Eating Disorders and Substance Abuse Recovery

Eating disorders impact about 30 million people in the United States. The National Association of Anorexia Nervosa and Associated Disorders (ANAD) warns that of all mental illnesses, eating disorders have the highest mortality rate, as an American dies about once every hour from causes directly related to an eating disorder.

Eating disorders drastically impact a person’s emotional and physical health, and they can have significant social, personal, and behavioral consequences. Work production and interpersonal relationships often suffer as a result of an eating disorder. An eating disorder can disrupt normal and daily life functioning and a person’s ability to carry out normal tasks and obligations.

Eating disorders are serious and potentially life-threatening mental illnesses that regularly go unchecked or overlooked. Shame, guilt, and denial are common barriers to treatment. Without professional help, an eating disorder can have tragic consequences, leading to a plethora of physical and emotional issues. Fortunately, with specialized care, eating disorders can be managed. The earlier a person seeks treatment for an eating disorder, the better.

The Connection between Eating Disorders and Substance Abuse

Individuals who suffer from an eating disorder are four times more likely than the general population to also struggle with a substance use disorder, the National Eating Disorders Association (NEDA) publishes. NEDA further reports that around half of all individuals battling an eating disorder also abuse alcohol and/or drugs.

Alcohol is a common substance of abuse for those suffering from eating disorders. The Anorexia Nervosa & Associated Eating Disorders (ANRED) reports that nearly 75 percent of women under 30 who struggle with alcohol addiction also battle an eating disorder. Drugs and alcohol may serve as form of self-medication for difficult emotions that may be an integral factor of an eating disorder. Low self-esteem, depression, and anxiety are often side effects of an eating disorder that may increase a person’s vulnerability to addiction.

Alcohol can make a person feel happy and reduce tension and anxiety, and it can also increase sociability and temporarily block emotional pain and distress. It also acts as a dehydrating agent and tool for promoting regurgitation. Stimulant drugs, such as cocaine, methamphetamine, and prescription amphetamines like those used to treat attention deficit hyperactivity disorder, or ADHD, are appetite suppressants, which may be desirable for someone who struggles with body image and weight. These substances may be misused in an attempt to control appetite and therefore induce unhealthy weight loss. Over-the-counter (OTC) medications, including laxatives, weight loss supplements, diuretics, syrup of ipecac, and diet pills, may also be regularly abused by individuals struggling with an eating disorder. Those who struggle with co-occurring eating disorders and addiction are at a greater risk for medical and emotional complications, including heightened odds for suicidal ideations.

Alcohol and drug abuse may precede an eating disorder, and addiction may even lead to the onset of an eating disorder. For instance, drugs and alcohol change brain chemistry and disrupt appetite levels. This may cause a person to eat more or less than they normally would and set up unhealthy eating habits that can potentially lead to an eating disorder. As brain chemistry becomes more fixed and drug dependence sets in, withdrawal symptoms can impact eating patterns and appetite levels as well. As the pleasure center of the brain is disrupted and suppressed during drug and alcohol withdrawal, individuals may overeat as a result, for example.

Eating disorders and addiction share many common vulnerabilities and overlapping risk factors, as published by the journal Social Work Today. These include:

• Dysfunctions in brain chemistry and/or issues related to similar regions of the brain
• Heightened sensitivity to advertising and messages put out by the entertainment and social media
• Shared family history and genetic risk factors
• High levels of stress or difficult transitions
• History of childhood neglect or trauma
• Incidence of physical or sexual abuse
• Susceptibility to peer pressure or unhealthy peer norms
• Impulsivity, anxiety, low self-esteem, or depression

More women, especially young women, suffer from eating disorders than men; however, anyone can struggle with one regardless of age, gender, race, or age. No matter which disorder came first, both substance abuse and eating disorders can be effectively managed through comprehensive and integrated programs.

Recognizing an Eating Disorder and Substance Abuse Issues

Co-occurring eating disorders and addiction exacerbate each other and complicate treatment. An integrated and simultaneous approach to managing both disorders is considered the optimal method to enhance recovery and minimize instances of relapse.

