Examining Treatment for Co-Occurring Substance abuse and Eating Disorders

Although it does happen from time to time, behavioral health disorders are known to occur simultaneously and in groups. As such it is not uncommon, for example, for a person with borderline personality disorder to also suffer from major depression. These disorders can amplify or trigger each other, causing a need for concurrent treatment that addresses both conditions.

Eating disorders are no different.

Anorexia nervosa, bulimia nervosa, binge eating disorder, and other forms of disordered eating are often forms of coping mechanisms for other negative emotions. These are often triggered by PTSD, depression caused by low self-esteem, or anxiety. According to a 2012 study (Mitchell et al), “approximately one-third of women with bulimia, 20% with binge eating disorder and 11.8% with non-bulimic/non-binge eating disorders met criteria for lifetime PTSD.” Depression, anxiety, and OCD are also common co-occurring diagnoses with various forms of eating disorders. These disorders are also frequently dually diagnosed with one of the more prevalent behavioral health issues in the United States: substance abuse.

What Is Substance Use Disorder?

As defined by the National Institute for Mental Health (NIMH), “A substance use disorder (SUD) is a mental disorder that affects a person’s brain and behavior, leading to a person’s inability to control their use of substances such as legal or illegal drugs, alcohol, or medications.”Essentially, some people are more susceptible to substance abuse and addiction, and a person’s brain can become “re-wired” by subspace abuse. In recent years, this has become more recognized (and treated) as a mental health issue rather than a criminal one, to the benefit of many.

Substance abuse treatment is similar to eating disorder treatment in many ways. Both are expected to be long processes, with relapses and regression to be expected. Both also require a full continuum of care that addresses underlying causes as well as symptomatic behaviors. Physical health and nutrition levels can be severely affected by both types of disorders as well. For this reason, understanding the connections between the two is a must for successful outcomes in treatment.

What Are Eating Disorders?

Eating disorders are a range of psychiatric conditions that center on a person’s eating habits, nutrition levels, and body weight (and often include issues with body image and perfectionism). They affect men and women, despite the misconception that only women can get eating disorders. They also disproportionately affect LGBTQ individuals, which adds comorbidity to an already at-risk population. Eating disorders are among the most dangerous forms of mental health disorders, leading to high rates of suicide and self-harm. The types of eating disorders observed in people include (but are not limited to):

• Anorexia nervosa – A form of restrictive eating disorder characterized by limited or no food intake for long periods, with associated weight loss and nutritional imbalances. Anorexia nervosa is often accompanied by excessive exercise and pronounced body image distortions.
• Bulimia nervosa – Characterized by binge eating episodes followed by purging behaviors to offset the calories taken in, often by self-induced vomiting but also through exercise or laxative abuse. Bulimia nervosa causes body image distortions as well, but the individual may or may not lose weight.
• Binge eating disorder – Also concurrent with body image and a desire to lose weight, binge eating disorder spurs binge eating episodes on a regular basis, often triggered by attempts to diet or control eating in public. Binge eating disorder does not include compensatory purging behaviors. It is the most common form of eating disorder in the United States.
• Other eating disorders – There are many other forms of eating disorders, many of which are not associated with body image distortions. These may include Avoidant/Restrictive Food Intake Disorder (ARFID), orthorexia nervosa, Other Specified Feeding or Eating Disorders (OSFED), and others. These can be as dangerous and complex to treat as the three listed above,

Substance Abuse and Eating Disorders

As mentioned both substance use disorder and many eating disorders share similarities in the brain and behavioral tendencies. They both result in dopamine releases by the brain (dopamine is the “feelgood” chemical that activates pleasure centers) and work as disordered coping mechanisms for negative thoughts or emotions. They are also prone to be co-occurring because of the effects that substances can have on a person’s physical health and self-image. Some of the substances found in combination with eating disorders include:

• Stimulants – These are substances (both illicit and prescription) that increase energy levels and metabolism. Illicit forms include cocaine and various amphetamines, such as “speed” or methamphetamine. Prescription and over-the-counter stimulants include weight loss drugs (some of which contain amphetamines), appetite suppressants, nicotine, and caffeine. Many of these substances are highly addictive and can lead to serious health complications as well as mental health disruptions or withdrawal when ceased. Eating disorder patients often use these substances to lose weight or lower their appetites, prevent weight gain, and cope with negative emotions.
• Alcohol –The most widely used psychoactive substance worldwide, alcohol has a complex relationship with disordered eating. Although alcohol does contain calories and can cause weight gain, it is often abused in combination with eating disorders. In some cases of people with anorexia nervosa, the primary source of caloric intake is through alcohol, a disorder sometimes (crudely) called “drunkorexia.” Alcohol can lead to overdoes known as alcohol poisoning and is more powerful when consumed on an empty stomach, and with people at lower weights. This makes the combination of alcohol abuse and disordered eating very dangerous. According to the study from SAMHSA linked above, alcohol abuse is also highly comorbid with binge eating disorder. Alcohol is a depressant and may exacerbate conditions such as major or clinical depression. 

• Other Illicit substances – Although they can be linked to appetite suppression, opiates such as heroin, oxycodone, and fentanyl show lesser rates of comorbid abuse than stimulants or alcohol. They are powerful depressants, however, and highly addictive, which can trigger emotional distress leading to disordered eating. Other illicit substances such as hallucinogens are not particularly associated with eating disorders. Finally, cannabis is known to increase appetite and in some experimental cases is used to help counteract restrictive eating behaviors. However, this is not widely studied and should be approached with caution and consultations with a psychiatrist who specializes in eating disorders.
• Medications – Diuretics, which increase the production of urine, and laxatives, which do the same for bowel movements, are both widely abused by people with eating disorders they cause the calories to be processed more quickly and less completely, leading to weight loss in some cases. Eating disorder treatment usually involves close monitoring or prohibition of medications that have these effects. Enemas are also sometimes abused for similar effects.

Treatment for Co-Occurring Disorders At and Eating Disorder Recovery Facility

Co-occurring presentations such as substance use disorder share common causal and maintaining factors with eating disorders that influence treatment and recovery.  Sensitively treating these presentations requires great clinical skill and an environment of enhanced trust, warmth, and safety. A successful treatment program must integrate specialized programming to address co-occurring presentations.

Many treatment modalities used for both substance use disorder and eating disorders are quite similar. These include evidence-based treatments like Dialectical Behavioral Therapy (DBT), Cognitive Behavioral Therapy (CBT), Motivational Enhancement Therapy (MET), and interpersonal therapy to address substance use and support behavior changes. Mindfulness, or a sense of experiencing thoughts and emotions without acting on them, is a watchword in modern behavioral health treatment, and for good reason. Understanding how thought affects emotion and emotion affects behavior helps an individual in recovery modify behaviors for a more positive outcome.

Recovery programs for eating disorders that also treat substance use disorder must treat both simultaneously, as leaving one of them untreated is a potential trigger for relapse. Most programs will include psychiatric, nutritional, and therapeutic consultations as part of their routine, on both a residential and day treatment basis. All working together, these programs allow an individual the best chance for a full recovery from both eating disorders and substance abuse.