 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 the biopsychosocial impact of addiction and mental disorders on the individual. We're going to examine the biological or the physical impact of addiction and mental health issues on the individual, the psychological impact of addiction and mental health issues on the individual, and the social impact on the individual. And then we'll try to identify some interventions in each area. Why am I doing this? Well, because if we're really going to approach a holistic recovery model, we need to look at when somebody is depressed, what are the effects? It's not just cognitive. So in order to help them achieve long lasting sustained recovery, we need to be able to look at how is this mood issue? And I try to avoid the word disorder as much as possible. How is this mood issue or addiction issue impacting the individual? And what else is going on that we may need to intervene with? Next time, we're also going to look at how these issues impact the family and the community because depression, anxiety and addiction all have huge costs to both families and communities and employers and all that kind of stuff. So we'll kind of take a look at that and talk about what we might be able to do in order to strengthen the support system because we, for recovery, effective recovery, regardless of whether it's mental health or addiction, we need to have a comprehensive system of care. We need to have resources available where people can access medical care, mental health care, prescription, social support and any needed resources to fill that lower level of Maslow's hierarchy, food, clothing, shelter, yada, yada. So the biological impact of mood disorders. Well, it's kind of an impact and a cause imbalances in serotonin, GABA, glutamate, norepinephrine and dopamine. Those are our big ones. Acetylcholine gets in there sometimes too, but the big five really cause a lot of mood disorders and we tend to think erroneously and we'll go into this in a different class on neuropsychobiology. But we tend to think erroneously that serotonin deficits cause depression. And what they found in the research is actually serotonin is a lot more linked with anxiety than it is with depression. Now, if somebody's depressed because they've been anxious for so long and they're plummeted gas, well then obviously you got a connection there. But the depressive symptoms tend to be, tend to and not exactly, linked with norepinephrine, which is your excitatory and motivation kind of chemical. But there are a lot of other imbalances such as, you know, a lack of or insufficient GABA, imbalanced with the rest of them. And I always liken it to making a marinara sauce because you've got like bunches of spices and if you've got too much of one, then the others are going to feel too weak. Or if you don't have enough of one, then the others will feel too strong and they balance each other out nicely. But so if you don't have enough GABA, for example, which is a calming chemical, again, that can lead to high levels of anxiety, but it can also lead to symptoms of depression over time. So we don't want to just assume it's a lack of a particular neurotransmitter because it is probably going to be different for each person and it might also not even be a neurotransmitter. We know that imbalances and other hormones like thyroid hormones can also and sex hormones, most especially estrogen progesterone and testosterone, can cause imbalances in the neurotransmitters. So when these things are out of whack, you're going to have people that have mood symptoms of some sort. What are the effects? You know, when those things are out of whack, we have disrupted sleep and we're going to take a look at how disrupted sleep or chronic stress affects the person over time because it's a reciprocal negative feedback loop. Fatigue, you know, obviously if you're not getting quality sleep, you're going to feel tired, but you also can feel fatigued due to not enough norepinephrine, not enough dopamine, not enough GABA to balance out the glutamate so you can chill out after you get stressed. Irritability, nutritional changes, increased muscle tension, reduced pain tolerance and gastrointestinal disturbances. Now, when we look at each one of these, we can see how, you know, when you're irritable, how patient are you with other people? When you're hungry or you haven't been eating a good balanced, relatively balanced nutritional protocol, how do you feel? I mean, generally junk in produces junk out. Increased muscle tension. When our neurotransmitters get out of whack and we get stressed, a lot of us store stress in our neck and our back, which can influence how well we sleep. It can also give us kind of chronic pain, make it difficult to concentrate and make us more cranky and increase the sense of hopelessness and helplessness. So you can see how the neurochemical imbalances can cause physical symptoms which can cause further neurochemical imbalances. So as I promised, the brain under stress. When the brain is under chronic stress, whether that sleep deprivation or just chronic stress from work or you're just one of those people who's wound tight, the brain tells the body to release cortisol and adrenaline. It says there's a threat. Your threat response system is activated. So your body does that and there's a whole cascade of other things that happens. But what it results in is the release of glucose. So you have an increase in blood sugar for that fight or flight reaction. Woohoo. It suppresses sex hormones. So your libido goes down, but also the access or availability of serotonin goes down once sex hormones are suppressed, which is okay because we don't want to be calming right now if it's time to fight or flee. And it suppresses serotonin. So which also when serotonin suppressed, we know that melatonin is made from the breakdown of serotonin. So people aren't going to sleep as well. So all of these things happen to prepare you for fight or flee. It's time to focus on whatever this threat is and not pay attention to other things. This causes a reduction of melatonin. So you don't sleep as well. And reductions in serotonin can also lead to increases in anxiety and anger, fight or flee. Actually, flee or fight the way I have it here. But this is your body's natural emotional response to a threat. So it makes sense. But then if that stressor continues, like I said, work stress, we're talking about your low-grade chronic stressors, not something like a car accident. We're talking about, you know, day-to-day life. If that continues, you know, you're not getting enough sleep and you're feeling kind of when you're tired, your body perceives it's more vulnerable. So it says we need to keep the threat system a little bit activated so we're not surprised. So we go back up here and the body says, well, we're tired, but we got to keep on alert because we're vulnerable right now. Think about a soldier in a foxhole. They don't sleep well. They may sleep, but they don't sleep well because their brain knows that they're not in a safe place or that there's a constant potential for threat. So we need to help