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Central Annals of and Mental Health

Review Article *Corresponding author Jerrod Brown, Pathways Counseling Center, St. Paul, 1919 University Ave. W. Suite 6 St. Paul MN, 55104, USA, Wernicke- Email: Submitted: 06 October 2017 (WKS): A Call for Criminal Justice Accepted: 27 October 2017 Published: 30 October 2017 and Forensic Mental Health Copyright © 2017 Brown et al. ISSN: 2374-0124 Professionals to be Informed OPEN ACCESS Jerrod Brown1,2,3*, Cody Charette4, Stephen Morgan1, Janina Keywords 1,3 5 • Wernicke-Korsakoff syndrome (WKS) Cich , and Bob Rohret • Criminal justice 1 Concordia University, St. Paul, USA • Forensic mental health 2 Pathways Counseling Center, St. Paul, USA • Training 3 The American Institute for the Advancement of Forensic Studies, St. Paul, USA • 4Alliant International University; USA 5Hennepin County Health & Human Services-Adult Behavioral Health Division, USA

Abstract Wernicke-Korsakoff Syndrome (WKS) results from a deficiency ( B1) and is a debilitating, characterized by ocular abnormalities, mental health status changes, memory deficits, and ataxia.The implications of this condition can result in a host of impairments, causing long- lasting consequences and in some instances, permanent brain damage. In most cases of WKS, chronic use is the contributing factor of the . WKS can have devastating consequences in forensic mental health and criminal justice contexts. Despite these issues, professionals working in these settings often have limited familiarity with WKS. As such, this article advocates for elevated awareness, advanced training and systematic research on WKS in forensic mental health and criminal justice settings. This includes an overview of WKS symptoms and related deficits, and potential assessment and treatment approaches for individuals with WKS. In addition, suggestions are made for future research on WKS, particularly in these settings. Through increased awareness, understanding, and training, forensic mental health and criminal justice professionals have the potential to help improve the short- and long-term outcomes of individuals with WKS.

INTRODUCTION threatening condition in which three classic symptoms are Wernicke-Korsakoff Syndrome (WKS) is most commonly generallyrelatively observed: short lived, eye yet movement quite severe disturbances, and potentially also called life- marked by the co-occurrence of two closely associated ophthamoplegia, mental confusion and mental health status neurological disorders: Wernicke’s encephalopathy (WE) and changes, and abnormal physical coordination or ataxia, which Korsakoff’s syndrome (KS). Although WKS can be caused by can be manifested in the form of an abnormal stance and walking prolonged , this condition is typically the result of persistent use of alcohol over many years [1-3]. In fact, research has found that almost 90% of individuals with WKS possess an gait [11-14]. It is important to note that not all three of these extensive history of alcohol use [3]. In both causal models, a byhallmark an array symptoms of symptoms are required including: for diagnosis apathy, [8,10]. , In contrast, Korsakoff syndrome is a long-lasting, chronic condition typified 6]. Thiamine is an important vitamin essential for the proper and personality changes [15-19]. In combination, WKS can be functiondeficiency of of many the B1 structures vitamin (thiamine) of the body, is the but driving for the force present [4- characterizeddelusional tendencies, by impairments disorientation, in executive mental control,processing short- deficits, and discussion it is critical for the brain’s nerve cells, glial cells, and long-term planning, decision making, problem-solving, memory, neurotransmitter production of the structures vital to memory, i.e. the , the forebrain, and medial temporal lobes [7]. and poor behavioral control [20,21]. WKS can co-occur with several conditions. These conditions include cancer, pancreatitis, thyroid issues, and immune loss including anterograde and retrograde [9]. In One of the most common consequences of WKS is memory Syndrome (AIDS). Similarly, WKS can also co-occur withdigestive deficiency disorders such as Acquired Immunodeficiency and eating conditions such as Crohn’s disease, bulimia, or as a ,particular, there especially is difficulty of prior forming autobiographical new short-term events. memories These (and, consequently, long-term memories) or accessing existing The symptoms of WKS, WE, and KS can vary substantially aids such as collateral informants or documentation. A lack result of gastric bypass surgery [4,8,9] . memory deficits may persist despite the presence of memory across individuals [10]. Wernicke’s encephalopathy is a of insight into these deficits (termed anosognosia: a lack of Cite this article: Brown J, Charette C, Morgan S, Cich J, Rohret B (2017) Wernicke-Korsakoff Syndrome (WKS): A Call for Criminal Justice and Forensic Mental Health Professionals to be Informed. Ann Psychiatry Ment Health 5(6): 1119. Brown et al. (2017) Email: Central

