 This episode was prerecorded as part of a live continuing education webinar. On-demand CEUs are still available for this presentation through all CEUs. Register at allceus.com slash counselor toolbox. I'd like to welcome everybody to today's presentation on mental disorders caused by addiction. Now a lot of the stuff we've been talking about over the past few sessions are correlated and we can see where like depression and anxiety may be triggered by. But what we're talking about today is stuff that there is a direct causative link between alcohol use in this case and, well, opiates to a certain extent too, and the development of these disorders. They actually cause them. So we're going to define alcohol related brain damage. That's where we're going to start like autism spectrum disorders and fetal alcohol spectrum disorders. ARBD is a spectrum and you can have certain characteristics. You can have certain issues. It can be mild, moderate or severe. But we're going to talk about what in general to look for today. We're going to explain how awareness of ARBD is vital for mental health as well as addiction counselors. Learn about the symptoms of ARBDs including alcoholic dementia and vascular dementia. And learn about fetal alcohol spectrum disorders. Now there is so much information out there on fetal alcohol spectrum disorders. And I've already done some presentations which are on our YouTube channel at youtube.com slash all CEU's education. If you want to go there and review those, we also have some CEU classes on it. And I will be doing more FASD classes in the future. I say that because we're not going to cover 1% of the information that's out there. So hopefully you'll get some useful tools for identifying if you might be working with a client with a FASD. And what you can do in order to improve the effectiveness of your treatment with that person. So alcohol related brain damage, ARBDs. Damage directly caused to the person by exposure to alcohol or other drugs. Now alcohol related dementia and in here we're also talking about Wernicke-Korsakov syndrome is one of them. Vascular dementia is another one and it's caused by the brain not getting enough oxygen, not getting enough blood supply and fetal alcohol spectrum disorders. So those are the three that we're really going to cover today. According to the CDC, and this is important, most excessive drinkers do not meet the criteria for dependence, meaning that they may present in mental health clinics for treatment of mood disorders. So, you know, think about some of the shows that you may watch on TV. Arrow is one I'm thinking of where his mother constantly had a martini or something in her hand. It didn't matter if it was 10 in the morning or 10 at night. She may not have met the criteria for alcohol dependence. She may not have been, you know, to the point where she would experience the physiological withdrawal symptoms and the tolerance, but she drank a lot. And we'll talk about what a lot is in a minute. About 17% of the adult population reported binge drinking and 6% reported heavy drinking, which is more than the recommended amount. So when we're talking about substance use disorders, you've got, you know, almost one in five people that reports binge drinking. So that's rapidly increasing the level of that toxin in your system that talks into your brain. Even, you know, sporadically can be really detrimental to the health of your brain tissue. ARBDs are caused by regularly drinking too much alcohol over several years. And what does regularly mean? We don't really know. But we do know that you don't have to be alcohol dependent in order to cause ARBDs. We do know that drinking too much such as binge drinking on the weekends can cause ARBDs. So think again, college, I don't know what your college was like. Mine was not a dry campus. So there was a lot of drinking that took place. And, you know, the people that were drinking typically binge drank on the weekends and not so much during the week. ARBDs cover several different conditions, which are similar to, but not actually dementia. And when we talk about dementia as the diagnosis, what we're talking about is certain brain changes that occur, such as in Alzheimer's. With ARBDs and alcoholic dementia, the symptoms are similar, but there are some vital differences. Namely, people with alcoholic related dementia, especially if it's caught early, may make a full or partial recovery. People with Alzheimer's, they don't turn that corner. And people with ARBDs, if they stop drinking and develop a healthy lifestyle, will likely not experience a worsening of their condition. So this is really optimistic for people if they notice that, you know, they're starting to have some cognition issues, starting to get harder to focus. And, you know, what we're talking about often we see in patients that are in their 40s and 50s. So they may start thinking, you know, I'm starting to get, you know, old person brain or whatever. You know, when I was in my 20s, I called it mommy brain. Because, you know, with two little kids and not sleeping, I couldn't remember my own name some days. But a lot of people may present in treatment with depressive type symptoms and have difficulty with concentration, have difficulty with remembering things and not attribute it necessarily to alcohol yet. But then you find out that they're drinking kind of heavily or binge drinking regularly. And this might start to become something that we look at because if they stop, they can improve their cognition. They can reverse some of these problems. And that is the hope that I want them to, you know, grab on to not, oh my gosh, what did I do to myself? But, oh my gosh, it can get better. ARBD is greatly undiagnosed. And the NIAAA is the National Institute for Alcoholism and something else. But there's a lot of A's in there. Anyway, what the study finds is that postmortem findings, and this is just think about this for a second, indicate that ARBDs affect about one out of every 200 of the general adult population. That means go into Walmart or go over to, you know, when you're in church, look around, especially if you go to a church that has two or 300 people in there. And I remember when I was in college, you know, we would have certain seminars that there were 700 people. So of those people, you know, if there were 700, well, let's do 800, so I don't have to do math too hard. That means four people in there may at some point, you know, drink enough that they're going to develop an alcohol-related brain disorder. That's, you know, interesting. That's kind of scary. Among