Zmiany w czasie w funkcjach wykonawczych i poznawczych jako skutek używania substancji psychoaktywnych: studium przypadku

■ INTRODUCTION

Executive functions (EFs) have been an area of scientific interest for years. Although a number of publications on this topic have been produced both internationally and in the Czech Republic, there is no single definition of the concept. Nevertheless, it is generally agreed that EFs are complex cognitive processes responsible for ongoing goal-oriented behaviours [1].
EFs refer to a group of cognitive domains which are involved in the good functioning of our emotions, thoughts and behaviour on a daily basis.
EFs are very important for our ability to adapt to new and unexpected events in life. They are very fluid and change over the course of our lives. Childhood and adolescence are periods crucial for their development. The development of EFs is influenced by social contexts – especially the home and school settings [2].
EFs help a person to become mentally prepared for an emerging situation and devise a plan for how to deal with it. These functions play a major role in a person’s decision making and reasoning. EFs allow us to be flexible in our responses to changing conditions around us and develop alternative coping strategies [1].
According to Gazzaley and D’Esposito [3], the EF group includes attention, planning ability, working memory, inhibition, problem-solving ability and strategic thinking. Ribner et al. [4] regard elementary EF as comprising working memory, inhibitory control and attention. On the other hand, Frolli et al. [5] define EFs as involving cognitive flexibility, the ability to adapt to emerging stimuli and handle information, the ability to generate ideas, working memory, reasoning, strategic thinking and achieving set goals, inhibitory control and self-control. They generally refer to EFs as cognitive abilities of a higher order.
A person may develop frontal syndrome, dysexecutive syndrome, frontal behavioural syndrome or behavioural disorders as a result of damage to their EFs. All these syndromes are very similar in nature but may differ in terms of their aetiology, extent and manifestation of symptoms [6].
Evidence shows that prolonged and regular substance use has a negative effect on the above-mentioned functions. The development of a cognitive deficit very often results from the interplay of several different factors, including drug or polydrug use and unhealthy, even pathological lifestyles. Early assessment and appropriate intervention are needed when execution and cognition are impaired [7]. There are several reasons cognitive rehabilitation should be incorporated into any selected intervention: cognitive rehabilitation can enhance a person’s quality of life by supporting their independent social functioning and their independence of their environment and institutions, preventing the deterioration and aggravation of the problem, avoiding or dealing with issues in interpersonal functioning and helping them to return to, or remain in, employment or school [8].
This case-study report does not aim to generate generalisable conclusions, but rather to present a carefully designed and clinically relevant example that illustrates potential changes in executive functioning in the context of long-term abstinence and sustained psychotherapeutic care. Case-based designs are well-established in clinical psychology, psychiatry and neurology, especially when the phenomena under investigation are difficult to capture through large-sample quantitative methods. Our goal is to contribute to the clinical understanding of individual recovery trajectories in cognitive functioning following dependence treatment.

