Acquired brain injury refers to any brain damage that happens after birth. Alcohol is one of the many causes of acquired brain injury. The injury inflicted by alcohol abuse is referred to as alcohol related brain injury (ARBI). Just how much damage is done depends on a number of factors. These include individual differences, as well as the person’s age, gender, nutrition and their overall pattern of alcohol consumption.

A person with ARBI might experience problems with memory, cognitive abilities and physical coordination. A younger person has a better chance of recovery because of their greater powers of recuperation. However, the effects of alcohol related brain injury can be permanent for some.

Alcohol and brain injury

Brain injury can be caused by alcohol because it:

• Has a toxic effect on the central nervous system.
• Results in changes to metabolism, heart functioning and blood supply.
• Interferes with the absorption of vitamin B1 (thiamine), which is an important brain nutrient.
• May be associated with poor nutrition.
• Can cause dehydration, which may lead to wastage of brain cells.
• Can lead to falls and accidents that injure the brain.
• Can lead to motor vehicle and other accidents

Alcohol consumption and ARBI

Alcohol consumption ranges from light (social drinkers) to heavy consumption. Decline in thinking and brain functioning is gradual, and depends upon the amount of alcohol consumed and for how long.

Alcohol related brain injury is more likely to occur if a person drinks heavily on a regular basis over many years. It is possible to develop ARBI over a short period of time, if the drinking is heavy enough. This can be known as ’binge drinking’, which means drinking more than six drinks at a time. Safe levels of alcohol consumption include:

For men – a maximum of four standard alcoholic drinks per day with at least two alcohol free days every week.

For women – a maximum of two standard alcoholic drinks per day with at least two alcohol free days every week.

Disorders associated with ARBI

• ARBI is associated with changes in cognition (memory and thinking abilities), difficulties with balance and coordination, and a range medical and neurological disorders. Some alcohol related disorders include:
• Cerebellar atrophy – the cerebellum is the part of the brain responsible for muscle coordination. Damage results in difficulties with balance and walking, which is called ’ataxia’.
• Frontal lobe dysfunction – the brain’s frontal lobes are involved in abstract thinking and planning. Damage results in cognitive difficulties.
• Hepatic encephalopathy – many people with alcohol related liver disease develop particular psychiatric symptoms, such as mood changes, confusion and hallucinations.
• Korsakoff’s amnesic syndrome – a loss of short term memory.
• Peripheral neuropathy – the extremities are affected by numbness, pain, pins and needles.
• Wernicke’s encephalopathy – a disorder caused by a severe deficiency of vitamin B1. Some of the symptoms include ataxia, confusion and problems with vision.

Treatment

A person with suspected alcohol related brain injury needs to be assessed by a neuropsychologist. Treatment depends on the individual and the type of brain damage sustained.

Helping people with ARBI

People with impaired brain function can be helped, if the demands placed on them are reduced. A predictable routine, which covers all daily activities, can also be a great help. Carers might like to consider the following points when communicating with people with ARBI:

• Break down information and present one idea at a time
• Tackle one problem at a time
• Allow the person time to work at their own pace
• Minimise distractions
• Avoid stress
• Allow for frequent breaks and rest periods.
• Where to get help
• Your doctor
• Neuropsychologist
• Acquired brain injury associations
• Support groups for alcoholism.

Things to remember

• Alcohol has a toxic effect on the central nervous system and can cause significant brain injury.
• Alcohol related brain injury is more likely in people who drink heavily over a long period of time, but aggressive binge drinkers are also at risk.
• The symptoms depend on which part of the brain has been damaged, but can include problems with coordination, thinking, planning, organisation, memory and perception.

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Thyroid function in depression and alcohol abuse : a retrospective study

Admission thyroid function tests were reviewed in 115 euthyroid patients with depression (66), depression and alcohol abuse (30), or alcohol abuse (19).

Estimated free thyroxine (EFT) levels ranged from 0.7 to 2.7 ng/100 ml (normal, 1.0 to 2.1).

Levels above 2.1 ng/100 ml were associated with agitation and values under 1.1 with alcohol abuse.

Mean EFT levels differed significantly among six diagnostic subgroups and paralleled rank order for severity of depression (none, secondary, reactive, single uncategorized, recurrent, psychotic).

