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Substance Abuse and Eating Disorders: Implications for Treatment

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Title: Substance Abuse and Eating Disorders: Implications for Treatment


1
Substance Abuse and Eating Disorders
Implications for Treatment
  • Debra Atkisson Kowalski, M.D.

2
SIX CRITICAL ADOLESCENT HEALTH BEHAVIORS
  • Alcohol and Drug Abuse/Dependence
  • Injury and Violence
  • Tobacco Use
  • Nutrition
  • Physical Activity
  • Sexual Behavior
  • Centers for Disease Control and Prevention

3
ADDICTIVE COMPONENTSOF EATING DISORDERS
  • Compulsive nature of behavior
  • Consequences to health and safety
  • Negative impact on relationships
  • Impairment in occupational functioning
  • Denial

4
DUAL DIAGNOSES
  • Clarity of Diagnosis for each diagnosis is
    necessary to develop treatment approach.
  • Medications and Psychotherapies may impact two or
    more disorders simultaneously, although
    polypharmacy may be indicated.
  • Stabilization of one disorder may bring another
    disorder more into focus.

5
Definition of eating Disorders
  • DSM-IV-TR

6
Types of Anorexia Nervosa
  • Restricting
  • Not engaged in Binge eating
  • Binge- Eating/ Purging
  • Regularly involved in binge and purge cycles

7
Anorexia Nervosa
  • Body weight below expected rate
  • Intense fear of weight gain
  • Body image distortion
  • Amenorrhea

8
Types of Bulimia Nervosa
  • Purging type
  • Regular self-induced vomiting or compensatory
    behaviors
  • Non-purging type
  • Use of fasting and not self-induced vomiting

9
Bulimia Nervosa
  • Recurrent binge eating
  • Recurrent inappropriate behaviors to prevent
    weight gain
  • Self-evaluation unduly influenced by body weight
    and shape

10
Eating Disorder NOS
  • Females- Anorexia but regular menses
  • Anorexia but weight is in normal range
  • Bulimia but inappropriate compensatory behaviors
    occur less than twice a week
  • Inappropriate compensatory behaviors after eating
    small amounts of food
  • Repeatedly chewing and spitting out food
  • Binge eating disorder

11
Epidemiology of an eating Disorder
12
  • .5-1 of American women suffer Anorexia
  • 5-20 will die
  • 90-95 of people with anorexia are female
  • 3 7 of adolescent girls and young women suffer
    from Bulimia
  • 25 of American women suffer Bulimia
  • 80 of people with bulimia are female
  • 89 of Bulimics show tooth erosion

National Eating Disorder Association
13
  • 10,000,000 American females have anorexia or
    bulimia
  • 25,000,000 Americans have binge eating disorder
  • 80 of American women are unhappy with their
    appearance
  • 40,000,000,000 per month is spent on dieting in
    America
  • 40-50 of women are trying to lose weight

National Eating Disorder Association
14
  • 90 of college woman are on a diet
  • 22 of them are always dieting
  • 40-60 of high school girls are on a diet
  • 46 of 9-11 year old girls are on a diet
  • 82 of their families are on a diet
  • 42 of 1st-3rd graders want to be thinner
  • 81 of 10 year old girls are afraid of being fat
  • The average American woman is 54 and 140 lbs
    the average American model is 511 and 117lbs

National Eating Disorder Association
15
Warning Signs of eating Disorders
16
Anorexia Nervosa
  • Dramatic weight loss
  • Preoccupation with weight, food, diets etc.
  • Refusal to eat certain foods
  • Frequent comments about feeling fat
  • Anxiety about gaining weight
  • Denial of hunger
  • Development of food rituals
  • Avoids meals
  • Excessive exercise
  • Withdrawal from usual friends and activities

National Eating Disorder Association
17
Bulimia Nervosa
  • Evidence of binge eating
  • Evidence of purging behaviors
  • Excessive exercise
  • Unusual swelling of the cheeks or jaw
  • Calluses on knuckles
  • Discoloration of teeth
  • Complex schedules to allow for binge and purge
  • Withdrawal from usual friends and activities

National Eating Disorder Association
18
Risk Factors
19
Risk factors
  • Familial
  • Genetic
  • Functional
  • Cultural
  • Social
  • Individual personality

