Eating Disorders and Substance Abuse: From Diagnosis to Treatment

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Addiction. The definition and understanding of addiction has experienced an enormous metamorphosis in the past hundred years. In the first half of the 20th century, the concept of addiction was undoubtedly confined to those with an extreme affinity to “demon rum;” cigarettes were still viewed as an enjoyable pastime, never a deadly addiction. The 60s was a pivotal decade for illegal drug use; and as abundant and diverse as those drugs were, it took time to fully realize how addictive many of those substances were. As the century moved toward its end, our knowledge of addiction grew at an accelerated pace.

Today, our culture routinely applies the term addiction to countless items and bailiwicks. Women are addicted to chocolate, shoes, reality shows, texting, etc. Men are addicted to sports, tools and cars. Conversely, the behavioral health community has remained focused on identifying and treating such addiction spectrum disorders as alcoholism, drug abuse, eating disorders, compulsive gambling and sex addiction.

Mental health professionals have long suspected a link existed between two of the most damaging and life-threatening of these: eating disorders and substance abuse. Recent research indicates such speculations were correct.

Eating disorders/substance abuse defined

Eating disorders are serious psychiatric illnesses, not unlike depression or anxiety. While males can and do get these disorders, anorexia and bulimia are far more prevalent in the female population. Approximately 11 million people throughout the country have an eating disorder, most commonly anorexia nervosa, bulimia nervosa and eating disorder not otherwise specified. Millions more struggle with binge eating disorder.

Anorexia is literal self-starvation. Those with anorexia starve themselves to dangerously thin levels, even to death. Bulimia is characterized by recurrent cycles of binging and purging. An individual consumes huge quantities of food, then eliminates it through purging, usually by vomiting, over-exercise, laxative use, or starving. Binge eating disorder is similar to bulimia with one notable exception: the binge is not followed by a purge, which means obesity is often a problem.

Substance abuse includes everything from compulsive use of seemingly benign substances such as caffeine and nicotine, to alcohol, prescription medications and highly dangerous substances such as crystal meth and heroin. Currently, an area of extreme concern is prescription drug abuse, which is escalating at an alarming rate, especially among adolescents. This is primarily the result of two factors: perception and availability. Young people, not unlike many adults, mistakenly believe pharmaceutical medications are safe, simply because they are prescribed by a doctor. They are wrong. Even worse, many mood-altering medications are often easily accessed through a parent’s medicine cabinet, or from illegitimate pharmacies on the internet.

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Co-occurring disorders

When an individual suffers from more than one illness at any given time, it is referred to as a dual diagnosis or co-occurring disorder. Increasingly, female patients are presenting with both an eating disorder and substance abuse, and research continues to validate a connection between the two. Up to 35% of alcohol or illicit drug abusers have eating disorders compared to only 3% of the general population. Similarly, up to 50 percent of those with eating disorders have a simultaneous problem with drug or alcohol abuse. Girls with eating disorders are four times more likely to use inhalants and cocaine. It is fairly easy to imagine why a woman or girl with an eating disorder would abuse drugs. If the goal is to be skinny, those with anorexia often become dependent on caffeine, nicotine, diet pills and stimulants such as Adderall to suppress appetite or speed up metabolism. In time, women and girls may graduate to cocaine, meth and even crack. Similarly, women with bulimia often abuse diuretics, stimulants and laxatives for purging purposes.

Although the weight loss component is clear, to fully understand the link between these disorders necessitates a deeper understanding of the “whys” of an eating disorder. Eating disorders, at their root, are not about food as much as they are about feelings and identity. An eating disorder is an unhealthy method to cope with unpleasant thoughts, painful life experiences and resulting cycles of painful emotions such as hurt, sadness, loneliness, rage and terror. Drugs and alcohol are often utilized to achieve the same end. When a girl is high or drunk, she is not sad, lonely, anxious or depressed. The boyfriend rejection, the parental arguments, the pain of the past, concern of the present, worry about the future: all gone. In other words, the function, what both the eating disorder and substance abuse can do for the girl, is similar.

Shared biological factors

Additional factors contribute to the onset of these disorders. Drug abuse and eating disorders are developmental in nature, meaning that onset is usually during adolescence when the brain is still developing. Further, studies have shown increased risk for eating disorders and substance abuse if one or both parents have alcoholism.

It is widely believed that genetics load the gun and environment pulls the trigger. This is absolutely the case with these diseases. Certain people are genetically predisposed to having food-related disorders or problems with alcohol and drugs. It is this same genetic component that makes these individuals more likely to experience environmental triggers associated with growing up with a family history of alcoholism or addiction-trauma, stress, neglect and early drug or alcohol exposure. Additional complexities involve personality factors, brain chemistry and functional changes in the reward center of the brain. Therefore, conditions that might galvanize one young women to become eating disordered or involved with drugs would not have the same impact on another.

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Imagine two young women entering college, one has a genetic predisposition toward eating and drug-related disorders, while the other does not. Each is exposed to the tremendous stress associated with academic expectations, new social systems, distance from home, and even the possibility of gaining the dreaded “freshman 15.” One freshman recognizes the pressure and copes with it in a healthy fashion. She eats well, exercises regularly, prays or meditates, and remains securely connected with her family and peer supports. The other freshman becomes overwhelmed, anxious and worried all the time. She restricts caloric intake to avoid weight gain and to mitigate her intense feelings; she may even engage in drunkorexia, a condition in which college students eat nothing all day, and then ingest their entire daily caloric intake on alcohol that night. She begins taking stimulant medication to help her study. All is a recipe for eventual disaster, up to and including death.

Recognizing the connection between eating disorders and substance abuse is critical, especially with regard to the treatment process. A treatment team for a girl with both an eating disorder and substance abuse must be comprised of experts in both. Ideally the treatment providers are well-versed in treating co-occurring addictive disorders and offer a unified treatment philosophy to help the woman recover in all areas. Fortunately, with the proper diagnosis and expert care, recovery is a real life possibility.


Kim Dennis, M.D., is a board-certified psychiatrist who specializes in treating addictions (substance, process and food), eating disorders and co-occurring disorders.

This article first appeared in the Jan/Feb 2012 issue of The Phoenix Spirit.

Last Updated on November 2, 2022

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