Daily Archives: September 22, 2010

Eating Disorders (EDs) and Substance Use Disorders (SUDs): Shared and Causal Etiology


The etiologies of both Eating Disorders (EDs) and Substance Use Disorders (SUDs) are perceived to be complex and multidimensional in nature.  No simple etiological path is indicated in either category.  Many contemporary theories “implicate a ‘collision’ among biological factors (e.g., genetic influences on neurotransmitter and hormonal function), psychological tendencies (problems with mood, temperament, and impulse controls), and social pressures (promoting body consciousness or generalized self-definition problems, and developmental processes (conducive to self-image or adjustment problems).”  (Blaney & Millon, 2009, p. 436)  The current model of SUD risk factors would not be complete without all of the above, perhaps with a few minor modifications.  This essay will attempt to address and discuss the common etiological factors between EDs and SUDs, as well an explore concepts of causal etiology that suggest that having one disorder predispositions an individual to succumb to another.

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Causal etiology has suggested that having one disorder (an eating disorder, for example) may put an individual at risk for developing another disorder (like substance abuse, or vice versa).  The statistics surrounding the comorbidity of substance abuse and eating disorders is considerable.  “Substance abuse and eating disorders have the highest mortality risks of all mental disorders and half of all clients with eating disorders abuse alcohol or illicit drugs.”  (Carbaugh & Sias, 2010, p. 125)  Shared or causal etiological factors between the substance abuse and eating disorders include psychological, environmental, and biological antecedents.  Both disorders are influenced by specific personality type (lack of control, craving, denial, impulsiveness), similar developmental issues (societal and familial pressures), as well as common family history (genetic predisposition) and specific biological vulnerability.  (Carbaugh & Sias, 2010)  Whether causal or shared, it is increasingly evident that SUDs and EDs share common etiological pathways, even to the extent that they may be causal in their relationship.

Common personality factors play a significant role in the onset and maintenance of both eating disorders and their comorbid conditions.  However, the personality of people whom suffer from AN tend to qualitatively different from the personalities of people whom suffer from BN.  Individuals whom suffer from AN have been found to be approval seeking, self-doubting, conflict-avoidant, excessively dependent, socially anxious, and have a tendency to be described as “perfectionists.”  Individuals whom suffer from bulimia often experience significant affective instability including highly variable mood states, impulsive behavior, low frustration tolerance, and high anxiety.  (Netherton, Holmes, & Walker, 1999, p. 401)  Differences in the underlying personality deficiencies can account for differences in comorbidity when comparing EDs among themselves, although EDs and SUDs generally continue to demonstrate remarkable comorbidity regardless of the type of ED we examine.

The news media frames obesity as a “moral problem.”  Obese populations are condemned by the media as engaging in gluttony and sloth while society overwhelmingly blames “bad individual choices” (despite increasing discussion of social-structural factors over time).  (Saguy & Gruys, 2010, p. 247)  The above statements easily could have been rewritten to drive home a different message.  The news media frames drug abuse as a “moral problem.”  Drug abusers are condemned by the media as engaging in greed and apathy (synonyms for gluttony and sloth) while society overwhelming blames “bad individual choices” (despite increasing discussing of social structural factors over time).  Obesity and drug abuse are 21st Century witches.  Will you join the hunt?

The contribution of the family only begins with biological disturbances in the serotonin, dopamine, gamma-aminobutyric acid and endogenous opioid peptide systems that may underlie both disorders.  (Pearlstein, 2002, p. 70)  Despite the fact that The Academy for Eating Disorders (AED) has specifically condemned statements that implicate family influences “as the primary cause of AN or BN,” they have acknowledged that particular styles of family behavior and biological vulnerability may increase risk for psychopathology in general, including eating disorders.  (“Role of Family in EDs”, 2009)  Dieting is one example of a behavior that is frequently encouraged by well intentioned families.  Research supports the positive association between the dieting behaviors (not just eating disorders themselves) and increased risk for alcohol use problems.  (Heidelberg & Correia, 2009)  Families who promote dieting in their children may inadvertently be promoting substance abuse.  Add latent genetic influence (like a parent with an eating disorder or who abuses substances) to that encouragement we may have a ‘perfect storm’ of predispositions that could potentially result in a full blown eating disorder comorbid with a substance abuse problem.  Be it through the environmental impact of familial behavior, or by latent genetic influence, family plays a significant role in the development of both disorders.

EDs and SUDs can be viewed through the same lens.  Shared etiology, including familial contributions, media influences, and personality factors; all play a role in the perpetuation of the stereotype.  If we perpetuated the image of common people drinking wate,r instead of hard bodies drinking alcohol, perhaps the association between substance abuse and eating disorders could be severed.

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References

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.

Blaney, P. H., & Millon, T. (2009). Oxford textbook of psychopathology (2nd ed.). New York, New York: Oxford University Press.

