 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 common co-occurring issues, exploring the interaction between mental health, physical health, and addiction. So we're kind of putting together the stuff that we've been talking about for a couple of sessions now. We're going to start out by talking about some questions and then reviewing what a healthy person needs, and then going through and talking about how different addictions may cause or be caused by mood disorders and physical health issues. And we're going to talk about things that you may see in private practice or in the facility that you're working in. Just real quickly, for those of you who are here, how many people, if you would just type in the chat window, if you're a mental health counselor, type MH, if you are an addictions counselor, type SA or whatever. So just kind of know who I'm talking to. Okay, so mostly mental health. Okay, cool. So what we're really going to look at and is what you may see in a private practice or in a mental health setting, because these clients, a lot of clients that have substance abuse or addiction issues, and I use the term addiction because we're talking about behavioral addictions too, many times they don't meet the criteria for admission for substance abuse, because they don't meet that threshold of a substance use disorder, tolerance, withdrawal, yada, yada. So substance abuse agencies can't get funding to provide the treatment. So they end up in a mental health facility or a mental health counselor's office, and they may be dealing with some of these addiction issues and wanting to address them, or they may not be, but those issues are out there and exist. So we want to know how they interact. So I told you we're going to have a couple of questions to think about, and I'm just asking you to ponder these for right now, and you can add throughout the class if you want, but we're going to talk about it more at the end. How can we, and why is it important to address chronic illness and disabilities that result from or that cause mood disorders or addictions? So thinking about, you know, like HIV or hepatitis, those are two of the big ones, cirrhosis of the liver, chronic obstructive pulmonary disease from smoking. So these are things that can result from addiction. Why or how is it important for us as clinicians, mental health clinicians, mainly, to think about addressing these? How can we address depression and or anxiety kind of our mood disorder genre and hopelessness that results from or causes depression and anxiety? So we know that thinking back to acceptance and commitment therapy, there's clean discomfort, which is what he calls your initial emotion. When you feel something, if you feel depressed, if you feel anxious, that's how you feel. And it's uncomfortable, but it's clean. It is what it is. And then he calls dirty discomfort the feelings that we have about those feelings. So we can get angry that we are depressed. We can get depressed that we're still depressed. And he calls that dirty discomfort because we're kind of layering on and piling in, think about just kind of throwing somebody into a hole and piling more dirt on top of them. So we want to think about how can we address these issues that result from depression or anxiety or sleeping, eating or energy changes. So if you've got somebody who is dealing with with a chronic illness or something else has happened or they've got some sort of an addiction and they are not eating well, not sleeping well, it could trigger depression or anxiety. So we're going to talk about that. How can we address sleeping, eating and energy changes? It seems like we're getting repetitive. We're looking at how each one interfaces. How can we address these things that are caused by or cause mood disorders or addictions? Because we know when we look at the diagnostic criteria for depression, for example, sleeping, eating and energy changes, primary in there. And how can we address guilt and regret, which may accompany addiction recovery or the diagnosis of the disease as the result of addiction, such as lung cancer or HIV or cirrhosis of the liver. And people who have liver disorders, cirrhosis of the liver and hepatitis are at a greater risk of liver cancer. So that can, they can have some additional anxiety that are related to that. So they may look back and go, I wish I hadn't. Well, you have. So how can we help you deal with that and come to some level of acceptance? So my little editorialized soapbox. When we're talking about addictions, I mean, sometimes we don't want to think that they exist. We want to pretend that our clients are coming in their mental health clients. Otherwise they're perfectly healthy. Things are going great. That may not be the case. A lot of people begin to use, and I mean, think about ourselves when we're, when we were in high school and college or, you know, even later. Some people use for recreation, you know, they want to go out and have a few beers, do whatever. Cool. You know, that's fine. Some people drink or use for relaxation. My son has a love of, we will use that word, video games. And he will get on his video games and we'll kind of get lost in it. It helps him escape from, you know, life as we know it for a little bit of, little bit of time. Some people use because of peer pressure, you know, it's everybody's doing it or, you know, you're at a football party or something and everybody's having a beer and somebody offers you one and you don't want to be rude. Things like that can happen. And some people begin to use straight up for self-medication. They're like, I feel crappy. I need something to help me feel better or numb the pain. So there's a lot of reasons people begin to use. So then you might say, well, why don't they just say no? Because, evidently, it's easy to say no. Well, it's not. Some people start to use because they're bored and they want something to bring some excitement, some euphoria to their life. And we're talking about everything from sex addiction, internet addiction to cocaine use. I mean, we're running the gamut here. They may lack the awareness of the dangers or how quickly you can become addicted. I know when I was working in the facility in Florida, there was this sort of knowledge, if you will, and knowledge is not really the right word. But there's this rule, I guess, that with crack cocaine, for some people, it was a one-hit wonder. You did it once and you were hooked. And there are several drugs that can be really highly addicting really quickly, especially if they're taken either through injection or inhalation. But we've talked before about the fact