Cluster addiction and co-occurring disorders, or a combination of multiple addictions and mental health disorders are quite common among persons seeking addiction treatment.
Based on recent and ongoing research, we now know that eating disorders and substance abuse share some very important characteristics. These characteristics point not only to commonalities between the two, but also to the promise of effective treatment for both.
Types of eating disorders
There are three main types of eating disorders: anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED). In addition, there are other types of eating disorder that have only some of the features required for a diagnosis. These are known as eating disorders not otherwise specified (EDNOS).
- Anorexia Nervosa — Anorexia nervosa is a potentially life-threatening eating disorder that is characterized by self-starvation and excessive weight loss. Sufferers have low self-esteem and often a tremendous need to control their emotions and surroundings.
- Bulimia Nervosa — Bulimia nervosa, or bulimia, is another type of eating disorder in which the person consumes a great amount of food in a short period of time (binging) and then tries to prevent any weight gain from the food by getting rid of it (purging).
Purging is accomplished by forced vomiting or taking laxatives (liquids or pills that accelerate the movement of food through the body and result in a bowel movement).
- Binge Eating Disorder — Binge eating disorder is an eating disorder not otherwise specified (EDNOS), characterized by recurrent binge eating without the regular use of compensatory measures to counter binge eating.
Types of substance abuse
Substance abuse is defined as excessive use of a substance (especially alcohol and drugs). While there is no universally-accepted definition of substance abuse, one that is frequently cited appears in the Diagnostic and Statistical Manual of Mental Disorders fourth edition (DSM-IV), issued by the American Psychiatric Association. Note that the work on DSM-V is currently underway, with the publication of the new manual in approximately two more years.
Briefly, DSM-IV defines substance abuse as a maladaptive pattern of substance abuse that leads to clinically significant impairment or distress, manifested by occurrence of one or more of the following within a 12-month period:
• Recurrent substance use resulting in an inability to fulfill major role obligations at work, school, or home
• Recurrent substance use in situations where it is physically hazardous (such as driving or operating heavy machinery)
• Recurrent substance-related legal problems, such as arrests for driving under the influence (DUI), or substance-related disorderly conduct
• Continued substance abuse despite persistent social or interpersonal problems caused by or exacerbated by the effects of the substance (such as physical violence, and arguments with a spouse over the consequences of intoxication)
Substances abused include: alcohol, illicit drugs such as marijuana/hashish, heroin, cocaine (including crack), hallucinogens, inhalants, or prescription-type psychotherapeutics used nonmedically (including pain relievers, stimulants, and methamphetamine).
Prevalence of eating disorders and substance abuse
Currently, about 10 million women and 1 million men suffer from anorexia and bulimia. Millions more have binge eating disorder. According to the 2008 National Survey of Drug Use and Health (NSDUH), in 2008 there were 23.1 million persons aged 12 and older who needed treatment for an illicit drug or alcohol use problem.
Research shows that up to 35% of individuals with substance abuse problems also have an eating disorder. Furthermore, up to 50% of those with eating disorders have a simultaneous problem with drug or alcohol abuse.
Although anecdotal evidence seemed to point to a relationship between eating disorders and substance abuse, actual hard evidence cemented the connection. A study conducted by the National Center on Addiction and Substance Abuse (CASA) at Columbia University, publicized in 2004, showed a stronger link than anyone had previously known.
Among the shared connections or potential links between eating disorders and substance abuse are the following:
• Self-medication: Various studies have shown that people with eating disorders will often self-medicate with drugs or alcohol when they are feeling depressed or have a low self-image about their body. Individuals who are dependent on substances and also have an eating disorder may regularly self-medicate in order to deal with unpleasant or painful moods, to achieve or sustain a high, to satisfy cravings, or to avoid withdrawal symptoms.
• Use of substances to help with weight control: Many individuals with eating disorders resort to use of caffeine, tobacco, diuretics, cocaine, heroin, and other illicit or prescription substances in an attempt to control their weight through appetite suppression or speeding up their metabolism. Heroin and cocaine act as appetite suppressants, while cocaine increases metabolism. Individuals often use both: They use heroin with cocaine to take the edge off the crash as the cocaine high wears off. Cocaine and heroin are extremely addictive, can result in irreversible damage to the body and brain, and are difficult to treat without intervention and professional help.
