All right, we should be good to go. All right, thanks. Okay, everyone, welcome to the Amherst Design Review Board meeting of November 27, 2023. My name is Erica Zekis and as the chair of the Amherst Design Review Board, I'm calling this meeting to order at 5.03 p.m. This meeting is being recorded and will be made available via the town of Amherst's YouTube channel. Minutes are being taken. Pursuant to Chapter 20 of the Acts of 2021 and extended again by Chapter 2 of the Acts of 2023, this meeting will be conducted via remote means. Members of the public who wish to access the meeting may do so via Zoom or by telephone. No in-person attendance of members of the public will be permitted, but every effort will be made to ensure that the public can adequately access the proceedings in real time via technological means. A hyperlink to the hearing will be posted on the town's online calendar. Board members, I'll take a roll call and when I call your name, please answer affirmatively. Catherine Porter. Here. Lindsay Schnarr. Here. Karen Winter. Here. Pat Oth. Present. And Eric Aziz. I'm present as well. Board members, if technological, if technical issues arise, we may need to pause temporarily to fix the problem and then continue the meeting. If the discussion needs to pause, it will be noted in the minutes. Please use the raise hand function to ask a question or make a comment. I'll see your request and call on you to speak. And after speaking, please remember to remute yourself. The general public comment item is reserved for public comment regarding items that are not on tonight's agenda. Please be aware the board will not respond to comments during general public comment period. Public comment could also be heard at other times during the meeting when deemed appropriate. Please indicate that you wish to make a comment by clicking the raise hand button when public comment is solicited. If you've joined the meeting using a telephone, please indicate that you wish to make a comment by pressing star nine on your phone. Please identify yourself by stating your full name and address and put yourself back into mute when finished speaking. Residents can express their views for up to three minutes or at the discretion of the board chair. If the speaker does not comply with these guidelines or exceeds their allotted time, their participation will be discontinued from the meeting. Tonight's agenda includes the following. We have one application, DRB FY 20, 2408, Town of Amherst, revisiting the ADA compliant accessible trail at the former Hickory Ridge Golf Course. We'll then have approval of meeting minutes, public comment period, and any other business not anticipated. So if we are ready to get started and I see that we have Mr. Zomek in the audience, we could jump in. Hi Dave. Hi, good evening everybody. I thought it was. And I'm joined by Jennifer Mullins. I thought it was better to unbler my background just to show the great architecture here in town hall. But anyway, I think Jennifer, you know, I was I was hoping that she could kind of take the lead in revisiting some of those items that that you all wanted us to follow up on. There were some questions about sign detail, bridge detail, kiosk detail, and a few others. And I think Jennifer's is well prepared to do that and I'm happy to answer any questions around the edges. That's okay with with you. Yeah, thanks so much, Jennifer. Are you able to share your screen. I believe I am. Okay, great. And thank you both for coming back so quickly and sharing all this info with us. Sure. So I have a number of documents here that I, you know, I don't know in what order but I'll just go ahead and start this is a, an example of a, of a kiosk that is already this is the type of kiosk that the town would install. This one I believe is that the podic coal. I hate to interrupt, but I just want to let you know that what I think we're seeing your kind of your folder icons and not a big image on the screen. Oh, okay. Let me try again then. I might have to open up the individual documents before sharing them. Which is going to, you know, it just makes it a little bit. All right, let me try. Okay. So here we go. This is a sample of a key, the kiosk. This is the one that I was speaking of when, when you weren't seeing it. Can you see it now. Yeah, it's, it's tiny, but we can see it. Maybe you can. Yeah. Let's see what we can do here. Resize the image. I can make it bigger. I think we can get the idea though, regardless. Yeah. I have, I have it in another form. If you just want to hold on, I can. Yeah, sure.  Let's see what we have here. Sorry, this is taking. They're going away. Okay, now let's see if you can see this one. This might be also small. But it's, I don't know how to make it bigger for this application. I'm sorry I can do it on my computer, but I don't know how to make it bigger for you guys. Jennifer, actually, if you look at the top right part of your screen. So I'll say click cancel. So right there to your right. Yep. You see a little magnifying glass next to where it says 100% top right. Right there. Yep. There's a little magnifying glass with a plus sign on it. If you click on that, it'll zoom in for you. A magnifying glass here. Yep. Yep. To the left of that number 100. I just have dots that say more. More. Am I looking? I don't see a 100. I have more slide control. I can assign control privileges to you. There you go. And if you want to. It's not working for me either. Yeah. I guess it's the best we'll get for, for zoomed in for now, but I've got it zoomed in on my screen. So why don't I share for this one? And then You can drive for the rest of them. How does that sound? Oh, wow. That's great. Yeah. So I've got the kiosk. Then you sent this one. Yeah. And I did. I sent them to Rob ahead of the meeting. Yeah, that's why. Okay. Perfect. Oh, that's great. Yep. So you got it. Thank you. That's beautiful. All right. The floor is yours. Well, if you, if this is the kiosk one that, okay, so we've already kind of discussed it in various forms as we're poking through it. This is a kiosk that already exists in another town property. And this will go up in the. Spot where in the last meeting, we sort of showed a map where we have. There are different items shown on a key that. You know, where this will go, but this it'll be in the accessible like right near the parking lot when you come in so that you'll be able to see. The map of the, of the area where people, you know, the trails, there's the one trail that goes off if you're in the parking lot looking at say looking at this kiosk, there's going to be a trail. Off to the left and a trail kind of off to the right. And this is, if I could add this is pretty standard, you know, trail kiosk, we're trying to standardize them across town. Unfortunately, we've got different generations, different styles. It actually drives me crazy a little bit when I go to different conservation areas and I see them but they are very expensive and we're just trying to standardize them across town. We're also trying to standardize what we put on these kiosks. We're working with the Kestrel Trust. They have helped us purchase and fund many of the conservation areas in town so they have a pretty good trail. Template that we are trying to work with them on and so we would have standard rules and regulations hours of operation. And a trail map on the kiosk as Jennifer said when you first arrive at Hickory Ridge and park and disembark from your car and then enter the trail system. Okay, so yes, this is a good one too because it shows not only the kiosk but it shows the sign that would be posted out by the road out on West Pomeroy to indicate that there is, you know, a conservation area. Again, we're trying to standardize these we have not put these into production yet, but ultimately we would have one of these at every conservation area in town so it's easily visible from the road from both directions standardized. Same colors using the town of Amherst seal at the bottom and town of Amherst and the name of the conservation area. Where the red block is. Similar to the trustees of reservations they should have said that is the trustees of reservation sign, which is at all of their, their properties throughout Massachusetts. And you sent this one that's labeled kiosk detail I see that there are some other details on here but I assume that that's just showing us the construction. Okay. I think you would asked, you know on the map it did show the potential for a kiosk in the future we don't have fun, excuse me not a kiosk a structure shade structure. We don't have funding for a shade structure at this time in the grant. But we will, in all likelihood, at least create a pad of a crushed stone pad that could be could be finished if you will in the future, and have some sort of a pavilion added to the park conservation area in the future. I think Dave. Similarly, there's a, there's a sample of a bench up here. But the bench design has not been decided on. So I know we talked the last time about various different bench options, but we still don't have a bench design that has been agreed on, or that you know that has been decided on. We can reproduce. The reason for that is we're not quite in the bidding stage yet. We're we're beginning to pull together bid documents, and we're still going our team is still kind of going back and forth and looking at different designs. So we're going to go with a with a fairly simple design it needs to be durable. We are not going to this shows I believe I can't see the detail but I believe it shows a poured concrete footing, we are not going to, you know, likelihood pour a full, a full slab under these benches that would be more more of an application for recreation area like golf park or community field.  