Eating disorders—anorexia nervosa, bulimia nervosa, and binge-eating disorders—are serious but treatable mental illnesses that feature disturbances in both eating behavior and weight regulation. They are associated with significant adverse psychological, physical, and social consequences.
It is not uncommon for people with eating disorders to also abuse drugs or alcohol. People who struggle with both a substance use disorder (SUD) and a mental illness are said to have a dual diagnosis or co-occurring disorders. Nearly 8 million people have a dual diagnosis in the U.S., according to the 2014 National Survey on Drug Use and Health.1 Although thought to predominantly affect women—and as many as 5.9% of women in the U.S. do have one—eating disorders are present in 2.8% of American men too.2
There are different underlying reasons for developing both disorders, which we will explore in greater detail later in this article. But first, let’s get a better understanding of the various forms an eating disorder can take.
The hallmark of anorexia nervosa is an unhealthy obsession and fear around food, how much you eat, and how much you weigh. Distorted body image is also a significant part of this disease, which causes you to see yourself inaccurately (most commonly as weighing more than you actually do), or perceiving some flaw in your appearance that does not exist. People with anorexia may repeatedly weigh themselves, obsessively portion their food, or refuse to eat. They may exercise excessively, attempt extreme diets, self-induce vomiting, or misuse diuretics, laxatives, or enemas—or any combination of these behaviors.3
Other warning signs of anorexia include:3
- Having an extremely low body weight.
- Having an intense fear of gaining weight.
- Refusing to eat in front of others.
- Experiencing low self-esteem.
Anorexia has the highest mortality rate of any psychiatric disorder—18 times higher than other mental illnesses.3,4 Without proper treatment, more severe symptoms and complications may develop, including:3
- Amenorrhea (absence of menstruation).
- Bone thinning or weakening (osteoporosis or osteopenia).
- Severe constipation.
- Cardiac arrhythmias.
- Heart failure.
- Multiorgan failure (liver, kidneys, etc.).
- Brain damage.
People with bulimia nervosa have frequent episodes of eating excessive quantities of food (binges), followed by compensatory behaviors, such as self-induced vomiting, excessive exercise, misuse of laxatives, diuretics, or enemas, or some combination of these behaviors. Those who suffer from this disease feel unable to control these binge-and-purge episodes.3,4
Unlike anorexia, people with bulimia are generally within average or overweight ranges, but they still have an overwhelming fear of gaining weight and struggle with a negative body image or body distortion. Bulimic behaviors are usually conducted in secret because of the shame associated with them. However, these feelings are often temporarily relieved by binge eating and purging until their stomach feels empty again. This cycle can occur weekly, daily, or even multiple times a day.3,4
Some of the physical consequences of bulimia include:3
- Acid reflux disorder.
- Other gastrointestinal issues caused by misusing laxatives or diuretics.
- Chronically inflamed or sore throat.
- Swollen salivary glands.
- Worn tooth enamel, sensitive teeth, or decaying teeth due to repeated exposure to stomach acid.
- Severe dehydration from purging fluids.
- Electrolyte imbalance (which may lead to heart attack or stroke).
Binge Eating Disorder
When you have binge eating disorder, you engage in regular binging episodes but do not follow them with the compensatory behaviors seen in bulimia. As a result, people with binge eating disorder are often overweight or even obese. You may experience guilt and shame over these behaviors, which often leads to more binging as a means to numb out those painful feelings. Binge eating disorder affects the same amount of men as it does women.4
The negative physical results of binge eating disorder can include:3
- Cardiovascular issues.
- High blood pressure.
With this better understanding of eating disorders, let’s examine what may drive co-occurring substance abuse in many of the people who suffer from them.
What Causes Eating Disorders?
Research indicates that eating disorders are caused by a complex interaction of genetic, psychological, and social factors.3 Genetics are particularly strong—one study found that 50% of eating disorders and disordered eating behaviors can be attributed to them.5 Psychological features that may predispose someone to developing an eating disorder include low-self-esteem, an intense dissatisfaction with the way they look, and feelings of helplessness. Perfectionism is an extremely common trait among people with anorexia, while impulsivity is a hallmark in people with bulimia.4
Various environmental issues can lay the groundwork for an eating disorder in those who are more susceptible, such as being teased or bullied (about your body or other things), or by engaging in a sport that emphasizes a certain body image or promotes low weight, such as ballet or wrestling. Traumas, such as abuse, rape, or death are also extremely common predecessors to those with eating disorders.4
Substance abuse is predicted heavily by genetics as well: between 40 and 60% of your susceptibility to drug or alcohol addiction is influenced by them.6,7 Other factors include gender, ethnicity, and the presence of other mental disorders (like an eating disorder). Similar to eating disorders, trauma and other environmental challenges contribute to drug and alcohol abuse.7
All of these similarities in underlying causes makes it far more likely that a person with one disorder will develop the other. In fact, a 2007 study found that women with a substance use disorder or an eating disorder are 4 times as likely to develop the other one. A 2006 study discovered specific associations between the two disorders, including:2
- As eating disorders become more severe, so does the increase of substance use.
- Attempts to lose weight by purging are associated with the use of stimulants, such as amphetamines; sleeping pill abuse is also common.
- Severe binge eating disorder is consistently associated with alcohol abuse.
- People may use food, drugs, and alcohol to help them cope or numb out negative feelings.
- A person recovering from an eating disorder may use a substance to cope with the discomfort associated with recovery.
- A person recovering from substance abuse may develop patterns of disordered eating to compensate for the missing drug or alcohol.
