Understanding Substance Abuse in Clients with Disordered Eating

Disordered eating is more common in people suffering from substance abuse issues, and is often co-morbid with other mental health concerns. In this study, the clients who initially presented with some manner of eating disorder were found to be around 13% more likely than the general population to also have a concurrent substance abuse problem. Alcohol, in particular, seemed to be the primarily abused substance, with methamphetamine coming close behind. 

In anxiety and depression sufferers, the incidence of concurrent substance abuse is much lower and tends to have other mitigating factors, such as age; substance abuse in anxiety clients is far more common in a much younger subset, primarily teens. Eating disorders seem to have a much higher prevalence of related substance abuse than other common mental health conditions in the general population.

There are many reasons why a person suffering from an eating disorder might turn to various drugs or alcohol:

  • Management of related depression or anxiety, at least in the short term.
  • The feeling of an overwhelming need for control makes substance abuse attractive because it provides an outlet to relax.
  • The pressure that a person with an ED feels can also be the outlet that drives them towards alcohol or other drugs; often, especially in young clients, this is peer pressure.
  • Abusing alcohol or other substances can be a subconscious cry for help, particularly before a patient is actually in treatment.

We will examine these specific conditions for concurrent substance abuse in ED clients, what needs to be addressed first in each scenario, what treatments might work and how to help clients cope in long-term recovery.

Identifying Signs of Substance Abuse and ED

A person who is suffering from substance abuse and/or an eating disorder may present in varied ways, but there are some common emotional, psychological and physical traits that you can identify. The first step in treating someone with a disordered eating pattern is to remove as many confounding variables as possible. Because substance abuse can and often does occur concurrently, it’s best to address that first.

Some common physical signs of substance abuse are:

  • Weight loss
  • Lack of sleep
  • Bloating and poor skin tone — this is particularly evident in alcohol abuse
  • The shakes
  • Sweating

Physical symptoms of most eating disorders can be similar:

  • Weight loss
  • Lack of sleep
  • Poor skin quality
  • Impaired immune system
  • Lethargy
  • Mottled hands and feet and complaints of being cold all the time

While these physical symptoms can be manifestations of a thousand different things, if you already have reason to suspect substance abuse or an eating disorder, physical symptoms can help identify them for sure.

For both substance abuse and eating disorders, the more common means of identification will be behavioral. Both diseases manifest very similarly:

  • Mood swings
  • Lack of interest in hobbies or social groups
  • Guarded behavior around food and alcohol; a person with alcohol dependency may act aversive to it when around others
  • Preoccupation with physical appearance

In particular, if you have a loved one who is already suffering from an eating disorder, signs of substance abuse may be more subtle. A patient who is in eating disorder treatment but suddenly has a dramatic mood or attitude shift that seems to manifest concurrently with the physical conditions listed above might have turned to alcohol or drugs to cope.

Successful eating disorder recovery begins with the identification of the disorder itself and any confounding variables, including substance abuse but also anxiety and depression, which go hand-in-hand with most disordered eating patterns.

Anxiety – Concurrent with ED and a Cause

Often anxiety arises first out of external pressures and leads a person to an eating disorder as a means of control. It can also be the opposite, where anxiety about an eating disorder manifests and it’s not on you as the loved one to figure out chicken or egg here. If you know your family member or friend is already suffering from one of these issues, it can be a matter of observation and patience to determine if the other is present. Thankfully, once during treatment for an eating disorder, other comorbid disorders can be identified. 

In the course of treatment, if anxiety caused the ED, the treatment center will work to figure out the root of the anxiety and address it. That should make treating the eating disorder less complex.

Depression – Concurrent with ED and a Cause

Depression is usually found in concurrence with eating disorders — around 50-90%, adjusting for all potential variables — but it’s not often a primary cause. Often depression arises out of incongruities and stressors in a patient’s life that may impact the development of an eating disorder but will not often generate both at the same time.

Putting It All Together

Treatment of an underlying eating disorder requires confounding variables to be addressed. It is very common for a person suffering from disordered eating to be clinically depressed or anxious, and about 30% turn to substance misuse for self-medication. If the confounding variables can be identified, they can be treated and then a clear path to eating disorder recovery can be established.

Treatment of Eating Disorders and Substance Abuse

As we have already established, the treatment of an eating disorder is most functional when other concerns are addressed and met beforehand. In a person with eating disorders concurrent with substance abuse, the primary path that needs to be addressed looks like this:

  • Cessation of substance abuse
  • Physical well-being — this means improving diet, reestablishing good sleep hygiene, personal hygiene and some manner of physical activity and this is concurrent with the next step
  • Counseling and introduction of any medication for underlying anxiety, depression or other mental health concerns
  • In-patient or out-patient therapy for substance abuse and eating disorders, with follow-ups to maintain sobriety and normal eating behaviors.