Alcohol abuse negatively affected EFT: there was a significant decrease of mean EFT level from nonabusers to abusers and, further, to intoxicated abusers. A positive association between EFT level and severity of depression, and a negative one with alcohol use, were significant when other variables considered were controlled. These two factors accounted from 28.2% of variability in EFT levels, with a minimal additional contribution of medication effect.

T. Kolakowska and M. E. Swigar. Thyroid function in depression and alcohol abuse: a retrospective study. Arch of general Psychiatry. Vol. 34 No. 8, August 1977

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TSF TARGET POPULATIONS

Clients Best Suited for This Counseling Approach

TSF has been utilized in controlled outcome studies with alcohol abusers and alcoholics and with persons who have concurrent alcohol-cocaine abuse and dependency. It has been used with clients of diverse socioeconomic, educational, and cultural backgrounds and a range of maladjustment.

Clients Poorly Suited for This Counseling Approach

Individuals who have severe symptoms of addiction to cocaine or opiates, who are unemployed, and who also have no source of spousal or other family support appear to have the poorest prognosis. That is not to say that alternative treatments have proven effective with that group of individuals. When treating addiction to cocaine, it is recommended that sessions be scheduled twice a week for the first 3 weeks.

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Twelve Step Facilitation (TSF)

Twelve-Step Facilitation (TSF) consists of a structured, and manual-driven approach to facilitating early recovery from alcohol abuse/alcoholism and other drug abuse/addiction. It is intended to be implemented on an individual basis in 12 to 15 sessions and is based in behavioural, spiritual, and cognitive principles that form the core of 12-step fellowships such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA). It is suitable for problem drinkers and other drug users and for those who are alcohol or other drug dependent.

TSF seeks to facilitate two general goals in individuals with alcohol or other drug problems: acceptance (of the need for abstinence from alcohol or other drug use) and surrender, or the willingness to participate actively in 12-step fellowships as a means of sustaining sobriety. These goals are in turn broken down into a series of cognitive, emotional, relationship, behavioural, social, and spiritual objectives.

The theoretical rationale is based in the 12 steps and 12 traditions of AA and includes the need to accept that willpower alone is not sufficient to achieve sustained sobriety, that self-contredanses must be replaced by surrender to the group conscience, and that long-term recovery consists of a process of spiritual renewal. The primary mechanism action is active participation and a willingness to accept a higher power as the locus of change in one’s life.

The facilitator in the TSF treatment model is more truly a facilitator of change than an agent of change. The true agent of change (i.e., sustained sobriety) lies in active participation in 12-step fellowships like AA and NA along with the principles set forth in the 12 steps and 12 traditions that guide these fellowships.

Alcoholism and other drug addiction are considered illnesses that affect individuals both mentally and physically in such a way that they are unable to control their use of alcohol or other drugs. Viewed from this perspective, the concept of controlled use of alcohol or other drugs amounts to denial of the primary problem, that is, loss of control. Specific causative factors are of less relevance in recovery than is acceptance of both the loss of control and the need for abstinence and a willingness to follow the pathway laid out in the 12 Steps.

After Nowinski J. NIDA, 2000.

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My own experience

By an AA member

I first came into contact with Alcoholics Anonymous 20 years ago. I had just been discharged from mental hospital after a suicide attempt and after losing two jobs within a few weeks. AA was the main thing which kept me going over the following months, although I also got help from family, friends, my doctor and my therapist. I have not had an alcoholic drink since my first AA meeting. I have had many problems getting my life together since then, not least with depression.

With the benefit of hindsight depression was probably one of the reasons why I drank, but the drinking was more a cause than an effect of my problems.

I still attend AA meetings regularly. I do not want to drink again and I still value the support I get in maintaining sobriety, among other things by listening to people who have had a harder time than I have, have only just stopped drinking or are still trying to stop. AA is also part of my social life.

Carrying the AA message

The 12th step of the AA programme encourages its members to carry the AA message to other alcoholics. The proposition that helping others helps you to stay sober has support in peer-reviewed scientific literature as well as in the practical experience of AA groups. In London, where I live, current initiatives include AA members speaking to school children about their experiences, giving presentations at magistrates courts, working with the probation service and supporting AA meetings at prisons. A seminar about the work of AA was held at the Houses of Parliament in March 2005 and a repeat of this is due in May 2006.

AA has been particularly successful in working with some leading hospitals which provide treatment for alcohol dependence. AA meetings are held in the hospitals and AA members give separate talks to the patients to help them to think about becoming members too.

