OCTOBER 2009
Review Article
Current Update on Cognitive Retraining in
Neuropsychiatric Disorders
Shahzadi Malhotra*, M.S. Bhatia**, Gaurav Rajender**, Vibha Sharma*, T.B. Singh*
*Department of Clinical Psychology, Institute of Human Behaviour and Allied Sciences (IHBAS)
**Department of Psychiatry, UCMS & GTB Hospital, University of Delhi, Dilshad Garden, Delhi-110095
Introduction
Cognitive retraining (CR) seeks to directly
improve and/or restore cognitive functions utilizing
a variety of pen and paper or computerized tests or
games requiring cognitive skills such as attention,
planning, problem-solving, and/or memory1.It is a
teaching process that targets areas of neuro-
psychological functioning involved in learning and
basic day to day functioning. Thus, a more
comprehensive definition of cognitive retraining
can be, “ therapeutic interventions involving
activities that improve a brain injured person’s
higher cerebral functioning or help the patient to
better understand the nature of those difficulties
while teaching him/her methods of compensation”2.
Theoretical Models Of Cognitive Retraining
Bracy et al.2 have strongly stated that CR should
be grounded in theory. Many different theoretical
models have been proposed to explain the process
of CR and the mechanisms for change. A few
important ones include:
1. Descriptive (Procedure, Transcript) Models
The theoretical basis for CR can be traced to
the work of Luria 3 who proposed that the
concept of brain plasticity. There are
anatomical, physiological and psychological
basis for the plasticity. Psychologically brain
plasticity is conceptualized to be mediated by
the re-organization and re-establishment of
functions. CR approaches use the potential of
the brain to change and adapt to help restore
the lost functions. Studies have reported that
high levels of stimulation and numerous
learning opportunities at the appropriate times
lead to an increase in the density of neural
Delhi Psychiatry Journal 2009; 12:(2) © Delhi Psychiatric Society
DELHI PSYCHIATRY JOURNAL Vol. 12 No.
connections. Further support to this comes
from the works of early connectionist research4
demonstrated that simple networks trained on
unstructured tasks can, when retrained after
damage, exhibit rapid recovery on treated items
and generalization to untreated items.
In addition to Luria’s model another
descriptive model of CR is the model of Diller5
derived from the concepts of clinical
neur opsychology. Here CR starts with
identifying the defect of a certain ability. Then
a task is chosen that appeals to the respective
ability in an adequate manner and is analyzed
in terms of stimulus and reaction qualities. The
ability and the task are evaluated from the point
of view of the activities of daily life (ADL),
achievements on other tasks that may reveal
abilities associated with the trained ability and
with neurological correlates. Thus a
rehabilitation diagnosis is formulated which
forms the base of the training process.
2. Information Processing (Analytical) Models
are based on the following three principles:-
(a) principle of functional specificity, (b)
principle of functional hierarchy, and; (c)
principle of training circuits (tracks). Reitan et
al. 6 gave a model with three levels of
information processing. The first level implies
attention, concentration and memory, the
second level reflects the lateralized processes,
i.e. verbal and language skills in the left
hemisphere and spatial and manipulatory skills
in the right hemisphere. The highest level of
information processing is considered as the
central one, enhancing abstraction in the form
of concept formation, reasoning and/or logical
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analysis.
3. The SORKC Model of behavioural
psychology is considered to be of great import-
ance in CR because it allows incorporation of
physical as well as of neurological status of the
individual along with motivation, emotion,
behaviour. Stimulus (S) refers to antecedent
events, organism (O) refers to per son’s
biological conditions and individual differences
resulting from previous experiences. Response
(R) is for the behaviours (motor, cognitive or
physiological) that are of concern, Contingency
(K) refers to schedules of reinforcement in
operation and Consequence (C) refers to events
that follow behaviour (physical, social or self
generated).
4. The Holistic Model7 is a model of hierarchical
stages in the holistic approach through which
the patient must work in rehabilitation. These
are in order: engagement, awareness, mastery,
control, acceptance and identity. It is empha-
sized that it is futile to separate the cognitive,
social, emotional and functional aspects of
brain injury. Holistic programmes, are
concerned with (i) increasing the patient’s
awareness of the problems, (ii) increasing
acceptance and understanding of the problems,
(iii) providing strategies to improve cognitive
functions, (iv) develop compensatory skills, and
(v) provide vocational counseling. All holistic
programmes include both individual and group
sessions.
Approaches to CR
1. Neuropsychological Educational Approach to
CR8 - Learning is done in real life contexts
(simulated driving exp), 6-10 clients, 2-3
sessions/week for 45 min to an hour.
2. Cognitive Adaptation Training (CAT)1 is based
upon the idea that impairments in executive
functioning lead to problems in initiating and/
or inhibiting appropriate behaviors. CAT
utilizes environmental supports including
alarms, signs, checklists, and the reorganization
of belongings to cue and sequence adaptive
behavior in the home environment.
