Assessing The Patient In Context: Determining Neurocognitive and Personality

Profiles Associated With Substance Abuse

LauraNa'a,Ph.D.DirectorofNeuropsychological&ComprehensiveDiagnos=cAssessmentProgram

ALTA MIRA

Disclosures

Background

•  Substanceusedisorderscon=nuetobeamajorhealthconcernintheUnitedStatesandCanada

•  Specificcausalfactorsandeffec=vetreatmentscon=nuetobema'ersofgreatdebate.

•  Co-occurringsubstanceuse/mentalhealthdisordersareresponsibleforagreatdealofthecurrentpublichealthcrisis,causingmental,physicalandemo=onaldamagetothepa=entaswellastheirfamilyandfriends.

•  Thefrequentpresenceofcomorbidpsychological,socialandmedicaldisordersforsomeareaprecursortothesubstanceabuseandforothersarearesultofit

Importanttolookatsubstanceusedisorderincontext-alongwiththepsychologicaldisorder-toinformtreatmenttherebymaximizingsuccessful

outcomes.

Comprehensive Diagnostic Assessment – What?

•  Oneofthefirststepstowardaproperdiagnosisandsuccessfultreatment.

•  Effec=velyinformingtreatment.•  Neurocogni=veandpersonalityprofilesassociatedwith

substanceabuse•  Psychodiagnos=cprofileinfluencesthepa=ent’scogni=on•  Treatmentandimplica=onsforrelapse.

Comprehensive Diagnostic Assessment – Why?

Mostpeopleseekingaddic=ontreatmenthaveco-occurringdisorderssuchasanxiety,depression,ortraumathatneedtobeaddressedinordertosustainlong-termrecovery

ü TBIü Demen=aü Strokeü Depressionü Traumaü Anxiety

Comprehensive Diagnostic Assessment – How?

Ø  Psychodiagnostic Ø  Personality Ø  CognitionØ  Mood and Emotional functioningØ  Trauma AssessmentØ  Symptom SeverityØ  Crisis AssessmentØ  Interest Assessment

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

Why Doesn’t Everyone Use Assessment?

1. Expensive2. Time

3. Complex

4. Popula=on5. Individualdifferences6. Thought“Notthepoint.”

Neuropsychological Evaluation

•  IntellectualFunc=oning•  AcademicSkills•  A'en=onandConcentra=on•  ProcessingSpeed•  LearningandMemory•  ConceptualandProblemSolvingCapacity•  Language•  Visuospa=alabili=es•  Sensory-Perceptualfunc=oning•  Motorperformance

Personality Testing

•  Emo=onaladjustmentandresilience•  PersonalityStyle•  Constructssuchas:

–  Interpersonalfunc=oning–  Anger/Hos=lity–  Cynicism–  Depression

(MMPI-2,MCMI-III,SDIP-IV,Rorschach,TATetc.)

Psychodiagnostic Testing

•  Self-reportmeasures•  Interviews(SCID5,MINI)•  SpecialtyInterviews(Y-BOCS,ProdromalQues=onnaire)InventoryofsymptomsCriteriafordiagnosisAidsinlookingatsymptomoverlapGivessomeinsightintocogni=on

•  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”

•  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)

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

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.

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.

Assessment of Substance Abuse Patients

Wetendtowanttoanswertheclient’sques=ons:“WhatdidIdo?WhatdamagedidIdotomybrain?”ClassicAnswer:NeuropsychologicalImpairmentduetoabuseof__________

The Brain Needs Time

Ask Questions Outside The Box

WhataretheeffectsofACUTEuse,CHRONICuseandRESIDUALUseonneuropsychologicalperformance?Whereismyclient’scogni=onnow?Willtheyclear---andwhen?HowfastcanIgo?Whydon’ttheyseemtounderstandme?HowamInotmatchingmytreatmenttotheirabili=es?Whataretheyabletodo?Whatarereasonableexpecta=ons?

What Are We Going to Do with Them after Treatment?

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

Alcohol – Chronic Use

ChronicUsed/oü  Varia>onsinmedicalriskfactors,sexdifferences,family

history,ageDeficits:•  Complexvisuospa=alability•  Psychomotorspeed•  Learnedskills•  Short-termrecall•  Subtledeficitsinconceptforma=onandmentalflexibility

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)

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)

Prolonged Use Changes

the Brain in

Fundamental and Lasting

Ways “Healthy” Brain

“Cocaine Addict” Brain

Addiction is a Brain Disease

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

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)

Cocaine Phenomena

1.  Heavycocaineusersmayshowpersistentchangesinbrainmetabolismwithnodetectableeffects

AlternateneuralsubstratesareusetoperformtaskPowerandsamplesizeofstudies

2.  ETOHandCocaine–moststudiesfoundthatmostcommonShortandlong-termmemoryandvisualmotorfunc=onsNotanyworsethanseparateuse(Penningsetal.,2002)

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

Opiates – Residual

•  Mentalflexibility,a'en=onandabstractreasoningreturnedtobaseline(non-user)levelsaqerabs=nence,howeverimpulsivityremainedatadeficitcomparedtocontrolgroup(Pavetal,2001)

•  Overall–Long-termopiateusedoesnotseverelyimpaircogni=vefunc=oning

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

Methamphetamine – Acute

•  Aggression•  Euphoria•  Decreasedanxiety•  Irritability,anxiety,hallucina=ons,compulsivity,paranoia(bingeandheavyuse)(Sempleetal.2003)

•  A'en=on•  Memory•  Impulsivity•  Motorfunc=oning

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

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)

Methamphetamine Residual

•  Globalfunc=onalimpairmentinmanycases•  IADLS•  Financialmanagement•  Unemployment•  DeficitsinProspec=vememory–poorcompliance

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

Marijuana - Acute Effects

ü  Acutehallucinatoryandreac=veemo=onalstates(Brust,2000).ü Manyacuteeffectsaredosedependent.Severalresolveaqer

habitua=on.Disorienta=onto=meTransientmemorylossA'en=on(selec=veandsustained)impairment–althoughmayresolveifindividualhabituatesSlowedvisualprocessingWorkingmemoryProcessingspeed

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.

Drugs Have Long-term Consequences

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)

•  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.

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

ALTA MIRA

Assessment and Relapse Prevention

Cognitive Dysfunction and Change

Recoveryinneuropsychologicalfunc=oning

–  Mostoftreatmentisduring=meofgreatestdysfunc=on

–  Recoveryis:•  Time-dependent

–  Duetosustainedabs=nence•  Experience-dependent

–  Ac=verehabilita=onorrepe==vebehavior

Cognitive Rehabilitation

•  Repe==verecovery-orientedbehaviors

•  Repe==verecovery-orientedthoughts

Suggestions

•  Repe==on•  Mul=-modallearning•  MemoryAids•  Self-efficacytraining(e.g.workingmemorytraining)•  Consulta=on

Questions?