those with alcoholism, those who actually meet the criteria for tolerance and dependence and withdrawal, this figure rises to as high as one in three. So if you work with people who are diagnosed as having alcoholism, it's important to recognize that as many as one in three of them may have enough going on or may have consumed enough alcohol that they have caused actual brain changes that will probably get better with time and not drinking. So we want to help people look at this, but we also want to educate them if they keep drinking their memory, their ability to think clearly, all that stuff is going to get worse. People with an ARBD tend to be in their 40s or 50s. So they've been doing this binge drinking or excessive drinking probably for a while. But like I said, a lot of times when we diagnose it, if you will, or when we identify it, it's people who are coming into treatment, maybe with some depression or anxiety, but also complaining that they're foggy-headed and they're confused all the time and they forget things a whole lot more easily and they attribute it to stress. Well, what do you do when you're stressed? I have a few drinks. Okay, so let's take a look at that. Alcohol-related brain damage is thought to cause more than 10% of dementia symptoms in people under 65. So interesting to kind of take a look at that. Now, for your quiz, I'm not going to test you on specific percentages. That's kind of irrelevant. I just want you to get an idea of the scope of what we're talking about and how often clients who are walking into your office who don't meet any criteria for alcohol dependence may actually have an alcohol-related brain disorder or alcohol-related brain damage. Drinking more than the recommended limit for alcohol increases a person's risk of developing common types of dementia, such as Alzheimer's and vascular dementia. So, drinking does increase your risk of developing actual dementia, but alcoholic dementia or Wernicke-Korsakov syndrome are not true dementia. Recommended limits, I keep saying heavy drinking. Well, what is heavy drinking? Recommended limits are now a maximum of 14 drinks each week with a maximum of two each day. And I'm not talking about, you know, filling this with vodka and calling it a single drink. I'm talking about normal amounts. Vodka would be, you know, your hard liquors are going to be like one ounce and you're a can of beer, you know, a couple ounces of wine. Those sorts of things is what we're talking about is one drink. So a maximum of two per day is moderate drinking. Go higher than that. You've crossed over into that heavy area. One of the things that's important to recognize about that is alcohol becomes much more toxic in women's bodies much more quickly, partly because we have more fat composition and just the makeup of our bodies and everything else. We know that alcohol affects us more strongly, more quickly. So, well, well, you may have a man and a woman and both have a blood alcohol of 0.25 and they're both standing amazingly. The woman with 0.25 is going to experience more symptoms and probably be a whole lot drunker and sicker. So it's important to recognize also that that also means that the toxicity to our brain tissue is a lot stronger and happens at kind of a lower level. Repeated binge drinking, heavy drinking in one session is particularly harmful. Like I said earlier, when you binge drink, you go and you go and you go until you're puking in the toilet or doing whatever you're doing. You drink multiple drinks in a relatively short period of time, which just bathes your brain tissue in alcohol, basically. I mean, there's more to the biochemistry than that, but you get my point. There's an increased risk of dementia, the higher the level of alcohol consumption. But remember, you don't need to be an alcoholic or to get drunk often to be at an increased risk of developing vascular dementia, alcohol-related brain damage. Those are things that could happen, you know, just with heavy drinking or regular binge drinking. Regular drinking, even a little above recommended levels increases your risk and they didn't define what a little above means. But, you know, we'll just stick with the 14 drinks each week with a maximum of two per day. Alcohol-related brain damage causes a range of conditions, including alcohol, dementia, or alcohol-related dementia depending on where you are, the same thing. And we're Nikki Korsakov syndrome, sometimes just called Korsakov syndrome. ARBD, as you know, an umbrella, is defined as long-term decline in memory or thinking caused by excessive alcohol use and lack of vitamin B1. Alcohol affects the way your body processes vitamin B1 and excessive use also damages the internal lining and stuff so your body can't absorb nutrients as well, which causes B1 to go down. Regular heavy, more than 14 drinks a week, drinking over time can cause damage to nerve cells because of the alcohol. Chemical changes in the brain, so your neurochemicals get all wonky. Shrinkage of brain tissue, so you're kind of shrinking those things down. Think like when you put toner on your face, you're shrinking your pores while you're kind of doing the same thing when you're taking alcohol and putting it on your brain tissue. Not the same way, but just helps you remember it. Intestinal damage leads to poor nutrient absorption. Poor handling of thiamine. Damaged blood vessels. So your blood vessels get stiffer and can get thicker, which causes problems, can cause high blood pressure. And damaged blood vessels, reduced circulation, high blood pressure combined with that increases your risk of heart attacks and strokes. Why do we care? Well, because when heart attacks and strokes happen, then blood and or oxygen gets cut off to the brain because blood brings oxygen to the brain. And if you don't have enough blood going to the brain, then you're clearly not going to have enough oxygen. So it's important to make sure that the cardiovascular system keeps going. Symptoms of alcohol related dementia largely reflect the areas in the person's brain that are damaged. Well, that makes sense. What we're looking at are any of these poor planning and organizational skills, problems with decision making, judgment and risk assessment. When we get down to fetal alcohol syndrome, a lot of this is going to sound really familiar. Why is that? Because the fetus was exposed to toxic levels of alcohol in utero. But I digress. Problems with impulsivity, making rash financial decisions, for example, and difficulty controlling emotions. So they may have some irritability outbursts. So we can use emotion