Personality Disorders, Substance Use Disorders & Eating Disorders

Personality Disorders

  • Definition: Long-term patterns of behavior and traits that differ from societal norms, emerging typically in adolescence or early adulthood.

  • Characteristics: These disorders involve unhelpful thoughts and behaviors causing distress and impairing effective functioning in daily life.

  • Organization: Personality disorders are organized into three clusters based on shared features.

Cluster A: Odd or Eccentric Disorders

  • Overview: Characterized by dysfunctional ways of thinking and behaving, often indicating a lack of trust or social interest.
      - Paranoid Personality Disorder:
        - Lack of trust; doubts the loyalty of others.
        - Prone to anger when perceived insults occur.
      - Schizoid Personality Disorder:
        - Tendency to isolate; shows little interest in forming relationships.
        - Minimal emotional expression; lacks social awareness.
      - Schizotypal Personality Disorder:
        - Characterized by unusual thinking or beliefs.
        - May hold strong convictions in superstitions or believe their thoughts influence others.

Cluster B: Dramatic or Erratic Disorders

  • Overview: Characterized by dysfunctional emotional patterns and unpredictable behavior.
      - Borderline Personality Disorder:
        - Fractured sense of self; fear of abandonment.
        - Exhibits impulsive behavior; has labile moods.
        - Struggles to maintain stable relationships; may threaten self-harm.
      - Histrionic Personality Disorder:
        - Exhibits dramatic emotions and is attention-seeking.
        - Concerned with appearance; prone to shallow and rapidly changing emotions.
        - May overestimate closeness of relationships.
      - Narcissistic Personality Disorder:
        - Believes they are special and superior to others.
        - Manipulates the truth to enhance self-image; seeks constant admiration.
        - Shows a tendency to exploit others without remorse.
      - Antisocial Personality Disorder:
        - Little regard for others' feelings; engages in deceitful behavior.
        - Often involved in violent or aggressive acts and recurrent legal issues.

Cluster C: Anxious or Fearful Disorders

  • Overview: Characterized by a sustained pattern of anxious thinking or behavior.
      - Avoidant Personality Disorder:
        - Highly sensitive to criticism or rejection.
        - Tends to isolate oneself and avoids new experiences or people due to fear of disapproval.
      - Dependent Personality Disorder:
        - Exhibits clinginess; relies heavily on others for emotional support and decision-making.
        - Endures poor treatment in relationships; fears being left alone.
      - Obsessive-Compulsive Personality Disorder:
        - Focuses excessively on order, details, and rules.
        - Perfectionistic tendencies; rigid and stubborn thinking.

Causes of Personality Disorders

  • Genetics:
      - Many personality disorders have hereditary components.
        - For instance, 30% of individuals with paranoid features have a family history of schizophrenia.
        - Borderline personality disorder is associated with genetic factors affecting serotonin functioning.

  • Childhood Trauma:
      - Studies show a link between childhood trauma (especially sexual abuse) and personality disorders, particularly borderline and antisocial traits.

  • Verbal Abuse:
      - Exposure to verbal abuse in childhood increases the likelihood of developing various personality disorders by threefold.

  • Cultural Factors:
      - Cultural influences show diverse prevalence rates among personality disorders; for example, less frequent cases of antisocial personality disorder in Asia compared to Western countries.

Working with Personality Disorders

  • Therapeutic Alliance: Develop clarity, consistency, and empathy with clients.

  • Safety/Risk Management: Monitor both self and client for risk factors, such as aggression or suicidal tendencies.

  • Boundaries: Implement clear boundaries to prevent any boundary testing.

  • Professional Awareness: Recognize that many personality disorders may go undiagnosed; clients may not perceive their issues accurately.

  • Counter Transference: Manage personal emotional responses; seek supervision for debriefing.

Substance Use Disorder

Definition

  • Substance Use Disorder: A mental health disorder that affects an individual's behavior and brain, leading to a loss of control over substance intake such as alcohol, cannabis, opioids, and stimulants.

Criteria for Substance Use Disorder (DSM-5-TR)

  • Impaired Control (Criteria 1 to 4):
      - Consuming larger amounts of the substance for longer than intended.
      - Persistent desire or unsuccessful efforts to cut down or control use.
      - Spending extensive time obtaining, using, or recovering from substance effects.
      - Experiencing strong cravings for the substance.

  • Social Impairment (Criteria 5 to 7):
      - Substance use results in failure to fulfill major obligations at work, school, or home.
      - Continued use despite significant social or interpersonal issues.
      - Reduction of recreational, social, or occupational activities due to substance use.

  • Risky Use (Criteria 8 and 9):
      - Recurrent substance use in hazardous situations.
      - Continuation despite knowledge of physical or psychological problems exacerbated by substance use.

  • Pharmacologic Effects (Criteria 10 and 11):
      - Tolerance: Increasing doses are required for the desired effect or reduced effect from usual doses.
      - Withdrawal: A range of symptoms occur when substance levels decrease, compelling individuals to seek more substance for relief.
      - Note: Medical treatment context (e.g., properly prescribed pain medication) is excluded from SUD criteria.

