PSYCHOTHERAPY WITH COGNITIVELY IMPAIRED POPULATIONS CADY K. BLOCK, MS.

PSYCHOTHERAPY WITH COGNITIVELY IMPAIRED

POPULATIONS

CADY K. BLOCK, MS

COURSE OF TREATMENT

COURSE OF TREATMENT

• Check assumptions

• Order a neuropsychological evaluation if one has not been done already

• Detailed history-taking: patient and collateral interviews

• Intervention

• Follow-up

ASSUMPTION CHECKS

COURSE OF TREATMENT




• Intervention

• Follow-up

THERAPIST ASSUMPTIONS

• Lack of recognition of the role that the brain plays in psychological processes

• “Brain intimidation”

• Anxiety regarding new area of therapeutic skill and research literature

• Potential of losing face when “unskilled” with a new population

• Hopelessness regarding change in cognitively impaired patients

• Frustration in the face of slowed therapeutic progress

CHECK YOUR ASSUMPTIONS

• The psychiatric and/or behavioral issues you see in your patient may not always be due to environmental/psychosocial factors – they may be neuroanatomically based

• Left vs. right hemisphere- Left: motor/speech- Right: affect, insight

• Lobes:• Frontal: self-regulation motivation, action• Parietal: perception• Temporal: memory


• Further, there is a neuroanatomical basis to all psychiatric disorders:

- Depression: frontal-limbic dysregulation

- PTSD: dysregulation of the mPFC, which is involved in contextualization of stimuli

- OCD: dysfunctional activity in a circuit involving the OFC cortex (reward), ACC (error detection), and basal ganglia (motor/behavior), PFC (memory retrieval for behavior sequences)

NEUROLOGIC AFFECT

• (+) Pseudobulbar affect: - Involuntary and/or uncontrollable displays of emotion that

may or may not be mood-congruent- Can occur in many neurologic conditions- Due to lesions along the corticobulbar pathway

• (-) Masked facies: - “Frozen face” due to bradykinesia and rigidity of the facial

muscles, typical of Parkinson disease patients - Could be easily mistaken for flat/blunted affect and/or

apathy as seen in depressed patients

NEUROLOGIC SPEECH

• (+) Wet, Wobbly, and Wacky: - Normal pressure hydrocephalus is the buildup of CSF in the

brain as a result of trauma, hemorrhage, or meningitis- Can result in hyperverbality in children, delirium in adults

• (-) Mutism: - Can occur following brain lesion to left frontal region known

as Broca’s area- There is an “akinetic” variant that also involves slowed or

reduced motor and speech output and apathy, due to left frontal lesion or thalamic stroke

NEUROLOGIC BEHAVIOR

• (+) Impulsivity/Perseveration/Mania: - The tendency to act without apparent forethought, reflection,

or consideration of the consequences of one’s actions- Inability to disengage from a behavior, repetitive behavior- Damage to prefrontal/orbitofrontal cortical areas

• (-) Apathy: - Seeming disinterest and lack of motivation- Anterior cingulate lesions

PSYCHIATRIC MANIFESTATIONS: STROKE, TBI

• Stroke: depression, GAD, pseudobulbar affect, mania (rare)

• TBI: - Anxiety- Major depression: risk factors depression history, poor

premorbid social function:- Changes in personality: families complain of patients who are

“no longer themselves” and are more aggressive, irritable, moody, impulsive, and disinhibited

- Apathy: usually distinguished by the lack of dysphoric symptoms seen in depression, can be misinterpreted as laziness by caregivers, reduces gains from rehabilitative therapies

PSYCHIATRIC MANIFESTATIONS: MS/ALS/SLE

• Depression: - Very common earlier in the disease course in both

MS/ALS/SLE- Can exacerbate immune system activity and disease

symptoms- Difficult differential as neurovegetative/somatic signs

similar to both MS/ALS/SLE and depression- Static problems with energy/fatigue in MS/ALS vs. diurnal

variations in depression- Difficulties with sleep onset/maintenance in MS/ALS vs.