regulation, vulnerability prevention, distress tolerance, skills. And in certain circumstances relapse prevention techniques to help people control their emotions because they just may be really hair trigger for lack of a better phrase when they are at the state of ARBD that they're at. If it improves, a lot of other stuff will probably improve. But, you know, sometimes we interact with somebody when they are at this point. I remember distinctly one client I worked with who had Korsakov syndrome and bless his heart. He was having difficulty with organization. He would, you know, have problems getting dressed in the morning. You know, he was pretty bad off and he would just get so frustrated and so angry and just have the outbursts. A lot of times, you know, especially getting ready for group and stuff in the morning when he was having to do a lot of things independently. So we can look at when do these outbursts occur? How can we help them manage this during their recovery period? And that's what I always emphasize is it's probably going to get better. But during your recovery period, what do we need to do to help you get through the day? They may have problems with attention and slower reasoning. So go slow. Some people with ARBDs, many actually, will not do well in group, psychoeducational groups because it just goes too fast for them. They may need smaller chunks of information. So if you're working in a treatment center and you've got 12 patients in a group and one of them has an ARBD, being aware that that person is probably only getting about 20% of what you're talking about. So they're going to need handouts to look at maybe some more individual sessions, etc. They may have lack of sensitivity to the feelings of other people, inability to kind of read what's going on. It sounds a lot like a FASD once we get down there. Behavior which is socially inappropriate. Unlike Wernicke-Korsakov syndrome, however, not everyone with alcoholic dementia has a loss of day-to-day memory. So they may remember things from day-to-day but have these big gaps in what's going on. In order to diagnose this, the person must have stopped drinking alcohol for several weeks to enable the symptoms of alcohol intoxication to withdrawal. Alcohol intoxication and withdrawal to resolve. Then they need a full physical from a doctor which will include a detailed history from the person and ideally someone who knows them well. Why? Because of those gaps in memory. We need to know what's going on and we don't want our best guess. We would like to know exactly how much is the person drinking, how long have they been drinking, what else has gone on, have they had head injuries, how their symptoms started and they're affecting their life. The test of the person's mental abilities, their memory and their thinking. Now that's something we can do without a significant other but sometimes it's helpful if we're asking where were you born. We don't necessarily know that. So if we have the significant other, we've got a fund of information that we can draw from to test prior memory. And tests for depression because confusion, difficulty with decision making, many of these symptoms are also common in depression. So if they're experiencing a major depressive episode, you know, we want to differentially diagnose. A brain scan obviously ordered by the physician might be required to rule out other possible causes of symptoms such as an actual stroke, brain bleed or a tumor. And this can kind of freak people out but generally I reassured them that, you know, a lot of the time it's from the alcohol. So, you know, let's just go in and rule out these other things so we can get the best course of treatment. The brain scan may show changes such as shrinking at the cerebellum at the back of the brain, which supports diagnosis of ARBD rather than true dementia. So if they get the brain scan and they see the shrinking in the cerebellum, you know, remember alcohol causes shrinking in the brain tissue, then we can kind of make a positive diagnosis at that point or the doctor can, which in a way gives people hope because we can say this is not Alzheimer's. This is alcohol related brain damage, but the chances are it will improve at least some with good treatment, which makes people feel a little bit better. And ARBD should be diagnosed if the person has impaired memory thinking or reasoning, which is bad enough to affect daily life and a recent history of several years of alcohol misuse. And other physiological causes have been ruled out, such as the stroke, the brain bleed, chronic fatigue, lupus, hypothyroid, and medication side effects. And I'll give you a little anecdote here. My grandfather, when, oh golly, he was probably in his mid 60s when his Parkinson's disease started setting in. And he had had, he had been in World War II sustained some pretty severe brain injuries and had a metal plate in his head and he was in pain a lot, a lot of anxiety. The doctor, you know, that was leading up to saying the doctor put him on a benzodiazepine. And evidently this doctor was not familiar with working with the geriatric population because there are certain benzodiazepines, the majority of them actually do not clear an elder's system the same way they clear a younger person system. So grandpa was taking the recommended dose for somebody of his size, but not of his age, which built up in his liver. And he developed severe toxicity and had to be in the hospital for a little over a week, I believe, to get the benzos out of his system, but his symptoms were very similar to what's going on here. I mean, he had respiratory depression, depression, depression, confusion, basically no memory at all. You know, we started wondering if he was developing Alzheimer's or something until we figured out what was going on and a geriatric physician said, oh my gosh, you know, that's like the last thing he should be on, especially, you know, every four hours continuously. So being aware if you're working with someone that side effects of Medicaid medication can also cause these opiates, even taken as prescribed in some people. I know if I take opiates at the level that the doctor prescribes, I can't think straight. I can, I have blurry vision. I have no short term memory at all. You know, you'd think I was drunk as a skunk. So it's important to recognize that sometimes even taken at the prescribed level. Some people have a sensitivity to these medications and they'll react more strongly to them, which can produce these sorts of symptoms, which takes us back to looking at how long of these symptoms been going