Wasting away: The double danger of eating disorders and substance use

CrossCurrents

By Helen Buttery

At 13* Cassandra was put on a new epilepsy medication. The doctor said it would make her lose 10 per cent of her body weight. “I was so excited I took extra pills to lose weight,” she recalls. From that point on, everything was about losing weight. This included turning to cocaine at 14, which contributed to the 5 foot 11” straight-A student plunged from 128 to 115 pounds. As her weight dropped, so did her grades and her place on her school’s basketball team.

Cases like Cassandra’s – having both an eating disorder and a substance use problem – aren’t so rare. A groundbreaking 2003 study by the National Center on Addiction and Substance Abuse at Colombia University (CASA) in New York found that up to 50 per cent of people with an eating disorder also have alcohol or other drug problems. A shocking discovery, considering only about nine per cent of the general population has substance use issues. The study also found that up to 35 per cent of people with substance use problems have an eating disorder, which affects up to three per cent of the general population.

Canadian statistics are equally disturbing. A 2002 Health Canada report on concurrent mental health and substance use disorders cites prevalence rates of comorbid bulimia and substance use problems between nine per cent and 55 per cent. (Substance abuse is more common in people with bulimia than anorexia nervosa.) Prevalence rates of eating disorders within the substance abuse treatment population ranged between one per cent and 32 per cent. More recent studies have found equally high rates.

Yet despite the connection, few programs exist that treat substance use and eating disorders concurrently. This is partly because developing such programs means revamping how health services are delivered. Treatment programs for eating disorders and substance use operate in two separate and distinct spheres, and in fact, often do not exist at the same facility. “That’s a problem,” says Dr. Blake Woodside, director of the Inpatient Eating Disorders Program at Toronto General Hospital. “Substance use is a de-medicalized area of treatment; hospitals don’t provide it.”

Criteria for program participation pose another barrier. Eating disorders programs won’t take clients with substance use problems and vice versa. It wasn’t always that way. There was “no discussion” about substance abuse when Ann Kerr, a Toronto eating disorders specialist in private practice, started working in an eating disorders clinic almost 30 years ago. She remembers a client being discharged and then revealing she was addicted to cocaine – stoned for most of her treatment. “I remember thinking, ‘Oh, we’re so naïve and blind to this issue.’”

Today, that same client probably would have been turned away from an eating disorders program. “Although we are now more aware of the co-occurrence, we are not equipped to deal with it,” says Kerr. “It’s either take your addiction somewhere else or don’t tell us about it, because we don’t know what to do about it,” says Kerr. Unfortunately, this approach hasn’t served clients well, and many, like Cassandra, who is now 18, spend years in and out of various treatments, trying to deal with both problems.

Dealing with both problems begins with timely detection. A 2007 study in the journal Addiction calls for routine screening for the presence of an eating disorder when presenting to substance abuse treatment services. This initial screening is important for clinicians who may be inclined to overlook emaciation and poor appearance as a secondary effect of substance use, although bulimia is more common, in which individuals often have a normal weight.

The Eating Disorders and Addiction Clinic at the Centre for Addiction and Mental Health (CAMH) in Toronto offers one of Canada’s few concurrent treatment programs. This outpatient program treats women and men (but women with eating disorders far outnumber men) by melding therapeutic approaches from both substance use and eating disorders treatment. Treatment may involve weekly group sessions; individual psychotherapy, including dialectical behavioural therapy, which helps clients develop problem-solving skills around deficits in emotional regulation and interpersonal skills; and dietitian consultation. Clients commit to attend treatment for a minimum of 10 weeks to one year, depending on the specific program stream.

“We look at the interrelationship between these issues – how the eating disorder affects the substance use and how the substance use affects the eating disorder and then match treatment to the needs of the client,” explains Dr. Christine Courbasson, clinic head of the program. But Courbasson’s small clinic – it has the capacity to take about 80 clients – can only do so much.

There is a long way to go in understanding the eating disorders / substance use connection. Substance use seems less likely to motivate eating disorders – Courbasson points out that for clients at the clinic, the onset of the eating disorder is on average two years before the substance use problem – but women who feel guilty about the calories consumed during a drinking binge may engage in compensatory behaviour such as restricting food intake or purging. A woman with a substance use problem may feel the need to take control over one aspect of her life and restrict food intake to gain this sense of control.

Treating the substance use problem first makes some sense, say many clinicians. Someone high on cocaine can’t properly engage in the demanding psychological component of eating disorders treatment. “Many of my clients say their addictions were infinitely easier to deal with than their eating disorder, and they have had much more success treating their addiction than their eating disorder,” says Kerr.

In part this may be because we have clearer notions of what is right and wrong when it comes to drugs, but society’s relationship with food is hazier. Just take socially sanctioned measures like stomach stapling or gastric-bypass surgery. It’s not socially acceptable to snort cocaine in your office, but if your lunch consists of a few carrot sticks and a black coffee, few co-workers blink an eye.

Cassandra was able to remain clean for two years before she began using cocaine again. Now, clean for a month, she says, “I’ve been treated for the addiction and it’s very easy treatment, but for the eating disorder, it’s heart wrenching; it’s really, really hard.” Today, she only eats salads and fat-free foods.

Still, many clients have at least as difficult of a time overcoming the substance use problem. Many are not taking illegal substances, but have serious problems with alcohol or prescription or over-the-counter medication.

The problem in Cassandra’s case, and in many cases like hers, is that when she stops using alcohol and other drugs, the eating disorder worsens. “I have this empty feeling, and when I’m using cocaine I get rid of it,” she says. “When I don’t have the drugs anymore for it, food is the only way to handle it. My eating disorder becomes my answer.”

This symbiosis may point to an underlying link between eating disorders and substance use. Divergent theories have been put forth to explain the association, emphasizing the biological, psychological and behavioural mechanisms that link them. One theory is that the eating and substance use disorders are linked by underlying difficulties in the regulation of affect. From this perspective, the problematic behaviour functions to regulate painful affect, a situation that Cassandra seems to describe and which suggests why treatment may be so challenging.

Some, like Woodside, point to a genetic cause. There may be a family of genes that produces risk for eating disorders and another that produces risk for substance use. These genes can be turned on and off like a switch. “Those genes load the gun and then what happens to you pulls the trigger,” says Woodside. Exactly “what happens” is unclear, but may include sexual abuse, low self-esteem or an unhealthy relationship with a parent. If a person has eating disorder genes, they can be set off by these or other prompts. In turn, the eating disorder makes the substance use genes more vulnerable. “If you develop a substance use problem, that might activate your genetic liability to an eating disorder, or the reverse,” says Woodside.

Whatever the underlying link, many, including Anne Elliott, program director at Sheena’s Place, a support centre for people with eating disorders in Toronto, would like to see treatment focus on what eating disorders and substance abuse have in common. “Both are a way to mask feelings and cope with terrible situations, so it’s important that the professional community be better integrated,” she says.

Elliott would like to take it one step further and include child sexual abuse in this integration. The casa study found that people with concurrent eating and substance use disorders are more likely to have experienced childhood abuse than the general population. Cassandra is not ready to talk about it, but she does say she experienced both sexual and physical abuse growing up.

While Cassandra may not be ready to talk, professionals in the eating disorders and substance use fields need to come together to discuss the links between substance use and eating disorders and how best to treat these issues. Cassandra thinks that if her cocaine habit and eating disorder had been addressed together when she was younger, she might not still be struggling with them today: “Linking them would make treatment a lot easier,” she says. “The longer it goes on, the harder it is to let go.”

*not her real name

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