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Cognitive Impact
Crystal Meth Information Session
January 19, 2018
Carolyn Lemsky, Ph.D., C.Psych. ABPP-CN
Community Head Injury Resource Services of Toronto
Overview
Really quick review of the actions of Methamphetamine
Neurobehavioural impacts
Cognitive impacts
A brief overview of strategies to address cognitive
impairment with an example from CHIRS
Quick review of screening for TBI
Amphetamines…the GOOD
Synthetic amphetamine-like drug
Used as treatment for Nasal Congestion
Recognized side effect euphoria and increased arousal
Methamphetamine first synthesized in
Japan
Methamphetamine
Created as a
Reduction of
ephedrine.
Used for simulant,
effects and appetite
suppression
Using the effects of stimulants in war
Increased arousal
Appetite suppression
Euphoria
Prescribed in the 40’s
and 50’s
Pill forms to
treat
disorders of
arousal, mild
depression,
obesity
Methamphetamine the BAD
Recreational use of Benzedrine and other
stimulants
1940’s -50’s epidemic of addiction in Japan
Recognizing associated psychosis
Medical impacts
1980’s popular in homosexual men
1990’s new methods of cooking
“From the very first time I tried meth, I loved it. Nothing had ever made me feel as happy or alive or confident as meth did. That’s because no natural experience can make your brain produce dopamine like meth can”.
Wil Miller, June 2014 issue of the Washington State Bar
Association’s NWLawyer
Action in the brain
Causes dopamine release
Block re-uptake of dopamine
Inhibit storage of dopamine
Inhibit the destruction of dopamine and by enzymes
Structurally similar to other transporters resulting in increased serotonin and noradrenaline.
Meth Math
0
200
400
600
800
1000
1200
Resting Sex Cocaine Meth
Amount of Dopamine Release
Neurotransmitters effected…
Dopamine
Reward system
Movement
Attention and Working Memory
Noradrenaline
Mediates cardiovascular function
Arousal
Attention
Concentration
Learning
Memory
Serotonin
CNS and the GUT
Smooth muscles
Blood pressure
Mood
Appetite
Sleep
Temperature Regulation
Pain Control
Sexual Activity
IMMEDIATE EFFECTS
Increased feelings of pleasure
Heightened sexuality
Reduced sleep
Increased alertness
Increased awareness
Increased energy
Elevated mood/reduced anxiety
Rapid, Irregular heartbeat
Increased blood pressure
Course of the drug action RUSH (30 min.)
Elevated pulse, BP
HIGH (4-16 hours)
Feeling of invincability/Clarity
Excessive focus
BINGE (days to weeks) Re-use to maintain the high (days to weeks)
Hyperactivity
TWEAKING Loss of identity
Intense itching
Psychotic state
CRASH (1-3 days) Unable to initiate action (even anger)
METH HANGOVER (days to weeks) Malnurished, dehydrated,
Withdrawal
A month may pass before withdrawal is evident
Depression
Loss of Energy
Anhedonia (loss of pleasure)
Cravings
Suicidality
Neurotransmitter Depletion
Dopamine receptors damaged directly
Brain’s homeostatic mechanisms may also reduce
receptors.
Depressed irritable mood
Anxious, paranoid, irrational fears
Hallucinations
Prolonged sleep
Development of Meth Use Chipping
Tweaking
Moderate Use (with crashing)
The UGLY
Recovery
Effects of
traumatic injury
Types of Damage
Acute changes in neurotransmitter balance
Changes in the connections among the structures
that make up the reward system
Cytotoxicity (cell death)
Long-term course
Balancing of neurtransmitters
Weeks to 18 or more months
Cytokine-induced neuronal changes (extra pathways) in
the reward system (learned associations)
Changes are permanent
Cell Death in Frontal Lobe, Caudate nucleus and
Hippocampus
Changes are permanent
Toxicity related death of glial cells
Changes in blood vessels/increased stroke risk.
Recovery over time
Motor and verbal skills may recover more readily
Changes in neuro-behavioural functioning may be lasting.
Changes to the reward system are responsible for life-
long cravings
Neuro-behavioural Impact
Gap between ‘say’ and ‘do’.
What do problems with delay discounting look like?
The “A-B-C’s” of Self-Regulation
Affective (emotional) regulation
Behavioral planning
Cognitive resource allocation
Sensitivity to Rewards
The reward system is responsible
for seeking natural rewards that
have survival value
seeking food, water, sex, and
nurturing
Dopamine is this system’s primary
neurotransmitter
Somatic marking
Addiction is a special case of learning
• Caged Rats took 19 x
more than the Rat Park
Rats
• Rat Park Rats preferred
plain water to morphine
• Even after morphine
water for 57 days, they
preferred plain water
when moved to the rat
park
• There was no way to
produce addition in the
rat park rats
Delay Discounting
(Duncan, 1986)
Choosing a small
immediate reward in lieu
of a larger delayed reward
You have to see the door…
Feldstein, Filbey, Hendershot, McEachern & Hutchison, 2011
Behavioural Approaches
A peek at SUBI group
Meaningful engagement
Behavioural Intervention
Harm Reduction
Cognitive Compensation
Motivational Interviewing
Skills Training
Relapse Prevention
Addressing inhibitory control deficit
Reduced access to the drug/Triggers
Provide contingent reinforcement
Medications to address reduced number of receptors in
the dopaminergic networks.
Light users Buproprion (selective serotonin re-uptake
inhibitor).
