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Eating Disorders

When Eating Disorders and Drug Addiction Collide

Are eating disorders addictions?

Most people think of eating disorders and drug addiction as separate and distinct issues, but as many people who suffer with these maladies know firsthand, there is often significant overlap between the two. According to The National Center on Addiction and Substance Abuse (CASA) at Columbia University, up to one-half of individuals with eating disorders (especially bulimia) abuse drugs or alcohol, compared to 9 percent of the general population. Up to 35 percent of drug abusers have eating disorders, compared to 3 percent of the general population.

Similarities Between Eating Disorders and Addiction

Because the diagnostic criteria for these conditions closely resemble one another and there is a trend toward broadening the definition of addiction to include process addictions such as gambling, sex and food, eating disorders could be described as a type of addiction. With a few exceptions, screening for eating disorders is markedly similar to screening for drug addiction. As clinicians, we look for:

  • Obsessive preoccupation, cravings and rituals surrounding an addictive behavior
  • Escalation in frequency or intensity over time
  • Sacrificing other interests to spend more time on an addictive substance/behavior
  • Inability to stop a destructive behavior despite repeated attempts
  • Loved ones expressing concern about a particular behavior
  • Continued use of a substance/behavior despite negative consequences

The root causes of eating disorders and drug addiction are similar. Research suggests a strong genetic component to both, as well as links to certain chemical processes in the brain, personality traits such as impulsivity, social pressures, family dynamics, media messages, environmental triggers and emotional trauma. Eating disorders and addictions frequently develop during stressful times in an effort to cope with difficult emotions or to self-medicate underlying mental health issues such as depression or anxiety. Both are chronic diseases with resistance to treatment and high relapse rates, requiring intensive, long-term therapy.

Differences That Impact Recovery

Despite all of these similarities, there are a few important differences that make recovery from eating disorders and addictions distinct processes. While addicts can sever their relationship with drugs and alcohol, people with eating disorders cannot abstain from food. Instead, they face the unique challenges of developing a healthy relationship with food and learning to sit at a dinner table, eat in public and engage in other triggering activities without relapsing. For this reason, eating disorder treatment programs must address both the disordered eating itself and the broader relationship with food – a task that can be extremely difficult even for those who do not have an eating disorder.

Another aspect that is unique to eating disorders is that their self-evaluation is very dependent on their weight and/ or appearance. Whether an individual is severely underweight or overweight, their self-worth is unduly influenced by their body shape or the number on the scale. In some cases, the self-loathing reaches a point of suicidality (the suicide rate for someone with anorexia is 57 times what we would expect to see in that age group). While most people without eating disorders would like to lose weight, what differentiates someone with an eating disorder is the compulsion to go to extremes to make it happen through starving themselves, purging or excessive exercise.

This distinction adds another dimension of difficulty in treating eating disorders. The body serves as a metaphor for the individual’s emotional state. They may say, “I feel fat,” but the underlying issue is unaddressed emotions such as anger, shame or sadness that get expressed through the body. Even years into recovery, someone with an eating disorder can be triggered by seeing a stick-thin model or stepping on the scale. For this reason, they must form a sense of identity separate from their eating disorder.

Concurrent Treatment for Eating Disorders and Addiction

Recognizing the high level of cross addiction between drugs and eating disorders, some dual diagnosis treatment centers screen for and treat both conditions simultaneously. This type of care is surprisingly difficult to find as most addiction programs are ill-equipped to address eating disorders (e.g., few offer meal-time support, access to eating disorder specialists and intensive medical monitoring) and most eating disorder programs aren’t well-versed in treating addictions. Yet a large body of research shows that this concurrent approach is essential for a complete recovery.

Treated separately, what usually happens is that the individual gets help for either an eating disorder or drug addiction, and when that goes into remission the other condition crops up. The patient goes from one treatment facility to another, thinking they’re making progress but ending up stuck in an endless cycle of remission and relapse. This observation supports the theory that these conditions are used as a coping mechanism. In the absence of new coping skills, insights into their disease(s) and some form of social support (often through involvement in a 12-Step program), the individual will perpetually be fighting one or the other condition.

With either condition alone, and especially both at the same time, recovery is a long-term process. Thirty days of treatment doesn’t cure either disease. Studies show that 25 percent will get better and do well throughout their lives (usually the ones who get quality care early on); 50 percent will fall into the relapse-remit cycle; and 25 percent will continue to struggle. In the case of eating disorders, 10 percent of those who continue to struggle will die from the disease.

The link between eating disorders and substance abuse is often overlooked, to the detriment of our patients. Recognizing that where there are eating disorders, there’s often addiction, and vice versa, and offering concurrent, multidisciplinary care, we can help some of our sickest patients get on the road to recovery faster and stay there for life.

More from Carolyn C. Ross M.D., M.P.H.
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