How to Recognize Life Threatening Alcohol Withdrawal Symptoms

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1 How to Recognize Life Threatening Alcohol Withdrawal Symptoms Instructor: Don Cleveland

2 Course Description: This course will provide the counselor with assessment techniques to identify whether a client who has recently quit drinking is now suffering from the Alcohol Withdrawal Syndrome (McKeon & Frye, 2008). Course Objectives Demonstrate: a. How to recognize conditions and symptoms of a client who needs a medical detoxification b. How to ask questions that will help the counselor see through the client s attempts to hide his need for a detoxification and why this sometimes happens c. How to utilize state laws to have someone taken to a facility if they are in obvious danger Course Outline I. Understanding the physiological withdrawal symptoms of a client who has recently abstained from ethanol use (Alcohol Withdrawal Syndrome) II. Understanding the brief assessment process including how to ask questions to get the most accurate answers The Case of John s Death - Post Interview IV. Closing Considerations How to Recognize Life Threatening Alcohol Withdrawal Symptoms Chronic alcohol users seeking to quit drinking pose a special challenge for the counselor. Therefore, an assessment for the Alcohol Withdrawal Syndrome (AWS) is needed to determine whether or medical detoxification is needed. If this task is not performed accurately, this could result in a difficult detoxification process leading to death. In order to build the profile of a chronic, alcohol-dependent individual, consider the case below of Henry. Having worked with hundreds of Henrys over the years, I m presenting a two-part case study to give you an idea of a typical chronic alcohol abuser s background. Although there is no way to determine how close a client is to recovery, you can perform assessments and provide counsel that could save a person s life. In order to help you determine whether or not a person needs medical detoxification, this course will provide you with the tools and techniques to become proficient in counseling people like Henry. The Case of Henry: Part 1 Henry had a lifelong love affair with alcohol which felt like his only friend while experiencing a stressful world of anxious interactions with others. It was in high school the Henry found this unfaithful friend who gave him the liquid courage to become the life of the party. This also relaxed him enough to approach girls. One such affair resulted in a daughter, Melanie; she developed a deep attachment to her father despite having only seen him four times a year during her childhood and adolescence. As an adult, Melanie tried everything to help her dad quit drinking. Over the next 20 years, she witnessed his going in and out of treatment centers but never staying sober longer than a couple of months. Heartbroken and busy with her own family, Melanie finally told her father to never call or come back into her life again until he was ready to quit forever. With tears in her eyes, Melanie said, The next time will be the last time and if you go back to drinking again after treatment, I will never speak to you again. Five years went by before Melanie heard from her father, a month after her husband and daughter were killed in a car accident on Christmas Eve. Feeling deeply alone in the world and having fallen into a deep depression, Henry came back into her life and in a way she had never witnessed before. For the first time she could remember, he didn t look haggard and strung out. Henry had found religion and had been sober for over a year. Melanie was overjoyed and for the next two years things went well. Henry was there to console her and became the dad he always wanted to be. Midway through year three, Henry became engaged. Unfortunately, things didn t work out so he turned to drinking once again and lapsed for two years before begging Melanie to take him back. She agreed to take him to the local gospel rescue mission and promised to be there, if he completed the 16-month program. Assessing for AWS The active ingredient in alcohol is a psychoactive chemical agent known as ethanol. The chronic daily reliance on ethanol to maintain a sense of subjective well being, creates a condition of maladjusted homeostasis throughout the human body. The domains significantly affected include biological, neurobiological, cognitive,