We're really grappling a little bit with what is the conservation look versus kind of what is a more urban recreation look, any recommendations or, or benches that you all as as your, you know design quite well we're trying to get that feel something like the benches at grove park versus or, or contrasted with something like at the Conti trail over in Hadley. Those most of those bridges are kind of built in place built into the railing of that trail at Conti at the US Fish and Wildlife Service refuge. And they're just, most of them I think are really just pressure treated two by fours they're they're quite nicely done they're done with accessibility in mind, of course we will be doing that as well. But we really haven't found exactly what we want and like yet so any recommendations you might make to us in writing will will certainly be taken into consideration fully. All right, thank you. And Jennifer, do you want to take back over the screen share or do you want me just to click through the additional documents that we have here for you today. I mean, you might as well go ahead because I think it's, it's in a much more concise format on your computer on mine they're all different, they're all different types of files. And so this is the bicycle rack detail. This is going to be placed in the parking area near probably near the kiosk or, you know, somewhere off the actual where the cars would travel but visible when you first come in. There is a bylaw requirement that requires bicycle racks to be placed in areas where there is parking specific number of spots so this is going to satisfy that requirement as well as encourage, you know just in general encourage people to utilize the trail system via their bicycles and and with their bicycles. I think it's likely we would have more than one of these given the size of Hickory Ridge and the length of the trails, and the number of people who may bike on them. I think the DRB has seen these presented for the Podic coal conservation area parking or trailhead and parking as well as the sweet Alice parking lot over on Bay Road. Given the location, given what we think is going to be the popularity of this trail, I think we would probably be in the, you know, at least to start off to maybe as many as four of these. So just to give the group a sense. Thanks, Steve. Shall I go forward. If there are no further questions from the group, certainly. Yeah, I think we might save up our questions for. Oh, I think Karen has one. Do you want it. Do you have a specific about the bike record. Yeah, when, when, can you hear me now. Yeah, yeah. When you say four of them how many loops are there on one. So how many bicycles with you accommodate. You don't mean just four loops. Yeah, they typical typically come in. This is the loop like this. So this, you know, So that's just two bicycles. Yeah, that's just two bicycles. So you only have room for eight bicycles in the whole park. In all likelihood, I mean, again, we'd be open to your recommendations. I don't know how costly these are off the top of my head, but we could certainly look at that with our planning department. I think, you know, if you look at UMass, there's just a rack of bicycles. I don't think one loop. I don't know. Yeah, I think it would be worth looking at this looking at UMass and seeing just a rack of bicycles because I can imagine you're going to have 16 bicycles maybe for sure. I'm imagining. We'll definitely take a look at that. It's, it's, yeah, we're not. Yeah, we're not sure where people are going to be coming from. I mean, the trails will be open to some degree to bicycles. Oh, I see. So you think that people will stay on their bicycles rather? They might. We won't be encouraging them to bike on the accessible loop trail, but they can bicycle and they'll be encouraged to bicycle on the north south trail. I think that is more of kind of a commuter getting, you know, certainly enjoying the, the environment and nature and all of that, but getting to and from East Adley Road all the way down to the village center at Pomeroy at the new roundabout. So I'm, but, but I don't, I think you're right. I think we should lean toward more. People also come in a group often. I mean, if I was going bicycling often, I'd be with my whole family. So there might be, you know, four bicycles at once and you want to leave them someplace. Yeah, I think that would be a great recommendation. The more more will be better here and we can look at at cost of these and what our budget looks like for sure. It's a great suggestion. So sure, yeah, if you would like to click on that existing, that's the storage shed that is in place now you can see it from the road from West Pomeroy. I believe Dave, if I'm my understanding is that it will remain it might be painted. Correct. Yes, I think I think at our last meeting, you all had some questions about both the, the existing clubhouse and then this building, which is to the west of the clubhouse. So our intention is to have the clubhouse come down. As I mentioned, I don't have the budget for it yet, but I'm working to get to find that that funding to take the clubhouse down and make the site more aesthetically appealing, et cetera, and safer. But this, this Morton building is in great shape. We have every intention of keeping it and using it for maintenance equipment. It's poured on slab. So it's very dry and it's just in really good shape. Today, as Jennifer said, we certainly would, would paint it at some point in the future. It really plays very little to no role in terms of public, there won't be any public in it shouldn't be public around it it'll be appropriately signed as it is now. We'll pass by it on their way to the accessible trail, but we will not be encouraging public use it's locked 24 seven 365 on both ends of the building. And it's really a very nice place to store equipment that will maintain the trails and the meadows and, and the like. So, yeah, those two images are there. One is a detail of the, of the other that shows the bridge sample bridges and an up close view of the railing. Now the bridge, this bridge that you can see where it meets the earth that would be built up so that someone, you know, in a wheeled vehicle or someone who couldn't didn't have the mobility to take a step would be able to go right from the trail to the bridge. Is this built somewhere on an Amherst property already. It is, it looks like sweet Alice isn't it. No, it is. In Lawrence swamp. Over the hop brook. And that would be kind of the typical style we would use, you know, pressure treated pressure treated bridge itself, and then the the railings would be designed very similar to this. As I said Erica you asked me I think you, you or I mentioned something about height. And I think I was right which is third over 30 inches requires a railing so anything over 30 inches. So what we would have I think this would be similar detail. There is one walking bridge, one boardwalk, and then one bridge which will double as both for pedestrians and for maintenance conservation maintenance equipment.  And so similar detail will be used on all three of those structures. For safety so that young children cannot fall, you know, into in this case into the hop brook. Okay. Yeah, that's hop brook. Yeah. All right, so we've seen the bridge and railing we've seen the bike rack. The storage shed the kiosk and a signage idea so I just wanted to open the floor to some conversation with the DRB members and I see Lindsay share some thoughts. Thanks for all these images I think overall it looks great. So what a concern about the railing. And if I missed this I apologize, but will it have an extension beyond where it meets the bridge edge, I think it technically needs to come out about a foot beyond that edge so that, like the corner is protected. Oh that's a very good point are you saying from an ADA standpoint. Yes. Yeah, that's a very good point and again I'd be happy to, you know, I know you, you all will make recommendations to us to the town on this project so we would welcome that I think Jennifer and I may have missed that. This bridge is clearly not because of the topography. So we're actually adding we're adding ramps to either side of this you can see this was actually an early picture it's the bridge wasn't even finished I think I see a two by four or something in the in the foreground there. But that's a really good point that you're saying the railing should come out. What were you saying, Lindsay. The handrail. If it is. If it is to be ADA than the handrail needs to come out of foot. I could also imagine, you know, just in terms of safety, having you could consider having like a triangular edge of railing there where it, instead of just coming at a 90 degree down it goes more to 45, just to give some kind of corner protection there. But yeah from an ADA standpoint, the handrail needs to come out a foot from the edge. And I believe that our our ramps will be. And Jennifer can check this but I believe they will be. I think they'll be poured in place concrete I'm not sure but we will have a ramp, and then one of the. I think part of it will be poured in place concrete as far as I know we're working with Rob more our building commissioner on that on that detail, but we will add the extension of the handrails. While we're here on this bridge image are there any other comments on the bridge and rail design storage shed. You didn't talk about the color would you just be kind of repainting in this sage green. You know we haven't even far ahead but if you have any, if you have any suggestions we'd be open to them. Because it's in fairly good shape we haven't really prioritized it is not part of the grant where, as we said before our deadline is June of 24 so we're really pushing for that but you know I could see us doing a protective coat a new protective coat of paint on this at some point. Given that this is conservation land, I think something pretty background neutral make sense. I will I will say, let's see where we were 23. I think it was the class the immerse regional class of 23 or 22 somehow discovered a way into this barn and and at a wonderful celebratory party in in our barn so we beefed up our security somewhat. So that was a little bit of a surprise to us, but they had quite the indoor celebration in our morning building. Luckily, nothing was really damaged and nobody was hurt but it was a little bit of a surprise to us they were. They were quite covert about the whole operation but we, we increased our security so no one's getting in there any longer. Thank you. I'm actually got my hand up a little late I was going to make a comment about the bridge. When I, when I look at it, I'm concerned that what that there's wide spaces that are wire protects, but is it isn't really protective to small children and and animals would it not be better to have more, more wood spacing. As you know, many, many walkways like this require just, I'm surprised to see the wire as opposed to more wood in the design to make the spaces smaller. I think the wire as long as it's. I mean it looks like a welded wire fabric like it's pretty stiff I think it there's no issue of. Well, I just wonder but I don't think it's a code issue that as long as there's no gap that's like more than four inches and this is smaller than that but I'll let Jennifer. Just a question, only because I think the wood has the potential to be more durable than the wire. I think it is a this was this the use of this wire mesh, it is very robust as Erica said I don't know what gauge it is but is a very robust wire mesh. I think again it was both for safety but also also aesthetic to kind of so that you can see the resource you're walking over in this case the the brook. All of the that both the pedestrian slash vehicular bridge the pedestrian bridge and the the boardwalk. When we say bridges, they'll be going over wetlands, they will not be going over the Fort River they won't even be going over anything as high as this this bridge. They're really quite low these structures and they're going over they're going over wetlands we're basically pulling out culverts so there's I'm not saying anyone will will. I'm not trying to lessen the concern about safety but there's really very little, you know, in the middle of the summer you could walk over the the marsh that we're going to bridge over. It's just kind of a squishy area. So, so they're not very high at all so but but again they're robust wire mesh with with virtually kind of a swampy areas under each one. So, from a pet or child safety standpoint some kids may not even go over the bridge and they may just bound right through the swamp. I'm hoping I'm hoping that all dogs will be on leash, and that adds an extra safety element for dogs. Yeah, I think, you know, I thank you for your explanation and I do think the suggestion that the railings be extended is is the most important aspect of this comment.  