Interventions for co-occurring addictive and other mental disorders (AMDs)

While research on the management of co-occurring addictive and mental disorders (AMDs) has grown substantially in recent years, we still have little guidance on specific strategies. Consideration of epidemiological research and ethical principles can supplement existing clinical trials in providing a way forward. High frequencies of co-occurring disorders, equity of access for affected individuals and potential clashes between services in priorities and procedures, suggest that a stepped model of care by a single service may often be required. Typically, problems are multiple rather than dual, with potential for mutual influence, suggesting a need for interventions that are sensitive to and encompass complex co-occurring problems. Motivational problems are endemic, initial gains are often partial and unstable, and relapses potentially have serious consequences, suggesting a need for long-term, assertive follow-up. Principles such as these provide a solid framework for designing both services and interventions. However, there is a continuing need for controlled trials that unpack effective components of interventions, and increase their impact.

The pursuit of thinness : an outcome study of anorexia nervosa

INTRODUCTION: Anorexia nervosa (AN) is a growing problem among young female Singaporeans. We studied the demographics and follow-up data of AN patients referred to dietitians for nutritional intervention. METHODS: A retrospective nutritional notes review was done on 94 patients seen from 1992 to 2004. All patients were given nutritional intervention, which included individualised counselling for weight gain, personalised diet plan, correction of poor dietary intake and correction of perception towards healthy eating. We collected data on body mass index (BMI), patient demographics and outcome. RESULTS: 96 percent of the patients were female and 86.2 percent were Chinese. The median BMI at initial consultation was 14.7 kilogramme per square metre (range, 8.6-18.8 kilogramme per square metre). 76 percent were between 13 and 20 years old. 83 percent of the patients came back for follow-up appointments with the dietitians in addition to consultation with the psychiatrist. Overall, there was significant improvement in weight and BMI from an average 37 kg to 41 kg and 14.7 kilogramme per square metre to 16.4 kilogramme per square metre, respectively, between the fi rst and fi nal consultations (p-value is less than 0.001). The average duration of followup was about eight months. Among the patients on follow-up, 68 percent showed improvement with an average weight gain of 6 kg. Patients that improved had more outpatient follow-up sessions with the dietitians (4.2 consultations versus 1.6 consultations; p-value is less than 0.05), lower BMI at presentation (14.2 kilogramme per square metre versus 15.7 kilogramme per square metre; p-value is less than 0.01) and shorter duration of disease at presentation (one year versus three years; p-value is less than 0.05) compared with those who did not improve. Seven patients with the disease for more than two years did not show improvement with follow-up. CONCLUSION: We gained valuable understanding of the AN patients referred to our tertiary hospital for treatment, two-thirds of whom improved with adequate follow-up treatment. Patients that had suffered AN longer before seeking help appeared more resistant to improvement.

An interpretative phenomenological analysis of participation in a pro-anorexia Internet site and its relationship to disordered eating

Pro-anorexia Internet sites aim to promote, support and discuss anorexia nervosa. Media coverage has raised concerns that sites may increase the level of eating disorders. This research examines the meaning of participation in a pro-anorexia Internet site and its relationship with disordered eating by using an interpretative phenomenological analysis of fifteen separate message ‘threads’ followed over a six-week period. Four themes were identified: (1) tips and techniques; (2) ‘ana’ v. anorexia nervosa; (3) social support; and (4) need for anorexia. Findings suggest participation was multi-purpose, providing a coping function in relation to weight loss, and the contribution of sites to increased levels of eating disorders is not inevitable.

Book Review : "The Psychology of Eating : From Healthy to Disordered Behaviour"

WHEN JANE Ogden embarked on writing a book about the psychology of eating I wonder whether she realized the enormity of the task given the breadth of research literature in this field. Through a series of 12 closely related chapters on eating, health, food choice, dieting, obesity, body image, eating disorders and others, an extensive range of areas of the psychology of eating is covered. As well as these areas, included within each chapter is a discussion of the significance of historical, cultural, social and familial factors, theoretical approaches and empirical data in the understanding of the multifaceted problems related to eating. At the end of each chapter there is a box entitled ‘Towards an integrated model of diet’ that links the content with that of the following chapters...

