Tuesday, July 16, 2013
addiction
PsychiatricTimes SearchMedica Medline Drugs
Psychiatric Times. Vol. 28 No. 6
SUBSTANCE ABUSE: ADDICTION & RECOVERY
Novel Therapies for Cognitive Dysfunction Secondary to Substance Abuse
Brief Screening, Referral, and Cognitive Rehabilitation
By Antonio Verdejo-GarcÃa, PhD | June 8, 2011
Dr Verdejo-GarcÃa is Researcher and Lecturer at the Department of Clinical Psychology and Institute of Neuroscience, Universidad de Granada, Spain. He reports no conflicts of interest concerning the subject matter of this article.
The prevalence and durability of cognitive deficits in patients with substance use disorders raises the need to develop specific assessment and rehabilitation strategies. This is pertinent because general deficits in cognitive function and specific deficits in executive functions are robustly associated with worse drug treatment outcomes, including poorer adherence, shorter retention, and greater risk of relapse.14-16
In this article, I propose the use of a brief screening instrument for frontal-executive deficits in patients with substance use disorders and provide examples of novel treatment interventions aimed at addressing these deficits.
Instruments to assess substance use–related cognitive deficits
Key manifestations of cognitive/executive dysfunction among patients with substance use disorders are:
• Difficulties in understanding complex instructions
• Distractibility
• Premature or disinhibited responses
• Thought and behavioral inflexibility
Some other symptoms may be neglected by the patient but stressed by significant collaterals, including problems with initiating and planning novel activities, disorganized behavior, lack of insight into his or her mistakes, and lack of concern about the consequences.
Insight is often lacking in the patient, which underscores the need for the clinician to effectively screen for cognitive dysfunction. If cognitive impairment is suspected in light of clinical observations and interviews, I recommend the use of a brief screening instrument to detect frontostriatal systems–derived cognitive, behavioral, and emotional deficits. For example, the Frontal Systems Behavior Scale (FrSBe) is a sensitive instrument used to detect frontostriatal-related deficits in patients with substance use disorders.17-19
The FrSBe is composed of 46 items (rated on a 1 to 5 Likert scale) that yield 3 scores for symptoms of apathy, disinhibition, and executive dysfunction (working memory, planning, or awareness deficits), as well as an overall score of frontostriatal-systems dysfunction. The scale includes a self-report and a collateral report. Both reports have shown adequate reliability indices, but the use of the latter is especially recommended when the patient’s insight deficits are overtly manifest.17 The scale also possesses norms extracted from the healthy population of the United States, which provides easy classification of patients as impaired or nonimpaired in comparison with demographically adjusted norms.
If the information from the clinical interviews and the scale’s scores converges to suggest at least mild cognitive impairment (below 1.5 standard deviations [SDs] in some of the FrSBe scales), the clinician can complement the assessment by administering a brief battery of neuropsychological tests focused on those cognitive abilities with well-known implications for addiction treatment prognosis (Table). Response inhibition is measured with the Stroop test, the Wisconsin Card Sorting Test (WCST) is used to measure flexibility/perseveration, decision-making capacity is measured using the Iowa Gambling Task (IGT).14-16
The Stroop test measures response inhibition, and it is based on the interference effect driven by the demand of naming the color of a word that is printed in a color incongruent with the name (eg, the word blue printed in red).20 The test consists of 3 conditions. The first condition (W) presents the words red, blue, and green printed in black ink, and patients are requested to read aloud these words. The second condition (C) presents strings of XXX printed in the same 3 colors, and patients have to name the colors as quickly and accurately as possible. The third condition (WC) introduces the interference effect: the words red, blue, and green are printed in incongruent colors and patients have to name the color and ignore the word. The interference score (IS) is calculated by subtracting a weighted mean of the first 2 conditions from the third condition [IS = WC 2 (C 3 W)/(C + W)]; then results are compared with normative values to evaluate the degree of impairment.
The WCST21 is a measure of flexibility to change. It measures response patterns in the face of changing schedules of reinforcement. The clinician presents 4 stimulus cards; the sh apes on the cards differ in color, quantity, and design. The patient is given a stack of 64 cards that he has to sort according to initially unknown criteria. However, the examiner knows the criteria (the fi
Frank Lloyd Wright’s famous house: A River Runs Through It
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A River Runs Through It
One of the most famous and beloved houses in the country has not survived without a struggle.
BY: Renee Valois
June 09, 2009
From the very beginning, Fallingwater made a huge splash in the world of architecture. In 2000 the American Institute of Architects voted it the Building of the Century. But Frank Lloyd Wright’s famous house did not always look like it would last through the century.
The house remains as unique today as when it was designed in 1935. But the very originality that made Fallingwater so beloved has also endangered it.