Thank you. Thank you for your question. Comments of the bike rack. We had a conversation about numbers and appreciate that you'll do some careful consideration of how many should be provided. We've approved this design before for other conservation areas, painted black. They will be black. Yes. It is. It's a great comment and we will take it because I think this is going to be this is going to be really kind of a hybrid of a conservation area recreation area. I will say that at sweet Alice, and Potec. I have never seen a bike at either bike rack, but that's just me, you know, I was actually a Potec Catherine Cole today. Both of those conservation areas are in difficult places in my estimation difficult places to bike to because of the high volume of traffic Potec Cole is across 116. And sweet Alice is on Bay Road, not far from the double roundabouts, not to say that people wouldn't bite there, but they're they're not easy places to bike to but I do agree that this has the potential for people to come as a group.  And speaking of kiosk, we've got the kiosk design and then also signage. And again, thank you for for sharing these I know that again this is something that we've approved at other locations. We've talked about the, we've talked about the sign, the street sign design before, and I know you haven't implemented them yet but this is this looks very similar to what we reviewed for sweet Alice. Anybody want to weigh in thoughts concerns. Lindsay. I think it looks great overall my only question was on the kiosk if there's any intention for plexi. If you mentioned that or not. Sorry, there's any intention for plexi for plexiglass on the. That's a really good question. Again, my, my dream here is to, to standardize all of these across town. It's really a question of funding that's all it is is it's really not an easy thing for me or the town to fund these. We do have plexi in some locations. I found it to be a little bit of a double edged sword in that. Yes, you get more life out of what you put behind the plexi, but vandals love to scratch the plexi insects get behind them. You know, we're kind of moving more toward like a lexan lexan product. But yeah, we may cover some of the material there with some sort of plexi some sort of plastic covering like the map so that they weather better in the UV, you know UV affects everything you put on these and fades everything so there may be part of the kiosk that we put plexi on. I think a really good example of that is that the applewood orchard orchard or at applewood there's the orchard arboretum conservation area, and that has a very similar kiosk to this. And we've worked with the steering committee at applewood and they've covered one side of it with plexi and it's it's worked quite well. Again, low vandalism area. You know you spend a lot of money on plexi and then one person comes by and vandalizes it and you're out whatever 150 bucks or, you know, I don't know the exact cost but yes so that that would be a consideration. Thank you yeah and I don't I don't know that I would. I asked the question was a discussion, so I think that it makes sense to consider where it might be appropriate and where it may not be, and if there's various products that may not lend themselves to the issues that plexi typically does whether it's condensation or vandalism or, you know, various things getting trapped. So I was mostly just curious what the plan is for that. I appreciate your time and and again, you know any comments, recommendations suggestions guidance we we would appreciate it and Jennifer and I have kind of heard you and taken some notes. And the sooner anything comes from the DRB and through through Rob would be wonderful as I said we are pulling together together our bid documents this month or excuse me, next month. We have a calendar here in December, and we want to try to bid this out in January and try to get a jumpstart on spring construction. That's great. I think, DRB folks, I would love to hear emotion. You approve of the. What do we call them does features design elements shown to us tonight with. I was taking a few notes it seems like the only real actionable recommendation is to ensure that the handrail design on the bridges meets code extends beyond the base of the bridge. But although that's really the guardrail there's no handrail. But checking in on that I think seems important but I think everything else is kind of meeting with approval. Everything that we've seen so far we'd love to see that move forward. Rob. Sorry, it took me a second to meet myself. So just to make sure we're clear about I guess we have recommendations before we take a motion so just from my notes and what I've heard it seems so far. One recommendation is to make the railings come out a foot off the bridge on each side. Or as Lindsay mentioned, there's also the option of taking, I guess, the railing from a 90 degree to 45 degree as well. Lindsay, do you want to elaborate on that a little bit more or is that something that you suggest as an alternative. I'm sure. Yeah. Thank you for asking. I, I, from a code standpoint if they are to be ADA, just make sure that the handrail meets those requirements. Okay. I would just make it that general. And then from a, from a comfort standpoint, you might want to consider changing the shape of that edge condition just so that it or the extension of it just so that it feels that it protects somebody at that corner. Okay. And then I have written down. I've discussed about the utility building I have written down keeping the color as a conservation neutral. I'm sure that was pretty much implied from discussion right okay. And then we have possibly exploring plus plexi on the kiosk, but it has to be an area with low vandalism so does the board want to keep that sort of like a recommendation to explore, or does the board not feel that's necessary to keep in there. No, okay. Okay, so I guess the biggest one is just the railings for the bridge and then, of course, there was also Karen's suggestion to consider the bike racks, but I don't think that's really a design consideration. So Karen, please. Not this design but I hope when you're looking at the bicycle racks there are some that might be less expensive they're much lower they're not this big loop. But there's a number of them just like 10 in a row little ones, and you just park you just put your, your belt around the bicycle on that. So just a recommendation to really look at the different kinds of bicycle racks I think maybe the design isn't of a bicycle rack should be just very simple. But I do think you should have possibilities for a group to come and be able to lock up their bicycle, if possible. That's just my recommendation is against not designed. So like, I guess having more concentrated bike racks in a single area, as opposed to just like these single loops that you'd see every once in a while like every like, two or three feet or something like that. Is that, I know it's you're mostly not talking about from just design standpoint but you're talking about more from a usage standpoint. Correct. Okay. Now that makes sense. Alright. That's all the questions I had about recommendations. Okay, so could I ask for a motion with recommendations as summarized by Rob. To approve. I would make the motion as summarized by Bob it for the recommendations, concerning the design and improvement of the bridges and the number of bike racks. Thank you for their second. I'll second. Thank you, Catherine. All those in favor, please say aye raise your hand. Hi. Fantastic. Thank you. Very much for your work on this good luck with all the big proposals and Thank you so much. Thank you very much. We're very much wanting to be under construction, April, May, June, so we're going to try to work quickly and have at least the ADA loop done by the end of June and the north south done sometime later in the summer. Fantastic. Before you dash, I was, we have to approve meeting minutes. And there was one comment, one statement in the minutes that kind of in response or clarification or questions that all paths will be accessible. And my memory that it wasn't all, and I just wanted to what would be the appropriate language to substitute. So I can quickly summarize that. So our intention, obviously we have a park grant to consider the to build the loop trail to the west, which we've been talking about this evening. That will be fully accessible. The north south trail will be fully accessible. The connection between those two will be accessible. We don't have funding to build that yet. But then the remainder of the trails will be typical. And I use the word typical, you know, with some purpose here, typical conservation trails, we kind of call them single track trails just like many of the 80 miles of trails we have in Amherst. And they will simply be a mode bath, and they will not be accessible. So there will be many options at Hickory Ridge to go north to go over toward the Village Center to do about a three quarter mile loop on this accessible trail and get between those two trails. But then if you want to go in other places, you know, it's 150 acres, it's a pretty big area. If you want to, for instance, go around one of the solar arrays, that will be a single track conservation type trail, and we'll simply be a mode bath. So we're giving as many opportunities for those people with disabilities to get out there in nature to get down near the Fort River. And our design has incorporated, you know, access to the river, access to wildlife areas, scenic vistas, etc. I think that's important to be accurate that not all the trails will be fully ADA. So the trails that you mentioned, Dave, are that loop trail at the west and then that north-south trail. Those are the only two trails that you're just, okay. And then we will in phase, I call that kind of phase one, phase two, we will connect the north-south trail with the loop trail, and then you will be able to move or you will have accessibility between those two trails. And the single track conservation type trails will be mowing as soon as we get approval from the conservation department, or excuse me, conservation