Regular Article

Psychother Psychosom 2008;77:289297

DOI: 10.1159/000140088

Published online: June 18, 2008

Psychosocial and Cognitive Rehabilitation of

Patients with Solvent-Induced Chronic Toxic
Encephalopathy: A Randomised Controlled Study
Moniek S.E. van Hout a Ellie M. Wekking b, c Ina J. Berg d Betto G. Deelman e
a

Medical Spectrum Twente Hospital, Enschede; b Departments of Psychology, Neurology and Neuropsychology,
University of Leiden, Leiden; c Academic Medical Centre, Netherlands Centre for Occupational Diseases,
Amsterdam; d Stroke Rehabilitation Unit, Nursing Home Neerwolde, and e Department of Neuropsychology,
University of Groningen, Groningen, The Netherlands

Key Words
Brain diseases, chemically induced Brain diseases,
rehabilitation Chronic toxic encephalopathy
Malingering Solvents, toxicity Treatment outcomes

Abstract
Background: There is little experience with the (neuro)
psychological treatment of patients with solvent-induced
chronic toxic encephalopathy (CSE). In this randomised controlled trial (RCT), a treatment programme was evaluated
based on previous outcome studies of patients with chronic
fatigue, whiplash and traumatic brain damage. Methods:
The treatment consisted of 8 group sessions based on cognitive behavioural principles focusing on inadequate illness
behaviours, and 8 sessions of cognitive strategy training to
compensate memory problems. The research design was an
RCT with follow-up, comparing the cumulative effect of the
2 interventions allocated in random order with a waiting-list
control group. Outcome measures were treatment satisfaction, self-ratings of psychosocial and cognitive changes, psychosocial and memory questionnaires and neuropsychological tests. Multiple linear regression analyses were performed
with baseline scores, treatment versus control condition, effort status, and litigation or financial compensation status as
predictors. Results: Ninety-five patients started treatment,
84 patients had complete data. Treatment satisfaction was
high. After the treatment, only the treatment group had im-

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proved on objective memory tests and on complaints related to CSE, but not on other questionnaires. Treatment effects diminished at follow-up. Insufficient effort and litigation
were negatively associated with treatment outcome. Conclusions: The positive treatment effects on the cognitive
tests were only temporary. It might be important to study
the effect of booster sessions to update practiced cognitive
strategies. Effort was an important predictor of success,
more important than involvement in a litigation procedure.
This finding should have implications for the selection of patients.
Copyright 2008 S. Karger AG, Basel

Introduction

Long-term exposure to organic solvents may lead to

neurasthenic and cognitive symptoms of impaired memory and concentration, irritability, fatigue, instability of
affect and difficulties in impulse control. This syndrome
is called chronic solvent-induced toxic encephalopathy
(CSE). Four conditions must be fulfilled for the diagnosis
of CSE: a relevant pattern of complaints, substantial exposure, a plausible relation in time between exposure and
complaints, and the exclusion of other explanations for
the complaints [1, 2].
In clinical practice, it is difficult to determine whether
a patients cognitive and emotional symptoms are solvent
M.S.E. van Hout
Department of Psychology, Medical Spectrum Twente Hospital
PO Box 50000
NL7500 KA Enschede (The Netherlands)
Tel. +31 53 487 2830, Fax +31 53 487 3072, E-Mail M.vanHout@ziekenhuis-mst.nl

Table 1. Treatment design

Week

Condition A
Condition B
Condition C

18

17

1825 26

38

A1
A1
A1

X1
X2

A2
A2
A2

A3
A3
A3

X2
X1

A5
A5
A5

A4
A4
A4

A = Assessment; X = treatment; A1 = Pre: before treatment;

= Post 1: after completing the first series of 8 sessions; A3 = follow-up 1: before the second 8 sessions; A4 = Post 2: after completing the second series of 8 sessions; A5 = follow-up 2: about
12 weeks after completing the treatment programme; X1 = PST;
X 2 = CST.

