Substance abuse is something most therapists are familiar with and feel comfortable addressing with their clients. I have been giving the information in this article to hundreds of substance abuse therapists, and the common response is “I had no idea.” The comorbidity of substance abuse and eating disorders is common. The difference is that patients will frequently talk about their drug use, but refrain from sharing their eating disorder because of the shame, guilt, and fear associated with anorexia nervosa (anorexia), bulimia nervosa (bulimia), and binge eating disorder (BED) behaviors. This article will help us understand our role in helping patients work towards recovery.
Anorexia is often easier to identify because patients must have been at 85 percent of their normal body weight. They often wear loose clothing to hide their bodies and because they have such a skewed perception of them—called “body dysmorphia”—they are not alarmed by the physical changes caused by food restriction. These patients have formed their primary relationship with “ED,” their eating disorder. They avoid social interactions with loved ones and will often hide their food or trade it at school. The effects of starvation on the brain have shown that the ability to make good choices is minimal at best (Keys, Brozek, Henschel, Mickelsen, & Taylor, 1950).
If patients come to us for their substance abuse issues, the first thing we should consider is their presentation. Today’s social culture worships thinness, and the degree to which it is pursued is based on the consequences of starvation that our patients may or may not share with us. Some of the physical parameters we can look for are the fact that they may be wearing clothing that is heavier than expected based on the temperature. Do they complain of being cold? They may have some psychomotor retardation such as moving slowly or feeling dizzy when they change their position from sitting to standing. They may have difficulty holding on to recent discussions or forget what they told us in previous sessions. They may talk about their depression and anxiety and minimize their extreme fear of gaining weight. They will complain of fatigue and inability to participate in normal physical and cognitive activities—they have used up their store of carbohydrates (glycogen in the liver) and are now relying on fatty acids for energy. They may be eating less than five hundred calories per day and their bodies are used to this decreased amount. If they are open to increasing their food intake, they have to do so with the supervision of a nutritionist and medical provider. When they are refed too quickly, the heart may not be able to handle the increased metabolic demand and can have serious complications (Bermudez & Beightol, 2004).
When parents ask about changes with starvation, I use the analogy of the ticket books used before the days of the FastPass at Disneyland. The ticket ride coupons were labeled A through E. The E coupons were the best because you could get on the Matterhorn, the main attraction ride at that time. Kids did not care about the A–C tickets, so I compare the E tickets to the heart and lungs. The body will divert what calories it is receiving to keeping those organs functioning. The D and C tickets are the liver, kidneys, and other important organs that need to function to sustain life. The A and B tickets are the systems that the body will shut down to keep the major organ systems working. The immune system, reproductive system, and endocrine systems are sacrificed to keep the other organ systems working. Female patients may stop having menstrual cycles (i.e., amenorrhea) and males may have low testosterone levels. They may have more infections due to their compromised immune systems and thyroid function may be low. Muscle mass is lost, energy levels are compromised, and the body slows down the metabolic rate (Andersen & Yager, 2004). These patients may continue to exercise compulsively, causing more muscle wasting and dizziness.
How Do We Begin Helping these Patients?
Patients may be willing to enter into a therapeutic alliance with therapists if we stick to their substance abuse issues and gradually work into learning about what consequences they are experiencing due to the behaviors of their eating disorder. Remember, their perception is they are “fat”; they do not see their bodies the way we see them. They may be rigid in their ideas and we will not win in a battle of wills. These patients need to hear more than “just eat.” The fear level is high and it is difficult for non-eating-disorder specialists to understand how difficult it is to even talk about food, let alone eat it. Patients may have only allowed themselves to have half a bagel, a quarter cup of yogurt, and a piece of hard candy as their daily intake and this might have gone on for a year. Can you imagine the control it takes to follow these self-imposed rules? Anyone who has started a diet on Monday realizes that by Wednesday they are struggling to keep it going. The level of control and perseverance around food is extremely hard to challenge. The best treatment for these types of patients—who may also have drug addictions—may be a referral to an eating disorder specialist or a higher level of care. Our job may be to ensure that patients get the medical care needed to ensure they are medically stable.
