strategies

Response InhibitionResponse Inhibition Inhibiting pre-potent responsesInhibiting pre-potent responses

Neuropsychological Deficits Neuropsychological Deficits and Substance Abuse and Substance Abuse Treatment ProcessTreatment Process

Failure to acquire strategies taught Failure to acquire strategies taught during treatmentduring treatment

The cognitive and behavioral strategies The cognitive and behavioral strategies taught in treatment may be less effective taught in treatment may be less effective in preventing relapse in preventing relapse

Impaired individuals have different Impaired individuals have different change processes than unimpaired change processes than unimpaired individualsindividuals

Block, Bates, & Hall, 2003; Morgenstern & Bates, 1999Block, Bates, & Hall, 2003; Morgenstern & Bates, 1999

Neuropsychological Neuropsychological Function and Treatment Function and Treatment Process / OutcomeProcess / Outcome Clinicians’ misattributions of patients’ Clinicians’ misattributions of patients’

behaviors behaviors Verbal skills (previously learned information) Verbal skills (previously learned information)

remain relatively preserved, so patients remain relatively preserved, so patients appear unimpairedappear unimpaired

Clinicians fail to identify cognitive Clinicians fail to identify cognitive impairment in at least 40% of patients impairment in at least 40% of patients (Fals-Stewart et al., 1993; 1994)

Neuropsychological dysfunction may Neuropsychological dysfunction may result in more rule violations in treatment result in more rule violations in treatment (Fals-Stewart et al., 1994)

TreatmentTreatment

Evidence-Based Evidence-Based TreatmentsTreatments

Cognitive-BehavioralCognitive-Behavioral Motivational Enhancement (MI)Motivational Enhancement (MI) Twelve Step FacilitationTwelve Step Facilitation Community ReinforcementCommunity Reinforcement

CRAFTCRAFT

Behavioral Couples TherapyBehavioral Couples Therapy

Cognitive-BehavioralCognitive-Behavioral

Change thoughts, feelings, and Change thoughts, feelings, and behaviors associated with addictionbehaviors associated with addiction

Relapse-Prevention Coping Skills Relapse-Prevention Coping Skills TrainingTraining

Communication Skills TrainingCommunication Skills Training Cue Exposure TreatmentCue Exposure Treatment

Motivational Motivational EnhancementEnhancement

Increase self-directed motivation to Increase self-directed motivation to changechange

Increase self-efficacy for changeIncrease self-efficacy for change Be non-confrontationalBe non-confrontational

Twelve StepTwelve Step

AA/NA/CAAA/NA/CA Emergency planningEmergency planning Sober social supportSober social support

Common ThemesCommon Themes• Empirically-supported psychosocial Empirically-supported psychosocial

treatments for SUDs treatments for SUDs (Finney, Willbourne, and Moos, 2007)(Finney, Willbourne, and Moos, 2007)::– Enhance/maintain motivation to change.Enhance/maintain motivation to change.– Involve teaching/learning of coping skills.Involve teaching/learning of coping skills.– Restructure the social environment.Restructure the social environment.– Can involve conditioning-based interventions.Can involve conditioning-based interventions.– Change perceptions of social norms.Change perceptions of social norms.– Enhance self-efficacy for robust behavioral Enhance self-efficacy for robust behavioral

change.change.

ParticipantsParticipants

187 Alcohol-Dependent patients in 187 Alcohol-Dependent patients in residential treatmentresidential treatment Clinical trial of naltrexone and coping skills Clinical trial of naltrexone and coping skills

trainingtraining 31% female31% female 39.0 ± 9.4 years of age 39.0 ± 9.4 years of age 13.4 ± 2.3 years of education 13.4 ± 2.3 years of education 66.1 ± 28.3 % alcohol use days during the 66.1 ± 28.3 % alcohol use days during the

6 months pre-treatment6 months pre-treatment

MeasuresMeasures Urge-Specific Strategies (USS;Urge-Specific Strategies (USS; 6 mo. 6 mo.

