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Rusmiddelmisbruk og spiseforstyrrelser. Sammenfall og sammenhenger : en litteraturstudie

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ABSTRACT

NORSK SAMMENDRAG: Det første temakapittelet refererer studier av ungdom og sammenfallende atferd, både i den generelle ungdomsbefolkningen og i behandling for henholdsvis spiseforstyrrelser og rusmiddelmisbruk. De epidemiologiske studiene viser sammenhenger mellom slankeatferd, bulimisk atferd og kroppsmisnøye, – og bruk av tobakk, alkohol og narkotika, blant både gutter og jenter i alderen 10 til 20 år. De kliniske studiene viser at ungdom i behandling for bulimi bruker rusmidler i større grad enn ungdom i behandling for anoreksi. Ungdom i behandling for rusmiddelproblemer ser ut til å vise større grad av spiseforstyrret atferd enn annen ungdom. Samvariasjon Befolkningsstudier av voksne omfatter kvinner i alderen 16 til 59 år. Studiene ser på spiseforstyrrelser/spiseforstyrret atferd i forhold til bruk/misbruk av henholdsvis tobakk, alkohol og narkotika/flere rusmidler. Røyking ser ut til i en viss grad å samvariere med spiseforstyrrelser/spiseforstyrret atferd, misnøye med kroppen, vektfobi, lav selvfølelse samt sosial utrygghet. Kvinner med diagnostisert bulimi eller med bulimisk spiseforstyrret atferd misbruker og/eller opplever negative konsekvenser av alkohol i større grad enn andre kvinner. Det samme gjelder for bruk av narkotiske stoffer. Bulimi og rusmidler Studier av voksne i behandling for enten spiseforstyrrelser eller rusmiddelproblemer viser at kvinner i behandling for bulimi røyker, drikker og bruker mer narkotika og legemidler utover det foreskrevne, enn kvinner i behandling for anoreksi. Sammenlignet med prevalenstall for befolkningen for øvrig, ser det ut til at kvinner i behandling for bulimi viser en høyere frekvens enn kvinner generelt når det gjelder bruk av tobakk, alkohol, narkotika og legemidler utover det foreskrevne. Blant kvinner og menn i behandling for rusmiddelmisbruk kan det synes som om fullt utviklede spiseforstyrrelser (spesielt av typen bulimi) eller spiseforstyrret atferd er mer utbredt enn i den øvrige befolkningen. Kjønnsfordeling Når det gjelder kjønnsfordelingen, ser vi at for voksne utgjør kvinner majoriteten av utvalget med komorbide lidelser, i likhet med utvalg med spiseforstyrrelser. Når det gjelder ungdom ser vi imidlertid en økt hyppighet av spiseforstyrret atferd blant gutter, slik at den sammenfallende problematferden er likere fordelt mellom kjønnene. Sammenhenger mellom spiseforstyrret atferd og bruk av rusmidler er til dels like sterke eller sterkere for guttene. Kvinner og menn, jenter og gutter, som lider av både spiseforstyrrelser og rusmiddelmisbruk ser ut til å utvikle spiseforstyrrelser først og rusmiddelproblemer senere. Dette er i tråd med det vi vet om debutalder for de to lidelsene hver for seg. Årsaker til samvariasjon Det siste kapittelet gjengir mulige årsaksforklaringer til samvariasjoner mellom rusmiddelmisbruk og spiseforstyrrelser. Vi deler forklaringene inn i biologiske, psykologiske og kulturelle årsaksforklaringer, der de biologiske inkluderer forklaringer med utgangspunkt i hjernens impulser og nervebaner, genetisk arv og kroppslig utvikling. De psykologiske forklaringstypene berører temaer som selvfølelse, mestring, impulsivitet, psykologisk avhengighet, traumatiske erfaringer, samt andre psykiske lidelser (særlig depresjon, angst, personlighetsforstyrrelser). Kulturelle forklaringer omfatter her jevnaldrene og massemedia. Hjernefysiologi, impulsivitet, selvfølelse og flere psykiske lidelser ser ut til å være forklaringstyper som samler støtte. Gjennomgangen antyder også at mange faktorer synes å virke sammen i utvikling av sammenfallende spiseforstyrrelser og rusmiddelmisbruk, for eksempel i form av disponerende, utløsende og vedlikeholdende faktorer. Det er imidlertid få studier som beveger seg inn i de komplekse relasjonene mellom forklaringstyper. De inkluderte artiklene inneholder i liten grad håndgripelige råd om forebygging og behandling, bortsett fra en sterk anbefaling av kartlegging. I norsk sammenheng står vi overfor store utfordringer når det gjelder både kartlegging og dokumentasjon av de sammensatte lidelsene, forebygging, utvikling av behandlingsmodeller og forskning. Mangelen på kvalitative forskningsbidrag og fenomenologisk kunnskap på dette området, også internasjonalt, er iøyenfallende. ENGLISH SUMMARY: This is a literature study of co-occurence and connections between eating disorders and substance abuse. The object of this