The Complex Relationship Between Eating Disorders and Substance Use Disorders
By Amy Baker Dennis, PHD, FAED & Tamara Pryor, PHD, FAED
Eating disorders (ED) and substance use disorders (SUD) frequently co-occur but are rarely treated in a comprehensive integrated manner. Substance abuse programs often do not admit patients with active ED. Likewise, ED programs frequently admit patients with over-the-counter (OTC) diet pill, laxative, or diuretic abuse but exclude patients abusing alcohol, benzodiazepines, cannabis, stimulants, or opiates. The lack of available integrated treatment programs, at all levels of care, has left individuals with both ED and SUD vacillating between disorders and treatment providers. Unfortunately, this leads to consumer confusion, extends time in treatment, increases treatment costs, and can compromise continuity of care as patients travel through different levels of care (Dennis, Pryor & Brewerton, 2014). In addition, studies suggest that patients who receive nonintegrated services have poorer treatment outcomes (Drake et al., 2001).
According to the National Center on Addiction and Substance Abuse, approximately 50 percent of individuals with ED abuse alcohol or other illicit substances, compared with 9 percent of the general public, and approximately 35 percent of drug abusers have ED (CASA, 2003). This study may be an underestimate of the actual substance abuse in individuals with ED. This research does not take into account OTC laxatives, diet pills, and diuretics; internet supplements; caffeine; nicotine; artificial sweeteners; or the misuse of insulin, thyroid medications, or other prescribed medications frequently abused by individuals with ED.
Individuals with SUD rarely enter treatment without other psychiatric comorbidities. Researchers have found that 28 percent of those seeking treatment for SUD will have five or more comorbid disorders, including mood disorders, anxiety disorders, posttraumatic stress disorder, and borderline personality disorder (Compton, Thomas, Stinson, & Grant, 2007). When an ED is also present, this can further complicate assessment and treatment planning for these complex patients.
Alcohol and other substance abuse is more prevalent in ED subgroups that engage in binge eating/purging or just purging, with lower rates of SUD in individuals with anorexia nervosa restricting type. However, there is a significant body of research that elucidates the relationship between food restriction/starvation and the use of psychoactive substances. This research has found that food deprivation leads to increased self-administration of virtually any psychoactive drug, including alcohol, nicotine, amphetamines, barbiturates, phencyclidine, and opioids (Carroll, France, & Meisch, 1979; Specker, Lac, & Carroll, 1994). The presence of either disorder increases the risk of suicide, and when left untreated, they have high mortality rates (Bulik et al., 2008). Both disorders are long-term, relapsing illnesses associated with significant medical complications and cognitive impairments that interfere with social, occupational, and interpersonal functioning. ED and SUD “run in families” and are heritable conditions. Studies report that 50 percent to 80 percent of phenotypic variance found in alcohol use disorder and SUD is due to genetic factors (Hicks, Krueger, Iaconco, & Patrick, 2004). Likewise, twin studies, designed to distinguish environmental from genetic effects, reported that 50 percent to 80 percent of the contribution to liability is genetic in anorexia nervosa and bulimia nervosa (Bulik et al., 2006).
ED and SUD share several behavioral similarities. As alcohol/drug use continues and tolerance builds, patients describe intense cravings and uncontrollable consumption, despite negative consequences. Similarly, ED patients, particularly individuals with bulimia nervosa and binge eating disorder, report powerful food cravings and a sensation of “loss of control” that leads to overconsuming. Food, drugs, and alcohol are often used for their mood-altering effects; to escape, avoid, or numb; or to manage negative emotional states (Brewerton & Dennis, 2016).
While there are similarities between ED and SUD, there are also differences. From a psychological and pharmacological perspective, ED and SUD are unique disorders that are conceptualized and treated quite differently. Although both ED and SUD are classified as psychiatric illnesses, as listed in the fifth edition of Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2013), during the past several decades there has been a strong movement in the medical community to view SUD as a chronic medical illness that can be arrested but not cured. Treatment of SUD is designed to help patients increase restraint, and abstinence is considered the path to sustain remission. Individuals with SUD are strongly encouraged to continue participation in self-help programs (Alcoholics Anonymous and Narcotics Anonymous) during remission because this has been found to improve outcomes and decrease relapse (Donovan et al., 2008).
