Drugs, Alcohol and Eating Disorders

Editor’s Note:

Welcome to a New Year with the NEDC!

As we open the doors to 2019, we usher in the New Year period of celebration. For some, New Year is a time to party, a time to revel in what the past year was and what the New Year holds. It is a time of year that we associate with celebration and festivity — a time to party.

This time of festivity also brings with it the possibility of interaction with alcohol and/or drugs. When we seek to evaluate alcohol and drugs in the realm of eating disorders, it is interesting to consider the link between the use or misuse of drugs and alcohol and individuals experiencing disordered eating behaviours.

Comorbid substance use is commonly found in individuals living with an eating disorder and can lead to relapse, longer recovery periods and poor mental and physical health outcomes (Gregorowski, Seedat, & Jordaan, 2013). While not all individuals experiencing an eating disorder will use substances, research suggests that up to 50% of patients with an eating disorder will abuse alcohol or an illicit substance, compared with 9% of the population (Gregorowski et al., 2013). Further, Individuals with eating disorders are up to five times likelier to abuse alcohol or illicit drugs, and those who abuse alcohol or illicit drugs are up to 11 times likelier to have eating disorders (The National Center on Addiction and Substance Abuse at Columbia University, 2003).

Additionally, individuals living with bulimia nervosa have been shown to report a stronger association with substance use when compared with other disordered eating behaviours (Gregorowski et al., 2013). This association is directly linked to impulsive, purging behaviours associated with disordered eating behaviours.

We know that individuals experiencing disordered eating are more likely to develop substance use disorders than the reverse (Gregorowski et al., 2013) and the abuse of substances may occur as a means to self-medicate the negative feelings and emotions that typically accompany such disorders (The National Center on Addiction and Substance Abuse at Columbia University, 2003).

In this e-Bulletin we take a look at substance use and eating disorders – why are these two disorders interlinked? How do we support individuals living with both an eating disorder and substance use disorder? What does this mean for the health professional and the recovery process?

Read on.

References
Gregorowski, C., Seedat, S., & Jordaan, G. P. (2013). A clinical approach to the assessment and management of co-morbid eating disorders and substance use disorders.
The National Center on Addiction and Substance Abuse at Columbia University. (2003). Food for Thought : Substance Abuse and Eating Disorders. Nancy Reagan Linda Johnson Rice George Rupp, (December), 73.

Contents:

Article 1- What are the factors at play in disordered eating behaviours and substance abuse?
Article 2- Working in the area of drugs and eating disorders: NEDC Resources for our Health Professionals  
Article 3- The NEDC e-Bulletin: How is this working for you?

Article 1 – Why is this so? What are the factors at play in disordered eating behaviours and substance use disorders?

Comorbidity between two disorders arises solely because one disorder is a risk factor for the other (unidirectional effect) or because each disorder is a risk factor for the other (reciprocal effects) (Eric Stice, Emily Burton, 2004).

Eating disorders and substance abuse have some characteristics in common. Eating Disorders Victoria (Victoria, n.d.), outline the following shared risk factors:

• common brain chemistry
• common family history
• both emerge in times of stress or transition;
• both are more likely to develop in individuals with low self-esteem;
• depression
• anxiety
• a history of physical or sexual abuse.

• unhealthy parental substance use
• dieting behaviours
• social pressures
• the advertising, marketing, and entertainment industries

Other shared characteristics of these disorders include an obsessive preoccupation with a substance (food or a drug), intense craving, compulsive behaviour, attempts to keep the problem a secret, social isolation, and risk for suicide. Both disorders have similar effects on the brain, and linked to other psychiatric disorders such as obsessive-compulsive disorder and mood disorders. Both - are chronic, recurring, life-threatening diseases (The National Center on Addiction and Substance Abuse at Columbia University, 2003).

Research suggests that underlying personality traits such as novelty seeking, impulsivity, anxiety and affective instability may predispose individuals to these comorbid disorders (Gregorowski, Seedat, & Jordaan, 2013).  Additionally, these impulsive and underlying factors are more commonly associated with eating disorders with purging behaviours when compared with other disordered eating behaviours (Gregorowski et al., 2013).