In other hospitals AA meetings may be held in the premises without such a close working relationship. There may be a clash of cultures. There are sometimes strong contrasts in general approach and language between AA members and those who work professionally in the field of addiction, although both sides are usually trying to achieve what is essentially the same thing.

Working with AA

A doctor in charge of an alcohol treatment unit once told me that I was the first AA member he had met. Others may strongly encourage their clients to try AA without having any direct contact with the fellowship themselves.

Professionals who want to make optimal use of AA as a resource may sometimes need to make a greater effort to understand its programme, meet with members involved in outreach activities and attend a few “open” meetings (which should usually be done far enough away from where you work to ensure that you do not meet your own clients). This is surely not a disproportionate time commitment. It can enable the professional, for instance, to tell his or her patients or clients at first hand what they should expect. You do not have to become an alcoholic yourself (or apply the ‘Minnesota Model’, which involves integrating the AA programme within treatment) to get to this point.

Why should you make the effort? Partly because there is now a sound body of scientific evidence suggesting that AA does work for a significant number of people with drink problems. It operates at no cost to the taxpayer and is paid for entirely by voluntary contributions from those members who can afford to make them. It is also most active outside normal working hours and thus complements the help that can be provided at a professional level.

The need for AA to adjust

AA members actively involved in its public relations activities may need to make an equivalent effort to understand other people’s points of view and find common ground. Involvement in AA outreach activities helps to achieve this up to a point as does, for instance, reading some scientific literature, contact with professionals, attending conferences focusing on alcohol problems and involvement in working groups at a local level.

One of the co-founders of AA, William Wilson, acknowledged that some AA members ‘decry every attempt at therapy except our own’ but the majority ‘don’t care too much whether new and valuable knowledge issues from a test tube, a psychiatrist’s couch or revealing social studies’.

AA has changed considerably over the 20 years I have been a member. There are, for instance, more people under 30 and more women. There are meetings focused on the needs of young people, women, gays and lesbians and some provision in Central London (although still not nearly enough) for child care. It was rare in the 1980s to see anyone from racial minorities at meetings. Now it is rare not to see them. The fellowship is making every effort to provide help to people whose first language is not English or who may have other communication problems or disabilities.

The Internet and email has also helped to spread the AA message. For instance the basic ‘Alcoholics Anonymous’ textbook is now available online in full text in English, French and Spanish as well as being available in hard copy in many other languages.

The anonymity tradition

There is sometimes a tendency to over-interpret the AA anonymity tradition. It only requires members to maintain anonymity at the level of press, radio, film etc. The second cofounder of AA, Dr Robert Smith, argued that maintaining anonymity at any other level and in particular “being so anonymous you can’t be reached by other drunks” was itself a breach of the anonymity tradition. He also considered that AA members should let themselves be known as such in the community.

This may be feasible in North America, but in Europe it is perhaps more an ideal to be strived for. I am a professional myself, although I do not practise in the field of addictions. I do not tell my colleagues at work (whom I have only known for about 18 months) about my past drinking problems and my membership of AA. When I get to know them better, and if it were to serve a useful purpose, I might perhaps do so.

References

1 www.alcoholicsanonymous.org.uk/geninfo/05steps.shtml 2 See Zemore SE, Kaskutas, LE and Ammon LN (2004) ‘In 12-step groups, helping helps the helper’, Addiction 99, 1015. 3 See www.hazelden.org/servlet/hazelden /go/INFO_MNMODEL 4 See, for instance: Vaillant, GE (2003) ‘A 60-year follow-up of alcoholic men’ Addiction, 98, 1043- 1051. Gossop M, Harris, R, Best D, Man L-H et al, ‘Is attendance at Alcoholics Anonymous meetings after inpatient treatment related to improved outcomes? A 6 month follow-up study’ Alcohol and Alcoholism, Vol 38 No 5 421-426. Project MATCH Research Group (1997) ‘Matching alcoholism treatments to client heterogeneity: Project MATCH post treatment outcomes’. Journal of Studies on Alcohol 58, 7-29. 5 ‘Let’s be friendly with our friends’,AA Grapevine March 1958. 6 www.aa.org/bigbookonline/. 7 ‘Doctor Bob and the Good Oldtimers’, page 264, 1980 AA World Services inc

Alcohol Alert (2006) is published by The Institute of Alcohol Studies an initiative of the Alliance House Foundation, www.ias.org.uk

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