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Rehabilitation for improved cognition in stress-related exhaustion: cognitive, neural and clinical perspectives
Umeå University, Faculty of Social Sciences, Department of Psychology.ORCID iD: 0000-0003-3256-9018
2019 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Stress-related exhaustion disorder (ED) has been associated with concomitant cognitive impairment, perceived by patients to have large impact on everyday life. However, little is known about how to address cognition in stress rehabilitation and how this could influence stress recovery over time. The aim of this thesis was to evaluate the efficacy of additional cognitive and aerobic training for patients with ED who participated in a multimodal stress rehabilitation program. A further aim was to explore the neural correlates of ED. The main focus of this thesis was on cognitive training, the effects of which were studied from a cognitive, neural, and clinical perspective (Study I-III). The final part of this thesis (Study III) broadened the perspective and investigated the long-term effects of cognitive and aerobic training on cognitive and clinical outcomes.

Study I and II evaluated the effects of process-based cognitive training immediately following the intervention. The results from Study I showed that generalization of training effects following cognitive training was selective and restricted to tasks similar to those trained. The cognitive training group showed a greater reduction in burnout symptoms, and partial support was given for fewer subjective cognitive complaints compared to stress rehabilitation alone. Study II used functional neuroimaging to explore the neural effects of cognitive training, showing training-related activation increases at high working memory load; however, conclusions were restricted due to the small sample.

Study II additionally explored the neural correlates of ED by investigating within-group associations between burnout level and functional neural response during working memory updating. The results revealed that patients with higher levels of burnout showed greater recruitment of working memory-related regions during task execution, potentially reflecting a compensatory mechanism serving to uphold task performance.

Study III evaluated the clinical utility of addressing cognitive impairments in stress rehabilitation. Here, the effects of cognitive and aerobic training on several ED-related variables were investigated 1 year after the intervention. Cognitive training was associated with a small and lasting improvement in cognitive performance. Aerobic training yielded improvements in episodic memory immediately following the intervention, but no significant difference was found between the aerobic training group and the control group at 1-year follow-up. For psychological health and work ability, no additional benefits were seen for the added interventions relative to stress rehabilitation alone. However, a long-term improvement in burnout symptoms favouring cognitive training was observed when restricting the analysis to only include patients who had completed the intervention. This highlights the importance of supporting patients in adhering to added treatments.

In sum, the papers in this thesis provide initial evidence of neurocognitive plasticity in patients with ED and tentatively suggest that cognitive improvements following cognitive training may translate into alleviated clinical symptoms. These results support the argument that interventions targeting cognitive impairments holds a place in the effective rehabilitation of ED.

Place, publisher, year, edition, pages
Umeå: Umeå Universitet , 2019. , p. 74
Keywords [en]
stress rehabilitation, burnout, exhaustion disorder, cognitive training, aerobic training
National Category
Applied Psychology
Research subject
Clinical Psychology
Identifiers
URN: urn:nbn:se:umu:diva-154965ISBN: 978-91-7601-998-6 (print)OAI: oai:DiVA.org:umu-154965DiVA, id: diva2:1275762
Public defence
2019-01-31, S213, Samhällsvetarhuset, Umeå, 09:15 (Swedish)
Opponent
Supervisors
Available from: 2019-01-10 Created: 2019-01-07 Last updated: 2019-01-10Bibliographically approved
List of papers
1. Effects of a process-based cognitive training intervention for patients with stress-related exhaustion
Open this publication in new window or tab >>Effects of a process-based cognitive training intervention for patients with stress-related exhaustion
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2015 (English)In: Stress, ISSN 1025-3890, E-ISSN 1607-8888, Vol. 18, no 5, p. 578-588Article in journal (Refereed) Published
Abstract [en]

Stress-related exhaustion has been linked to a pattern of selective cognitive impairments, mainly affecting executive functioning, attention and episodic memory. Little is known about potential treatments of these cognitive deficits. The purpose of the present study was to evaluate the effects of a process-based cognitive training intervention, designed to target the specific cognitive impairments associated with stress-related exhaustion. To this end, patients diagnosed with exhaustion disorder (ED) were randomized to either a multimodal stress rehabilitation program with the addition of a process-based cognitive training intervention (training group, n = 27) or a treatment-as-usual control condition, consisting of multimodal stress rehabilitation with no additional training (control group, n = 32). Treatment effects were evaluated through an extensive cognitive test battery, assessing both near- and far transfer effects, as well as self-report forms regarding subjective cognitive complaints and burnout levels. Results showed pronounced training-related improvements on the criterion updating task (p < 0.001). Further, evidence was found of selective near transfer effects to updating (p = 0.01) and episodic memory (p = 0.04). Also, the trained group reported less subjective memory complaints (p = 0.02) and levels of burnout decreased for both groups, but more so for the trained group (p = 0.04), following the intervention. These findings suggest that process-based cognitive training may be a viable method to address the cognitive impairments associated with ED.

