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Co-Occurring Disorders: Anorexia Nervosa And Substance Abuse

Dr. Richard Foster, LICDC-CS

Medically reviewed by

Dr. Richard Foster, LICDC-CS

March 26, 2019

Anorexia nervosa is characterized by a distorted body image, an overwhelming fear of weight gain, a preoccupation with becoming thin, and restrictive eating habits. Anorexia and substance use disorders often occur together, as co-occurring disorders. Due to this, their individual side effects and dangers are often compounded, increasing the risk for numerous adverse effects and medical issues, including various organ damage, suicide, and death.

As co-occurring disorders, these require the assistance and support of a good treatment program, such as that which is offered in an inpatient drug rehab center. Inpatient drug rehab programs are adept at treating co-occurring disorders, including anorexia, by offering a wide and integrated spectrum of treatment modalities, including various behavioral therapies, family support, nutrition support, counseling, and other modalities which aid an individual in regaining their health and sobriety.

A co-occurring disorder is that which occurs alongside a substance abuse disorder (SUD). This often contributes to a person’s substance abuse and can also change the scope of treatment. The National Center on Addiction and Substance Abuse (CASA) reports that “up to 50% of individuals with eating disorders abused alcohol or illicit drugs, compared to 9% of the general population,” and continues to note that anorexia was one of two eating disorders most commonly linked to substance abuse, a connection linked to numerous medical concerns.

What Is Anorexia Nervosa?

Manifesting most typically within an individual’s adolescence or teen years, anorexia nervosa (AN) commonly continues into adulthood.

Below follows the most current criteria for anorexia nervosa, as referenced from the American Family Physician:

  1. An individual limits their caloric intake in a way that leads to “a significantly low body weight in the context of age, sex, developmental trajectory, and physical health.” Specifically, this change in body weight is one “defined as a weight that is less than minimally normal or, for children and adolescents, less than that minimally expected.”
  2. An individual becomes scared of putting weight on or becoming fat or is exceedingly preoccupied with behaviors that limit their ability to gain weight, even when a person already exists at a weight which is markedly low.
  3. An individual fosters an altered and incorrect perception of their weight or shape, thoughts of their weight or shape dominate their self-image and behaviors, or they chronically exhibit a lack of acknowledgments regarding the critical nature of their present state of low body weight.

Further, there are two subtypes of anorexia, including:

  • Binge-eating/purging type: If, throughout the previous three months, a person has repeatedly employed behaviors consistent with binging (eating to excess in a short period in an amount that is greater than what is typically considered a meal) or purging (self-induced vomiting, or using diuretics, enemas, or laxatives inappropriately).
  • Restricting type: If, throughout the previous three months, a person has not employed behaviors of binging or purging as stated above, but has instead sought to lose weight by enacting diets, exercising to the extreme, or fasting.

Scientists do not yet fully understand why anorexia occurs, however, researchers theorize that it is a combination of factors, including: genetic and hormonal influences, gender, age, childhood anxiety, onset of puberty, a poor self-image, and/or societal influences.

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What Are The Characteristics Of Anorexia?

Intensely preoccupied with circumstances regarding dieting, eating, food intake, and weight loss, to the effect these thoughts become forefront in their mind and behaviors, a sufferer of anorexia will commonly exhibit numerous behavioral changes that are indicative of this disorder, including:

  • Ignoring a sense of hunger
  • Excessive anxiety about weight gain or becoming fat
  • Constantly comments and worries aloud of these fears
  • Self-esteem is inexplicably linked to perceived body image
  • Behaviors continue despite apparent threat of harm to self
  • Strict refusal of maintaining a healthy weight
  • Compulsive behaviors centered on becoming thin
  • Isolating themselves from their friends or family
  • Wearing baggy clothes to cover up their body
  • Refraining from eating certain food-types, or groups of goods (i.e. fats or carbohydrates)
  • Consuming more of certain foods (i.e. diet foods, fruits, and vegetables)
  • Initiating food rituals, such as cutting food into small bites or rearranging the food on the plate to give the appearance of eating
  • Becoming increasingly absent from meals
  • Exercising in excess to negate any food or calories they consumed

How Does Anorexia Harm A Person?

Anorexia is very invasive to the body. It disrupts your body’s delicate chemical, biological, and physiological functions, creating a host of mental and physical dangers. These may include:

  • Dry mouth
  • Hair and nails become brittle
  • Skin becomes dry and exhibits a yellow tinge
  • A fine hair may begin to cover the body (lanugo)
  • Constipation
  • Becoming overly sensitive to the cold, due to reduced body mass and reduced internal temperature
  • Being overly tired or lethargic
  • Depression or anxiety
  • Confusion or decreased cognitive abilities
  • Impaired memory or judgement
  • Brain damage
  • Cardiovascular damage
  • Failure of various organ systems
  • Decreased blood pressure, respiratory functions, and breathing rate
  • Loss of menstruation
  • Infertility
  • Bones become depleted (osteoporosis)
  • Muscle wasting and loss of body fat stores
  • Anemia or malnourishment accompanied by weakness

In the most severe of instances, this disorder may be life-threatening. The National Institute of Mental Health asserts that out of every mental disorder, anorexia is the most fatal, with a mortality rate that is roughly one out of every ten individuals, with deaths attributable to starvation, metabolic collapse, and suicide. For those who suffer from a co-occurring SUD, many of these serious health effects and critical dangers are even more apparent.