Understanding body image disturbance in the promotion of mental health : a discourse analytic study

Health care interventions in the area of body image disturbance and eating disorders largely involve individual treatment approaches, while prevention and health promotion are relatively underexplored. A review of health promotion activities in the area of body image in Australia revealed three programmes, the most extensive and longest standing having been established in 1992. The aims of this programme are to reduce body image dissatisfaction and inappropriate eating behaviour, especially among women. Because health promotion is concerned with the social aspects of health, it was hypothesized by the authors that a social understanding of body image and eating disorders might be advanced in a health promotion setting and reflected in the approach to practice. In order to examine approaches to body image in health promotion, 10 health professionals responsible for the design and management of this programme participated in a series of semi-structured interviews between 1997 and 2000. Three discursive themes were evident in health workers' explanations of body image problems: (1) cognitive-behavioural themes; (2) gender themes; and (3) socio-cultural themes. While body image problems were constructed as psychological problems that are particularly experienced by women, their origins were largely conceived to be socio-cultural. The implications of these constructions are critically discussed in terms of the approach to health promotion used in this programme.

Measurement of disordered eating in Latina college women

The Eating Disorder Risk Composite (EDRC) comprises the Drive for Thinness, Bulimia, and Body Dissatisfaction subscales of the Eating Disorder Inventory, Third Edition (EDI-3, Garner, 2004). Past research conducted with Latina college women (LCW) has found older versions of the EDRC subscales to be reliable, but the EDI-3's EDRC factor structure has yet to be studied among LCW. The present study investigated the pattern of responses to and the factor structure of the EDRC in LCW. It was hypothesized that eating pathology would be present and that a factor analysiswould find some discrepancies between the original factor structure of the EDRC and the factor structure from LCW. Analyses of data on a 6-point Likert scale indicate that drive for thinness and body dissatisfaction are far more prevalent than is bulimic symptomology in LCW. Principal Axis Factoring with promax rotation was used to extract three factors very similar to the original EDRC. Some discrepancies in the item loadings were observed, most notably that half of the items from the original Body Dissatisfaction subscale did not load together on one factor. Overall, the EDRC appears to be a goodmeasurement of eating- and body-related phenomena among LCW. Implications, limitations, and future directions are discussed.

Early-onset depressive disorders,related mental health disorders and substance use-A prospective : longitudinal study of Finnish twins born 1983-1987

Early-onset psychiatric illnesses effects scatter to academic achievements as well as functioning in familial and social environments. From a public health point of view, depressive disorders are the most significant mental health disorders that begin in adolescence. Using prospective and longitudinal design, this study aimed to increase the understanding of early-onset depressive disorders, related mental health disorders and developing substance use in a large population-derived sample of adolescent Finnish twins. The participants of this study, FinnTwin12, an ongoing longitudinal population-based study, came from Finnish families with twins born in 1983-87 (exhaustive of five birth cohorts, identified from Finland s Central Population Register). With follow-up ongoing at age 20-24, this thesis assessed adolescent mental health in the first three waves, starting from baseline age 11-12 to follow-ups at age 14 and 17½. Some 5600 twins participated in questionnaire assessments of a wide range of health related behaviors. Mental health was further assessed among an intensively studied subsample of 1852 adolescents, who completed also professionally administered interviews at age 14, which provided data for full DSM-IV/III-R (Diagnostic and Statistical Manual for Mental Health disorders, 4th and 3rd editions) diagnoses. The participation rates of the study were 87-92%. The results of the study suggest, that the diagnostic criteria for major depressive disorder (MDD) may not capture youth with clinically significant early-onset depressive conditions outside clinical settings. Milder cases of depression, namely adolescents fulfilling the diagnostic criteria for minor depressive disorder, a qualitatively similar condition to MDD with fewer symptoms are also associated with marked suicidal thoughts, plans and attempts, recurrences and a high degree of comorbidity. Prospectively and longitudinally, early-onset depressive disorders were of substantial importance in the context of other mental health disorders and substance use behaviors: These data from a large population-derived sample established a substantial overlap between early-onset depressive disorders and attention deficit hyperactivity disorder in adolescent females, both of them significantly predictive for development of substance use among girls. Only in females baseline DSM-IV ADHD symptoms were strong predictors of alcohol abuse and dependence and illicit drug use at age 14 and frequent alcohol use and illicit drug use at age 17.½ when conduct disorder and previous substance use were controlled for. Early-onset depressive disorders were also prospectively and longitudinally associated to daily smoking behavior, smokeless tobacco use, frequent alcohol use and illicit drug use and eating disorders. Analysis of discordant twins suggested that these predictive associations were independent of familial confounds, such as family income, structure and parental models. In sum, early-onset depressive disorders predict subsequent involvement of substance use and psychiatric morbidity. A heightened risk for substance use is substantial also among those depressed below categorical diagnosis of MDD. Whether early recognition and interventions among these young people hold potential for substance use prevention further in their lives has potential public health significance and calls for more research. Data from this population-derived sample with balanced representation of boys and girls, suggested that boys and girls with ADHD behaviors may differ from each other in their vulnerability to substance use and depressive disorders: the data suggest more adverse substance use outcome for girls that was not attenuated by conduct disorder or previous substance use. Further, the prospective associations of early-onset depressive disorders and future elevated levels of addictive substance use is not explained by familial factors supporting future substance use, which could have important implications for substance use prevention.

