Practical Assessment of
Cognitive Impairment
Robert A. Battisti
Clinical Psychologist, PhD
Department of Oncology
Cognitive impairment – key insights
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Factoring in cognitive limitations allows for
effective intervention
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Clinic level assessment can identify these
limitations
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Achievable treatment goals can be set that
promote abstract reasoning and cognitive
flexibility
Neurobiological Models of Addiction
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Impairment in goaldirected behaviours
• dopamine reward pathways
(Kalivas & Volkow, 2005)
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Proceduralised
overtraining resulting in
neural circuitry changes
(Jog et al., 1999)
• Limbic – reward pathways
• Access to executive system
is blocked
Cognitive Factors in Addiction
Cognitive
► Memory
► Impulsivity
► Abstract Reasoning
► Cognitive Flexibility
Psychological
► Punishment Sensitivity /
Resilience
► Sensation Seeking
► Pleasure Seeking
Black and White Thinking
Flexible
Processing Distress / Delayed Pleasure
Problem /
Event
Cognitive &
Psychological
Drivers
FAST
Addiction
Behaviour
Decreased
Distress /
Increased
Pleasure
Problem /
Event is not
resolved
FAST
Other
Avoidance
Behaviours
Functional
Resolution
Case Study – Heroin Dependence
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Jane: Heroin Dependence and Bipolar Disorder
• 32 years old
• Creative industry (production lighting)
• Ongoing mood difficulties
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Heroin became primary coping mechanism while
others underused
Black and white thinking style with poor cognitive
flexibility
Her ability to refrain from heroin use could not
compete with high level distress.
Assessment - Jane
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Timing
Structured
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Referral to a Neuropsychologist
Mini Mental State Exam (MMSE) – Extended
GPCOG
Measures of impulsivity (e.g. SSS, BIS)
Clinical Interview - Jane
• “Do you answer the phone when your mother rings?
What do you do?”
• “What do you do to calm yourself down? Do you use
any of these often? How well do they work?”
• “What could be some activities/strategies you could
use when feeling stressed?”
• “How likely will you use these?”
Case Study – Gambling Addiction
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John: Gambling Addiction with comorbid low
mood
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•
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•
•
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27 year old male
Tradesman
Very high intellect but low perceived ability
Poor impulse control
Black and White thinking style for problems/distress
Gambling was about both sensation seeking and
distress avoidance (i.e. debt)
High need for action to reduce feelings of shame
Treatment options
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Treatment options have
limited efficacy
• 12-step programs
• Motivational Enhancement
Therapy (MET)
• Cognitive Behavioural
Therapy (CBT)
• Pharmacological options
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No manuals for treatment
Psychiatric comorbidity
difficulties
Treatment - John
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Shift the goal posts within
reach
Functional and
achievable
SMART goals
Factor in mood for goal
setting
Incorporate inhibitory
control exercises
Conclusions
Disorders of Addiction create a system around and within
the sufferer that perpetuates addictive behaviour
Repeated exposure to the addictive behaviours results in a
gradual erosion of cognitive control
Understanding the cognitive mechanisms at play allows us
to bridge the gap to effective treatment
Thank you
►
Acknowledgement to Dr Antoinette RedobladoHodge
• Clinical Neuropsychologist
• The Children’s Hospital at Westmead
Contact Details
[email protected]
www.mindplasticity.com.au
Cognitive Impairment
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Goal directed behaviour (e.g. Cocaine)
Memory and Attention (e.g. Ecstasy, THC)
Cognitive flexibility (e.g. THC)
Perseveration (e.g. METH)
Impulsivity and Inhibition (e.g. ETOH)
Habituation (e.g. BZDs)
Impacts upon treatment goals and
implementation
Memory
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This is a big issue for substance users and can very much
inhibit the ability to adhere to treatment (despite a possible
strong willingness to do so)
There are several structured memory assessments that can
be administered (e.g. WMS)
In a clinical interview, it involves querying everyday memory
ability. For example:
• Do you forget where you leave things? (e.g. car keys)
• Have you noticed that this has gotten worse?
• What type of things do you find it easier to remember? (looking for
things that are routine-like as these will be easier)
• Do you forget to follow-through on things you have agreed to?
• Do you keep a diary, calendar, etc?
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Use of aids (i.e. Scaffolding) helps considerably in mitigating
for memory effects.
Impulsivity
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Multiple measures for this exist but they do not
converge well or necessarily reflect substance
use behaviours
For individuals, it is more effective to observe
clinically, i.e. via interview
Related to executive control
• Less developed in adolescence and continuing to
adulthood
Cognitive flexibility
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By far having a greater capacity for the
generation of alternate and easily accessible
solutions and coping strategies will be a basis
for protecting against substance dependence
Ability/capacity for generating alternative coping
strategies
Assessment example:
• Wisconsin Card Sorting Task
Black & White Thinking / Abstract Reasoning
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Relates to abstract reasoning ability and proceduralised overtraining
Involves the ability to conceive a problem and that there are
alternative solutions to it
Closely related to cognitive flexibility
Assessment example:
• Wisconsin Card Sorting Task
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Difficulties with engaging in goal-directed behaviours generalise and
can become not only specific to the addiction but across an
individual’s life
Very few things in life are as efficient, or as on-demand, as a
substance (or an instant win) in achieving altered emotional states
Individuals suffering from disorders of addiction gradually shift away
from healthy means of coping with distress and become increasingly
avoidant
Punishment Sensitivity / Resilience
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Positive reinforcement / pleasure is not the only
reason for substance use
Escaping from punishers (e.g. withdrawal,
distress) can also be a motivator for substance
use and this may operate independently of
impulsivity
Relates to coping mechanisms and cognitive
flexibility
This is a motivational factor
Clinical Interview - John
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When you walk up to a poker machine and sit down at it,
what feelings or sensations are going through you?
Are there build-up sensations even entering a pub?
What goes through you / your head when you get a
feature? When you lose a big bet or when you lose
repeatedly?
These questions highlight the very immediate nature of
the sensations occurring with addictive behaviours.
Future directed thinking will tend to be avoidant in nature
(e.g. escaping debt, getting rid of stressors) and rarely
adaptive (i.e. stopping the addictive behaviour in order to
move forward as this has no action tied to it)