What Is The Connection Between Anorexia And Substance Abuse?

These disorders have much in common. Commenting on this, CASA states “Eating- and substance-related behaviors both operate on similar reinforcing and rewarding motivational systems in the brain. Both disorders involve an obsessive preoccupation with a substance (drugs or food), craving and compulsive behavior characterized by a loss of control.” They note further similarities, including:

  • Mood altering effects
  • Linked to co-occurring disorders
  • Impulsivity
  • Secretive behaviors
  • Ritualistic behaviors
  • Low self-confidence
  • Social isolation
  • Involve negative behaviors used as self-medication
  • Linked to dopamine changes in the brain
  • Shared risk factors
  • Resistance to treatment
  • Requires intensive treatment
  • High rates of relapse

Perhaps the greatest shared characteristic is that these individuals continue to engage in these self-destructive behaviors despite the consequences and obvious negative health effects.

Additionally, a person may abuse a substance to temper symptoms of psychological distress caused from AN, such as depression or anxiety, or in an attempt to moderate their weight. Certain drugs, such as caffeine, tobacco, cocaine, amphetamines, or methamphetamine may be used as appetite suppressants or to accelerate weight loss. Other drugs such as alcohol, marijuana and various sedatives may be used to manage the stress attributed to this disorder. After marijuana, one report cites that hallucinogens were the second most abused drug across all subtypes of AN with women.

What Are The Dangers Of These Co-Occurring Disorders?

The greatest cause for concern is that these disorders often cause many of the same adverse effects, medical issues, and damage to the same organ systems. Anorexia can cause malnourishment or anemia, which many SUDs also create, together this negative and life-threatening state is compounded. While anorexia causes muscle wasting and bone density loss, several substances, including alcohol, cocaine, and amphetamines may also foster muscular damage, while others, such as alcohol and possibly opiates, may harm a person’s bones.

Various organ systems may be affected, supported by information from the National Institute on Drug Abuse. Anorexia and SUDs can cause cognitive decline and brain damage. Both are linked to cardiac complications, including heart failure. Dehydration commonly occurs in anorexia, which may lead to kidney damage, and is linked to certain opioid painkillers, alcohol, heroin, inhalants, MDMA, and PCP. Lastly, liver damage may occur with anorexia and is connected to alcohol, certain opioid painkillers, heroin, inhalants, and steroids.

While anorexia alone may be fatal, in many cases, substance abuse can increase your risk of premature death. Cautioning us, the CASA publication cites research suggesting that Due in part to the prevalence of co-occurring disorders, and the impact of these two disorders on one’s mood and mental health, individually, anorexia and SUDs may increase the risk of suicide, together, this risk may increase further.

How Are These Disorders Treated?

Fortunately, though the process may at times be difficult, both of these disorders are treatable, and often employ the same modalities. Firstly, in more severe forms of addiction, such as those which occur with a co-occurring disorder, a dual diagnosis inpatient drug rehab program is recommended, due to its residential and intensive format. Within treatment, a person will encounter behavioral therapies and counseling that are specifically focused on these unique needs, possibly including medication-assisted treatment.

Research illustrates that cognitive behavioral therapy and family therapy both garner positive and long-lasting results for both anorexia and substance use disorders. Due to the way these disorders disrupt a person’s health, special attention will be placed on nutritive support and classes on proper nutrition. Various self-help groups, both during treatment and after, may be helpful in aiding an individual through both of these struggles, by offering support, advice, accountability, and experience-based coping skills.

Renew Your Body And Mind

Having one disorder can be daunting, having two may seem utterly overwhelming. Despite this, compassionate and expert care exists that offers dual diagnosis treatment for both anorexia and addiction. Better health and sobriety are possible. At our staff understands the complexity of your situation and would like to offer you guidance and support in creating a personalized addiction treatment plan. Contact us now.

Medline Plus - Anorexia

National Institute on Mental Health - Eating Disorders: About More Than Food

American Family Physician - Initial Evaluation, Diagnosis, and Treatment of Anorexia Nervosa and Bulimia Nervosa

The National Center on Addiction and Substance Abuse - Food for Thought: Substance Abuse and Eating Disorders

Social Work Today - Insatiable Hungers: Eating Disorders and Substance Abuse

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