Co-occurring Disorders Require Co-occurring Treatment
Treating an eating disorder is difficult. So is treating an addiction. Treating them both at the same time, though, is a special challenge for any practitioner.
Unfortunately, eating disorders and addictions occur together frequently. The National Center on Addiction and Substance Abuse found that:
- Half of all people with eating disorders abuse drugs or alcohol, compared with 9% of the general population.
- Up to 35% of people who abuse drugs or alcohol have an eating disorder, compared with 3% of the general population.
Given the frequency of co-morbidity, it’s not surprising that patients with eating disorders and addictions have much in common, including similar brain chemistries. They often have been physically or sexually abused, and have low self-esteem. Both eating disorders and addictions are complex and difficult to treat, and result in frequent setbacks.
Patients with both an eating disorder and an addiction also often have a third co-morbidity, such as depression, obsessive-compulsive disorder or an anxiety disorder.
Addressing Co-Morbidities with Eating Disorders and Addictions
In spite of the frequency of co-occurrence, when patients are admitted for one disorder, other disorders are often overlooked.
One reason is that patients diagnosed with an addiction or eating disorder are typically sent to a hospital specializing in that disorder. Hospitals that treat addiction, rarely treat eating disorders. Those that treat eating disorders rarely treat addiction.
So how can we address co-occurring disorders?
First, when admitting a patient, assume a co-morbidity exists. Conduct a complete physical and psychiatric evaluation, including an inventory of drug and alcohol use, by a team that includes a physician, psychiatrist, psychologist, nutritionist and social worker.
Step 1. Develop A Treatment Plan
The team should review presenting information, provide an in-depth evaluation and design a treatment plan specific to the patient. The team should chart all symptoms, note any co-morbidities and assign a case manager, nurse and physician experienced with co-morbid disorders.
The treatment plan is key to successful treatment. Treatment should be individualized, but structured. While the condition deemed most life-threatening receives the initial focus of the treatment, the plan should address both disorders and anticipate an increase in the intensity of treatment for the secondary disorder as the life-threatening condition subsides. Ongoing treatment and life-changing activities – such as AA, NA and eating-disorder support groups – must proceed simultaneously for both the eating disorder and the addiction.
There are both similarities and differences in the treatment of eating disorders and addictions. Treatment for both eating disorders and addictions typically include:
- Disease-specific psycho-education and targeted psychotherapy
- Group therapy focused on building motivation to change, understanding triggers identifying coping strategies and preventing setbacks
- Analysis of social context (family, friends, job, school, community connections) and intervention to build support for change
The treatment plan should consider the whole person, integrating medical, psychiatric/addiction and nutritional needs. The plan must be flexible, too, because every patient reacts differently to treatment. The right treatment is whatever works, but successful treatment for either and both disorders will invariably call for significant changes in a person’s lifestyle and day-to-day routines.
Co-occurring disorders such as eating disorders and addictions must be treated concurrently. When patients receive care for one disorder and not the other (or others), the disorder being treated may subside, but as one improves, the other will likely become more acute. If the other disorder is then treated, as it improves, the initial disorder may worsen. This seesaw effect often leaves the patient feeling caught in a cycle from which they cannot escape.
Step 2. Stabilize the Patient
Patients with advanced eating disorders are typically dehydrated and close to starvation. Their lives are in danger, but re-establishing a healthy diet must take place gradually to prevent heart failure caused by “re-feeding syndrome.”
Patients in need of medical stabilization typically suffer from depression, anxiety, obsessive-compulsive disorder or other disorders that make it difficult to focus. It usually 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.
If a patient’s addiction is the priority, likewise, the patient cannot be expected to adopt a structured, healthy eating cycle during withdrawal from drugs or alcohol.
Step 3. Begin Therapy
Once the patient is medically stable, psychotherapy can begin. An in-patient setting is likely needed until the patient is motivated enough to continue in residential treatment or partial hospitalization.
Treatment for addiction and eating disorders requires an imposed discipline. Those being treated for addiction must abstain from drugs or alcohol, in spite of intense cravings. Those being treated for eating disorders must eat structured meals.
Just as in-patient treatment and fulltime monitoring is necessary to ensure that the addicted patient does not indulge in drugs or alcohol, the same diligence is needed to ensure that the patient with bulimia is not binging and purging.
Behavior Therapy for Eating Disorders and Addictions
Cognitive-behavior therapy (CBT) can be effective for treating bulimia, but it is also believed to be effective as part of an overall plan for treating co-morbidities. 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 that lead to desired actions.
Both group therapy and individual therapy are used frequently, with the emphasis on group therapy. Group treatment is used for therapy and education. The more patients know about their eating disorders and addictions, the better they are able to control them.
Pharmacology for Eating Disorders and Addictions
Fluoxetine, a Serotonin reuptake inhibitor (SSRI), is the only medicine approved by the U.S. Food and Drug Administration for bulimia and no drugs are approved for treating anorexia. SSRIs may also be used to treat alcoholism, but only when there is co-morbid depression.
Nutrition for Eating Disorders and Addictions
Disordered eating and drug or alcohol addiction both severely affect a person’s health. Good nutrition is necessary for the patient’s physical health, but may also have a positive impact on mental health.
Support of Family and Friends for Eating Disorders and Addictions
Outside support is critical for preparing the patient for independent living. Likewise, though, support groups are important to help family and friends deal with having a loved one in crisis.
Step 4. Follow a “Continuum of Care” Treatment Plan
A “continuum” of care, in which treatment changes based on the patient’s changing needs, is needed to provide a transition from intensive in-patient care to independent living.
The continuum is also helpful because treatment needs change as the patient progresses through the treatment of their eating disorder and/or addiction. Patients begin treatment at different stages of their illness, and when they have a relapse, they need to step back to more intensive care.
A continuum for a patient with an addiction and an eating disorder would likely begin with in-patient care, progress to residential care or partial hospitalization, then to intensive outpatient care and finally to community-based counseling.
Patients with eating disorders and addictions do not proceed straight from illness to recovery; neither should their treatment. Treatment should adjust to the patient, rather than expecting the patient to adjust to eating disorder and addiction treatment.
By James Greenblatt, M.D.
Chief Medical Officer – Walden Behavioral Care