A2

induced. Usually, there is no significant neurological and

neurophysiological impairment [3]. Neuropsychological
testing is the cornerstone of the diagnosis [4], but the differential diagnosis is complicated. Many factors have to
be considered when interpreting test results, such as premorbid problems in learning and attention, or the interaction between alcohol abuse and solvent exposure.
Moreover, performance on neuropsychological tests can
be negatively influenced by the presence of affective disorders, pain, somatisation disorders and motivational
problems. Patients with suspected CSE are often involved
in litigation or financial compensation procedures, and
many such patients show insufficient effort in test situations [57].
There is little experience with the (neuro)psychological
treatment of patients with diagnosed CSE. We found only
5 evaluation studies, all uncontrolled clinical case series
yielding inconsistent results [812]. From treatment outcome studies of equally controversial syndromes characterised by a comparable symptom cluster, such as chronic fatigue syndrome and chronic whiplash syndrome, it
might be concluded that cognitive behaviour therapy
techniques focusing on changing illness attributions and
on stimulating graded activity would be useful for patients with CSE [13]. Moreover, the cognitive deficits of
CSE patients might probably best be addressed by cognitive rehabilitation aiming at compensatory memory techniques [1315]. Thus, when designing a treatment procedure for these patients, it seems wise to focus treatment
on this interrelatedness of cognitive, psychosocial and
personality factors [13].
In this study, a newly designed psychological rehabilitation programme of 16 (2 ! 8) sessions will be evalu290

Psychother Psychosom 2008;77:289297

ated. The programme consisted of 8 group sessions based

on cognitive behavioural principles focusing on coping
with the psychological and psychosocial implications of
the syndrome (psychosocial therapy or PST), and 8 sessions, partly group, partly individual, focusing on strategies to compensate for cognitive problems (cognitive
strategy training or CST). The study design was a randomised controlled cross-over design in which the sequence of the therapies was alternated, and results of the
treatment groups were compared to those of a waiting-list
control group. Outcome measures were psychosocial as
well as cognitive variables.
The aims of this study were: (1) to determine whether
the treatment group as a whole showed more improvement on the outcome variables after treatment and at follow-up than the waiting list control group; (2) to investigate whether individual factors, such as the involvement
in a litigation procedure, or insufficient effort on neuropsychological testing contributed to the (lack of) success
of the treatment, and (3) to determine how many individuals improved according to a criterion of clinical relevant change (reliable-change index) [16, 17].

Methods
Participants
Ninety-five patients with diagnosed CSE participated in the
study. All patients had been referred by general practitioners or
medical officers to 1 of the 2 locations of the Netherlands Centre
of Occupational Diseases from 1998 to 2003. Diagnosis was based
upon a 3-stage process of assessment, including a clinical neurological examination, assessment of exposure and a comprehensive psychological evaluation [18, 19]. A CSE diagnosis was made
if exposure was substantial, neuropsychological deficits were objectified, and alternative diagnoses were not applicable.
Participants were accepted for treatment if they met the following additional selection criteria: (1) a CSE diagnosis was made;
(2) memory problems were objectified on neuropsychological
tests, operationalised as a standardised sum score of !1.28 (corresponding with the 10th percentile) on the total acquisition score
of the Dutch version of the California Verbal Learning Test [20]
and the immediate recall of the stories subtest of the Rivermead
Behavioural Memory Test [21, 22], and (3) the patient was motivated for treatment.
Study Design
Participants were randomly assigned to 1 of the 2 treatment
groups (A or B) or the control group (C). An independent staff
member performed the group assignation without knowledge of
clinical and psychological data.
Each patient in the treatment groups participated in 2 series of
8 treatment sessions: PST and CST. In treatment group A participants first participated in the PST, and then in the CST. In treatment group B this order was reversed. See also table 1. After com-

