Substance abuse and eating disorders Flashcards
Eating Disorders facts
A group of disorders characterised by one or two abnormal eating habits that involve insufficient or excessive eating detrimental to an individual’s physical and mental health
Eating disorders include anorexia nervosa, bulimia nervosa and binge eating.
Most clients with eating disorders have additional psychiatric co-morbidity increasing complexity of treatment
Treatment is challenging and recovery can take 5 – 7 years
The key to management of these disorders is to break the cycle of the eating disorder behaviour
Presentation of eating disorders
Age: develops during adolescence
Sex: common in young women
Prevalence: 0.3% to 3.7% for anorexia nervosa and
1% to 4.2% for bulimia nervosa
Pathophysiology of eating disorders
Family factors: emphasis on physical appearance
Recent research shows that over 50% of people with clinically diagnosed eating disorder have a co-morbid personality disorder. Martinussen et al (2017).
Social factors: media and fashion industry emphasis on thinness
Cultural factors: societal and culture that glorify thinness
Self-esteem
Control
Perfectionism
Anorexia nervosa
Anorexia nervosa is a serious mental disorder characterised by significant weight loss resulting from excessive dieting
Anorexic clients consider themselves to be fat, no matter what their actual weight is
Usually strive for perfection
Set very high standards for themselves and feel they always have to prove their competence
Believe that the only control they have in their lives is in the area of food and weight
DSM-IV Criteria for Anorexia nervosa
Refusal to maintain body weight at or above minimum normal body weight for age and height
Intense fear of gaining weight or becoming fat even though underweight
Dissatisfaction with body weight or shape, undue influence of body weight and self-evaluation and denial of the seriousness of current low weight
Absence of at least 3 menstrual cycles
Medical complicationsof anorexia nervosa
Cardiac irregularities due to protein-calorie malnutrition
Electrolyte abnormalities: low potassium and sodium levels
GIT effects: feeling bloated or full even after eating small amounts
Renal dysfunction: Reduced glomerular filtration rate
Neurological changes due to brain atrophy
Cognitive changes: impairment in attention and concentration
Skin changes due to protein-calorie malnutrition
Re-feeding syndrome due to imbalance in electrolytes and fluids
Bulimia
Bulimia is a mental disorder characterised by a cycle of dieting, binge eating followed by purging to try and lose weight
A binge may range from 1,000 to 10,000 calories
Purging methods usually involve vomiting and laxative abuse Other forms of purging can involve use of diuretics, diet pills and enemas
People with bulimia usually do not feel secure about their own self-worth and often strive for approval of others
Presentation of bulimia
Eating in a discrete period within any 2 hours, eating much larger amounts of food than most would
Sense of lack of control during eating episode and recurrent inappropriate compensatory behaviour (overuse of laxatives, induced vomiting, excessive exercise, fasting etc.) to prevent weight gain
Above – occur at least twice weekly for 3 months period
Self-evaluation is unduly influenced by body shape and weight
The disturbance does not occur exclusively during the episodes of anorexia nervosa
Binge eating
Binge eating is a mental disorder characterised by consuming large quantities of food in a very short period of time until the individual is uncomfortably full
Binge eating disorder is much like bulimia except the individual does not use any form of purging
Individuals usually feel out of control during a binge episode, followed by feelings of guilt and shame
Most clients with binge eating disorder are at risk of developing conditions such as cardio-vascular diseases and diabetes
Management of Eating Disorders
Aim of treatment is to free sufferers from dominant worries about eating, weight and help them take control of their own lives
Treatment modalities are:
Pharmacotherapy
Psycholigical therapy
Nutrition rehabilitation
Pharmacotherapy, psychological therapy and nutrition rehabilitation for Eating Disorders
Pharmacotherapy
Antidepressants have been found to be useful
Other medications such as anti-psychotics in low doses
Multivitamins, Phosphate Sandoz, Calcitrate Plus Vitamin D
Psychological therapy
Cognitive Behaviour Therapy
Psycho-education
Family support and education
Interpersonal relationship therapy
Nutrition rehabilitation
Substance misuse- an overview
Drug - a substance that is used to modify the way in which a person functions, feels etc. This includes use of over counter drugs, prescription drugs and illegal drugs
Drug misuse - refers to inappropriate use of drug
Physical dependence – a state in which an individual needs a substance in order to function and to satisfy physical needs
Tolerance - need to take larger doses of a substance in order to achieve intoxication or desired effects
Intoxication - refers to elevated blood level of drug concentration such that a person cannot function normally
Withdrawal - when a person dependent on a substance stops taking the substance, certain physical and psychological symptoms occur
Commonly abused substances
Alcohol
Caffeine
Cigarette
Amphetamines
Cannabis
Cocaine
Hallucinogens
Inhalants
Opioids
Benzodiapines,
Sedatives and hypnotics
Aetiology of substance abuse
Biological factors
Psychological factors
Environmental factors
Social factors
Personality factors: associated with anxious people
Cultural factors: alcohol is accepted as part of relaxation and celebration
Mental illness
Substance Types
Stimulants - increases activity of the central nervous system (CNS)
Depressants - decreases activity of the CNS
Hallucinogens - psychoactive drugs that induce hallucinations or altered sensory experiences
DSM-V Criteria for substance abuse
A maladaptive pattern of substance use leading to clinically significant impairment or distress manifested by one or more of the following, occurring within a 12 month period
Recurrent substance use resulting in a failure to fulfil major role obligations at work, school or home (poor work performance, suspensions or expulsions from school, neglect of children or household)
Recurrent substance use in situations such as when driving or operating machinery
Recurrent substance use – leading to legal problems (arrests, disorderly conduct etc)
Continued substance use despite having persistent social or interpersonal problems caused by effects of substance abuse (arguments with spouse or physical fights)
Management of substance abuse
Management and treatment of addictions will be dependent on the substance.
