Concurrent Eating Disorder Treatment in Substance Abuse Rehabilitation
Yes, concurrent eating disorder treatment is appropriate and recommended for someone in rehabilitation for substance abuse, as co-occurring conditions should be addressed simultaneously using a multi-disciplinary approach. 1
Rationale for Concurrent Treatment
- Eating disorders and substance use disorders frequently co-occur, with research showing that patients who have both conditions demonstrate worse eating disorder symptoms, poorer outcomes, increased medical complications, longer recovery times, and higher relapse rates compared to those with eating disorders alone 1
- The American Psychiatric Association (APA) guidelines acknowledge that data are limited on individuals with eating disorders and co-occurring psychiatric conditions, including substance use disorders, but indicate that guideline statements should generally be applicable to individuals with co-occurring conditions 2
- The functional relationship between eating disorders and substance use disorders varies within and across eating disorder subtypes and depends on the class of substance, requiring careful assessment for each patient 1
Assessment Considerations
- APA recommends that the initial psychiatric evaluation of a patient with a possible eating disorder identify co-occurring health conditions, including co-occurring psychiatric disorders 2
- Screening for eating disorders should be part of an initial psychiatric evaluation, which is particularly important in substance abuse rehabilitation settings 2
- Assessment should include:
- Height and weight history
- Patterns of restrictive eating, food avoidance, or binge eating
- Compensatory behaviors (purging, excessive exercise)
- Preoccupation with food, weight, and body shape
- Prior treatment history for eating disorders 2
- Laboratory assessment should include complete blood count and comprehensive metabolic panel to detect abnormalities common in both eating disorders and substance use disorders 3
- An electrocardiogram is recommended for patients with restrictive eating disorders, severe purging behaviors, or those taking medications that may prolong QTc intervals 2, 3
Treatment Approach
- A comprehensive, culturally appropriate, and person-centered treatment plan that incorporates medical, psychiatric, psychological, and nutritional expertise via a coordinated multidisciplinary team is recommended 2
- The eating disorder and substance use disorder should be addressed simultaneously rather than sequentially 1
- Common therapeutic elements across interventions include:
- Psychoeducation about the connections between eating disorders and substance use
- Dietary education and planning
- Cognitive challenging of eating disordered attitudes and beliefs
- Building skills and coping mechanisms
- Addressing obstacles to improvement
- Relapse prevention 1
Evidence-Based Treatment Options
- Cognitive-behavioral therapy (CBT) has been frequently used in treating co-occurring eating disorders and substance use disorders, though randomized controlled trials are lacking 1
- Dialectical behavior therapy (DBT) has shown efficacy in reducing both eating disorder and substance use behaviors 1, 4
- For specific eating disorder types:
- Anorexia nervosa: Eating disorder-focused psychotherapy that normalizes eating behaviors and addresses psychological aspects 2
- Bulimia nervosa: Eating disorder-focused CBT, potentially with serotonin reuptake inhibitors 2
- Binge-eating disorder: Eating disorder-focused CBT or interpersonal therapy 2, 4
Potential Challenges and Considerations
- Treatment providers should avoid competitive positions between addiction treatment models and eating disorder treatment approaches 5
- A collaborative therapeutic relationship is essential, avoiding power struggles 1
- The need for medical stabilization, hospitalization, or inpatient treatment should be assessed based on general medical and psychiatric considerations 1
- Some patients may benefit from 12-step programs as part of their overall treatment plan, which can provide practical support and decrease feelings of isolation 5
Treatment Selection Framework
- When co-occurring mental health conditions impede effective treatment of the eating disorder, an integrated intervention approach is recommended 6
- Treatment selection should be guided by:
- Severity of each condition
- Impact of each condition on functioning
- Patient preferences and treatment history
- Available resources in the rehabilitation setting 6
By addressing both conditions simultaneously with appropriate evidence-based interventions, patients have the best chance for comprehensive recovery and reduced risk of relapse in either condition.