commission, and the state, because we are being regulated by a number of state agencies because I agree, Ridge is such a sensitive ecological area that we have many hoops to jump through beyond just the conservation commission, the planning board, and some state agencies. So really exciting, but thank you for all of your guidance and we hope to see you all out there in the summer of 24. Great. Thank you so much. Thank you. Thank you, everyone. Thank you so much. Thanks Jennifer. Thanks Dave. Rob, I didn't notice any members of the public. We were just eight on the participants. I didn't call anybody in but thought I'd double check. All right, we can move on to approval of minutes. We'll do a screen share. And so, you know, my usual record for minutes was two pages, but fortunately I had to get to the third page for this last meeting. There was a lot that was talked about. But yeah, I mean, I did take out on your one point about the accessibility of trails. I just didn't want to misrepresent their intentions since this is a public document. It's a lot of accessible trail, but it's not all of the trails. All right, so forgive me if I usually scroll through these for the board members, but if you all have read them, I don't need to take your time to do this. Let me know please. If you want me to scroll or I don't need you to scroll. Anyone else. No, you could just scroll kind of quickly. That would be helpful for me. Got you. Speed reading. Yeah, so we did games underground approval of their signage that the recommendations were to just be really mindful of their blue. There was no, there was no decision made, no vote. We just had a nice conversation with Babe and Jennifer on Hickory Ridge. And so obviously we have to change that ADA. And you can do what you did last time I just vote to approve with the recommended changes and I'll make those changes currently and then post the minutes tomorrow. If the board satisfied with the minutes that is I don't want to assume that you like the minutes maybe you want them to be rewritten completely. That would be unreasonable. Yeah, back to my screen. All right, so. Approved with amendments. Second. Thank you a second. Second. Thank you. Pat. All those in favor of approving the minutes. From the date. Thank you. Appreciate your answer ahead of me. Great. Approved. Okay. Okay. Fantastic. Any other business not anticipated. No. Okay, Rob, could I ask you to identify what our next meeting date is? Sure, let me pull out my calendar. So I noticed the end of December is going to be tricky with the holidays for people. So the last meeting date would have been December 25th, but that's Christmas. So I guess for now, the last meeting date could be December 18th, which is the third Monday. Or if the board decided that they would rather skip the month of December, that's also an option. But I would say as of right now, the most logical date would be December 18th for our next meeting. Just because of the holiday. So I think that would be helpful. I mean, I don't think the meetings works for me. I don't. I think we need to decide now, but if anybody. If we could do a calendar check, if you have a. A conflict already in place. That would be helpful. Karen. I'm going to be gone from the 17th until January 10th. Oh. Oh, wow. I mean, there's a time change. Sure. Yeah. The 18th works for me. Okay. Thanks. Yeah, I could do it. Why don't we pencil it in? I think that's a good plan. And I'm seeing like we're likely to have a quorum. Yeah. But as long as we have at least three people, it's fine. Yeah. And at this point, we don't know if we even have any applicants. So. Yeah. To have it penciled in and we'll cancel it weekend. All right. It was lovely to see you. Thanks for your continued guidance and shepherding. Sure. A lovely. A lovely rest of this month and beginning of December. All right. Thank you. Thank you.


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. We're going to be talking about 12 errors in addiction and eating disorder diagnosis and treatment. And obviously there's probably, well, I'm sure there's a lot more than 12 errors, but we're only going to cover 12 today. We're going to briefly review avoidant restrictive food intake disorder, anorexia, bulimia, binge eating disorder, substance use disorder, internet gaming disorder, gambling disorder, and sex addiction. So we're going to review those things because a lot of times people aren't real familiar with diagnosing some of the non mood disorders. So we're going to talk about it a little bit, but we're specifically going to keep focusing more on differential diagnosis and some errors that might come up. So avoidant restrictive food intake disorder is an eating disturbance manifested by a persistent failure to meet appropriate nutrition and or energy needs associated with only one of the following. So it is really easy to get the ARF ID diagnosis, significant weight loss or in the case of children failure to achieve a expected weight gain, significant nutritional dependency, dependence on enteral feeding or oral nutritional supplements and or marked interference with psychosocial functioning.  Are they do they have a nutritional deficiency? Are they having interference with psychosocial functioning or are they having a significant weight loss or are they failing to meet developmental goals? So those are all going to go through my mind if somebody is presenting with this issue and we'll kind of talk about how it might come up in your office. In this, there is no body dysmorphia or fear of becoming fat. So this issue with food is to do with the food itself, not because of a fear of fat or perception of some flaw in one's in one's body. Okay, so the behavior is not better explained by lack of available food or by an associated culturally sanctioned practice. Now, culturally sanctioned practices, you know, we have in a variety of religions, there are periods of prescribed fasting, but those periods of fasting are short. There are also periods of restricted types of food intake. I know my old boss used to go on the Ezekiel diet for a period of time. It was a couple of months, I think each year and you know, so there were certain types of foods he couldn't eat during that period, but that was a culturally sanctioned practice. Did he lose weight during that period sometimes? Was he meeting his nutritional goals? Overall, probably yes, he was in eating the diet that he was eating.  But with anorexia, remember there is a fear of fat or significant effect of their body image or their body size and shape on their self image. And we're going to talk about that. Can't occur exclusively during the course of bulimia or body dysmorphic disorder. So again, the restrictive food intake disorder has to do with the food itself, not anything to do with the body. The eating disturbance is not better attributed to a medical condition or better explained by another mental health disorder. When people are depressed, sometimes they just don't want to eat. It's not that they're fearing getting fat. They're just, they have no appetite and even smelling it or tasting it kind of makes their tummy upset. So we want to consider is this a symptom of the depression or is this a standalone diagnosis? Look at anxiety. I don't know about you, but when I get really stressed out, I can't eat.  So somebody who has persistent generalized anxiety may also have difficulty eating and may lose weight and rely on, what did they call it back here? Nutritional supplements like insure or whatever just to meet their basic nutritional requirements. And obviously we're going to be working with the anxiety and working with their primary care physician and their nutritionist to make sure they're getting comprehensive care, but it wouldn't qualify for ARFID if it's a part of or part of the symptoms of the depression or anxiety. If it's part of a psychotic disorder, if someone has a delusion that some food, you know, is bad is evil, it's going to do something to them. They're in the middle of a psychotic episode. They may refuse to eat and it's rare, but it can happen. Or when we're talking about things like Crohn's disease, the person's stomach is painful and upset and they're having difficulty ingesting and processing foods. They may refuse to eat.  One of the things that may bring someone into your office where you're having to try to figure out what the diagnosis is or if the person meets criteria is for example, if an adolescent is brought by their parent to your office and they're like this child won't eat is restricting and the child doesn't report fear of fear of fat doesn't report meeting the criteria for anorexia or bulimia. They are on a fad diet of sorts or they have decided that this is their new eating pattern and we want to look at it in terms of is it causing them problems? I mean, if it's obviously causing conflict at home, so that could be a problem in psychosocial functioning. But what is motivating this behavior in this particular adolescent at this time to see if it meets the criteria of a feeding disturbance or if it doesn't quite meet that criteria. The good news is if you're looking for a way to bill for this and they meet the criteria then by the bank. So moving on to anorexia. So if avoidant restrictive food intake disorder is probably what you would consider sort of your other not otherwise specified diagnosis anorexia persistent restriction of energy intake leading to significantly low body weight in context of what is minimally expected for physical health. So these are people who are well underweight. Now I know a lot of people especially adolescents it's like they've got metabolisms that are through the roof who have very, very low body weight and don't meet the criteria for anorexia. So we don't want to just say every person who is really, really thin is anorexic. They need to have an intense fear of gaining weight or becoming fat or the persistent behavior interferes with weight gain. So they may be doing things in order to prevent gaining weight like exercising or purging. They experience a disturbance in the way their body weight or shape is experienced and when I was in graduate school I was able to assist somebody on their doctoral dissertation on eating disorders and we had this cool little thing where we would take a picture of somebody in a black onesie leotard and we would distort it. You know, we would make it really, really big and distorted. So it was way out of proportion. You couldn't look at it and go, oh my gosh, is that what I look like? It was really obvious. It was like funhouse mirror sort of thing and we would let them adjust the dials to get the picture back to represent what they think they looked like and then we compared it to what they actually looked like and those people who had more of who had eating disorders obviously had a much different image of what they looked like and generally it was anywhere from 20 to 60 percent. 