mayincrease the Additionally, any training should highlight various aspects of likelihood of suggestibility and confabulation in an effort to WKS including risk factors, symptoms, and post-mortem physical compensateawareness of for one’s gaps mental in memory health [22,23]. deficits) The combination of these memory impairments coupled with the other symptoms of WKS makes these individuals very challenging to interact with on screeningconfirmation and of assessing the syndrome living [12].patients.Training Another suggested should topic also notethat an interpersonal level. thatpropertraining the presence, should or suspected cover is thepresence intricacies of WKS, and can difficulties play a key in One key area where WKS can present challenges is clinical involved in the criminal justice system. As such, memory issues settings where WKS may be over-represented relative to the arerole likelyin determining to impact how a competency to manage andto stand treat trialafflicted determination. individuals Those same issues may also result in confabulation of testimony, which in turn can create due process issues for both the defendant healthgeneral population, clinicians andsuch as medical alcohol stafftreatment who and can detoxification sometimes and the court. Lastly, any training should be careful to highlight becomefrustratedwithclientscenters [22,24]. The challenges who canhave be WKS. seen The inbehavioral problems what is not presently well understood about WKS. Areas of future stem from the fact that the symptoms of the disorder limitthe possibility of utilizing many common, reliable, and valid assessment and treatment methods [20]. These clients often research and key questions should be presented so that motivated researchersRecommendations can begin answeringfor Further these Research questions going forward. therapy sessions because they continually need to be re-oriented Nuanced and advanced research has the potential to improve andhave provided difficulty extraparticipating guidance. in treatmentDelaysin diagnosis that incorporates and treatment group understanding of the diverse impacts of WKS in mental health, addiction treatment, and legal settings. A promising starting individual but also for they family members and other invested point would be identifying what exactly professionals in these stakeholders.can also have The devastating importance consequences of accuratelyidentifying not only for and the settings are aware of concerning WKS. The systematic surveying providing appropriate treatment for with WKS is emphasized of a range of professional groups and other stakeholders is one by the fact that it is a complex and multi-faceted neurological death, if it is not diagnosed and treated in its early stages [3,10,25]. such method. Specifically, legal professionals such as defense disorder that has catastrophic consequences, up to and including The pervasive symptoms of WKS may also contribute to its encounterattorneys, throughout prosecutors, the and criminal judges justice are system. uniquely Analogously, positioned overrepresentation in criminal justice settings. For instance, mentaltoprovide health insight and into addiction difficulties professionals, that individuals particularly with WKS those may