■ CASE DESCRIPTION

The report presents the case of a 33-year-old man who was admitted to outpatient treatment for his alcohol and cocaine dependence. The identity of the patient in the case study has been changed to prevent easy identification. The patient started attending our addiction clinic in April 2023. The patient’s executive and cognitive functions were initially screened. After receiving individual psychotherapy for a year and abstaining for nine months, the patient was retested to determine whether any improvements had been achieved in the areas under investigation.
In view of his history and in accordance with the ICD-10 rules, the patient was diagnosed with F10.2 Disorders resulting from the use of alcohol – dependence syndrome, F14.2 Disorders resulting from the use of cocaine – dependence syndrome.
At the time of the preparation of this case-study report, the patient had actively attended individual psychotherapeutic sessions on a weekly basis for nine months. It is recommended that his treatment continues to involve psychotherapy at the given frequency.
In April 2023, the patient sought help from the outpatient addiction facility for his cocaine-binge and alcohol-use related problems. He had been drinking regularly since he was 15 and had been a regular cocaine user since he was 18. The patient confirmed his wide experience and experimentation with other substances (including marijuana, LSD, methamphetamine, amphetamine and various hallucinogens while abroad). In 2021, he had managed to abstain for nine months in a row and did a great deal of sports during that period. In April 2023, the patient used once in two weeks, when he went out to drink with his friends. Typically, he would first drink alcohol and then seek cocaine in a spree would stretch out over the entire weekend, with him not returning home and being on something all the time. He would stay out in a bar or a pub, with no contact with the outside world, and he would not sleep at all. After these binge spells, the patient would experience hangovers lasting for days, when he felt miserable and found it hard to work. He would do this for several years. The patient never drank or used drugs at home as his substance use was associated with socialising and going out.
The patient was born as the middle child in a complete family. He has a sister who is four years older and a two-years younger brother. He describes the family atmosphere and relationships when he was a child as harmonious. When he was six, the family moved to a different town to where he originally grew up. He describes his upbringing as very liberal and full of understanding. Since his parents divorced in 2018, the patient has not maintained any contact with his mother. He shares a household with his father, who he perceives as his role model, especially as regards his professional career. He describes his admiration for his father he has felt since childhood and refers to his relationships with other family members as superficial. His father knows about his substance use, but they do not talk about it much.
The patient did not go to pre-school. He completed his compulsory school attendance in two different places (he went to the eighth and ninth grades elsewhere). His marks were rather average and the patient describes himself as not really being an academic type. He dropped out of grammar school in the first grade and decided to continue at a secondary school focused on economics.
After secondary school, he chose to go to university but did not complete his studies. He reports and describes that at the time he abused THC (tetrahydrocannabinol) with a frequency of several times per day. This period lasted until he was 20. For the next four years, he did sports regularly. He is still in contact with a lot of friends from his sports activities. At the time of both interviews, the patient was not in a relationship and had no children.
He admits that, in the past, he used to experience anticipation anxiety when he went out. A minor clinical burden was identified in the patient in 2023, with overeating, fear of public areas and of leaving the house, inner restlessness, a lack of energy, and difficulty in falling asleep being the most prominent symptoms. In April 2024, the patient reported during the sessions that these states had improved and that he was feeling much better in all aspects. He has never been admitted to an inpatient psychiatric or addiction treatment facility. The patient has not used psychopharmaceuticals on a regular basis. He has consulted a psychiatrist before. He discussed the possibility of using Selincro (nalmefen) with a physician. He started using the medication in 2023, but as he describes took it only a few times. When asked in April 2024, he said he was using no medication whatsoever. The patient has never been in treatment for any physical condition and also denies having been diagnosed with any physical illness.
This case study employed a test battery created as part of another research project by the first author [9]. No medical imaging methods were used.
The test battery consists of the anamnestic record and the following instruments:
The Lawton Instrumental Activities of Daily Living Scale (IADL) is an instrument used to measure the degree of individual independence in day-to-day functioning. The test consists of eight items, with each covering a common everyday task (mode of transport, shopping, making a phone call, using medications, housekeeping, cooking, money management and laundry) [10].
The Beck Depression Inventory (BDI), first developed in 1964, has undergone several modifications. The BDI-II version was used for the purposes of this case study. The test includes a total of 21 questions, each inquiring about a certain depressive symptom. The respondent is asked to indicate the severity of the symptom experienced in the past seven days [11].
The Beck Anxiety Inventory (BAI) addresses anxiety symptoms. It contains a total of 21 items covering 21 common symptoms of anxiety. The respondent is asked to indicate whether they have experienced a specific symptom within the past seven days and if so to what degree [12].
Addenbrooke’s Cognitive Examination (ACE-R) is designed to identify cognitive deficits. This test is specific in that it incorporates another cognitive test, the Mini-Mental State Examination. ACE-R consists of 26 tasks addressing attention and orientation, memory, verbal fluency, language and visuospatial abilities [13].
The Frontal Assessment Battery (FAB) is intended to measure cognitive and behavioural functions. The instrument consists of six subtests, each looking into a different cognitive domain like conceptualisation, mental flexibility, motor programming, sensitivity to interference, inhibitory control and environmental autonomy [14].
The Trail Making Test (TMT) is mainly used for assessing cognitive functions. It primarily measures attention, visuoconstructive functions and EFs. The test is composed of Part A and B. In the first part, the subject is asked to connect numbers displayed on paper in numerical order. In the second more complex part, the subject is asked to connect numbers and letters sequentially while alternating letters and numbers (1-A-2-B-2-C-4-D, etc.). The subject must complete both parts as fast as possible [15].
The Barthel Index of Activity of Daily Living is used to assess a person’s functional independence in everyday activities and the level and quality of their self-care ability. The instrument is widely used in psychology, medicine, physical therapy and neurology. It explores ten domains of daily life [16].
The Life Satisfaction Questionnaire measures an individual’s satisfaction with life. It covers health (ZDR), marriage and partnership (MAN), work and employment (PAZ), housing (BYD), leisure time (VLC), financial situation (FIN), sexuality (SEX), relationships with one’s own children (DET), oneself (VLO) and friends, acquaintances and relatives (PZP) [17]. The Dysexecutive Questionnaire (DEX) is a tool for assessing dysexecutive deficits. It is composed of 20 questions addressing common symptoms of clinical manifestations of impaired EFs. The questionnaire works on the principle of the subjective awareness of difficulties perceived in relation to EFs [18].
The evaluation of test results was based on standard clinical norms commonly applied in the Czech Republic and other European countries. According to these frameworks, test performance was classified as “normal” (within expected range), “below average” (mild to moderate impairment) or “extremely below average” (clinically significant deficit). These categories were applied consistently across all assessment tools to enable comparison between the two sessions.