60 percent was obviously on the high side larger than they really were. So understanding that a person who was looking in the mirror with an eating disorder is oftentimes not seeing the same thing as you are. You know, they are seeing something someone who was larger. There's undue influence of body shape and weight on self evaluation. So this is a treatment issue that we want to look at. Why are you only lovable if you are a size whatever or if you weigh so much and a persistent lack of recognition of the seriousness of the current low body weight. So again, we're looking at body dysmorphic disorder a little bit here too. The person may be looking in the mirror and seeing someone who in their mind is overweight. They're seeing an image that is bigger. They're not seeing the fact that their arms are five inches around or however big. So we want to rule out what their perception is we want to rule out body dysmorphic disorder in order to figure out do they really conceptualize how thin they really are most people with anorexia don't they don't see that they see fat when they look in the mirror and then you want to specify whether it's restricting or binge eating and purging and so your next question might be well, how do you differentiate anorexia with binge eating and purging from bulimia and the biggest criterion is the refusal to maintain a minimal body weight. We want to rule out obsessive compulsive tendencies which are common in people with anorexia anorexia nervosa one of the things that we find is the lower weight goes the more people start to obsess about food which when you think about it makes a lot of sense the brain is trying to get you to feed it to protect it so you can survive makes total sense but when someone with anorexia is in that starvation mode they'll start obsessing about food they'll start obsessing about calories they'll start obsessing about you know what they might be able to eat and it starts taking up a whole lot of their mental energy and time and then there are compulsive rituals surrounding eating that a lot of times they need to engage in so you want to rule out OCD when you're looking at anorexia which obviously with OCD you're not going to have that fear of getting fat and undue influence of body shape on self evaluation. Please remember and these numbers are so low because we have a lot of people who don't admit to it who don't seek treatment we have a lot of eating disorders that go undiagnosed but even with that 3% 3.6% of males have an eating disorder so let's not forget the guys in there there's a lot of pressure put on men now that you know men's magazines are you know almost as prevalent on the on the news stands as the women's magazines that show men with like 2% body fat or 1% body fat the bodybuilders the emphasis on having that cut physique and those 6 pack abs and everything else it's a lot of pressure you know the guys experience the same media pressures that women do in many cases. Eating disorders are not just a childhood adolescent thing they can start anywhere from puberty or even a little bit before up to age 40 is your average age of onset age of onset now. Eating disorders can start earlier than puberty. It's not uncommon but it is not the norm and they can start later than 40 but again that those are your outliers there but up to age 40 someone can begin showing symptoms of an eating disorder. So a lot of times we rule out eating disorder diagnosis in our head when we have someone come in who is not your typical high school college age person and that would set us up to be wrong. So up to age 40 depressive symptoms can be present so we want to rule out are they restricting eating are they not eating because of depression. And if they've got depression we need to make sure to treat it because they're going to have a hard time in their recovery if we're not also addressing that so what causes depression in people with anorexia well you've got you know cognitive and mood issues and you know potential body dysmorphic disorder you also have when somebody's weight goes really low potential for anemia anemia can cause fatigue and lethargy and symptoms of depression. As we've talked about before low estrogen or testosterone both affect the availability of serotonin and contribute there they've done studies that you can find online that contribute to depressed mood when those either one of those are low estrogen for women testosterone for men reduced thyroid hormones can occur in people when they're in that starvation area makes total sense again think about it the body is in starvation mode is not getting enough food so it's going to turn down the thermostat it's going to say I can't use any more energy than I absolutely have to so everything else is going to start to slow down. The other thing that can be very dangerous are nutritional imbalances so the body can't make the neurotransmitters that needs to make to make your happy chemicals. But you also can have potassium imbalances and arithmias potassium imbalances can lead to cardiac arrest and other big problems so it's not something to play with and the arithmias can keep the oxygenated blood from effectively getting throughout the body which can contribute again to fatigue lethargy anxiety a variety of symptoms. So we want to figure out if the person has anorexia and is presenting with depressive symptoms again what is causing them what is what is the etiology of those depressive symptoms and there's probably multiple but we can't I can't emphasize enough how important it is to have a medical doctor on the treatment team with someone even with if you can conceptualize mild anorexia even somebody who's only like 5 or 10% below the norm. We really want to get a doc in there. Common co-occurring disorders are depression and anxiety so again differentiate anorexia from obsessed obsessive compulsive disorder don't forget men don't discount the late onset make sure we refer for a medical evaluation when somebody comes in and reports a history of you know restrictive dieting yoyo dieting you know anything that might perk up your spidey senses a little bit that may say this person is nutritionally deficient which is going to negatively impact any other recovery we try to address because if their body can't make the neurotransmitters and stay balanced and regulated we're fighting an uphill battle and rule out body dysmorphic disorder as the primary binge eating disorder now this is kind of interesting when we look at it binge eating is characterized by both of the following eating in a discrete period of time within any two hour period is generally the rule window you'd they give you an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances so you know I'm thinking to myself. Well what does that mean in our society I've seen people go to a restaurant and eat a big meal and put down five six thousand calories and you know I've seen people who are you know having a bad day eating entire pizza or you know a large amount of ice cream or half a chocolate cake now is that healthy. No but is it when we're looking at what most people would do in a similar time frame under similar circumstances if somebody else was really really stressed and they were self soothing with food. You know. You know is this behavior all that uncommon is it healthy no we're not saying that but we want to kind of look at normalizing what's going on and figuring out how often these binges occur. So next criteria that has to be there is a sense of lack of control over eating during the episode a feeling that they can't stop eating or control how much they're eating and I find a lot of clients get some relief from this when I'm working with them if they instead of eating out of the bag when they have eating potato chips or Oreos or whatever it is put it on a plate put it on a small plate force yourself to sit down you know changing some of their eating habits can help them get more control over their eating because mindless eating is very common in our society and so you may say okay last chip I'm not going to have any more than the bags just still sitting there. And you may eat again and then the person can start feeling like they don't have any control or any willpower. So we want to give them a sense of self efficacy and we want to help them establish sort of ground rules so they can start controlling how much they eat but this is not necessarily going to make the binges go away so we want to look at what's precipitating those binges what function is the binge serving when we're talking about treatment. Binge episodes are associated with three of the following eating much more rapidly than normal. Now again I don't know about you but me if I've gone all day long and I skip lunch and it's 6 o'clock at night and it's been like you know 12 hours since I've eaten or something. I'm probably going to inhale food and then worry about tasting it later when my son was little he used to have gastric reflux really bad and if we got 15 minutes without crying it was it was good. So anytime I would make food I would kind of eat it as quickly as I could because I knew I was going to have to pick the baby up in short order. Yes there are probably other ways to deal with that yada yada but anyhow. So there are times when I would eat much more rapidly than normal but does it qualify as a binge. Eating until feeling uncomfortably full now we're coming up on Thanksgiving and how many people do you know who after Thanksgiving meal kind of undoes their belt a little bit like oh my gosh I ate way too much. We all do it occasionally so we're normalizing eating large amounts of food when not feeling physically hungry. I think we've all done that occasionally. Eating alone because of feeling embarrassed by how much one is eating. So that's one of those indicators that people are embarrassed to eat in public. But we also want to look when I see that one I start thinking let's rule out bulimia here because a lot of times people with bulimia their self evaluation is very strongly based on their body shape and size. So they feel like people are judging them when they're out eating no matter how much they're eating. So you know we're looking at binge eating disorder obviously with binge eating disorder you don't have the compensatory mechanisms that you do in bulimia. And a binge eat episode can be characterized by feeling disgusted with oneself depressed or very guilty afterwards when you're looking at the bag and you're like I ate an entire bag of M&Ms. You know and again sometimes we do that and when I'm talking to clients and trying to figure out what's going on. Most of the time I don't want them to get all that hung up on making a diagnosis. I want to look at what symptoms are bothering them and let's just deal with those. But we do talk about the fact that you know sometimes people do people do occasionally binge. I mean even people without binge eating disorder. What does that mean to them? What does that mean about them? If they occasionally binge. What do they think about their best friend who may occasionally binge? You know what does that mean?  