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Treat Eating Disorders Concurrently

July 1, 2006
by James Greenblatt, MD and Stuart Koman, PhD
| Reprints
Treatment will require intensive monitoring at the outset

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.