report is to give a presentation of relevant international studies of co-occurence and co-morbidity between eating disorders or disordered eating and use or abuse of various substances. We have reviewed 55 clinical and community studies from 1986 to 2005, mainly from North America and Western Europe, as well as five reviews/reports and a number of theme articles. This report consists of eight chapters, including an introductory chapter. Chapter two describes substance abuse and eating disorders providing definitions, prevalence and instruments for measurement. The next five chapters are based on types of studies, all with introductory information about the studies, the samples, and the use of tests. Chapter three includes studies of co-occurring problem behaviours among youth, focusing both on youth in general and on youth residing in treatment for either eating disorders or substance abuse. According to the community studies, there are links between dieting, bulimic behaviour and body dissatisfaction, on one side, and the use of cigarettes, alcohol and drugs (illegal substances) on the other among both boys and girls ages 10 to 20. The clinical studies demonstrate that young people in treatment for bulimia nervosa use more substances than young people in treatment for anorexia nervosa. Young people in treatment for substance abuse show more disordered eating than young people in general. Community studies of adults include women aged 16 to 59. The topic is eating disorders/disordered eating in relations to tobacco, alcohol and drugs. Smoking shows some co-occurrence with eating disorders/disordered eating, body dissatisfaction, drive for thinness, ineffectiveness and social insecurity. To a larger extent than women in general, women with diagnostic bulimia or with bulimic disordered eating abuse alcohol and/or experience negative consequences of alcohol. The pattern is similar for the use of drugs. Studies of adults in treatment for either eating disorders or substance abuse show that women in treatment for bulimia smoke more cigarettes, drink more alcohol and use more drugs and psychotropics (by self-prescription), than women in treatment for anorexia. Compared to prevalence numbers for women in general, women in treatment for bulimia seem to show a higher prevalence concerning use of tobacco, alcohol, drugs and psychotropics (by self-prescription). Among men and women in treatment for substance abuse, full-blown eating disorders (especially bulimia) or disordered eating is more prevalent than in others. The included studies demonstrate that for adults, women constitute the majority of those with comorbid eating disorders and substance abuse, as they constitute the majority of those with eating disorders only. For youngsters we find an elevated frequency of eating disorders among boys, making the comorbid problem behaviours more equally distributed among the sexes. The connections between disordered eating and use of substances seem to a certain extent to be equally strong or stronger among boys than girls. Women and men, girls and boys, suffering from both eating disorders and substance abuse, predominantly develop eating disorders first and substance abuse later. This is congruent with what we know about age of onset for each of the two disorders. The last chapter of this report looks at various possible risks or reasons for the co-occurence between substance abuse and eating disorders. Dividing them into biological, psychological and cultural explanations, the biological explanations include brain impulses and circuits, genetics and physical development. The psychological explanations concern self-esteem, coping, addiction, traumas, and psychiatric diagnoses (especially major depression, anxiety and personality disorders). Cultural explanations include influence from peers and mass media. Brain physiology, impulsivity, self-esteem and additional psychopathology seem to be the most common type of explanations. The review of the articles also suggests that various factors can play together in the development of comorbid eating disorders and substance abuse, for instance as predisposing, eliciting and maintaining factors. The included articles offer little advice on prevention and treatment but strongly recommend screening/testing for substance abuse when dealing with eating disorders, and vice versa. In Norway we face great challenges regarding documenting and prevention, developing of treatment models, and further research. There is an obvious scarcity of qualitative research and phenomenological knowledge in the field.

