L’éthylisme chronique entraîne des problèmes psychocomportementaux et des déficits cognitifs qu’il est nécessaire de traiter conjointement. Les troubles intellectuels des personnes alcoolo-dépendantes vont compliquer et ralentir le travail thérapeutique. Une prise en charge intégrant un programme de réhabilitation cognitive n’est pas toujours facile à mettre en place et à suivre chez ce type de patient. Les résultats fonctionnels directs sont souvent difficiles à anticiper. En revanche, les conséquences d’une telle approche sont multiples et les interactions entre les composantes psychoaffectives, comportementales et cognitives nombreuses. Le cas clinique décrit permet d’illustrer l’influence d’un travail neuropsychologique sur la prise en charge globale. Les outils utilisés pour les évaluations ainsi que pour la rééducation peuvent secondairement permettre un travail sur la métacognition. Ainsi, les performances obtenues aux tests effectués, le temps nécessaire à la réduction des pertes intellectuelles et les restaurations fonctionnelles réalisées facilitent la prise de conscience des troubles et donc des conséquences neurobiologiques sur le cerveau d’une prise excessive d’alcool. Cette influence indirecte des interventions sur les déficits cognitifs peut réduire les fluctuations motivationnelles de ces patients et constituer une aide à l’abstinence. Il est important de considérer l’ensemble de ces effets dans les propositions thérapeutiques afin d’optimiser les chances de résultats.

Alcoholism causes psychological, behavioral and cognitive symptoms that need to be addressed together. The neuropsychological alterations among alcohol-dependent people are considered to make the therapeutic work complex and longer. A cognitive rehabilitation program is sometimes difficult to achieve with these patients. Functional results are often difficult to anticipate. However, the consequences of this therapeutic approach are multiple and there are many interactions between psycho-affective, behavioral and cognitive components. A neuropsychological approach can be used like a tool to improve metacognition. A bad contribution to treatment programs is often secondary to the illusion of a satisfying intellectual functioning. Patients’ motivation for the therapeutic work is very changeable. A complete consciousness of impairments can help them to stay involved.

The following case shows the cognitive effects and secondary benefits associated with a neuropsychological work, which was carried out by a chronic ethylic patient with severe physical and cognitive symptoms. The patient aged 50, with a good qualification level (scientific section in the final year of secondary school, with no diploma, then attended a training program to become a croupier) was suffering from chronic alcoholism since his adolescence. He arrived in the closed unit after many hospitalizations in psychiatric and hepato-gastroenterology units. He had been showing mental confusion. He presented a frontal and subcortical profile of alcohol-related dementia according to Oslin's criteria. MRI revealed global cerebral atrophy, more pronounced on the fronto-parietal cortex with cerebellar leukoencephalopathy, but no pontine central myelinolysis. The neurocognitive program had two main lines: reducing attentional, executive and graphical deficits with training exercises (individual and group sessions) and compensating memory, and executive disorders with an external aid. The cognitive program had been assessed by means of repeated psychometric measures, behavior and metacognition estimated by direct clinical observations. The cognitive remediation was carried out during a 10-month hospitalization, and then in an outpatient rehabilitation setting over a 12-month period. The external individual sessions were associated with medical consultations and support for reintegration at home provided by the mobile psychiatric team.

The test results showed a significant improvement in attentional processes and executive functions. On graphic level, his writing was recovered after 10 months. Impairment within episodic memory processes-encoding was observed, and prospective memory was reinforced by external aids. At the end of the program, the use of an agenda proved to be effective even if updating was difficult once back home. Although a part of these effects could be expected, their psychological influence on the patient must be underlined: his perception of the alcohol related problem had been modified with more consciousness of the neurobiological consequences and a strong desire of personal implication. He worked a lot on his own (always under supervision) on cognitive exercises and succeeded in remaining abstinent for nearly 2 years. He died of complications of acute hepatitis.

All the cognitive assessments and rehabilitation results seem to have increased his participation in the global therapeutic care. Therapeutic tools used for cognitive work give a concrete picture of the consequences of alcohol consumption and the necessary time to retrieve brain capacities. Visible improvements in terms of reduction in disability-handicaps encouraged the patient, valued his efforts, and increased his determination to solve his alcohol related problem. Thus, cognitive programs can help to reduce passiveness and develop activeness. This patient regarded therapeutic difficulties as a challenge, not as an obstacle. We can reasonably assume the effect of the cognitive rehabilitation on the Persistence of the Cloninger's biosocial model. This increase in temperament corresponds to a certain form of tenacity, which would facilitate abstinence.