PROBLEM SOLVING DEFICITS AND SMALLER SOCIAL NETWORK IN PERSONS TREATED FOR ALCOHOLIC LIVER DISEASE Dr. Maja Zorko 1, Saška Roškar 1, Valentin Bucik 2, Helena Jeriček 1, Zdenka Čebašek-Travnik 3, Borut Kocijančič 4, Borut Štabuc 4 1 Institute of Public Health of the Republic of Slovenia 2 University of Ljubljana, Faculty of Arts, Department of Psychology 3 University Psychiatric Hospital Ljubljana 4 Gastroenterological Internal Clinic, University Medical Centre Ljubljana

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1 WHO, 2004 in Šešok in Sedlak, 2005; 2 Source: World Health Organisation, 2008, HFA-Mortality Database; EUR-A average 3 Source: Mortality database, Institute for Public Health of the Republic of Slovenia, ; 4 Šešok in Sedlak, 2005 alcohol related causes of death 3% 1 SDR ( ) = above EU average 2 costs of alcohol related absenteeism and mortality (year 2003) 37 million EUR 4 app. 350 people per year 3 majority of deaths are due to alcoholic liver disease BURDEN OF DISEASE IN SLOVENIA

BECK DEPRESSION INVENTORY: BDI-II, (Beck, Steer in Brown, 1996) PERCEIVED SOCIAL SUPPORT QUESTIONNAIRE (Kogovšek in dr., 2002; Kogovšek in dr., 2003) 4 SOURCES OF SUPPORT: - instrumental support - informational support - social companionship - emotional support - structural characteristics: network size, type of relationship - characteristics of ties: closeness, importance, frequency of contact, degree of conflicts, satisfaction with support, alcohol specific social support … SIGNS AND SYMPTOMS OF DEPRESSION SOCIAL SUPPORT SPECIAL FEATURES OF COGNITION loss of control craving Wisconsin Card Sorting Test (WCST; Heaton in dr., 1993) DEFICITS IN COGNITION impaired cognitive flexibility problem solving deficits Means-ends problem solving test (MEPS; Platt in Spivack, 1985) number of solutions how effective? is the person active? AIMS AND METHOD people with alcoholic liver disease treated at gastroenterological departments = or = ? i) chronic physical illness ii) synergistic effects of ethanol, thiamine deficiency and impaired liver function on cognitive functions alcohol dependent persons treated at psychiatric wards

NO DIFFERENCES IN: - age (F = 1,20; df = 2; p = 0,307), M age = 54,37 (SD = 8,16), - gender (χ2 = 3,30; df = 2; p = 0,192), - marital status (χ2 = 2,31; df = 2; p = 0,316), - education (χ2 = 2,32; df = 2; p = 0,313), - employment status (χ2 = 4,32; df = 2; p = 0,115). persons with alcoholic liver cirrhosis N = 42 persons with non-alcoholic liver cirrhosis N = 9 exclusion criteria.: harmful drinking* hospital controls N = 31 inclusion criteria: physical disease except liver disease exclusion criteria: pathological liver enzymes, harmful drinking* PARTICIPANTS

alcoholic liver cirrhosis non-alcoholic liver cirrhosis hospital controls - more cards used (F = 49,38; df = 2; p < 0,001), - less categories completed (F = 19,42; df = 2; p < 0,001), - more errors (F = 34,63; df = 2; p < 0,001), - more failures to maintain correct sorting principle (F = 22,28; df = 2; p < 0,001), deficits also in interpersonal problem solving? problem solving deficits hospital controls alcoholic liver cirrhosis non-alcoholic liver cirrhosis p = 0,060 p = 0,532 p < 0,001 - number of perseverative responses (F = 16,79; df = 2; p < 0,001) (holding on to a sorting principle even when it is incorrect) decreased cognitive flexibility and impaired ability to utilize environmental feedback in persons with cirrhosis (alcoholic and non-alcoholic) responses of persons with alcoholic liver cirrhosis characterized by perseverations COMPULSIVE DRINKING! LOSS OF CONTROL OVER DRINKING! RESULTS I cognitive flexibility, problem solving ability to utilize environmental feedback WCST

less relevant solutions, more irrelevant solutions alcoholic liver cirrhosis non-alcoholic liver cirrhosis p = 0,005 p = 1,000 p < 0,001 hospital controls NUMBER OF SOLUTIONS HOW EFFECTIVE IS THE SOLUTION? HOW ACTIVE IS THE PERSON WHEN SOLVING THE PROBLEM? no differences between the groups: F = 2,34; df = 2; p = 0,103 F = 0,24; df = 2; p = 0,790 RESULTS II: interpersonal problem solving MEPS IMPAIRED PROBLEM SOLVING IN THE PHASE OF GENERATING SOLUTIONS less solutions = lower chance of finding an optimal solution

F = 2,05; df = 2; p = 0,136 p = 1,000 p = 0,604 p = 0,207 persons with alcoholic liver cirrhosis persons with non-alcoholic liver cirrhosis hospital controls RESULTS III: signs and symptoms of depression BDI-II non-depressed; mostly physical symptoms differences in cognition are not due to differences in depression

hospital controls alcoholic liver cirrhosis non-alcoholic liver cirrhosis p = 1,000 p < 0,001 p = 0,047 15,44 9,94 15,96 ATTENTION! PERCEIVED SOCIAL SUPPORT! we don’t know whether: 1. support is actually not available 2. a person is not seeking help MEPS: persons with alcoholic liver disease had less solutions including help seeking behaviour seeking help to a lesser extent smaller network size in persons with alcoholic liver disease relatives proved to be the most supportive off all sources of support RESULTS IV: social network characteristics no differences in: - satisfaction with support (F = 0,09; df = 2; p = 0,917), - closeness (F = 1,03; df = 2; p = 0,362), - importance (F = 0,16; df = 2; p = 0,857), - frequency of contact (χ2 = 1,28; df = 2; p = 0,527), - degree of conflicts (F = 0,01; df = 2; p = 0,991), - alcohol specific support (F = 2,61; df = 2; p = 0,081) CHARACTERISTICS OF TIES : NETWORK SIZE: 3. doesn’t name people because of cog. impairm. significant correlation between network size and cog. tests

some CONCLUSIONS, SHORTCOMINGS AND … SIGNS AND SYMPTOMS OF DEPRESSION SOCIAL SUPPORT SPECIAL FEATURES OF COGNITION decreased cognitive flexibility impaired ability to utilize environmental feedback perseverative responses problem solving deficits no signs and symptoms of depression no nevropsychological batery other factors that could influence cognition not included (e.g. premorbid functioning, localization and duration of brain impairment) egocentered network analysis vs. entire network analysis BDI-II: last 14 days longitudinal studies to estimate the prevalence of depression PRACTICAL IMPLICATIONS CBT problem solving techniques enhancing help seeking behaviour THE NEED FOR PSYCHOLOGICAL TREATMENT FOR ALL PATIENTS TREATED AT GASTROENTEROLOGICAL DEPARTEMENTS smaller network size focusing on psychological symptoms

THANK YOU! Institute of Public Health of the Republic of Slovenia