Binge eating disorders characterized by marked distress regarding binge eating. So if they're embarrassed about it if there's marked distress if they feel like they're spending way too much money on the food that they're binge eating on if they're having significant health problems because of their weight because of the binge eating then we might start looking at that binge eating occurs on average at least once a week for three months. So we want to look at the time criteria. It's not associated with the current use of inappropriate compensatory behaviors. So that helps us rule out bulimia. Understand that binge eating disorder is less common but much more severe than overeating. So it's not just going to a restaurant and having a big meal. It is eating you know several thousand calories in a particular setting you know 10,000 20,000 calories. Binge eating disorder is associated with more subjective distress regarding the eating behavior than just normal overeating people who just overeat you know and it's not a binge. It's not binge eating disorder. They're like oh I'm going to have to do an extra hour at the gym tomorrow or something and they're done with it. You know they don't beat themselves up for the rest of the night about how much they ate or feel bad about it or feel totally disempowered and and defeated. So again we're looking at a continuum. We have overeating over here which is well get back on the screen overeating which is you know normal people do it occasionally and then we've got binge eating which not only tends to have involve more calories in a shorter period of time but it has a lot more distress associated with it. And then bulimia recurrent episodes of binge eating which we just went through an inappropriate compensatory behavior in order to prevent weight gain self induced vomiting. That's one of them misuse of laxatives. That's another issue that we want to consider misuse of diuretics or other medications and and this can include diet pills that they think are going to speed up their metabolism metabolism amphetamines anything like that that they think is going to help them have less of an appetite and speed up their metabolism fasting. So you may see people who binge and then they don't eat for two days and then they binge and they don't eat for two days. Or excessive exercise and so what is excessive mean. We want to look at the average I mean if somebody's in in the gym for an hour that's different than if if they're in the gym for six hours. So paying attention to the excessive exercise and also in terms of how is it affecting their life you know spending occasionally spending a couple hours in the gym isn't that uncommon for some people going on a really long run is not that uncommon for people especially people training for marathons or something is that excessive exercise and when I'm talking with clients I'm looking for things like they're exercising despite the fact that they're starting to have joint problems they they are exercising or their exercise takes precedence over everything else in their life so they give up hobbies they give up spending time with family when it's really important or they set their work schedule around their exercise and they just can't function if they don't exercise that day. So that's what I'm looking at is you know does the anxiety level go through the roof if somebody can't exercise especially after they've been being an inappropriate compensatory behaviors both occur on average at least once a week for three months. Self-evaluation is unduly influenced by body shape and weight just like with anorexia the disturbance doesn't occur exclusively during the episodes of anorexia and and remember the biggest defining feature is the person's body weight whether they are meeting the criteria for anorexia because they refuse to maintain minimum body weight most people with bulimia are average or slightly above average body weight. We also want to rule out histrionic and borderline personality disorder one of the things that we see is as a co-occurring sometimes with bulimia is people having histrionic tendencies histrionic characteristics in their behaviors overly sexualized behaviors there's a strong correlation between trauma especially childhood sexual trauma and the development of bulimia later in life so sometimes we see some histrionic characteristics it may be something that needs to be addressed in treatment in order for the eating disorder to completely remit because if someone is unduly concerned with their shape and body size engaging in overly sexualized behavior in order to get approval then you know we've got to look at what is your body shape mean does it mean you're only lovable if you are a sexual being and the same thing with borderline personality disorder we see that come out a lot in people who've had early childhood sexual trauma so it may be another co-occurring issue that we want to attend to if it's present so you want to take a look at the personality disorders make sure there's not one that also needs to be attended to the current severity of bulimia mild one to three episodes of inappropriate compensatory behaviors per week so moderate is four to seven episodes so we're looking at you know about one a day severe is 18 to 13 8 to 13 episodes per week and extreme is 14 or more episodes of inappropriate compensatory behavior per week I will share with you when I was in college at my sorority purging was sort of a natural or an expected behavior so I would say that the majority of women in my sorority met the moderate criteria because you know after meals the bathrooms would be busy for quite a while so we're looking at anywhere from seven to 14 episodes per week so we want to be cognizant now when we're working with people who are in a community that supports that kind of behavior you know you're going to have a lot of resistance to changing the behavior because it's sort of inculturated in in that particular community so you know something that also probably will pop up as a treatment issue occasionally people with eating disorders very often don't have peers that they share it with but there are those occasional groups that will provide social pressure to the person to maintain the compensatory behaviors okay other common issues in eating disorder treatment that we want to consider from a therapist's point of view nutritional imbalances when someone is coming in whether it's bulimia anorexia even binge eat disorder generally you're not going to binge eat on the healthy things so if somebody is binge eating on you know Krispy Kreme donuts they're not getting their nutritional profile met so we want to look at nutritional imbalances make sure that they're being assessed for nutritional deficiencies by a medical professional to make sure again that they can make the neurotransmitters they need to in order to feel happy and calm and all that we also don't want to assume lack of knowledge one of the quickest ways to get someone with an eating disorder to shut down is to start educating them about what healthy eating is and what they need to eat and what carbohydrates are then most of them know that probably better than most registered dietitians they eat sleep and breathe calories macros macros you know it's it's part of what they obsess about as part of what they focus on so we don't want to assume they lack knowledge we want to look at again what's the behavior functioning for what is the basis of the behavior it's not that they don't know how to eat well it's serving a different purpose we also want to look at issues of sleep deprivation someone who is sleep deprived is going to maintain low levels of stress which is going to make it harder for them you know it's going to reduce the amount of available serotonin and all that kind of stuff going back to our HPA axis but we're also going to look at issues of hunger you know if they're hungry it may be keeping them from sleeping or they could be uncomfortable because they've been abusing laxatives because they're hungry because they're malnourished any of those things can negatively impact sleep which is going to negatively impact what we're trying to do and their ability to not only feel happier but also remember and learn those things because if they're focused on food and they're in a group therapy session and all they're thinking about is what can I eat that's within my calorie limit for today they're not hearing what you're saying they're not able to focus on that and retain it so we want to make sure they're getting enough sleep so they can focus they can retain stuff they don't create symptoms of depression we want to treat mood issues with the person that has an eating disorder but most people especially if they present and they say I've got an eating disorder if you tell them we're going to treat you know these other anxiety issues or whatever and once you develop the coping skills you won't need to binge anymore you won't need to restrict anymore so that's just secondary they're also probably going to walk out of your office because they don't feel hurt they're presenting and saying I've got a problem I have I feel like I have no control over this and I need to feel like I've got some sense of control so some people although you know well meaning may minimize the impact of the binging the purging the restricting which will turn off a lot of clients and may make them feel even more hopeless and helpless and isolated and failing to address the rebound effects from laxative and deretic abuse when you've been abusing deretics and you stop a lot of times people experience water retention fluid retention for several days or even a couple of weeks afterwards while the body's trying to adjust to oh wow we've got a lot of fluid coming in here and the person's not using the deretics so we want to pay attention to that now remembering laxative abuse and deretic abuse can also cause problems with internal organs so something that the MD needs to assess laxative abuse can also cause the colon to become lazy if you will and when people stop using laxatives they will become constipated they may have difficulty going to the bathroom which will increase their feelings of gassiness and bloating which will increase their feeling of oh my gosh you know I feel so bloated I can't exist like this if this is what recovery is like I can't do it helping people understand the process of basically getting the body back online and it takes several months helping them make sure to work with a nutritionist and a physician to you know ease that transition to ensure treatment compliance is going to be really important because they start freaking out if this you know if they're constipated the scale is going to go up if the scale goes up markedly you know it's it's a shock it's a huge anxiety trigger so