3 and social. The chronic alcohol abuser, the one sitting in front of you, has a relationship so dependent on ethanol that every part of his body has been affected. Thus, this person is not the best judge when it comes to whether or not he or she needs medical detoxification. In fact, I have sat with many men who flatly refused based on some dangerous sense of pride that sprang from either a nonsensical belief in machismo, or a promise that, I would never get so bad that I needed detox. In this section we will review two assessment techniques. First, the DSM IV-TR which will serve as foundational list of the type of issues you will generally be looking for. Secondly, the CIAW-Ar, used by medical personnel to monitor those undergoing detoxification in a facility. You will also be looking specifically for this. The latest edition of the Diagnostic and Statistical Manual of Mental Disorders (2000) (DSM IV-TR) defines the client suffering from alcohol withdrawal as: 1. A reduction in or a termination of the heavy use of alcohol 2. Two or more of the following presentations: a. Sweating or pulse greater than 100 b. Hand Tremors c. Insomnia d. Nausea or vomiting e. Fleeting hallucinations or illusions within the senses f. Psychomotor agitation g. Anxiety h. Grand mal seizures 3. The symptoms above create significant distress in social, occupational, or other important areas of the client s experience. The DSM IV-TR descriptions serve as a foundation for the CIWA Ar used in the medical profession. In their treatise, Assessment of Alcohol Withdrawal: The revised Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWA-Ar), Sullivan, Sykora, Schnederman, Naranjo, and Sellers (1989) also tackle the issue of understanding the symptoms of AWS and from the standpoint of shortening a previous instrument through an empirical research study. What they came up with is critical for our purposes because it highlights the top four symptoms that highly correlate with the AWS symptoms. These are also most likely presented in an intake interview with a chronic alcohol abuser who has very recently quit using ethanol. Based on the findings of Sullivan et al. (1989), the top characteristics demonstrated by someone needing medical detoxification are: sweating, anxiety, tremor, auditory and visual disturbances, and nausea. Let s take a look at how these issues play out in Henry s case as he attempts to return to treatment after a lifetime of drinking and with two years sobriety, then a sixmonth relapse. The Case of Henry: Part 2 Henry and Melanie arrived at the Grand Rapids Rescue Mission determined to have Henry begin treatment immediately. Henry was longing for a Christian program and Melanie was wondering if she had any more compassion left for a dad who had let her down countless times over her 40-year lifetime. Morgan, the intake counselor, spent 15 minutes getting to know Henry by providing a brief overview of what happens at the mission and why. Morgan then asked Henry a handful of key, open-ended questions like these: What brings you in today? How long have you been drinking daily? How much alcohol do you consume daily per day when you are drinking? When Henry shared about his lifetime of drinking, the assumption was that he could dazzle Morgan with his ability to consume massive amounts of alcohol per day. Instead, Morgan seemed concerned and asked: What happened the last time you quit drinking for more than two days? Have you ever had a medical detox? Why not? Considering your drinking patterns, would you consider a medical detox? Henry immediately became defensive. He explained that his last detox was, hell on earth but made it through then so he can make it though now. It was clear to everyone that the focus of the meeting had changed from Henry getting into treatment right away, to shouldn t Henry go to detox? Melanie was also concerned. She feared that if Henry didn t get in today, he could relapse within a few hours. She became equally adamant that Henry did not need a detox and desperately needed to start the program now. In response Morgan asked Henry if he had experienced sweating, nausea, and vomiting. Henry responded angrily, definitely not. However, almost from the beginning of the interview Morgan noticed Henry s sudden sweating and shaky hands. One of the program men informed Morgan that Henry was vomiting violently before the interview. Morgan took 20 minutes gently explaining that while popular culture believes the worst detox is heroin, the facts are much different. Alcohol is not only the worst drug for chronic abusers to quit but that death is a real risk. Upon hearing that, Henry jumped up shouting his objections, My pastor knows your director and I ll be in here by closing time! Sure enough, despite Morgan s objections, Henry had a bed in the program dorm by the end of the day. When Morgan came in the next morning the night manager stopped him and went on to say, That new guy went nuts last night. He was talking to invisible people and seeing things. I told him he had to take that stuff outside.