In order to better care for these co-occurring disorders, it is helpful to be able to recognize the signs. Some of the most common eating disorders, and rates of their co-occurrence with substance abuse, are highlighted below.

Bulimia nervosa

People who suffer from bulimia may be able to maintain a healthy weight, and it may be difficult to recognize that a problem exists. Someone who struggles with bulimia will eat food in unhealthy binge and purge patterns. Individuals will eat relatively large portions and be unable to control these binges, which are then followed by some mechanism of purging what was taken in. The purge may be done by forced vomiting, excessive exercise, misuse of laxatives and/or diuretics, fasting, or through several of these behaviors combined.

The Substance Abuse and Mental Health Services Administration (SAMHSA) reports lifetime co-occurrence of bulimia and addiction to be 36.8 percent, with a 33.7 percent lifetime co-occurrence of alcohol addiction and a 26 percent lifetime co-occurrence of illicit drug addiction. Individuals struggling with bulimia may be highly impulsive, which can lead to other self-destructive and risk-taking behaviors, including drug and alcohol abuse, gambling, and/or promiscuity. Additional recognizable symptoms of bulimia include:

• Degradation of tooth enamel and overall oral health from repeated exposure to stomach acid
• Swollen jaw and neck from inflamed salivary glands
• Chronic sore and irritated throat
• Significant dehydration
• Electrolyte imbalance
• Gastrointestinal problems, including intestinal irritation or acid reflux disorder

The National Institute on Mental Illness (NIMH) publishes that approximately 1.5 percent of women and 0.5 percent of men in the United States battled bulimia in 2007.

Anorexia nervosa

NIMH reports lifetime anorexia prevalence rates of 0.9 percent for women and 0.3 percent for men. People who suffer from anorexia will commonly see themselves as overweight no matter how underweight they actually are and may therefore starve themselves, or eat very small amounts, in an attempt to control their weight. Individuals battling anorexia regularly weigh themselves and significantly restrict how much and what types of foods they eat.

Symptoms of anorexia include:

• Extreme fear of weight gain
• Significant thinness or emaciation
• Distorted body image
• Self-esteem that heavily relies on perception of body shape and size
• Denial of low body weight
• Suicidal thoughts and/or actions
• Unwillingness to maintain healthy body weight
• Unrelenting pursuit of weight loss and thinness

Anorexia can result in brittle nails and hair, anemia, thinning of the bones, severe constipation, low blood pressure, muscle loss and weakness, fatigue, sluggishness, dip in body temperature and feeling cold constantly, yellowish and dry skin, infertility, growth of lanugo (fine hair) all over body, organ failure, and damage to the heart, brain and other internal organs.

SAMHSA reports that there is a lifetime prevalence rate of co-occurrence with addiction and anorexia of 27 percent. Alcohol addiction and anorexia co-occur at lifetime rates of 24.5 percent, while illicit drug abuse and anorexia have a lifetime co-occurrence rate of 17.7 percent.
Binge eating disorder

Approximately 3.5 percent of women and 2 percent of men suffer from binge eating disorder at some point in their lifetime, NIMH reports, making it the most common eating disorder in America. Binge eating episodes are similar to those associated with bulimia without the purging, generally resulting in people struggling with binge eating disorder being overweight or obese. Individuals are unable to control their eating and will eat when they are not hungry or when they are already uncomfortably full.

Symptoms of binge eating disorder include:

• Episodes of binging, or eating large amounts of food during a set time
• Eating quickly during binges
• Isolating oneself while eating or eating in secret
• Feelings of shame and guilt about eating patterns
• Numerous attempts to diet, often without losing weight

Approximately 23.3 percent of Americans who struggle with binge eating disorder in their lives will also battle addiction, with a 21.4 percent lifetime co-occurrence rate for alcohol addiction and a 19.4 percent lifetime co-occurrence rate for illicit drug addiction, SAMHSA publishes.

