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).
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.