Substance abuse and eating disorders

Question 1

Eating Disorders facts

Answer 1

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 ​

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Eating disorders include anorexia nervosa, bulimia nervosa and binge eating.​

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Most clients with eating disorders have additional psychiatric co-morbidity increasing complexity of treatment​

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Treatment is challenging and recovery can take 5 – 7 years​
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The key to management of these disorders is to break the cycle of the eating disorder behaviour

Question 2

Presentation of eating disorders

Answer 2

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

Question 3

Pathophysiology of eating disorders

Answer 3

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

Question 4

Anorexia nervosa

Answer 4

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

Question 5

DSM-IV Criteria for Anorexia nervosa

Answer 5

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

Question 6

Medical complicationsof anorexia nervosa

Answer 6

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

Question 7

Bulimia

Answer 7

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

Question 8

Presentation of bulimia

Answer 8

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

Question 9

Binge eating

Answer 9

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

Question 10

Management of Eating Disorders

Answer 10

Aim of treatment is to free sufferers from dominant worries about eating, weight and help them take control of their own lives​

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Treatment modalities are: ​

Pharmacotherapy​

Psycholigical therapy ​

Nutrition rehabilitation

Question 11

Pharmacotherapy, psychological therapy and nutrition rehabilitation for Eating Disorders

Answer 11

Pharmacotherapy​

Antidepressants have been found to be useful​

Other medications such as anti-psychotics in low doses​

Multivitamins, Phosphate Sandoz, Calcitrate Plus Vitamin D​

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Psychological therapy ​

Cognitive Behaviour Therapy​

Psycho-education​

Family support and education ​

Interpersonal relationship therapy​

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Nutrition rehabilitation

Question 12

Substance misuse- an overview

Answer 12

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

Question 13

Commonly abused substances

Answer 13

Alcohol​

Caffeine​

Cigarette​

Amphetamines​

Cannabis​

Cocaine​

Hallucinogens​

Inhalants​

Opioids​

Benzodiapines, ​

Sedatives and hypnotics

Question 14

Aetiology of substance abuse

Answer 14

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

Question 15

Substance Types

Answer 15

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

Question 16

DSM-V Criteria for substance abuse

Answer 16

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)

Question 17

Management of substance abuse

Answer 17

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)

Question 18

Withdrawal Syndrome

Answer 18

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.

Question 19

Substitute Prescribing and Harm Minimisation

Answer 19

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

Question 20

Substitute Prescribing

Answer 20

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.

Question 21

Other forms of harm-minimisation re: substance abuse

Answer 21

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?

Question 22

Alcohol detoxification

Answer 22

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

Question 23

Benzodiazepines

Answer 23

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

Question 24

Poly drug use

Answer 24

Its not unusual for heroin users to also have benzodiazepine and alcohol dependencies which might all need physical detoxification and continued management.

Question 25

Continued management of substance misuse

Answer 25

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.

Question 26

Drug induced mental illness

Answer 26

Drug-induced delirium​

Drug-induced dementia​

Drug-induced psychosis​

Drug-induced mood disorder​

Drug-induced anxiety disorder​

Drug-induced sleep disorder

Question 27

Dual diagnosis issues

Answer 27

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.

Question 28

What is refeeding syndrome

Answer 28

• 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.