Substances that require physical detoxification and cause severe psychological and physical dependance. (Opiates, Alcohol and Benzodiazepines)
Substances that cause severe psychological addiction (Cocaine, Methamphetamine etc)
Route and associated physical harm; psycho-social harm (harm reduction policy)
Withdrawal Syndrome
Contrary to popular belief, there are only 3 main substance types that cause withdrawal syndrome which include severe physical effects.
Alcohol:
Opiates:
Benzodiazepines:
It’s important to recognise therefore that only the treatment of the above substances will usually include a period of pharmacological detoxification.
Substitute Prescribing and Harm Minimisation
In the case of heroin addiction, the physical dependence adds to the maintenance of the use.
Heroin user “chaos”; socio-economic, significant acquisitive criminal activity and physical harm to the user.
Harm minimisation policy, where the emphasis is on reducing harm to the user and chaos associated with use addresses physical addiction and harm caused by non-pharmaceutical opiates (street heroin)
Maintenance methadone prescribing
Buprenorphine
Substitute Prescribing
Maintenance methadone prescribing.
Maintenance and long term management use. Very long half life, one dose daily, sometimes daily dispensed.
Buprenorphine
A partial opiate agonist with “blocking” effects of full agonists (heroin), therefore useful in chronic use and detoxification where continued use of heroin is an issue.
Other forms of harm-minimisation re: substance abuse
Needle exchange
Drug education around safe injecting techniques
BBV screening and immunisation
Drug “clinics”, addressing physical harm
Controversial aspects: De-criminalisation through medicalisation of a social issue?
Alcohol detoxification
Alcohol withdrawal syndrome can be acute and severe, causing
Delirium tremens
Hallucinations
Convulsions
Usually includes the use of substitute benzodiazepines which mimic alcohol on receptor sites.
Dose reduction over 7-14 days depending on severity of dependance
Often out patient monitored by specialist nurse, or in patient if chronic use, previous complications
Use of Alcohol Withdrawal Scales common
Benzodiazepines
Work on the same receptor sites as alcohol
Can cause severe withdrawal syndrome
Benzodiazepine seizure if use has been long term
Gradual tapered reduction in primary care with caution, usually with a switch to short acting benzodiazepines
Poly drug use
Its not unusual for heroin users to also have benzodiazepine and alcohol dependencies which might all need physical detoxification and continued management.
Continued management of substance misuse
Once physical dependence issues are addressed, the continued management of addiction will be ongoing and lifelong. In the case of stimulants and other drugs, many users choose to manage or limit their use, but clinical evidence suggests that total abstinence results in best outcome. Usually ongoing treatment will be tailored to the individual user and drug of choice, but might include..
12 Step groups: Alcohol Anonymous (AA ) and Narcotic Anonymous (NA)
Change of peer group, career counselling, training, education and occupational therapy
Continued Individual psychotherapy; usually cognitive based.
Residential rehabilitation and therapeutic communities.
Continued pharmacotherapy: Naltrexone, Acamprosate, Antabuse, anti-depressants.
Drug induced mental illness
Drug-induced delirium
Drug-induced dementia
Drug-induced psychosis
Drug-induced mood disorder
Drug-induced anxiety disorder
Drug-induced sleep disorder
Dual diagnosis issues
Dual diagnosis is defined by presence of both mental health disorders and substance use disorders.
Many drug users suffer with anxiety and/or depression, as a result of their use, but many also use drugs to alleviate the symptoms of mental illness and trauma. It’s also recognised that drug users suffer “residual depression” and feelings of loss and grief following detoxification which will require addressing for best outcome.
What is refeeding syndrome
- metabolic disturbance that occurs as a result of reinstitution of nutrition in people who are starved, severely malnourished, or metabolically stressed
- Occurs when too much food or liquid nutrition supplement is eaten during the initial four to seven days following a malnutrition event
- glycogen, fat and protein in cells may cause low serum (blood) concentrations of potassium, magnesium and phosphorus
- Cardiac, pulmonary and neurological symptoms
- the low serum minerals, if severe enough, can be fatal.
