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Treatment of Persons with Co-Occurring Disorders
Based on SAMHSA TIP 42 Part 9
Host: Dr. Dawn-Elise Snipes
Executive Director: AllCEUs Counselor Education
Podcast Host: Counselor Toolbox and Addiction Counselor Exam Review

~ Substance Induced Disorders
~ Substance-induced persisting amnestic disorder
~ Substance-induced psychotic disorder
~ Substance-induced mood disorder
~ Substance-induced sexual dysfunction
~ Substance-induced sleep disorder
~ Substance-induced persisting dementia and ARD
In General
~ Substance Induced Disorders
~ Substance-induced persisting amnestic disorder
~ The development of memory impairment as manifested by impairment in the ability to learn new information or the inability to recall previously learned information
~ Substance-induced psychotic disorder
~ Substance-induced mood disorder
~ Substance-induced sexual dysfunction
~ Substance-induced sleep disorder
Hallucinogen-Persisting Perception Disorder
~ Flashbacks, echo phenomena and other psychotic manifestations typically occur after drug-free periods and may persist for years
~ Such experiences may take the form of various geometric shapes, objects in the peripheral visual fields, flashes of different colors, enhanced color intensity, trailing and stroboscopic perception of moving objects.
~ Pharmacotherapy of this very distressing condition is limited Ther Adv Psychopharmacol. 2012 Oct; 2(5): 199–205.
~ Symptoms– Sudden onset of:
~ Disturbance in attention and awareness/orientation
~ Disturbance in cognition, memory, perception
~ May result from use of or withdrawal from a variety of drugs, including:
~ Cannabis
~ Alcohol
~ Amphetamines
~ Opioids/Narcotics
~ Hallucinogens
~ Sedatives/Benzos

~ Mood lability and lowered impulse control can lead to increased rates of violence toward others and self.
~ Symptoms of alcohol withdrawal include agitation, anxiety, tremor, malaise, hyperreflexia (exaggeration of reflexes), mild tachycardia (rapid heart beat), increasing blood pressure, sweating, insomnia, nausea or vomiting, hallucinations, delusions, and often seizures.
~ Protracted withdrawal: Continued mood instability, fatigue, insomnia, reduced sexual interest, and hostility for weeks
~ Differentiating protracted withdrawal from a major depression or anxiety disorder is often difficult.
Alcohol Related Brain Damage
~ Damage directly caused to the person by exposure to alcohol or other drugs
~ Alcohol Related Dementia (Wernicke-Korsakoff’s syndrome)
~ Vascular Dementia
~ Fetal Alcohol Spectrum Disorders
~ According to the CDC
~ Most excessive drinkers do not meet the criteria for dependence (meaning they may present in mental health clinics for treatment of mood disorder)
~ About 17% of the adult population reported binge drinking, and 6% reported heavy drinking
Alcohol Related Brain Disorders
~ Caused by regularly drinking too much alcohol over several years.
~ Covers several different conditions which are similar to, but not actually dementia, including:
~ Wernicke-Korsakoff syndrome
~ Alcoholic dementia.
~ In contrast to dementia (i.e.Alzheimer's disease), most people with ARBD who receive good support and remain alcohol-free
~ Make a full or partial recovery
~ Will not experience a worsening of their condition
Alcohol Related Brain Disorders
~ ARBD is greatly undiagnosed.
~ Post-mortem findings indicate it affects about 1 in 200 of the general adult population.
~ Among those with alcoholism, this figure rises to as high as one in three
~ People with ARBD tend to in their 40s or 50s
~ Alcohol-related brain damage is thought to cause more than 10% of ‘dementia' in people under 65.