Carbaugh, R. J., & Sias, S. M. (2010, Apr). Comorbidity of bulimia nervosa and substance abuse: Etiologies, treatment issues, and treatment approaches. Journal of Mental Health Counseling, 32(2), 125-138. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=2026599321&sid=1&Fmt=3&clientId=4683&RQT=309&VName=PQD

Heidelberg, N. F., & Correia, C. J. (2009, Dec). Dieting behavior and alcohol use behaviors among national eating disorders screening program participants. Journal of Alcohol and Drug Education, 53(3), 53-64. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1959547071&sid=9&Fmt=3&clientId=4683&RQT=309&VName=PQD

Netherton, S. D., Holmes, D., & Walker, C. E. (1999). Child and adolescent psychological disorders: A comprehensive textbook. Oxford, NY: Oxford University Press.

Paper stresses important role of family in eating disorders. (2009, Nov). Journal of Psychosocial Nursing & Mental Health Services, 47(11), 11. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1908060671&sid=9&Fmt=3&clientId=4683&RQT=309&VName=PQD

Pearlstein, T. (2002, Mar). Eating disorders and comorbidity. Archives of Women’s Mental Health, 4(3), 67-78. Retrieved from http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?index=24&did=687270031&SrchMode=2&sid=11&Fmt=6&VInst=PROD&VType=PQD&RQT=309&VName=PQD&TS=1274809726&clientId=4683

Saguy, A. C., & Gruys, K. (2010, May). Morality and health: News media constructions of overweight and eating disorders. Social Problems, 57(2), 231-250. doi: 10.1525/sp.2010.57.2.231

Sexual Dysfunction vs. Sexual Disorder


A “dysfunction” is literally defined as an abnormality or disturbance of function.  (Colman, 2009, p. 232)  It may also be defined as abnormal or unhealthy interpersonal behavior or interactions.  (Merriam-Webster Online Dictionary [MWOD], 2010)  Specifically, sexual dysfunctions are defined as “conditions that impair the desire or ability to achieve sexual satisfaction.”  (Blaney & Millon, 2009, p. 399)  With and within the DSM-IV-TR, the term sexual dysfunction is conceptualized as an umbrella category that encompasses a wide variety of sex related conditions, some of which may or may not “belong” in a manual that is intended to cover and contain “mental disorders.”  This essay will give a brief overview of what are currently considered under the broad title of Sexual Dysfunctions, and provide some subjective thought on efficacy of continued inclusion as we move toward the newest revision of the “psychiatric bible,” the DSM-V.

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Under the rubric set forth by the current DSM, the DSM-IV-TR, the following disorders are considered under the broader category of Sexual Dysfunctions: Sexual Desire Disorders (i.e., Hypoactive Sexual Desire Disorder, Sexual Aversion Disorder), Sexual Arousal Disorders (i.e., Female Sexual Arousal Disorder, Male Erectile Disorder), and Orgasmic Disorders (i.e., Female Orgasmic Disorder, Male Orgasmic Disorder, and Premature Ejaculation), Sexual Pain Disorders (i.e., Dyspareunia, Vaginismus), Sexual Dysfunction Due to a General Medical Condition, Substance-Induced Sexual Dysfunction, and Sexual Dysfunction Not Otherwise Specified (NOS).  (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000, p. 535)  Comparatively speaking, a “disorder” is literally defined as an abnormal physical or mental condition.  (MWOD, 2010)  In the DSM-IV-TR, sexual dysfunctions are differentiated from Paraphilias and Gender Identity Disorders (GIDs).  The essential features of a Paraphilia are arousing fantasies, sexual urges, or behaviors generally involving non-hum, the suffering or humiliation of oneself or one’s partner, or children or other non-consenting persons.  (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000, p. 566)  Paraphilias include Exhibitionism, Fetishism, Frotteurism, Pedophilia, Sexual Sadism, Transvestic Fetishism, Voyeurism, and Paraphilia NOS.  Conversely, GID is characterized by strong and persistent cross-gender identification coupled with a persistent discomfort about one’s assigned sex and/or gender role.  (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000, p. 576)

Among those disorders, there are some that appear to fit better than others.  Take the Sexual Desire Disorders (i.e., Hypoactive Sexual Desire Disorder, Sexual Aversion Disorder) for example… what is considered normal libido?  Is there any objective way to quantify or qualify the need or desire to have sexual relations?  Honestly, I don’t think there is.  What is normal sexual activity to me and my partner may be too much or too little for another.  Like most disorders, one of the key diagnostic criterions of the DSM-IV-TR sexual dysfunctions is “marked distress or interpersonal difficulty.”  As a result, it’s not a problem unless the potential client makes it one, regardless of the presence of desire to engage in sexual activity.  Furthermore, it’s not a disorder unless a deficiency is detected and deemed appropriate by the clinician, thereby inserting another level of subjectivity.  It should come as no surprise that inter-rater reliability is lacking, and epidemiological data is mixed based on the definition of the disorder.