on. Was there a triggering factor that we can identify other than alcohol. So Corsikov syndrome is a form of alcohol related brain damage caused by a lack of thiamine. It's much less common than other forms of ARBD, such as alcoholic dementia, which we've talked about and does improve in most people over time, maybe not completely, but a lot of the skills and stuff generally come back. It's diagnosed in about one in eight people with alcoholism. Remember ARBD is it was one in three. Corsikov's is only one in eight. Woohoo. But this is a really important thing for us as mental health clinicians to be aware of. And you'll understand why in a minute. It develops as part of a condition called Wernicke-Corsikov's that consists of two separate but related stages, Wernicke's encephalopathy, followed by Corsikov syndrome. It's important to remember though, not everyone has a clear case of Wernicke's encephalopathy before Corsikov syndrome develops. So just because they don't have some of the symptoms we're fixing to talk about doesn't necessarily mean they're not going to develop Corsikov syndrome, which is a medical emergency. There are no specific lab tests or brain scan procedures to confirm this diagnosis. Wernicke's encephalopathy usually develops suddenly, often after abrupt and untreated withdrawal from alcohol. And that's why it's important for us as mental health clinicians to be aware. If we have a client who has been drinking and maybe they got divorced and they hadn't drunk, you know, really hadn't had a problem with alcohol. They got divorced or separated or something and they've been drinking pretty hard for about two months. Well, we might have a problem. If they started, they decided, you know what, I'm not going to drink anymore. I'm going to get my life back on track and pick myself up and move on. That's awesome. But if they abruptly stop that alcohol and they are not under medical supervision because a doctor would be able to, you know, figure out the thiamine issue. They can start developing Wernicke-Corsikov syndrome. Symptoms of Wernicke's encephalopathy, and this is, you know, phase one if you want to think of it. Disorientation, confusion or mild memory loss, malnutrition. They may be eating well but not gaining weight. Involuntary, jerky eye movements or paralysis of the muscles that move the eyes. And this is one of those telling factors. Not everybody has it, but if you notice they've got some jerky eye movements going on. That is a huge clue that we got a problem. Poor balance, unsteadiness, staggering, stumbling and lack of coordination. They may not be drunk. They may not be intoxicated at all. It may be because they're not intoxicated that they're experiencing this right now. So if we notice something's going on like that, we need to pay attention. The last one, poor balance or unsteadiness, staggering, stumbling and lack of coordination is also a symptom of serotonin syndrome, which is another medical emergency. So if somebody starts acting physiologically not like they normally do, we need to pay attention to sweet. If we're in a case encephalopathy is suspected, immediate medical treatment is essential to prevent permanent brain damage. So unlike ARBD, which often gets better, there's lack of thiamine. It can be a problem and cause permanent brain damage. If the encephalopathy is left untreated or isn't treated soon enough, Corsikov syndrome gradually develops. And you remember I told you the client I worked with had Corsikov syndrome. He had been drinking hard for many, many years. He was in his mid 60s when he came to our treatment center. So it had been a long progression where he had tried to stop for a while. He'd gone to 12 step meetings. He's like, I'm going to clean myself up. So he would detox himself at home and start going to 12 step programs and stay clean for a little while and then relapse. But because he was doing it that way without any medical monitoring, unfortunately it also contributed to the thiamine deficiency. Damage occurs in several regions of the brain. Symptoms include severe loss of short term memory and day to day memory. He would put on his socks and then forget he put on his socks and start going around looking to try to find socks in the morning. Or pour his coffee and forget he had poured coffee in there and pour it in again and spill coffee all over the place because he overfilled. So paying attention to some of these things which can seem, you know, peculiar that we want to look out for. Problems learning new information including new routines and life skill. Somebody in treatment who has Corsikov syndrome and most likely you're probably only going to see people with Corsikov syndrome. If you're in a dual diagnosis facility, if they come to you in a mental health facility, you're probably going to see that there's more going on there than you can handle once a week for an hour. But, you know, hypothetically if you're seeing them any new routines or life skills that you're teaching them from distress tolerance to mindfulness to, you know, avoiding triggers to getting good sleep. They're going to have problems learning that so we're going to have to go back to basics writing it down, breaking it into small chunks. Their ability to remember recent events is going to be damaged. They may have gaps in their long term memory. They may not be able to remember what they did last Christmas and it can be very frustrating, especially if, you know, maybe last Christmas was the last time that they saw their children and they can't remember that. It can be devastating to them. Memory problems may be severe while other thinking and social skills are relatively unaffected. For example, individuals can carry on a coherent conversation and he could, I mean, he could spin a yarn, but moments later be unable to recall that the conversation even took place or to whom they spoke. So, you know, occasionally I'll have these, I think we all do, we have these periods where we can't remember if we said it in our head or we said it out loud. I was talking to my husband about something today and I said it and I'm like, did I already tell you that? And he's like, no, I was like, okay, said it in my own head, but that's normal. What we're talking about here is totally not even remembering a conversation you just had not 15 minutes ago, which is not uncommon. So you can see in treatment centers, especially in residential treatment centers where this can cause problems. If you're telling somebody to do something and they are spot on, they're like, okay, I got it. I'm going to go do it. And they