Effects of Substance Use Disorder

  • Chronic Effects: Alters brain neurochemistry, exhausting dopamine pools, disrupting neurotransmitter connections, ultimately leading to severe anxiety and depression.
      - Creates intense negative emotional states and diminishes emotional regulation abilities.
      - The brain develops new connections driving the reinforcement of drug use, leading to significant health complications for the individual and societal burdens.

Prevalence and Impact

  • Global Statistics (2021): Approximately 297 million drug users worldwide, with 13.2% engaging in injectable drug use.

  • Rising Rates: Rates of SUD have increased by approximately 45% over the past decade.

  • Australia Statistics:
      - Accounts for 7.2% of the disease burden.
      - Alcohol alone represents 50% of disability-adjusted life years for ages 15-34.
      - Average life expectancy for individuals with SUD is under 50 years; many die within 15 years post-treatment initiation.
      - 71% of deaths related to substance use disorder are considered accidental.

Risk Factors and Health Impacts

  • High-risk populations include First Nations, individuals diagnosed with ADHD, LGBTQIA+ communities, those with unstable housing, and individuals with poor mental health.

  • Health Risks:
      - High correlation with tobacco use (75% of SUD cases also smoke/vape), leading to increased mental distress and treatment dropout.
      - Cognitive deficits increasing dementia risk, and impulsivity are commonly observed among SUD patients.
      - Metabolic disorders, cardiovascular diseases, malnutrition, and chronic health issues also prevalent.

Treatment Approaches: Abstinence vs Harm Minimization

  • Abstinence Treatment Models:
      - Focus on eliminating all substances from the client’s life, often through 12-step programs.
      - Belief that total abstinence is the safest approach to substance use.

  • Harm Minimization Models:
      - Emphasizes a therapeutic relationship aimed at decreasing harm from substances.
      - Support clients in making healthier choices for their well-being, which may involve gradual substance reduction instead of total elimination.

Harm Minimization Strategies

  • Implement needle exchange programs.

  • Facilitate pill testing and opioid substitution therapy.

  • Promote take-home naloxone programs and liver screening in treatment settings.

  • Establish safe injecting centers and educate on safe drug-use practices.

  • Include lifestyle interventions.

Benefits of Exercise in Substance Use Disorder

  • Enhances self-esteem and cognitive function.

  • Reduces stress and improves sleep quality.

  • Fosters routine and positive self-image while acting as a distraction from cravings.

  • Contributes to overall quality of life and alleviates symptoms of depression, anxiety, and mood disorders while supporting pain management and social interaction.

Safety Considerations

  • Awareness During Exercise: Monitor intoxication and withdrawal signs during outpatient services.

  • Increased risks such as impulsivity and cognitive impairments may lead to injury.

  • Certain substances heighten risks during withdrawal (e.g., seizures during alcohol withdrawal).

  • Aggression Management: Create safe environments for potentially aggressive clients and techniques for signaling assistance.

  • Burnout and Vicarious Trauma: Acknowledge emotional strain from working with SUD and establish robust debriefing practices.

  • Maintain professional boundaries to prevent emotional overconnection with clients.

Eating Disorders

Definition

  • Eating Disorders: Manifest as obsessive control over food, weight, and body image, often aimed at managing deeper psychological issues, ultimately leading to feelings of hopelessness and self-loathing.

Eating Disorders in Australia

  • Approximately 22.2% of adolescents meet criteria for an eating disorder (31.3% among females).

  • Roughly 4.45% of the Australian population (1.1 million individuals) is currently living with an eating disorder.

  • Eating disorders hold some of the highest mortality rates among mental illnesses, with Anorexia Nervosa alone accounting for 450 deaths annually.

  • Rates of eating disorders are on the rise in Australia.

Types of Eating Disorders

  • Anorexia Nervosa: Extreme dietary restriction, notable weight loss, and fear of gaining weight.

  • Avoidant/Restrictive Food Intake Disorder: Restriction due to sensory aversions or significant concerns about negative consequences of eating, leading to nutritional deficiencies.

  • Binge Eating Disorder: Characterized by episodes of binge eating without compensatory measures.

  • Bulimia Nervosa: Involves binge eating followed by methods to prevent weight gain (e.g., purging).

  • Other Specified Feeding or Eating Disorder: Affects life significantly but does not fully meet other diagnostic criteria.

  • PICA: Consistent consumption of non-nutritive substances.

  • Rumination Disorder: Regular regurgitation of food, which may be re-chewed or spit out.

  • Unspecified Feeding or Eating Disorder: Disordered eating behaviors that significantly impact one’s life, not classified under other categories.

Risk Factors for Eating Disorders

  • Genetic Factors: No specific genes identified but may share risks with other psychopathologies like depression.

  • Trauma and Life Experiences:
      - Childhood sexual abuse, neglect, or post-traumatic stress contribute significantly to development.

