Among adolescents with eating disorders, half also abuse drugs or alcohol. Among substance abusers, 35% have eating disorders. The rate of comorbidity is highest among patients who binge and purge, whether they have bulimia nervosa, anorexia nervosa or binge eating disorder.1
Often teenagers with eating disorders will abuse Adderall or Ritalin because they diminish appetite while maintaining energy levels and can provide a buzz without consuming any calories. Some will then add benzodiazepine to counter the effects of the stimulants. Those who drink frequently find that alcohol blunts feelings of hunger and the experience of psychological distress. Others may abuse medications prescribed for their parents or other family members initially and then progress to buying them from friends at school. When those become too expensive, they may move on to the more cost-effective street version of opioids, heroin.
Because of the high degree of overlap, whenever a young person presents with symptoms of one of these disorders, clinicians should screen for the other. For someone suspected of having an eating disorder, the questions around substance abuse may be whether the adolescent smokes cigarettes or vapes tobacco, drinks alcohol, uses drugs or takes medications that have not been prescribed for them or continue to take prescribed pain medication after the pain subsides. Skittish teens might be approached by asking whether their friend do any of the above activities, as research shows that friends’ behaviors often provide a good proxy for an adolescent’s own behavior. If the answers indicate that the individual may have a substance abuse disorder, a urine test can help confirm the suspicion. If the screen returns a positive result, follow-up questions should include when the individual started using any substance, whether they experience any side effects and whether they have tried to reduce their usage or suffered any negative consequences from using. Those who have used drugs or alcohol for longer, have tried and failed to cut back, or continue to use in the face of failing grades, family problems or alienation of friends should be considered for inpatient treatment.
If the answers indicate that the individual may have a substance abuse disorder, a urine test can help confirm the suspicion. If the screen returns a positive result, follow-up questions should include when the individual started using any substance, whether they experience any side effects and whether they have tried to reduce their usage or suffered any negative consequences from using. Those who have used drugs or alcohol for longer, have tried and failed to cut back, or continue to use in the face of failing grades, family problems or alienation of friends should be considered for inpatient treatment.
With adolescents, involving the family in treatment substantially increases the likelihood of long-term recovery. If the young person can discuss their addiction with their family, trust can begin to be rebuilt and the family can make adaptations to reduce the risk of relapse. Parents will need to know what substance has been abused, for how long and how it was obtained.
Many times a family that thinks their child simply has an eating disorder is shocked to find that he or she also abusing drugs or alcohol. An experienced therapist can help the family deal with emotions separately from the child in treatment. They may mourn the loss of the son or daughter they thought they knew and will often need to work through guilt about not recognizing the signs of addiction or enabling abuse to take hold. Some may blame themselves for the addiction, particularly if they abuse or have abused drugs or alcohol. Allowing them their own time to talk with the therapist permits them to be more fully available to their child.
For adolescents with both disorders, treatment must address them simultaneously to ensure improvements in one condition do not lead to worsening of the other. Stabilizing patients physically must take priority. That may mean refeeding and nutrient supplementation in some cases. It will always include establishment of healthy dietary habits. For all patients with a dual eating disorder and substance abuse disorder diagnosis, detoxification must take place, followed by continued abstinence from substances for recovery to start.
Therapy can then help patients come to terms with the trauma and intense emotions that often underlie both disorders. For eating disorders, therapy will focus on accepting and loving their body and themselves. It will encourage them to adopt more realistic expectations of themselves and abandon a potentially deadly pursuit of perfection. For substance abuse, treatment will encourage participation in a 12-step program and development of healthier practices, such as moderate exercise and meditation, that can help keep an addict on track with recovery.
Ultimately, getting to the core issues and helping the individual with both diagnoses develop better coping mechanisms, learn how to reduce their reactivity to situations and positive ways to self-soothe will strengthen patients’ ability to take control of their recovery — and their lives.
Krahn D, Piper D, King M, Olson L, Kurth C, Moberg DP. Dieting in sixth grade predicts alcohol use in ninth grade. Journal of Substance Abuse. 1996;8(3):293-301.
