Cognitive rehabilitation in addictive disorders.

Substance use disorders are frequently associated with neuropsychological deficits. A comprehensive assessment of attention, memory, executive functions, language and mental speed is often warranted. Cognitive rehabilitation is a therapy programme designed as an intervention to help people with cognitive, behaviour and emotional deficits. Using systematic approaches such as cognitive retraining and EEG neurofeedback, the individuals are helped to be integrated into society.

INTRODUCTION

The aftermath of addictive disorders is devastating and one of the fallouts of extended substance use is the development of cognitive deficits. Unfortunately, the advent of these impairments creates a downward spiral, making it harder for the person with addiction to make wise choices. Like a moth that cares not if its wings are singed and continues to be enamored by the flame, the addict begins to travel down a dangerous path of self-destruction.

“The Moth don't care when he sees The Flame.

He might get burned, but he's in the game.

And once he's in, he can't go back, he'll

Beat his wings ‘til he burns them black.

No, The Moth don't care when he sees The Flame…”

~ Aimee Mann

Neuropsychological Assessment in addictive disorders

One of the most important pre-requisites for a good cognitive rehabilitation programme is a comprehensive neuropsychological assessment. A neuropsychological assessment is a performance-based method to assess cognitive functioning which has been used to examine the cognitive consequences of brain damage, brain disease and severe mental illness1. Some of the cognitive deficits commonly seen in addictive disorders include impairments of attention, memory, executive and visuo-spatial functions23. Prolonged exposure to the substance results in progressive damage to the brain which may even lead to dementia like neuropsychological profiles4. Neuropsychological assessments typically include tests of attention, mental speed, executive functions, language, learning and memory as well as visuo-spatial functions. The value of the neuropsychological assessment cannot be over emphasized as it forms the basis of designing the cognitive rehabilitation program. Domain specific tasks and treatment protocols are chosen based on the neuropsychological profile of the patient with substance use. In India, The NIMHANS Neuropsychology Battery (2004) is extensively used in conjunction with other tests5. This battery was standardized on the Indian population between the ages 16 to 65 years for literates and illiterates. The battery contains tests of motor speed, mental speed, focused attention, sustained attention, divided attention, verbal fluency, category fluency, design fluency, working memory, planning, set shifting, response inhibition, verbal comprehension, verbal learning and memory, visual memory and visuo-spatial construction.

Cognitive Rehabilitation

Cognitive rehabilitation is a therapy programme designed as an intervention to help people with cognitive deficits. Cognitive rehabilitation operates on the principle that functions or deficits as a result of substance use can be restored through the brains ability to transform, heal, learn and adapt. The degree to which the improvement in neuropsychological functions is due to spontaneous recovery, abstinence of the substance use or due to the neuropsychological rehabilitation techniques used is still unclear.

Cognitive rehabilitation is a continuous process and should be designed for each person based on the clinical, cognitive and other psychosocial factors impacting the individual's activities of daily living. The process of rehabilitation should be complete and intensive in order help patients return to pre-morbid level of functioning and gainful employment. Follow-up of the patients are vital.

Among individuals with alcohol dependence alone, approximately 50-80% are reported to have alterations in cognition which affect their prognosis and treatment6. The presence of cognitive deficits in substance dependent patients have also been found to be associated with a higher drop-out rate of established treatment programmes78. Thus, the importance of cognitive rehabilitation in a psycho-social rehabilitation programme for individuals with addictions cannot be over-emphasized. In a fast paced world that depends so much on using one's mental faculties to get ahead, cognitive deterioration can leave the already floundering addict in a seemingly hopeless situation.

In the National Institute of Mental Health and Neurosciences (NIMHANS), India, cognitive rehabilitation is carried out in the form of Cognitive retraining and EEG Neurofeedback.

Cognitive retraining

Cognitive retraining is a programme that helps augment and improve cognitive functions such as attention, mental speed, planning, memory etc., Zangwill in 1947, described three processes of rehabilitation. Restitution of a function involves restoration of the lost or impaired function. The Substitution training focuses on the replacement of impaired functions by other strategies that substitute the impaired function and is found to be functional. The third, which is described as compensation involves compensatory mechanisms when the first two approaches cannot be carried out9. Cognitive retraining involves the use of specific programmes used in retraining the brain to recover its lost functions. Some of the retraining programmes used at NIMHANS include letter cancellation, grain sorting, shading, spatial and temporal encoding and working memory tasks such as mental arithmetic. Both home based as well as hospital based tasks have been developed for patients. This training has been found to be useful in improving the deficits of attention, information processing, memory and executive functions. Results of the use of this programme revealed reduction in symptoms, enhancement of cognitive functions and well-being in patients with brain injury101112. Two approaches have been commonly taken with regard to cognitive retraining.

The holistic approach

The holistic approach focuses on involving a multi-disciplinary team in the process of neuropsychological rehabilitation.