van Hout /Wekking /Berg /Deelman

pleting all evaluations, the control group C was offered treatment

(no results available).
Participants were evaluated 5 times: about 2 weeks before treatment (Pre), about 1 week after the first 8 sessions (Post 1), about 8
weeks later before the second series of sessions (follow-up 1), about
1 week after the second series of 8 sessions (Post 2) and about 3
months after completing the treatment programme (follow-up 2).
In this study, we will focus on the treatment effects of the treatment as a whole, for the entire treatment group, compared to the
results of the control group, at Post 2 and follow-up 2.
Treatment Procedures
Psychosocial Therapy
This semi-structured group therapy of 8 weekly 2-hour sessions was psycho-educational and based on cognitive behavioural
principles. Treatment focus was on recognition and acceptation
of complaints, and on social reintegration. The group members
were seen as experts with respect to coping with CSE, and were
stimulated to give feedback to each other. The therapeutic aim
was to challenge inadequate cognitions regarding coping with the
syndrome and to develop more active coping styles. For each
group member a specific and attainable personal goal was formulated, and in each session the achievements regarding this goal
were evaluated. The therapy format was semi-structured in the
sense that there was a treatment protocol for each session, but
there was opportunity to focus on acute problems presented by
the participants.
Cognitive Strategy Training
This treatment of 8 weekly sessions focused on the development of compensation strategies for memory problems and their
use in daily life, based on evidence from studies on cognitive
(memory) rehabilitation [2325]. Patients were instructed in
groups on the use of memory aids (3 two-hour group sessions), and
received individual treatment in which 6 internal memory strategies were discussed and practised in daily homework exercises, in
relation to 1 of 3 target problems chosen by the patient (four 45min sessions). These strategies were: spend more attention and
time to the memorandum, repeat it a few times, try to find associations, organise and link the input and retrieval situation [23].
Possible target problems were remembering names, remembering
written text and coping with attention problems. These sessions
were individual because the strategies were tailored to the target
chosen by the patient and had to be exercised during the sessions.
Treatment was structured according to a standardised protocol.
The participants received a workbook with information and exercises to practice learned strategies. The treatment ended with a
plenary session summarising and evaluating treatment.
Subject Characteristics
Litigation Status
Current involvement in a litigation procedure, a workmans
compensations claim, a procedure for receiving a disability pension, or any other form of financial compensation procedure was
registered.
Effort Status
Effort status was assessed by a test specifically designed for the
detection of insufficient effort, the Test of Memory Malingering
[TOMM; 26], and by extremely low scores on the Warrington

Neuropsychological Rehabilitation of
Chronic Toxic Encephalopathy

Recognition Memory Test for Faces [RMT-F; 27] as an indicator

of suboptimal effort [28]. TOMM and RMT scores were dichotomised into 2 categories: sufficient or insufficient effort. The recommended cut-off scores for the TOMM were used. The cut-off
score of the RMT (27/28) was based on the Iverson study [28].
Evaluation Measures
Treatment Satisfaction and Perceived Changes as a Result of
Treatment
Treatment satisfaction was assessed (only for the treatment
groups) by a short evaluation questionnaire (at Post 1, Post 2 and
follow-up 2), consisting of 8 questions using a 10-point scale concerning satisfaction, usefulness of the treatment for everyday life,
and experienced support and empathy by group members and
therapists. Perceived changes in psychosocial and cognitive functioning since the treatment were measured (only for the treatment
groups) by a short evaluation questionnaire completed at Post 1,
Post 2 and follow-up 2. This questionnaire consisted of 7 questions using a 7-point scale ranging from very much worse (1) to
very much improved (7). Improvement was defined as a score of
5 (moderately improved) or higher. Questions concerned acceptation of CSE, the relationship with the partner, children, friends
and acquaintances, and leisure activities. Partners were asked to
give their opinion about the patient by independently completing
these same questionnaires.
Psychosocial Functioning
(1) Acceptation was assessed by a 6-item questionnaire referring to acceptation of and coping with complaints.
(2) Sickness Impact Profile (SIP-68) scales 4 (social behaviour,
12 items), 5 (emotional stability, 6 items), and 6 (mobility range,
10 items), were used to give an indication of health-related functional condition [29]. For all items yes-no responses were used.
(3) Complaints related to CSE were investigated with the Target Complaint List (TCL), a Dutch adaptation of the Swedish Target Complaint Lists [30]. The TCL consists of 26 questions asking
for a judgment on the frequency of complaints specifically related
to CSE (min 0 = never, max 2 = often per item) and the experienced hindrance (min 0, max 10 per item). The total score is obtained by multiplying reported frequency and experienced hindrance of complaints.
(4) Mood symptoms were identified by a standardised sum
score of the Dutch version of the Hospital Anxiety and Depression
Scale, consisting of 14 questions on a 4-point scale [31, 32], and
the mood scale of the Neurotoxic Symptom Checklist (NSC-60).
The NSC-60 consists of 53 questions divided into 7 subscales designed to elicit information regarding mood and affect, absentmindedness and memory problems, sensory and motor disturbances, chest problems, equilibrium disturbances, somatic problems, fatigue and sleep disturbances [33]. Responses are given on
a 4-point scale: never seldom sometimes often.
(5) Somatic symptoms were assessed by 5 subscales of the
NSC-60 (sensory and motor disturbances, chest problems, equilibrium disturbances, somatic problems, fatigue and sleep disturbances).
(6) Two subscales of the Utrecht Coping List were used to assess passive and avoidant coping styles [34]. These scales consist
of 7 and 8 items, respectively. Responses are given on a 4-point
scale: never sometimes often very often.