our clients understand this, that things like poor nutrition, not having enough food, you know, if they're restrictive dieting and not getting enough sleep, can contribute in addition to nicotine and caffeine, which impair, increase the cortisol release and impair sleep, can all tell the body that it's vulnerable, which increases the stress response and has a whole cascade of negative physical and mood effects. The biological impact of addictions, and we're talking about behavioral and chemical. We're talking about anything you do that produces a rush of dopamine especially, but other neurochemicals as well in your brain, a pleasure response. And the best way I can explain that is Black Friday. We're getting ready to come up on that, so this may give you all some things to think about whether you want to do your shopping early. On a normal day, a store capacity is 750 people. So on a normal day, your brain lets through a certain amount of dopamine and norepinephrine and stuff and it's just ebb and flow, ebb and flow. The store needs a constant 500 to stay open. Normally your body needs a constant, you know, amount of dopamine and stuff to be available in order for you to feel happy. The store has eight doors to allow for people to easily enter and exit without getting bunched. And think about Target or Walmart or one of those. It's not just one store. So we can come and go pretty easily and not worry about it. And I'll go back to this slide here and you see the receptors in your brain. Normally there are a bunch of receptors open. So the neurotransmitter is released into the synaptic space and then it's got plenty of different doors to go through to get, continue the message throughout the body. Well, on Black Friday or when somebody uses an addictive behavior, it's like 1500 people push through the door as soon as it opens. There's just a rush of these molecules of dopamine and norepinephrine and whatever else was triggered by the substance. And, you know, in the case of Black Friday, the store is destroyed, staff's exhausted and it takes a lot of time to restock and for staff to get refreshed. They're just like, whoa, that was a rough day. During this time to prevent further damage, management closes all but two doors and adds security guards to manage flow. Think about, you know, clubs that have bouncers outside and they maintain the levels in order to prevent it from getting past the fire marshals recommended occupancy. Same sort of thing happens on Black Friday. The brain gets a rush of these neurochemicals and that's like way more than your body's used to having and all of a sudden your circuits are flooded which produces the euphoria, your score. Inside your body is, feels this euphoria but it uses up a lot of the dopamine or norepinephrine that your body normally makes and your body says, I shouldn't be running this happy. I shouldn't be running this hot for this long. It's not good. This is not how I'm supposed to function. So it takes your body time to rebalance after that. If you have a rush of dopamine or whatever, it takes your body a while to produce enough dopamine to restock its personal shelves, if you will. And it takes your body a while to recover from that rush and start producing normal levels again. When people are addicted, it's like having Black Friday every day. So instead of having eight doors open every morning, the management just starts saying, you know what? We're just going to have security guards out front and we're going to control the flow so we don't get overwhelmed. Unfortunately, when there's not a rush, you know, the people aren't feeling happy. They're not getting enough through the door in order to feel like what they consider normal or what they consider happy. So things that would normally make them happy just don't do it anymore because they don't have enough dopamine for whatever reason and the research is out about whether it's not producing enough dopamine or not enough getting through or it could be both. But it's important to understand that the brain adapts is really cool because it adapts to protect itself and that's what we need to focus on is it can adapt and it can also re-adapt when it's not getting it after the person goes through withdrawal. The brain can repair itself and if for some reason it can't completely repair itself it finds really good workarounds. Most people can restore normal levels of functioning after a period of sobriety. Biological impacts that are indirect and this applies to generally any addiction whether it's gambling and staying up all night, playing poker, at a gambling casino or even online to cocaine use. Reduced immunity. When you are exhausted, your body does not have the energy to focus on your immune system. That's one of the first things that goes. More rapid aging. We know that people who are exhausted don't have time to rest and rebalance. Their body can't repair itself as easily so we see more rapid aging. Sleep difficulties because of higher anxiety because of use of stimulants because of not keeping the circadian rhythm in balance, rhythmic people will find that they may sleep a lot or may not sleep much at all but the quality of sleep is just non-existent. Nutritional deficits impact a lot of people with addictions because as your sleep gets out of whack your body doesn't really know when to eat, when to sleep and a lot of people tend to lean towards high fat, high sugar foods in order to get the pleasurable feelings from that but also for sustained energy when your body is tired, it craves dense sources of energy which come in high sugar, high carb, high fat foods. Reduced pain tolerance and increased pain. Serotonin is responsible in part for our pain tolerance level so if you don't have enough serotonin if it's not available because your body is in that threat response system and other cascade effects are happening that's making serotonin not as available then you may have a reduced pain tolerance which is why people who are depressed sometimes feel more pain. They sometimes feel achier they sometimes feel heavier and there's also increased pain because people who are depressed or anxious or have addictions may experience gastrointestinal distress they may experience aches and pains and things that normally aren't there but are there because of stress the pain from too much muscle tension, etc. and addictions in particular also run the risk of increased risk of hepatitis HIV, TB and MRSA. MRSA is the antibiotic resistant bacterial infection. So it's important to be aware of these things and we're not going to talk about all the reasons for the increase in disease but it's important to understand that people who are engaging in addictions are probably for all these reasons stated here at greater risk of having vulnerabilities or increased vulnerabilities for depression and anxiety. And this includes we're going to get to it in a few minutes this includes what you would normally think of as, you know, maybe excessive use but not addiction use of substances. So alcohol, that's one of those things that's legal it's socially sanctioned, lots of people use it. Occasional use, you