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An alcoholic patient poses specific questions for a clinical neuropsychologist:
Has this individual's brain function been significantly compromised by alcohol?
What is the severity of the impairment?
Its manifestation in day-to-day functioning?
Are the deficits reversible or permanent?
What can be done to compensate for the neuropsychological deficits caused by alcohol abuse?
In its most severe form, alcoholism can lead to irreversible amnesia as is seen in Wernicke-Korsakoff's syndrome. This syndrome typically occurs after a prolonged period of very heavy drinking (such as a 2-week binge) during which an individual fails to ingest enough food containing essential vitamins. Even with adequate food intake, chronic, heavy alcohol abusers are still at risk for developing alcohol dementia in which they experience marked impairment of memory, abstraction, problem solving, and complex motor skills.
The deficits most commonly associated with alcoholism are memory problems and frontal lobe dysfunction. Alcohol abusers underestimate the extent to which they suffer from memory problems or deny them altogether. They frequently display problems with short term memory and learning efficiency.
Frontal lobe deficits in alcohol abusers may be manifest in a variety of ways. Their thinking typically shows decreased flexibility so problem solving strategies tend to be simplistic. When alcohol causes damage to the frontal lobes, it significantly compromises an individual's ability to evaluate problems and learn from experience, thus the abuser's poor recognition of the extent to which his or her use of alcohol is problematic.
Despite repeated interpersonal conflicts, damaged friendships, declining physical health, and deterioration in work performance, the alcohol abuser may still fail to see the need to seek help. The neurocognitive skills that are most needed to recognize the nature and severity of the problem are among those that are most likely to be organically impaired secondary to the toxic effects of alcohol on the brain.
Studies demonstrate that excessive alcohol use can cause structural brain abnormalities. The most common abnormality is cortical atrophy or shrinkage of brain tissue. In 50 to 60 percent of alcohol abusers such changes can be are verified by CT scanning and Magnetic Resonance Imaging. Other documented changes include enlargement of the cerebral spinal fluid-containing ventricles of the brain, decreased flow of blood to brain regions that are heavily involved in memory, and damage to brain structures that control balance and coordination.
Brain damage tends to be an early effect of alcohol abuse. It may be present years before liver damage is readily detectable. Liver damage provides an additional mechanism by which brain function can be further compromised.
Fortunately, studies show that alcohol-related brain abnormalities are reversible in many alcohol abusers who abstain for extended periods of time. Females display the same type of alcohol-related brain abnormalities as males, although at a faster pace and with less intense drinking histories. This appears to result from the fact that females have lower levels of alcohol processing enzymes which allows more of the alcohol consumed to pass into the bloodstream and directly to the brain. However, females also tend to recover more quickly than males once alcohol use is discontinued. It has also been observed that younger alcohol abusers generally have a better prognosis for recovery of function compared to older alcohol abusers.
During treatment, it is important to take neuropsychological status into account. Deficits in memory and frontal lobe functions can make it very difficult for the alcohol abuser to learn new information, make logical connections, or transfer information from one context to another. Information may need to be presented repeatedly and use of concrete examples may help to compensate for impaired abstraction ability. Memory aids, journal keeping, and telephone reminders are often beneficial. The use of structured problem solving strategies can also be of considerable benefit to most alcohol abusers both during and after treatment.
Remember, some 10 percent of alcohol abusers meet the diagnostic criteria for either amnesia or dementia. Of the remaining 90 percent, half have mild to moderate neuropsychological impairments after 3 weeks of abstinence, and 35 to 45 percent will display impairments that improve with months and/or years of abstinence. 5 to 15 percent will display impairments despite years of sustained abstinence. These figures tell us that when the issue is chronic alcohol abuse, the odds are on the side of intervention and "time is not your friend".
Gary Thompson, Ph.D. has been the Coordinator of Neuropsychological Services at Saint Luke Institute for the past 13 years.
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