Eating disorders and Addiction
Connections and Implications
By Abigail H. Natenshon, MA, LCSW, GCFP

Practitioners who treat eating disorders, as well as those who treat substance abuse, need to understand the implications of these co-occurring conditions for each other. An awareness of the highly significant relationship between eating disorders and substance abuse calls for the therapist's mindful appreciation of the need for diagnostic savvy, for concomitant attention in treatment, and for understanding the implications for the recovery of one or both conditions.


Roughly 50% if individuals with an ED are also abusing drugs and alcohol, which is more than five times the abuse rates seen in the general population (The National Center on Addiction and Substance Abuse [CASA] 2003). 30-40% of women with an alcohol use disorder and 16.3% of woman with substance-abuse disorder report a history of an eating disorder. (Blinder, Blinder and Samantha, 1998; Taylor, Peveler, and Hibbert, 1993) as compared to .9 to 3.5% of woman found in the general population (Hudson, Hiripi, Pope, and Kessler, 2007). A co-occurrence of these disorders yields high rates of mortality, with a rate of suicide 23 times greater than what is seen in the general populations. (Renfrew Perspectives, Winter 2010, Dennis and Helfman p.1).


Eating disorders are not addictions
Though eating disorders appear to be addiction-like in the compulsive quality of their behaviors, it is important for clinicians to understand that ED are not addictions, and to distinguish how they differ. And whether they treat addictions or eating disorders, it is also critical for practitioners to understand the significance of the chemical relationship between the two… to become aware of how addictions affect, and are affected, by eating disorders…and vice versa. The prevalence and duration of eating disorders is higher in those who also abuse substances; for those with eating disorders, bulimia (purging type) is most commonly associated with co-occurring substance abuse, and alcohol is the most commonly abused substance when these two conditions co-occur. (Gordon, Johnson, Greenfield, Cohen, Killeen, Roman, 2008) Genetic propensities for addiction increase the individual's susceptibility to the onset of eating disorders, which are capable of triggering the same kind of endorphin-related chemical responses in the brain as does the abuse of an addictive substance. Perhaps the most significant difference between addictions and eating disorders is that eating disorders, unlike addictions, are completely curable in close to 90% of cases where they treated in an effective and timely manner.


Diagnosticians of addictions need to become alert to the presence of an ED
Diagnosticians of ED need to become alert to presence of addiction
In considering the delivery of services to the eating disordered and substance abusing patient, an integrated approach requires a though understanding of the relationship between the co-morbid conditions For example, does the ED trigger the SA? Do they occur concurrently> Do they function in the service of each other? (Renfrew p. 3) It is critical that professionals who diagnose and treat addictions become highly alert to the possibility of an undisclosed eating disorder that may underlie the presenting problem of addiction; diagnosticians typically need to "read between the lines" to infer and investigate the co-existence of these two conditions. Eating disorders all too frequently go unrecognized by therapists who, never having been formally trained about the unique qualities of these disorders and the unique demands of their treatment, are unfamiliar with the constellation of underlying issues that might imply their existence. In evaluating a 30 year old woman who came to see me for treatment of depression, having learned about her past symptoms of perfectionism, obsessive behaviors and body image concerns in college, I inquired if, at some previous time, she might ever have suffered from an eating disorder. To this question she responded "Yes!" in amazement that I could have guessed such a thing, as she had never mentioned this reality to anyone. Having acknowledged this past eating disorder now would promote a deeper understanding about herself and of personal issues that would have a significant impact on her current therapy work.


The importance of a dual treatment focus for dual diagnosis
It is critical that underlying eating disorders be diagnosed as early as possible, as intervention for these most lethal of all the mental health disorders is most effective in the early stages of disease, but also because addictions and eating disorders feed upon and exacerbate each other. For the effective recovery of both conditions, substance abuse and eating disorders need to be attended to simultaneously, though the reality is that currently, most treatment facilities for alcohol abuse do not provide concomitant treatment for co-occurring eating disorders. (Gordon, et. al. 2008) Sequential (as opposed to integrative) treatment is often conducted at different times, with different providers with different brief systems, and in different locations. SA literature suggest that when co-morbid diagnoses are treated concurrently and integrated on-site, treatment retention and outcome improve (Saxon and Calsyn, 1995; Weisner, Mertens, Tam, and Moore, 2001); to date, there are no formal connections between the eating disorder and substance abuse professional communities, interfering with our ability to serve this population effectively. (Renfrew, p. 3)


