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