• Shared underlying risk factors: Much research centers on common underlying risk factors. These include low self-esteem, depression, family history, impulsivity, high levels of stress, and genetic predisposition.
One recent study of anorectic men with opioid dependence showed that the subjects displayed higher harm avoidance and lower self-directedness and cooperativeness, while anorectic men displayed lower reward dependence and higher persistence, and opiate addicts had higher novelty-seeking and self-transcendence. The study results showed that anorectic and heroin-dependent subjects share personality traits that are related to anxiety, fearfulness, and antisocial features. Study researchers caution, however, that such personality profile doesn’t completely overlap and could influence the abused substance of choice as well as related clinical difference between heroin dependence and anorexia.
Another study of bulimia nervosa and drug use disorder comorbidity found that their association is due mostly to overlapping genetic influences with a smaller contribution from nonshared environment. Depression, neuroticism, and childhood sexual abuse, these researchers found, are likely important shared correlates.
Characteristics common to both
Individuals with substance abuse and/or eating disorders display similar characteristics. These include:
• Preoccupation with the behavior — such as drinking, using drugs, eating too much or not eating at all and other forms of unhealthy eating behavior
• Secrecy, use of rituals, engaging in compulsive behavior
• Both substance abuse and eating disorders may produce mood-altering effects in the individual
• Both substance abuse and eating disorders require intensive, professional treatment
• Both are chronic diseases/disorders with high rates of relapse
• Substance abuse and eating disorders may be life-threatening
Treatment for eating disorders and substance abuse
While individuals entering treatment facilities for addiction as a primary admission reason used to be treated just for that addiction, it is now common practice to pre-screen incoming patients for the presence of co-occurring disorders, or dual diagnosis, and multiple addictions. Prior to research that showed that concurrent treatment for co-occurring disorders is more effective than treating either disorder separately, treatment professionals generally believed that the individual needed to be treated for substance abuse first and then treatment could begin to tackle the eating disorder problems.
With the knowledge that eating disorders and substance abuse share many underlying characteristics and have many of the same risk factors, treatment professionals now are tailoring their treatment plans to work on both simultaneously. Due to the complexity of co-occurring substance abuse and eating disorders, the most effective treatment generally involves the patient entering a residential treatment facility (as opposed to an outpatient facility) that specializes in treating both on a concurrent basis.
What kind of treatment is proving effective for eating disorders and substance abuse? As with any addiction, it depends on the type of eating disorder and the type and number of substances abused. As mentioned previously, individuals with an eating disorder who use heroin and cocaine may require longer more intensive treatment modalities or for longer periods, than someone who uses marijuana or another substance in conjunction with an eating disorder.
It is important to note that there is no single one-size-fits-all treatment program that works for everyone. Whether an individual is addicted to alcohol alone, or has an alcohol addiction and an eating disorder, for example, the type and duration of the treatment plan is tailored to the patient’s unique needs. What works for one patient may not be as effective for another, or may not work at all. Different approaches may need to be utilized during the course of treatment for concurrent eating disorder and substance abuse. Long-term counseling is a necessary ingredient in an overall treatment program for co-occurring disorders.
Nevertheless, there are some treatment modalities that are generally utilized in the treatment for patients with eating disorders and substance abuse. While this list is not all-inclusive, it is instructive as to the types and variety of treatment modalities that may be used to help the patient overcome both substance abuse addiction and eating disorders:
- Thorough Evaluation and Assessment — When anyone comes into a treatment facility, the first step is a thorough evaluation and assessment. This is important for any addiction but is even more important with dual diagnosis of eating disorder and substance abuse, since many of the symptoms may mimic each other. The treatment facility professionals conduct a complete assessment, including a screening questionnaire that covers patient input on type of substance used, length of use, frequency and strength of use, family history, medical history, social/environmental factors, mental health concerns, and many others. Psychiatric and psychosocial assessment, along with psychological testing may be included. A physical examination is also generally conducted in order to identify and treat any medical conditions. The evaluation may be on an outpatient or inpatient basis, depending on the severity of the patient’s condition(s). Numerous tests may be required, again, depending on the nature, type, and severity of the co-occurring conditions or disorders.