■ RESULTS

The tools constituting the test battery explore 13 selected domains, eight executive and five cognitive functions. Table I briefly explains the domains and indicates which instrument of assessment was applied.
We saw the patient for the second time in April 2024. He was actively contacted by the case-study report authors and was offered to have his EFs retested. Communication with the patient took place via email. When the patient showed interest in being retested, a date was agreed. The patient arrived for the appointment in time, by himself, and exhibited regular ways of establishing social contact. His verbal expression showed no speech anomalies and his thinking was coherent. The patient’s mood was assessed as being within the norm, with no signs of anxiety being observed. The patient did his best during the test; his performance was not affected by any lack of effort on his part. At the time of Testing 2, the patient had been abstaining for nine months. The entire test took 40 minutes in total, which was ten minutes less than in the case of Testing 1.
At both testing sessions, the same test battery; i.e., four screening tests and five questionnaires, was administered to the patient, with the individual parts of the battery being presented in the same order.
The self-report anxiety and depression questionnaires showed no positive symptoms. The patient scored normal values in the Frontal Assessment Battery and the Trail Making Test, Part B, while he scored below average in Addenbrooke’s Cognitive Examination and the Trail Making Test, Part A. The Instrumental Activities of Daily Living Scale demonstrated that the patient was fully self-sufficient in everyday tasks. The same result was achieved on the Barthel Index, while the patient scored strongly below average on the life-satisfaction measure. The tests results are summarised in Table II.
The comparison between the testing sessions indicates improvements in self-reported symptoms of anxiety and depression. In April 2023, the patient’s scores indicated mild signs of depression and anxiety. One year later the patient’s mood tested normal, with no signs of pathology. No changes were identified by two assessment tools, specifically the Life Satisfaction Questionnaire and the Trail Making Test, Part A. In both rounds of testing, the former showed extremely below-average and below-average values respectively. On the other hand, improvement was found in the Trail Making Test, Part B where the patient’s scores moved from below average to normal. Poorer performance was recorded in Addenbrook’s Cognitive Examination as while in 2023 the patient’s scores were within the norm range in this test, he scored below average in 2024. No changes were identified on the Barthel Index and the Instrumental Activities of Daily Living Scale. Both measurements demonstrated the patient’s full self-sufficiency and functional independence in daily activities.
Marked improvements were observed in the domains under scrutiny. At Testing 1 in 2023, the patient scored norm values in six of the domains under investigation. At the same time, he displayed deficits in five of the domains under scrutiny, with two domains revealing very strong below-average levels. On the other hand, the patient scored above-average results for two domains. The comparison of these results with Testing 2 shows that the patient improved in four out of the five impaired areas. The only area in which a deficit was also identified during the second testing was Attention and Orientation. As mentioned earlier, the patient scored above-average values for two domains at Testing 1. These were Verbal Fluency and Phatic Function. The patient failed to repeat his above-average result at Testing 2, which means deterioration, as he moved from above-average results towards average. None of the domains that showed normal measurements during Testing 1 recorded any deterioration towards a deficit at Testing 2 (Table III).

■ DISCUSSION

The objective of the case study was to identifyvchanges in the executive and cognitive conditions of a selected patient. The patient was tested at the outset of his dependence treatment and then after a year of his intensive participation in regular psychotherapy sessions. The patient was tested following a nine-month period of abstinence. At the time of the testing, he had been abstaining from all addictive substances. The case study report sought to compare the patient’s results from a screening test administered at the beginning of his outpatient dependence treatment with those scored at a one-year follow-up.
The results show that the patient experienced general improvements in the domains under study. Several factors may have contributed to his better executive and cognitive performance, one of which is certainly the nine months of abstinence. Hassaan et al. [19] report that significant improvements among substance users typically occur after six months of abstinence. They also note that six months may not be long enough for executive and cognitive functions to resume their previous normal levels and it is perfectly common for patients to continue to show minor deficits. This is reflected in our testing, where the patient continued to score below-average levels for one domain. In addition, Hassaan et al. [19] refer to the phenomenon of polydrug dependence. In the event that a patient is dependent on multiple substances, they may have sustained more serious neuropsychological impairment and cognitive rehabilitation as a whole may take longer. This phenomenon can also be found in the patient in our case-study, who had sought help for his harmful use of alcohol and cocaine at our clinic. Recovery of executive and cognitive functions can range from a few months to five years [8]. Brandt et al. [20] compared the cognitive performance of three experimental groups, characterised by different lengths of abstinence from alcohol, specifically one to three months, one to three years and five years or more respectively. They found that the length of the period of abstinence was crucial for the state of cognitive functions. Among the functions under study, psychomotor speed and short-term memory showed the greatest improvement, while long-term memory was often impaired even in patients who had been sober for five years or more.
In addition, the regular psychotherapy received by the patient could have had a positive effect on the improvement of the domains under scrutiny. The therapeutic sessions were scheduled to take place on a weekly basis for 11 months. Bilgi et al. [21] observed cognitive improvements in their patients undergoing regular group psychotherapy after three months. Improvements of this kind were detected as regards visuo-spatial learning in particular.
Behavioural and cognitive-behavioural models are the psychotherapeutic approaches that seem to be the most effective in improving cognitive functions. The patient in the present case study has not received this type of therapy as he underwent psychoanalytically-oriented psychotherapy [22]. There are opinions that there is considerable potential for combining psychotherapy with pharmacological treatment. The combination of these two therapeutic approaches has been shown to have a positive effect on cognitive performance [23].
At the initial testing in 2023, the patient showed mild anxiety and depressive symptoms. Cognitive deficits are very common in patients with depressive disorders, with these cognitive deficits often persisting even after the depressive symptoms have ceased [23]. Cognitive impairments were noted in up to 41.6% of the patients with depression [21]. Anxiety symptoms may have the same implications [24]. Nevertheless, the retest revealed no symptoms of anxiety or depression.
Finally, the patient was asked during the session whether he had undergone or received any form of cognitive rehabilitation within the past year. He indicated that after Testing 1, on the basis of which he was advised to undergo cognitive rehabilitation, he contacted a centre that provides services of this kind. He completed the initial session and one appointment there, but he never entered into any long-term or regular engagement with the facility. The question is therefore whether this could have had any effect on the patient’s cognitive condition.