Patients may have switched from restricting food to becoming bulimic, which means they are using some compensatory behavior to get rid of calories. This may be purging through exercise, vomiting or laxative use. Bulimic patients may be of normal weight or slightly above. They are at risk for numerous medical complications due to any of these purging behaviors. They may be bingeing and also experiencing a “brain fog,” frequently experienced when bingeing on thousands of calories at a time. The difference between BED and bulimia is that bingeing patients do not use any compensatory behaviors to get rid of the ingested calories. Look for an excoriated red area over the index finger (i.e., Russell’s sign) caused by rubbing their finger against their teeth while trying to induce vomiting (Mehler & Andersen, 2010). Some patients get to the point where they can spontaneously vomit. I have had patients tell me that they can go to a movie, order a large popcorn tub, and purge it without the people sitting next to them having a clue as to what they are doing. Purging can cause a change in serum electrolyte levels (sodium, potassium, chloride, bicarbonate) and can lead to a change in heart rhythm and sudden death. The combination of vomiting alcohol and gastric acid can also lead to erosion of the esophagus, causing them to bleed out (Fairburn & Harrison, 2003).
Compulsive exercising often leads to fainting or severe dehydration. The patients can exercise for hours and ignore pain, weakness, and dizziness. They may even be shaking their leg, sitting on the edge of the chair in your office, to maintain constant motion and burn calories. They would rather exercise than spend time with family or friends, adding to their social isolation.
Laxative abuse can lead to a medical emergency called a “carthartic colon” (Mehler, 1997). When the colon does not function on its own due to the heavy use of laxatives, patients need to get immediate medical care. They may complain of different GI complaints and these need to be taken seriously.
How Do We Approach Eating Behaviors?
The first thing is to determine if these patients need a higher level of care. Can they refrain at all from the behaviors? How many times per day are they engaged in purging, exercising or laxative abuse? The need for a medical work-up is first and we may need to insist that patients see their primary physician. Patients can become medically compromised quickly and they lose control by being sent to an emergency room or hospital setting. I tell my patients that this is not the option they want to risk due to their need for control.
Compulsive overeaters may be overweight, and although they are coming to you for their drug addiction, the one rule to help these patients is to understand that they have no control over their bingeing. It may get to the point that they are facing financial complications due to overspending on food. Their increased consumption of carbohydrates may have caused diabetes or metabolic syndrome (i.e., central obesity, hypertension, high serum triglycerides) affecting their ability to lose weight or control their hunger (Kaur, 2014). These patients may be abusing alcohol or marijuana, leading to an increase in food consumption whether it is a side effect of the drug or the environment they chose to continue their addiction.
The above descriptions of patients dealing with these disorders bring their therapeutic challenges to us. If we decide to keep and treat these patients, here are some guidelines to determine where to start.
Trauma and Co-Occurring Conditions
The common theme of trauma and abuse history in eating disorder patients is like that seen in substance abuse patients (Brewerton, 2007). It can start during the initial session when we take the history. A trauma history is a strong indicator that patients may be dealing with an eating disorder. The addition of other compulsive behaviors such as gambling, sexually acting out or shopping may also be causing consequences in their lives. What other behaviors are they concerned about? When we take a social history, we may ask about a typical day related to their eating. Do they eat with others? Did they have any “rules” around the kitchen when they were growing up? Could they eat what they wanted any time of the day or were there restrictions? Did they ever get teased about their weight? Who else in the family has disordered eating? These are the questions that may lead to our suspicions being accurate.
When to Refer
Once there is evidence to support the idea that our patients have a dual diagnosis, this is where some soul searching on our part may help us decide whether to treat or refer patients to a higher level of care. The idea of body image does not just apply to our patients—we need to examine ourselves. What are our feelings about our bodies? Do we have a bias with obese patients? Can we connect with their feelings of hopelessness and fear? What are our issues around our bodies, and can we deal with these in supervision and not let them into the session?
