By Taylor Knopf

Sandra Wartski specializes in treating patients with eating disorders at a Triangle-based psychology practice and recently, she said she’s seen a growing number of clients with a co-occurring substance use disorder.

It turns out that’s not unusual. According to the National Eating Disorder Association (NEDA), 50 percent of people with eating disorders, such as anorexia or bulimia, abuse alcohol or illegal drugs at some point.

That’s been the case, even as there’s been an increase in opioid and heroin use nationwide over the past decade, leading to a rise in overdose death rates.

Experts say people use substances and behaviors associated with eating disorder to self-treat underlying, often undiagnosed, mental health issues.

However, there’s an overall lack of eating disorder specialists in North Carolina and even fewer who are equipped to treat co-occurring disorders, even as there’s a dire need. In the U.S., about 20 million women and 10 million men will experience an eating disorder at some point, according to the association.

The mortality rate for people with anorexia is 10 percent, and 1 in 5 deaths of people with anorexia are by suicide, according to NEDA.

Steven Crawford, director of The Center for Eating Disorders at Sheppard Pratt in Maryland has spent 30 years providing inpatient and outpatient care. His 34-bed center takes an average of 13 admissions a week and treats about 3,000 outpatients a year from across the East Coast and Midwest.

There’s such a demand for the center’s services that he began a telehealth counseling program two years ago to treat patients in rural Maryland and Virginia.

Chicken or the egg debate

But which comes first, the substance use disorder or the eating disorder? It’s hard to say.

“Either diagnosis can occur at any point along the way in the course of the other illness,” Crawford said.

It’s important to continue to follow up with patients about substance abuse, he advised. Just because they don’t present with signs at the first visit, doesn’t mean they won’t develop them later.

People with eating disorders most frequently abuse caffeine, tobacco, alcohol, laxatives, emetics, diuretics, appetite suppressants (amphetamines), heroin and cocaine, according to NEDA.

Crawford puts the substances in three distinct groups.

The first category are easily accessible substances, such as cigarettes and caffeine, which Crawford said people use to suppress their appetites. However, he pointed out that many studies show those are not effective weight loss tools, and some people still gain weight no matter how much they smoke or drink coffee.

The second is illegal substances, such as marijuana, heroin and cocaine. It’s known that some people use substances to self-medicate their mental health issues. People use eating disorder behaviors to manage negative emotions as well, Crawford said. His patients talk about how acting on their eating disorder behavior reduces their anxiety or improves their mood.

The third category of drug abuse is more unique to this population, such as laxatives and diet pills.

Similarities and differences

At a mental health conference in Greensboro last month, Wartski presented the similarities and difference between substance use disorders and eating disorders.

Both food and substances are used for mood-altering effects, she said. As tolerance builds, the cravings and loss of control intensify.

Both are complex, long-term illnesses in which people can experience relapses.

Eating disorders and substance abuse share common risk factors, such as brain chemistry, family history, low self-esteem, depression, anxiety and social pressures, Wartski said.

Denial and secrecy are common with both types of disorders. Eating disorders and substance abuse can disrupt a person’s cognitive and social abilities, as well as their work and personal lives.

“Their illness is a secret and so part of treatment and part of recovery is helping people to let go of their secrets, acknowledging the struggles that they’re having,” Crawford said.

With both, there’s a “clear preoccupation with a particular substance,” he said. With an eating disorder, there’s a preoccupation with food. People have similar compulsions and cravings around their drug use.

“People with drug use also tend to engage in lots of ritualistic type behaviors around their drug use,” he said. “And people with eating disorders also do that as well.”

There are some differences, though. Wartski said much of the treatment around substance use disorder is about restraint and abstinence, and with eating disorders, the goal is to moderate and normalize eating.

How to treat both

At the center in Maryland, there is a special track for people with a co-occurring substance use disorder. Crawford recommends that people receive treatment for both concurrently rather than sequentially.

But specialty treatments often take place in isolation from one another. Therapists who work with substance users might not feel comfortable working with someone whose eating is disordered. Instead, providers tend to make referrals to other specialists.

“But people often don’t come in with just one thing,” Wartski said. “Ideally, you want to integrate care.”

If you don’t treat eating disorders and substance abuse simultaneously, there’s the potential for “symptom substitution,” Crawford said.

For example, when someone is working on managing their substance use, their eating disorder behaviors tend to escalate and vice versa. So the treatments have to be concurrent.

When he has a patient that presents with both disorders, that person is put into a treatment environment with an intense focus on normalizing eating patterns and helping them work on their body image. At the same time, the patient attends groups, such as a 12-step program and they might engage in cognitive behavioral therapy.

Crawford also emphasizes the need for a patient’s home environment to be supportive of recovery. That means ridding the home of the abused substances and engaging the family or an outside support group.

Unfortunately, it can take a while for someone to be diagnosed with an eating disorder and get into treatment. He said it takes an average of nine months for some to get into treatment.

Part of the problem is that many in the medical community aren’t trained to recognize signs of these disorders.

“Early intervention makes a huge difference in outcome,” he said. “The sooner they get into treatment and get to a healthy body weight, the better the outcome. But people tend to deny their eating disorder, so once they are looking for help, they’ve already progressed pretty far.”

Inpatient beds at Crawford’s center are for these more acute cases.

Criteria for a higher level of care includes weight — particularly for patients with anorexia — and severity of symptoms.

Symptoms are considered severe if someone is purging multiple times a day and developing medical consequences, such as vomiting blood or their blood pressure drops when they stand up.

A glamorized disease

Eating disorders are frequently misrepresented on TV, Wartski said. There are several myths, such as eating disorders are “only a rich, white girl disease.” There is also the myth that eating disorders are a “girl’s issue,” but one in 10 men struggle with an eating disorder, she said.

“It’s not,” she said. “And we need to spread the word that it’s a biopsychosocial illness.”

Social pressures exacerbate the disease. Nearly a third of the advertisements an American consumes in a day are about beauty and appearance, Wartski said. Fashion models are thinner than 98 percent of women in the U.S., she added.

Then there are the oversizing food markets on top of that.

“The food is getting bigger and cheaper as the models get smaller,” she said. “That’s confusing. What do we do about that?”

“People in American think body weight is something they can choose,” Wartski added. “But it’s much more like foot size and height. It’s genetic.”

Crawford agreed, saying he doesn’t think people grasp the severity of the illness and the mortality rates associated with it.

“I think, unfortunately, eating disorders are sometimes glamorized in the public,” he said.

“I think there is a thought that it’s a lifestyle choice rather than a biological illness,” Crawford said. “They think, ‘If people would just eat, there wouldn’t be a problem.’ But it’s not that easy.”

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