that our bodies can start developing tolerance to opiates within three to five days. So, you know, people may not, a lot of people don't realize when they go in and their doctor writes them a script for two weeks of opiates and they take it as prescribed that they're actually becoming somewhat addicted to those opiates if they take the whole prescription. So they may not understand that. Some people don't say no because they have low self-esteem. So they're looking for comfort to help them relax, to help them loosen up so they can be more fun at the party and or to peer pressure. Somebody tells them why don't you use or why don't you come out and go drinking with us or whatever the case may be. So to fit in, they may try to use in order to fit in to feel part of a crowd. Part of it can also be, you know, with that peer pressure, just generally the culture promoting this kind of behavior going, it's okay. I think I've shared with you before at the beginning of some of the original Beverly, Beverly Hillbillies episodes. They still advertise Winston cigarettes like they are the greatest thing and cool people have them and that's the thing to do. So if that message gets out, people may start believing it and not do their research so to speak on what the true problems or risks may be. And then again, self-medication. Some people may be struggling just to get by from day to day and this helps them survive the best they can with the tools they have until we give them some new tools. So just saying, you know, and I had, I grew up during the era of Nancy Reagan and, you know, God love her, she was trying to help. And for a certain small percentage, she probably did. But for a larger percentage, just saying no is not that easy. We need to give people the tools so they can say no. So they don't, so they aren't relying on these drugs for some reason because when people start using for recreation and relaxation, some people may not have a big, big issue with it. Other people, it may start throwing their neurotransmitters kind of at a whack depending on how much, how often they use what combinations if they're on any medication. So people may inadvertently start messing with their neurotransmitters and creating, and we'll talk about this, creating the depression or anxiety that they end up trying to self-medicate. So that is my soapbox for it is not that easy to just say no. We as a culture, not just as clinicians, have some work to do. So what do we need to do in order to help people be able to just say no, they need to have access to healthy nutrition and knowledge of what that means. My son and it's still like drawing fingernails down a blackboard to me today this week, told his sister that, you know, he didn't understand why she was so concerned with nutrition. He's a guy. He doesn't need to pay attention to nutrition. It's just whatever. And I was just like, Oh my gosh, you know, everything I've said has fallen on death, deaf ears, but okay, we'll back up and figure out a way. But they need access to it. And then they also need to eat it. You know, if we have healthy foods available, but people are still eating peanut butter and jelly sandwiches for every single meal. It's not going to help. So we need to make sure people understand what a healthy diet looks like and how to do it in a way that's not painful. You know, we're not asking you to just eat rabbit food, as my daddy used to say. But so what does it look like to eat a diet or nutrition that makes you feel good, that's happy, that makes you feel happy, fulfilled, you like it, it tastes good, whatever you want to say. But that's also healthy. You know, it's not just pizza or just peanut butter. We need to educate people. And a lot of adults that I work with have no clue about sleep hygiene. You know, they know they're supposed to try to go to sleep, but they don't know anything about turning off the blue turning on blue light filters. So the blue lights are not keeping them up. So we need to do some education here, ideally in elementary schools. But if we can get it out to the community so they can pass it on to their little minions will be on a good path. Pain control, we need people to start having pain control, but we need to also have them have alternatives to pain control besides opiates. And there are a lot of them out there again, people don't know about. So it's important that we educate and we're not prescribing pain control. That's not our job. But if we have a client who's in chronic pain, we can suggest that they work with their doctor that they look into options for pain control. You can Google it and find a lot of different alternatives now if they don't want to go to the doctor. But, you know, there are a lot of different things from acupressure to 10s units to things that are non pharmacological. They can help people manage their pain so they can sleep, which will help them rest and rebalance, deal with fatigue and be able to deal with life kind of on life's terms because they won't be in this constant state of stress. People need access to regular medical care to prevent problems. So, you know, we want to prevent this thing on your face from becoming skin cancer. We want to prevent anything else that that might trigger problems and early intervention. So like with Lyme disease, if people get early intervention, they don't end up with the chronic problems with HIV. The earlier the intervention, the better. Same thing with hepatitis, you know, the list goes on. So we want to make sure that if people have some sort of issue that's disrupting their ability to get enough sleep, process nutrition, go to work, do any of these things that they have access to some method, whatever method they need to address it. So sometimes it's medical, sometimes it's mental health, sometimes it's social services. They need safe housing. So we're on to social services now. And that includes a roof over their head that they're not worried when they go to sleep at night, but also being safe from domestic violence and things like that. Safety. And this kind of goes with safe housing. And I put internal and external because, you know, the first part is external safety. We want to be able to know that our patients can relax wherever they're at. They have enough money to keep a roof over their head in a safe place. And, you know, typically that's not something that we think about as mental health counselors. We think about helping them deal with their anxiety. But if they can't get enough sleep and they never feel safe when they're at home, they're not going to be able to rest. And they're at best, their recovery is going to be