What does this impulsive behaviour look like?

Impulsive behaviour refers to actions that incorporate a component of rashness, lack of foresight or planning or behaviour that occurs without reflection or careful deliberation (Dawe & Loxton, 2004).  Research suggests that there are two independent factors involved in impulsivity; reward sensitivity and rash-spontaneous impulsivity, both contributing to substance abuse and binge-eating behaviour (Dawe & Loxton, 2004).

In binge eating disorders, the factor of reward sensitivity may contribute to greater sensitivity and attention towards food-related cues and subsequent cravings, purchasing and preparing of binge food. Rash impulsiveness, on the other hand, may be reflected as disinhibited, a loss of control over eating during a binge-episode or the inability to resist binge cravings (Dawe & Loxton, 2004).

These components of impulsivity are common to these two disorders with Food and drugs of abuse stimulating the neural reward circuits; manifesting in the observation of consistently high rates of comorbidity (Dawe & Loxton, 2004) for eating disorders and substance misuse

What part does impulsiveness play in disordered eating behaviour and substance use?

Impulsive tendencies increase the likelihood of binge eating and purging behaviours and have a potential impact on the co-occurrence of adverse behaviours, such as substance use and self-harm. Specific disordered eating behaviours are directly related to impulsive tendencies (Nøkleby, 2012). 

Impulsivity is multi-faceted. Five distinct dispositions for impulsive action have been defined as sensation seeking, lack of planning, lack of perseverance, positive urgency (i.e., the tendency to engage in rash action in response to intense positive emotions), and negative urgency (i.e., the tendency to engage in rash action in response to intense negative emotions) (Nøkleby, 2012).

When examining disordered eating behaviour and substance use, it is clear that these facets of impulsive behaviour are in play.

A person experiencing substance use (Nøkleby, 2012) and/or purging behaviours tends to display higher sensation seeking than those with restricted eating behaviours; this is similar for those experiencing bulimia nervosa. Negative emotional response (negative emotion-based tendencies for rash action), is also a shared factor of substance use disorder and eating disorders, where negative states commonly cause disordered eating behaviours. While, the construct of positive urgency is linked to co-occurring behaviours, such as substance use.

Research suggests that individuals living with an eating disorder, across all types, experience higher rates of mental ill health (up to 97% comorbidity), which includes impulse control disorders (Gordon, 2008). Impulsive behaviour is considered a key feature of various psychiatric conditions, including substance use disorders, binge eating disorders, borderline personality disorder and antisocial personality disorder (Dawe & Loxton, 2004).

When examining different factors of individuals experiencing disordered eating behaviours and the relationship with substance use, it is evident that consistent personality differences exist between individuals with anorexia nervosa and bulimia nervosa.

Individuals experiencing bulimia nervosa appear to be relatively less inhibited, with a more impulsive personality that is indicative of a relatively greater incidence of substance use (Wiederman & Pryor, 1996), while individuals living with anorexia tend to have higher rates of obsessive-compulsive disorder (Gordon, 2008). It is these reported differences in behavioural characteristics displayed by individuals living with an eating disorder that suggest individuals experiencing bulimia or binge eating behaviours may be predisposed to substance use (Gordon, 2008).  This specific occurrence experienced by those living with bulimia nervosa has been formally described as B multi-impulsive bulimia (Nøkleby, 2012).

What we know about substance use

Not all individuals living with an eating disorder are affected by substance use. It is evident that substances of use may vary across eating disorder subtypes and may be used as a form of emotional regulation in a pattern of controlling or impulsive, risk-taking behaviour (Gregorowski et al., 2013).