Inpatient experience of anorexia nervosa

Anorexia nervosa (AN) is an extremely serious mental illness, with a high mortality rate and many debilitating physical and psychological symptoms. While hospitalisation is sometimes required for patients with AN there remains no evidence base for “best practice’ inpatient treatment. With patients’ views recognised as critical to improving efficiency and outcomes, calls have been made for more qualitative research into inpatients’ experiences. In light of this the current paper utilised thematic analysis to examine 16 semi-structured interviews with inpatients diagnosed with AN, at a specialised eating disorders hospital unit. The study found an overarching theme of relationship ambivalence in connection with sub-themes of patients’ eating disorders, eating disorder co-patients, staff and treatment. Participants’ goals in relationship to their eating disorder and engagement in treatment shaped and were shaped by interactions with other inpatients with AN and staff. Clinical implications for this study and future research directions are discussed.

As relações entre raiva e habilidades sociais em indivíduos com transtornos alimentares

Os Transtornos Alimentares (TA) são caracterizados por graves perturbações no comportamento alimentar, geralmente de início precoce e curso duradouro. Vários fatores estão associados a sua etiologia, como fatores familiares, socioculturais, biológicos e psicológicos. Alguns autores demonstraram existir correlação entre gravidade nos comportamentos alimentares inadequados, baixos níveis de assertividade, altos níveis de hostilidade autodirigida e dificuldade em expressar a raiva. Além disso, a raiva tem sido relacionada principalmente aos episódios de compulsão alimentar e métodos compensatórios. A literatura, já há algum tempo reconhece o papel central do afeto negativo na etiologia e manutenção da compulsão alimentar. A teoria da regulação do afeto pressupõe que os episódios de compulsão alimentar estão associados a uma dificuldade para regular as emoções de forma adaptada, configurando-os como uma estratégia inadequada para aliviar sofrimento e reduzir afetos intensos. Pesquisadores indicam que um terço das mulheres com compulsão alimentar, comem em resposta a emoções negativas, mais especificamente a raiva, depressão e ansiedade. A compulsão alimentar teria como função regular a experiência emocional, reduzindo a consciência da emoção. A raiva também tem sido associada a déficits em habilidades sociais. A literatura sugere que os indivíduos socialmente habilidosos são mais propensos a manejar com a emoção da raiva do que aqueles com déficits em habilidades sociais e resolução de problemas, e que muitos dos tratamentos efetivos para raiva e comportamento agressivo incluem o desenvolvimento dessas habilidades. Assim como elevados níveis de raiva estão associados a comportamentos alimentares disfuncionais, evidências apontam para a relação entre déficits em habilidades sociais e gravidade do comportamento alimentar. A literatura mostra que no tratamento da raiva, o treinamento de habilidades sociais tem sido bastante efetivo. Dessa forma, identificar de que forma a raiva se relaciona ao comportamento alimentar inadequado , bem como aos déficits em habilidades sociais se torna relevante para a criação de programas de intervenção que tenham como objetivo ensinar o indivíduo a manejar com a raiva e frustração, aumentando assim, a capacidade de resolução de problemas e diminuindo a ocorrência de comportamentos alimentares inadequados. Portanto, o objetivo desse estudo é avaliar as relações entre habilidades sociais e a raiva em pacientes com Bulimia Nervosa e Transtorno da Compulsão Alimentar Periódica. Em função das críticas ao uso de questionários de auto-informe em pesquisas, essa tese foi dividida em três estudos. O primeiro foi uma revisão sistemática da literatura que teve como propósito avaliar as relações entre níveis disfuncionais de raiva e compulsão alimentar em pacientes com bulimia nervosa e TCAP. O segundo estudo avaliou as relações entre níveis de habilidades sociais, raiva disfuncional e gravidade da compulsão alimentar em amostra clínica, através de questionários de autorrelato. E por fim, o terceiro estudo teve como objetivo identificar pensamentos automáticos e comportamentos associados a emoção da raiva através de entrevista estruturada, composta por cinco questões abertas. Os resultados de cada estudo serão discutidos, assim como sua implicação no tratamento dos TA

Identifying novel molecular mechanisms of ghrelin receptor signalling underlying neural control of food intake: interaction with stress and impulsivity