Alcohol Related Brain Disorders
~ Drinking more than the recommended limit for alcohol increases a person's risk of developing common types of dementia such as Alzheimer's disease and vascular dementia.
~ Recommended limits are now a maximum of 14 drinks each week, with a maximum of 2 per day
~ Repeated binge drinking – heavy drinking in one session is particularly harmful
~ Increased risk of dementia is greatest at higher levels of alcohol consumption
~ But you do not need to be an alcoholic or get drunk often to be at increased risk of developing dementia.
~ Regularly drinking even a little above recommended levels increases your risk
~ Alcohol-related brain damage causes a range of conditions
~ Alcoholic dementia/alcohol-related dementia
~ Korsakoff's syndrome/ Korsakoff's psychosis.
~ ARBD is defined as long-term decline in memory or thinking caused by excessive alcohol use and a lack of vitamin B1 (thiamine)
~ Regular heavy (>14/week) drinking over time can cause:
~ Damages nerve cells because alcohol
~ Causes chemical changes in the brain
~ Shrinkage of brain tissue
~ Intestinal damage  poor nutrient absorption
~ Poor handling of thiamine
~ Damaged blood vessels
~ High blood pressure
~ Increased risk of heart attacks and strokes
Alcohol Related Dementia
~ Symptoms largely reflect the areas in the person's brain that are damaged.
~ Poor planning and organizational skills, and problems with decision-making, judgement and risk assessment
~ Problems with impulsivity (eg rash financial decisions) and difficulty controlling emotions (eg irritability or outbursts)
~ Problems with attention and slower reasoning
~ Lack of sensitivity to the feelings of other people
~ Behavior which is socially inappropriate.
~ Unlike Korsakoff's syndrome, however, not everyone with alcoholic dementia has loss of day-to-day memory.

Alcohol Dementia Diagnosis
~ Person must have stopped drinking alcohol for several weeks, to enable the symptoms of alcohol intoxication/withdrawal to resolve.
~ Full physical examination
~ A detailed history from the person and someone who knows them well if possible. Includes:
~ How their symptoms started and affecting the person's life.
~ The person's history of alcohol use (how much, how often, and for how long).
~ Tests of the person's mental abilities (eg memory, thinking)
~ Tests for depression.

Alcohol Dementia cont…
~ A brain scan may also be required to:
~ Rule out other possible causes of symptoms (eg stroke, bleed, tumor).
~ Show changes such as shrinkage of the cerebellum at the back of the brain, which supports a diagnosis of ARBD rather than dementia.
~ ARBD should be diagnosed if:
~ The person has impaired memory, thinking or reasoning which is bad enough to affect daily life, and
~ A recent history of several years of alcohol misuse
Alcohol Dementia cont…
~ ARBD should be diagnosed cont…
~ Other physiological causes have been ruled out
~ Stroke
~ Brain bleed
~ Chronic fatigue
~ Lupus
~ Hypothyroid
~ Medication side effects (i.e. benzos in the elderly)

Korsakoff's syndrome
~ Is a form of ARBD caused by lack of thiamine.
~ Is much less common than other forms of ARBD such as alcoholic dementia.
~ Is diagnosed in about one in eight people with alcoholism
~ Develops as part of a condition known as Wernicke-Korsakoff syndrome.
~ Consists of two separate but related stages: Wernicke's encephalopathy followed by Korsakoff's syndrome.
~ Not everyone has a clear case of Wernicke's encephalopathy before Korsakoff's syndrome develops
~ No specific lab tests or brain scan procedures to confirm diagnosis

Korsakoff's syndrome
~ Wernicke's encephalopathy usually develops suddenly, often after abrupt and untreated withdrawal from alcohol.
~ Symptoms of Wernicke's encephalopathy can include:
~ Disorientation, confusion or mild memory loss
~ Malnutrition
~ Involuntary, jerky eye movements or paralysis of the muscles that move the eyes
~ Poor balance or unsteadiness, staggering and stumbling, lack of coordination
~ If Wernicke's encephalopathy is suspected, immediate medical treatment is essential to prevent permanent brain damage.

Korsakoff's syndrome
~ Where Wernicke's encephalopathy is untreated, or is not treated soon enough, Korsakoff's syndrome gradually develops
~ Damage occurs in several regions of the brain
~ Symptoms
~ Severe loss of short-term, day-to-day memory
~ Problems learning new information (including new routines/life skills)
~ Inability to remember recent events
~ Gaps in long term memory
~ Memory problems may be severe while other thinking and social skills are relatively unaffected. For example, individuals may carry on a coherent conversation, but moments later be unable to recall that the conversation took place or to whom they spoke.
Korsakoff's syndrome
~ Those with Korsakoff’s syndrome may “confabulate,” or make up, information they can't remember.
~ They are not “lying” but may actually believe their invented explanations.