early awakenings typical to depression- Cognitive difficulties in depression variable with a

tendency to highlight difficulties and put forth poor effort

PSYCHIATRIC MANIFESTATIONS: MS/ALS/SLE

• “Steroid mania”: - Steroid therapy is a mainstay to manage immune system

problems inherent across these conditions and autoimmune conditions

- Steroids can be activating (i.e., increased energy, decreased need for sleep, variable euphoria, irritability)

- Personal and family history of mood disorder and especially Bipolar disorder show increased risk for mania

• Also: Pseudobulbar affect, apathy


• Severity of injury or extent of disability does not necessarily predict presence or extent of psychiatric issues

- In fact, in the case of traumatic brain injury, milder injuries are often associated with more frequent and persistent mood disturbance

• In neurodegenerative conditions (e.g., MS, ALS, dementia, movement disorders) psychiatric issues do not necessarily increase as the disease progresses

- In fact, they may decrease (keeping in mind to always check anyways, lack of emotional affect ≠ lack of emotional experience

ETIOLOGY OF PSYCHIATRIC COMORBIDITIES

• As part of the neuropathology: lesions themselves, delayed effects of death of brain tissue over time due to ischemia and necrosis, and metabolic disturbances can all disrupt neurotransmitter production and uptake

• In the hospital: secondary physical issues(e.g., neuroendocrine, pain, nutrition, medication effects), overstimulation, exhaustion from therapies, deconditioning, isolation from support system, coping

• At home: continued or emergent physical issues, substance use, realization of deficits, visible disability, adjustment to new limitations and changes in social roles, disruption in academic and occupational plans

SUBCLINICAL PSYCHIATRIC ISSUES

• Demoralization is common across all neurologic patients, due to:

- Impairment of cognitive capacity

- Impairment of physical function

- Reduction of social role

- Reduction of independence


• Across numerous studies and patient populations, perceived cognitive deficits do not correlate with actual cognitive deficits

• It is important to assess both

• Perceived deficits in the absence of actual deficits (or when disproportionately elevated) are shown to be more related to depression, anxiety, and cognitive style (e.g., catastrophizing)

• Good target for therapeutic intervention, just make sure to take care to normalize this experience for the patient and explain the mind-body connection


• Psychotherapy can be validly attempted with neurologic patients

• The therapist can harness the brain’s neuroplasticity for positive change

• It is important to carry these positive beliefs into therapy with cognitively impaired populations

• However, it can be difficult and frustrating at times, and will require some creativity on the part of the provider

• Work closely with other specialists who can supply you with accurate knowledge and appropriate recommendations

• Take proper steps for self-care and use peer mentoring

THE IMPORTANCE OF TREATMENT

• Psychiatric disorders in neurologic patients can:- Exacerbate cognitive impairment - Inhibit treatment gains or even result in injury- Complicate functional recovery- Disrupt relationships with caregivers

• Psychiatric issues may have a greater impact on patient-reported quality of life than:- Physical disability- Fatigue- Cognitive impairment

NEUROPSYCHOLOGICAL ASSESSMENT

COURSE OF TREATMENT




• Intervention

• Follow-up

NEUROPSYCHOLOGICAL DOMAINS

• Arousal and orientation• Effort and motivation• Sensation and perceptual function• Motor function (speed, dexterity, strength, gait, balance)• Attention/concentration• Processing speed• Expressive and receptive language• Verbal and visual memory• Abstraction and concept formation• Executive function (organization, planning, flexibility)• Intellectual function• Emotional and personality function

NEUROPSYCHOLOGICAL ASSESSMENT

• Neuropsychologists are able to integrate information across clinical psychology, medical psychology, pharmacology, behavioral neurology, neuroanatomy and neuropathology, and psychometrics

• Provides essential quantitative and qualitative data on the patient’s cognitive, emotional, behavioral, social, and functional strengths and weaknesses that you can use to modify your interview, intervention, and follow-up

• May also help you to identify family issues that need to be addressed

• Consider serial assessment – but space out assessments by at least 6 months to 1 year to avoid practice effects

HISTORY TAKING: CLINICAL INTERVIEWS

COURSE OF TREATMENT




• Intervention

• Follow-up

HISTORY TAKING & INTERVIEWS

• Consider your findings in light of neuropsychological assessment results:- Remember that perceived deficits do not necessarily = actual deficits- Remember that your patient may not necessarily possess good insight

into their own deficits

• Thus, it’s important to talk to BOTH the patient and a supportive family member (when possible). If possible, continue to involve a family member in treatment process (as a compensatory aide – good opportunity to evaluate their capacity to do so)