20
INDIVIDUAL RISK FACTORS
  • Dissatisfaction with body image
  • Low self-esteem
  • Depression
  • Anxiety disorders/ Obsessive behaviors
  • Substance Abuse
  • Childhood sexual and/or physical abuse
  • Personality disorders

21
FEMALE ATHLETE TRIAD
  • EATING DISORDER in sports emphasizing leanness,
    50 have pathological eating
  • AMENORRHEA cessation of menses due to decreased
    body fat
  • OSTEOPOROSIS loss of calcium secondary to
    malnutrition stress fractures may result

22
CROSS ADDICTIONS
  • EATING DISORDERS
  • SUBSTANCE ABUSE
  • SEXUAL IMPULSIVITY

23
BULIMIA AND ALCOHOL
  • Study 1997-1998 of 11,000 teens to assess alcohol
    use, tobacco, bulimia
  • Tobacco 4.3 F 3.6M
  • Alcohol 5.3F 4.8M
  • Bulimic Behaviors 2.4F 0.6M
  • Among girls, weight concerns were most predictive
    of engaging in any of these
  • JAACAP 417 July 2002

24
Contributing Variables
25
BIOLOGICAL PREDISPOSITION
  • Auto-Addiction Opioid Theory Chronic eating
    disorder is an addiction to bodys production of
    endogenous opioids and is identical to psychology
    and physiology of substance abuse in general.
  • Huebner, 1993

26
Neurotransmitters and Food
  • DOPAMINE
  • Fewer brain receptors for dopamine in obese
    patients study of 10 obese pts vs. 10 controls
    using PET imaging
  • Wang Volkow, Brookhaven National Laboratory,
    Lancet Feb. 3, 2001

27
Neurotransmitters (cont.)
  • B-Endorphins increased by starving, exercise,
    bingeing
  • B-Endorphins increase Dopamine in the mesolimbic
    system

28
Emotional Manifestations
  • Poor Self-Esteem or Self-Worth
  • Shame
  • Dichotomous Thinking
  • Feeling of emptiness
  • Perfectionism
  • Desire to be special and unique
  • Difficulty expressing feelings
  • Need for safety
  • Poor coping skills

Carolyn Costin 1996
29
Adaptive functions
  • Comfort, soothing, nurturance
  • Numbing, sedation, distraction
  • Attention, Cry for help
  • Discharge tension, anger, rebellion
  • Predictability structure identity
  • Self-punishment
  • Create small or large body for protection
  • Avoid Intimacy
  • I am bad

30
Medical Effects
31
DETECTION AND DIAGNOSIS DIFFERENTIAL DIAGNOSIS
  • Inflammatory bowel disease
  • New onset diabetes mellitus
  • Thyroid disease
  • Abdominal maligancies
  • Chronic infection
  • Central nervous system disease
  • Psychiatric disorders (depression, OCD,
    psychosis, substance abuse)

32
How do eating disordered patients present?
  • Usually by referral by a patient, school nurse,
    or coach or with complaints of the following
  • Fatigue
  • Dizziness
  • Headache
  • Constipation
  • Amenorrhea

33
COMMON MEDICAL FINDINGS ANOREXIA NERVOSA
  • Cardiac
  • Bradycardia
  • Orthostatic hypotension
  • Mitral valve prolapse (1/3 of patients) most
    common cardiac
  • Prolonged QT interval
  • Arrhythmias
  • Fatal cardiomyopathy

34
COMMON MEDICAL FINDINGS ANOREXIA NERVOSA
  • Endocrine
  • Secondary amenorrhea affects almost all AN
    patients and is the most common complication
  • Delayed puberty
  • Growth retardation
  • Sick euthyroid syndrome
  • Hypercortisolism
  • Partial diabetes insipidus

35
COMMON MEDICAL FINDINGS ANOREXIA NERVOSA
  • Gastrointestinal disturbances
  • Parotid and salivary gland hypertrophy
  • Hair and skin disorders thinning scalp hair
    lanugo
  • Cold extremities
  • Emaciation (may hide with oversize clothes)

36
Common Medical Findings for Bulimia Nervosa
  • Cardiac
  • Bradycardia
  • Other cardiac arrhythmias
  • Orthostatic hypotension
  • Cardiac murmur (mitral valve prolapse)

37
Common Medical Findings for Bulimia Nervosa
  • Hypothermia
  • Dry skin/dull hair
  • Parotitis
  • Mouth sores
  • Russells sign (Callus on knuckles from
    self-induced emesis)
  • Dental enamel erosions