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    ABSTRACT: NORSK SAMMENDRAG: Rapporten er en evaluering av Regionprosjektet, et statlig styrt, lokalt basert forebyggingsprosjekt som ble initiert av Bondevik II-regjeringen. Ingeborg Rossow, Bergljot Baklien, Hilde Pape og Elisabet E. Storvoll står bak evalueringen, som er gjort på oppdrag av det tidligere Sosialdepartementet. Analysene bygger på et omfattende datamateriale der bl.a. intervjuer med aktører på sentralt og lokalt nivå, observasjon av møter og iverksetting av tiltak, spørreskjemaundersøkelser av 40 000 skoleungdommer og kjøpsforsøk i butikker som selger øl inngår. Ingen kortsiktige effekter Regionprosjektet hovedmålsetting om å redusere rusmiddelbruk og begrense rusrelaterte skader blant ungdom ble ikke innfridd i løpet av den perioden som evalueringen dekker (2004-2006). Prosjektet bidro heller ikke til å begrense ungdoms tilgang på alkohol. Rapporten peker på flere mulige forklaringer på de manglende resultatene. Bare et fåtall av tiltakene som kommunene ble anbefalt av Sosial- og helsedirektoratet hadde dokumentert effekt på rusmiddelbruk og rusrelaterte skader. Mange av tiltakene hadde et langt tidsperspektiv og noen ble satt i gang i ufullstendige "light"-versjoner. Samarbeid og ny kunnskap Regionprosjektet har derimot ført til at en del av kommunene har etablert nye tverrfaglige samarbeidsformer både internt og seg i mellom. Når det gjelder tilpasning og videreutvikling av forebyggingstiltak, har dessuten den lokale kompetansen økt. Organiseringen i kommunene har vært funksjonell, og prosjektet har hatt god politisk og administrativ forankring lokalt. Samarbeidet med Sosial- og helsedirektoratet på sentralt nivå opplevde derimot mange av de involverte kommunene som problematisk. Framtidig forebygging Rapporten peker på at ingen av kommunene i Regionprosjektet har tatt i bruk de mest virksomme strategiene i rusforebygging. Forskning viser at det å begrense tilgjengeligheten på alkohol har effekt. Strengere håndheving av salgs- og skjenkebestemmelsene kan også være virksomme forebyggingstiltak. Fakta om Regionprosjektet Regionprosjektet var en del av Bondevik II-regjeringens Handlingsplan mot rusmiddelproblemer (2003-2005). Hovedmålsettingen var å utvikle gode forebyggende tiltak og å videreutvikle eksisterende tiltak med sikte på å begrense rusmiddelbruk og rusmiddelrelaterte skader, med hovedfokus på barn og unge. Seks kommuner/regioner ble valgt ut til å delta i prosjektet: Larvik, Haugesund, Narvik, Os, Nesodden og fire kommuner på Ytre Søre Sunnmøre. De mottok til sammen 20 millioner kroner over en periode på tre år, og fikk i tillegg faglig veiledning fra de regionale kompetansesentrene for rusmiddelspørsmål. Sosial- og helsedirektoratet sto for den sentrale styringen av prosjektet. ENGLISH ABSTRACT: This report deals with the evaluation of the Regional Project. This project was part of the Plan of Action to Prevent Alcohol and Drug Problems (2003-2005) of the Norwegian Government under Prime Minister Bondevik (II). As we interpret the Plan of Action, the main aim of the project was to develop effective preventive measures and to develop further existing measures with a view to limiting the use of alcohol and drugs, and harms related to substance use, with the main focus on children and young people. Six municipalities / regions (called test municipalities) were chosen to participate in the Regional Project. Altogether they were granted NOK 20 million over a period of three years; the amount per municipality reflected the population size. In addition they were given professional guidance from the Regional Resource Centres for Alcohol and Drug Issues. The Norwegian Directorate for Health and Social Affairs was responsible for the central management of the project. The aims of the evaluation were: • to assess how the intentions of the Plan of Action were translated and interpreted by the Norwegian Directorate for Health and Social Affairs, and subsequently by the test municipalities • to find out how the extra allocation of funding for preventive work in the field of alcohol and drug problems, together with central management and professional follow-up from the Regional Resource Centres, were transformed into measures at the local level • to investigate how organization of the Regional Project, both centrally and locally, influenced the implementation and accomplishment of the measures • to identify whether there were indications that the activities had resulted in reduced use of alcohol and drugs, fewer alcohol-related problems, and more limited availability of alcohol for young people under the age-limit • to find out whether the use of resources had had other positive effects in the local community, for example in the form of increased skills or new structures for cooperation • to highlight positive experiences that can be developed in other locally-based measures. We carried out both process and effect evaluation of the Regional Project. The analyses were based on a comprehensive data material, which included documents, videos, observations of meetings and implementation of measures, a large number of interviews with key persons at the central and local levels, questionnaire surveys of almost 40 000 school children in the test and control municipalities before and after implementation of the measures, attempts to buy beer in shops before and after the measures, and a survey of preventive activities in all the lower secondary and upper secondary schools in all the test and control municipalities during the project period. A central working group for the project was appointed with