assessing the patient in context: determining neurocognitive … · ü detox effect within 1st two...
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Assessing The Patient In Context: Determining Neurocognitive and Personality
Profiles Associated With Substance Abuse
LauraNa'a,Ph.D.DirectorofNeuropsychological&ComprehensiveDiagnos=cAssessmentProgram
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ALTA MIRA
Disclosures
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Background
• Substanceusedisorderscon=nuetobeamajorhealthconcernintheUnitedStatesandCanada
• Specificcausalfactorsandeffec=vetreatmentscon=nuetobema'ersofgreatdebate.
• Co-occurringsubstanceuse/mentalhealthdisordersareresponsibleforagreatdealofthecurrentpublichealthcrisis,causingmental,physicalandemo=onaldamagetothepa=entaswellastheirfamilyandfriends.
• Thefrequentpresenceofcomorbidpsychological,socialandmedicaldisordersforsomeareaprecursortothesubstanceabuseandforothersarearesultofit
Importanttolookatsubstanceusedisorderincontext-alongwiththepsychologicaldisorder-toinformtreatmenttherebymaximizingsuccessful
outcomes.
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Comprehensive Diagnostic Assessment – What?
• Oneofthefirststepstowardaproperdiagnosisandsuccessfultreatment.
• Effec=velyinformingtreatment.• Neurocogni=veandpersonalityprofilesassociatedwith
substanceabuse• Psychodiagnos=cprofileinfluencesthepa=ent’scogni=on• Treatmentandimplica=onsforrelapse.
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Comprehensive Diagnostic Assessment – Why?
Mostpeopleseekingaddic=ontreatmenthaveco-occurringdisorderssuchasanxiety,depression,ortraumathatneedtobeaddressedinordertosustainlong-termrecovery
ü TBIü Demen=aü Strokeü Depressionü Traumaü Anxiety
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Comprehensive Diagnostic Assessment – How?
Ø Psychodiagnostic Ø Personality Ø CognitionØ Mood and Emotional functioningØ Trauma AssessmentØ Symptom SeverityØ Crisis AssessmentØ Interest Assessment
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Comprehensive Diagnostic Assessment
1. Properlydiagnoseandtreatanextensiverangeofillnessesanddisordersthatmaybecontribu=ngtosubstanceuse
2. Createamedica=onstrategybasedonempiricalevidenceandmakeappropriateadjustmentsduringcourseoftreatment
3. Iden=fyandworkoninterpersonalissuesthatmightotherwisecompromisetreatment
4. Informongoingtreatmentusingobjec=vedataforbe'ertreatmentadherence,complianceandefficacy
5. Informrelapsepreven=onplanandgivepa=enttoolstoreducerelapseriskandmakeplausible,informedreferralsandrecommenda=ons
6. Presentpa=ent/referent/clinicianwithtangibledatatobe'erunderstandpa=ent’sillnessandrecovery
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Why Doesn’t Everyone Use Assessment?
1. Expensive2. Time
3. Complex
4. Popula=on5. Individualdifferences6. Thought“Notthepoint.”
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Neuropsychological Evaluation
• IntellectualFunc=oning• AcademicSkills• A'en=onandConcentra=on• ProcessingSpeed• LearningandMemory• ConceptualandProblemSolvingCapacity• Language• Visuospa=alabili=es• Sensory-Perceptualfunc=oning• Motorperformance
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Personality Testing
• Emo=onaladjustmentandresilience• PersonalityStyle• Constructssuchas:
– Interpersonalfunc=oning– Anger/Hos=lity– Cynicism– Depression
(MMPI-2,MCMI-III,SDIP-IV,Rorschach,TATetc.)