impeded. At worst, you know, it's going to contribute to the issue that they're seeing us for. So safe housing is important. We're not going to get it for them, but we can point them in the right direction. Your local United Way, which is 211 in most places, generally has a listing of different resources for accessing safe housing if you don't work in a facility that's used to dealing with that. And then internal safety. That's shutting up that internal critic. That's being able to go through a day without being derogatory to yourself. And that's something that we definitely can help with. We can help people shut down that internal critic or that internal person that is always calling gloom and doom and, you know, waiting for the other shoe to drop or whatever the case may be. We can help clients change their cognition so it's safe inside their own head. And then people need love and acceptance. And this should sound pretty familiar. This is, you know, Maslow's hierarchy here kind of in reverse. People need love and acceptance, but in order to have love and acceptance, in many cases, they also need to love and accept themselves. So we're going to work on self-esteem. We're going to help people develop relationship skills. Hopefully there are some people in their life that have provided some level of love and acceptance, maybe not the unconditional positive regard we've hoped for, but they're there. So these are things that the healthy, happy person needs. And these are things in large part we can through education, referral and direct services help people get. So why do we care about co-occurring issues as mental health counselors? Well, 35% of people with anxiety disorders have, according to one of these studies, abused opiates. So that's a lot. If you've got somebody with an anxiety disorder, this isn't just panic. This isn't just something, you know, really severe. This is, you know, any of your anxiety disorders, one in three, roughly, have abused opiates. They've used some sort of opiate drug to help them kind of chill out. Of opiate or alcohol dependent patients, 20% have major depressive disorder. So of that 35%, you know, there's going to be a percentage of them who may be opiate or alcohol dependent. And there's a lot of our clients that we see in mental health treatment who are not willing to be truthful about how much they really drink or how often they really drink, because they might be suspecting it's a little bit of a problem, but they're not wanting to go there yet. They're in what we call pre-contemplation. Okay. So let's just go with this in mind that there may be some underlying other stuff that they haven't told us about. Opiate or alcohol dependent patients, 20% have major depressive disorder. So, you know, we're taking them and we may be seeing them in clinic for depression. And we really do want to be suspect of whether there's either some opiate or alcohol issues there. Depression and opioid dependent patients, including pain management patients, so those who are opiate dependent by prescription, has been associated with poor physical health, decreased quality of life, increased risk taking behaviors and suicidality. Am I saying that pain management clinics are bad? No. But what I'm saying is those who are in pain management clinics for a variety of reasons are in a higher risk category. I mean, think about it. If your pain is bad enough that you need to be going to a pain management clinic, think about how much that must hurt. Think about how much that must impair your daily life. Think about the impact of the drugs that you're taking on your mood, your energy levels, and the stigma in some cases associated with it. Some people hear suboxone and they're like, yeah, whatever, my neighbor takes that. Other people hear suboxone and they're like, oh, you can't be taking that. So there is still a lot of social stigma that goes along with medication assisted therapies. So there's a lot of things that may contribute to depression in opioid dependent patients. The prevalence and severity of depression tend to decline within the first few weeks after treatment initiation. So if they are trying to get off of ideally their detox and they're trying to remain sober, the prevalence and severity of depression tends to decline. So we need to get them off of it first, get them through that acute withdrawal. Withdrawal from depressants, including alcohol, and I know this slide is boring, but we're going to be thrown in a second. Withdrawal from depressants, including alcohol, opioids, and even stimulants invariably includes potent anxiety symptoms. So it's important to pay attention and withdrawal from stimulants can also include potent depressive symptoms. If they've been on a crack binge for, you know, five days, they're going to sleep for a while. Many people with substance use disorders may exhibit symptoms of depression that fade over time and are related to acute withdrawal. When we talk about acute withdrawal, we're talking about the first three months. We're not talking about the detox period, which is generally three days. So encourage people if they've gone through detox and maybe they're seeing you on an outpatient basis. Encourage people to, you know, be patient, work with the treatment team if they need to, but the first three months is always the hardest. So chicken or egg, you know, did the person start using and become depressed or was the person depressed so they self-medicated? Does it matter? Depression and anxiety are associated with addiction because if you have stimulant withdrawal or recovery, that period after you quit using, that's maybe a week, maybe two weeks where your body is going, ooh, that was a run. People may feel depressed, fatigued, have difficulty concentrating, which can impact how well they eat. It will definitely impact their sleep. They're going to sleep a lot more, but the quality of sleep may be poor so they can mess up their circadian rhythms. And, you know, they may not have access to the social support that they wanted. They may, but really with stimulant withdrawal, we're definitely looking at nutrition and sleep. So we want to educate patients if they decide to stop taking stimulants, what they need to look at. Stimulant use can also be associated with depression and anxiety because many people, not, you know, the majority, but a lot of people out there will self-medicate depression with stimulants from anything from caffeine, which, you know, may be like mild dysthymia, but if you abuse enough caffeine, you know, it starts getting into your system, you become dependent on it. But if you start combining caffeine and