Another example is Sexual Arousal Disorders (i.e., Female Sexual Arousal Disorder, Male Erectile Disorder).  Although at the core, there may be some genetic or psychological factors at play, I am not sure I could consider it a disorder if someone simply isn’t attracted to their potential partner?  There are so many variables at play in Female Sexual Arousal Disorder that it may be increasing difficult to identify specific etiology.  Perhaps her partner is less than skilled.  Perhaps there is a developmental basis for the lack of lubrication (menopause).  Perhaps there are underlying biological causes in the form of circulatory problems that contribute to an inability to attain sufficient swelling response during periods of sexual arousal.  All of these situations are in fact treatable, but should we consider them “mental disorders?”  In some cases yes, where psychological factors are at play… however, there are an abundance of situations where psychological factors have little relevance in the diagnosis and treatment of Sexual Arousal Disorders.

Orgasmic Disorders (i.e., Female Orgasmic Disorder, Male Orgasmic Disorder, and Premature Ejaculation) may be propagated by psychological factors, and subsequently appropriate for inclusion in the DSM-V.  Conversely, there are a whole host of “combined factors,” including a very wide variability in type or intensity of stimulation that can trigger organism, that are likely less than “psychological” in nature.  Take premature ejaculation for example.  I think we would be hard pressed to find men who don’t want to last longer… and that inability may be a significant cause of duress for some men.  But as currently envisioned, there is no baseline as to what constitutes a threshold between a disorder, and simply being “excitable.”

Paraphilias are a hot topic in the psychological community because the presence of “mental disorders” like pedophilia seems to justify the behavior.  It would appear to me that any suggestion that paraphilias are in fact a mental disorder would present the opportunity to present a legal argument that “he or she is mentally ill, and as a result, can’t be considered liable for these actions.  In my opinion, simply having a legal option like that is counterintuitive and reprehensible.

We have addressed what is present; however, there is one glaring absence in the current nosology.  Where is the diagnostic category of “sexual dysfunction due to mental disorder?”  One possible solution is to redefine sexual dysfunction due to substance abuse as a dysfunction due to mental disorder “with onset during intoxication.”  (Segraves & Balon, 2007)  Including such a category would be intuitive in my opinion, despite the fact that our meanings of the words disorder and dysfunction have become rather convoluted in their practical application.  It seems to meet the definition of “abnormal or unhealthy,” more so than some of what we currently consider to be dysfunctions.  Without, there is a great deal of work that needs to be done in terms of clarification and codification as we approach the watershed appearance of the latest version of the DSM.

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References

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.

Blaney, P. H., & Millon, T. (2009). Oxford textbook of psychopathology (2nd ed.). New York, New York: Oxford University Press.

Colman, A. M. (2009). Oxford dictionary of psychology (3rd ed.). Oxford, NY: Oxford University Press.

Merriam-Webster Online Dictionary. (2010). disorder. Retrieved May 23, 2010, from http://www.merriam-webster.com/dictionary/disorder

Merriam-Webster Online Dictionary. (2010). dysfunction. Retrieved May 23, 2010, from http://www.merriam-webster.com/dictionary/dysfunction

Segraves, R. T., & Balon, R. (2007, Aug). Toward an improved nosology of sexual dysfunctions in DSM-V. Psychiatric Times, 24(9), 44. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1313390581&Fmt=2&clientId=4683&RQT=309&VName=PQD

Anorexia


Like so many other mental disorders, eating disorders project people who are really “out of balance.”  I don’t think anyone would be an obesity advocate… after all; obesity presents as many or more health problems as being overly thin.  In the end, it’s all about balance.

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1 in 5 women have an eating disorder.  Kids start dieting as early as 4th grade.  I can actually see this, I see a bit of it in my daughter… she is age 8 (2nd grade) and has shown concerns about “being too heavy.”  We have turned the focus onto “being healthy” not “being thin.”  80% of 13 year olds have tried to lose weight… this doesn’t surprise me, considering the “ideal image” that western culture projects to children.  1 in 5 anorexics die?  Our text indicates it was closer to 1-10, that’s nearly double NHW’s estimate.  I know it’s a real problem, but having good epidemiological data would be a good start to “justifying” expending resources to extinguish it.

With regard to what a clinican should know or ask about eating disorders, the following questions are at the top of my list.

1)      Clinicians should know your subtypes of Anorexia Nervosa (AN):

  1. Restricting Type describes presentations in which weight loss is accomomplished primarily through dieting, fasting, or excessive exercise.
  2. Binge-Eating/Purging Type describes presentations where the individual engages in binge eating, purging, or both.  They may employ self induced vomiting, misuse of laxative, diuretics, or enemas.  (American Psychiatric Association, Diagnostic and statistical manual of mental disorders, 2000, p. 585)

2)      Probe for comorbid disorders and associated features, especially depression, anxiety disorders, dissociative disorders, substance abuse, and personality disorders (particularly borderline personality disorder).  (Netherton, Holmes, & Walker, 1999, p. 401)

3)      Clinicians should know that, while these disorders predominantly effect females, males can also suffer from either AN or BN.  “There is some evidence that ED prevalences are recently increasing in males.”  (Blaney & Millon, 2009, p. 433)

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References

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.

Blaney, P. H., & Millon, T. (2009). Oxford textbook of psychopathology (2nd ed.). New York, New York: Oxford University Press.

Netherton, S. D., Holmes, D., & Walker, C. E. (1999). Child and adolescent psychological disorders: A comprehensive textbook. Oxford, NY: Oxford University Press.