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Psychodiagnostic Testing
• Self-reportmeasures• Interviews(SCID5,MINI)• SpecialtyInterviews(Y-BOCS,ProdromalQues=onnaire)InventoryofsymptomsCriteriafordiagnosisAidsinlookingatsymptomoverlapGivessomeinsightintocogni=on
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• Presentation with cognitive symptoms such as loss of memory and vagueness, as well as prominent slowing of movement and reduced or slowed speech that is due to depression, not dementia
• Although cognitive symptoms are seen to improve with treatment of depression…
• On follow-up, most patients develop further cognitive decline over time, and are diagnosed with an irreversible dementia
Cognitive Deficits Due to Depression “Pseudodementia”
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• In most cases the dementia is real and likely to persist or progress despite the treatment of depression
• Patients with dementia should still be screened and treated for depression
• Successful treatment of depression may not reverse the dementia but may improve function and quality of life
• Truly reversible causes of dementia are much more rare than previously thought
• Depression is less likely an imitator of dementia than a predictor of dementia in later life
Cognitive Deficits Due to Depression “Pseudodementia” (cont’d)
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Differential Diagnosis: Depression vs. Dementia
Criterion Depression Demen>a
Dura=on Atleast2weeks,some=mesmonths Monthstoyears
Mood/Affect Depressedmood,anhedonia Disinterested,detachedPsychomotorSpeedMental&physicalslowing Normaltomildlyslow
A'en=on Borderlineselec=vea'en=on,difficultywithcomplexa'en=on
Normaltomildlyabnormalun=llateincourse
Memory Mildimpairment,memoryretrievaldifficulty
Abnormal,amnes=cpa'erninmostcases
Speech/language Decreasedamountofspeech Anomicaphasia,emptyorsparsecontent
Othercogni=on Difficultywithefforgultasks Mul=plecogni=vedeficits
Otherbehavior Indecisive,delusionsandotherpsychiatricsymptoms
Psychiatricsymptomsmaybepresent,usuallylessprominent
Physicalsymptoms Lackofenergy,sleepandappe=tedisturbances
Usuallynoneun=lmiddleorlatestages
18
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Schizophrenia - General and Specific Cognitive Deficits
• There are deficits spanning all aspects of cogni=on rela=ve to healthycontrol.
• There is a varia=on in the extent of involvement across domains withevidence from mul=ple studies suggested thatmemory and execu>vefunc>ons are the two domains most likely to show differen=alimpairment.
• Mostcommoncogni=veimpairmentsfoundinpa=entswithschizophreniaarethoseofa@en>on,memoryandexecu>vefunc>ons.
• Average cogni=ve impairments for pa=ents with schizophrenia in thesecogni=vedomainreach2SDbelowthatofhealthycontrol.
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General and Specific Deficits
• Rather than localized cogni=ve deficit, illness shows amorewidespreadneuropsychologicaldysfunc=on.(Buchbaum,1990)
• Selec=vity of cogni=ve deficits occurs against background of generalimpairment, with even the less sensi=ve tasks.(Heinrichs and Zakzanis,1998)
• Cogni=ve domains of IQ, memory, language, a'en=on and execu=vefunc=on-consistenttrendofpoorperformance.(Fioravan=etal2005)
• Confirmatoryfactoranalysisofvariouscogni=vefunc=onsreflectedmoregeneralizedcogni=vedisability.(Dickinsonetal2006)
• Social Cogni=on also is seen to suffer and this decline has treatmentimplica=ons.
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Assessment of Substance Abuse Patients
Wetendtowanttoanswertheclient’sques=ons:“WhatdidIdo?WhatdamagedidIdotomybrain?”ClassicAnswer:NeuropsychologicalImpairmentduetoabuseof__________
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The Brain Needs Time
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Ask Questions Outside The Box
WhataretheeffectsofACUTEuse,CHRONICuseandRESIDUALUseonneuropsychologicalperformance?Whereismyclient’scogni=onnow?Willtheyclear---andwhen?HowfastcanIgo?Whydon’ttheyseemtounderstandme?HowamInotmatchingmytreatmenttotheirabili=es?Whataretheyabletodo?Whatarereasonableexpecta=ons?
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What Are We Going to Do with Them after Treatment?
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Alcohol Use – Acute Effects
AcuteEffects:• Heartrate–BP• Disinhibi=on• Balanceinstability• Slowedpsychomotor,cogni=veandsensoryinforma=onprocessing
ü Depressant–CNS–lookslikepa'ernoftranquilizerandhypno=cdeficits
ü Deficitstendtocorrelatewithintakequan=ty,dura=onandage(began)
ü Pa'ernsareimportant(bingevs.heavychronicuse)ü Posi=verela=onshipbetweenamountandfrequencyof
consump=onandcogni=vedeficits
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Alcohol – Chronic Use
ChronicUsed/oü Varia>onsinmedicalriskfactors,sexdifferences,family