nicotine plus, oh, let's add in some workout supplements or, you know, the occasional ritalin or something, not suggesting it, then it's, these things can wear the body down, which can lead to additional depression. But people may use these things to try to feel better because think depression is really related. For some people, they may not feel like they can wake up. They're fatigued, they're lethargic all the time, and they're feeling blue. So if they take stimulants, they get that dopamine rush, they're starting to feel really good and they're awake. Stimulant use can cause anxiety. Well, so if you've got somebody who already has, maybe they are depressed, but they've also got some anxiety and they start using stimulants. It may make the anxiety way worse. Alcohol or opiate use. Some people use these things to numb or to forget, and that's just your standard use of the depressant. Some people will use either one of these, but especially opiates to deal with physical pain. To medicate depression or anxiety. Remember, there are a lot of trial, no, several trials right now that are looking at using opiates to treat intractable depression. But a lot of people also use opiates off-label illegally to address anxiety. So if you've got a client with depression or anxiety, just kind of be alert for how they're behaving. If they've got pinpoint pupils, or if they're itching and picking all the time. I mean, not the occasional, it's winter and the heat just turned on and I've got dry skin itch, but constantly itching and picking and, you know, where you're like, please just settle down. Detox from opiates can often produce depression. It produces a lot of flu-like symptoms, which can make people feel really crappy. And the flu-like symptoms, I won't get graphic, impair nutrient absorption, impair sleep. You know, they're sleeping a lot because they feel like crap, but they're also having to get up every 10 minutes to go to the bathroom sometimes. So the first week or so during the initial, if they go cold turkey, so to speak, can be really rough. Detox from alcohol, as I've talked about before, can produce anxiety symptoms. So understanding that when people are going through detox, whether they are alcohol-dependent and have been drinking a whole lot, which really needs to be medically monitored. I can't say this enough and I'll say it a lot more tomorrow when we talk about Wernicke-Korsakov syndrome. But people who are detoxing from alcohol will have anxiety symptoms and a period of high blood pressure. And sometimes depression and anxiety is associated with addiction just because they sober up one morning and they look at their life and they're like, what the hell have I done? So, you know, and you're looking at them going, yeah, don't blame you for feeling that way. Now let's see what we can do to improve the next moment. Making sure that we understand that these things are going to go hand in hand. And to be on the lookout, because like I said, a lot of people aren't forthcoming, even about alcohol use, which is legal. But if they're using something illegally or using maybe their kid's Ritalin or something, they're pretty much almost guaranteed not to tell you. So we want to be on the lookout for signs and symptoms. Bipolar disorder can be triggered by drug use. So we just know that we can, the person could get worn down, mess with the neurotransmitters enough. They're not exactly sure how it happens. But we have seen the initial acute episode of bipolar disorder triggered, mania triggered by drug use. It is more common for people with bipolar to use stimulants when they're depressed and just about anything when they're manic. Now if you're working with somebody with bipolar, you know, you're probably already having these discussions about how do you stay safe when you're in a manic episode. People with ADHD may use to self-medicate. And we're talking cannabis is a big one for ADHD to help people feel like they've got more focus and not feel like they've got so much coming in and so much stimulation all the time, which can be exhausting. And after use of any of the substances of abuse, the disruption in neurotransmitters can make people feel like they've got ADHD type symptoms, difficulty concentrating, difficulty following through with things, etc. So understanding that even if things don't meet the threshold for DSM five diagnosis, we want to look at what symptoms are there and how can we help people manage them. So they're getting adequate sleep, nutrition, pain control, social support and safety. Borderline and antisocial personality just kind of threw those in there because we see those a lot when we're working in dual diagnosis facilities. People are more likely to use addictions to cope with a lack of sense of self and their emotional ability at their borderline. So, I mean, their world is so chaotic. Many people with borderline personality disorder are likely to use to try to get some calm in the storm. Now I will put out my other soapbox here with both of these personality disorders. When you see somebody in active addiction or in early recovery, they probably have symptoms that would meet diagnosis. You know, their symptoms are pervasive in multiple areas of life. Their symptoms would meet diagnosis for one of these two personality disorders during this period, but it's resolves as recovery becomes the norm as the neurotransmitters stabilize as they develop interpersonal skills. So, you know, giving people a little bit of time before we say it's borderline personality disorder versus borderline personality characteristics, if you will, can be helpful because both of these diagnoses can block people from getting into certain treatment centers and getting some of the services they need. Okay, so we're going to move on to some of our more common addictions. Alcoholism is associated with eating disorders. There's a really strong association, and it usually flip flops between bulimia and alcoholism. So if somebody's symptomatic for bulimia, they may not be drinking a lot of alcohol, but they may during periods of remission from the bulimia drink a lot more alcohol become alcohol dependent. So there's a lot of research out there that has shown there's a strong correlation between these two things. And it's also associated with binge eating disorder, but especially bulimia. Nutritional deficiencies from alcoholism can cause mood disorders. So even if somebody is not. And I use the term, I should have put alcohol instead of alcoholism, because even the heavy use without physical dependence can cause nutritional deficiencies that can cause ulcers that can cause physical