This multi-disciplinary team helps the patient to be seen from a bio-psycho-social perspective ensuring that the multiple factors affecting the patient's rehabilitative process are addressed.

A holistic approach to Neuropsychological rehabilitation (Rajeswaran, 2013 p. 47)13

Innovative advances in the field of neuropsychological rehabilitation has led to the development of a new development in technology. EEG Neurofeedback training (NFT).

The Circuitry Approach

The Circuitry approach highlights the interplay between cortical and subcortical circuits in mediating neuropsychological functions. The understanding of the neuro circuitry approach is therefore vital in creating a sound neuropsychological rehabilitation programme as it allows for the development of circuit based cognitive retraining tasks.

Cognitive retraining- A circuitry Approach (Kumar, 2013 p. 114)14

EEG Neurofeedback

Innovative advances in the field of neuropsychological rehabilitation has led to the development of a new advancement in technology. Research by Nowlis and Kamiya in 1963 involved training the subject using verbal reinforcement to recognize alpha wave patterns15. Another significant finding by Sterman and his colleagues was that training used to increase sensori-motor rhythm led to seizure resistance in cats16. These findings are monumental in the area as it brought about the understanding that EEG could be brought under voluntary control and that modification of EEG had therapeutic implications.

Neurofeedback uses operant conditioning to modify brain activity and bring it under voluntary control. The placement of electrodes depends on the International 10-20 system. According to this system each scalp location is given letters and numbers. Based on the treatment protocol, these positions are used to guide placement of electrodes based on which appropriate training is given16.

Dr. Rajeswaran is credited with being the first in the country to bring this treatment modality to India. The following is a case study of a patient with Alcohol dependence syndrome and his experience with Neurofeedback. The patient reported several reasons for his current lapse into drinking. The precipitating factor was the loss of his friend in a drowning accident. This incident also incited severe fear in the patient especially when he found himself alone. He began to avoid large water bodies like rivers or going to beaches. The patient began to use alcohol to cope with this fear and recurrent memories of his friend. The patient's alcohol dependence also affected interpersonal relationships, particularly with his girlfriend. This led to an increase in alcohol consumption. The patient stopped working regularly, had poor social interaction, lack of confidence, decreased sleep and appetite. He had to be admitted against his will by family members.

The patient had been admitted twice in the past and his maximum period of abstinence was two weeks. EEG Neurofeedback training began after the pre-assessment of neuropsychological functions and baseline QEEG recording. The patient attended the sessions regularly. During the third session, the patient broke down and began to cry. This was accompanied by physiological arousal and palpitations, sweating and tremors. He reported memories of his friend's death and loss of relationship with girlfriend. The patient described vivid imagery and feelings associated with painful early experiences. The unlocking of repressed memories is commonly seen in alpha/theta training16. After the fifth session, the patient subjectively reported a reduction in stress levels and an increase in motivation to participate in the EEG Neurofeedback sessions. By the third week, the patient was able to relax and reported an increase in confidence levels as well as a decrease in rumination about his friend as well as girlfriend. During the one month follow up post intervention, the patient had remained abstinent for a month. He had also begun gainful employment as an auto driver again. The patient continued to maintain abstinent 6 months following the intervention, indicating the permanence of the initial gains of the intervention. The following tables reflect the pre to post intervention changes in Patient V.R.

V.R. is a 24 year old unmarried male, who completed high school upto the 10th grade. He is from a middle socio-economic strata of society. He was employed as an auto driver.. He was admitted for the second time in NIMHANS with a history of alcohol use for the past 5 years. He was initiated into alcohol use since the age of 14 and began to drink regularly from the age of 19. The patient had symptoms of withdrawal, tolerance, craving, loss of control and was using alcohol despite knowledge of its harmful effects.

At post assessment there was a reduction in withdrawal symptoms. He obtained a score of 2 on the Clinical Institute Withdrawal Assessment for Alcohol scale indicating absent or minimal withdrawal and a score of 6 in perceived stress scale indicating reduction of stress level.

Significant improvement was defined as shift of percentile to a higher level by one quartile (25 percentile or more). There was significant improvement on focused attention, verbal working memory, verbal learning and memory, response inhibition, visuo-spatial construction and visual memory.

This case illustrates the positive changes associated with EEG Neurofeedback training. Future research in this area could potentially provide ground breaking advances in the field of Neuropsychological Rehabilitation in Addiction disorders.

Reduction of cognitive deficits has a positive impact on patients with addictive disorders. Like a moth enamored by a flame, addictive substances will continue to entice the person with addiction. However, improvements in cognition and the reduction of anxiety associated with Alpha-theta training, equips the affected individual to make more productive choices.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Table 1

Comparison of clinical measures pre to post NFT

Table 2

Comparison of cognitive measures pre to post NFT