we want to kind of look at working with them to address that so moving on from eating disorders because you know they are really prevalent unfortunately in our society more so than I would like to think so we need to pay attention to what's out there and whether our clients are struggling with an eating disorder substance use disorders now I know that types a little small here but I wanted it all on the same page taking the substance in larger amounts and for a longer period than intended wanting to cut down a quit but not being able to spending a lot of time obtaining the substance craving or a strong desire to use the substance failure to carry out major obligations at work school or home due to use continued use despite persistent or recurring social interpersonal physical psychological problems caused or made worse by use stopping or reducing important social occupational or recreational activities due to use and recurrent use of substances and physically hazardous situations now tolerance is indicated by an increased need for increased amounts of the substance or diminished effect with the use of the same amount and when we when we get down to gambling disorder you will see how these same criteria are basically worded a little bit differently but they're pretty much the same criteria gamblers for example need to gamble more money they need to take bigger risks in order to get the same rush that they got before withdrawal syndrome or or the substance is used to avoid withdrawal so when somebody stops using you know let's take alcohol for example we've talked about alcohol a lot and they start to detox from the alcohol their characteristic signs of alcohol withdrawal including the increase in blood pressure and anxiety or the person may be like no you know I I can't go through withdrawal I'm not going to go with through withdrawal but in order to prevent those symptoms they have to continue to use so you know you may see somebody who hasn't experienced withdrawal because they're not willing to stop long enough for their body to actually cleanse it out of their system now one of the caveats here is this does not apply when the drug is used appropriately under medical supervision so let's think about opiates here you know some people have persistent pain from you know a car accident from you know a wartime injury whatever and nothing else handles their pain they've tried you know gabapentin and some of some of the other medications out there they're supposed to help and it's just not working for them so they're on opiate based medications so do they need to take the substance in larger amounts over a period of time well yeah they do because their body adjusts to it and they develop a tolerance and a withdrawal to it but what we don't see in people who are using it appropriately under medical use supervision is continued use despite persistent interpersonal social problems using in hazardous situations or the reduction in important social occupational and recreational activities due to use now they may not be doing those things due to pain but they're not doing it due to use so they're not avoiding going to their kids ballgame because they want to stay home and shoot heroin they are not going to their kids ballgame because they're in too much pain even though they're taking the medication as prescribed will people who are taking it appropriately under medical supervision experience cravings sometimes yeah they will especially if they miss a dose will they spend a lot of time obtaining the substance you know probably not unless you know your doctor has a really long wait and is never running on time some people who are on prescribed opiate medications want to cut down but they're not able to do it it's not because it's because the pain is too bad the pain is too severe it's not because of the drug interaction it's because when they start cutting down even when they let their endogenous opioids kick back in there's just too much pain for them to have a quality of life so some people may want to quit that cut down or quit and not be able to do it because the underlying physical issue is just too severe so we want to look at you know not stigmatizing people we also want to look at you know when we start talking about medication assisted therapy methadone buprenorphine suboxone those sorts of things all of those things are also going to be present in in many circumstances so we want to look at is this a substance use disorder or you know are they able to carry out major obligations at work school and home whoops now that they're on methadone when they were shooting heroin they couldn't do that are they continuing to use and while they're using while they're on the medication assisted therapy are they experiencing as a result of the medication assisted therapy recurring social interpersonal physical or psychological problems generally the answer is no my experiences most people once they get on medication assisted therapy and they're in a treatment program they tend to start doing a lot better so just kind of bearing that in mind because in recovery circles and and certain self-help groups and stuff the use of medication assisted therapy is greatly frowned upon and the belief that some people need to be on pain medication for their entire lives for the entire rest of their lives is not accepted by some people so we really want to look at the individual and talk about you know what's going on with them told you we can move up to gambling disorder because that was added in the DSM five so you know we're starting to see the switch the move of the American Psychiatric Association to look at addictions and starting to look at behavioral addictions and the next one we're going to look at is internet gaming disorder that didn't make the cut that is in areas for further study but it did make it into the book so we're starting to see an acceptance or an awareness that there are things other than substances that can cause people significant psychosocial or physical problems and it can also contribute to psychological and mood issues so I think that's an awesome positive step that we're starting to legitimize people suffering if you will and we're saying yeah you know we can see it's a problem instead of there's nothing I can do so gambling disorder we're looking at a 12 month period here and a person needs to have for the criteria needs to gamble with increasing amounts of money for excitement you know if they started out with quarter slots and they're up to the $20 tables or whatever I don't gamble so I'm just kind of swinging it here you know we're seeing an increase is restless or irritable when attempting to cut down or stop gambling so if they can't go bet on the ponies or bet on the sports games or fantasy football or whatever it is they start getting really irritable and cranky cranky and restless and especially if they figure out that they could have won some money they can get really cantankerous have made repeated unsuccessful efforts to control or stop gambling so you know if they're put in a situation maybe they play poker at a buddy's house and they say you know I'm going to stop after I lose $500 or $100 or whatever it is and they keep going and even though they said this is my hard line I'm going to stop here they keep going after that and they are unable to quit the game at that point it qualifies is often preoccupied with gambling when feeling distressed so they start getting anxious whether it's about money or not gambling when you're gambling it takes a lot of mental focus to figure out what you're going to bet on or play the game that you're playing so people can start kind of drifting off and start thinking about gambling when stress gets really high because they're looking for that escape they're looking for that rush after losing money gambling often returns another day to get even so they're chasing the high they're trying to come back they're trying to get even trying to win their money back but they're also trying to get that rush because they left on it on a down if you want to make a parallel with drugs it's like getting a bad hit of something and having a really bad high experience a lot of people will come back and try to do it again going now that's not how it's supposed to be they lie to conceal the extent of involvement with gambling they've jeopardized or lost significant relationships jobs or educational or career opportunities because of gambling you know gambling a lot of times is not during the day it's at night so people stay up really really late so they may be barely conscious when they're at work and they may get terminated they may have difficulty in their relationships because they're always going out gambling instead of staying home or going out with their significant others to do something else likewise people I know people who've gotten in trouble at work gambling they can't even put gambling aside long enough to be at work so they end up getting terminated for that and they rely on others to provide money to relieve desperate financial situations caused by gambling not everybody has to meet this criteria before they meet gambling disorder remember they only have to meet four of these criteria a lot of times people are not going to present for treatment until they get into those situations that are financially desperate but paying attention especially if you're in an area where there is a lot of gambling that's prevalent there's casinos there's those things definitely pay attention to that but even in places where there's not there's always poker games and you know online betting online gambling is huge and if you go to the right sites there are a lot of places that will tempt people and they'll give them the first five hundred dollars worth of chips free so to the gambler they make it on and go well you know what can it hurt because I'm not spending any money but then they lose that five hundred that they got free and then they start putting their own money into it so the online gambling establishment sort of enticed people to get started and then once they get started hope that the person can't stop gambling behavior is not better explained by a manic episode when people are manic and this is not new news they will engage in thrill seeking impulsive behaviors they can be wide open for days on end and sometimes people engage in a lot of gambling during this it's risk-taking it's thrill seeking so we want to rule out is this person in a manic episode you know is there a history of bipolar disorder or could it be the onset of bipolar disorder or is it just gambling when bipolar is not adequately controlled people may engage in gambling behavior during a manic episode which there's there was a recent lawsuit against one of the medications for bipolar disorder claiming that people who took that medication also sometimes developed a gambling problem and my thought was well doesn't that tell you that the medication