problems. Physical exhaustion, which can disrupt sleep. Alcohol impairs sleep quality. Alcohol makes apnea worse. So if you've got a client who has sleep apnea, they're drinking, they're probably going to sleep even worse than they normally do. Depression is the result of use. Well, alcohol is a depressant. So what do people expect? Well, most people expect to relax. They don't think about the rest of the stuff that's going on. Neurochemical imbalances because the alcohol exits our system a lot faster than our brain can catch up and go, okay, it's not in there anymore. So I need to adjust the temperature and sleep disruption. Anxiety can also be triggered as a result of use. I've said before, say it again. After that initial period where people feel the depressant or relaxing effects of alcohol, there is an upsurge in anxiety. So a lot of people have another drink to kind of quell that anxiety feeling. But, you know, people with anxiety disorders are going to feel it more prominently and the neurochemical imbalances that alcohol use causes can worsen preexisting anxiety conditions or trigger anxiety conditions. Nicotine is another one that we see a lot even in just straight up mental health clinics, not co-occurring. So what effect does nicotine have? Well, anxiety and depression are 70% more likely in smokers. So that's one of those statistics we want to look at. Nicotine triggers dopamine release. Okay, so nicotine is one of the most addictive drugs on the planet and you're thinking, I thought that was opiates. Well, opiates are in there, but nicotine not only is nicotine legal, but it's also one of the most addictive drugs on the planet. So that's another important point to think about. People are using their triggering dopamine release, their brain gets used to being flooded with dopamine. So the receptors on the other end start sensitizing. So we're creating an artificial environment basically when people are smoking. Blood vessel changes. When people smoke, it causes blood vessel changes that can cause high blood pressure as well as depression and fatigue and confusion. The blood vessels narrow and get stiffer. So the oxygenated blood has a harder time getting to where it needs to be. So people start feeling blah. And that can cause them to think that they're starting to feel depressed. It can also cause loss of energy. People with severe and persistent mental illnesses are two to three times more likely than the general population to use nicotine. So that's just an interesting little fact to have out there if you work with people with SPMI. And people with ADHD may smoke because it increases their concentration and attention for about five minutes, literally for about five minutes. But during that five minutes, they're like, Oh my gosh, it's a relief. I can actually like focus for half a second. So we want to look at what else is going on, whether the person has adult ADHD, for example, physical health mental. So nicotine is linked with COPD and emphysema and lung cancer. So, you know, all kinds of lung and cardiopulmonary stuff. Well, when that happens, you know, we have less oxygenated blood, efficient, efficiently getting through the system, we're going to have increased fatigue, increased confusion, some grief that may go along with that, especially if people are starting to have to carry an oxygen tank around with them or something, you know, we may have to help them deal with disability acceptance and depression. And stroke, because smoking, like I said, increases blood pressure and reduces circulation. So by cutting off or greatly reducing circulation to the brain, they have shown that people who smoke, especially heavy smokers are at a much greater risk of stroke. And addiction, nicotine is strongly correlated with other addictions. A lot of people when they're in the bar, well, not so much anymore since smoking is not allowed in public places, but used to be when they were in the bar, they would also be smoking. But a lot of people associate alcohol and nicotine or nicotine and other drugs. So if somebody is using other drugs, likely they're smoking. Now it doesn't work the other way around just because they're smoking doesn't mean they're likely using other drugs. The reason this is more important is because people who continue to smoke after they have gone into recovery for their drug of choice have relapse rates as high as 68% higher than for people who quit smoking. So we start thinking about that and we say, well, why is that? Well, because nicotine is a mood altering substance, you know, we don't really think of it as such because it's not a woohoo. It's more of a, hey, okay. It's not as prominent of an interaction as maybe cocaine or something. But it does change the balance and people still do use smoking to cope with life when things get stressful, they smoke. Well, if things get stressful and, you know, they're too stressful for smoking to handle, then they may start going back to what else can I take use or do that will make this feeling go away right now. We know also that with smoking and that repeated release of dopamine, they're messing with the neurochemical balances in their brain. So it makes sense that eventually just like tolerance to other drugs happens, it may not be enough at a certain point and they may fall back into other habits. Nicotine has been known to suppress appetite and but whether it keeps weight off or not, they haven't really shown but alcohol and nicotine both are appetite suppressants, which is another reason people with bulimia tend to drink. And one of the reasons when people quit smoking, they tend to be hungrier. So helping them get through that period. Now, whether it helps them keep weight off, part of that deals with the reason that they eat is not really that it's suppressing their or increasing their metabolism so much is it's nicotine suppresses the anxiety and sometimes the hunger. But if people are still eating out of anxiety, if they're still eating stress eating, then, you know, when they stop smoking and they don't have a cigarette to put in their mouth when they're stressed, they tend to go for other things. And so we need to help people figure out what when they stop smoking, are you eating because you're hungry, or are you eating because your stress, and if they're eating because they're hungry and they're getting heavier than they want to be they need to talk with their doctor. About, you know, thyroid tests, and also let their doctor educate them on biological set point theory of, you know, not everybody's going to be a size zero. So, you know, that may be something we can help them deal with