The gut-hormone, ghrelin, activates the centrally expressed growth hormone secretagogue 1a (GHS-R1a) receptor, or ghrelin receptor. The ghrelin receptor is a G-protein coupled receptor (GPCR) expressed in several brain regions, including the arcuate nucleus (Arc), lateral hypothalamus (LH), ventral tegmental area (VTA), nucleus accumbens (NAcc) and amygdala. Activation of the GHS-R1a mediates a multitude of biological activities, including release of growth hormone and food intake. The ghrelin signalling system also plays a key role in the hedonic aspects of food intake and activates the dopaminergic mesolimbic circuit involved in reward signalling. Recently, ghrelin has been shown to be involved in mediating a stress response and to mediate stress-induced food reward behaviour via its interaction with the HPA-axis at the level of the anterior pituitary. Here, we focus on the role of the GHS-R1a receptor in reward behaviour, including the motivation to eat, its anxiogenic effects, and its role in impulsive behaviour. We investigate the functional selectivity and pharmacology of GHS-R1a receptor ligands as well as crosstalk of the GHS-R1a receptor with the serotonin 2C (5-HT2C) receptor, which represent another major target in the regulation of eating behaviour, stress-sensitivity and impulse control disorders. We demonstrate, to our knowledge for the first time, the direct impact of GHS-R1a signalling on impulsive responding in a 2-choice serial reaction time task (2CSRTT) and show a role for the 5-HT2C receptor in modulating amphetamine-associated impulsive action. Finally, we investigate differential gene expression patterns in the mesocorticolimbic pathway, specifically in the NAcc and PFC, between innate low- and high-impulsive rats. Together, these findings are poised to have important implications in the development of novel treatment strategies to combat eating disorders, including obesity and binge eating disorders as well as impulse control disorders, including, substance abuse and addiction, attention deficit hyperactivity disorder (ADHD) and mood disorders.

A cross-site, comparative effectiveness study of an integrated HIV and substance use treatment program.

Co-occurrence of HIV and substance abuse is associated with poor outcomes for HIV-related health and substance use. Integration of substance use and medical care holds promise for HIV patients, yet few integrated treatment models have been reported. Most of the reported models lack data on treatment outcomes in diverse settings. This study examined the substance use outcomes of an integrated treatment model for patients with both HIV and substance use at three different clinics. Sites differed by type and degree of integration, with one integrated academic medical center, one co-located academic medical center, and one co-located community health center. Participants (n=286) received integrated substance use and HIV treatment for 12 months and were interviewed at 6-month intervals. We used linear generalized estimating equation regression analysis to examine changes in Addiction Severity Index (ASI) alcohol and drug severity scores. To test whether our treatment was differentially effective across sites, we compared a full model including site by time point interaction terms to a reduced model including only site fixed effects. Alcohol severity scores decreased significantly at 6 and 12 months. Drug severity scores decreased significantly at 12 months. Once baseline severity variation was incorporated into the model, there was no evidence of variation in alcohol or drug score changes by site. Substance use outcomes did not differ by age, gender, income, or race. This integrated treatment model offers an option for treating diverse patients with HIV and substance use in a variety of clinic settings. Studies with control groups are needed to confirm these findings.

Components of Shame and Eating Disturbance among Clinical and Non-Clinical Populations

OBJECTIVE: To examine the association between components of shame (characterological, behavioural and bodily) and eating disturbance.

METHOD: This was a cross sectional study of 859 female and 256 male participants from the general population [non-clinical (NCP)] and 167 female participants from an eating disordered population [clinical (CP)] completing the Experience of Shame Scale. The NCP samples also completed the Eating Attitudes Test-26, and the CP samples completed the Eating Disorder Risk Composite of the Eating Disorder Inventory-3. Participants were recruited via schools/colleges, eating disorder charities and the Internet.

RESULTS: Bodily and characterological shame were independently predictive of eating disturbance in female NCP samples (both, p?<?.001); bodily shame was uniquely predictive of eating disturbance for the male NCP (p?<?.05) and female CP samples (p?<?.001).

CONCLUSION: The aetiology of eating disturbance may be different for male and female NCP samples. The male NCP and the female CP samples displayed a similar pathway to eating disturbance. It is important to acknowledge the different components of shame associated with eating disturbance in different populations.

Posting Incognito ... Males with Eating Problems: Online Emotional Expression and Support

Qualitative research in the area of eating disorders (eds) has predominantly focused on females,whilst the experiences of males’ remains poorly understood. due to the secretive nature of eating problems/eds it can be difficult to explore the experiences of males with these problems; however, online support groups/message boards, which are common and popular, provide a non-invasive
forum for researchers to conduct research. This study analyzed naturally occurring discussions on an internet message board dedicated to males and eating problems using content analysis. Two major overarching themes of emotional expression (sharing feelings of disturbed eating attitudes and emotions; being secretive) and support (informational and emotional) were identified. The message board provided a vital support system for this group, suggesting that online message boards may be an important avenue for health professionals to provide information, support, and advice.