  • Temperamental and Cognitive Features:
      - Common across disorders include low self-esteem, body dissatisfaction, and impaired emotional regulation.

  • Family Dynamics: Parental behaviors, high expectations, and childhood experiences play crucial roles in the development.

  • Cultural and Social Influences: Participation in aesthetic sports and societal pressure regarding weight can be significant.

Exercise in Eating Disorders

  • Benefits of Exercise:
      - Supports mental health and aids in emotional regulation.
      - Enhances compliance with treatment and maintains bone density.
      - Improves quality of life and body image.
      - Addresses gastrointestinal symptoms during recovery.
      - Combats exercise addiction during recovery.

  • Risks of Compulsive Exercise: Described as an uncontrollable need for exercise despite adverse consequences such as injuries and social isolation.
      - Factors of Exercise Addiction:
        - Salience (overvaluing exercise), conflict with personal relationships, mood modification (to escape of improve mood), tolerance (increased exercise volume), withdrawal (anxiety from missed sessions), and relapse (inability to cut back).

Safe Exercise at Every Stage Guidelines (SEES)

  • Components:
      - Highly individualized with consideration for intensity, duration, stretching.
      - Different levels (A to D) outline progressive exercise plans from basic to more intense exercises.

    • Level A: review weekly - cardiovascular profile, biomechanical profile, psychological profile, other (temp).

    • Level B: review fortnightly - cleared all prior risk markers and is also adhering to: positive weight gain trajectory, weight stabilisation/mobilisation aligned to treatment goals, BMD assessment when needed.

    • Level C: review monthly - cleared all prior risk markers and is also adhering to: weight stabilisation/gain, level A markers related to ED are completely normalised, managing ED behaviours, normalised sex hormones without exogenous replacement.

    • Level D: review as required - cleared all prior risk markers and is also adhering to: weight progression >90% of IBW.

  • Exercise Protocols:

    • Level A: Medically supervised low intensity, limited duration - no cardiovascular/respiratory or resistance exercise.

    • Level B: Supervised moderate intensity, limited duration - low impact or social/game focused cardiovascular/respiratory and social/functional body weight resistance exercise.

    • Level C: High intensity workouts with prolonged duration - moderate impact cardiovascular/respiratory and all resistance exercise.

    • Level D: Individualised intensity and duration - high impact/return to sport cardiovascular/respiratory and all resistance/previously dysfunctional resistance exercise.

Potential Impacts of Unmodifed Exercise and Low Energy Availability (LEA)

  • Cardiovascular Problems: Bradycardia, tachycardia, hypotension, and electrophysiological complications such as prolonged QTc intervals and arrhythmias.

  • Electrolyte Malfunctions: Issues related to potassium, magnesium, and phosphate imbalances, hypercarbia (higher than normal bicarbonate level), hyponatremia (low sodium - mild to severe symptoms).

  • Hormonal Disruptions: Hypothalamic amenorrhea, central hypothalamic hypogonadism, and decreased bone mineral density.

    • Hypothalamic Amenorrhea: a condition characterized by the absence of menstrual periods resulting from disruptions in the hypothalamus due to stress, significant weight loss, or excessive exercise.

    • Central Hypothalamic Hypogonadism: a condition where the hypothalamus fails to produce adequate gonadotropin-releasing hormone (GnRH), which can lead to reduced levels of sex hormones and may result in symptoms such as infertility, decreased libido, and impaired sexual function.

  • Hypothermia or Hyperthermia: hypothermia (decreased psychological and cardiac functioning), hyperthermia (heat stroke).

Body Neutral Approach

  • Concept: Promotes body acceptance based on abilities rather than appearance, emphasizing the importance of recognizing one's health over weight.

  • Focus Areas: How exercise feels physically, nurturing the body with adequate fuel/rest, and acknowledging personal progress without focusing on visible changes in body shape or weight.

Review of Exercise Guidelines and Conclusion

  • SEES Guidelines provided a framework for safe exercise in eating disorder treatment, enhancing clients’ physical and mental well-being throughout their recovery journey.

References

  • Mitchison D, Mond J, Bussey K, et al. (2020). Psychological Medicine.

  • InsideOut Institute for Eating Disorders.

  • Hopkins D. W., et al. (2023). ACSM's Health & Fitness Journal.

  • Cook BJ, et al. (2016). Med Sci Sports Exerc.

  • Bergmeier H. J., et al. (2019). Eating Disorders.

  • Griffiths MD, et al. (2005). British Journal of Sports Medicine.

  • Lichtenstein M. B., et al. (2017). Psychology Research and Behavior Management.

  • Abrantes A. M., et al. (2011). Mental health and physical activity.

  • Dowla R., et al. (2021). Journal of Clinical Exercise Physiology.

  • Nock N. L., et al. (2024). Current Sports Medicine Reports.

  • AIHW (2024). Alcohol, tobacco & other drugs in Australia.

  • Nazmin F., et al. (2024). Cureus.