is body acceptance issues, if, you know, maybe they're programmed genetically to be, you know, a size X, whatever that is. And they're not happy because they want to be a zero, which our culture really does tell us to do. As clinicians, we can help them look at, you know, the costs and benefits of continuing to smoke and what is being, you know, a size zero really mean for them. Opiate abuse. There's a lot of physical stuff, and we're just going to run through it real quick because you're not as concerned with it. The physical stuff the doctors are going to see, but we need to be aware of from a clinical point, because it can keep people from getting their basic needs met. Blood and injection site infections. You know, that's probably going to lay them up for a while, but if they have repeated infections and are repeatedly out of work, they can lose their job they can lose their housing. They can, you know, get some sort of Mercer or something else which can be really expensive it can be life threatening yada yada collapsed veins and this is more common obviously this is only for injection drug users. But collapsed veins just as you would expect keep the oxygenated blood from getting where it needs to be. So people are more likely to experience strokes, and may have certain forms of vascular dementia, because of the strokes. People were familiar with endocarditis is the inflammation around the heart. So, again, this is really only for needle drug users. But if you've got a client who is using needles to inject any kind of drug, being aware of that, and what they get and what they inject is rarely pure. Knowing what else they're injecting into their system if they're, you know, crushing pills from the pharmacy you're a little bit more sure about what they're getting, as opposed to if it's from the corner dealer. And sometimes they're cut with really nasty things like, you know, Comet bathroom cleaner and stuff. HIV, if people get HIV from injection or some other risky behavior. They're probably going to experience some depression. And a lot of times. HIV from opiate abuse. They're going to experience depression, remorse, regret, all that kind of stuff. Anxiety about how long they're going to live what's going to happen. And oh, those medication side effects, those, the antiretroviral medications that they have to take are doozies. I've seen people go through the induction weeks on their medications, and it is a rough, rough time. People get through it so they are medication compliant so they can continue to live. We need to help them maintain hope and self efficacy and all that kind of stuff to maintain that forward movement to get through the induction period. Liver damage from acetaminophen can set people up for, you know, physical pain, among other things, and a decreased pain tolerance. This generally, the decreased pain tolerance generally goes away after the body starts producing its own endorphins and natural painkillers again. But that initial period, if somebody quits using, and maybe, you know, they, you were seeing them as a mental health client and they had an accident or had surgery or something. They started using pills. They got a couple of refills, then the doctor said, no, I'm cutting you off. And now they're going through a detox period. Detox from opiates is unpleasant, but it is rarely life threatening unless somebody become their electrolytes get imbalanced because of the flu symptoms. But we still may see this in private practice, in mental health practice, because of the scenario I just told you. People can start taking painkillers as prescribed for something. They may get addicted, you know, take them for a month or so. Then when they get off of them, not only do they feel like, you know, really bad, but their pain is also back. Maybe they had their wisdom teeth out. That pain may be gone, but other aches and pains and everything you feel is probably going to be intensified until the body kicks back in. So educating clients about this is what happens, you know, it's not uncommon. If you think it's too bad, obviously go see your doctor. Helping them make sure they're getting good nutrition. You know, it's hard if you've got flu symptoms to feel like you want to eat or hold anything down. So what can you do to make sure your body has the building blocks to make the stuff that it needs to help you feel better? What can you do to improve your sleep? And a lot of our clients and, you know, where I used to work, we had a methadone clinic and we also had a mother baby unit. And as soon as the mothers would give birth, then the doctor would start them on their detox from methadone. And he didn't believe in the kinder, gentler taper. He was just like, okay, baby's gone. Threat's gone because you can't detox from somebody from opiates when they are pregnant because it can cause the baby to die. But anyway, so as soon as they would stop or as soon as they weren't pregnant anymore, he would just DC them and they would feel really bad. I mean, not only did they just push an eight pound something out of their body, but they also are experiencing a decreased pain tolerance because they're not on the opiates anymore. And all they want to do is sleep. It's just like, please. So understanding that is really important. Helping people get through that period, even though they may want to sleep all the time, helping them understand that it's important to maintain their circadian rhythms. If they have to take two or three, 10 minute power naps throughout the day to get through the day, you know, more power to them. But if they can practice good sleep hygiene, they're going to be way better off in the long run. Opiate abuse is also or opiate use is also associated with treatment of depression, but it can cause depressive symptoms due to its pharmacological properties. I mean, it slows everything down from your gastrointestinal to your heart rate to your respiration. You're not breathing as much. You're not getting as much as much oxygen in. You're going to have more fatigue. You're going to have more confusion. You're going to have more of those symptoms of depression. For some people, they find it is uncertain opiates. They find it is a powerful way to reduce anxiety. It makes them feel like they've got a ton of energy because they're not stressed out anymore. And this last one is one of the main reasons that I find people don't want to give up opiates because they finally feel better when they're on them. Eating disorders commonly co-occur with depression and anxiety, which can be caused by nutritional deficiencies. You're not given your body the building blocks, so