The Australian Government’s, National Drug Strategy (Gordon, Drug and Alcohol Services South Australia (DASSA), & Clinical Services and Research, 2008) and National Centre on Addiction and Substance Abuse at Columbia University (2003), suggest that the substances most frequently abused by individuals living with eating disorders or with sub-clinical symptoms of these disorders include:

• caffeine
• tobacco
• alcohol
• laxatives
• emetics
• diuretics
• appetite suppressants (amphetamines),
• heroin and cocaine

The use of cannabis has also been shown to be one of the most commonly used substances across all eating disorder subtypes (Gordon, 2008); with alcohol the most commonly used substances amongst individuals with bulimia or bingeing/purging behaviours (Gordon, 2008).  Higher rates of cocaine and amphetamines use are observed in people living with an eating disorder, with the severity of bulimia shown to correlate with the frequency of MDMA and amphetamine use as a tool in weight loss or weight management (Gordon, 2008). 

Where do we go from here?

Eating disorder patients who abuse substances demonstrate increased symptoms and poorer outcomes than those with eating disorders alone (Gregorowski et al., 2013). Additionally, the presence of an eating disorder in substance use disorder patients leads to greater severity of substance abuse and poorer outcomes (Gregorowski et al., 2013) for the individual.

Shame, stigma, and guilt surrounding both eating and substance use disorder patients challenge health professionals in complicating diagnosis and providing treatment (Gregorowski et al., 2013). Notably, many individuals with comorbidity have more than one mental disorder and may have problematic use of several substances (Gordon, 2008).

Presently, patients may receive adequate treatment for one disorder or the other, but rarely for both, as it is considered that the two disorders require separate treatment (The National Center on Addiction and Substance Abuse at Columbia University, 2003).  The dynamic and individual presentation of illness makes eating disorders one of the most difficult psychopathologies to treat (The National Eating Disorders Collaboration, 2014). No single treatment is effective; treatment must be specific to the disorder, the person and their circumstance (The National Eating Disorders Collaboration, 2014).

Even though the connections between eating disorders and substance abuse have been known for some time, current research shows that many addiction treatment programmes fail to offer both assessment and treatment based on this knowledge (Gordon, S.M. & Johnson, S.F. & Cohen, L. & Killeen, & P.M., 2008). There is little evidence around best practice treatment, as a whole complex occurrence, where symptoms and experiences are linked (Gordon, 2008).  Research (Killeen, T.K. & Greenfield, S.F. & Bride & Cohen, L. & Gordon, S.M. & Roman, 2011) indicates a need for educating health professionals in assessment, referral, and treatment of eating disorders and substance use disorder collectively.

Fundamentally, health professionals must be familiar with basic screening and assessment techniques. All health professionals working within high-risk populations and professionals required to work within multidisciplinary teams should receive best practice training to enable them to identify, assess and contribute to the treatment of eating disorders and comorbid disorders  (The National Eating Disorders Collaboration, 2014). Screening tools and assessment techniques are available on the NEDC website.

The NEDC works in partnership with our primary health care providers to support and educate our health professionals, to better understand the existence of comorbidity with substance abuse and eating disorders. We provide resources and training for health professionals; to strengthen our workforce so that health professionals may successfully respond to eating disorders in a coordinated and consistent approach.

Resources on supporting individuals with an eating disorder and links to additional support networks are available on our website.

Eating disorder Information for health professionals is available on the Professional Development section of the NEDC website.

You will also find further information on Comorbidity with other disorders on the NEDC website.

If you or someone you know is currently in need of urgent support, please contact the National Helpline on 1800 33 4673. The national helpline is available to those in need of support health professionals seeking additional information about eating disorders.

References

Dawe, S., & Loxton, N. J. (2004). The role of impulsivity in the development of substance use and eating disorders. Neuroscience and Biobehavioral Reviews, 28(3), 343–351. https://doi.org/10.1016/j.neubiorev.2004.03.007

Eric Stice, Emily Burton,  and H. S. (2004). Prospective Relations between Bulimic Pathology, Depression, and Substance Abuse: Unpacking Comorbidity in Adolescent Girls, 72(1), 62–71. https://doi.org/10.1016/j.neuroimage.2013.08.045.The

Gordon, S.M. & Johnson, J. A. & G., S.F. & Cohen, L. & Killeen, T. & R., & P.M. (2008). Assessment and treatment of co-occurring eating disorders in publicly funded addiction treatment programs. Psychiatric Services, 59(9), 1056–1059.