αα = .91; 12 mo. = .91; 12 mo. αα = = .90) .90) 21 situation-specific strategies taught in cue 21 situation-specific strategies taught in cue

exposure, communication skills, or exposure, communication skills, or relaxation/meditationrelaxation/meditation

General Strategies for Alcoholics (GSA; 6 General Strategies for Alcoholics (GSA; 6 mo. mo. αα = .92; 12 mo. = .92; 12 mo. αα = .90 = .90) ) 21-item lifestyle change strategies taught in 21-item lifestyle change strategies taught in

communication skills and in the general communication skills and in the general treatment program treatment program

DesignDesign

nn = 131 = 131

55% 55%

n n = 117= 117

70%70%

6 and 12 mos post-Tx:6 and 12 mos post-Tx:

1.1.USSUSS2.2.GSA GSA 3.3.Measure of substance useMeasure of substance use

6 months 12 months

Sample size

Relapse rate

USS - CognitiveUSS - Cognitive

Months 4-6Months 4-6 Months 7-12Months 7-12 Months 4-6Months 4-6 Months 7-12Months 7-12

LapseLapse LapseLapse prpr prpr

Positive consequencePositive consequence **** **** -.47**-.47** -.29*-.29*

Negative Negative consequenceconsequence

**** **** -.31*-.31* -.15-.15

Mastery messagesMastery messages **** ** -.42**-.42** -.27*-.27*

Distracting thoughtsDistracting thoughts nsns **** -.26*-.26* -.37**-.37**

Challenge the Challenge the thoughtsthoughts

** ** -.24*-.24* -.32**-.32**

Think about treatmentThink about treatment nsns ** -.13-.13 -.28*-.28*

*p < .01; **p < .001

USS – Cognitive, BehavioralUSS – Cognitive, Behavioral



Alternative behaviorAlternative behavior **** **** -.33**-.33** -.33**-.33**

Solve the problemSolve the problem ** **** -.30*-.30* -.34**-.34**

Think through behavior Think through behavior chainchain

**** **** -.21-.21 -.37**-.37**

Refuse the drinkRefuse the drink **** ** -.21-.21 -.35**-.35**

*p < .01; **p < .001

USS – Behavioral, OtherUSS – Behavioral, Other



EscapeEscape nsns ** -.25*-.25* -.32*-.32*

Delay, wait it outDelay, wait it out nsns ** -.25*-.25* -.23-.23

Other social supportOther social support **** ** -.21-.21 -.31*-.31*

Spiritual copingSpiritual coping ** ** -.21-.21 -.15-.15

*p < .01; **p < .001

GSA - CognitiveGSA - CognitiveMonths 4-6Months 4-6 Months 7-12Months 7-12 Months 4-6Months 4-6 Months 7-12Months 7-12


Positive consequence Positive consequence **** **** -.50**-.50** -.46**-.46**

Remind self soberRemind self sober **** **** -.43**-.43** -.49**-.49**

Challenge thoughtsChallenge thoughts ** **** -.34**-.34** -.41**-.41**

Negative consequenceNegative consequence ** nsns -.27*-.27* -.24*-.24*

Think about treatmentThink about treatment ** **** -.25*-.25* -.30**-.30**

Spiritual focusSpiritual focus ** ** -.25*-.25* -.21-.21

*p < .01; **p < .001

GSA - BehavioralGSA - Behavioral



Sober good timeSober good time **** **** -.47**-.47** -.49**-.49**

Work toward future Work toward future goalsgoals

**** **** -.40**-.40** -.45**-.45**

Other social supportOther social support **** ** -.36**-.36** -.26*-.26*

Work on problems Work on problems regularlyregularly

**** ** -.30*-.30* -.18-.18

Tell others soberTell others sober **** ** -.29*-.29* -.17-.17

*p < .01; **p < .001

GSA – Behavioral, OtherGSA – Behavioral, Other



Keep busyKeep busy nsns ** -.40**-.40** -.39**-.39**

Eat, sleep, healthy Eat, sleep, healthy behaviorbehavior

nsns ** -.39**-.39** -.30**-.30**

Talk over feelingsTalk over feelings **** nsns -.31**-.31** -.25*-.25*

Avoid tempting Avoid tempting situationssituations

nsns nsns -.27*-.27* -.32**-.32**

Relax or meditate Relax or meditate regularlyregularly

** nsns -.16-.16 -.26*-.26*

*p < .01; **p < .001

SummarySummary

Top 5 situation-specific coping strategiesTop 5 situation-specific coping strategies Positive consequence thoughts, mastery messages, Positive consequence thoughts, mastery messages,

alternative behaviors, problem solving, think through alternative behaviors, problem solving, think through a behavior chaina behavior chain