it can't make the neurotransmitters it needs. And it also probably disrupts your sleep some. And depression and anxiety can cause or trigger or whatever you want to say, eating disorders. Because people with eating disorders may fear becoming fat, have low self-esteem, have a sense of lack of self-control, or have body dysmorphic disorder. So we also want to be aware that there's mental health stuff that can trigger dysfunctional eating patterns. There's about a 24% prevalence of PTSD among people with eating disorders. So if you've got a client with eating disorders, especially bulimia, be on the lookout for depression, anxiety, body dysmorphic disorder, alcoholism, and PTSD. They may be smoking too, but of the things I just listed, that's probably the least of their worries. Eating disorders are also associated with alcoholism and smoking, like I said. Physical health issues. Now, you're seeing somebody with an eating disorder, it's a mild eating disorder, you're seeing them once a week outpatient, so you're not. And you have, you know, obviously you have training and working with eating disorders. Or maybe it's mild enough that you're just getting supervision on treating this issue, whatever. Being aware that people with eating disorders, anorexia or bulimia, can have irregular heartbeats and cardiac arrest due to potassium imbalances and electrolyte imbalances. So if they're not eating, or if they are binging and purging in some way, shape, or form, and that includes excessive exercise, it can trigger a lot of heart problems. They may have loss of bone mass and osteoporosis, so they may break bones a little bit easier. Going back up to the heartbeat, not to belabor the point, but again, heart problems mean lack of available oxygen, mean confusion, fatigue, potential difficulty sleeping, depressive symptoms. And, you know, cardiac arrest in and of itself is bad. Kidney damage from deretic abuse and low potassium can also potentially damage the adrenals, which are on the kidneys. And so it's important to be aware of what people are using. A lot of people with eating disorders are going to creatively use stimulants to suppress their appetite. Think about any of your diet drugs. Fentermine, I think, is one of them. The ones they give to help people actually lose weight. They're stimulants. They're intense stimulants. So people who are struggling with eating disorders are likely to go towards abusing stimulants, or at least using them, which can drain the adrenals. It can, in some cases, has been linked to the development of Addison's disease. Liver damage from not eating or binging and purging, causing toxin buildup and possibly pain. We can help people deal with it as much as we can. Anemia, which can cause symptoms of depression in and of itself. So it goes back to that nutrition, making sure they're getting enough. Infertility, which, in and of itself, can be devastating for young women if they can't have children anymore or can't have children ever. That may be a grief issue that we need to help them deal with. Cathartic colon, and this is an important one to be aware of because you don't have to have somebody who uses laxatives all the time, but people who regularly use or abuse laxatives can become dependent on them. So when they don't use them, they have a feeling of bloating, feeling full and abdominal pain, which, especially in people with eating disorders or body dysmorphic disorder surrounding just general body fat, can greatly increase anxiety, depression, hopelessness, and in some cases, suicidality. So, again, educating people is the first step to help them understand what's going on and how dangerous laxatives can be. But also, if somebody is trying to cut back on their use of laxatives or just recently stopped using laxatives, just like when people stop using opiates, it takes the body a while to get back online. But for most people, it eventually does. People with eating disorders also have chronic ulcers, which are painful, can keep you up at night with gastric reflux, and pancreatitis, which can flare up at a moment's notice, will, is extraordinarily painful and can cause people to lose time from school or work, social activities, feel really bad about themselves, and it also, pancreatitis also causes a lot of bloating, which in eating disorders is a huge trigger for anxiety and depression. Pathological gambling is associated with stimulant abuse, especially cocaine, methamphetamine and Ritalin to stay focused, disrupted sleep and rebound depression. When they quit taking that stuff, they wake up and they're like, oh, wow, what did I just do? Alcoholism is also associated with pathological gambling. Some people drink to calm their nerves. Some people drink because it's the culture. If you go to any of the casinos, you know, they're handing out drinks, they're trying to get you drunk, so you keep gambling more. And there's, as we spoke about earlier, rebound depression or anxiety. Smoking may help people increase their focus or make them think they can increase their focus. Since you can't smoke in public places, this is more of an issue if you have somebody who does a lot of online gambling, or they gamble at their friend's house or somebody's house where there's poker games and stuff. Smoking has some anti-anxiety properties and may be part of the culture. I know when my daddy used to have his poker games, everybody would smoke cigars. And even the one woman who went there would be smoking a cigar with everybody else. And it was just the culture of being there. So there are a lot of different reasons that people may use substances in addition to gambling. Mental health issues from gambling, anxiety from the stimulant use, or from the tension and release of am I going to, you know, I'm down $20,000, am I going to make it back? ADHD is also strongly associated with pathological gambling. Bipolar disorder, especially during manic phases, is associated with pathological gambling. Generally, you see them co-occurring. It's not like gambling causes it. You will see them co-occur. Depression can occur due to losses. And gambling can start because somebody's depressed because of their financial situation and they're trying to figure out a way to, you know, borrow from Peter to pay Paul and get ahead. You also see pathological gambling more strongly associated with people who have obsessive-compulsive disorder. If you've got clients with these diagnoses, just kind of, you know, be attentive to the fact that they are more likely to engage in pathological gambling. Or if they start gambling, it's more likely to become a problem than for people who don't