Other specified feeding or eating disorder (OSFED)

Eating disorders that do not quite fit the criteria for bulimia, anorexia, or binge eating disorder are often classified as OSFED. These disorders may include anorexia without significantly low weight, night eating, purging disorder, or bulimia or binge eating disorder with fewer episodes than standard versions of the disorders. ANAD reports that about 10 percent of people battling an OSFED also struggle with addiction, generally with alcohol addiction.

Getting Help for Eating Disorders and Co-Occurring Substance Abuse

Treatment for co-occurring eating and substance use disorders is specialized and individual in nature. A thorough evaluation and drug screening should be done before a person is admitted into a treatment program in order to determine the proper level of care and the right treatment modality. Polydrug abuse is common in co-occurring disorders, and it is imperative to know what substances are being abused before administering any kind of medications.

Addiction can make the side effects and risk factors for an eating disorder worse and vice versa. It is important to treat both disorders together in a seamless fashion. Both food and drugs/alcohol may be used as unhealthy coping mechanisms in recovery for one of the disorders. For instance, drugs and alcohol may be a method of managing the stress of recovery for an eating disorder while unhealthy eating patterns may become substitutes for drugs and/or alcohol in recovery for addiction.

If either or both disorders are severe, a higher level of care is needed during treatment to foster recovery from both disorders simultaneously. Both residential and outpatient programs can offer support and treatment services for eating disorders and addiction; however, residential treatment programs are typically optimal in caring for co-occurring disorders.

Medications and Therapeutic Treatment Approaches

Individuals who are significantly malnourished due to an eating disorder may need medical stabilization before any further treatment is administered. In similar fashion, individuals who are severely dependent on drugs or alcohol will often need to reach a level of physical stabilization through a medical detox program before entering into a complete addiction treatment program. Bulimia and binge eating disorder may be treated with medications like fluoxetine, an antidepressant selective serotonin reuptake inhibitor (SSRI), or topiramate, an anticonvulsant. During medical detox, medications may be beneficial in helping to manage withdrawal symptoms and cravings. Pharmacological tools may also be beneficial during treatment and recovery to dispel cravings, work as deterrents for further drug or alcohol abuse, and stabilize moods.

Nutritional rehabilitation is often needed for individuals battling eating disorders and addiction. A dietician can help to correct malnutrition issues and design a plan to help the person achieve a healthy weight. Individuals struggling with anorexia may need to undergo “refeeding,” which is a supervised and slow reintroduction of nutrients to stabilize malnutrition due to anorexia.

Medications and physical stabilization are only part of the treatment protocol for co-occurring addiction and an eating disorder. Therapeutic methods are very important as well. Cognitive Behavioral Therapy (CBT) is used to treat both eating disorders and addiction as it can help people to learn healthy coping mechanisms and tools for managing stress and difficult emotions. Thoughts, feelings, and actions are complexly intertwined, and CBT can explore these connections and lead to improvements in self-esteem while teaching new and healthy habits for recovery. It can be relevant to know which disorder came first, the eating disorder or addiction, when working through a treatment program, and CBT aids in uncovering the root cause of these disorders. Group therapy and counseling sessions comprised of other people who also suffer from similar disorders can be highly beneficial as participants learn from shared experiences.

The Maudsley approach is a short-term family therapy that is generally used to treat adolescents struggling with eating disorders. This method involves parents and families who are to take initial control over the teen’s eating under a therapist’s direction. Additional sessions help a person to regain control over their eating after weight gain and significant resolution of eating disorder symptoms are achieved. Interpersonal therapy is regularly used to treat bulimia and focuses on improving relationships with others in order to reduce frustration and control negative emotions.

Relapse prevention programs are especially important for a sustained recovery from both disorders. Support groups that are tailored to individuals struggling with co-occurring addiction and an eating disorder offer ongoing encouragement and healthy peer connections for recovery as well as tools for minimizing and reducing relapse.

While the presence of co-occurring disorders complicates treatment, eating disorders and addiction can be managed with a comprehensive treatment program that is individually tailored to improve each client’s overall health and wellbeing.