walk away and don't do it. Not because they're being resistant, but because they completely forgot that you even had the conversation. It doesn't transfer from that immediate short term memory into anything else. Those with Korsakov syndrome, and this is another problem in treatment as well as in the legal system and relationships. Those with Korsakov syndrome may confabulate or make up information they can't remember, but they're not lying. They may actually believe their invented explanations. So if you're talking to somebody and you tell them, I need you to go arrange the chairs for the meeting in the cafeteria. And the person says, okay, I'm on it. And they walk away and they forget the conversation and they don't do it. Then when you confront them later about, we had this conversation. You said you were going to go arrange the chairs in the cafeteria for the meeting and you didn't do it. What happened? They may come up with some, there was a fire drill and we had to go outside. Well, maybe they went outside to have a smoke or something. So parts of it, they may remember and they try to weave it together to figure out, okay, what was it that I was doing? How did I get distracted? So they're not lying. They actually believe their explanations. And that's a hard one for a lot of us to wrap our heads around the difference between confabulation and intentional misleading. There's a good chance of stabilization or improvement if the person is given high doses of thiamine and remains free from alcohol and adopts a healthy diet with vitamin supplements. So, you know, there's, you may have some minor improvement. Chances of them going from not being able to live independently to living independently, they're pretty small, not unheard of, but pretty small. But there are likely going to be improvements as the fog clears, so to speak. Brain scans show that with abstinence, abstinence, some of the damage caused by excessive drinking can be reversed. The brain is really cool. It wants to maintain the person. It wants to survive so it can rewire itself. This is why after brain trauma, you know, if somebody loses a portion of their brain because of a tumor or something or damage, they get shot in the head. The brain can actually do workarounds and people can regain some skills that they didn't, that they had lost because of the injury or accident. So the brain is really cool. And I encourage people, if they're dealing with this or even family members who are trying to support their loved ones through it, I encourage them to look with curiosity at how is the brain helping this person recover now. What really cool things did it do today? I think about when you've got young children at home, and especially really young ones where every day they do something new. And it's just like, oh, wow, that's so cool that you figured out that you can put your hand into a glass jar. That's awesome. Well, look on it with the same curiosity. What is the brain doing? And that makes it more of a activity than rehabilitation, which can be kind of daunting sometimes. So vascular dementia is a little bit different. Vascular dementia can be caused by a variety of things, not just alcohol or opiates, but it's caused when blood supply to the brain is interrupted. So auto-asphyxiation, we're not going to talk about that right now. But if it interrupts the blood supply to the brain, crush those arteries on either side can cause a stroke, can cause vascular dementia. You also see this potential during the second stage of alcohol withdrawal, which is usually 24 to 72 hours post-drink. It's when the blood pressure starts to go up, the anxiety really goes up, body temperature goes up, heart rate becomes unusual. You can have fluttering, you can have tachycardia, you can have alternating bouts of tachycardia, which is too fast, and bradycardia, which is too slow. You know, the heart starts doing flippy flops during the second stage. It's trying to figure out what the heck's going on and confusion. If you're not getting enough blood and oxygen to the brain, you're going to get confused. It's just the way it happens. So this is the period where people are a lot more likely to actually have a stroke, which can cause vascular dementia. If somebody has a vein collapse from IV drug use, they can also cause reduction in circulation and impairment of blood to the brain. You can impair blood to one portion of the brain, for example, which can cause a stroke or can just cause lack of blood to that area, which can cause vascular dementia. And stimulants use can cause high blood pressure and result in somebody having a stroke. So when I talk about stimulants, I'm not just talking about illegal drugs, cocaine, methamphetamine. I'm talking about spice, which can make people's heart rate go up to, you know, 200, and that's not exaggerating. It can make their blood pressure go way up. I'm talking about pre-workout supplements that some people take that are loaded with lots of caffeine and other things to increase blood pressure and heart rate. So there are a lot of over-the-counter herbs and medications and supplements that people can take that are stimulatory, which can increase blood pressure and increase the risk of stroke dramatically. And Guarana, which was legal back when I was in college. It was in a lot of pre-workout supplements is now not able to be sold in pre-workout supplements or in, you know, mixes, but it is still legally being sold in the United States. And a lot of athletes, not professional athletes, but like bodybuilders and stuff, do take it. So be aware, if you've got a bodybuilder who is, you know, working out, you want to talk about what kind of subs that person uses. And that's something they love talking about. So it's not hard to get into that conversation and make sure to educate them about high blood pressure. Bratocardia, too slow of a heart rate, can be caused by severe hypothyroid. Usually this is caused by some sort of an injury. You don't just go from being fine to having severe hypothyroid, but something to look at. Opiate overdose, if somebody takes too much, it slows your respiration, slows your heart rate. It can slow it down to literally nothing, which cuts off that blood supply to the brain. Heavy alcohol use produces arrhythmias and hypertension, which can disrupt the brain access to alcohol. But it can also, the arrhythmias going too fast and then too slow for a while and then too fast again, really monkeys with the works. And alcohol poisoning. You drink too much of it. Alcohol is a depressant. What do you think happens? Which is why people