3. Human Experience Modeler: Context Driven
Cognitive Retraining To Facilitate Transfer Of
Learning9 emphasizes the role of retraining in
214 Delhi Psychiatry Journal 2009; 12:(2) © Delhi Psychiatric Society
OCTOBER 2009
patient’s real environment.
Procedures Used for CR
CR includes a considerable amount of
repetitive practice that targets the skills of interest.
These methods typically involve massed practice
and drill approaches, along with other psycholo-
gically based intervention methods. Cognitive
deficits must be analyzed and subdivided into their
individual components. Retraining then involves
extended practice and over learning on tasks similar
in nature to that of the component deficit. The two
key elements of any CR programme are: repetition
to make the skill automatic , and appropriate
reinforcement. Retraining usually begins with
simpler cognitive skills like attention, short term
memory and information processing and then
proceeds to more complex skills like problem
solving. Each identified skill is retrained using
graded practice of activities using the method of
saturation cueing.
A number of CR methods have been utilized,
many of which use specially designed computer
software, and are called computer assisted cognitive
rehabilitation (CACR). The empirical evidence for
CACR seems to indicate a potential for improving
cognitive function. There is substantial evidence
supporting the effectiveness of CACR for those
suffering from traumatic brain injury, and it is
strongly suggested that “micro-based rehabilitation”
elicited improvements in the areas of “attention/
information processing” and “memory dysfunc-
tion”, new learning and problem solving skills 10.
Most of the CR procedures are computer based as
computers allow accurate timing of stimulus
presentation along with the possibility to regulate
time of stimulus presentation based on individual’s
performance. However, the drawback of these
programmes is their rigidity with respect to patient
needs. The floor and ceiling level along with the
task content are relatively fixed. Further, the cost
of cognitive retraining soft wares is another major
limitation.
Manualized CR programmes overcome these
limitations though at the cost of precision. However,
have found no difference in outcome between
computer assisted and manualized CR methods11.
Evaluation of CR needs to be done at three
levels - LEVEL 1 consists of improvement on the
OCTOBER 2009
task which is being used as the skill enhancing
activity in the session. Task specific improvement
would indicate whether the patient is learning the
function which is being taken up. A biweekly review
of performance would indicate whether this
improvement is occurring. LEVEL 2 – The second
level of improvement is whether the tasks which
are not routinely used as the enhancing activity but
which require the same skills/ abilities show similar
improvement. These include other tasks with same
cognitive skills in the same situation. Improvement
here signifies that the improvement is not task
specific but is getting generalized. LEVEL 3- This
level refers to improvements in everyday behaviour
and activities. If the patient functions better in
spheres/ tasks involving the trained cognitive skill
then this indicates that the cognitive ability has
enhanced.
CR for Various Neuro-cognitive domains
The neuro-cognitive domains which are usually
considered for retraining include- arousal and
orientation, attention and concentration, memory,
visual and spatial perceptual abilities, language and
verbal skills, executive functions (reasoning,
planning, organization, problem solving), life skills
and social skills. Enormous data to support the
efficacy of CR for enhancing these domains is
available:
1. Attention and concentration - CR aims to
improve several abilities, including focusing
attention; dividing attention; maintaining
attention while reducing the effects of boredom
and fatigue; and resisting distraction. This area
of CR has been widely researched, and has been
shown to improve patients’ abilities in various
tasks related to attention12 - 14. Visuo-spatial
inattention is also reported to improve after
CR15.
2. Memory - Empirical evidence16 supports the
efficacy of memory retraining strategies which
are largely divided into three basic categories
1) the use of spared skills in the form of
mnemonic devices or alternative function
systems 17 ; 2) use of direct retraining with
repetitive practice and drill18 , and 3) use of
behavioural prosthetics or external devices19 .
These gains are reported to have a positive
Delhi Psychiatry Journal 2009; 12:(2) © Delhi Psychiatric Society
DELHI PSYCHIATRY JOURNAL Vol. 12 No.2
effect on functional skills of the patient20.
3. Problem solving and Decision Making -
Problem-solving retraining is usually done
using the “SOLVE,” approach from the first
letter of the name of each step: Specify;
Options; Listen; Vary; and Evaluate. The
“SOLVE” technique is reported to be highly
efficacious with individuals at a higher level
of functioning.21, 22,23
4. Executive functions -because of the increasing
evidence that executive functions affect lower
level tasks, more effort has been dedicated to
the systematic development and evaluation of
CR programmes to ameliorate these deficits.
Dual task procedures along with charts and
videotapes that may be used to monitor
behavior, and a variety of questions, tasks, and
games have been reported to be highly
effective21, 22. Metacognition training24,25 which
employs strategy-oriented task practice is also
an effective intervention for executive
functions.
