July/August 2008 Issue

Insatiable Hungers: Eating Disorders and Substance Abuse
By Adrienne Ressler, MA, LMSW, CEDS
Social Work Today
Vol. 8 No. 4 P. 30

Many shared risk factors and characteristics link these two disorders, but there are also significant differences when it comes to treatment and recovery.

The word satiate comes from the Latin root satis, which means enough and implies the capability of being fully satisfied. But for the thousands of individuals who experience the ravages of eating disorders and/or chemical dependency, 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.

In recent years, a strong link between substance abuse and eating disorders in women has become apparent. Studies reveal that up to one half of individuals with eating disorders abuse alcohol or illicit drugs compared with 9% of the general population (National Center on Addiction and Substance Abuse [CASA] at Columbia University, 2003). Also, approximately 35% of alcohol or illicit drug users have eating disorders compared with 3% of the general population (CASA, 2003). Both groups share risk factors and personality characteristics.

What are the underlying risk factors, characteristics, and belief systems that propel individuals into a relentless quest for the perfect body, the perfect life, and the magic balm that will soothe anxiety, fear, and depression?

Substance Abuse and Eating Disorders Links
The most consistent agreement in the literature on the link between eating disorders and substance use is that individuals with eating disorders experience higher rates of substance abuse than do those in the general population, and those who binge and purge are more likely than restricting anorexics to engage in substance abuse (Krahn, Piper, King, Olson, Kurth, & Moberg, 1996).

Until recently, eating disorders and substance abuse were usually treated separately, and few specialists even screened for the presence of both. Speculation often surrounded the causal relationship in terms of onset, an issue still not well understood (CASA, 2003). Does the presence of the addiction emerge as the eating disorder subsides? Conversely, is the eating disorder camouflage for underlying substance abuse? Does one disorder drive the other, or do the two occur simultaneously? The possibility also remains that co-occurrence is coincidental, but no one theory is exclusive and any combination is possible.

It is known that certain substances may help an individual with an eating disorder lose weight or may be a way that a client self-medicates 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 & Wolfe, 2003).

The question of whether an eating disorder or substance dependence occurs first raises numerous possibilities, all of which should be taken into consideration. When the eating disorder is already present, substance use may assist an individual with maintaining or reducing weight or may ameliorate psychological distress. An individual may develop an eating disorder after his or her appetite has been suppressed through the use of particular drugs, smoking, or alcohol. Overeating may result when stimulation to the brain’s pleasure center is lessened during withdrawal from substances. 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, Sunday, Halligan, Korn, Broan, & Halmi, 1999).

While there are many shared risk factors and characteristics between those who abuse substances and those with eating disorders, there are differing theories to explain this association. The theories 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 the association between eating disorders and substance abuse.

Adverse events in early life have also been linked to a host of serious, long-term, and relatively intractable health problems. Kaiser Permanente’s department of preventive medicine in San Diego, CA, and the Centers for Disease Control and Prevention studied the effects of adverse childhood events in more than 17,000 patients for more than a decade (Felitti, Anda, Nordenberg, et al., 1998). The findings revealed that core issues such as trauma, grief, a history of abuse, parental neglect or abandonment, and parental substance use or abuse are often at the root of long-range symptomatology. These symptoms include physical illness, health-jeopardizing behaviors (e.g., overeating, smoking), eating disorders, substance use disorders, other disorders in the compulsive spectrum, anxiety, and depression (Felitti et al., 1998). 

Dusty Miller addresses childhood trauma in her book Women Who Hurt Themselves: A Book of Hope and Understanding and concludes that destructive behaviors such as self-mutilation, alcoholism, drug addiction, and eating disorders represent a reenactment of trauma and labels this as trauma reenactment syndrome. Miller identifies various central characteristics of it that are seen in many of the clients with both eating disorders and addictions, such as the following:

• the sense of being at war with one’s own body;

• an inability to self-protect, often evident in a specific kind of fragmentation of the self; and

• relationships in which the struggle for control overshadows all else.

Shared Risk Factors
In 2003, CASA 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, including the following:

Shared Risk Factors
• occurrence in times of transition or stress;

• common brain chemistry;

• common family history;

• low self-esteem, depression, anxiety, or impulsivity;

• history of sexual or physical abuse;

• unhealthy parental behaviors and low monitoring of children’s activities;

• unhealthy peer norms and social pressures; and

• susceptibility to messages from advertising and entertainment media.

Shared Characteristics
• obsessive preoccupation, craving, compulsive behavior, secretiveness, and rituals;

• experience mood-altering effects, social isolation;

• linked to other psychiatric disorders or suicide;

• difficult to treat, life threatening;

• require intensive therapy; and

• chronic diseases with high relapse rates.

A link with the defining criteria for substance dependence as cited in the fourth edition of the Diagnostic Statistic Manual of Mental Disorders also could make a case for an overlap with addiction. Three (or more) of the following occurring at any time in the same 12-month period constitute substance dependence:

• tolerance, as defined by either of the following:

            - a need for markedly increased amounts of the substance to achieve intoxication or the desired effect; or

            - a markedly diminished effect with continued use of the same amount of the             substance.

• withdrawal, as manifested by either of the following:

            - the characteristic withdrawal syndrome for the substance; or

            - 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.

Some of the behaviors, rituals, and thinking that accompany the eating disorder fit the previously listed criteria. Both eating disorders and substance use tend to begin with experimentation but, certainly, not everyone who experiments becomes psychologically and physically compromised (Davis, 1993). Those who do are often 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; 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 and Substance Use Disorders
The examination of differences that exist between the two disorders must focus on the at-risk populations. While recent indications note an increasing diversity in age, race, and sex among those with eating disorders, they are most prevalent in young women (Grunbaum, Kann, Kinchen, et al., 2002). Differences are also seen in the approach/avoidance relationship. The substance abusers position themselves 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 cost (Davis, 1993).