ED are conceptualized as complex, curable psychiatric illnesses that require aggressive psychological intervention, medical management, and, in some instances, psychopharmacological intervention to treat target symptoms and/or other comorbid conditions. One of the primary goals of treatment is to moderate overcontrol (i.e., eliminate dieting, food restriction, and compensatory behaviors) and normalize eating patterns. Self-help programs are not considered an essential component of ED treatment recovery, and lifelong participation is not required to prevent relapse.
Currently, a majority of the interventions offered to these comorbid patients is either sequential or parallel treatment. The availability of fully integrated SUD programs that screen, admit, or treat SUD patients with active ED is seriously lacking. Likewise, there are very few ED programs that provide integrated programing for ED patients with significant SUD.
Lack of access to integrated programming, where the same providers provide all services in the same location, leaves the dually diagnosed patient vacillating between the ED and the SUD. It is not uncommon for patients who enter treatment for their SUD to experience an increase in ED symptoms as they are working on recovery. Likewise, patients being treated for ED often increase their substance use when attempting to eliminate ED behaviors. As a result, even programs that do not admit patients with these co-occurring disorders may see the emergence or reemergence of the ED or SUD during the treatment process.
We believe that treatment for patients with comorbid ED/SUD should take place in settings that have substantial expertise in treating both disorders. Results of a recent survey conducted by the authors indicate that most SUD programs lack the staffing and protocols to medically manage ED patients, create meal plans, provide meal therapy, monitor bathrooms, or prevent overexercising. In addition, very few SUD programs have clinical staff that is cross-trained in evidence-based interventions for ED. These results support our belief that a robust partial hospitalization program or a residential ED program is best suited for those with these comorbid disorders. Although both ED and SUD are clearly disorders highlighted by dysfunction, they also represent adaptive attempts to manage a broad range of biopsychosocial problems, skills deficits, and co-occurring psychiatric problems. Programs providing integrative treatment can support patients through their ED and sobriety with containment, medical oversight, and a curriculum that offers such options as: motivational interviewing; 12-Step facilitated groups; SMART Recovery groups; dialectical behavior therapy; enhanced cognitive behavioral therapy; family-based treatment; and either the option of supervised housing or sober living arrangements (Dennis & Pryor, 2018).
About the authors:
Amy Baker Dennis, Ph.D., FAED, is a researcher, educator, author, and clinical psychologist. Dr. Dennis has maintained a clinical practice for four decades and has specialized in the treatment of eating disorders since 1977. She served on the faculties of Wayne State Medical School, the University of South Florida Medical School, and the Hamilton Holt Graduate School at Rollins College. She is a Founding Fellow of the Academy for Eating Disorders, Founding member of the Eating Disorder Research Society, Founding member of the National Eating Disorder Association, Founding Fellow/Diplomate of the Academy of Cognitive Therapy and a Certified Cognitive Therapist. She has received numerous awards including the “Outstanding Contributions to the Field of Eating Disorders” presented by AED and the “Lifetime Achievement Award” presented by NEDA. She has lectured and published extensively, and her most recent book, is entitled “Eating Disorders, Addictions and Substance Use Disorders: Clinical, Research and Treatment Perspectives.”
Tamara Pryor, PhD, FAED, Executive Clinical Director and Director of Research at EDCare, has been privileged to work in the field of eating disorders for the past 30 years. Dr. Pryor has published research examining personality disorders, substance abuse, sexual functioning, and the neurobiology of the eating disordered individual. She has presented nationally and internationally, and she co-authored a prevention curriculum, as well as 4 book chapters on Eating Disorders and Substance Abuse. Dr. Pryor is a member of the Eating Disorder Research Society, a Fellow of the Academy of Eating Disorders, and serves on the Board of Directors of the National Eating Disorders Association.
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