4 By lunchtime the word on the street was that Henry was dead and by the close of business that very same day it was confirmed, Henry no longer walked among the living. The staff was unusually silent at staff meeting the next day. When a staff member invited Morgan to gloat about being right he merely stood up, took one last look around the table and simply said, I quit. Reviewing the Interview If you have worked with substance abusers for any length of time you understand that lying is woven into the pattern of their thinking. With a client potentially suffering from AWS it s a little more complicated. As the depressant drug ethanol is leaving their system the breaks are off a formerly sedated nervous system. The brain is racing and sufferers can easily become agitated as the body attempts to adjust. They have sincerely decided to quit and that should be good enough. And in many ways it is except in one area, a medically assisted detox. Avoiding it s a precarious risk not worth taking. Morgan had an easy time discerning the necessity of a medical detox so we could see the symptoms in action. Most of the time you have to dig. You need to ask the same questions a couple of different ways during the interview to make sure the answers are reasonably consistent. Ask him or her about their inconsistencies going to great lengths to make sure they understand you re not judging but sincerely have their best interests at heart. If your concerned about the client leaving due to the symptoms you are witnessing based on the DSM IV-TR for alcohol withdrawal or the CIWA-Ar for the Alcohol Withdrawal Syndrome than keep the conversation going and make every attempt to get through to them using person-centered strategies. I have seen many clients work their way out an angry position because I simply waited them out. When some of these men came back from detox (many will not) I was already well on my way to a therapeutic relationship as I was able to build some trust through the process as I was there when they came back. Part of your job is caring more for the client than he cares for himself. Normally this is called enabling and prohibited but if you have a likely AWS client in front of you what your dealing with is a cognitively impaired person that may be temporarily disabled. In Florida we have something called the Marchmen Act for such persons whereby a licensed mental health counselor under court supervision according to state laws can involuntarily commit them. The State of Texas is also one of the 37 states that also allows for involuntary commitment through the court system. Check out your state laws as well as the your state s organization for mental health counselors to provide guidance for the role you can play. Know these policies and laws before the event so you can confidently take action when client is willing to let him or herself die. Accessing for AWS When Henry presented for recovery from chronic alcohol abuse Morgan asked a handful of key questions alongside several observations and even included the use of an informant. Use these questions and several more similar ones to facilitate your goal of putting the client at ease so they can share as freely as possible. By doing this you are gathering information to see how it matches up with a CIAW-Ar type assessment. When you start asking about symptoms a clients radar typically goes up. Substance abusers like to know where you re going so they can find a way out. Henry s guard went up when, rather than give attention to his drinking abilities, Morgan was concerned about his health. This doesn t mean the client is acting intentionally deceitful but that his trust level is being tested and he or she isn t sure they want you to know just yet. Practice relating to clients in a direct but also a caring and compassionate way. By doing so with some occasional humor, when appropriate, you can increase their trust and keep them communicating with you. In the beginning you can simply use the CIAW-Ar questionnaire towards the end of the interview. After several interviews you should be able to fly solo without the form and paint a reasonably accurate picture. The biggest challenge is prying the most honest version of the truth out of a client. When successful, it is often because of the investment of the time and patience from the counselor. When my efforts fail I remember that if I can t make any headway during that initial interview, the future with the client is murky at best. After reflecting on the interview and learning what I could have done differently, I let the situation go and take enough notes in case they come through my office again. Remembering them upon their return is a great compliment and a great way to start the whole process over again on stronger footing. You may have noticed that I mentioned the rarity of a client dying and the importance of an accurate assessment a few times. This is because the story about Henry is only partially fiction. You can avoid this fate by knowing the symptoms of both the DSM IV-TR and the CIAW-Ar and always working on your relational interview techniques.

5 Websites For Further Study: Clinical Institute Withdrawal Assessment of Alcohol Scale information/assessment_tools/clinical institute withdrawal assessment for alcohol (ciwa).pdf CIWA-AR Original Research Quiz 1. The best way to describe the Alcohol Withdrawal Syndrome is that its a. An assessment tool to determine whether not a person needs a medical detox from alcohol b. A set of symptoms associated with discontinuing alcohol use when a chronic alcohol abuser stops using alcohol c. An excuse to delay treatment d. An assessment tool that results in a better understanding of why a particular person drinks 2. According to the DSM IV-TR the following symptoms are associated with alcohol withdrawal: a. Sweating or pulse greater than 100, hand tremors, and anxiety b. Insomnia, Nausea or vomiting, and occasional blindness c. Fleeting hallucinations or illusions within any of the senses and displays of physical strength d. Psychomotor agitation, grand mal seizures, and belief in a supernatural power 3. The CIWA-Ar is used by medical personal to monitor those undergoing a detox but can also be used by counselors who need to assess whether or not a client needs a medical detox. True False 4. Based on the findings of Sullivan et al. (1989) the top characteristics demonstrated by someone needing a medical detox are: a. Sweating, anxiety and tremor b. Auditory and visual disturbances c. Sweating, anxiety, tremor, auditory and visual disturbances, and nausea d. Sweating, anxiety, tremor, and nausea 5. The most likely reason Morgan refused to go to detox was that he a. Wasn t really serious about recovery b. Felt he was strong enough mentally to handle detox without medication c. He planned to leave the mission that night and go out and get drunk d. Was probably scared to face the experience alone References Alcohol Withdrawal. (2010). In DSM-IV-TR Diagnostic and Statistical Manual of Mental Disorders (IV-TR, p ). Arlington, VA: American Psychological Association. doi: /appi.books McKeon, A., Frye, M.A., Delaney N. (2008). The alcohol withdrawal syndrome. Journal of Neurology, Neurosurgery and Psychiatry, 79(8), 854. Oscar-Berman, M., & Marinkovie, K. (2007). Effects on neurobehavioral functions and the brain. Neuropsychology Review, 17(3), Retrieved from Sullivan, J. T., Sykora, K., Schnederman, J., Naranjo, C. A., & Sellers, E. M. (1989). Assessment of alcohol withdrawal: The revised clinical institute withdrawal assessment for alcohol scale (CIWA Ar). British Journal of Addiction, 84, Retrieved from com.ezproxy.lib.usf.edu

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