know, I think it's up to seven drinks a week isn't considered to be problematic but in excess of that, or maybe it's 14. Anyway 14, no more than two drinks a day. In excess of 14 drinks a week you can start seeing heart damage, high blood pressure, fatty liver, hepatitis, cirrhosis, pancreatitis, cancers of the mouth, throat, liver and breast, reduced immunity and brittle bones. Alcohol is really rough on the body and people who already have pre-existing issues like diabetes find that those issues tend to be worsened when they drink alcohol. Alcohol can also cause brain damage because the toxic effect of alcohol on brain cells. And then there's also the biological stress of repeated intoxication and withdrawal. I mean, it's just a lot of stress on your brain to have substances in it a lot. There's also alcohol related cerebrovascular disease. When people drink alcohol is a sedative. So a lot of times your respiration slows and this is another thing if you've got apnea, alcohol makes sleep apnea worse. How many of our clients have sleep apnea is there's quite a few people and even if they don't have apnea or hasn't been diagnosed if they snore a lot especially if they sometimes wake themselves up snoring they need to get evaluated. That aside, if they go to bed and they have alcohol in their bloodstream it could cause more sleep apnea episodes more episodes where they stop breathing in their sleep. So it's important for people to understand that even if they're not an alcoholic even if they're not abusing alcohol use of alcohol can make some other issues that they have worse and contribute to fatigue and lethargy and some of those symptoms of depression that we often see. And head injuries can also be caused from alcohol because of fall sustain when people are inebriated so or car accidents or whatever the case may be. So alcohol can cause directly or indirectly brain damage and we know that it is probably one of the worst drugs for causing birth defects. Nutrient deficiencies we don't go into this much depth on most of the other substances because they don't seem to have as much of a negative impact which is why I find it interesting that alcohol is still legal you know, whatever. Nutritional deficiencies are often prominent in people who misuse not just alcohol dependence but people who misuse alcohol including vitamins A, E, D, K, B12, folic acid and thiamine. So A and E are kind of vitamins that help prevent diseases and I mean they have a lot of other functions. Vitamin D we know is responsible for in part for mood. There are a lot of vitamin D receptors in the areas of your brain that are responsible for mood and especially responsible for depression prevention which is why a lot of people experience seasonal effective disorder when there's not enough sunlight when they're vitamin D deficient they start feeling really depressed. We don't exactly know how that all works together but we do know vitamin D deficiencies contribute to feelings of depression. So people are drinking alcohol and especially if they're not getting enough sunlight and vitamin D so they were already deficient they're going to at least exacerbate their depressive symptoms. B12 is another one of those vitamins that people go in and get B12 shots to help with their energy. What are some of the symptoms of depression? Fatigue, lack of energy, apathy. So if your body can't absorb B12 then you might be having depressive symptoms. And thiamine can cause deficiencies can cause severe neurological problems such as impaired movement and memory loss seen in Wernicke-Korsakov syndrome which is basically what we call alcohol related dementia. A lot of times Wernicke-Korsakov is only seen in Alzheimer's so if you've got somebody who doesn't have Alzheimer's and they've got these symptoms then you want to evaluate for alcohol use. I've only worked with two patients who had alcohol related dementia and they needed a lot of case management. Calcium, needs fat in order to be absorbed. The drinking alcohol also reduces the amount of calcium that's available which can lead to brittle bones. Intestinal bleeding from alcohol consumption sometimes it's one drink sometimes it's chronic drinking it depends on how sensitive your belly is can lead to iron deficiencies and anemia. We know anemia also can cause symptoms of depression. And dehydration, alcohol is a deretic which means you drink it you're going to cause your body to lose excess water. And the excess water can lead to confusion, difficulty concentrating and fatigue, lack of energy and lack of motivation. They found one percent dehydration can lead to difficulty making decisions and in impaired short term memory. That's way before you start feeling parched. The other interesting thing is water is an alcohol combined in the system. So the more water you have the better hydrated you are the less impact a alcohol is going to have on you. So women who tend to have less water in their bloodstream compared to men tend to feel a greater effect from a smaller amount of alcohol when you control for weight than men do. So if somebody's already dehydrated because they've been drinking then they're going to start to feel the effects exponentially. So people who go out and party all Friday night or all Saturday night or if they were out I know we used to go out fishing when I was younger. And we'd come back in and you know my dad and my uncle and my grandfather were all dehydrated but that didn't slow them down at all. So the dehydration you got to look at am I well hydrated? So alcohol can have a lot of nasty side effects that we want to make sure our clients are aware of especially if they already have symptoms of depression or anxiety because it can make it a lot worse even if they're not abusing the alcohol. Alcohol also is contraindicated with benzodiazepines, barbiturates can be deadly and with SSRIs. Alcohol increases serotonin, SSRIs increase serotonin which both when you combine the two it can lead to serotonin syndrome which is potentially deadly. So that's enough on the soapbox on alcohol. It does have some protective factors. I mean you can do the research and certain amounts of alcohol especially red wine is thought to be protective in some ways but we're really talking about clients who are already symptomatic of depression or anxiety or substance issues. The other issue with alcohol that I didn't put on there alcohol when you first drink it you feel kind of calm, kind of relaxed may have some feelings of happiness, euphoria or just you know it's a depressant it makes you kind of less caring about what's going on but as it starts to wear off the body doesn't respond with GABA in the same rate that it wears off. So people often when the alcohol starts to wear off can experience high levels of anxiety which can lead them to want to drink again. People who are prone to panic attacks often will experience panic attacks when they are, when the alcohol is leaving their system I don't even want to say detoxing this can happen after a single drink or two drinks. So advising clients you know if they have anxiety and they're not on medications and they're