Psychother Psychosom 2008;77:289297

291

Partners were asked also to complete 3 questionnaires in order

to provide an intersubjective indication of the psychosocial functioning of their spouse: the questionnaire referring to acceptation,
the SIP-68 and the TCL.
Cognitive Functioning
(1) Subjective memory complaints were assessed by a memory
questionnaire of 37 questions on a 7-point scale (item range 17;
total score min. 37, max. 259) rating the frequency of everyday
memory complaints [23], and by Sickness Impact Profile 3 (psychic autonomy and communication). Partners were also asked to
complete these questionnaires.
(2) Memory and learning were defined by a sum score, based
on the Name Face Test (total acquisition and delayed recall score)
[24, 25], the Groningen 15-words test, a Dutch version of Reys
auditory verbal learning test (total acquisition and delayed recall
score) [35], and the Stories subtest of the Rivermead Behavioural
Memory Test (acquisition score) [21]. For each memory test, 2
parallel versions were used and all parallel versions were standardised per version.
(3) Control task: CST is not primarily intended to increase
speed of response [36]. To differentiate the effect of cognitive
strategy training from general effects of recovery or increased
task motivation, the Colour Word Vigilance Test of the Neurobehavioural Evaluation System was administered.
Analysis
Data were analysed using SPSS 12.0 for Windows. When comparing group means at baseline, 1-way analysis of variance was
used. Pearson correlations were used for analysing relationships
between continuous variables and 2 tests for the relations between discrete variables.
To answer the first research question (is treatment effective?),
global estimates of the effect of treatment on the various outcome
measures were obtained by linear regression analyses with group
assignment (treatment or control) and baseline values of the effect
measures as the independent variables. Baseline values were included because treatment outcome is highly correlated with baseline scores, and these should be corrected for first [37, 38]. Regarding therapy satisfaction and reported changes in psychosocial and
cognitive functioning, descriptive statistics were given for the entire treatment group at Post 2 and follow-up 2.
To answer the second research question (which factors contribute to success?), a priori hypothesised potential confounders
(e.g. effort and litigation status) were added to the global linear
regression models. A person with insufficient effort on neuropsychological tests, or involved in a litigation or financial compensation procedure, might have reduced motivation to achieve therapeutic success as well. The relation between treatment satisfaction
and reported change and potential confounders was studied by
the Mann-Whitney U test and Spearmans . Considering the
third research question (how many individuals improve?), the
proportion of individuals with a relevant improvement was determined according to the reliable change index [16, 17, 36]. For reasons of efficiency, these frequencies will only be presented for
variables for which in the previous analyses significant effects had
been reported. With a 1-tailed hypothesis, a reliable-change index
larger than 1.64 is unlikely to occur (p ! 0.05) without actual
change.