Gordon, D. A. (2008). Comorbidity of mental disorders and substance use: A brief guide for the primary care clinician. Commonwealth of Australia 2008. Retrieved from http://www.nationaldrugstrategy.gov.au/internet/drugstrategy/publishing.nsf/Content/FE16C454A782A8AFCA2575BE002044D0/$File/m719.pdf

Gordon, D. A., Drug and Alcohol Services South Australia (DASSA), & Clinical Services and Research. (2008). Comorbidity of mental disorders and substance use: A brief guide for the primary care clinician. https://doi.org/10.1016/j.biosystemseng.2003.09.010

Gregorowski, C., Seedat, S., & Jordaan, G. P. (2013). A clinical approach to the assessment and management of co-morbid eating disorders and substance use disorders.

Killeen, T.K. & Greenfield, S.F. & Bride, B. E. &, & Cohen, L. & Gordon, S.M. & Roman, P. M. (2011). Assessment and treatment of cooccurring eating disorders in privately funded addiction treatment programs. American Journal on Addictions, 20(3), 205–211.

Nøkleby, H. (2012). Comorbid drug use disorders and eating disorders - A review of prevalence studies. NAD Publication, 29(3), 303–314. https://doi.org/10.2478/Y10199-012-0024-9

The National Center on Addiction and Substance Abuse at Columbia University. (2003). Food for Thought : Substance Abuse and Eating Disorders. Nancy Reagan Linda Johnson Rice George Rupp, (December), 73.

The National Eating Disorders Collaboration. (2014). National Eating Disorders Collaboration. Sydney, NSW. Retrieved from http://www.health.gov.au/internet/main/publishing.nsf/Content/mental-nedc

Victoria, E. D. (n.d.). Eating Disorders, Drug and Alcohol Addiction.

Wiederman, M. W., & Pryor, T. (1996). Substance use and impulsive behaviors among adolescents with eating disorders. Addictive Behaviors, 21(2), 269–272. https://doi.org/10.1016/0306-4603(95)00062-3

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Article 2: Working in the area of drugs and eating disorders: NEDC  Resources for our Health Professionals

The NEDC have a number of useful resources for health professionals.

Our professional resource for pharmacists is useful for health professionals that may come into contact with someone with an eating disorder and comorbid substance use disorder. This resource will support the pharmacist’s role in the prevention, identification, medical management, and referral of patients with eating disorders.

Additional information about eating disorders, identification, treatment, and support is available on the NEDC website.

Additional resources fro health professionals are available on our website page for Health Professionals and Primary Health Networks (PHN).

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Article 3: NEDC e-Bulletin Review: How are we doing?

It is the New Year, and with the New Year brings a time for the NEDC to examine how we are supporting our members in providing the most up to date and useful information about eating disorders.

To do this we have created a very short (less than 10 questions!) survey. We would love your input. Please let us know what you think below. Thanks for participating!

https://www.surveymonkey.com/r/K3JDF7N

 Remember - Becoming a member of the NEDC is free, but the participation and support of our members is invaluable! If you are not yet a member, we would love to have you involved!

Why join?

As an NEDC member, you have the opportunity to become part of an eating disorders network: a community of people with expertise or an interest in eating disorders through which you will learn, contribute and engage in project activities.

Becoming an NEDC member enables shared learning, networking, and access to evidence-based research. NEDC members are valuable partners and key contributors to the development of improved approaches to the prevention and treatment of eating disorders in Australia. With the assistance of our members, together we will continue to ensure:

1. Eating disorders are a priority mainstream health issue in Australia;
2. A healthy, diverse and inclusive Australian society acts to prevent eating disorders;
3. Every Australian at risk has access to an effective continuum of eating disorder prevention, care, and ongoing recovery support.

To become a member, simply fill out our online application form.

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