5. Visuoperceptual skills – Irrespective of the
approach (from basic skill training to functional
skills or vice versa) and methodology used, all
reported studies have unanimously supported
that CR is effective in improving visuo-spatial
skills and the gains are reported to be
maintained at follow up 4 months to 1 year post-
treatment.17, 23
CR as an intervention for various
Neuropsychiatric Conditions
CR was initially intended to be used with those
who have suffered from a traumatic brain injury (a
stroke, tumor, or a head injury. However, growing
empirical evidence supports its use in various
neuropsychiatric conditions:
Dementia - In the recent years many studies
have reported cognitive improvement, functional
stabilization and fewer behavioral problems
following CR in dementia patients 26 . Reality
orientation therapy and validation therapy) have
been the most widely used and studied techniques
in dementia27, 28 leading to improvement in Quality
of life of patients and caregivers26.
Traumatic Brain Injury (TBI) - By now there
is ample evidence that holistic neuropsychological
rehabilitation programmes, which have cognitive
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retraining as a major technique improve the
psychosocial outcome of head injury patients.29, 30,31
Multiple Sclerosis (MS) - it is reported that
patients with MS have specific deficits in working
strategies and that interventions aimed at improving
the capacity to develop and use these strategies may
necessarily precede other cognitive rehabilitation
programmes. However, despite the known cognitive
dysfunctions in multiple sclerosis very limited
attempts have been made to reduce these impacts
through CR.18, 27
Parkinson’s Disease - It has been reported that
a CR programme was effective in reversing the
cognitive deficits associated with the early stages
of Parkinson’s disease, but it is reported to be highly
difficult to expect such gains from CR programmes
at later stages27.
Epilepsy- Owing to the high prevalence and
incidence rates of epilepsy, various attempts have
been done towards developing effective CR
programmes for the deficits in cognitive functioning
associated with various subtypes of epilepsy32.It has
been found that CR is effective in ameliorating the
cognitive deficits in patients with focal seizures
receiving carbamazepine (CBZ) monotherapy.33
Substance Abuse - CR has very important role
even in cases of chronic substance abuse,20, 25 which
has been found to be associated with a wide range
of cognitive deficits like impairments in perceptual
motor skills, visual spatial functions, learning,
memory, abstraction and problem solving.
Schizophrenia Several recent reviews of CR
have concluded that the known cognitive deficits
in schizophrenia respond to retraining.34, 35, 36 The
studies have not just focused on schizophrenia,
researchers reported the effectiveness of CACR on
inpatients diagnosed with psychotic disorders but
not meeting the criteria for schizophrenia.37 These
results indicate that psychiatric patients can
productively work with computers, and that
computer-assisted cognitive rehabilitation can
produce short-term improvements in psychiatric
inpatients’ cognitive performance. These gains of
CR in schizophrenia have been reported to be
sustained over a follow up period of up to one year38.
Affective Disorders - There is growing
evidence of impairments in affective disorders. CR
has been reported to be more effective in cognitive
impairments in depressive disorders as compared
216 Delhi Psychiatry Journal 2009; 12:(2) © Delhi Psychiatric Society
OCTOBER 2009
to gains of CR when compared to gains of CR in
patients with BPAD in remission or remitted
mania11.
ADHD - Research studies have found evidence
for treatment of ADHD through CR combined with
other psychological interventions like behavioural
intervention and parental counseling39.
Learning Disabilities - Recent studies have
reported the positive effects of CR interventions to
ameliorate the known neurocognitive deficits in
children with learning disability.2, 40, 41
Evidence from Neuroimaging
Few recent studies provide evidence for CR
leading to changes in brain functioning through
various neuroimaging techniques. Functional
magnetic resonance imaging (fMRI) has been used
to study task-related brain activation in patients
before and after 10–15 weeks of verbal memory
exercises The patients who were observed to have
a 50% performance increase in a series of practiced
and unpracticed auditory and visual verbal serial
position tasks also had changes in brain activation
on fMRI while doing the auditory serial position
task (4-word lists) over the course of training.
Strong temporal and left inferior frontal activations
were reported post intervention whereas prior to
treatment, relatively normal temporal activation but
essentially absent left inferior frontal activation
were noted.42, 43,44
Conclusion
CR may refer to cognitive remediation, which
implies a cur ative or restorative treatment,
compensatory training, or environmental
approaches, which manipulate the environment to
decrease cognitive demands. CR is an effective
intervention for enhancing various neuro cognitive
domains across many neuropsychiatric disorders.
All but the Pilling et al.44 study conclude that clinical
benefit of 1 type or another. However, owing to the
paucity of evidence for CR effects beyond proximal
outcomes36,41, 45 as improvement on trained tasks or
on closely related but untrained neuropsychological
tests, there is a need for studies examining the
generalization of CR gains.
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