• May also need to involve a great deal of psychoeducation. Excellent opportunity to begin to foster a collaborative relationship – often, patients have already encountered multiple frustrating and unsuccessful setbacks in an attempt to return to their exact former selves


• Demographic data: age, gender, educational history, marital status, current family composition, occupational history, living situation, ability to complete ADLs and IADLs

• Social history: preinjury substance use and legal problems, family function and dynamics

• Medical history: prior medications and neurologic history, prior medical and psych history and treatment history

• Injury/disease-related data: circumstances surrounding onset, disease/injury course, secondary complications, treatment adherence, current therapies, subjective report of current status, compensatory techniques, support system


• Level of awareness: how much does the patient understand their deficit areas? You can ask open-ended questions about what sorts of problems they are having, then rate each on a 10-point rating scale to assess perceived severity. Readiness for change benchmark: identify at least ONE deficit area

• Acceptance: how much has the patient integrated their injury/illness into their present self/narrative? Do they possess realistic expectations? Are they using compensatory strategies or resources? Patients tend to struggle more in this area. Can yield prognostic information about their “coachability” in acquiring new skills. Family input is especially helpful here.

- There is a difference between “restoration” of function and “compensation” of function…what’s patient’s goal and is it feasible?


• Goal Setting: it is a good idea to delineate broad goals at the outset, such as improved relationships and return to work or school

• Written Contract: to assist a patient in remembering the details of and structure of therapy (e.g., structure, regimen, accountability) and broad goals, provide a written and explicit contract along with in-session explanation – revisit this often. Review with a family member when possible. Provide them with a memory book to store information from therapy, including the contract

• Frontal lobe prosthesis: this is how the therapist should see themselves, as a facilitator who can provide the right structure and direction for the patient. Train family member to take over this role, or patient if possible

INTERVENTION & FOLLOW-UP

COURSE OF TREATMENT




• Intervention

• Follow-up

COGNITIVE ISSUES

• Arousal and orientation: may need to schedule sessions at a time most optimal for patient, take breaks, reorient patient often

• Effort and motivation: do not assume that patients operate on delayed gratification – memory and low motivation may prevent this. Build rewards in (fun time, general socialization, token system). Do not assume that the patient is lazy or unmotivated – it may be apathy or depression

• Sensation and perceptual function: adjust session verbal and non-verbal interactions, and environment for deficits. Have adjustable lighting

• Motor function (speed, dexterity, strength, gait, balance): provide notes to alleviate burden of handwriting, be patient, have comfortable seating

COGNITIVE ISSUES

• Attention/concentration: switch therapy tasks often to stimulate attention, use visuals when possible. Modulate the tone and volume of your voice slightly and use eye contact to counter distractibility

• Processing speed: adjust the pace of therapy as needed, don’t heap on too many interpretations or make length or complicated ones so patient can process each one sequentially, practice patience, restrain yourself from “jumping in” to fill silence during the session (the patient may be thinking)

COGNITIVE ISSUES

• Expressive and receptive language: avoid open-ended, lengthy, or complicated questions. Speak clearly and directly, avoid jargon, use visual resources (like a board), use body language and gestures to augment your verbal message, check patient understanding often and have them repeat it back in their own words

• Verbal and visual memory: solicit assistance from family for reminders about appointments and homework (or do reminder calls), teach mnemonics, download mobile apps to help patient, provide a memory notebook for therapy materials and review at session beginning and end, highlight important points of therapy tasks, summarize summarize summarize!