Place, publisher, year, edition, pages
Taylor & Francis Group, 2015
Keywords
burnout, cognition, executive function, exhaustion disorder, stress rehabilitation, working memory training
National Category
Psychology
Research subject
Psychology
Identifiers
urn:nbn:se:umu:diva-111130 (URN)10.3109/10253890.2015.1064892 (DOI)000369888600011 ()26305186 (PubMedID)
Available from: 2015-11-06 Created: 2015-11-06 Last updated: 2019-01-07Bibliographically approved
2. Rehabilitation for improved cognition in patients with stress-related exhaustion disorder: RECO – a randomized clinical trial
Open this publication in new window or tab >>Rehabilitation for improved cognition in patients with stress-related exhaustion disorder: RECO – a randomized clinical trial
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2018 (English)In: Stress, ISSN 1025-3890, E-ISSN 1607-8888, Vol. 21, no 4, p. 279-291Article in journal (Refereed) Published
Abstract [en]

Stress-related exhaustion has been associated with selective and enduring cognitive impairments. However, little is known about how to address cognitive deficits in stress rehabilitation and how this influences stress recovery over time. The aim of this open-label, parallel randomized controlled trial (ClinicalTrials.gov: NCT03073772) was to investigate the long-term effects of 12 weeks cognitive or aerobic training on cognitive function, psychological health and work ability for patients diagnosed with exhaustion disorder (ED). One-hundred-and-thirty-two patients (111 women) participating in multimodal stress rehabilitation were randomized to receive additional cognitive training (n = 44), additional aerobic training (n = 47) or no additional training (n = 41). Treatment effects were assessed before, immediately after and one-year post intervention. The primary outcome was global cognitive function. Secondary outcomes included domain-specific cognition, self-reported burnout, depression, anxiety, fatigue and work ability, aerobic capacity and sick-leave levels. Intention-to-treat analysis revealed a small but lasting improvement in global cognitive functioning for the cognitive training group, paralleled by a large improvement on a trained updating task. The aerobic training group showed improvements in aerobic capacity and episodic memory immediately after training, but no long-term benefits. General improvements in psychological health and work ability were observed, with no difference between interventional groups. Our findings suggest that cognitive training may be a viable method to address cognitive impairments for patients with ED, whereas the effects of aerobic exercise on cognition may be more limited when performed during a restricted time period. The implications for clinical practice in supporting patients with ED to adhere to treatment are discussed.

Place, publisher, year, edition, pages
Taylor & Francis, 2018
Keywords
burnout, stress rehabilitation, cognitive training, aerobic training, exhaustion disorder, randomized controlled trial
National Category
Applied Psychology
Identifiers
urn:nbn:se:umu:diva-147074 (URN)10.1080/10253890.2018.1461833 (DOI)000442694000001 ()29693483 (PubMedID)
Funder
Forte, Swedish Research Council for Health, Working Life and Welfare, 2009-0772Forte, Swedish Research Council for Health, Working Life and Welfare, 2013-2056Swedish Social Insurance Agency, 99368-2009/RS09Västerbotten County Council
Available from: 2018-04-26 Created: 2018-04-26 Last updated: 2019-01-07Bibliographically approved
3. Neural activation in stress-related exhaustion: cross-sectional observations and interventional effects
Open this publication in new window or tab >>Neural activation in stress-related exhaustion: cross-sectional observations and interventional effects
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2017 (English)In: Psychiatry Research: Neuroimaging, ISSN 0925-4927, E-ISSN 1872-7506, Vol. 269, p. 17-25Article in journal (Refereed) Published
Abstract [en]

The primary purpose of this study was to investigate the association between burnout and neural activation during working memory processing in patients with stress-related exhaustion. Additionally, we investigated the neural effects of cognitive training as part of stress rehabilitation. Fifty-five patients with clinical diagnosis of exhaustion disorder were administered the n-back task during fMRI scanning at baseline. Ten patients completed a 12-week cognitive training intervention, as an addition to stress rehabilitation. Eleven patients served as a treatment-as-usual control group. At baseline, burnout level was positively associated with neural activation in the rostral prefrontal cortex, the posterior parietal cortex and the striatum, primarily in the 2-back condition. Following stress rehabilitation, the striatal activity decreased as a function of improved levels of burnout. No significant association between burnout level and working memory performance was found, however, our findings indicate that frontostriatal neural responses related to working memory were modulated by burnout severity. We suggest that patients with high levels of burnout need to recruit additional cognitive resources to uphold task performance. Following cognitive training, increased neural activation was observed during 3-back in working memory-related regions, including the striatum, however, low sample size limits any firm conclusions.

Place, publisher, year, edition, pages
Clare: Elsevier, 2017
Keywords
Working memory fMRI, Burnout, Stress rehabilitation, Exhaustion disorder, Cognitive training
National Category
Neurosciences Applied Psychology
Research subject
Psychology
Identifiers
urn:nbn:se:umu:diva-139932 (URN)10.1016/j.pscychresns.2017.08.008 (DOI)000412461700003 ()28917154 (PubMedID)
Available from: 2017-10-10 Created: 2017-10-10 Last updated: 2019-01-07Bibliographically approved

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Malmberg Gavelin, Hanna

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