When department store magnate Edgar J. Kaufmann commissioned Wright to design a country house for him on the Bear Run stream on forested mountain property in western Pennsylvania, he expected Wright to build a retreat with a view of the waterfall his family loved. He did not anticipate a house built right on top of the river—incorporating the very boulders upon which the family enjoyed basking.
Legend has it that the design for Fallingwater spewed out of Wright in one frantic session. It started one morning in September 1935, when Kaufmann called Wright to inform him that he was in Milwaukee, about to drive up to Taliesin (Wright’s home and studio in his childhood town of Spring Green, Wis.) to see Wright’s designs. Kaufmann had been waiting impatiently for months. Wright replied “Come along, E.J. We’re ready for you,” implying that the plans were finished. In reality, Wright had not even begun to work on the designs—at least on paper.
As his apprentices Edgar Tafel and Bob Mosher later recalled, Wright talked to himself as he laid out plans for the house. “Liliane and E.J. will have tea on the balcony . . . The rock on which E.J. sits will be the hearth, coming right out of the floor, the fire burning just behind it . . .” He kept his two assistants sharpening the colored pencils he rapidly used up. The plans, elevations, and sections were finished just in time for Kaufmann’s arrival.
Fallingwater comprises a series of concrete levels anchored in rock. It is so integrated into the landscape that the huge boulder Wright envisioned actually protrudes through the floor of the living room. Multilevel platforms and balconies mimic the natural ledges of the falls, and stone quarried from the area enhances the organic look. The cantilevered house projects over the river, and steps from the living room lead right down to the water.
The spectacle of breathtaking architecture enfolded in a beautiful forest stream has drawn visitors from around the world. In 1963 Edgar Kaufmann Jr., who was instrumental in his father’s original decision to hire Wright, gave Fallingwater and its acreage to the public in care of the Western Pennsylvania Conservancy as a memorial to his parents. Today, 135,000 people visit annually.
But peaceful surroundings belie the danger Fallingwater has endured through the decades. In 1956 a tornado hit, and Edgar Jr. wrote, “The house was being racked . . . The main stairs . . . carried a cascade from the hillside behind the house. Ankle deep in water, we looked over an alien lake obliterating the glen and shoving restlessly against glass doors, while the wind howled and the rain poured down in wild sheets . . . The next morning we awoke to a house thick with sludge. The banks of Bear Run were ravaged . . . smaller boulders were swept away, trees were down . . . Two bronze statues, set outdoors near the house, had disappeared.”
Fallingwater came through the terrible storm structurally intact, and the mud and drowned snakes were cleaned out, but nagging problems have resurfaced through the years.
When the house was built, many engineers feared the cantilevers that supported the floors would eventually collapse—or the river would cause the house to disintegrate. Indeed, the cantilevers sagged so much over time, and moisture damage was so pervasive, that in 1999 a plan was formulated to resolve both issues. In 2002 the cantilevers were stabilized with post-tensioning, using high-strength steel cables buried inside the floors.
Lynda Waggoner, director of Fallingwater, says water damage had warped doors, peeled paint, and caused stains and cracks in walls, creating problems that rivaled the sagging cantilevers in importance. Fortunately, advances in modern technology have made it possible to completely waterproof the building.
However, Waggoner says that, just as with any home, one might put a new roof on, but then something else needs to be replaced—there are always new issues. She says that although the original glass was replaced with UV-filtering laminate glass in 1987, it’s beginning to fail. Also, it has always been difficult to get paint to adhere to the building because Fallingwater has a lot of horizontal surfaces.
Waggoner says it’s difficult to ask fans of preservation for more money after the big capital campaign that recently funded the extensive structural and waterproofing work.
But the physical poetry of Fallingwater will surely ensure its preservation. As Waggoner says, “It’s one of our national treasures. It’s the most famous modern house museum on the planet. Few houses speak to a whole host of people. But you don’t have to be an architectural aficionado to love Fallingwater.”
Renee Valois wrote about Civil War battle relics in the September/October 2006 issue of the magazine.
Tuesday, July 9, 2013
BE MINDFUL NOW
LOST
Stand still.
The trees ahead and the bushes beside you Are not lost.
Wherever you are is called Here,
And you must treat it as a powerful stranger,
Must ask permission to know it and be known.
The forest breathes. Listen. It answers,
I have made this place around you,
If you leave it you may come back again, saying Here.
No two trees are the same to Raven.
No two branches are the same to Wren.
If what a tree or a bush does is lost on you,
You are surely lost. Stand still.
The forest knows Where you are.
You must let it find you.
An old Native American elder story rendered into modern English by David Wagoner, in The Heart Aroused - Poetry and the Preservation of the Soul in Corporate America by David Whyte, Currency Doubleday, New York, 1996.
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