38
HISTORICAL EVALUATION OF THE PATIENT
  • Comprehensive patient history including the
    following three questions.
  • 1. How much would you like to weigh?
  • 2. How do you feel about your present weight?
  • 3. Are you concerned, or is anyone else
    concerned, about your eating or exercise habits?
  • Medical history/menstrual history
  • Family history
  • Psychosocial history ALWAYS ASK SUICIDAL
    IDEATION PHYSICAL/SEXUAL ABUSE DOMESTIC
    VIOLENCE SUBSTANCE ABUSE

39
MEDICAL EVALUATION OF THE PATIENT
  • Complete physical exam and vital signs
  • Complete blood count
  • Complete chemical profile
  • Depending on history and physical,
    electrocardiography, or brain MRI.

40
COMORBID PSYCHIATRIC CONDITIONS
41
  • Depression
  • Anxiety disorders
  • Obsessive compulsive disorder
  • Delusional disorder
  • Risk for substance abuse

42
SUBSTANCE ABUSE
  • Drugs and Alcohol lessen inhibitions, and can
    precipitate a relapse of eating disorder
  • Level of secretiveness much greater when both
    disorders (SA ED) present
  • Greater rate of relapse when both present
  • Zerbe, Kathryn, M.D. The Body Betrayed

43
Treatment Approaches
44
EVALUATION
  • Complete Medical and Psychiatric History
  • Complete Medical Exam, including appropriate
    laboratory and imaging studies
  • DETERMINE APPROPRIATE LEVEL OF CARE

45
INDICATIONS FOR HOSPITALIZATION Anorexia Nervosa
  • Prolonged QT interval
  • Bradycardia of 40 beats/min or less
  • Other arrhythmias
  • Body temperature lt 96 F
  • Symptomatic hypotension
  • Refusal to eat
  • Intractable weight loss despite treatment

46
INDICATIONS FOR HOSPITALIZATION Bulimia Nervosa
  • Syncope
  • Hypothermia
  • Suicide risk
  • Alcohol or drug abuse
  • Uncontrolled vomiting
  • Hematemesis

47
MANAGEMENT OF THE PATIENT
  • Medical stabilization
  • Nutritional support and Education
  • Psychotherapy
  • Pharmacotherapy
  • SSRI usage sertraline and fluoxetine both have
    FDA indications
  • Atypical Antipsychotics usage is off-label and
    symptomatic

48
Nutritional
  • Educate
  • Determine
  • Address
  • Work with
  • Monitor
  • Establish

49
Psychotherapeutic
No needs
Perfect
  • Family Therapy
  • Cognitive behavioral Therapy
  • Narrative Therapy
  • Strategic Therapy
  • Shadow work

High GPA
Thin
Happy
Successful
Laziness
Anger
Unhappiness
50
FAMILY THERAPY
  • 10 year review of literature showed positive
    benefits for the following
  • Conduct Disorder Substance Abuse Depression
    Anxiety Eating Disorder ADD
  • JAACAP, vol. 44, Sept. 2005, Josephson, Allan,
    M.D.

51
Education and prevention
52
  • Educate early
  • Continuing Education
  • Parent Education

53
Families and parents
  • Model a good balance of nutrition
  • Dont criticize your own body
  • Provide validation
  • Encourage to try hard not to be the best
  • Dont tell anyone you need to lose weight
  • Avoid sarcasm and jokes about weight

54
Families and parents contd.
  • Focus on health not weight
  • Dont criticize your own looks
  • Use good communication
  • Read, study, take classes
  • Be a consultant to your children
  • Take care of yourself

55
Resources
  • Costin, Carolyn, MA Med, MFCC, Eating Disorder
    Sourcebook, Lowell House, 1996
  • Ford, Debbie, The Secret of the Shadow, Harper
    2002
  • Hargrave, Terry, Forgiving the Devil, Tucker and
    Theisen, 2001
  • NEDA. National Eating Disorder Association. 13
    Aug 2004 ltwww.national eatingdisorders.orggt.

56
Resources (cont.)
  • Zerbe, Kathryn M.D. , The Body Betrayed,
  • American Psychiatric Press, 1993.
  • Journal of the American Academy of Child and
    Adolescent Psychiatry

57
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