- Medical care and monitoring: This may begin with thorough physical and psychiatric examinations to address (or rule out) any potential medical or additional mental health issues. Ongoing care may involve FDA-approved medications, such as antidepressants.
- Individual and group therapy: Mental health professionals help you explore the root causes of your eating disorder; teach you to challenge negative thought and behavior patterns; and develop healthy coping mechanisms for common triggers.
- Family therapy: You will work through interpersonal issues related to the eating disorder with your family and help your family members understand the eating disorder and how they can better support your recovery. Nutritional assessment, management, and counseling: A nutritionist or dietician helps you relearn how to relate to food in a healthy way, and supports you through meal prep, meals, and restaurant outings.
- Mutual support groups: You may join and regularly attend support groups—such as Food Addicts in Recovery Anonymous (FA), Overeaters Anonymous (OA), or other programs—that offer peer support and a safe place to share frustrations, celebrate successes, and find community referrals and resources.
- Inpatient and outpatient detoxification and rehabilitation: Treatment may include detox, counseling, mutual support groups, and alternative therapies (e.g., equine therapy, yoga, or Reiki).
- Medication: FDA-approved medications can help ease the withdrawal symptoms associated with various substances.
- Psychotherapy: Mental health professionals apply various therapeutic modalities to help you uncover the root cause of your addiction; strengthen your motivation and confidence to recover; help you build a healthy support system; repair damaged or unhealthy relationships; set reachable goals; and help you develop skills to help you cope with triggers or avoid them altogether.
- Mutual support groups: Groups such as Alcoholics Anonymous (AA) and other 12-step or non-12-step programs provide peer support for those trying to stay abstinent from drugs and alcohol.
- National Association of Anorexia Nervosa & Related Disorders (ANAD): This organization provides information and resources about anorexia nervosa and other related disorders.
- National Alliance on Mental Illness (NAMI): The nation’s largest grassroots mental health organization, dedicated to providing support to those affected by mental illness.
- Binge Eating Disorder Association (BEDA): This national organization focuses on providing recognition, prevention, and treatment for binge eating disorder.
- The National Association for Males with Eating Disorders, Inc. (N.A.M.E.D.): This group provides peer support, information, and resources for men with eating disorders.
- Double Trouble in Recovery: A 12-step peer support program for those managing both substance abuse and a mental illness (dual diagnosis).
- Food Addicts (FA): A collection of international food addiction or eating disorder mutual support groups.
- Substance Abuse and Mental Health Services Administration (SAMHSA): A U.S. Department of Health and Human Services agency attempting to reduce the impact of substance abuse and mental illness via education, resources, programs, and campaigns.
- Moderation Management: A peer support program for those considering moderating or completely abstaining from their substance use.
- Alcoholics Anonymous (AA): The original 12-step peer support program for those recovering from alcohol addiction.
- National Institute of Drug Abuse (NIDA): The leading organization in research on the causes and consequences of substance use and addiction.
- Narcotics Anonymous: A 12-step peer support program for those recovering from a drug addiction.
- Secular Organizations for Sobriety: A peer support program for those maintaining sobriety and abstinence without the emphasis on spirituality or a higher power.
- Smart Recovery: A sobriety peer support group for those with addictions (not faith-based).
- Women for Sobriety: A drug and alcohol addiction peer support group for women.
While there isn’t any single predictive factor to determine whether you will develop co-occurring substance abuse and eating disorder issues, the more risk factors you have, the most susceptible you are. However, comprehensive, timely treatment can help you manage both conditions.
Available Options for Treatment
It is possible to recover from eating and substance abuse disorders with various treatment methods. The sooner you find help, the better, since the negative consequences associated when these diseases when left untreated can be deadly.
Eating disorder treatment must begin with medical stabilization. Depending on the severity of your disorder, hospitalization may be required due to extreme malnutrition and low body weight. Heart arrhythmias are among the most serious of issues that must be resolved before moving onto the next stage of treatment.
Some evidence-based treatment options for eating disorders include:3
Once a substance use disorder is diagnosed, it is most beneficial to simultaneous treat it along with the eating disorder using different evidence-based treatments, including:8
Many treatment facilities combine eating disorder and substance abuse treatment into one holistic program that supports you through your early recovery from both disorders.
Locating advocacy groups, government, educational, and non-profits that focus on eating disorders and substance abuse can provide you the information and support you need to begin your recovery journey.
There is no one-size-fits-all treatment solution to manage all instances of co-occurring disorders. It is important to first visit your primary physician or mental health professional for an assessment if you think you might have an eating and a substance abuse disorder. They will discuss your best treatment options and make any necessary referrals based on your health. Getting clean and restoring your health are simply the first aspects of recovery. It’s important to remain persistent, hopeful, and engaged in the treatments that work best for you, because a lifetime of recovery is within reach.
- National Alliance on Mental Illness. (2015). Dual Diagnosis.
- Substance Abuse and Mental Health Services Administrators. (2011). Clients with Substance Use and Eating Disorders.
- National Institute of Mental Health. (2018). Eating Disorders: About More Than Food.
- American Psychological Association. (2011). Eating Disorders.
- Berrettini, W. (2004). The Genetics of Eating Disorders. Psychiatry (Edgmont), 1(3), 18-25.
- Bevilacqua, L., Goldman, D. (2009). Genes and Addictions. Clin Pharmacol Ther, 85(4), 359-361.
- National Institute of Drug Abuse. (2018). Drugs, Brains and Behavior: The Science of Addiction.
- The National Institute on Alcohol Abuse and Alcoholism. (2014). Treatment for Alcohol Problems: Finding and Getting Help.