Overcoming "pre-contemplative" diagnostic challenges in working with eating disorders
Many eating disordered/substance abusing individuals are not ready to disclose their eating disorder. Some may fool themselves into believing that they do not have an eating disorder at all. The "honeymoon" stage of the patient believing that there is nothing wrong in the realm of eating has been called the pre-contemplative stage of change by Prochaska and DeClemente, a stage that occurs and re-occurs throughout the process of recovery. Addiction counselors need to become aware that eating disorder patients can be counted on not to be reliable reporters of their eating dysfunctions, to choose not to disclose the presence of an eating disorder because the thought of life without the emotionally sustaining disorder becomes unthinkable and brutally painful. The process of movement towards eating disorder recovery is typically far more uncomfortable than is the disease process. This is because the weight restoration that comes with recovery from anorexia or bulimia (restricting type) increases anxiety exponentially; this state of high anxiety continues until such time as the re-fed brain and body become capable of evoking a new-found sense of well-being that will, in turn, diminish the anxiety. In the meantime, the extent of pain from withdrawal from eating disordered behaviors and compulsive exercising can be equivalent to that of withdrawal from an addictive substance. It is interesting to note that in some instances, therapists and counselors may inadvertently compound and enable a patient's reluctance to disclose eating issues by not inquiring directly about the patient's relationship with food, and/or in not fully understanding what constitutes a truly "healthy" eating lifestyle.

TIP: It is critical that all addictions counselors, in diagnosing co-occurring eating disorders, to invite their patients to describe what a "typical eating day" might be like for them. Do they eat three meals and snacks throughout the day? Do they understand what a healthy eating lifestyle is? Do you? Are you aware that people who restrict certain groups of foods, who engage in dieting behaviors, or who eat only when hungry, are, under certain circumstances, not eating "healthfully?"

It is also interesting to note that when a patient struggles simultaneously with addiction and eating disorders, interventions intrinsic to effective care of one problem may interfere in the progress of treatment and recovery for the other. For example, the 12 Step programs, as successful as they are for the treatment of addictions, may effectively serve some of the eating disordered population, though not all. When Overeaters Anonymous and Anorexia and Bulimia Anonymous Problems do not work, it is generally because the very concept of restriction or abstention, which lies at the heart of alcohol recovery, can be counter-therapeutic in healing an eating disorder. Far from abstaining, eating disordered individuals must learn how to ingest food 6 times a day and to do so with self-determined judgment, self-regulation and moderation. It has been my experience that the 12 Step groups are a better option for those eating disordered individuals who also suffer from addictions.

TIP: For those eating disordered patients who feel that giving themselves over to a Higher Power runs counter to their religiosity, integrity, or to their goals for internal self-direction, it can be helpful to reframe the concept of Higher Power as a power not necessarily held by God, but that exists in the potency of community support, which is the treasure that lies at the hub of Twelve Step care. The Power of the community may be seen as offering a positive influence that is "horizontal" rather than "vertical."


Conclusion: Practitioners who treat eating disorders, as well as those who treat substance abuse, need to understand the implications of these co-occurring conditions for each other. An awareness of the highly significant relationship between ED and SA calls for the therapist's mindful appreciation of the need for diagnostic savvy, for concomitant attention in treatment, and for understanding the implications for the recovery of one or both conditions.



Abigail teaches and speaks about eating disorders and addictions on-site and on-line.
Read her books, When Your Child Has an Eating Disorder: A Step-by-Step Workbook for Parents and Other Caregivers and Doing What Works: An Integrative System for the Treatment of Eating Disorders from Diagnosis to Recovery



References:
Assessment and Treatment of Co-occurring Eating Disorders in Publicly Funded Addiction Treatment Programs Psychiatr Serv 59:1056-1059, September 2008 doi: 10.1176/appi.ps.59.9.1056 © 2008 American Psychiatric Association Susan Merle Gordon, Ph.D., J. Aaron Johnson, Ph.D., Shelly F. Greenfield, M.D., M.P.H., Lisa Cohen, Ph.D., Therese Killeen, Ph.D. and Paul M. Roman, Ph.D.

Renfrew Perspectives; Winter 2010, p 1-3 Understanding the Complex Relationship between Eating Disorders and Substance Abuse Disorders. Helfman and Dennis.

Abigail H. Natenshon
North American Serial Rights 2010