Disordered Eating in first year university students: A qualitative study exploring student and support service needs

The paper reports on a qualitative study exploring disordered eating in younger first-year students studying for professional health care related degrees (n=12), and highlights a number of support mechanisms and services required for those students at risk.

Key issues emerging in relation to disordered eating included: concealment; lack of understanding to the nature/risks associated; its use as a stress coping mechanism; isolation; perception as mental health issues with attaching stigma and reticence to acknowledge; invisible experience; wariness of eating in more public refectories. Finally positivity about their arrival at university and that their experience with disordered eating could potentially add to their repertoire as future health care professionals.

Conclusion: The University could; further develop its outreach to new students with a more consistently supportive person-centred program including stress training and more support via student buddying; extend its program on positive mental health; greater awareness particularly the sub-clinical group; consider some small changes and adaptations to the refectory eating areas to better facilitate at- risk students. Finally the University could perhaps better use the first few months of student's arrival at university to help embed a program to develop a stronger sense of coherence and well-being.

Le rôle du sentiment d’efficacité personnelle, de l’insatisfaction corporelle et de l’alexithymie dans l’étiologie et le maintien des troubles des conduites alimentaires

La forte prévalence des troubles des conduites alimentaires (TCA) chez les jeunes femmes et les faibles taux de rémission suite à un traitement ont encouragé les chercheurs à mieux comprendre les facteurs impliqués dans ce trouble mental. L’un des premiers modèles à mettre l’emphase sur des traits de personnalité associés au développement d’un TCA a été proposé par Hilde Bruch (1962, 1973, 1978) et a toujours une grande influence dans la recherche actuelle. Le modèle de Bruch inclue trois facteurs, soit l’insatisfaction corporelle, l’inefficacité et la conscience intéroceptive. Le but de cette thèse est d’apporter un support empirique au modèle de Bruch. En se basant sur une revue extensive des écrits scientifiques, cette thèse vise aussi à déterminer si deux facteurs reliés, soit l’alexithymie et le sentiment d’efficacité personnelle face à l’adoption de conduites alimentaires saines, améliorent la précision du modèle dans la prédiction de symptômes de TCA. Pour répondre empiriquement à cette question, il était d’abord nécessaire de disposer d’un questionnaire évaluant le sentiment d’efficacité personnelle en lien avec les conduites alimentaires qui peut être utilisé dans tout le spectre de présentation des TCA. Ainsi, le Eating Disorder Self-Efficacy Questionnaire (EDRSQ) a été adapté en français et ses propriétés psychométriques ont été évaluées. Une analyse factorielle confirmatoire a révélé une structure bi-factorielle, soit le sentiment d’efficacité personnelle en lien avec l’insatisfaction corporelle et avec l’adoption d’une alimentation normative. Chaque échelle a démontré une bonne fiabilité ainsi qu’une validité de construit cohérente avec la théorie. Par la suite, la capacité des facteurs proposés par Bruch à prédire les symptômes de TCA a été évaluée et comparée à des adaptations du modèle découlant des écrits. Au total, 203 étudiantes de premier cycle universitaire ont complété les versions validées en français du Eating Disorder Inventory 2, du Eating Attitudes Test, et du Toronto Alexithymia Scale en plus du EDRSQ. Les résultats montrent que le modèle de Bruch explique 46% de la variance des symptômes de TCA. Alors que l’insatisfaction corporelle et la conscience intéroceptive démontrent chacun une contribution importante dans la prédiction des symptômes de TCA, il a été démontré que l’inefficacité présente seulement une contribution spécifique négligeable. Le modèle de Bruch est amélioré par la substitution de l’inefficacité par le sentiment d’efficacité personnelle tel que mesuré par le EDRSQ; le modèle explique alors 64% de la variance des symptômes de TCA. Finalement, cette étude démontre que l’alexithymie n’a pas de contribution spécifique dans la prédiction des symptômes de TCA. Ainsi, la combinaison d’une faible conscience intéroceptive, de l’insatisfaction corporelle et d’un faible sentiment d’efficacité personnelle en lien avec les conduites alimentaires est fortement associée aux symptômes de TCA dans un échantillon non-clinique de jeunes femmes. Finalement, les implications conceptuelles et cliniques de ces résultats sont discutées.