Cognitive rehabilitation in a modified therapeutic community for patients with dual diagnosis

1. Cognitive rehabilitation in a modified therapeutic community for patients with dual diagnosis K. Krysta1, EwelinaPilarska1, Witold Siudek2, A. May-Majewski2 1Department of Psychiatry and Psychotherapy, MedicalUniversity of Silesia, Katowice, 2Center for Mental Health and AddictionTherapy, Gliwice, Poland

2. Introduction The dependence on such substances like cannabis, amphetamine, or cocaine is more common among patients suffering from schizophrenia, than among other psychiatric patients. It was found that in the North American population every fourth person suffering from schizophrenia abused alcohol [Barbee et al., 1999].

3. During the relapses of schizophrenia 22% of the patients use psychoactive substances. The motivation to do it is often a result of subjective profits that the patients using them experience. The patients with schizophrenia use those substances in order to handle depression, to experience more profoundly different emotions, and to reduce the side-effects of the medication they are prescribed. The data show that illicit drugs are used to reduce depression (72%), and tension (64%) to increase pleasant emotions (62%), to enhance the ability to work and to learn (17%), to decrease the side-effects of the medication.(15%), to reduce hallucinations (11%) and suspicion (4%) [Dixon et al., 1999].

4. In the study done in Glenside Hospital in Australia (1995) 53 patients with comorbid diagnoses of schizophrenia and addiction to psychoactive substances were interviewed with the use of Brief Symptom Inventory and Schizophrenia / Substance Abuse Interview Schedule. Most of the patients reported that the use of substances was the reason for a development or exacerbation of their disease, 80% of them used drugs to handle their dysphoria and anxiety. The amphetamines caused their subjective improvement better than alcohol, however the choice of the substance depended mainly on what they could afford. Only cannabis exacerbated the positive symptoms and only amphetamines reduced negative symptoms [Baigent at al., 1995].

5. In the studies done by Coben and Levy (1995) it was proven that different substances have influence on different problems related to the disease. For example alcohol, cannabis and cocaine decrease depression, cannabis and alcohol decrease the level of anxiety and cocaine increases it. According to LeDuc (1995) the only result of substance abuse is the increase of frequency of hospitalizations. According to Soyka (1994) the impact on different symptoms may be diverse, e.g. alcohol causes an increase of positive symptoms, and it is also responsible for a higher frequency of suicidal attempts.

6. What is the impact of substance abuse on cognitive functioning in schizophrenia?

7. Inconsistent results of studies: Worse cogninitive functioning in patients suffering from schizophrenia addicted to cocaine [Serper et al., 2000] Better cognitive prfomance in patients addicted to psychoactive subsatnces [Carey, 2003, Serper, 2004]. No impact of psychoactive substances on cognition in schizophrenia [Cleghorn, 1991, Addington, Addington, 1997, Liraud, Verdoux, 2002].

8. Thestudy • Objective: To analyzecognitivechangesinpatientswith dual diagnosisparticipatingin a cognitiverehabilitation program. • A group of40patients diagnosed with schizophrenia was examined: • They had an additional diagnosis, namely addiction to • psychoactive substances, including: opiates, amphetamines, hallucinogens and cannabis.

9. Thestudy During their treatment they also took part in a program of rehabilitation of cognitive functions. The cognitive functions were assessed twice: first time at the beginning of the treatment and second time after six weeks of cognitive rehabilitation.

11. The study The examined patients participated in the program of TC „Familia” in Gliwice, Poland.

12. Methods • Neuropsychological assessment with following tests: • TMT A • TMT B • Stroop Test • Verbal Fluency Test

16. Results: After six weeks of cognitive rehabilitation all patient improved significantly in most of the applied neuropsychological tests.

17. Table3.Comparison of the results of neuropsychological testing before and afterrehabilitation

18. Conclusions Theaboveresultsconfirmthenecessity of introducingcognitiverehabilitationintherapeuticprograms for patientswith dual diagnosis. Theaboveresultsmayalso be an effect of othertherapeuticinterventionsusedinthe TC rehabilitation model, antipsychotictreatmentorotherfactors, whichneedfurtherinvestigation.

19. An important element, which should be taken into consideration in programs for dual diagnosis patients is the training of cognitive skills, which helps the patients to get the insight of their disease. There is no impact of this training on the increase of psychopathological symptoms [Nieznański et al, 2002]. Another important factor is the training of social skills, like: communication skills, solution of interpersonal problems, active participation in patient’s pharmacotherapy, self-observation [Sawicka, 2005].

20. Social cognition abilities that might be impaired in schizophrenic patients include empathy, perspective taking, reflection, appraisal of social contexts, planning and foresight. Individuals suffering from schizophrenia cannot cope with the huge information processing capacity that must be involved in acquiring many social skills [Lewis, 2004]. Poor premorbid function, negative symptoms and cognitive dysfunction are significantly associated with unemployment in schizophrenia [McGurk, Meltzer, 2000].

21. Higher general intellectual, executive, and memory functioning are significantly related to greater scores in readiness to change substance abuse in dual diagnosis patients. Cognitive ability may be an important variable to consider in the motivation and treatment of dually-diagnosed patients [Blume et al, 1999] Positive relationship between neurocognitive functioning and length of stay in therapeutic communities (TCs) was found [Fals-Steward, Schafer, 1992].