Education Articles
CLINICAL MANAGEMENT OF EATING DISORDERS AND CO-OCCURRING SUBSTANCE ABUSE
Controversy remains among experts as to whether eating disorders (EDs) are true addictions. Yet, scientific evidence indicates addiction qualities to the binge/purge and restricting behaviors peculiar to eating disorders. In eating disorders, the substances being used are food, starvation, exercise, diuretics, diet pills, and laxatives.
As such, an ED program is in many ways similar to chemical dependency (CD) programs. The Apostle Paul said, “I have the desire to do what is good, but I cannot carry it out. For what I do is not the good I want to do: no, the evil I do not want to do – this I deep on doing.” This summarizes the experience of many who fight additions (Romans 7: 18-19, NIV).
DSM-IV Criteria for EDsOther than obesity – which is becoming a national epidemic disorder = there are three primary eating disorders currently identified.
Anorexia Nervosa occurs in 1% of the U.S. It’s defined as a failure to maintain body weight at 85% of ideal; an intense fear of weight gain or becoming fat, even though underweight; body image issues; three or more months of amenorrhea, if the individual is female and having menses.
Bulimia Nervosa occurs in 3% of the U.S. It’s defined as binge eating (eating more than one would normally eat) two times a week for three months: regret after a binge; compensatory mechanism after a binge to eliminate the effect of the food; body image issues. The compensatory mechanisms are usually vomiting, fasting, excessive exercise, the misuse of diet pill, diuretics, enemas, ipecac or laxatives.
Binge Eating is like the binge described above, but engaged in when the individual is not hungry. A great deal of food is consumed rapidly, often when the person is alone. The behavior is often followed by disgust, guilt and depression. Whereas distress exists over the binges, no compensatory purging occurs.
Course of Illness
Many similarities exist between EDs and CDs. EDs, not unlike classical additions, often begin with seemingly benign experimentation. Typically, they start with diets, caloric restriction, and occasional self-induced vomiting to regulate weight. A full 90% of U.S. adults have tried alcohol, yet only 14-15% has an alcohol proble3m. At any given time, one-fourth of American men and on-half of women are engage in dieting. Only 1-3% develops diagnosable Anorexia Nervosa or Bulimia Nervosa.
Pleasure Circuits
Consider what motivates individuals to use substances. Drugs produce pleasure, due to the dopamine released by the brain. The production of dopamine, along with other pleasure-producing chemical, is stimulated by cocaine, alcohol, nicotine, and other chemicals. Because dopamine also regulates food intake through the meso-limbic circuitry – the pleasure center of the brain – it has been suggested that EDs’ core behaviors (staving, binging, and purging) can be viewed as drug-delivery devices. These behaviors increase production of B0endorphins, which are chemically identical to exogenous opiates such as heroin.
Reliance on Substances
More than 22% of the women admitted to Remuda Ranch meet criteria for a dual-diagnosis of an ED and substance abuse – dependence on alcohol, cocaine, marijuana and opiates. Many substances are used to reduce eating, hunger, or weight. Alcohol, caffeine and water are used to decrease appetite by filling up the stomach; they are also used to facilitate the self-induced vomiting process. Cocaine, amphetamines and stimulants decrease the appetite and decrease eating or binging. Nicotine is also an appetite suppressant and can increase metabolism in females as much as 10%. This makes nicotine highly attractive to those with EDs and motivates many young girls to start smoking. Most health professionals do not view over-the-counter laxatives, diuretics, and diet pills as drugs of abuse or dependence. However, individuals can become highly dependent on them, developing symptoms of tolerance and withdrawal. Profound medical complications can occur from their use, including death. In a self-report study done at Remuda in 2005-06, up to 43% of adult women and 25% of adolescents reported using laxatives for weight control.
Symptom Severity and Substitution
It has been observed that patients addicted to 1,000 mg of diuretics a day, or 100+ laxatives a day, are often more seriously ill and need even greater medical intervention during detoxification than someone experiencing heroin withdrawal.
Frequently, when dually diagnosed patients must discontinue substance use while in treatment, their ED intensifies. Likewise, when dually diagnosed patients enter ED treatment and must curtail binging, purging, and food restriction, their desire for substances increases.
Treatment recommendations
According to the American Psychiatric Association Practice Guideline for the Treatment of Patients with Substance Use Disorders (1995), CD treatment programs should diagnose and treat co-occurring mental disorders. However, due to the complexities of treating EDs, most CD programs do not have the staff required to provide adequate monitoring needed for ED patients.
According o the American Psychiatric Association Practice Guideline for the Treatment of Patients with Eating Disorders (2006), concurrent treatment for ED and CD is also recommended for these dually diagnosed patients. This is because of their common medical complications, lengthy duration of inpatient stays, and lack of compliance with post0hopitalizations treatment.
Providing detoxification services are available – the preferred course of action is to treat ED and CD patients at an ED inpatient facility. Due to the interaction of detoxification and ED issues, along with the significant medical sequelae of ED, these illnesses are best addressed simultaneously.
At a minimum, the treatment team should include:
•A Psychiatrist;
•A Primary Care Provider:
•A Dietician;
•A Family Therapist;
•An Individual Therapist proficient in Cognitive
Behavioral Therapy
Patients with ED are usually very complex to treat. They have significant medical issues such as electrolyte imbalances, refeeding complications, bone density issues, and hormone imbalances. A dietician is necessary to support psychiatric providers face challenges regarding patient depression, obsessive-compulsive disorders, anxiety disorders and substance abuse disorders. At Remuda, 20% of patients have experienced sexual abuse, which causes even greater fragility.
Remuda works from a bio-psycho-social-spiritual framework. The basic treatment philosophy includes helping patients develop a relationship with Jesus Christ or strengthening the existing relationship. This Christian approach to treatment has allowed patients to get well and recover. Non-believing patients are not threatened by this approach of love and compassion. God offers promise for those in this place of hardship and suffering who have come to believe there is no escape.
”But remember that the temptations that come into your life are no different from what others experience. And God is faithful. He will deep temptation from becoming so strong that you can’t stand up against it” (1 Corinthians 10:13, NIV).
With Christ foundational, the ED and CD behaviors and diagnoses are understood and addressed as ineffective forms of emotion regulation and distress tolerance. In our 19 years, we have combined the best aspects of cognitive behavioral therapy, dialectical behavioral therapy, exposure with response prevention therapy, and motivational interview/readiness to change and created the Remuda Model for recovery.
To conclude, patients with both ED and CD can be extremely challenging since their symptoms interact and can lead to dangerous medical sequelae. It is preferable to address their behaviors in a treatment environment conducive to providing a parallel and simultaneous treatment course for both disorders.
