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Cognitive deficits as a treatment moderator?

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Cognitive Deficits as a Treatment Moderator? Jennifer J. Vasterling, Ph.D. VA Boston Healthcare System VA National Center for PTSD P3+ Research Summit – PowerPoint PPT presentation

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Title: Cognitive deficits as a treatment moderator?


1
Cognitive Deficits as a Treatment Moderator?
Jennifer J. Vasterling, Ph.D. VA Boston
Healthcare System VA National Center for
PTSD P3 Research Summit September, 2009
2
  • Cognition and Emotion
  • Not just a journal title

3
What do we mean by cognitive impairment (CI)?
Pre-defined threshold? Relative
weakness? Intra-individual change?
4
Questions
  • Contraindications for CI?
  • Does CI influence treatment response?
  • What factors influence the answers above?
  • Do we use adequate measures of CI?

5
Questions
Considerations
Severity of deficit
Contraindicates? Moderates response? Potential
to augment?
Type of deficit
Timing of deficit
Source of deficit
Intervention
Target of intervention
6
Sources of Cognitive Impairment
PTSD
Pain
Cognitive Impairment
Substance abuse
TBI
7
P3
Sleep Disturbance
Distractions
Neural/neurobiol Alterations
Meds
Cognitive Impairment
8
Other Factors
  • Treatment type
  • Type of cognitive deficit
  • Severity of deficits

9
CI Threats to Treatment? General Considerations
  • Adherence
  • Concentration/focus during sessions
  • Group behavior

10
CI Threats to Treatment?Exposure Based
Interventions (Memory)
  • Require controlled retrieval of the trauma memory
    assoc. emotions
  • Require modification of the memory assoc.
    emotions/formation of new associations

11
CI Threats to Treatment? Cognitive
Interventions (Inhibition and Flexibility)
  • Target distorted thoughts with goal of
    reappraisal
  • Require inhibition of maladaptive thoughts
  • Require sufficient flexibility to re-appraise

12
Treatment Benefits for CI?
  • Structure of cognitive-behavioral interventions
  • Certain pharmacological therapies may enhance
    cognition

13
Case Studies
  • Mixed results
  • Some successful
  • At least 1 showed contraindication with
    patient with executive dysfunction

14
Evidence
  • Bryant et al. (2003) (n 24)
  • RCT showed that CBT for acute stress
    disorder after mTBI was assoc with reduced PTSD
    at 6 mo. follow-up
  • CBT beneficial following mTBI for range of
    emotional concerns (Soo Tate, 2007 review)

15
Evidence from Kate Chard CPT to Treat PTSD
with TBI
  • Cincinnati mTBI/PTSD Residential Program
  • n 20 male vets 10 bed cohort
  • 33 mild, 66 mod, 1 severe TBI
  • CPT-Cognitive Only paradigm
  • Combined group and individual tx
  • Avg of 15 sessions
  • Augmented with group psychoeducation

16
PTSD and Depression (Chard cont.)
Variable Pre-treatmentM(SD) or Post-treatment M (SD) or Test statistic Cohens d
CAPS 78.21 (17.96) 40.14 (25.08) t(13) 7.95, p lt .001 4.41
PCL 63.57 (10.09) 40.43 (16.63) t(13) 5.07, p lt .001 2.81
BDI-II 34.71 (8.80) 20.64 (13.15) t(13) 4.06, p .001 2.25
PTSD diagnosis present 100 43 ?2(1) 6.13, p .01
MDD diagnosis present 86 36 ?2(1) 5.14, p lt .05
17
Cognitive prediction of post-treatment CAPS
(Chard cont.)
18
Cognitive Prediction of Post-treatment PCL
(Chard cont.)
19
Evidence
  • Wild Gur (2008) (n 23)
  • Pre-tx verbal memory ? poorer response to CBT
    (for PTSD)

20
Evidence
  • Bryant et al. (2008 a b)
  • Smaller pre-tx posterior ACC increased
    amygdala and ventral ACC activation ?
  • poorer response to CBT (for PTSD)
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