history,ageDeficits:• Complexvisuospa=alability• Psychomotorspeed• Learnedskills• Short-termrecall• Subtledeficitsinconceptforma=onandmentalflexibility
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Alcohol – Residual Effects
ü Detoxeffectwithin1sttwoweeks-allcogdomainsü 4weeksto8weeksimprovementsü Months–mostshowimprovement.Howmuchiscorrelatedwithindividual
differences.Long-termMRIsshowpermanentdamage.ü Agemakesreversibilitylessobvious
Execu=veFunc=ons• Problemsolving,decision-making,workingmemory,sequencing,• Shortterm,explicitanddeclara=vememory(mildtoanterogradeamnesia)• Visuospa=alprocesses• Balanceandgait,processingspeed(Canlastupto1year)(Fein&Greenstein,2013)• Affec=veComprehension(Monnotetal.,2002)
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Cocaine - Acute
ü Deficitsrela=vetoamountofuse,yearsofuseanddura=onofabs=nence
ü CTScanatrophy–evidenceofwhitema'erlesionsü Highcorrela=onwithstroke
• Disinhibi=on• Impulsivity• IncreasedHR/BP• Enhancelearningand/ora'en=on(NIMH,2010)
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Prolonged Use Changes
the Brain in
Fundamental and Lasting
Ways “Healthy” Brain
“Cocaine Addict” Brain
Addiction is a Brain Disease
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Deficits Chronic Cocaine
• Memoryandconcentra=on• Execu=vefunc=oning(workingmemory,inhibi=on,set-shiqing)• A'en=onspanandVigilance• MemoryimpairmentsSp.(verballearningandmemory)(Foxetal.,2009)
(Recrea=onalusersdisplaydeficitsofpoorerlearningandrecogni=onaccuracy)
• Decreasedmentalflexibility(Kelleyetal.,2005)• Emo=onrecogni=on(Fernando-Serranoetal.,2010)associatedwith
cumula=velevelsofexposure.• Narrowerabilitytoexperienceemo=onsimpliedinresearchbutnot
validated.Neurocogn=veeffects=dosespecificandpersistentevenaqersixmonthsofabs=nence
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Residual Effects of Cocaine Use
ü Subtleandspecificvs.Generalü Execu=vefunc=oning(a'n.planningmentalflexibility)
ü A'en=on,reasoning,spa=alplanning–bestindicatorsoftreatmentoutcome
ü Changesinaffectandpersonality–someshortlivedandsomepermanentASPDandBPD(associatedwithpoorercogni=vefunc=on–frontallobedysfunc=on)
ü Depression(duringwithdrawal–associatedwithcogni=vedeficits)
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Cocaine Phenomena
1. Heavycocaineusersmayshowpersistentchangesinbrainmetabolismwithnodetectableeffects
AlternateneuralsubstratesareusetoperformtaskPowerandsamplesizeofstudies
2. ETOHandCocaine–moststudiesfoundthatmostcommonShortandlong-termmemoryandvisualmotorfunc=onsNotanyworsethanseparateuse(Penningsetal.,2002)
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Opiates - Acute
ü Mentalandphysical“sluggishness.”CanbeseeninEEGslowingü Personalneglectü Fewstudiesdocumen=ngcogni=veeffectsofacuteuse
Non-Drug-AbusingPa=entsReducevisualacuityandincreaseperceptualimpairment(Zacnyetal.,2011)Slowmotorperformanceanddecreasedprocessingspeed(Zacnyetal.,2011)Focuseda'en=onimpaired,whilesustainedanddivideda'en=onsparedMentalflexibilityNon-dependentUsersPerceptualspa=alPsychomotorSpeed
Withincreasingopioidtoleranceanddependence,cogni=onappearstobeunaffectedun=limpairedbyhigherdoses
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Opiates – Residual
• Mentalflexibility,a'en=onandabstractreasoningreturnedtobaseline(non-user)levelsaqerabs=nence,howeverimpulsivityremainedatadeficitcomparedtocontrolgroup(Pavetal,2001)
• Overall–Long-termopiateusedoesnotseverelyimpaircogni=vefunc=oning
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Meth Cognitive Dysfunction and Change
ü Frontalcortex,cingulatecortexandmedialtemporallobe–lossofgreyma'er
ü Approximately50%enteringtreatmentsufferfromcerebral(cogni=ve)dysfunc=on– Lesslikelytoa'endcon=nuingcare– Lesslikelytobeemployed– Oqenmistakenasresistantorunmo=vated– Lessabletoabsorbinforma=on
ü S=mulantaddictslookliketheyhavedegenera=vebraindiseaseü Damagingeffectsonnervoussystem
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Methamphetamine – Acute
• Aggression• Euphoria• Decreasedanxiety• Irritability,anxiety,hallucina=ons,compulsivity,paranoia(bingeandheavyuse)(Sempleetal.2003)
• A'en=on• Memory• Impulsivity• Motorfunc=oning
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Meth - Chronic
Execu=ve&visuospa=alfunc=oningproblemsinclude:– LearningandMemory– Abstrac=on– Problemsolving– Cogni=veOrganiza=on– PsychomotorandProcessingSpeed– Cogni=veflexibility(WisconsinCardSor=ngTest,TrailsB)– Planning– ResponseInhibi=on(Color-WordInterferenceTest)– SocialCogni=on
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Methamphetamine Residual
• PoorerPerformanceacrosstheBoard–differentfromothers=mulants• Longterms=mulantabusecausesdamagetodopamineproducingcells
andleadstoreducedlevels• S=mulantaddictsmaysufferfrompoora'en=onandcompromisedfine
motorskills• SocialCogni=on• Execu=veFunc=onimprovesaqer2weeks(Chouetal.,2007)• Motorskills,processingspeed,verbalmemory(9+months)(Ludicelloetal.