have these issues. Internet addiction, which is actually diagnosable. So, you know, I'm not just making something up. Depending on your resource affects 8.2% to 38% of the general population. Now, obviously we were looking at, you know, like games versus, you know, games plus Facebook plus shopping or something. So, depending on the study you looked at, their parameters were a little bit different. But either way, up to 38% of the population has sacrificed significant personal recreational activities in order to engage in some sort of internet behavior. Internet addiction can cause anxiety or depression due to eye strain and chronic headaches. You know, if you're hurting all the time, it can make you feel wonky. It can also interrupt your sleep. It can cause circadian rhythm disorder, which can trigger depression, fatigue, reduce stress tolerance. This is a condition when your body doesn't know whether it's supposed to be awake or asleep. Because a lot of people who engage in internet addictive behaviors do so in the dark or, you know, they don't pay attention to whether the light's on or not. They may just sit there kind of in their cave. Carpal tunnel contributes to pain and sleep disruption because carpal tunnel does wake you up at night. Backache, again, may disrupt your sleep and can cause chronic pain during the day, which can interrupt your daily activities. Poor nutrition. I know a lot of gamers that will sit there for an entire weekend and not get up to go eat. So if it's not brought to them, they don't eat. They'll even wear adult diapers so they don't have to get up to go to the bathroom. Reduced immunity due to exhaustion from not sleeping and job or relationship problems. I know of several people whose marriage has ended over a world of warcraft. So internet addiction is a real thing. And it's something that we need to be cognizant of because it does cause a lot of problems in a lot of relationships. And it may be one of many problems, but it's something to look at. And sex addiction can cause hepatitis, a variety of different STDs, which if not treated can cause systemic problems. It's related to anxiety and depression because sex addiction may begin in order because somebody wants to feel loved or connected, maybe after a breakup or because they never felt loved or connected. And then they feel that rush and they're like, oh, I like that. I want to do that again. Part of it could be engaging in that behavior, which is so thrilling, you know, depends on the person. Psychological withdrawal from sex addiction, people who have been engaging in sex addiction type behaviors and I include pornography addiction in it for this presentation. If they're not able to access that may start feeling anxious or depressed. They can't get to that. They can't get to the thing that's going to cause the dopamine rush. And reflection on behaviors that they've engaged in as a part of their sex addiction can also prompt anxiety about a spouse finding out, you know, am I going to develop an STD? And am I, you know, how do I feel about what I've been doing? So as clinicians, if we're working with somebody who has compulsive sexual behaviors, even if, you know, anywhere on that spectrum, we need to be aware that these things may exist and figure out or help them figure out how they feel about it and what they need to do to make sure that they're getting good sleep, that they're dealing with their depression and their anxiety, that they can have a safe internal and external environment. So back to that global perspective. How can we and why is it important to address chronic illness and disabilities that result from or cause mood disorders or addictions? How can we address depression, anxiety and hopelessness that results from or causes depression anxiety or physical problems? How can we address physical problems that are caused by mood or addictions? And how can we address guilt or regret, which may accompany addiction recovery or the realization of a diagnosis of a disease caused by the addiction? So while you kind of ponder those, there was a question that came in. So the question is what about the robbing Peter to pay Paul in association with trauma, specifically a childhood trauma. So if you could clarify that for me a little bit. I had mentioned robbing Peter to pay Paul in terms of gambling. So I'm just so mental health issues can be caused by or trigger addictions or physical health issues. Addictions can cause or trigger mental health issues or physical health issues. Physical health issues can be caused by addictions or mental health issues. So again, chicken or egg, we don't necessarily know which one came first. But when you have any one of these, it's probably going to or likely impact each other person or each other area. Common issues seen in all three changes in sleeping changes in nutrition, fatigue and grief. Effective treatment requires addressing the underlying causes as well as the ripple effects, you know. So yes, after childhood trauma or trauma of any sort, some people may spend a lot of time feeding the addiction, as you put it, or engaging in addictive behaviors to avoid some of the PTSD symptoms to avoid thinking about it to deal with the grief to deal with the shame. So they may engage in something that makes them feel better or helps them forget in order to cope with the trauma that happened until they have other tools so they can actually come to some sort of terms with it and, you know, as I say close that chapter in their book. Alrighty, if there are no other questions tomorrow's presentation, I learned a lot creating it is on alcohol related dementia and vascular dementia and fetal alcohol spectrum disorders, all three of which are issues that are caused by substance use and specifically alcoholism. And in the, I'll give you a hint about Wernicke-Korsakov, a lot of clients who abuse alcohol, but they're not alcohol dependent who decide to stop drinking can actually trigger Wernicke-Korsakov syndrome and cause alcohol related dementia type symptoms. So again, in mental health, we need to be on a lookout for it if we hear that our clients are trying to cut down on their alcohol use. Alrighty everybody and so tomorrow is, is that presentation and then Thursday we're going to look at different models of new models of treatment. 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 allceus.com slash counselor toolbox. This episode has been brought to you in part by allceus.com providing 24-7 multimedia continuing education and pre-certification training to counselors, therapists and nurses since 2006. 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