blackout, why people pass out, among other things. I mean, they are poisoned at that point, but alcohol is a system depressant. So it can slow your heart rate, slow your breathing and cause problems with your brain getting the oxygen it needs. The most common cognitive symptoms are problems with planning, organizing, making decision or solving problems. Difficulty following a series of steps, like cooking a meal. What do I do first? A slower speed of thought, problems concentrating, including short periods of sudden confusion. A person in the early stages may also have difficulties with memory, language and visual spatial skills, such as perceiving objects in three dimensions. Vascular dementia can be caused when somebody has a stroke for a variety of other reasons too. So it's good for us to be aware of what the signs of this are because, you know, how many people do we know who especially once they got older had a mini stroke or multiple mini strokes. Many times when people start having strokes, it starts causing some degree of vascular dementia. We want to alter or tailor their treatment plan using some of this information by making sure that we help them with planning and organizing. That can be a treatment plan issue. Anything that we ask them to do that is complex or a series of steps, write it down so they can see it and they can follow it one at a time. Take things slower. They may not be able to get what's presented in a group setting. They may have to be in individual counseling or have an additional individual sessions. Problems concentrating and short periods of confusion, encouraging them to be willing to say when, if they're starting to get confused so they don't get frustrated. If they're having difficulty concentrating, then they start getting confused and they start getting frustrated and they get angry, then they're flooded with adrenaline and you're going to get nothing after that. So we want to help them become mindful so they can say, whoa, I need to back up for a second. With language, giving them time to speak because their speech may become less fluent, not jumping in, not finishing their sentences, but being patient and letting them try to get the words out. Many patients who use substances even recreationally may experience strokes or mini strokes well under the influence and not even realize they had one. So again, thinking about our bodybuilders, thinking about people who use recreationally on the weekends at raves, at frat parties, at, you know, for whatever reason. It's important to understand that when you're under the influence of any sort of minor mood altering drug, you're probably not going to be aware if you have a mini stroke because it's going to seem a lot like intoxication in most cases. High blood pressure plus alcohol or stimulant use greatly increases your chances of a stroke. If you've already got high blood pressure and then you start ingesting things that increase your blood pressure, it's a no brainer. Clinicians must be aware of the symptoms of dementia, be able to differentiate it from intoxication, which can be challenging. Encourage clients to seek immediate medical assistance if we notice anything that looks like a stroke or serotonin syndrome or alcohol related dementia, or wernicke's encephalopathy, and be additionally attentive if a patient reports self detoxing from alcohol. And by additionally attentive, I mean telling them they need to go see their doctor and have that monitored. We can't force them to, but helping educate them about how dangerous it is that they may experience a B1 deficiency. So FASDs are caused by fetal exposure to alcohol. So you think you have this thing full size of a peanut in your body, and there it's exposed to the blood in your body, and you drink and you've got a blood alcohol of 0.08. Well, that's the legal limit. So what's the big deal? Well, what you drank is the blood alcohol content for somebody your size to have a 0.08. For somebody that's the size of a peanut, that child is trashed. And I don't say that to make light of it, but I say that to help you kind of put things into perspective. The amount of alcohol that the fetus is exposed to is pretty significant, combined with the fact that their brain is still developing causes problems. So remembering that fetal alcohol spectrum disorders are a spectrum, and there are a lot of different features. Not every person with an FASD has the facial features, and even those that do often outgrow the facial features. So when you're seeing them as adults in counseling, they may never have been diagnosed with an FASD, but they may have some of the symptoms we're talking about. And it should give you pause to think, hmm, what's motivating these behaviors? Are these intentional behaviors? What else might be going on here? So facial features that they may have had as a child, I guess we're going to get to that on the next slide. People with FASD have many neurobehavioral problems which interrelate to produce profound problems with accurately processing information and relating to the world around them. What does that mean? This is the best visual I can give you. So they may be 18 years old chronologically. Okay, so theoretically they're graduating from high school, they're old enough to enroll in the military, not old enough to drink yet. Physical maturity, 18 years old. Developmental level, 9. Oh, daily living skills, 11. I wouldn't leave my 11 year old to live independently. So now we start to see we're having problems. So we've got this person who is, you know, 18 years old and you think they should be taking on adult responsibilities with a developmental level of 9. Daily living skills of 11, but expressive language of 23. Oh, we start to complicate the picture. Because people with an FASD may have, be very, very verbal and very able to carry on a conversation with adults and a lot of times there's no cognitive impairment. So they are very expressive and able to talk to people and interrelate well. So it's surprising when you start seeing problems in developmental functioning and daily living skills. They're receptive language. So what they're able to interpret from other people is that of a seven year old. So they can talk the talk of a 23 year old, but they're only interpreting that of a seven. So it creates a big conflict. And there's a lot of inappropriate interpretation of nonverbals, not understanding nonverbal behaviors. And not getting things like idioms and things like that. Artistic ability or other strengths can be at a 29 for this particular client that they used as a, as a prototype. Reading