Substance Abuse Recovery

Functionally, in-house detox and treatment is the best remedy for those who have access. Substance abuse withdrawals can be dramatically different depending on the drug of choice, and in some cases like the DTs from alcohol, withdrawal can be fatal if not properly overseen by medical staff. In-patient treatment will always be the best practice for long-standing or deeply ingrained substance dependence.

Understanding that someone with an eating disorder is 30% more likely to turn to substance abuse to cope is going to give you an edge in identifying the risks your loved one might be taking. Both with an eating disorder and misuse of drugs, the sooner that intervention happens, and treatment starts, the more positive the prognosis and likelihood of long-term recovery.

After detox occurs, the path to long term sobriety is usually based on regular therapy sessions and, in some cases, a sponsor for the patient to lean on when they feel weak or unable to resist the urge to drink.

Physical Health

A nutritionist working with the primary care provider and the primary counselor is critical in establishing good relationships with food and nutrition. Not only is it important to nourish the patient while they recover, working with a nutritionist in conjunction with other therapies can lay the groundwork for positive views of food, which aids in recovery.

Loved ones are especially important in this part of treatment because it will be you that helps them establish good sleep patterns and nutritional behaviors.

Treatment Plans

Once concurrent disorders are addressed, treatment of the underlying eating disorder can begin. While some factors that cause an eating disorder will have been touched on during the treatment of substance abuse or anxiety, it is much easier to create a plan that leads towards complete long-term recovery if the primary point of treatment is the ED.

Outpatient therapy is the most common, and often the best path to treatment for bulimia nervosa or anorexia nervosa. The setting for this type of therapy is a mix of group and one-on-one, in a comfortable, subclinical setting. Studies have shown that in-patient treatment or full hospitalization can have a profoundly negative impact on recovery from eating disorders AND substance abuse, so the most successful programs have turned to group therapy in relaxing, home-like settings.

Treatment is often multi-disciplinary, focusing on not just addressing the stressors that created the disordered eating pattern but also providing practical steps to eat healthily and avoid stress going forward. Additionally, most facilities will have a support structure in place to help former, recovered clients in the event of a difficult situation that jeopardizes their recovery.

As a loved one, your patience, support, and non-clients openness is the most important thing you can provide to the patient.

If recovery is not progressing in an out-patient setting — particularly if there are still substance abuse issues — then in-patient care is recommended for full recovery from all disorders. While this is more extreme, it often leads to complete recovery.

The Importance of Aftercare

Aftercare and follow-up are the most critical aspects of a successful treatment program. The fact is that most facilities make it a non-option; to be considered recovered, you must commit and stick with an aftercare treatment program. Having a program in place skyrockets the likelihood of long term success and positive change for a lifetime.

Eating disorder and substance abuse clients are similar in that when presented with a stressful situation, because they have a past self-medication technique of binge eating or restricting, or drinking alcohol, their first instinct will be to turn towards their maladaptive behaviors to cope. Without aftercare, a support system, and training for friends and family, this can lead to regression.

Aftercare programs can be dramatically different based on the type and severity of the mental health concerns, but usually include two or more of the following:

  • Transitional programs — these are like out-out-patient, in the sense that the person being treated will go to a group therapy session in the facility, but far less often and gradually less.
  • Family training — this can be a variety of things, from nutritional education to avoiding triggers, to helping your loved one if stress overcomes their ability to cope. Also, knowing when things might be too much to handle without a professional and being able to make that decision.
  • Integration of a therapist, primary care physician, and dietitian into the aftercare plan is critical as well. Often, treatment facilities will have referrals to professionals who are specifically trained in eating disorders to help.

Recovery and Acceptance

Eating disorders and substance abuse often present at the same time, usually as a method of coping. Clients need non-judgmental assistance in coming to terms with their problems and then caring, supportive help in finding professionals to help them. Anxiety and depression usually occur concurrent with eating disorders in particular, and it’s not uncommon to see all four conditions occurring in the same patient. In these cases, it’s critical to unravel each disorder to solve them before trying to tackle the next.

Through the integration of physician-overseen detox, counseling and medicinal therapy and out-patient group counseling, the overwhelming majority of clients see long term recovery. Through diligent management of aftercare, most recovered ED clients never relapse and go on to live happy, healthy lives.

As a loved one, your job is to help them decide to seek professional help, and in helping them integrate when they return home from treatment. The difficult burden of making sure they are properly cared for in the case of a stumble in recovery falls on you as well, but with focused attention, you can be your loved one’s greatest ally.