Eating Disorders and Chemical Dependency: Why so common?

By Tracy Welchoff, Ph.D.

​Eating and substance abuse disorders are a common combination that we see too often in our work.  The co-morbidity has been heavily researched, and the same evidence-based counseling practices- Cognitive-Behavioral Therapy, Dialectical Behavior Therapy, and Motivational Interviewing- have proven to help both disorders.  One of the many commonalities between EDs and substance abuse disorders is how often they are misunderstood.  We hear questions like “why can’t they just stop using?” just as others ask, “why can’t they just eat?” There are many reasons why these diagnoses often co-occur. Overlapping characteristics include high impulsivity, low self-esteem, history of trauma, tendency to isolate, and the desire to be outside of oneself and escape reality; consequences include poor physical health, depression, shame, and guilt.  Individuals with either of or both of these diagnoses can experience stigma that may be greater than other mental health diagnoses due to the general perception of both disorders as “self-inflicted”.  When attempting with a patient to compare their eating or substance abuse disorder to another disease like cancer or diabetes, I often hear the same response- “but this is my fault.  I chose to [insert symptom here].  It was my decision.”  Convincing them otherwise tends to be challenging, as individuals with these disorders are normally comfortable with self-blame and resistant to any suggestion to the contrary. 
 
According to research done by National Institute on Drug Abuse (NIDA), 6 out of 10 substance abusers also meet criteria for another mental health disorder.  This could be because drug abuse can cause mental illness, mental illness can lead to drug abuse, or drug abuse and mental illness are both caused by common risk factors, such as genetic vulnerabilities and environmental triggers.  Drug abuse and eating disorders also trigger the same “reward centers” in the brain to keep the behaviors going.  Endorphins are released as rapidly in a binge/purge cycle as in use of an opiate, and it takes time-usually weeks, months, or even years- without the unhealthy behavior for endorphins to be released normally again (as a result of another pleasurable behavior).   This explains the depression and anxiety our patients may experience without symptoms and their complaints that no other coping skills produce the same calming result.  No wonder it’s so difficult to give up symptoms!  It also explains why our dually-diagnosed patients may relapse into substance abuse while recovering from their ED (or vice versa).  
 
At Narins EDC, it’s often difficult for participants to talk about their substance use.  In chemical dependency treatment program, it can be challenging to talk about eating disorder behavior.   Ironically, even those suffering with these co-occurring disorders stigmatize other mental health disorders.   Hopefully, providing education and understanding about the risk factors of both disorders and their co-occurrence can encourage the openness needed to address both head-on.