~ There is a good chance of stabilization or improvement if the person:
~ Is given high doses of thiamine
~ Remains free from alcohol and adopts a healthy diet with vitamin supplements.
~ Brain scans show that, with abstinence, some of the damage caused by excessive drinking can be reversed.
Vascular Dementia
~ Caused when blood supply to the brain is interrupted
~ Stroke
~ During the second stage of alcohol withdrawal (24-72 hours post drink) people experience high blood pressure, increased body temperature, unusual heart rate, and confusion
~ Vein collapse (IV drug use)
~ Stimulant use causing high blood pressure
~ Bradycardia
~ Severe hypothyroid
~ Opiate overdose
~ Heavy alcohol use  arrhythmias, hypertension
~ Alcohol poisoning
Vascular Dementia
~ The most common cognitive symptoms are:
~ Problems with planning or organizing, making decisions or solving problems
~ Difficulties following a series of steps (i.e. cooking a meal)
~ Slower speed of thought
~ Problems concentrating, including short periods of sudden confusion.
~ A person in the early stages of vascular dementia may also have difficulties with:
~ Memory – problems recalling recent events (often mild)
~ Language – i.e. speech may become less fluent
~ Visuospatial skills – problems perceiving objects in three dimensions.
Vascular Dementia
~ Many patients who use substances, even recreationally, may experience strokes or mini-strokes while under the influence and not realize they had one.
~ HBP + Alcohol or stimulant use increase chances of a stroke.
~ Clinicians must
~ Be aware of the symptoms of dementia
~ Differentiate it from intoxication
~ Encourage clients to seek immediate medical assistance
~ Be additionally attentive if a patient reports self-detoxing from alcohol

Fetal Alcohol Spectrum Disorders
~ Caused by fetal exposure to alcohol
~ Along a spectrum
~ Facial features
~ Are not always present
~ Tend to disappear with age
~ Intellect may not be impaired
~ People with FASD have many neurobehavioral problems which inter-relate to produce profound problems with accurately processing information and relating to the world around them.

~ Skill/Characteristic Developmental Age Equivalent
~ Chronological Age ————————————————————–18
~ Physical Maturity—————————————————————18
~ Developmental Level of Functioning——————–9
~ Daily Living Skills———————————————11
~ Expressive Language————————————————————————23
~ Receptive Language——————————–7
~ Artistic Ability (or other strength)———————————————–29
~ Reading: Decoding———————————————————16
~ Reading Comprehension———————–6
~ Money and Time Concepts————————–8

Fetal Alcohol Spectrum Disorders
~ Diagnostic features
~ Poor coordination, poor muscle control
~ Cognitive deficits including SLDs
~ Executive functioning deficits (ADLs)
~ Attention problems or hyperactivity
~ Poor social skills
~ Difficulty interpreting nonverbal behavior

Issues for Clients with a FASD
~ Problems with cause and effect relationships and impulse control
~ Problems with time management
~ Problems with the ability to generalize information
~ Problems with understanding concepts and abstract thought
~ Problems with perseverative behavior
~ Perseveration is commonly described and thought of as some form of repetitive behavior – i.e. tapping toes, drumming fingers, knocking, pacing, etc.
~ it can also manifest as a particularly rigid way of looking at things, a refusal to let go of an idea {rigid tenacity which can border on fanaticism}; and/or a certain way of feeling or interpreting a feeling and refusal to consider any other explanation.
Issues for Clients with a FASD cont…
~ Problems in all areas of processing information, particularly auditory
~ Problems with short term memory
~ Difficulty anticipating consequences
~ Good expression, but poor comprehension
~ Good at reading, poor writing skills
Issues in Treatment of Someone with FASD
~ Will likely not benefit from “standard” treatments requiring conformance, motivation and follow-through on multiple tasks
~ Have clients write out their own weekly goals
~ Cannot accurately anticipate consequences, and repeatedly make the same mistake
~ Often seem to “shoot themselves in the foot”
~ May be unable to demonstrate remorse and get incorrectly labeled as anti-social
~ Have a right to specialized treatment and accommodations
~ May not have an alcohol or drug issue

Issues in Treatment of Someone with FASD
~ See themselves each time as making a single mistake– unable to conceptualize the past
~ Are easily manipulated and often “take the fall”
~ Often have gaps in their personal history account, including important facts
~ Tend to be quite impulsive and comedic
~ May not follow through with appointments due to inability, not lack of interest or motivation

~ Mental health clinicians are likely to see clients who present with depression and/or anxiety who are misusing or excessively using substances
~ ARBD can be caused by:
~ Use of the substance increasing blood pressure, causing a stroke, slowing the heart, collapsing veins
~ Withdrawal from the substance (alcohol)
~ Heavy use is defined as more than 14 drinks per week or 2 per day.
~ Many clients with ARBD are NOT alcoholics
~ FASD is brain damage caused by fetal exposure to alcohol
~ Those with a FASD experience deficits in interpersonal and executive functioning which make it difficult to comply with “traditional” treatment
~ Special approaches are required for persons with a FASD