■ CONCLUSIONS

The retesting of executive and cognitive functions showed improvements in the study domains after a year of intensive psychotherapy and nine months of abstinence. The patient had shown improvement in four out of the 13 domains under scrutiny. Specifically, he had improved in the Set Shifting, Plan Generation and Execution, Psychomotor Speed and Visuoconstructive Functions domains. In two domains (Plan Generation and Execution and Visuoconstructive Functions), the patient got extremely below-average scores at the initial testing while he scored the norm values in those domains in the one-year follow-up. At Testing 1, the patient achieved above-average scores for two domains (Verbal Fluency and Phatic Functions). At Testing 2, the patient failed to achieve the same result as the functions under consideration were found to be within the norm values. Attention and Orientation as the only domain was assessed as below average at the retest. Considering that a year earlier the domain showed normal levels, it was concluded that deterioration had occurred in this area.
At Testing 1 in 2023, the patient achieved below-average scores on three of the screening tools that were administered. At Testing 2, the patient scored below average on two screening tools, specifically Addenbrook’s Cognitive Examination and the Trail Making Test, Part A. Improvement was achieved in the Trail Making Test, Part B, where the patient scored normal values. Both testing sessions produced the same result as regards the Life Satisfaction Questionnaire. In both cases, the patient’s life satisfaction showed extremely below-average levels. No change was recorded in this domain.
Prior to the retesting, we met the patient to discuss his current condition and state of mind. The patient indicated that he found the regular weekly psychotherapy very helpful and felt he had made considerable personal progress. He added that he was very happy about his several months of abstinence, saying he experienced no craving for substances. He went on to describe success in both his personal and professional life. The patient felt much better about his performance in Testing 2 in comparison to Testing 1. He subjectively evaluated his performance at the retest as far better.
These findings suggest that abstinence and regular therapeutic care may facilitate significant improvements in patients’ cognitive performance. Moreover, the patients’ quality of life may improve and be in general enhanced.
While based on a single case, this report offers a detailed illustration of how executive and cognitive functions may improve during dependence treatment supported by regular psychotherapy and abstinence. Although the findings cannot be generalised, they may be clinically valuable for professionals working with similar patient populations. Case studies like this one can complement empirical research by offering practice-based insights and generating new hypotheses for future studies.

Conflict of interest/Konflikt interesów

None declared./Nie występuje.

Financial support/Finansowanie

This study was created within the framework of Specific University Research project no. 260-758.

Ethics/Etyka

This thesis was created as part of a project that was approved by the VFN Ethics Com¬mittee in March 2023 (ref. 48/23 S-IV – dissertation).
The work described in this article has been carried out in accordance with the Code of Ethics of the World Medical Association (Declaration of Helsinki) on medical research involving human subjects, Uniform Requirements for manuscripts submitted to biomedical journals and the ethical principles defined in the Farmington Consensus of 1997.
Treści przedstawione w pracy są zgodne z zasadami Deklaracji Helsińskiej odnoszącymi się do badań z udziałem ludzi, ujednoliconymi wymaganiami dla czasopism biomedycznych oraz z zasadami etycznymi określonymi w Porozumieniu z Farmington w 1997 roku.

References/Piśmiennictwo