Mirtazapine with CBT/MI
Topirmimate (may be best for re-lapse prevention)
Modafinil with CBT for reduction of use
Naltrexone (reduced use and greater abstinence)
Emotion’s role in regulating behaviour.
Somatic Markers (Damasio, 1991)
Reduced access to emotional information
Reduced emotional decoding
Difficulty using emotional responses to inform behaviour
Insensitivity or indifference to social cues
Cognitive Impact
Common findings across studies
Impaired episodic memory
Reduced complex information processing speed
Executive functions (response inhibition, novel problem solving)
Psychomotor functions
Impaired emotional control
Some evidence for impairment
Attention/working memory
Language
Visual Constructions
The flow of cognition
Alertness
Attention
Processing of information
Memory
Executive Functioning
Problems with Attention
Trouble staying tuned-in
Seeks stimulation
Looks bored
Restlessness/fidgeting
What to do
Command Attention
• Eye contact
• Use notes to focus
Break down information
• Talk in short sentences
• One point at a time
Make it active
• Get repetition
• Rehearse
• Repeat
• Allow walking/fiddling
Other things to do…
Remove distractions
Talk in short sentences
(not paragraphs)
Repeat information
Make Notes
Check comprehension
Make stressors
predictable (if they can’t
be avoided).
Rehearse responses
Ask clients how they will
remember future events
Problems with Processing Information
Only hears part of a message
Seems to get tired easily
Seems very passive
Looses attention (spaces out)
What you can do
Slow it down.
• Pause
• Write notes while you speak
Simplify • One idea at a
time
Check-in
• Ask for a repetition
Problems with Memory
Inconsistent in activities
Trouble recalling events
Difficulty Learning
Lack of follow-through
Seems to make things up
Memory
Most often impaired
Learning new information
Recalling new information without cues
Remembering to do things in the future
Memory for context (source memory)
Memory of episodes while using
Often show less impairment
Memory for faces
Recognition (cued)
memory
Procedural learning
(learning by habit/routine)
Biographical information
(pre injury)
What you can do
Use Notes • Write Stuff Down
Repeat • Repeat and ask for repetition
Provide organizers
• Announce topics
• Point out relationships
Teach Strategies
• Notes /reminders in phone
• Use routines
Problems with initiation
Appears unmotivated
Identifies goals, but doesn’t act
Needs constant reminders to complete a task
Others describe as ‘lazy’
How to help
Small Steps
• Create clear plans with small steps
Check Lists
• Signs, prompts
• Routines/lists
Cues • Alarms
• Calls
• Timers
Executive Functions
• Ability to set goals • Planning and organization to achieve goals • Initiating behaviour • Inhibiting behaviour • Monitoring progress toward the goal • Thinking strategically and flexibly • Insight • Emotional Regulation
Definitions
“The executive functions of the brain can be defined
as the complex process by which an individual
goes about performing a novel problem-solving
task from its inception to its completion.”
Sbordone (2000)
Meta-Cognitive Routines
Goal –Plan-Do-Review-Revise
• Format of each session
• Imbedded in problem-solving discussions
Ways to change
• What I think
• What I do
• My Environment
Cognitive Compensation
• Journaling
• Goal Posters
• Reminders
• Environmental changes
Screening
TBI questions
Ohio Valley Brain Injury ID
Ohio Valley Brain Injury ID
BASIC
Specialized
Specific
Challenges
Multiple co-morbid conditions require integrated care
Cognitive impairment
Impulsivity
Memory
Impaired Awareness
Psychotic Disorder
Opioid use disorder
History of incarceration for assault and theft
Screening
Why screen?
Brain Injuries may be invisible.
Some clients may be unaware of their brain injury
Many injuries are documented in the medical record.
http://www.brainline.org/content/2013/08/new-tbi-screening-tool.html
Ohio State Brain Injury ID Method
3-5 minute interview
Designed to detect
traumatic injury, not injuries
due to other causes.
Self-report history, not a
‘test’.
Found to be valid and
reliable
Cuing to Elicit Injuries
Please think about injuries you have had during your entire
lifetime, especially those that affected your head or neck. It
might help to remember times you went to the hospital or
Emergency room. Think about injuries you may have
received from a car or motorcycle wreck, bicycle crash,
being hit by something, falling down, being hit by someone,
playing sports or an injury during military service.
Injury With Loss of Consciousness
a. Thinking about any injuries you have had in your lifetime,
were you ever knocked out or did you lose consciousness?
____ Yes
____ No (IF NO, STOP HERE)
Worst Injury
b. What was the longest time you were knocked out
or unconscious? (Choose just one; if you are not sure
please make your best guess.)
____ knocked out or lost consciousness for less than 30
min
____ knocked out or lost consciousness between 30 min
and 24 hours
____ knocked out or lost consciousness for 24 hours or
longer
First Injury
c. How old were you the first time you were knocked
out or lost consciousness?
years old
This question allows 3 indicators of lifetime history of TBI
to be computed:
Positive for a lifetime history for TBI with loss of
consciousness (yes/no)
Worst TBI with loss of consciousness (LOC) was mild,
moderate or severe (no TBI with LOC, mild TBI with
LOC, moderate TBI, severe TBI)
Age at first TBI with loss of consciousness (in years)
Screen for Brain Injury History
Recognize Cognitive and Functional Impairment
Accommodate Cognitive and Behavioral Symptoms
Integrate with Community Resources
Monitor and Manage Co-Occurring Health and Mental Health Issues
Recognize Cognitive and Functional
Impairment
Raise awareness
(online training)
Cognitive Screening
Neuropsych.
Assmt.
Online training
Available Training
https://tbi.osu.edu/modules
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