Eating disorders and substance use often co-occur. To explain why and more, please find the following guest post by Adrienne Ressler, LMSW, CEDS, and Vice President, Professional Development at The Renfrew Center Foundation, which was established in 1990 due to the strong need for public and professional awareness regarding anorexia, bulimia and binge eating disorder. Today, the Foundation is dedicated to the elimination of eating disorders through education, prevention, research, advocacy and treatment.

Never Satisfied: Eating Disorders and Substance Use by Adrienne Ressler LMSW, CEDS

For many thousands of individuals who suffer from the ravages of eating disorders, chemical dependency and/or depression, their hungers are rarely satiated. For them, the high is never high enough, the scale is never low enough, and the image in the mirror is never good enough. There is always a longing for more, better, faster…even instant gratification takes too long!

There appears to be a strong link between substance abuse and eating disorders in women. Studies reveal that up to one-half of individuals with eating disorders abuse alcohol or illicit drugs, compared to nine percent of the general population (CASA, 2003). Also, approximately 35% of alcohol or illicit drug abusers have eating disorders compared to 3% of the general population (CASA, 2003). Both groups share risk factors, personality characteristics as well as underlying issues with anxiety and depression. Underlying risk factors, characteristics, and belief systems often propel individuals into a relentless quest for the perfect body, the perfect life, and the magic balm which will soothe away all anxiety, fear and depression. Attachment deficits, identity formation and the development of body image lay the groundwork for the use of relational strategies to bridge the therapeutic alliance between client and healer. The role of spirituality and the reciprocal relationship between body and mind should be explored as well as the effects of one’s susceptibility to messages from advertising and the entertainment media.

Substance Abuse and Eating Disorders- Links

Although there are many similarities, it is important to carefully assess whether or not the differences outweigh the areas in which there is overlap.The most consistent agreement in the literature on the link between eating disorders and substance use is that patients with eating disorders suffer higher rates of substance abuse problems than do those found in the general population and patients who binge and purge are more likely than restricting anorexics to engage in substance abuse (Krahn et. al., 1996, Bulik et. al, 1994. Relatively new studies from Sweden on premature death show surprising statistics on death from alcohol abuse in anorexics – even years after recovery.XXX Until recently eating disorders and substance abuse were usually treated independently of one another and few specialists even screened for the presence of both. Speculation often surrounded the causal relationship in terms of onset and even today is still not well understood (CASA, 2001). Does the presence of the addiction emerge as the eating disorder subsides? Conversely, is the eating disorder a camouflage for an underlying substance problem? Does one disorder drive the other or do the two occur simultaneously? There is also the possibility that co-occurence is coincidental. No one theory is exclusive – any combination is possible.

What is known is that certain substances may help the eating disordered individual lose weight or may be a way that the client self-medicates in order to alleviate negative psychological symptoms. Appetite is suppressed and the reward center of the brain experiences satiety when alcohol, nicotine, amphetamines, or cocaine are used; thus, the substance abuse may be present prior to the eating disorder (Wandler, K., 2003). There are indications that individuals whose eating disorder precedes their substance use disorder have rates higher than patients with eating disorders only. Those whose eating disorder was preceded by a substance use disorder are more likely to suffer from obsessive-compulsive disorder, panic disorder and social phobia. Individuals whose substance abuse precedes their eating disorder are typically dependent on more substances and more likely to have developed their dependency at an early age (Wiseman, C., 1999).

While there are many shared risk factors and characteristics between those who are substance abusers and those who suffer from eating disorders, there are differing theories to explain this association. Possibilities taken in account explore eating disorders as an addiction, the role of genetics, cultural influences, environmental theories, exposure to trauma, and the role of the brain and attachment – all or some of which contribute to the complexity of this topic. Early life adverse events have also been linked to a host of serious, long term, and relatively intractable health problems. For over a decade the effect of Adverse Childhood Events (ACE) were studied by Kaiser Permanente’s Department of Preventive Medicine in San Diego, California, and the Center for Disease Control and Prevention. Over 17,000 patients participated in the study. The findings revealed that patients’ core issues – which included trauma, grief, a history of abuse, parental neglect or abandonment, parental substance use/abuse, and others, are at the root of much long range symptomatology, including physical illness, health-jeopardizing behaviors (i.e. overeating, smoking), eating disorders, substance use disorders, the other disorders in the compulsive spectrum, anxiety, depression, and more. (Felitti, VJ, Anda, RF, Nordenberg D., Williamson D., Spitz, A., Edwards, V., Koss, M, et al . The relationship of adult health status to childhood abuse and household dysfunction. American Journal of Preventive Medicine, 1998:14:245-258.)

