Medicine Nursing and Health Sciences Cognitive impairment and

Medicine, Nursing and Health Sciences Cognitive impairment and cognitive recovery in substance related disorders A/Prof. Antonio Verdejo-Garcia Catania, July 2015

Outline 1. Cognition -- What is it (for)? 2. Subtyping/Matching 3. Prediction 4. Cognitive remediation Cognition and Outcomes 2

Updating and management OF input-independent info FOR goal-achievement and decision-making Cognition and Outcomes 3

3 D 5 B 1 H/ 135 BDH RED GREEN BLUE D RED GREEN BLUE X D Cognition and Outcomes 4

Moreno-López et al. (2012) Cognition and Outcomes 5

Gray Matter Moreno-López et al. (2012) White Matter 6

Factor Analysis of Executive Functions Components Measures Factor Load h 2 Updating Letter Number Sequencing 0. 5 -0. 8 0. 53 -0. 73 Inhibition Stroop 0. 7 -0. 8 0. 51 -0. 63 Switching Wisconsin Card Sorting Test 0. 5 -0. 9 0. 45 -0. 74 Decision-making Iowa Gambling Task 0. 9 0. 83 Verdejo-García & Perez-Garcia (2007)

Stimulants vs Opiate users Verdejo-García & Perez-Garcia (2007)

Components Prevalence Rate Drug of choice w/greater deficits Working memory 62. 2 % C=H Response Inhibition 38. 3 % C>H Shifting 27. 3 % C>H Global Impairment 68. 8 % Cognition and Outcomes 9

Focus of current interventions (MI or CBT) § Life goals § Self-control and self-monitoring § Avoid risk Cognition and Outcomes 10

Focus of current interventions (MI or CBT) g § Life goals n i rk ng o § Self-control and self-monitoringred w aki m i a n p o i m s i § Avoid risk i c s n e e e t e or d i s w i t u e q n b e o r i h t t i c t n b i a e h m , in m t s i a e M ory r t m and e m Cognition and Outcomes 11

What cognition may add… § Subtyping/Matching § Prediction § Focused interventions Neuropsychological Assessment Cognitive Rehabilitation Cognition and Outcomes 12

Albein-Urios et al. (2013, 2014) Cognition and Outcomes 13

LCA of trait and cognitive impulsivity scores in 96 addiction clients 10 9 Inatentive/Impulsive Cluster 8 Non-Impulsive Cluster 7 6 5 4 3 2 1 Albein-Urios et al. (2014) 0 Somatic (0 - Anxiety (0 - Depression. Social Dysf Craving (0 - Qo. L (0 -10) 3) 3) (0 -3) 10) Cognition and Outcomes 14

6 Non-Comorbid 5 Cluster B Cluster C Z scores 4 3 2 1 0 Working Memory Attention/ Inhibition Shifting Composite Albein-Urios et al. (2013) Cognition and Outcomes 15

6 Non-Comorbid 5 Cluster B Cluster C Z scores 4 3 2 1 0 Working Memory Attention/ Inhibition Shifting Composite Albein-Urios et al. (2013) Cognition and Outcomes 16

6 Non-Comorbid 5 Cluster B Cluster C Z scores 4 3 2 1 0 Working Memory Attention/ Inhibition Shifting Composite Albein-Urios et al. (2013) Cognition and Outcomes 17

6 Non-Comorbid 5 Cluster B Cluster C Z scores 4 3 2 1 0 Working Memory Attention/ Inhibition Shifting Composite Albein-Urios et al. (2013) Cognition and Outcomes 18

Medicine, Nursing and Health Sciences Prediction of at risk clients

Key cognitive processes § Delay Discounting § Decision-making Cognition and Outcomes 20

Delay discounting Marshmallows! http: //www. youtube. com/watch? v=QX_oy 9614 HQ Peters and Buchel (2011) TICS: 11(5) Presentation title 28 th February 2011 21

Christakou et al. (2011) 22

Delay discounting in addiction Albein-Urios et al. (2014) Presentation title 23

Delay Discounting longitudinally predicts who stay in treatment Stevens, Verdejo-Garcia et al. (2014) Cognition and Outcomes 24

Treatment readiness correlate with brain fitness Moreno-Lopez et al. (2014) Cognition and Outcomes 28 th February 2011 25

Decision-making Bechara et al. (2005)

Bechara et al. (2005)

Decision-making in addiction Verdejo-Garcia et al. (2007) 28

Association with severity of cocaine use Verdejo-Garcia et al. (2007) 29

Using the Iowa Gambling Task to predict relapse § Baseline assessments (~2 weeks after treatment commencement) and classification: § Insensitivity to future consequences § Hypersensitivity to reward § Intact § Follow-up – 3 months after baseline assessments, to provide a 3 cm hair sample to assess drug relapse. Verdejo-Garcia et al. (2014) Cognition and Outcomes 30

Outcome: Cocaine hair concentrations 3 months after treatment onset Verdejo-Garcia et al. 2014 31

Outcome: Cocaine hair concentrations 3 months after treatment onset Verdejo-Garcia et al. 2014 32

Medicine, Nursing and Health Sciences Cognitive enhancement interventions ✔ Cognition Amenable to Interventions ✔ ? Clinical Outcomes

Presentation title 28 th February 2011 34

Wiers and colleagues

Wiers and colleagues

Ø Cognitive training of skills needed to: ü Set personal goals – tailored (“mental blackboard”) ü Resist interference (“automatic pilot”) v Boredom v Stress v Habits ü Quality control – from external to self-generated feedback Ø Practice when and how utilise them in daily life

GMT Automatic pilot STOP! Present Mindedness Back to Goal A B State your Decision Quality control! C D Alfonso et al. (2011)

MFN Automatic pilot STOP! Present Mindedness Meditation motives (e. g. , endurance, willpower) A B Interoceptive scanning Decisionmaking When distracted Back to motive C D Alfonso et al. (2011)

Goal Management Training Long-term goals Decision-making in the Iowa Gambling Task * * STOP! Alfonso et al. (2011)

Conclusions § Most substance dependent clients have executive thinking deficits § Deficient skills are paradoxically prerequisites of addiction treatments we currently apply § There is potential to recovery, and cognitive training can improve treatment outcomes Cognition and Outcomes TP Nov 2013 42

Acknowledgements § Funding – Monash Strategic Grant Scheme – Red de Trastornos Adictivos, Universidad de Granada § Turning Point Drug and Alcohol Centre – Dan Lubman – Victoria Manning § Verdejo-Garcia’s group: – – – MJ Fernandez-Serrano Laura Moreno-Lopez Jose M Martinez-Gonzalez Jose C Perales Oscar Lozano Natalia Albein 43

Thank you! 44