level was at 16 for decoding. So he could read the words, but actually understanding what it meant, he was at the level of a six. So he could read the words, but didn't get anything out of it. Money and time concepts, level of an eight year old. That's second grade. So just to kind of put that into perspective. So people with, with an FASD don't all fit in this category. This is one particular person that's pretty prototypical, if you will. But understanding that their developmental functioning late living skills, receptive language, reading comprehension and concepts of money and time are usually all at the elementary level. Whereas their expressive language and artistic ability, maybe much more developed than even their chronological age. So they present a very confusing picture when you start assessing them in, in counseling. Diagnostic features, three distinct features. The philtrum, the ridge between the nose and the upper lip that there's usually a little groove right there. It's not there on people with an FASD sometimes very thin upper lip and a distance from their nose to the top of their upper lip is usually wider than for most people. And a short distance between the inner and outer corners of the eyes, giving the eyes a wide spaced appearance. So you can go online and look at facial features of an FASD to see what it looks like in children. But remember that as people grow, they generally grow out of those facial features. So that is not something you even want to really rely on at all for an adult diagnosis. And even for a child diagnosis, there's a significant percentage of children with an FASD, especially on the lower end of the spectrum that don't have the facial features. We don't want to miss them because we're only looking at people with the facial features. The children may have a height or weight or both at or below the 10th percentile. You know, this can be due to the mother smoking while she was pregnant using crack while she was pregnant. It can be due to a variety of other physiological issues between the mother or baby. So we don't want to just assume that it's FASD, but it's a factor to consider smaller than normal head size for the person's overall height and weight. So their height and weight might be 50th percentile, where their head size is the 10th percentile. So proportionally, it's a little bit wonky. But they can have height, weight and head size all below the 10th percentile. So you've got a little itty-bitty person. Significant changes in the structure of the brain as seen on brain scans such as MRI or CT scans. So we can see some changes if we put children through the or people through the MRI or CT scans. They have poor coordination, poor muscle control. The neurological system was flooded with alcohol when it was trying to develop. So it short circuited in some places. Cognitive deficits, including specific learning disabilities, executive functioning deficits, including activities of daily living. Attention problems or hyperactivity, poor social skills and difficulty interpreting nonverbal behavior. And you're looking at these and you're going, well, that sounds like six other diagnoses. And my answer is yes, it does. So we need to look at the person in the situation and figure out what they're presenting, what symptoms they're presenting with, how it's impacting their life and how we can help them improve that. Recognizing that, you know, if we start talking to them about mom's drug use or alcohol use when she was pregnant, they may not know that mom drank when she was pregnant. We do know that fetal alcohol spectrum disorders are often intergenerational because of the problems with impulse control and a variety of other things. People with FASDs are more likely to start drinking, you know, especially if they're undiagnosed, be susceptible to peer pressure, more susceptible to peer pressure, start drinking and have a FASD child themselves. Issues for clients, problems with cause and effect relationships and impulse control. So they don't really understand if I do this, you know, if I yell at Sam, then he might yell back at me. So maybe I ought not yell at Sam. Problems with the ability to conceptualize, internalize and structure time. So getting them to work, getting them ready in the morning, getting them to be somewhere on time is a difficult chore because they're not able to grasp the passage of time. You know, sometimes they feel like it could be three days, sometimes it could be three months. They also don't understand the concept of time in terms of if you tell them they're going into residential treatment, for example, for a month. That means nothing to them. Three days, three years, they don't know how long a month is. It's not meaningful. They have problems with the ability to generalize information, difficulty understanding concepts and abstract thoughts. So we're talking about concrete operational thought, which, you know, you go back to that list that I showed you and that would be right about right as far as age in Piaget's development. They don't progress to formal operational thought where they can think abstractly and generalize very well. Another key feature that can separate an FASD from some other things is problems with with perseverative behavior. Perseveration is commonly described and thought of as some form of repetitive behavior, not necessarily stemming like you see in autism, but like tapping toes, drumming fingers, knocking, pacing. These are things that this particular type of diagnosis has people with this diagnosis have problems with. We can also manifest as a particularly rigid rigid way of looking at things, a refusal to let go of an idea, a rigid tenacity which can border on fanaticism and or certain way of feeling or interpreting a feeling and refusing to consider any alternate explanation. Now, you know, I can think of some very some people who don't have an FASD that have some of these characteristics that they are bulldogs when they get an idea in their head. So we don't want to just say perseverative behavior means the person has an FASD, but we do want to recognize that these types of behaviors can set an FASD apart from something else, like some of the dementias that we talked about before. And for some people with an FASD, there may be some elements of obsessive compulsive disorder in it, but generally not. That's not something that's really talked about a lot in the FASD literature. Problems in all areas of processing information, particularly auditory. So think about how our sessions go. We talked to people. They're not going to pick it up that