Treat Eating Disorders Concurrently

Treating an addiction to drugs or alcohol along with an eating disorder poses a challenge for even the best practitioners. Unfortunately, professionals encounter this combination of problems frequently. The National Center on Addiction and Substance Abuse (CASA) at Columbia University has reported that half of all people with eating disorders abuse drugs or alcohol, while up to 35% of people who abuse drugs or alcohol have an eating disorder.

Eating disorders and substance abuse have much in common; in fact, many consider eating disorders to be an addiction. The compulsion to binge and purge can be as strong in a person with bulimia as the urge to drink is for an alcoholic.

Patients with eating disorders and addictions to drugs or alcohol typically have a similar brain chemistry and family history, which may include physical or sexual abuse. They often have low self-esteem, and their parents may have similar disorders that have influenced their behavior. Both types of disorders are complex and difficult to treat, and result in frequent relapses.

Patients with eating disorders and substance addictions often have a third comorbid condition, as both disorders frequently are linked to depression, obsessive-compulsive disorder, and anxiety disorders. It is especially common for women with bulimia to be addicted to alcohol or drugs, and many also have bipolar disorder.

Yet many times when patients are admitted for one disorder, other disorders are overlooked. One reason is that when patients are diagnosed with one condition or the other, they typically are sent for treatment to a hospital specializing in treating that disorder. In addition, patients with eating disorders and addictions feel shame about their disorders and often take drastic measures to hide them. Even when one disorder is discovered, they likely will hide the other.

Failure to diagnose co-occurring disorders endangers patients and can even have fatal consequences. Eating disorders have the highest mortality rate of all psychiatric illnesses. The mortality rate for anorexia nervosa is 5% at 5 years and increases to 20% at 20 years. A recent study found that one of the strongest and most consistent predictors of fatal outcome, including suicide, for patients with anorexia nervosa was severity of alcohol abuse after intensive treatment for the eating disorder.

Responding to the crisis

Given the consequences, we need to do a better job in diagnosing comorbidities. But how? First, assume at the outset that a comorbidity exists. Conduct a complete physical and psychiatric evaluation, including a thorough inventory of drug and alcohol use—not just by one person, but by a team of professionals, including a physician, a psychiatrist, a psychologist, a nutritionist, and a social worker. Screening questions can help to identify when a patient with an addiction also has an eating disorder (see table).

Table. Screening questions to help identify the presence of an eating disorder

1. What is the most you have ever weighed? How tall were you then? When was that?

2. What is the least you have weighed in the past year? How tall were you then? When was that?

3. How much do you think you ought to weigh?

4. How much exercise do you get? How often and at what level of intensity? How stressed are you if you miss a workout?

5. What are your current dietary practices? Ask for specifics regarding amounts, food groups, fluids, and restrictions, and include the following:

   • What is your 24-hour diet history?

   • Do you count calories or grams of fat?

   • Are there taboo foods that you avoid?

   • Have you had any binge-eating episodes? How often? How much did you eat? What triggered the binge eating?

   • Do you have a history of purging?

   • Do you use diuretics, laxatives, diet pills, or ipecac? What is your pattern for elimination? Do you have constipation or diarrhea?

   • Do you vomit? How often? How long after meals?

6. Have you previously received therapy for an eating disorder? What kind and for how long? What was and was not helpful?

7. What is your family's history with: obesity, eating disorders, depression, other mental illnesses, substance abuse?

8. What is your menstrual history? What was your age at menarche? How regular are your cycles? When was your last menstrual period?

9. How frequently do you smoke cigarettes or use drugs or alcohol?

10. What is your sexual history? Have you ever been physically or sexually abused?

Also ask the patient about any of the following symptoms:

• Dizziness, syncope, weakness, fatigue

• Pallor, easy bruising, or bleeding

• Intolerance of cold

• Hair loss, lanugo, dry skin

• Vomiting, diarrhea, constipation

• Fullness, bloating, abdominal pain, epigastric burning

• Menstrual irregularities

• Symptoms of hyperthyroidism, diabetes, malignancy, infection, inflammatory bowel disease

When a patient is considered for admission, the team should review the presenting information, provide an in-depth evaluation, and design a treatment plan specific to the patient. Based on the team's assessment, all symptoms should be charted and the diagnosis should note any comorbidities. Based on the diagnosis, a case manager, nurse, and physician experienced with comorbid conditions should be assigned.

The treatment plan is crucial to successful treatment. Treatment should be individualized but structured. The national consensus “four quadrant” model, which categorizes patients based on whether each disorder is of low or high severity, offers a good first step toward choosing appropriate treatment. Whichever condition, the addiction or the eating disorder, is deemed most life-threatening becomes the initial primary focus of treatment, but the treatment plan addresses both disorders and anticipates increasing intensity of the secondary disorder as the life-threatening condition subsides.

In working with each patient to achieve recovery, active, ongoing treatment and life-changing activities (such as AA, NA, and eating disorder support groups) for both conditions must proceed simultaneously. The model is more complex, of course, if an additional psychiatric disorder is present, as is frequently the case.

While there are both similarities and differences in the treatment of eating disorders and addictions, treatment for both typically includes:

• psychoeducation (disease-specific) and targeted psychotherapy;

• group therapy focused on building motivation to change, understanding triggers, identifying coping strategies, and preventing relapse;

• pharmacology;

• nutrition; and

• analysis of the social context (family, friends, job, school, community connections) and intervention to build support for change where necessary.