Top 5 general lifestyle coping strategiesTop 5 general lifestyle coping strategies Positive consequence thoughts, remind self that you Positive consequence thoughts, remind self that you

are sober, challenge thoughts about drinking, sober are sober, challenge thoughts about drinking, sober good time, work toward future goalsgood time, work toward future goals

ConclusionsConclusions

Improve treatment by:Improve treatment by: Teaching situation-specific AND general Teaching situation-specific AND general

lifestyle coping skillslifestyle coping skills Emphasizing strategies that are more Emphasizing strategies that are more

effectiveeffective Eliminating skills that are ineffectiveEliminating skills that are ineffective

(Dolan et al., in preparation)

Hypothetical PatientHypothetical Patient

Bill is a 50 year-old male veteran who Bill is a 50 year-old male veteran who presents for treatment of his “excessive presents for treatment of his “excessive drinking”drinking”

Self-reported alcohol consumption Self-reported alcohol consumption escalated to a fifth of vodka per night for escalated to a fifth of vodka per night for 7 months, following his divorce7 months, following his divorce

Hypothetical Patient - Hypothetical Patient - contcont

He has started getting into trouble at He has started getting into trouble at work, and his grown children “don’t seem work, and his grown children “don’t seem to know who he is anymore” because of to know who he is anymore” because of his behaviorhis behavior He used to be a very organized person and He used to be a very organized person and

now his apartment is a mess and he isn’t now his apartment is a mess and he isn’t able to get his bills paid correctlyable to get his bills paid correctly


He successfully completes detoxHe successfully completes detox On Day 1 of Intensive Outpatient On Day 1 of Intensive Outpatient

Treatment, he appears to have some Treatment, he appears to have some difficulty comprehending the structure of difficulty comprehending the structure of the treatment program, and he asks the treatment program, and he asks repetitive questionsrepetitive questions


A neuropsychological evaluation reveals A neuropsychological evaluation reveals that he has memory and executive that he has memory and executive dysfunctiondysfunction Very typical profile for alcohol-related Very typical profile for alcohol-related

neuropsychological dysfunctionneuropsychological dysfunction

What do we do to maximize treatment What do we do to maximize treatment benefit for this patient?benefit for this patient?

Factors that Might Influence Factors that Might Influence Treatment OutcomeTreatment Outcome

Treatment-specific variablesTreatment-specific variables Length and type of treatment Length and type of treatment

Individual differences Individual differences Severity of dependenceSeverity of dependence Presence of comorbid psychiatric disordersPresence of comorbid psychiatric disorders Personality factorsPersonality factors Anger level Anger level

(Project MATCH, 1997)

Patient-Treatment Patient-Treatment MatchingMatching

ComorbidityComorbidity Mood, anxiety disordersMood, anxiety disorders PTSDPTSD Medical conditionsMedical conditions

Factors that May Influence Treatment Outcome

What about neuropsychological function? Do these patients have the cognitive

capacity to participate in treatment aimed at changing thoughts and behaviors related to their substance use disorder? I.e., Are their brains intact enough to learn,

process, and apply new relapse-prevention skills?

MethodsMethods ParticipantsParticipants

Substance dependent individuals (n=20) from a Substance dependent individuals (n=20) from a local state-funded residential treatment programlocal state-funded residential treatment program Clean for > 21 daysClean for > 21 days

ProceduresProcedures Diagnostic interview (r/o psychotic disorder)Diagnostic interview (r/o psychotic disorder) QuestionnairesQuestionnaires Neuropsychological batteryNeuropsychological battery Coping Skills assessmentCoping Skills assessment

5757

Neuropsychological Neuropsychological BatteryBattery

Baseline IQBaseline IQ Verbal learning, memoryVerbal learning, memory WAIS-IIIWAIS-III

Attention, working memoryAttention, working memory Speeded information processingSpeeded information processing Visuospatial functioningVisuospatial functioning

5858

Block DesignBlock Design(visuospatial function)(visuospatial function)

5959

Neuropsychological Neuropsychological Battery (con’t)Battery (con’t)