2010)• Somecogni=vedeficitsmaypersistevenaqerlongerperiods–execu=ve
func=oning,a'en=on,strategiccomponentsofencoding(Ludicelloetal.2010)
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Methamphetamine Residual
• Globalfunc=onalimpairmentinmanycases• IADLS• Financialmanagement• Unemployment• DeficitsinProspec=vememory–poorcompliance
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Marijuana
ü Posi=velyCorrelatedwithpsychosis,depression–evenwithnopriorhistory
ü Otherdrugs(ETOH,cocaine,meth,reducedcerebralbloodflowseenonfrontal,limbic,cerebralregions)Marijuana=orbitalandmesialfrontalinsula,temporalanteriorcingulateandcerebellum
ü Subjec=vedoesn’tmatchobjec=vereportsduringacutephase–a'en=on,well-establishedmemories
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Marijuana - Acute Effects
ü Acutehallucinatoryandreac=veemo=onalstates(Brust,2000).ü Manyacuteeffectsaredosedependent.Severalresolveaqer
habitua=on.Disorienta=onto=meTransientmemorylossA'en=on(selec=veandsustained)impairment–althoughmayresolveifindividualhabituatesSlowedvisualprocessingWorkingmemoryProcessingspeed
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Marijuana - Long term Effects
• Researchismixed,butmagnitudeandpersistenceofimpairmentsvarywithquan=ty,frequency,dura=onofuseandageofonset.
• Observedimpairmentsweresevereandlong-las=nginthosewithmorefrequentandprolongedheavyuseandyoungerageoffirstuse(Kyprianidou,Malefaki&Papthanasopoulos,2006).Difficulttoascertainbecausepriortes=ngnotavailable.Thiswastrueforexecu=vefunc=oning,processingspeed.
• Researchindicatethatdeficitscouldbeexpectedtoresolveinhealthyadultsamples(Schreiner&Dunn).
• Everydayissuesreportedincludeinternallycuedprospec=vememory,drivingdecrements,concentra=on.
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Drugs Have Long-term Consequences
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Using Assessment During Treatment
• Impulsivityanddeficitsinexecu=vefunc=ons–informmodalityoftreatmentusedtotreat
• Currentevidence-basedprac=cestaxhigher-orderfunc=ons(planning,flexibility,learning,memory)
• Posi=vetreatmentoutcomesrelyonbehaviorchangeandimplementa=onofnewskills(Batesetal.,2013)
• Pa=entswithcogni=vedeficitscanbeseenashavinglowermo=va=onandgreaterdenial(Goldman,1995)
• Pa=entsgetafeelingof“Iwillnevergetthis!”contribu=ngtononcompliancewithtreatment(Weinstein&Schaffer,1993)
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• Increasereten=on,cut-downondrop-outsandlowerrelapserates(Smith,McCrady,1991).
• Visual-Spa=alcaninformre:cogni=veorganiza=on• A'en=oninformsscheduling• Trackingimprovementsincogni=onthatoccurwithsustained
abs=nencecanbeapowerfulmo=va=onaltool–andcaninformthenextcliniciantotreat.
• Pa=entsneedtoknowthatrelapseisassociatedwithACCELERATEDnega=vechangestobrainhealthandcogni=on(Loeberetal.,2010)
Using Assessment During Treatment cont’d.
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Using Assessment for Relapse Prevention
• Substancemostdisrup=ngeffects–prefrontalcortexdysfunc=on–problemswithexecu=vefunc=onandinhibitoryresponse
• MemoryImpairment(includingprospec=vememoryimpairment–memoryneededtoplanandcarryoutfutureac=ons)(Ellis,1996).
• Cogni=veimpairmentmaycontributetothefailuretoregulatesubstanceabuseinthemomenteveninthefaceofreal,nega=veconsequences.
• Associatedwithreducedtreatmentreten=onandcompliance,reducedself-efficacy,whichin-turnpredictedlesssuccessfuloutcomesaqertreatment(Bates,etal.,2006)
• Examples:AAinvolvement,SocialNetworks
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ALTA MIRA
Assessment and Relapse Prevention
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Cognitive Dysfunction and Change
Recoveryinneuropsychologicalfunc=oning
– Mostoftreatmentisduring=meofgreatestdysfunc=on
– Recoveryis:• Time-dependent
– Duetosustainedabs=nence• Experience-dependent
– Ac=verehabilita=onorrepe==vebehavior
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Cognitive Rehabilitation
• Repe==verecovery-orientedbehaviors
• Repe==verecovery-orientedthoughts
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Suggestions
• Repe==on• Mul=-modallearning• MemoryAids• Self-efficacytraining(e.g.workingmemorytraining)• Consulta=on
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Questions?