still drinking that the alcohol can trigger panic attacks so they can be aware and take precautions if they're insistent on drinking. Okay enough about alcohol. Caffeine can produce stimulant jitters increased blood pressure heart palpitations heartburn diarrhea disrupted sleep dehydration miscarriage and osteoporosis sounds like a drug commercial doesn't it? And this is in any amount depending on your sensitivity to the caffeine. Some people like me anymore because I haven't had caffeine in so long if I drink even a can of Diet Coke I'm like wired. So Starbucks would I would probably be in the heart hospital with heart palpitations if I had a regular Starbucks. So it's important for people to recognize how caffeine impacts their body and we do build up a tolerance to it. So what bothered you six months ago may not bother you now but it's important for clients to understand if they've got anxiety issues and it also can alter blood sugar and and it stimulates cortisol release which increases increases blood sugar in the in the body. So if somebody's diabetic caffeine can also have negative effects which can consequently impact their mood. Now the positive side with moderate intake it has been shown to lower risk of Alzheimer's and dementia it decrease suicide risk not sure how but the research shows it does increase endurance in endurance athletes and decrease the risk of oral cancer. When they talk about moderate intake they're talking about three to five six ounce cups a day. They're not talking about you know three to five of these I wish but nicotine and this includes gums and vapors a lot of people put the negativity on cigarette smoke because there are so many carcinogens associated with cigarette smoke. Well nicotine itself is a bad boy and so nicotine gums and vapors as they've been become more popular and more prominent and people are supposed to be trying to stop smoking but they just at least like my mother she's been using nicotine gum for 20 years now. So we want to look at what are the effects of just this substance it nicotine is the most highly addictive substance in cigarettes or any of these things and it goes really quickly into your brain and affects your acetylcholine receptors and that's not real important right now but what's important to understand is once your brain gets a hit of it it can be it's one of the most addictive substances known to man according to the National Institute of Health activates those neurotransmitters which can provide pain and anxiety relief which a lot of people use cigarettes to help control stress so it makes sense reduce appetite I know a lot of people use cigarettes to help them when they're on a diet because it does reduce their appetite but it can also cause respiratory irritation increased cough, phlegm, sputum production increased heart rate and blood pressure now the interesting thing is it provides some anxiety relief but it also increases heart rate and blood pressure so that's those neurotransmitters in some sort of different dance different balance than normal it can cause hyperglycemia so again putting more sugar more blood sugar out into the system for use it can decrease immune response and increase oxidative stress which is stress on the body that often results from the body not being able to repair and rebalance and it leads to cancer or can lead to cancer and an increased risk of diabetes is also seen in people who have habitual or heavy use of nicotine a lot of our clients smoke, dip or use the e-cigarettes so it's important to help them be aware of some of these side effects so we'll move on to marijuana you know we're not going to make non-smokers out of smokers if they're not ready to go there but helping them understand the effects of nicotine and also how that nicotine might interact with their mood issues is important if they're getting ready to start quitting or try to start quitting smoking or using nicotine it's important again to make sure that before they do ideally they already have other coping skills and strategies they can use to tolerate distress and deal with any mild pain they might have you know we want to make sure they have something to put in place of that nicotine look at the function the nicotine served and have something to put in place of it there's also the habitual thing and the social thing that goes along with you know going out to smoke with somebody or just smoking at certain times of day so we want to make sure that if somebody always smoked when they were on the way to the office what are they going to do with their hands instead and having them at ten and two is not the right answer because they'll look at you like you're crazy so make sure they have something else to do during those habitual times when they used to smoke and ways that they can interact socially where they won't be exposed to the nicotine okay so marijuana positive effects why are people so fired up about it it has some pain management effects in as little as three puffs a day they found that people don't need to smoke it you know a whole bowl of it three puffs a day did provide significant clinically significant pain management in the study that cited over here it can help improve sleep it can be used for nausea reduction in people especially undergoing chemotherapy hallucinations some people use marijuana so they can have that altered sense of perception and that altered sense of time and just the altered senses in general so that can be a reason people use not necessarily a drawback the negative side of marijuana and it's important to note that this is dependent on the amount of THC that's in the marijuana and straight marijuana some of my clients have told me that the marijuana they used when they were in high school doesn't even hold a candle to today's straight marijuana and you know I've had people who have relapsed and hadn't used in 10 years or something and they went out and they used current street marijuana and they're like oh I didn't want to do that again that was just way too strong the marijuana they found a way to selectively breed to increase the THC levels in marijuana and it's not an exact science I mean it's you can't say that this particular plant will have 0.003 percent THC we just can't control in a in a plant that way so you don't exactly know what you're getting anyhow the higher the THC the greater the problems neurochemical changes causing short-term memory problems and problems with attention and learning a lot of these are short-term and remit as soon as somebody quits using and I am going over this partly because marijuana is legal for recreational use in eight states now so it's important to be aware of the side effects so we can educate clients about how it might be affecting their recovery impacts brain development in children and adolescents and this includes second-hand smoke so if you've got a parent who's smoking marijuana especially if they're hot boxing which means like smoking in a car where it's a small confined area and they've got the windows rolled up and the child is there it's going to affect the child the brain changes that happen in adolescence