- Customized Treatment Plan — After an analysis of the various tests and the screening evaluation, professionals at the treatment facility create a customized treatment plan for the individual patient. This takes into account the specifics of the substance abuse and eating disorder and includes a treatment program that will deal with both problems concurrently.
- Detoxification — Before the active phase of treatment can begin, however, patients who are addicted to substances first have to undergo detoxification. This process is medically supervised on a 24-hour basis, and may require the use of prescribed medications to ease withdrawal symptoms. The traces of drugs or alcohol must be eliminated from the body and this takes varying amounts of times, depending on the drug. Detoxification, or detox, may take from 1 to 2 days to 10 days or longer. Some drugs, such as heroin, are more difficult to detox from than others. No one should attempt to detox without medical supervision.
- Types of Treatment — There are many different modalities and types of treatment that may be recommended for persons with substance abuse and eating disorders.
- Stabilization: First and foremost, the patient needs to be stabilized: off drugs and a normal weight re-established as soon as possible. For severely malnourished patients, this may involve intensive medical treatment with careful monitoring of weight, fluid, electrolyte balance, cardiac status, bone and growth development, and vital signs. Intravenous fluids (IVs) or even forced-feeding may be required.
- Pharmacology: Various medications may be prescribed for patients to help with eating disorders or substance abuse. In addition to helping reduce or eliminate withdrawal symptoms, medication is often prescribed to help with depression, anxiety, cravings, and insomnia, among other conditions. Patients with bulimia, for example, may be prescribed antidepressants, along with other medications and vitamins and supplements.
- Nutritional counseling: This focuses on the individual’s overall health rather than weight. This type of counseling is conducted by a nutritionist or dietician who helps the patient with an eating disorder to understand what their adequate nutritional needs are and to change their eating behavior. Individuals may be requested to keep a food diary to catalog all food intakes and to learn about and become aware of the triggers that precipitate bingeing.
Psychotherapy, considered the backbone of effective treatment for both eating disorders and substance abuse, is available in a number of different modalities. A combination of therapies may be utilized simultaneously or successively. Individual and group counseling is utilized.
- Cognitive Behavioral Therapy (CBT) — This type of psychotherapy focuses on trying to change the individual’s behavior by helping them recognize distorted patterns of thinking and replacing them with healthier and more realistic behaviors. CBT has been shown to be effective with both eating disorders and substance abuse.
- Dialectical Behavior Therapy (DBT) — Often used with patients who have self-harm tendencies, dialectical behavior therapy focuses on validating behaviors and life responses that are understandable, and working on conscious efforts to change those behaviors that have a negative effect or impact.
- Interpersonal Psychotherapy — The psychiatrist or therapist works with the patient to reveal the problems and issues underlying substance abuse and/or eating disorders. Then, together, they work on those issues to resolve them.
- Family Therapy — Treatment isn’t only for the individual with substance abuse and eating disorder. Without getting the family involved to change the dynamics of the home environment, treatment may not be effective. In this type of treatment, family members learn about the substance abuse as well as eating disorder and how their actions and attitudes affect the patient’s recovery. Besides information, family therapy provides advice on behavioral management and improving communication among family members.
Other aspects of treatment
Of course, treatment consists of more than a series of counseling sessions and taking medications as prescribed. Other important aspects of the active treatment phase for substance abuse and eating disorders may include:
• Stress reduction techniques
• Learning coping mechanisms and skills
• Exercise program
• Recreational activities
• Relaxation therapy
• Breathing training
• Creative expression
• Assertiveness training
• Body image counseling
• Relapse prevention training
• Aftercare program
• Planning for discharge
Outlook for patients with eating disorders and substance abuse
Although complex and long-term in nature, treatment for co-occurring eating disorders and substance abuse can prove effective. There is no short-cut to recovery, however, and results vary by individual. Motivation, an adequate support network, and time are huge factors in whether or not an individual can achieve lasting sobriety and adopt a healthier lifestyle.
For those suffering with substance abuse and eating disorder, or those who love them, it is important to know that treatment is available and it does work.