292

Psychother Psychosom 2008;77:289297

Results

Participants
There were 126 patients who met the inclusion criteria and were invited for treatment. Ninety-five patients
were motivated for treatment. Every patient completing
treatment and measurements at Post 2 was defined as a
complete data case. Thus defined, 11 patients (12%)
dropped out of treatment and/or did not complete all assessments: 7 patients dropped out because of health or
family circumstances and 3 because of motivation problems that led to a refusal to participate any further, and
1 found a full-time job. All drop-outs were in the treatment groups (6 patients in treatment group A, 5 patients
in treatment group B); in the control group all patients
completed the measurements. Two of the complete cases had no follow-up data (1 in group B, 1 in the control
group). The group with complete data did not differ
from the dropouts in any of the subject characteristics,
nor in any of the effect measures at baseline. Patient
characteristics from the complete data group are presented in table 2.
The treatment group appeared to differ significantly
from the control group in age (M treatment group 48, M
controls 51.0, p = 0.04) and exposure duration (expressed
in years, corrected for full-time/part-time differences)
(M treatment group 24 years, M controls 29, p = 0.02).
The groups did not differ in educational level (p = 0.32),
level of exposure (p = 0.44), effort status (p = 0.18) or litigation status (p = 0.72), nor in any of the outcome measures at baseline.
Results regarding Question 1 (Is Treatment Effective?)
Treatment Satisfaction and Reported Change
Overall, patients were very satisfied with treatment
(M = 8.5, SD = 1.0); they judged treatment as useful for
everyday life (M = 7.2, SD = 1.3), and they experienced
much support and empathy from their peers and therapists (M = 8.6, SD = 0.9). Satisfaction scores did not differ significantly between Post 2 and follow-up 2. Although the partners were also satisfied at Post 2, their
ratings were significantly lower than those of the patients (M satisfaction 7.5, p = 0.000; M usefulness 6.5,
p = 0.01). The partner ratings also remained stable at follow-up 2.
Changes in psychosocial and cognitive functioning at
Post 2 perceived by patients and their partners are presented in table 3. Results did not differ between Post 2
and follow-up 2 for all variables.

van Hout /Wekking /Berg /Deelman

Psychosocial and Cognitive Outcome Measures

In the linear regression analyses with group assignment and baseline values as independent variables, treatment had no effect on the majority of the outcome measures at Post 2. Only for 3 outcome measures did treatment reach borderline significance: the memory sum
score (regression coefficient = 0.40, 95% CI 00.80, p =
0.052), the target complaint list (regression coefficient =
0.41, 95% CI 0.840.02, p = 0.062), and the SIP sum
score (regression coefficient = 0.24, 95% CI 0.050.54,
p = 0.10). This means that the treatment group had 40-SD
higher memory scores at Post 2 than the controls, once
baseline levels were accounted for. The treatment group
had fewer complaints on the TCL than controls, but a
worse score on the SIP. At follow-up 2 treatment effects
were no longer present.
Results regarding Question 2 (Which Factors
Contribute to Success?)
Treatment Satisfaction and Reported Change
Satisfaction at Post 2 was significantly lower for patients exerting insufficient effort (Mann Whitney; p =
0.023). 69% of the patients exerting sufficient effort rated
themselves as cognitively improved at Post 2, compared
to 33% of patients exerting insufficient effort (p = 0.016).
Of the partners, these figures were 68 versus 7% (p =
0.0001). Differences were not significant for the other
variables. At follow up significantly more patients and
spouses of the sufficient effort group rated their relationship and the cognitive functioning of the patients as improved, as compared to the insufficient effort group.
Psychosocial and Cognitive Outcome Measures
In the linear regression analyses with group assignment, baseline values, effort and litigation status as independent variables, treatment only was a borderline significant (p = 0.059) predictor of Target Complaint scores
at Post 2. The treated group showed a decrease in complaints once baseline level, effort status and litigation status were accounted for. This effect was not present at follow-up 2. For the other psychosocial outcome variables
there were no significant predictors of treatment outcome at Post 2 or follow-up besides baseline level. One of
the other findings was that effort was a significant independent predictor of the partners ratings of target complaints of their husbands. Partners of patients exerting
insufficient effort on neuropsychological testing reported more complaints at Post 2.
Concerning the cognitive outcome measures, treatment (p = 0.02) and effort status (p = 0.008) were signifiNeuropsychological Rehabilitation of
Chronic Toxic Encephalopathy

Table 2. Patient characteristics (complete data group)

Frequency %

Primary education and lower 31

occupational (no diploma)
Lower occupational (diploma) 53
and mid-level or higher

37

Level of
exposure**

Moderate
High

51
33

61
39

Occupation

Painters
Spray-painters
Printers
Chemical/paint industry
Upholsterers
Others

42
11
14
4
4
9

50
13
17
5
5
11

Work situation

Working
Sick-leave
Disability pension
Retired
Unemployed

27
19
35
1
2

32
23
42
1
2

Effort

Sufficient effort
Insufficient effort

64
20

76
24

Litigation/financial No
compensation
Yes

48
36

57
43

Total

84

100

Education*

63

* This classification system is not based on years of education,

but on level of completed education.
** Exposure severity, based on workplace concentration,
symptoms of acute intoxication and use of personal protection
equipment, was assessed by an occupational hygienist and was
classified in 2 categories: moderate and high.

