Eating Disorders and Addiction

An eating disorder occurs when mental or cognitive impairments hinder an individual’s dietary behaviors and impairs physical health or psychosocial functioning (i.e., problems with friends and family or problems at work and school).1 While the terminology is often used interchangeably with restrictive or bingeing and purging behaviors, eating disorders also include overeating behaviors and eating non-food substances.1

Eating disorders frequently co-occur with substance use disorders and share similar behavioral characteristics such as cravings and patterns of compulsive use.1,2 Given that they share common behavioral patterns—and that treating one may therefore exacerbate the other—it makes sense to treat both the substance use disorder and the eating disorder when both are identified.2

Three eating disorders are found to co-occur frequently alongside a substance use disorder: 1) anorexia nervosa, 2) bulimia nervosa, and 3) binge eating.2 There are other eating disorders (pica, rumination disorder, avoidant/restrictive food intake disorder, etc.), however, they are not known to co-occur with any frequency with substance use disorders.1

Anorexia Nervosa

Anorexia nervosa is characterized by an obsession about weight loss or control to the point that a person restricts their food intake regardless of hunger.1,2 An individual with anorexia has a body weight that’s below minimal norms for someone of their size and age.1

Serious health consequences can occur if anorexia isn’t treated. The most dangerous side effects include nutritional deficiencies, severe anemia and cardiac abnormalities, all of which can be fatal.2 In fact, more than 10% of individuals diagnosed with anorexia die as a result of the eating disorder, most often from starvation, suicide or electrolyte imbalance.2

Addiction alongside anorexia isn’t uncommon. It’s estimated that 27% of individuals with anorexia will also have a substance use disorder at some point in their life.3

Individuals with anorexia often use prescription or over-the-counter diet pills as well as nicotine to suppress appetite and subsequently lose weight.4 Abuse of stimulants such as caffeine, cocaine and amphetamines is also common—in one study of individuals being treated for cocaine dependency or abuse, nearly 32% met the criteria for anorexia or bulimia.4

Bulimia Nervosa

Bulimia nervosa is an eating disorder where primary symptoms are purging food following a period of binge eating—where an individual consumes an amount of food larger than most people would eat in a 2-hour period.1,2 Subsequent purging of food is done in an effort to avoid weight gain and may be accomplished through self-induced vomiting, excessive exercise, or use of laxatives, diuretics or other medication.1

The long-term binging and purging characterized by bulimia has similar  consequences to anorexia—electrolyte imbalance, nutritional deficiencies and cardiac irregularities—in addition to other, potentially deadly complications that could result from purging, such as esophageal tears or gastric rupture.2 Bulimia is also associated with fertility problems and menstrual irregularity.2

Bulimia may involve incessant exercising, just as anorexia sometimes does. What often makes bulimia hard to pinpoint is that most people who suffer from it are of average weight.2,4 Left untreated, bulimia can cause depression, increase the risk of suicide, and even cause fertility problems.2,4

It’s estimated that 36.8% of individuals with bulimia nervosa will also have a substance use disorder at some point in their life.3

Binge Eating Disorder

Similar to individuals with bulimia, individuals with binge eating disorder eat larger amounts of food than normal within a 2-hour period, however, this is not followed by subsequent purging.1,2 Following the period of binge eating, these individuals feel too full and often a sense of shame, guilt or disgust for having overeaten.1

Binge eating disorder is often accompanied by obesity, and complications of obesity like type 2 diabetes, high blood pressure, high levels of cholesterol, cancer, arthritis as well as problems with the liver, gall bladder and infertility.2

It’s estimated that 23.3% of individuals with binge eating disorder will also have a substance use disorder at some point in their life.3

Treating Co-occurring Eating Disorders and Addiction

Managing addiction with a co-occurring eating disorder presents challenges for treatment professionals, as the ultimate goal is equipping a person with coping skills to manage both disorders following treatment.2,4 Additional team members, such as nutritionists and dietitians may need to be added to the already multidisciplinary group of professionals treating the substance use disorder.2

Physicians may consider not only medications to assist in withdrawal management (e.g., opioid replacement drugs, etc.) but also drugs that might aid in recovery from an eating disorder (e.g., stimulate appetite).2 Routine weight assessments help to keep individuals on track, and physicians may set a target for weight gain.2

Adding to the challenge may be the presence of anxiety and mood disorders (e.g., depression), which are also commonly seen in individuals with eating disorders (at rates between 40–80%) as well as addiction.2 In addition to learning how to resist triggers to use drugs and alcohol, learning how to resist triggers to binge and/or purge is critical for recovery from an eating disorder, as well as developing coping skills to help avoid obsessing about weight or stave off feelings of guilt about eating.2

Part of the recovery process will include learning healthy eating habits that need to be incorporated into daily life. This includes putting the individual on a path where they will get regular and adequate amounts of exercise.2,4

Cognitive behavioral therapy (CBT) is the most widely used form of treatment for both addictions and eating disorders.2,4 Interpersonal psychotherapy may also be used to cope with improving relationship skills so that personal interactions, such as those with family and friends, don’t lead to negative feelings about body image or guilt about eating.2

Group therapy and skills groups will help to bolster self-esteem and support the acquisition of the skills needed to adept. Family therapy may be appropriate, especially for adolescents.4

Treatment isn’t complete when a client leaves rehab. It’s important for clients to remember that continual support is needed. Ongoing aftercare is crucial to sustained recovery. Attending mutual-help group sessions, such as those held by Narcotics Anonymous or Overeaters Anonymous, can help maintain recovery and support abstinence from drugs, alcohol or overeating.4

References

  1. Diagnostic and statistical manual of mental disorders: DSM-5. (5th ed.). (2013). Washington, D.C.: American Psychiatric Association.
  2. Substance Abuse and Mental Health Services Administration. (2011). Clients with Substance Use and Eating Disorders
  3. Hudson, J. I., Hiripi, E., Pope, H. G., Jr, & Kessler, R. C. (2007). The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biological Psychiatry, 61(3), 348–358.
  4. Miller, S. C., Fiellin, D. A., Rosenthal, R. N., & Saitz, R. (2019). The ASAM Principles of Addiction Medicine, Sixth Edition. Philadelphia: Wolters Kluwer.
About The Contributor
Ryan Kelley, NREMT
Medical Editor, American Addiction Centers
Ryan Kelley is a nationally registered Emergency Medical Technician and the former managing editor of the Journal of Emergency Medical Services (JEMS). During his time at JEMS, Ryan developed Mobile Integrated Healthcare in Action, a series... Read More