In 2003, The National Center on Addiction and Substance Abuse (CASA) at Columbia University published the first comprehensive examination of the link between substance abuse and eating disorders. The three year study found common characteristics and risk factors between the two populations:

Shared Risk Factors
• Occur in times of transition or stress
• Common brain chemistry
• Common family history
• Low self esteem, depression, anxiety, impulsivity
• History of sexual or physical abuse
• Unhealthy parental behaviors and low monitoring of children’s activities
• Unhealthy peer norms and social pressures
• Susceptibility to messages from advertising and entertainment media

Shared Characteristics
• Obsessive preoccupation, craving, compulsive behavior, secretiveness, rituals
• Experience mood altering effects, social isolation
• Linked to other psychiatric disorders, suicide
• Difficult to treat, life threatening
• Require intensive therapy
• Chronic diseases with high relapse rates

A link with the defining criteria for substance dependence as cited in the DSM-IV (American Psychiatric Association, 1994)) also could make a case for eating disorders having an overlap with addiction. Three or more of the following, occurring any time in the same 12 month period, constitute substance dependence:

• Tolerance, as defined by either of the following:

a. A need for markedly increased amount of the substance to achieve intoxication or the desired effect or
b. Markedly diminished effect with continued use of the same amount of the substance.

• Withdrawal, as manifested by either of the following:

a. The characteristic withdrawal syndrome for the substance or
b. The same (or closely related) substance is taken to relieve or avoid withdrawal symptoms.

• The substance is often taken in larger amounts or over a longer period than intended.
• There is a persistent desire or unsuccessful efforts to cut down or control substance use.
• A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects.
• Important social, occupational, or recreational activities are given up or reduced because of substance use.
• The substance use is continued despite knowledge of having a persistent physical or psychological problem that is likely to have been caused or exacerbated by the substance.

Certainly the behaviors, rituals and thinking that accompany the eating disorder fall into many of the above categories listed above.

Both eating disorders and substance use tend to begin with experimentation but, certainly, not everyone who experiments winds up psychologically and physically compromised. Those who do often are attempting to distract or protect themselves from underlying problems by means of excessive drinking, drug use, eating or dieting. While these behaviors are self-protective by intent, they become self-destructive by consequence. Symptoms become functionally autonomous and the drive to drink, use, eat or starve loses its connection with the original underlying problems and takes on a life of its own – often becoming self-reinforcing and self-perpetuating. Recovery is complicated because it must address both the underlying original problem as well as the now-embedded cycle of self-destructive behaviors.

Differences between eating disorders and substance abuse

Differences that exist between the two disorders must focus, of course, on the fact that eating disorders are gender specific for females, particularly, teens, while substance abuse covers all gender age, race and income level. Another difference is reflected in at-risk populations. While recent indications note an increasing diversity in age, race, and sex, in the eating disorders community, the primary sufferer still is a young woman (Centers for Disease Control and Prevention, 2002). Another difference is reflected in the approach/avoidance relationship. The substance abuser positions herself to always be in “search of the substance. Fueled by cravings, the user moves toward the substance whereas the person with the eating disorder is constantly seeking to avoid food at all costs. The process of recovery is markedly different with each disorder. Whereas the substance abuser must restrict or abstain from the substance, the eating disorder patient must not abstain from the substance (food), as it must be utilized as an ally to sustain life. The eating disordered individual must work to form a new enhanced relationship with food – the substance abuser must cut off any relationship completely.

Abstinence for those with eating disorders involves abstinence from its symptoms: starvation, rigid dieting, binge-eating, purging and body loathing and the thoughts that accompany these behaviors. Rather than ending or cutting off the relationship with the substance, the eating disordered individual must work to form a new enhanced relationship with food.

In the field of eating disorders debate continues to examine what “full recovery” actually means. Quality of life, not just abatement of symptoms, must be considered in defining the elements of a fully recovered individual.

Recovery itself follows a difficult road – no one has a perfect journey. Recovery consists of stages – many of which need to be repeated. It is essential that the client understand that everyone struggles to manage destructive thinking and learn new coping mechanisms. New advances in treatment such as Acceptance and Commitment Therapy, DBT, CBT as well as mindfulness meditation are useful for helping all clients move into a more fulfilling life. Some of the stages of recovery involve:

• Letting go of full denial, acknowledging the disorder- committing to a treatment plan. Empowering self to make changes- get support
• Re-feeding, abstinence from substances, healthier relationship with food-cues, education around disorders and recovery- begin to understand, self discovery-underlying issues, tolerate emotion
• Relapse prevention
• symptoms/ substances
• Meaningful Grieving the loss of life/ activities, significant changes- commitment to recovery