Table 3. Perceived improvement by patients and partners at Post 2

Acceptation
Relationship partner
Relationship children
Relationship friends
Leisure activities
Cognition

Patients
(n = 57)

Partners
(n = 52)

42 (74%)
30 of 52 (58%)
27 of 49 (55%)
22 (39%)
30 (53%)
32 (56%)

29 (56%)
21 (40%)
19 (39%)
15 (29%)
22 (42%)
26 (50%)

cant predictors for memory scores at Post 2. This effect,

however, was not maintained at follow-up 2. For the control task no treatment effect was found, but effort status
was a significant predictor of scores on the control task at
Psychother Psychosom 2008;77:289297

293

Table 4. Treatment effects and interaction with treatment for the outcome measures

Outcome measures

Main treatment
effect*

Interaction with
treatment**

Psychosocial outcome measures

Subjective
Acceptation
Target complaints
Sickness impact profile
Mood
Somatic complaints
Coping style
Intersubjective
Acceptation according to partner
Target complaints according to partner
Sickness impact profile according to partner

0
+
0
0
0
0

0
Age, +
Exposure duration,
0
Exposure severity,
0

0
0
0

0
0
Education, +

Cognitive outcome measures

Subjective
Intersubjective
Objective: memory
Objective: control

0
0
+
0

Effort,
Education, +
Age, +
Effort,

* Main effect: 0 = no significant change; + = treatment group improved, compared to controls; = treatment group deteriorated, compared to controls.
** Interaction effect: 0 = no significant interaction with treatment; + = treatment group improved if presence/higher value of predictor; = treatment group deteriorated if presence/higher value of predictor.

Post 2 (p = 0.016), meaning that patients exerting insufficient effort had less improvement on Post 2. At followup 2 effort status was still negatively related to scores on
the control task, but not significantly. However, litigation
status was a significant predictor of follow-up 2 scores
(p = 0.023).
One of the other findings was that effort status and
litigation status were significant independent predictors
of subjective memory ratings at Post 2, in the sense that
subjects exerting insufficient effort and subjects in a litigation procedure reported more cognitive complaints at
Post 2. At follow-up 2, baseline scores were the only significant predictors. The stepwise regression analyses
yielded a significant interaction effect between treatment
and effort for the subjective memory ratings, in the sense
that patients in the treatment groups exerting insufficient
effort reported relatively more increase in memory complaints at Post 2.
Effects of Age, Education and Exposure on Outcome
Main treatment effects and interactions between predictors and treatment are summarised in table 4. Because
this study is focused on the effects of treatment, only the
294

Psychother Psychosom 2008;77:289297

main treatment effects and interactions with treatment

are presented here.
For the intersubjective memory ratings an interaction
effect was found for treatment and educational level:
partners of patients with a higher education reported
a relatively greater decrease in memory complaints at
Post 2.
For the memory score a significant interaction between age and treatment was found: the higher the age,
the greater the increase in memory scores in the treatment group.
Results regarding Question 3: Clinical Relevance of
Changes
The number of individuals with a relevant improvement was determined according to a reliable change index of 1.64. In the previous analyses effort status appeared to be negatively associated with treatment outcome. Therefore frequencies of clinical relevant change
are presented separately for the subgroups exerting sufficient and insufficient effort. Results are only presented
for the two variables for which a significant treatment effect was obtained in the previous analyses.
van Hout /Wekking /Berg /Deelman

As can be seen in table 5, 13 (32%) of the patients in the

treatment group exerting sufficient effort had improved
on the memory tasks at Post 2, compared to 0% of the treated patients with insufficient effort scores (p = 0.01). For the
controls these figures were 3 (13%) and 0 (p = 0.085). With
respect to the target complaints, only 2 treated patients
with sufficient effort improved, and 1 treated patient exerting insufficient effort. None of the controls improved.