COGNITIVE ISSUES

• Abstraction and concept formation: use mantras, pictures, diagrams, and visual metaphors to help patients understand and remember concepts

• Executive function (organization, planning, flexibility): make interpretations explicit and clear – provide time for questions, if patient is concrete in their thinking or cannot take on another’s perspective. Teach problem solving skill explicitly

• Intellectual function: make material appropriate to the individual’s level of intellectual function (e.g., in CBT or CPT, just restrict therapy to the ABC’s and avoid adding on other complicated cognitive restructuring steps)

BEHAVIORAL ISSUES

• Use a cue to signal the patient they have become tangential

• Model calm, controlled behavior – often, a lower and even will gain attention better than one that is raised

• Be aware of when patient is becoming overstimulated and have a plan to deal with it

• Increasing awareness can result in catastrophic reactions – use relaxation techniques and concrete/clear interpretations to help walk patient through it

• Learn what to ignore and what to address

BEHAVIORAL ISSUES

• Redirect: In emotional outbursts or instances of perseveration, a simple verbal or attentional redirect can often be sufficient to diffuse the situation

• Do not directly confront denial: What you perceive as denial may be lack of insight. Direct confrontation could provide anger/hostility and damage the working relationship. It is better to directly expose the patient to activities that naturally confront a lost ability

EMOTIONAL ISSUES

• Demoralization, anger, anxiety, depression all common• Fear of the future, hopelessness• Fear of failure and embarrassment• Heightened sense of mortality• Posttraumatic symptoms• Loss of bodily, cognitive, emotional, behavioral control• Loss of identity/sense of self• Financial standards/living concerns• Family and partner relationships disrupted

SEXUAL ISSUES

• Impulsivity/disinhibition – hedonism• Apathy – lack of initiation• Personality changes – “my spouse is no longer the same

person” • Role reversal/dependence and physical changes can reduce

desire and engagement in sex• Lack of romance and intimacy due to life disruption and

perceiving the individual as “the patient”

YOU SHOULD:• Create open communication between patient and spouse• Start off slow – create intimacy and romance before sex

PERSONAL NARRATIVE AND SELF-LOSS

• Self-Loss: A loss of personal narrative (loss of self-knowledge, loss of self in the eyes of others) that creates a change in one’s self-image, self-doubt, and decreased confidence

• Prigatano noted that survivors of TBI often ask: 1) why did this happen to me?, 2) Will I be normal again?, and 3) Is life worth living after this?

• Default mode network activity is associated with self-referential thought and neuropathology can often create a sense of “separation” from oneself. Personal narrative is also a part of autobiographical memory – which can be negatively impacted by neurologic conditions and subsequent cognitive deficits

YOU SHOULD:• Help individual acknowledge and accept losses• Help the individual to construct a new personal narrative

THE WORKING ALLIANCE

• Positive therapeutic outcome is related to the maintenance of a good working alliance with survivors/families (Judd & Wilson, 2005). Klonoff et al. (2001): working alliance at the time of treatment predicted outcome up to 11 years after initial treatment

• Unfortunately, the special challenges posed by this population can result in negative emotional reactions by therapists: frustration (cognitive deficits), anger/fear (behavioral), and helplessness/anxiety (emotional) (Judd & Wilson, 2005)

YOU SHOULD:• Be self-aware and consistently use self-reflective skills• Avoid power struggle and pick your battles• Focus on process vs. outcome (TTT = “things take time”, therapeutic

relationship)• Keep life balance, peer supervision may also be helpful

CAREGIVERS NEED INTERVENTION, TOO

• Numerous responsibilities: medical, emotional, treatment, and administrative needs of the patient in the context of adjusting to their injury or illness and preexisting psychosocial issues

• Prone to burnout, which can decrease the quality and quantity of care for the patient

• Prone to increased physical morbidity and mortality: physical morbidity is associated with caregiver depression, anxiety, and lower perceived social support (Schulz et al., 1999). At a 63% higher risk for mortality

• Psychiatric comorbidity linked to increased patient behavioral problems, higher perceived stress, and reduced life satisfaction (Schulz et al., 1994)

CAREGIVERS NEED INTERVENTION, TOO

• Often a lack of proper education, which can result in: - Misinformation (e.g., expectations for recovery, lack of

compliance)- Misattributions (e.g., apathy as laziness/lack of motivation- Reduced engagement of support resources

• Are an important source of social modelling for the patient

• Active coping and open family communication style are related to increased frequency of communication, which in turn is related to increased family cohesion and adaptability to adverse life events

QUESTIONS? FEEDBACK?

PSYCHOTHERAPY WITH COGNITIVELY IMPAIRED POPULATIONS CADY K. BLOCK, MS.

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