Eating Disorders: Anorexia and Bulimia

Eating Disorders

• A group of disorders marked by abnormal eating habits (insufficient or excessive).
• These habits are detrimental to an individual's physical and mental health.
• Includes anorexia nervosa, bulimia nervosa, and binge eating.
• Most clients with eating disorders have additional psychiatric co-morbidities, complicating treatment.
• Treatment is challenging; recovery can take 5–7 years.
• Breaking the cycle of disordered behavior is the key to management.

Presentation

• Develops during adolescence and is common in young women
• Anorexia nervosa prevalence: 0.3% to 3.7%
• Bulimia nervosa prevalence: 1% to 4.2%

Pathophysiology

• Family emphasis on physical appearance may contribute
• Over 50% of people with a clinically diagnosed eating disorder have a co-morbid personality disorder, according to recent research.
• Social and cultural emphasis on thinness may contribute
• Self-esteem, control, and perfectionism are factors

Anorexia Nervosa

• A serious mental disorder with significant weight loss from excessive dieting
• Clients consider themselves fat, regardless of their actual weight.
• Individuals usually strive for perfection
• Set high standards and feel they must prove their competence
• They believe food and weight is the only aspect of their lives they can control.

DSM-IV Criteria for Anorexia Nervosa

• Refusal to maintain a minimum normal body weight for age and height
• Intense fear of gaining weight, even when underweight
• Dissatisfaction with body weight/shape, undue influence of body weight on self-evaluation, and denial of the seriousness of low weight
• Absence of at least 3 menstrual cycles

Medical Complications

• Issues such as cardiac irregularities, electrolyte abnormalities, and GIT effects.
• Low potassium and sodium levels
• Feeling bloated/full even after small amounts of food
• Renal dysfunction and neurological changes.
• Reduced glomerular filtration rate and brain atrophy due to the condition
• Impairment in attention and concentration
• Skin changes due to protein-calorie malnutrition
• Refeeding syndrome due to imbalance in electrolytes and fluids

Bulimia

• Mental disorder characterized by dieting, binge eating, and purging cycles for weight loss.
• A binge may involve consuming 1,000 to 10,000 calories.
• Purging methods can include vomiting, laxative abuse, diuretics, diet pills, and enemas.
• People with bulimia feel insecure about their self-worth and seek approval.

Bulimia Presentation

• Eating much larger amounts of food than most would, within a two-hour period.
• Sense of lack of control during the eating episode and recurrent inappropriate compensatory behavior.
• Overuse of laxatives, induced vomiting, excessive exercise, or fasting occur at least twice weekly for three months.
• Self-evaluation is unduly influenced by body shape and weight.
• The disturbance does not occur exclusively during episodes of anorexia nervosa.

Binge Eating

• Mental disorder characterized by consuming large quantities of food in a short period until uncomfortably full
• Similar to bulimia, but without purging
• Individuals feel out of control during binge episodes, followed by guilt and shame.
• Clients are at risk of developing cardiovascular diseases and diabetes

Management of Eating Disorders

• Treatment aims to free sufferers from worries about eating and weight and help them take control
• Treatment modalities: pharmacotherapy, psychological therapy, and nutrition rehabilitation

Pharmacotherapy

• Antidepressants, anti-psychotics (low doses), multivitamins, and phosphate Sandoz may be useful

Psychological Therapy

• Cognitive Behavior Therapy, psycho-education, family support, and interpersonal relationship therapy are options

Substance Misuse - Overview

• Drug: A substance modifying a person’s functions, feelings, etc., including over-the-counter, prescription, and illegal drugs.
• Drug Misuse: Inappropriate use of drugs.
• Physical Dependence: State where an individual needs a substance to function and satisfy physical needs.
• Tolerance: The need for higher doses to achieve the desired effect.
• Intoxication: Elevated drug levels impairing normal function.
• Withdrawal: Physical and psychological symptoms occur when a dependent person stops the substance.

Commonly Abused Substances

• Many substances can be abused including: alcohol, caffeine, cigarettes, amphetamines, cannabis, cocaine, hallucinogens, inhalants, opioids, benzodiapines, sedatives, and hypnotics

Aetiology

• Biological, psychological, and environmental factors contribute
• Social factors such as cultural acceptance may play a role
• Anxious people and those with mental illnesses may be more prone to substance use.

Substance Types

• Stimulants increase the activity of the central nervous system (CNS).
• Depressants decrease the activity of the CNS.
• Hallucinogens are psychoactive drugs that induce hallucinations or altered sensory experiences.

DSM-V Criteria for Substance Abuse

• A maladaptive pattern of substance use leads to clinically significant impairment or distress within a 12-month period.
• This includes failure to fulfill major role obligations, recurrent use in dangerous situations, and legal problems.
• Continued substance use despite persistent social or interpersonal problems.

Management of Substance Abuse

• It depends on the substance.
• Consider motivation and access to services.
• Substances like opiates, alcohol, and benzodiazepines require physical detoxification.
• Cocaine and methamphetamine cause severe psychological addiction.
• Address route, physical harm, and psychosocial harm; harm reduction policy

Withdrawal Syndrome

• Only three main substance types cause this which includes severe physical effects: alcohol, opiates, and benzodiazepines
• Treatment usually includes a period of pharmacological detoxification.

Substitute Prescribing and Harm Minimization

• In cases of heroin addiction, physical dependence increases use.
• Heroin use can be socio-economic with significant acquisitive criminal activity and physical harm.
• Harm minimization policies reduce harm and address physical addiction.
• Maintenance methadone prescribing and Buprenorphine are utilized
• Methadone is for maintenance and long-term management with a long half-life, administered once daily.
• Buprenorphine is a partial opiate agonist useful in chronic use and detoxification when heroin use is an issue.

Other Forms of Harm-Minimisation

• Needle exchange, drug education, BBV screening/immunization, and drug "clinics"
• De-criminalization through medicalization of social issues is controversial

Alcohol Detoxification

• Alcohol withdrawal syndrome causes: delirium tremens, hallucinations, and convulsions
• Treatment includes substitute benzodiazepines mimicking alcohol on receptor sites
• Dose reduction over 7-14 days, monitored by a nurse and alcohol withdrawal scales are used.

Benzodiazepines

• They work on the same receptor sites as alcohol.
• They can cause severe withdrawal syndrome and seizures if long-term use
• Gradual tapered reduction in primary care, switching to short-acting benzodiazepines.

Poly Drug Use

• Heroin users may have benzodiazepine and alcohol dependencies, requiring detoxification and management.

Continued Management of Substance Misuse

• It is ongoing and lifelong once physical dependence issues are addressed.
• Total abstinence leads to the best outcome with stimulants and other drugs
• Ongoing treatment is tailored to the user and choice of drugs and may 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 (cognitive based)
  • Residential rehabilitation and therapeutic communities
  • Continued pharmacotherapy: Naltrexone, Acamprosate, Antabuse, anti-depressants

Dual Diagnosis Issues

• This is defined by the presence of both mental health and substance use disorders.
• Drug users suffer from anxiety and/or depression, using drugs to alleviate symptoms
• They may also suffer "residual depression" and require tailored detoxification

Drug Induced Mental Illness

• Drug-induced delirium, dementia, psychosis, mood disorder, anxiety disorder, and sleep disorder

Summary

• Significant mental illnesses and associated disorders include:
  • Eating Disorders (AN, BN, BE), presentation and key management features
  • Substance Misuse. Clinical features, harm minimization in the Australian context