well. So we need to make sure to write things down. Ideally have them write things down and then go over it with them. Problems with short term memory, difficulty anticipating consequences, good expression, but poor comprehension, like we talked about earlier, and good at reading, but poor writing skills. So they're really good at reading and have difficulty with auditory processing and difficulty with comprehension. So if we have them, if we write down lists and make sure that they understand what's on the list and they can explain to us what it means, and they have that to look at. That's the best case scenario for a client with an FASD. They will likely not benefit from standard treatments that require conformance, motivation and follow through on multiple tasks. So have them write out their own weekly goals at the end of the session, say, okay, we talked about a lot today. And, you know, they may remember what what you talked about. They don't have deficits in immediate short term memory. So we can, at that point, start brainstorming what are your goals for this week and hand them a piece of paper and help them, you know, if they need help writing because writing is difficult. You could write it for them, but you need to have them go over it at the end, you know, hand up to them after you've written it and say, Now I want you to read this to me and tell me what each thing means and what you're going to do. So make sure that they can explain to you what they're going to do. Cannot accurately anticipate consequences and repeatedly make the same mistake. They may seem to shoot themselves in the foot. So repeatedly getting DUIs. A lot of times if they've got criminal charges is the same low level misdemeanor criminal charge. They don't escalate the felonies or anything. They just keep doing the same darn thing and you're like, Dude, did you not learn that you can't do that. So identifying those the same thing can be in treatment if they know show and they give you a reason for no showing and you talk about why, why that's not okay what to do to prevent that and then they know show again. They may not be able to anticipate and manage their time well enough to get there may be unable to demonstrate remorse and get incorrectly labeled as anti social they have difficulty interpreting what's going on with other people and have difficulty expressing that remorse. So expression can be on the high level but when it comes to remorse that's one of the areas that seems a little gray because a lot of times they don't understand they did anything wrong. They have a right to specialize treatment and accommodations and remember they may not be using alcohol or drugs at all may never have used. So we don't want to lump them in as saying that they've got some sort of substance use disorder. They see themselves each time as making a single mistake, unable to conceptualize the past. So they don't see a pattern. They can't see patterns. It's like, Oh, I made a mistake won't do that again. They do it again. Oh, I made a mistake won't do that again. They're easily manipulated and often take the fall for people who don't have these problems. They may have gaps in their personal history account including important facts like where they went to high school. They tend to be quite impulsive and comedic. A lot of this is developed in order to fit in and gain acceptance when they're younger. May not follow through with appointments due to inability, not lack of interest or motivation. Last few strategies. When you're working with a client with an FASD uses few words as possible and keep them basic. Don't use, you know, lots of fancy Scrabble words. Always be clear and state what you want to happen. The desired behavior be very, you know, straightforward. Don't argue, debate or negotiate. You know, if you start negotiating, I will, if you will, they can't anticipate consequences. So negotiating often doesn't, it falls on deaf ears. Being direct is good, but don't become too authoritarian or the person with an FASD may likely shut down. Please don't expect them to be reasonable or act their age. A lot of times they're unable to and unable to interpret appropriate adult nonverbal behavior to act their age. If you get stuck in a no loop, and they're just, you know, no, I'm not going to do that. No, I'm not going to do that. You short questions you think the person will answer yes, just to get them stuck out of out of being stuck in the no loop. I'm not talking about trying to trick them like rabbit season duck season. I'm talking about just getting them to get out of that negativity for a second. And let's talk about some yes things. And then we'll go back and ask the questions again and see if they still say no. Try to be non-judgmental and remember to start with a clean slate each day, because they do. Don't get frustrated that you just dealt with the same type of issue yesterday. Think about the movie Groundhog Day. You know, for many people with an FASD each day, it's like starting all over again and the stuff that they already did, they haven't been able to learn from and may not even remember some of it. Mental health clinicians are likely to see clients who present with depression and or anxiety who are misusing or excessively using substances but not dependent upon them. Alcohol related brain damage can be caused by the use of a substance increasing blood pressure, causing a stroke, slowing the heart or collapsing veins. Withdrawal from the substance, namely alcohol, can also cause or trigger a cascade of effects that causes alcohol related brain damage. Heavy use is defined as more than 14 drinks per week with more than two per day. Many clients with alcohol related brain damage are not alcoholics. Remember that FASD is brain damage caused by fetal exposure to alcohol and those with an FASD experience deficits in interpersonal and executive functioning, which make it difficult or almost impossible to comply with traditional treatment. Special approaches are available and required for persons with FASD to provide ethical and effective treatment. Thank you for sticking with me on that. Are there any other questions? I will put that is our YouTube channel if you haven't already been to it and we do have some article videos on there on addressing FASD, specifically hour long videos on FASD. So if you have clients that may be struggling with that issue, you can access that information without having to get CEUs or whatever. Alright everybody, have a fabulous day and I will see you tomorrow. Since 2006. 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