It is at this point that if any answers cause us concern, we should refer patients for specialized treatment. If they have had their disease for a longer (rather than shorter) period of time, then they may need a team consisting of a psychiatrist, internist or GP, nutritionist, and a therapist specializing in eating disorders. Have we identified any additional comorbidities such as depression, OCD or anxiety? Do we feel comfortable with their current medications?
Levels of Care
Patients with a single diagnosis of substance abuse are probably starting to look more desirable, but less likely based on the current level of disease seen on an outpatient basis. Patients who had no problem meeting criteria for inpatient or residential care are now struggling with insurance companies and entering lower levels of care based on cost. An intensive outpatient (IOP) program usually consists of twelve hours per week in a program dealing with their eating disorder (Halmi, 2005). If they cannot control their behaviors (e.g., binging, purging), they may need a higher level of care such as a partial hospitalization (PHP). These patients would typically spend five to six days per week in the PHP and go home at night.
An inpatient level of care would be needed for those patients who are medically unstable and need twenty-four-hour supervision and monitoring. They may require GI studies, feeding tubes, daily labs, and cardiac monitoring. If they are suicidal, intoxicated or in withdrawal, this adds to the level of care they need.
One of the difficult decisions we have as substance abuse therapists is deciding whether patients have anorexia or whether they have become emaciated due to their heroin or drug use. They still face the same risks in refeeding as someone who meets criteria for anorexia nervosa. They may still be experiencing the same cognitive difficulties due to malnutrition.
Where Do We Start?
Now let us say that we decide to work with our patients and need a place to start. One of the easiest ways to approach patients is to ask them what their earliest memory is of their being upset with their body. Who else in the family was unhappy with the way they looked? They may come from a family of dieters or compulsive eaters. It is important to bring them into the here and now. How is their eating disorder taking over their lives? What are the consequences—poor energy, loss of ability to maintain grades, loss of friends, loss of job, increased conflict at home—of the abnormal eating behaviors?
The work starts when we can help them admit that their way is not working and something needs to change. What behaviors are they willing to change? What have they tried and failed to do? Patients suffering from an eating disorder and a substance abuse need treatment for both or they will cross from one problem to the other.
Most of our patients now have more complicated needs. I was amazed when I went from inpatient work to a private practice and realized that it was the same level of acuity of their disease—some just could afford the level of care they so desperately needed. We may have thought we were just dealing with one issue, but being human is difficult and their substance abuse may just be the one problem that gets them into treatment with us.
I have heard patients state that they can deal with no longer using a substance, but since they have to face food on a daily basis, they cannot imagine being okay with eating. This is one reason that the level of fear mentioned earlier becomes so important in their treatment. They are living in this fear every time they face food. It is our job to make the fear manageable. This involves working with the family to help them understand the behavior and let them know they have a role, but not as the food police, therapist, physician or nutritionist. Families need a lot of support and the National Organization for Eating Disorders (NEDA) is a great referral source.
There are some of us whose interests may or may not be in the treatment of these patients. There is now certification offered by the International Association of Eating Disorders Professionals (IAEDP), which can be a great resource to reach out to specialists or to obtain more information. Resources can be limited in various geographical locations, so I often tell patients to reach out for any support or Twelve Step group, whether it is AA, OA, CODA (codependency), EA (emotions anonymous) or somewhere they can share and not feel judged.
I hope that the message in this article for everyone reading is what I tell my patients: you do not have to handle these diseases alone. I would never work with patients without an ED team and I hope that the awareness of the need for a team approach is evident based on the behaviors described. We can all be an important part of the team with knowledge and experience in substance abuse.
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Mehler, P. S., & Andersen, A. E. (2010). Eating disorders: A guide to medical care and complications. Baltimore, MD: John Hopkins University Press.