Executive functioningExecutive functioning Wisconsin Card Sorting Test (Set-shifting, Wisconsin Card Sorting Test (Set-shifting,

working memory, responsiveness to working memory, responsiveness to feedback, cognitive flexibility)feedback, cognitive flexibility)

Trailmaking Test A&B (Visual scanning, Trailmaking Test A&B (Visual scanning, attention, cognitive flexibility)attention, cognitive flexibility)

Controlled Oral Word Association (verbal Controlled Oral Word Association (verbal fluency)fluency)

Stroop Color Word TestStroop Color Word Test6060

Trail Making Test Part BTrail Making Test Part B

Wisconsin Card Sorting TestWisconsin Card Sorting Test

Stroop Color Word TestStroop Color Word Test

6363

ResultsResults

6464

Results – Coping SkillsResults – Coping Skills

6565

Results – Relationship Results – Relationship Between Coping Skills Between Coping Skills and NP Measuresand NP Measures

6666

Results – NP Impairment Results – NP Impairment StatusStatus

6767

Study #2Study #2 More fine-grained analysis of executive More fine-grained analysis of executive

functioningfunctioning N=49N=49 Neuropsychological Battery:Neuropsychological Battery:

Verbal FluencyVerbal Fluency Trailmaking TestTrailmaking Test Wisconsin Card Sorting TestWisconsin Card Sorting Test Color-Word Interference (Stroop)Color-Word Interference (Stroop) Iowa Gambling TaskIowa Gambling Task Tower of HanoiTower of Hanoi

6868

Iowa Gambling TaskIowa Gambling Task

6969

Tower of HanoiTower of Hanoi

7070

DemographicsDemographics

Mean / Frequency SD

Age 32.06 10.01

Gender 46% M

Education 12.17 2.03

Daily Alcohol Intake 7.23 23.97

Prior Treatment Attempts 2.33 2.89

Sobriety Length 54.53 53.71

Contemplation Ladder 9.21 1.75

SETOT 88.44 35.19

SOTOT 87.24 32.14

VF 9.4 3.4

VF Letter vs. Category 9.3 3.0

7171

Verbal Fluency and Verbal Fluency and Coping SkillsCoping Skills

SETOT SOTOT Number of USC-E skills >4

GETOT GOTOT

VF - Letter -.25* -.30** -.24* ns ns

VF – Letter vs. Category

-.33** -.31** -.23* -.25* -.27*

7272

Clinical ImplicationsClinical Implications

Patient – Treatment MatchingPatient – Treatment Matching Pre-treatment neuropsychological assessmentPre-treatment neuropsychological assessment

Target skills to individual patient’s neuropsych profileTarget skills to individual patient’s neuropsych profile

Reduction in number of skills taught in CBTReduction in number of skills taught in CBT Behavioral possibly better than cognitive focusBehavioral possibly better than cognitive focus

Extensive repetitionExtensive repetition Extra role-playsExtra role-plays

Cognitive RehabilitationCognitive Rehabilitation A la TBI, schizophrenia A la TBI, schizophrenia

7373

Cognitive RehabilitationCognitive Rehabilitation

Computer-assisted cognitive stimulation Computer-assisted cognitive stimulation exercises may increase speed of exercises may increase speed of cognitive recoverycognitive recovery This may then improve treatment process This may then improve treatment process

and outcomeand outcome

However, time- and cost-intensiveHowever, time- and cost-intensive

(Grohman et al., 2003)(Grohman et al., 2003)

AcknowledgementsAcknowledgements

Grant SupportGrant Support Baylor University Baylor University

Research CommitteeResearch Committee NIAAA T32 (Brown NIAAA T32 (Brown

University; mentors: University; mentors: Damaris Rohsenow, Damaris Rohsenow, Ph.D. and Paul Malloy, Ph.D. and Paul Malloy, Ph.D.)Ph.D.)

StudentsStudents Graduate: Robyn Graduate: Robyn

Baldridge, Sarah Baldridge, Sarah Martindale, Laura Sejud, Martindale, Laura Sejud, Sean McGowan, Anthony Sean McGowan, Anthony GiardinaGiardina

Undergraduate: Sanja Undergraduate: Sanja TrtanjTrtanj

7575

Documents

The Role of Cognitive Function in Substance Abuse Treatment Sara L. Dolan, Ph.D. Baylor University Department of Psychology and Neuroscience Baylor Addiction