Substance Abuse and Eating Disorders: Implications for Treatment

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Substance Abuse and Eating Disorders
Implications for Treatment

• Debra Atkisson Kowalski, M.D.

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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

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ADDICTIVE COMPONENTSOF EATING DISORDERS

• Compulsive nature of behavior
• Consequences to health and safety
• Negative impact on relationships
• Impairment in occupational functioning
• Denial

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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.

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Definition of eating Disorders

• DSM-IV-TR

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Types of Anorexia Nervosa

• Restricting
• Not engaged in Binge eating
• Binge- Eating/ Purging
• Regularly involved in binge and purge cycles

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Anorexia Nervosa

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

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Types of Bulimia Nervosa

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

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Bulimia Nervosa

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

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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

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Epidemiology of an eating Disorder
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• .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
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• 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
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• 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
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Warning Signs of eating Disorders
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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
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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
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Risk Factors
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Risk factors

• Familial
• Genetic
• Functional
• Cultural
• Social
• Individual personality

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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

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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

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CROSS ADDICTIONS

• EATING DISORDERS
• SUBSTANCE ABUSE
• SEXUAL IMPULSIVITY

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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

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Contributing Variables
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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

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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

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Neurotransmitters (cont.)

• B-Endorphins increased by starving, exercise,
  bingeing
• B-Endorphins increase Dopamine in the mesolimbic
  system

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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
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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

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Medical Effects
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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)

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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

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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

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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

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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)

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Common Medical Findings for Bulimia Nervosa

• Cardiac
• Bradycardia
• Other cardiac arrhythmias
• Orthostatic hypotension
• Cardiac murmur (mitral valve prolapse)

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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

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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

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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.

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

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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

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Treatment Approaches
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EVALUATION

• Complete Medical and Psychiatric History
• Complete Medical Exam, including appropriate
  laboratory and imaging studies
• DETERMINE APPROPRIATE LEVEL OF CARE

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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

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INDICATIONS FOR HOSPITALIZATION Bulimia Nervosa

• Syncope
• Hypothermia
• Suicide risk
• Alcohol or drug abuse
• Uncontrolled vomiting
• Hematemesis

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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

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Nutritional

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

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Psychotherapeutic
No needs
Perfect

• Family Therapy
• Cognitive behavioral Therapy
• Narrative Therapy
• Strategic Therapy
• Shadow work

High GPA
Thin
Happy
Successful
Laziness
Anger
Unhappiness
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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.

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

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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

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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

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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.

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Resources (cont.)

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

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