While all clients should be assessed for both disorders, it is particularly important is to target higher risk clients for co-morbidity. According to the CASA report (2003), these categories would include:

• High caffeine users
• Smokers
• Frequent users of over the counter and prescription drugs to reduce water retention, bloating, or induce purging
• Girls at puberty
• Athletes, especially dancers, gymnasts, figure skaters, wrestlers, crewing

Non-traditional methods for treatment

In recent years, the incorporation of complementary medicine and non-traditional techniques has been utilized to promote healing. Yoga with its combination of postures, breathing and meditation, drumming, art and dance movement therapy, massage, meditation, and spirituality have all been effectively utilized to address the underlying depression and emptiness that fuel these disorders. Philip Cushman coined the phrase “the empty self” to describe the malaise produced by our current culture of overabundance and mindless consumption. In both eating disorders and substance abuse, healing involves filling the “empty” self with material that is life-sustaining. The body must be a place where the client lives – not an object needed to be controlled – and nonverbal methods for accessing and expressing emotion must be made available to the client. Edward Hopper, the American artist said “If I could say it in words, there would be no reason to paint”.

Many of the alternative methods for healing reflect the research done on the right, non-verbal area of the brain, the “emotional brain”. A recent study at Boston University and McLeans’s Hospital found a twenty-seven percent increase in levels of GABA, an inhibitory neurotransmitter that has been implicated in both depression and anxiety, after just one hour of hatha yoga.

Many of the alternative methods for healing reflect the research done on the right, non-verbal area of the brain, the “emotional brain”. A recent study at Boston University and McLeans’s Hospital found a twenty-seven percent increase in levels of GABA, an inhibitory neurotransmitter that has been implicated in both depression and anxiety, after just one hour of hatha yoga (Forbes, 2007). New MRI studies suggest that meditation – and possibly yoga – leads to positive cortical changes in the brain. Bo Forbes, in her article Yoga and the emotional body: The evolution of yoga therapy, postulates that “artfully practiced”, yoga therapy can help rewrite the ‘code’ that has been inscribed onto the nervous system, changing neural pathways and offering a drug-free alternative to mood disorders and other psychological challenges.

Studies have also shown that yoga and the accompanying asanas (postures) can decrease and/or alleviate depression and anxiety. Woolery, Meyers, Sternleib, and Zeltzer (2004) posited that Iyengar yoga would be particulary potent in decreasing self-reported symptoms of depression. Results indicated the expected reduction in levels of both depression and anxiety at the end of the ten week project. However, after only five classes of Iyengar yoga, levels of both were significantly reduced after only five classes of Iyengar yoga.

Drumming also offers many benefits to those who have difficulty focusing or calming the self. Clohosey (2009) identifies the following potential benefits from rhythm activities:

• Increase body awareness
• Regulate energy levels
• Allow clients to reach a state of relaxed alertness
• Build self-esteem through creativity and skill mastery
• Build self-esteem through creativity and skill mastery
• Strengthen impulse control
• Provide non-verbal forms of self expression
• Enhance listening, communication, eye contact, assertiveness skills
• Facilitate mindfulness, full awareness to the present moment
• Integrate creative and logical thought processes

Massage, also, has deep and lasting effects on depression and anxiety. In a study conducted under the directon of Tiffany Field of the Touch Research Institute at the University of Miami Medical School (Field, T., Schanberg, S. Kuhn, C., Tidld, T., et al, 1998) adolescent patients at the Renfrew Center suffering from bulimia underwent a course of two massages weekly over a five week period. Results indicated that the massaged patients showed immediate reductions in anxiety and depression. At the end of the time period they had lower depression scores, lower cortisol (stress) levels, higher dopamine levels, and showed other indications of psychological and behavioral progress. These findings suggest the possible effectiveness of massage as an adjunct treatment for bulimia, which is often closely associated with drug and alcohol use.

Conclusion

While it appears clear that eating disorders and alcohol and substance use disorders have much in common and frequently appear together in certain individuals, it is not clear that there is research to indicate that eating disorders be classified as an addiction. A new text, (2013), “The Hunger Fix” by Pamela Peeke, MD, provides both research and case study information that substantiates the need for another look at Binge Eating Disorder and its possible inclusion as an addiction. The high number of shared characteristics and risks of the two disorders as well as their similar downward course indicate that further study on the implications for prevention, treatment, and recovery maintenance would be helpful to both sufferers and professionals alike. It is essential, however, that the high rate of morbidity for eating disorders warrants that clinicians familiar with protocols for treating substance use be required to have thorough, long term training and supervision in order to treat the complexity of the eating disorder patient population.
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