Discussion

The general results of this first randomised controlled

study evaluating psychological treatment for patients with
CSE were modest. As in another study [13], treatment satisfaction and reported psychosocial and cognitive change
by patients and partners were high, but these findings
were not reflected in the questionnaires concerning psychosocial, somatic and cognitive functioning.
There are several possible explanations for this difference between satisfaction ratings and questionnaires:
First, most questionnaires investigate symptoms and not
functional changes. It can be questioned whether somatic and cognitive symptoms related to a chronic somatic
or cerebral disorder can be substantially reduced by psychological treatment [38]. On the contrary, it might well
be that a patient experiences improvement in social reintegration and physical activities, but nevertheless experiences the same somatic and cognitive symptoms. Second,
the exchange of experiences in a group setting might lead
to more recognition of symptoms associated with CSE.
Finally, it is not certain whether a questionnaire designed
to differentiate sickness severity at one specific moment
is the optimal instrument to measure responsiveness to
treatment. Disease-specific measurements might be more
responsive than generic instruments [39, 40]. The treatment effects found only on the Target Complaints seem
to be in line with this idea. Treatment had a positive,
though not lasting, effect on objective memory test performance. It is important to stress that the tests used for
treatment evaluation were not practised during the strategy training. Thus, it might be suggested that, at least
temporarily, the memory techniques learned in the training had a generalised effect. The fact that treatment effects were not found on the control task where the strategies could not be applied indicates that the improvement
was an effect of strategy training. Unfortunately, this
treatment effect was no longer significant at follow-up.
This is consistent with some other treatment evidence
concerning memory strategy training [25]. It might be
Neuropsychological Rehabilitation of
Chronic Toxic Encephalopathy

Table 5. Number and percentage of patients with relevant change,

using an RCI of 1.64

Treatment group

Control group

sufficient
effort

insufficient
effort

sufficient
effort

insufficient
effort

Memory sum score

Improved
13 (32%)
Unchanged
28 (68%)
Deteriorated
0

0 (0%)
16 (100%)
0 (0%)

3 (13%)
20 (87%)
0 (0%)

0 (0%)
2 (50%)
2 (50%)

Target complaint list

Improved
2 (5%)
Unchanged
39 (95%)
Deteriorated
0 (0%)

1 (6%)
14
1

0 (0%)
19
2

0 (0%)
4 (100%)
0 (0%)

interesting to study the effect of booster sessions on a

regular basis, to update trained cognitive strategies.
The second research question of this study was which
individual factors might contribute to the success of the
treatment. Patients exerting insufficient effort were less
satisfied and benefited less from the treatment. Effort appeared to be a more important predictor of treatment failure than involvement in a litigation or financial compensation procedure. This is an important finding that as far
as we know has not yet been described elsewhere. The fact
that effort was not significantly correlated with litigation
status (Spearman 0.094; p = 0.39) in our study group,
suggests that there are more reasons for insufficient effort
than external financial motivations. Possibly the influence of being trapped in unconscious sick-role playing is
more important. In this sense it was rather disappointing
that the psychosocial therapy, focusing on challenging inadequate illness cognitions and on developing more active
coping styles, was not effective for subjects exerting insufficient effort. Methods to detect insufficient effort on neuropsychological tests should be used when selecting patients for a cognitive rehabilitation programme. Which
treatment programme would be useful for patients exerting insufficient effort remains a topic for further study.
Regarding the third research question considering the
proportion of patients with clinical relevant improvement, the difference between the sufficient- and the insufficient-effort groups was striking. In the insufficienteffort group there was not a single patient with significant
improvement.
Finally, we want to make a remark as to the choice of
effect measures. Our results suggest that it is necessary to
use or develop questionnaires that are more responsive to
Psychother Psychosom 2008;77:289297

295

individual changes in psychosocial functioning. Further

development of the CSE-specific Target Complaint List
might be useful. In our research design we only crudely
evaluated changes in everyday life. In future studies more
objective measures of social relations and reintegration
should be used, such as family interactions and activities,
(part time) return to work, and medical consumption. In
our treatment, every patient formulated an individual
goal. It is interesting to focus attention on an adequate
measurement of these individual treatment goals in future evaluation studies, for example by goal attainment
scaling techniques [41].

Acknowledgements
The Solvent Team Project is funded by the Health Care Insurance Board, Amstelveen, The Netherlands. We are grateful to Ingrid Baveld and Joke Bruins, who acted as co-therapists in the
treatment groups, and to Kim Beukenhorst, Rhody Haalboom,
Joyce Kip and Ieteke de Vries for conducting the assessments. We
thank Job van der Palen and Ivo Molenaar for methodological and
statistical advice. We express our special gratitude to Iris Schmidt
for so willingly providing training and test materials.

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