provide powerful insights.These professionals often administer thiamine deficiency is present in somewhere between 20% and athat battery serve of as psychological forensic evaluators, measures are to also defendants uniquely and positioned then later to media80% of stories chronic suggest alcohol that users the [4,26]. use of With alcohol such lowers a wide inhibition span, the inquestion combination is, “Why with is the this symptoms the case?”Case of WKS studies may andincrease popular the likelihood of becoming involved in the criminal justice system for professionalstestify about their (including findings. law Outside enforcement), of active probation participants and in parole trials, a host of reasons. Once entangled in the criminal justice system, it is also important to find out more about what corrections friends understand about WKS as it relates to them. Regardless challenges, as the symptoms may interfere with the ability to ofofficers, the intended and other respondent’s invested partiesbackground, like familyany potential members survey and makethe presence legal decisions of WKS inor criminaleven just justice stand settingstrial competently present unique [27]. should be based on a concerted effort to better understand In light of inherent limitations about self-reported information how an individual’s capacity to navigate the criminal justice during interrogations and testimony in the criminal justice system, including competency to waive legal rights and stand system, the memory impairments of WKS are particularly the essential purpose of enhancing services and treatment, confessions to wrongful convictions [27]. Nonetheless, there is whichtrial, is then influenced has the by potential WKS. Any of improving insights gained short- canand helplong-term serve aconcerning. dearth of research The consequences on the impacts of WKS of WKS may in range criminal from justice false settings. outcomesCONCLUSION for individuals with WKS [28-30]. Greater awareness among forensic mental health and criminal Wernicke-Korsakoff Syndrome (WKS) is a debilitating justice professionals may be one of the best ways to reduce future incidences of WKS and its associated brain damage.Despite this substantial and merited need, the opportunities for advanced affliction characterized by diverse cognitive and behavioral training and education on WKS are few and far between for these resultingsymptomatology from chronic that can alcohol be quite use, pernicious these symptoms in clinical include and professionals. To begin to address these needs, the purpose of impairmentscriminal justice in settings. executive Caused function, by behavioral a vitamin B1 changes, deficiency and memory-related problems. As a result, individuals with WKS WKS and provide suggestions for future training and research. this brief article is to review the basic definitional features of struggle to compensate for these memory issues, which may Suggestions for Further Training increase their risk of suggestibility and proclivity to confabulate. Criminal justice and forensic mental health professionals are strongly encouraged to seek out continuing education (CE) conjunction with early and effective intervention programs must takeEfficient precedence. and accurate The importance screening of and this assessment is highlighted techniques by the fact in that while WKS is relatively treatable in its early stages, a lack of courses on the topic of WKS. This should involve the acquisition treatment can result in chronic illness and ultimately lead to death andof knowledge etiology about of WKS the includinglatest research the rootfindings causes from is a anumber must. in many cases. To help prevent this from happening two things of key areas in the field. Comprehensive coverageof the history

Ann Psychiatry Ment Health 5(6): 1119 (2017) 2/3 Brown et al. (2017) Email: Central are necessary. First, improved assessment tools and treatment programs to help those suffering are necessary. Second, increased gastrointestinal surgery for cancer. Support Care Cancer. 2016; 24: awareness of WKS in forensic mental healthand criminal justice 15. Caulo77-82. M, Van Hecke J, Toma L, Ferretti A, Tartaro A, Colosimo C, et al. Functional MRI study of diencephalic amnesia in Wernicke–Korsakoff in evidence-based practices for professionals in these settings, butsettings there is also essential. must be Not a concerted only will thiseffort require to increase advanced coordination training 16. syndrome.Halliday G, Brain. Cullen 2005; K, Harding128: 1584-1594. A. Neuropathological correlates of and collaboration among those that work with these individuals memorydysfunction in the Wernicke-Korsakoff syndrome. Alcohol who suffer from WKS. Together, mental health and addiction professionals (such as psychiatrists, psychologists, and addiction 17. Alcohol Suppl. 1994; 2: 245-251. counselors), as well as criminal justice personnel (such as judges, lawyers, and correctional staff) can work together to improve Parkin AJ, Blunden J, Rees JE, Hunkin NM. Wernicke-Korsakoff short and long-term outcomes for clients with WKS. syndromeof nonalcoholic origin. Brain Cogn. 1991; 15: 69-82. 18. Roh JH, Lee BH, Chin J, Kim GH, Na DL. Graphabulation: A graphic form REFERENCES 19. ofSullivan confabulation. EV, Pfefferbaum Cortex, A.2012; Neuroimaging 48: 356-359. of the Wernicke–Korsakoff 1. 20. syndrome.AlcoholNilsson M, Sonne C. and Diagnostics . and 2009; treatment 44: 155-165. of Wernicke-Korsakoff Hargrave DD, Schroeder RW, Heinrichs RJ, Baade LE. Wernicke- Korsakoff Syndrome as a Consequence of Delusional Food Refusal: A 2. Hoyumpa AM. Alcohol and thiamine metabolism. Alcoholism: Clinical Case Study. Cogn Behav Neurol. 2015; 28: 215-219. syndrome patients with an . Ugeskrift Laeger. 2013;

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Cite this article Brown J, Charette C, Morgan S, Cich J, Rohret B (2017) Wernicke-Korsakoff Syndrome (WKS): A Call for Criminal Justice and Forensic Mental Health Profession- als to be Informed. Ann Psychiatry Ment Health 5(6): 1119.

Ann Psychiatry Ment Health 5(6): 1119 (2017) 3/3