and childhood sometimes and they're not sure the exact percentage don't recover they don't repair so it's the early use is the more problematic use it's related to increased risk of testicular cancer increased heart rate and blood pressure and there's a significant increase in the risk of heart attack in the hours after marijuana use and this is actually well I can't say that with the stronger street marijuana and with spice and K2 I've had a couple of clients who've used spice or K2 that when I worked in the residential unit we had to call the ambulance for because their heart rate was like 190-195 they felt like they couldn't move they felt like they were going to have a heart attack and die and you know with a heart rate that high yeah I wasn't taking any chances so there is an increase in the risk of heart attack dependent on the amount of THC your spice and your K2 is a regular plant or herb with synthetic drugs sprayed on them that are similar in composition to THC but there is no control for the amount of drugs that are sprayed on them so people that who get a really strong batch can have heart attacks and there have been cases of ongoing psychosis that have lasted multiple days from people who have taken the synthetic marijuana marijuana can also increase the risk of bronchitis cough and phlegm production and in high enough doses can trigger delusions and psychosis something to be aware of now in those states that have approved recreational use of marijuana I don't know if they have quality controls out there on the different strains that are available would be really nice so people knew how much THC was there but helping clients understand that you may have a bad experience one time or a couple of times if you're using marijuana that has a really high THC content and you're used to using something with a lower content now we move on to opiates opiates we know provide pain relief and a sense of euphoria so it connects to those opiate receptors that your mu receptors and stuff but it also causes a release of dopamine a really good release so they've and I've told you this before they've started using it in the treatment of intractable depression as well as in the treatment of pain among other things the negative effects and remember things like coding are still opiates they're just kind of lower level lower level opiates so coding the cough medicine negative impact of opiates you take a depressant like this a system depressant it reduces your heart rate and respiration which can cause you to stop breathing in high enough doses again if somebody's taking antidepressant medications or anything else that increases their serotonin and combines it with opiates it can actually cause serotonin syndrome so because opiates also increase serotonin that's one of their secondary functions but it's important to pay attention to constipation anybody who's been on chemotherapy and opiates knows that they can be really constipating fatigue, nausea highly addictive with tolerance developing in three to five days and the body quits producing the natural pain killers in that three to five days it starts tapering how much it produces because you're just you're giving it more than it needs the important thing for us to take home if you're not working with people with addictions but you're working with a client who just had shoulder surgery or oral surgery help them understand that immediately after especially if they don't taper off their opiates immediately after they quit taking their opiates as prescribed even as prescribed they may feel achier for a couple of days until their natural opioids production kicks back in help them understand that so they don't feel frustrated and heaven forbid they don't go back and try to get more opiates so what can we do? we can help clients improve sleep quality you know these are biological interventions ensure adequate nutrition with good solid protein so they can make the building blocks so they don't feel depressed so they can help their body repair and rebalance if they've been engaging in addictive behaviors and burned through all their happy chemicals so to speak we want to give them every opportunity for their body to restore itself because your body wants to to exist it wants to survive so generally it does really well repairing and rebalancing to what is baseline for it now if somebody you're working with has a genetic predisposition to be low in serotonin then they're not going to recover and be to the point where they make enough serotonin to feel happy I mean some people will need to be on medications or supplements or something but that's a very very small percentage assist in the development of non-pharmacological pain management if we reduce pain we improve sleep we improve sleep we improve functioning and the whole symptom system and if we keep people from leaning towards opiates we prevent all the problems associated with opiate addiction and there's a lot of research out there now on all the problems associated with non-steroidal anti-inflammatories causing gastrointestinal problems as well as heart problems we want to help encourage clients to rule out address physical causes of depression and anxiety including thyroid issues hormone balances imbalances adrenal insufficiency which is you know when your CNS system gets really out of whack and your body just can't produce enough cortisol or can't produce it anymore because of some sort of damage to the adrenal cortex brought on by substance use or PTSD they found that it can be caused by PTSD diabetes diabetes can cause mood issues and heart problems and I try to kind of avoid addressing this one kind of right out necessarily because it can freak clients out when you say well heart problems can cause you to feel can cause you to feel anxious or depressed because if you're not pumping enough blood and keeping everything oxygenated you'll start to feel confused and lethargic and I don't want to go there because I don't want people to be like oh my gosh I'm having a heart attack now obviously if you have that concern they need to be transported but letting people know that there are a variety of medical issues that at the very least can contribute to feelings of depression I mean very rarely is our depression anxiety addiction any of those things caused by one single thing where we can go oh we just addressed this and everything will be hunky-dory because if somebody has a physical cause that's been causing them to feel fatigued and lethargic and frustrated and apathetic for a while then their thoughts and what they've picked up on in the environment when you're in that kind of mood you don't notice all the happy things as much you tend to be more internally focused so their cognitions have changed somewhat and it's probably altered their relationship somewhat so we need to you know not just assume that okay this is the quick fix no problem but we do want to make sure that we address it because if these underlying issues keep going on then the person is going to get to a certain point and just not be able to feel any better psychological impact of mood disorders hopelessness