Cognitive remediation

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Cognitive remediation is a behavioral intervention consisting of training activities that aim to improve cognitive skills, such as attention, memory, problem solving, social cognition, and processing speed, with the ultimate intent of improving functioning in everyday life. Cognitive remediation is used to treat the cognitive dysfunction that is associated with a range of neurologic and psychiatric disorders. It is predicated upon evidence that people with impaired neural systems can learn and that when cognitive skills improve, it is easier to function at school, work and in the community.

Training approaches[edit]

The two primary training approaches used to enhance cognitive functions are restorative and compensatory. Restorative approaches include specific drills and exercises, using computers, web based technology, paper and pencil, or discussion. The goal is to improve specific cognitive skills through practice. Compensatory strategies teach ways to bypass or compensate for a cognitive deficit by relying on alternate methods. Rather than trying to improve the impaired cognitive skill, techniques are taught to work around it either by using intact cognitive skills or external aids and supports. Strategy based instruction is used in both restorative and compensatory approaches to teach how to approach a cognitive task with greatest efficiency. Hybrid cognitive remediation programs offer both restorative and compensatory approaches.

Various theoretical approaches drive the structure and format of restorative remediation techniques. For example, In “bottom-up” programs, exercises gradually progress through a hierarchy of abilities from the more elementary cognitive domains of basic attention, reaction time and working memory, to more complex abilities such as abstract reasoning, sequencing and problem solving. In “top-down” programs, complex abilities like problem solving are initiated from the outset, according to the notion that basic foundation skills are being engaged and trained simultaneously along with more complex abilities. The role of engaging metacognitive processes (i.e. “thinking about one’s thinking) in cognitive remediation has gained increasing emphasis, as employing analytical skills not only exercises specific neurocognitive abilities, but also increases awareness of cognitive processes in relation to real-world functions.

While the immediate goal of cognitive remediation is to improve cognitive functioning, the ultimate goal is to impact daily functioning. Training activities may be selected to target specific cognitive abilities in the context of an individual’s personal strengths, weaknesses, and unique rehabilitation goals. Thus a fundamental element of cognitive remediation is that a treatment plan may be tailored to suit the specific needs of the individual.

Empirical Support[edit]

Empirical support for cognitive remediation in traumatic brain injury and schizophrenia is documented by a wealth of published randomized controlled trials. This literature has been reviewed in meta-analytic studies,[1] [2] [3] which typically find moderate to large effect sizes on the impact on neurocognitive performance and functional outcome. Effects on cognitive skill performance in schizophrenia are durable for months after the therapies are withdrawn, particularly in terms of executive functioning, working memory, and verbal memory. Importantly, neurocognitive gains have been linked to improvements in obtaining and working in competitive jobs.[4][5]

Cognitive Remediation in Clinical Practice[edit]

Narrowly defined, CR is a set of cognitive drills or compensatory interventions designed to enhance cognitive functioning. However, from the vantage point of the rehabilitation field, CR engages the participant in a learning activity to enhance the neurocognitive skills relevant to overall recovery goals.[6] CR programs vary in the extent to which they reflect these narrow or broader perspectives, and there is ongoing research to identify the active ingredients that result in a positive response to treatment. Data suggests that when cognitive remediation is provided to people with schizophrenia, it is most effective when given in the broader context of psychosocial rehabilitation.[7][8] Recent attention has turned to incorporating motivational enhancements into the treatment of cognitive dysfunction for psychological disorders.[9] The learning context in and by which cognitive remediation is implemented is relevant to the strength of the effect of treatment via impact on beliefs about competency to learn, treatment adherence and magnitude of learning.

Comparison to Traditional Medication[edit]

One important fact to notice when comparing traditional medication versus the cognitive remediation approach is that there's no direct evidence that supports the claim that one is method is better than the other.[10] One means of comparison is the cost. In 2010, a three month supply of of the schizophrenia drug clozapine costs nearly $900 whereas a three month course cost roughly $700.[11] This being said, it is now known that lower cost can be a benefit of cognitive remediation. Another benefit to cognitive reeducation is the practice. Since patients are allowed to actually apply and try out their new skills versus continuing medication. On the other side of the spectrum, cognitive mediation is more time consuming, and for many individuals is not realistic in terms of the time commitment.[12] Overall, both of these methods have benefits and drawbacks.

References[edit]

  1. ^ Cicerone, KD; Langenbahn, DM; Braden, C; et al. (2011). "Evidence-based cognitive rehabilitation: Updated review of the literature from 2003 through 2008". Archives of Physical Medicine and Rehabilitation 116 (92): 519–530. 
  2. ^ McGurk, SR; Twamley, EW; Sitzer, DI; McHugo, GJ; Mueser, KT (2007). "A meta-analysis of cognitive remediation in schizophrenia". American J Psychiatry 164 (12): 1791–1802. doi:10.1176/appi.ajp.2007.07060906. 
  3. ^ Wykes, T; Huddy, V; Cellard, C; McGurk, SR; Czobor; P (2011). "A meta-analysis of cognitive remediation for schizophrenia: Methodology and effect sizes.". American J Psychiatry 168: 472–485. doi:10.1176/appi.ajp.2010.10060855. 
  4. ^ McGurk, SR; Twamley, EW; Sitzer, DI; McHugo, GJ; Mueser, KT (2007). "A meta-analysis of cognitive remediation in schizophrenia". American J Psychiatry 164 (12): 1791–1802. doi:10.1176/appi.ajp.2007.07060906. 
  5. ^ Wykes, T; Huddy, V; Cellard, C; McGurk, SR; Czobor; P (2011). "A meta-analysis of cognitive remediation for schizophrenia: Methodology and effect sizes.". American J Psychiatry 168: 472–485. doi:10.1176/appi.ajp.2010.10060855. 
  6. ^ Medalia, A; Saperstein, A (2011). "The role of motivation for treatment success". Schizophrenia Bulletin. 37 (suppl 2): S122–S128. 
  7. ^ McGurk, SR; Twamley, EW; Sitzer, DI; McHugo, GJ; Mueser, KT (2007). "A meta-analysis of cognitive remediation in schizophrenia". American J Psychiatry 164 (12): 1791–1802. doi:10.1176/appi.ajp.2007.07060906. 
  8. ^ Wykes, T; Huddy, V; Cellard, C; McGurk, SR; Czobor; P (2011). "A meta-analysis of cognitive remediation for schizophrenia: Methodology and effect sizes.". American J Psychiatry 168: 472–485. doi:10.1176/appi.ajp.2010.10060855. 
  9. ^ Medalia, A; Saperstein, A (2011). "The role of motivation for treatment success.". Schizophrenia Bulletin. 37 (suppl 2): S122–S128. 
  10. ^ Wykes, Til (November 11, 2010). "Cognitive remediation therapy needs funding" (468). 
  11. ^ Wykes, Til (November 11, 2010). "Cognitive remediation therapy needs funding" (468). 
  12. ^ Wykes, Til (November 11, 2010). "Cognitive remediation therapy needs funding" (468).