representatives from all the seven Regional Resource Centres and the central project leader in the Norwegian Directorate for Health and Social Affairs. In addition to professional follow-up of the test municipalities, the Regional Resource Centres acted as coordinators between the central and local levels. This organization meant that the test municipalities had limited influence on the central management of the project. The Norwegian Directorate for Health and Social Affairs operationalized the Plan of Action, and developed a list of twelve recommended preventive measures. However, only a few of these measures had documented effect on substance use and related harms. This recommendation of preventive measures reduced the sense of ownership of the intervention at the local level Follow up from the Regional Resource Centres varied between the municipalities both in extent and content. The local conditions for implementation also varied, both with regard to continuation of established projects and cooperation, and with regard to organization of the project. At the start of the project, the management of the project by the Directorate was fairly strong and detailed. Moreover, communication from the central to the local level was unclear, both with respect to the time scale for the project, how much funding each test municipality would receive, and whether the municipalities could choose measures that were not on the list. The unclear signals from the central level led to frustration as well as a delay in implementation of measures the local level. The test municipalities’ own considerations (regarding factors such as whether the measures were easy to implement) were of primary importance when the test municipalities chose preventive measures. In addition to the measures on the Directorate’s list, most of the municipalities also chose a range of other interventions. In several cases this involved continuation of projects that were already underway. Children and young people were the most important target groups, and many of the measures had a long-term perspective. Not all the measures were implemented according to the plan. Several of the municipalities implemented more measures than they had originally committed themselves to, and we saw much enthusiasm and drive in the test municipalities. Effect evaluation was primarily based on questionnaire surveys of 13-19 year old school children in the test municipalities and in seven control municipalities. The results gave no indication that the Regional Project had led to reduced alcohol use, drug use or related harms. There was also nothing to indicate that the project had contributed to limiting the availability of alcohol to young people. The analyses also did not give any indication that the Regional Project had contributed to improving young people’s knowledge or changing their attitudes to alcohol and drugs, or to the limits set by parents with regard to alcohol and drugs, or parents’ communication about this. We also evaluated the effect of one measure, for which the aim was to limit sale of alcohol to young people under the age-limit, and found no effects. There are several possible explanations for the discouraging results of the effect evaluation: The measures had very limited potential for prevention, several measures had long-term perspectives and some of them were implemented as incomplete “light versions”. It is also worth mentioning that background figures indicate that the number of establishments for selling and serving alcohol in the test municipalities was relatively stable during the project period. However, the Regional Project seems to have had other positive effects. Local coordination and local ownership were central concepts in the Plan of Action. The project’s only example of inter-municipal cooperation and coordination showed that this is both demanding and productive. Some municipalities had their own coordination measures, and they all succeeded in improving multi-sectoral and inter-agency cooperation. In addition, local skills in adaptation and development of measures were improved. The local organization in the test municipalities was generally good and functioned well, and led to coordination of personnel resources between agencies and departments. The Regional Project had a sound political basis in most of the test municipalities, as a result of both the involvement and active commitment of the chairperson of the municipal council and the chief municipal executive. Personal factors such as enthusiasm and competence, legitimacy and ability to find room to manoeuvre, were important for the project at all levels. Another important experience gained was related to the time-scale. Several of the municipalities regarded prevention of alcohol and drug problems as long-term work. Both building the foundation and implementing the work take time, but the centrally-determined time-scale took little account of long-term ambitions. In conclusion, we found that the Regional Project achieved the aims of the Plan of Action only in some areas. This was primarily in the areas of local coordination and cooperation. We found no evidence that the main aims of limiting use of alcohol and drugs, limiting alcohol related harms, and limiting availability of alcohol to young people, were achieved. This is probably related to the fact that none of the municipalities implemented measures that are most likely to be effective; - i.e. limiting the availability of alcohol (number and opening hours of outlets), and increased enforcement of alcohol sales regulations (controls and sanctions).
    Full-text · Article · Jan 2007