and helplessness is a is a diagnostic symptom but it's also a impact if you feel anxious for long enough if you feel depressed for long enough you're start going to going to start throwing your hands up in the air and go I'm so sick and tired of being sick and tired but nothing I do seems to work so encouraging people and figuring out ways to develop hope increase empowerment you know help them start getting baseline data help them start using small interventions help them figure out when you felt okay before what was different let's take one of those things and start doing it now to try to help empower them to improve their situation even if it's placebo I will take it guilt plays a huge issue when people have mood disorders anxiety depression they may feel very guilty but they're not able to meet the needs of other people in their life or they may feel guilty for having those feelings we need to address it anger about not being normal and normal is just such an awful word because normal is different for everybody but what I want to ask them is you're angry about not being able to be tell me what you want to be like what does normal look like for you anxiety that things won't improve you know I have a lot of people who start on treatment and if two weeks later they're not feeling you know 80% better they start getting stressed out that it just doesn't seem like anything's working so we talk about you know the brain needs time to rebalance and old habits die hard and all that kind of thing and grief over loss of prior functioning if somebody is clinically depressed or has generalized anxiety or social anxiety and they didn't always have it or they always thought they would go into public speaking or teaching and then they developed social anxiety they have to grieve the loss of that dream that they had or the knowledge that they had this function that they they no longer have if it's something that's not going to come back or you know sometimes they need to grieve it even if it's something that they don't have right now I know right now I'm getting over being ill and it's really frustrating to me that I just don't have the energy to go out into my garden and spend as much time out there as I wanted want to and it it makes me kind of irritable and cranky because I look out there I'm like oh the weeds so we need to help people figure out how to avoid the secondary emotions that are associated with their mood disorders addictive behaviors the initial impact euphoria and relaxation and then we have depression lack of pleasure and anxiety when the drugs start to wear off or when the person starts to become tolerant we start to see problems there's insufficient dopamine or imbalance of those neurotransmitters indirect effects of the addictive behaviors similar to the the mood issues lack of sleep malnutrition guilt being overwhelmed by the mess that's you know all the things that they've avoided or all the problems they've caused because of their addiction you know think about somebody with a gambling addiction who can't pay the mortgage because they went ran through all the savings in one night and the initial pain emotional or physical is still there every time they sober up and that's really depressing that they're just like oh wow I can't even begin to look at that right now I can't believe that I've let things get to this point so we want to help people see that depression and anxiety as a result of addiction are really normal and they're expected it doesn't mean you're always going to to struggle with symptoms of depression or anxiety it just means that right now it's a pretty normal reaction to the current situation what can we do to intervene enhance hope and empowerment develop resilient skills help them see how they've survived in the past help them look forward and start making plans setting goals small goals you know smart specific measurable attainable reasonable and time limited for what they want to achieve in the future so they have some hope they feel empowered they're like okay you know getting from here to the top of Mount St. Helens is wow overwhelming but getting from the bottom of Mount St. Helens to you know the first plateau I can do that so we want to help them get those plateaus and ideally help them put you know if you're a rock climber you have those little pegs that you put in the wall and if you're a mountain climber I assume you have similar things so you have anchors that you can grab onto as clients climb out of their depression or climb out of their anxiety encourage them when they hit a plateau or a place where they're you know feeling okay to put in a stake put in something so they can get traction which is kind of the metaphor I use for you know take a breath and before we go further let's solidify these coping skills and strategies that you have right now you're doing really well let's make sure you got these before we move on to the next phase that way if they start to relapse they have stuff that they can grab on to along the way to slow their fall or stop it completely we want to help them identify and address cognitive distortions because when we're depressed we tend to think in unhelpful ways and so helping people identify thought changes that may have occurred because of their anxiety or depression or thinking patterns that may have been there all along that contributed to it it doesn't matter we need to address them we want to help people enhance their self-esteem and focus on what they do have and what they do bring not what they don't have right now or what they wish they had you know if they wish they were and I use I don't like the term normal but they wish they were normal as they define it teach distress tolerance coping and problem-solving skills all of these are going to help clients educate about the connections between behaviors thoughts and feelings address guilt and identify their grief triggers so again looking back at what does this person have to grieve and it's not just tangible stuff like loss of a house or you know death of somebody or loss of a pet but it's intangible stuff like loss of dreams loss of hope loss of innocence loss of a sense of security and help them grieve that move through the process so they can come to acceptance and be able to say alright that happened or this is the status of things what now and write that into their life narrative social impact isolation and withdrawal is true for mood or addictive disorders you know people if they don't feel like other people understand or they just don't have the energy to deal with other people or don't want to deal with being lectured by other people will tend to withdraw and isolate just you know go into their own little place loss of supportive healthy relationships occurs because again people with mood or addictive disorders can push others away either because they're just too much of a downer to be around or because they have gotten angry or irritable and pushed others away because they're not pleasant to be around or because they chose to leave they just said you know what I am no good to anybody I just I'm going to withdraw so whether they