Recovery is markedly different with each disorder. The substance abuser must restrict or abstain from the substance; the individual with an eating disorder cannot abstain from the substance (food) since it is needed to sustain life. Abstinence for those with eating disorders involves abstinence from its symptoms: starvation, rigid dieting, binge eating, purging, body loathing, and the thoughts that accompany these behaviors. Rather than ending the relationship with the substance, the individual with an eating disorder must work to form a new enhanced relationship with food, while the substance abuser traditionally severs the relationship with the substance(s) of abuse completely (although harm reduction and moderation management strategies are gaining attention).

 Another difference is that the substance abuse recovery community instructs the individual to continue to claim the disease as an identity. Alcoholics Anonymous and Narcotics Anonymous meetings always begin with the introduction, “Hello, my name is ______ and I am an alcoholic (addict).” For the individual with an eating disorder, a shift away from claiming the disease is important. The punishing body image mantras that accompany every glance in the mirror, every competition lost to another who is thinner, every quarter pound gained bring with them severe self-loathing and stinging criticisms: “I am fat,” “I am ugly,” “I am disgusting.” Often repeated hundreds of times a day for years, these become so familiar they compromise or even overtake an individual’s identity. It is essential for individuals to give up that identity and claim their authentic self or the self they can “grow into” over time through practice. “I am graceful,” “I am elegant,” “I am flexible” must all capture the essence of each individual person and reflect a part of herself that she values. This emphasis on the body and body image is specific to eating disorders. No such central focus is identified in substance abuse clients.

Methods used to foster recovery in the substance abuse community rely on an externally imposed locus of control. Bill Davis (1993) finds that this approach can actually undermine internal control or empowerment in individuals with eating disorders by replicating the conditions that initially triggered the eating disorder.

Davis distinguishes between a “power over” and a “power with” approach to recovery. The first focuses on the domination of the disease and substance and the second focuses on transcending or transforming the disorder through inner empowerment that relies on the power of relationship. In this second model, the therapist attempts to create a safe haven for clients in which the attachment to the therapist takes on more significance than their relationship with the disease. This model allows clients to reduce their reliance on the symptoms and work together with therapists to deal with the underlying problems that precipitated the eating disorder.

While it appears that eating disorders and substance use disorders have much in common and frequently appear together in certain individuals, there is insufficient research to indicate that eating disorders be classified as an addiction. The high number of shared characteristics and risks of the two disorders as well as their similar downward course suggest that further study on the implications for prevention, treatment, and recovery maintenance would be helpful to both clients and professionals.

— Adrienne Ressler, MA, LMSW, CEDS, is the national training director for The Renfrew Center Foundation. As a senior staff member, she has designed and conducted hundreds of training seminars for professionals throughout the United States and internationally on eating disorders and body image disturbance, sexual abuse, depression, and women’s issues.

Screening for Both Disorders
Behavioral health professionals should use simple screening tools to rule out or confirm the presence of a co-occurring condition. To screen for substance use in individuals with eating disorders, the CAGE (Cut down, Annoyed, Guilty, Eye-opener) and the MAST (Michigan Alcohol Screening Test) are both effective (Wandler & Wolfe, 2003). The EDI (Eating Disorder Inventory) and the SCOFF (Sick, Control, One Stone, Fat, Food) also may be used (Wandler & Wolfe, 2003). The SCOFF includes the following questions (Morgan, Reid, & Lacey, 1999):

1. Do you make yourself SICK because you feel uncomfortably full?

2. Do you worry you have lost CONTROL over how much you eat?

3. Have you recently lost more than ONE STONE (15 lbs.) in a three-month period?

4. Do you believe yourself to be FAT when others say you are too thin?

5. Would you say that FOOD dominates your life?

While all clients should be screened, it is particularly important to target higher risk clients for comorbidity. According to the National Center on Addiction and Substance Abuse at Columbia University (2003), these categories include the following:

• high caffeine users;

• smokers;

• frequent users of over-the-counter and prescription drugs to reduce water retention, bloating, or induce purging;

• girls at puberty; and

• athletes, especially dancers, gymnasts, figure skaters, wrestlers, and crew members.

References

Davis, B. (1993). Eating disorders vs. drug and alcohol addiction. Addiction & Recovery, 13(5), 11.

Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., et al. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine, 14(4), 245-258.

Grunbaum, J., Kann, L., Kinchen, S. A., Williams, B., Ross, J. G., Lowry, R., et al. (2002). Youth risk behavior surveillance — United States, 2001. Morbidity and Mortality Weekly Report. 55(SS04), 1-64

Krahn, D., Piper, D., King, M., Olson, L., Kurth, C., Moberg, D. P. (1996). Dieting in sixth grade predicts alcohol use in ninth grade. Journal of Substance Abuse, 8(3), 293-301.

Morgan, J. F., Reid, F., & Lacey, J. H. (1999). The SCOFF questionnaire: Assessment of a new screening tool for eating disorders. BMJ, 319(7223), 1467-1468.

National Center on Addiction and Substance Abuse (CASA) at Columbia University. (2003).Food for Thought: Substance Abuse and Eating Disorders. New York, National Center on Addication and Substance Abuse.

Wandler, K. & Wolfe, K. (2003) Eating disorders and substance abuse: Treating the co-morbid patient. Presentation at the International Association of Eating Disorders Conference, Miami, FL.

Wiseman, C., Sunday, S., Halligan, P. Korn, S., Broan, C., & Halmi, K. In: National Center on Addication and Substance Abuse. (2003).Food for Thought: Substance Abuse and Eating Disorders. New York, National Center on Addication and Substance Abuse.