wasn't very effective because it didn't stabilize the manic episode but that was just me so we want to rule rule that out you want to specify if it's episodic or if it's persistent and persistent means continuous for multiple years because remember we're looking at criteria for a year just for diagnosis and then you can specify whether it's in early remission or sustained remission but for remission it says none of the criteria can have been met for 12 months or longer so you know there's a lot of criteria there that may be met in 12 months so it's hard for people to get in full remission and finally internet gaming well not finally one more after this internet gaming disorder right now repetitive use of internet games causing significant issues with functioning five criteria must be met within a year preoccupation with the games withdrawal when not playing the games tolerance more time is needed to be spent playing the games now if you know anybody back in early 2000s I think it was when world of warcraft became really popular I know people who you know called in sick to work and ended up getting divorced I know two people who ended up getting divorced over their engagement in world of warcraft so you know it can get to be an obsessive kind of behavior tried to stop or curb playing but failed to do so has had a loss of interest in other life activities such as hobbies they just come home get on the computer play until it's time for bed or maybe even for go sleep and we've seen pictures of or media portrayals of gamers who wear adult diapers and have food brought to them they don't even get up to go to the bathroom or eat the person as I continued overuse of internet games even when knowledge of how much they were impacting their life so they may look around to go yeah my wife left me I lost my job but you know whatever they've lied to others about the extent of their internet game use use internet games to relieve anxiety or guilt it's a way to escape and has lost or put at risk and opportunity or relationship because of internet games right now the internet gaming disorder only includes internet games it does not include general use of the internet online gambling that would go under gambling criteria and it does not include social media so for those of you who are hoping there was a diagnosis for somebody who's addicted to Facebook it doesn't exist right now so you know those are things that we're kind of looking at but anytime somebody comes into our office and they evidence these criteria preoccupation withdrawal tolerance inability to stop and two or more problems in life because of their use of whatever it is you know it is a clinically significant issue that needs to be addressed regardless of whether the DSM has a diagnosis for it or not sex addiction has also not made it into the DSM yet despite what all of the internet would have you believe you know because it's on the internet it must be true right sex addiction is not an official diagnosis what they're looking at is hoping to try to get it included in the next version of the DSM as an area for further study but the criteria they're using is similar to the others recurrent failure to resist sexual impulses engaging in sexual behaviors to a greater extent or for longer than intended unsuccessful efforts to stop excessive time spent obtaining sex being sexual or recovering from sexual experiences obsessed with parent preparing for sexual activities frequently engaged in sexual behavior when expected to be fulfilling occupational academic domestic or social obligations I can't tell you how many people I've had to write up for looking at porn while they were at work continued sexual behavior despite knowing it's caused or exacerbated problems in their life increased intensity frequency number or risk of sexual behaviors to achieve the desired effect so sometimes people will go to something that's more shocking which is one of the ways we see the development of you know once they've looked at all of the average run of the mill porn we see people going to more hardcore stuff given up or limited social occupational recreational activities because of the sexual behavior and become upset anxious or restless if unable to engage in the behavior one of the big controversies is that sex is a natural behavior so who are we to say what's normal and what's abnormal what frequency is normal and I think what the proponents of this diagnosis come back with is we're not saying we're looking at frequency for what's normal or abnormal we're looking at how is it impacting the person psychologically occupationally interpersonally is it causing them problems is it forming a major portion of their day where they're obsessing about it and they're giving up other things that they used to like that's what I'm gleaning from the material that I read about the people that are pushing to have this added as a diagnosis as I said it's not currently an area for further study or in the DSM-5 but we're seeing a gradual opening of awareness to behavioral type addictions what do we do how do we treat someone who presents claiming to have sex addiction you know obviously we're not going to go well that's not in the DSM so it's private pay or nothing but a lot of the treatment centers that's what they're doing now they advertise they treat sex addiction and they say that most insurance companies cover addiction treatment what they fail to say is unless you have another addiction that's actually in the DSM insurance ain't going to pay for it in every case that I know now there could be exceptions obviously you want to assess for concurrent diagnoses if somebody presents with sex addiction do they have other things that may be motivating that compulsive behavior are they trying to basically self-medicate are they dealing with adjustment disorder dependent personality depression histrionic personality or PTSD those are you know common diagnoses which you could see co-occurring with sex or pornography addiction so if you're trying to work with somebody who's presented and they're in a great amount of distress and they have you know self-diagnosed sex addiction but they also have other issues going on you know you can code for those issues and get reimbursed for those it may not be enough to sessions to treat the sex addiction but it can get the person started addiction treatment issues we always regardless of what the addiction is or what they proclaim their addiction is examine the reasons of the function of the use to identify areas for intervention what triggers their use is it anxiety is it stress is it sobering up you know we also want to look at when you're using you're disrupting the neurotransmitter balance so you know when you stop using you're probably going to experience some depression and or anxiety and so when the person tries to stop on their own they experience these dysphoric emotions and they're like ah and they may return to use in order to not feel that way so we want to look at what needs to be done to get the person through the initial acute withdrawal period and what other functions is this behavior serving if it's to help them deal with stress anxiety or depression well what's causing those and we want to help people develop distress tolerance skills to deal with urges even after they're in recovery or however you want to say it there are going to be times when they're triggered and they have the desire to use again they think about using again and that can be really scary for somebody who has been addicted to something so we want to help them develop those distress tolerance skills to deal with the urges one analogy I use for some of my clients is thinking about a bumblebee you know assuming you're not deathly allergic to them if a bee lands on your arm your immediate urge is probably to swipe it off you know if a fly lands on me my natural instinct my immediate urge is to wipe it off now if you swat a bumblebee what's going to happen it's probably going to come back and sting you so distress tolerance skills is like dealing with that bumblebee taking a breath and deciding you know what I don't want to get stung so I'm going to tolerate the bee sitting there even though it makes me a little bit uncomfortable I'm going to tolerate it sitting on my arm until it's ready to fly away which will be in a few minutes so in summary whether you're alone or concurrently with mood medical psychotic or personality disorders so we want to make sure to really do a comprehensive assessment because we need to address all of the areas of presentation common errors we want to make sure to differentiate eating disorders from obsessive compulsive disorder you know if they are using it ritualistically if they're having obsessions about it don't forget males in your eating disorder diagnosis or discount late onset for men or women it can have an initial presentation you know as late as 40 years old and that's still within the norm range ensure that we make referrals to physicians for eating disorders alcohol or benzo misuse not even necessarily meeting the criteria for substance use disorder generally you know we should be referring making sure the person's had a physical when they present or anything to rule out physiological causes but alcohol and benzo withdrawal can be life-threatening and eating disorders can put the person in a position where they're damaging their organs and in a life-threatening position rule out body dysmorphic disorder with eating disorders it can co-occur but you want to make sure it's not just BDD emotional eating likely doesn't meet criteria for binge eating so we don't want to assume that address nutritional imbalances send them to a physician get them with a registered dietitian for any people that we're working with whether it's somebody who's got a gambling disorder and they've been up drinking and gambling all the time and they're not eating well or the person with an eating disorder make sure to address sleep deprivation in the treatment plan don't treat a mood issues and expect food issues to spontaneously remit address the rebound effects from laxative and erratic abuse addiction treatment does not apply when the substance is being used appropriately under medical supervision so we don't want to you know necessarily diagnose somebody with an addiction if they're using it appropriately and rule out bipolar disorder specifically a manic episode when we're evaluating somebody for gambling disorder all righty thank you everybody for coming today and if you're here tomorrow I will be remember we don't have class on Thursday because it's Thanksgiving if I didn't um uh if I didn't what I lost my train of thought oh if I don't see you tomorrow have a very happy Thanksgiving and I will see you next week 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 use coupon code counselor toolbox to get a 20% discount off your order this month


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