don't have those relationships around because it was their choice or the other people left they still don't have supportive relationships so we need to help them figure out where to find those and how to nurture them if they have supportive relationships their friends may share the same dysfunctional thinking and minimization rationalization blaming if you've got a client who tends to be depressed I'm thinking of one in particular very angry gentlemen engaged in a lot of blaming behavior and the friends the social circle he hung out with tended to feed into that and they would get on this whole everybody's awful sort of diatribe so it's not again it's not just addiction but we want to look at what attitudes are our clients friends and social circles contributing to their environment and how is it impacting their mood and friends may share the same cognitive cognitive distortions and dysfunctional thinking like everything is all about me magnification of things that happen personalization so you know we just kind of want to look at that social interventions enhance social support and reduce isolation through support groups and these can be online support groups if clients don't want to go out and meet people face to face or there's not a support group that's convenient or conducive or whatever the case maybe it doesn't have to be face to face I think there's a great benefit in the face to face groups but I'll take what I can get and and I'm old school you know I grew up before the internet started improve interpersonal effectiveness skills so people can communicate one thing we've seen with a lot of the youth as of late I mean it was it's never been a hundred percent you know there's no generation that can say oh we had great interpersonal effectiveness skills but the the youth that grew up communicating via text and emojis and stuff and not communicating face to face tend to have much worse interpersonal skills especially in a face to face environment they have difficulty with nonverbals and because they can't backspace and erase things and you know think it out they're kind of you know on the spot tend to have a problem saying things right the first time so interpersonal effectiveness skills can be hugely helpful educate about healthy relationships and boundaries what do these look like you know what is a healthy relationship what is a dominating relationship what are assertiveness skills what are emotional and physical boundaries is it okay and why is it okay to say no to request sometimes and assert boundaries and say you know what I it's just more than I can do right now so helping clients manage their time and manage all of their energy and still maintain healthy healthy relationships and we can examine and address characteristics of current relationships that mitigate or exacerbate problems so have them list their 10 closest friends confidence family members whomever and let's identify things that each person does that helps you feel better and things that each person may or may not do that may make you feel worse or may contribute to the problem and help people figure out how to address that you know because you can have somebody in your in your social system who is really supportive but they also you know are triggering in certain ways so we need to help people figure out how to navigate that relationship how to navigate those instances and effectively work with that person so the total picture someone who's physiologically less able to experience happiness or pleasure may have a desire to find that feeling again which can lead to substance misuse or addictive behaviors gambling shopping porn eating and they may try to keep that feeling protecting the addictive behavior or substance at all costs which can lead to habitual use and progress to abuse independence mood disorders contribute to a host of other problems you know there's it's not just depression depression can exacerbate pain it can even cause pain reduced immunity sickness sleep problems lost work time and productivity and relationship issues so all of these things are things we need to assess and address in order to help people have the best chance at effective sustained recovery addiction and mood disorders have both direct and indirect consequences for the person biologically psychologically and socially all aspects of the person in recovery must be addressed because it's hard to change your thinking when you don't feel well or you don't have a safe place to sleep and you're exhausted or you're hungry you know it's you're not focused on cognitive distortions you're focused on finding a meal it's hard to change physical habits when you're depressed and unmotivated so if your mental attitude is low if your motivation is low if your energy is low and you know I'm talking more psychological energy to get up and go motivation it's going to be hard to get your body moving and and change behaviors and it's hard to change thinking or health habits those go back to Linahan's concept of vulnerabilities it's hard to change a lot of these habits without social support which can be one of our greatest stress buffers or energy you know if you don't have any energy it's going to be hard to go yeah I need to get up and make a healthy meal or yeah I need to go find my phone so I can call so-and-so and get some social support so we need to make sure that we're assessing and addressing the whole person are there any questions okay let's see my cute little headphones so I am going to mute everybody but you have the ability to unmute yourself now if you have any questions and you want to ask them verbally instead of typing them into this mental illness with addiction tell me a little bit about what you want to know about that what we do know and I'll wait for your answer yes it's a two-edged sword if you have somebody who is clinically depressed and alcohol-dependent and they come into treatment and you deal with the alcohol if you deal with the alcoholism but you don't deal with the depression then you're going to have a depressed clean person who's probably going to struggle to stay clean in in recovery if you don't treat both likewise if they come in and they're alcohol-dependent and depressed and you go you know what your alcoholism is what's causing all of these mood problems and as soon as we treat this the depression will remit that generally doesn't happen because they don't have skills to really replace it so you end up with a person who's clean and depressed still you treat the depression and allow them to keep drinking then the drinking is going to mess up the neurochemicals and probably cause a depression relapse so it's a really a chicken egg thing which is why in co-occurring disorders we emphasize the need to treat both concurrently we need to make sure that we're addressing any mental health issues well and I go concurrently three ways if you will the mental health issues the physical health issues and any addiction issues because they all feed into one another and they can all make each other worse or they can all make each other better a depression relapse can cause a can trigger an addiction