The treatment plan should be multifaceted and consider the whole person, addressing medical, psychiatric/addiction, and nutritional needs concurrently. A treatment plan that integrates each of these elements offers an essential starting point, but the plan also must be flexible. Every patient reacts differently. Whatever works is the right treatment.

It is essential for co-occurring disorders to be treated concurrently. When patients receive care for one disorder and not the other (or others), the disorder being treated likely will subside, but the other likely will become more acute. If the other disorder is then treated, the initial disorder will often worsen, a phenomenon that can leave the patient feeling caught in a cycle from which there is no escape.

It would be counterproductive for the patient to be shipped back and forth between hospitals specializing in one disorder or another, so treatment should take place at a facility with specialized professionals who can treat either disorder or both.

After a treatment plan is in place, stabilizing the patient becomes the next priority. Patients who are admitted with advanced eating disorders are typically dehydrated and close to starvation. Their lives are in danger, but reestablishing a healthy diet must take place gradually; otherwise, “refeeding syndrome” can cause heart failure.

Patients needing medical stabilization typically meet one or more of the following criteria, some of which are based on guidelines established by the American Psychiatric Association:

• medically unstable vital signs;

• a seriously abnormal lab value for Na+, K+, C1, CO2, BUN, serum creatine, AST, ALT, albumin, phosphorus, magnesium, calcium, or glucose;

• serious arrhythmia with any degree of heart blockage (after 24 hours of telemetry monitoring), junctional bradycardia, sinus bradycardia or prolonged QTc, and a need for antipsychotic medications;

• dehydration;

• medical complications that require intensive monitoring, such as intestinal atony with an obstruction, nutritional anemia, impaired renal function, fluid imbalance, or an exercise-induced injury; and

• nutritional requirements that must be met immediately because of pregnancy, diabetes, or other complications.

The patient in need of medical stabilization typically suffers from extreme depression, anxiety, obsessive-compulsive disorder, or other psychiatric disorders that make it difficult to focus on treatment. It typically takes a couple of weeks of intensive, 24-hour care before eating patterns are established and work can begin on motivating the patient to want to receive psychotherapy and other treatment for both the eating disorder and the addiction.

If a patient's addiction is the priority and a period of withdrawal from drugs or alcohol is needed, the patient cannot be expected to adopt a structured, healthy eating cycle during withdrawal. After the patient adjusts to withdrawal, more attention can be given to establishing healthy eating patterns.

Beginning therapy

Once the patient is medically stable, psychotherapy can begin. At the start, an inpatient setting is likely needed for patients with co-occurring disorders until the patient is motivated enough to continue either in a residential or partial-hospitalization program.

Treatment for both disorders requires an imposed discipline. Those being treated for drug or alcohol addiction must abstain from using substances, in spite of intense cravings. Those being treated for eating disorders must receive structured meals, and mealtime must be carefully monitored to ensure that the patient is not bingeing and purging.

Imposed discipline, of course, is ineffective long term. Patients must be motivated to want to change their behavior. Studies have shown that cognitive-behavioral therapy (CBT) can be effective for treating bulimia, but it is also believed to be effective as part of an overall treatment plan for comorbid disorders. CBT teaches that we can affect how we feel and what we do by identifying the thinking that is causing unwanted actions and replacing it with thoughts leading to desired actions.

Dialectical behavioral therapy (DBT), a type of CBT, is frequently used. DBT begins with accepting behavior, then working to change it. It teaches patients skills for dealing effectively with others, handling emotions, and changing harmful behavior.

Both group therapy and individual therapy are used frequently, with the emphasis on groups. The day typically begins with an intentions group, during which each person states a goal for the day. At the end of the day, the group reconvenes and members share their level of success in achieving goals. Because patients can benefit from one another's success stories, sessions ideally should include others with co-occurring disorders.

Behavior therapy is used in combination with medication for treating co-occurring disorders. Patients with eating disorders typically have altered serotonin activity in the brain. Selective serotonin reuptake inhibitors (SSRIs) can help re-adjust serotonin activity; they also are effective for helping patients with bulimia to reduce bingeing and purging. Other classes of medications are sometimes tried, in-cluding atypical antipsychotics and appetite stimulants (for anorexia nervosa).

Good nutrition is necessary for the patient's physical health, and also might have a positive impact on the patient's mental health. In addition, outside support is critical and is especially important for preparing the patient to reenter the world outside the hospital. Likewise, support groups are important to help family and friends deal with the stress that can result from having a loved one in crisis.

A typical continuum of care for a patient with an alcohol or drug addiction and an eating disorder likely would begin with inpatient care, which initially would include 24-hour supervision and monitoring. It would progress to residential care or partial hospitalization, so that the patient could gradually adjust to independent living. The next step would incorporate intensive outpatient care, during which group therapy would continue along with medical monitoring. Finally, the patient would be ready for independent living with ongoing community-based counseling.

Patients do not proceed straight from illness to recovery—and neither should their treatment. Treatment should be designed to accommodate not only setbacks, but also breakthroughs. In short, it should adjust to the patient; no treatment provider should expect the patient to adjust to the program.