relapse an addiction relapse can trigger a relapse of a mood disorder so yeah they are pretty much inextricably intertwined and the research has indicated that co-occurring mental health and substance abuse are the expectation not the exception for just the reasons I said in the presentation when somebody is has an addiction so much other stuff happens and goes wrong and gets ignored and they're messing with the neurochemicals in their brain that there's a situational a bunch of situational factors that can all kind of collide to create depression now it doesn't mean that they are necessarily going to ever have another major depressive episode once they get out of treatment doesn't mean they had to have depression ahead of time but from anybody's standpoint it would make sense to experience depression or anxiety when you're looking at all this stuff that you've got to deal with and clients who have stopped using and think that they're no longer an addict and there's a lot of debate on that okay why hang on oh I opened the wrong one there are some schools of thought that say that people can recover completely um what I the analogy I use is imagine somebody is a car salesman and they can sell a car to a man that has a whole fleet of cars I mean it they can sell sand to a man in the desert and they're really good at it and but they decide one day that it's not fulfilling they don't want to do it anymore so they switch careers completely and they become a plumber or something and the being a plumber meets their needs it's fulfilling they enjoy doing it but one day for whatever reason they're not able to make enough money being a plumber what do they fall back on those skills that they've already learned being a salesman it wasn't fulfilling it wasn't you know really where they wanted to be but they do have those skills and they know those skills work so addictions kind of the same way it helped a person survive the best way they knew how with the skills they had at the time and if they're going along in life and life throws them a curve ball or they quit taking care of themselves for whatever reason and the skills that they're using don't seem to be working they're not experiencing the pleasure and euphoria and stuff and I'm not talking about super euphoria I'm talking about the feeling you feel when you see a really awesome autumn moon or something not but anyway when they're not experiencing happiness in life despite using all the skills and tools we've given them or they're not using them effectively or whatever they may desire that happiness or they may have a curve ball thrown at them that overwhelms their coping skills so what do they do they go back to what works just like the plumber went back to selling cars they go back to the addictive behaviors because they know that that will help numb the pain and help them survive for the moment so I try to help people look at it from a and when we have clients argue that if everything is going good in their life there isn't a need to use that's true but does everything go good all the time there are going to be times when life throws you a curve ball and I hear this argument a lot more at a clients who want to return to recreational use and you know that's that's a personal choice it's a harm reduction issue that has to be taken on a case by case basis but yeah I mean if everything's coming up roses and you don't have any stress in your life then you probably don't feel the need to use because the coping skills you have are working but if they're not then then you've got a problem and yet the old saying what is it one drink isn't one drink is too many and a thousand is never enough help helps people understand a little bit that once they go back down that road and they feel that euphoria and especially with people who are using substances once they start monkeying with that those neurotransmitters even one drink or one hit it can start a cascade effect their bodies like oh I remember this here we go again and it starts going into protection mode which can start triggering cravings and all that kind of stuff but another thing I do with with those clients is to talk to them about what it means to think about it is something that they've got lifelong versus something that they're completely recovered from I have a lot of clients who don't like to use the term addict they find that to be demeaning and and okay that's fine but the fact is right now you do meet the criteria for substance dependence or you have had an addiction depending on how you approach it in your treatment center so what's to keep that from happening again and and I do in the facilities I work at I emphasize that people are people with addictions because I want them to understand that their people first and and they do have the ability to make some choices in their life to prevent going returning to these behaviors but yeah it's it can be a tricky road with a lot of clients and obviously the safest is complete abstinence but that's not going to work or be acceptable to certain people or for certain addictions I mean it's really important to understand like for eating disorders and things people can't completely abstain with incarcerated people the what we've been talking about about wanting to go back to controlled use or not wanting to be an addict or seeing themselves as completely recovered I see this a lot not only in incarcerated population populations but also in people in residential because they've been living in the safety of this little cocoon and they haven't had to deal with life on life's terms you know the kid getting sick and the car breaking down and the bills coming in and everything else that they've been shielded from for 28 to 90 days and encouraging them to recognize that it takes a while to develop a recovery lifestyle and we spend a lot of time talking about the difference between being clean you know not using a substance and actually embracing a recovery lifestyle as and sobriety as we define it and we define and I have clients define specifically what sobriety or a recovery lifestyle looks like for them and and when I've had clients that have gone to meetings whether they want to or not whether they think they need to be there or not I want everybody to come out of a meeting with something they can tell me that they got out of the meeting you know what did you learn or what was poignant to you about either what somebody said they did or they didn't do or maybe something you learned that you didn't want that's something you don't ever want to do but I really believe that if we look we can learn from everybody and so being in those meetings gives people the ability to try to find a life lesson for the day that makes it a little bit more palatable for some that are mandated to meetings okay if we are good then I will call it and I will see you guys on Tuesday if you enjoy this podcast please like and subscribe either in your podcast player or on YouTube you can attend and participate in our live webinars with Dr. Snipes by subscribing at allceuse.com slash counselor toolbox this 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