The consumption of food is a basic necessity of life, but even behaviors that provide basic life-sustaining necessities can be the focus of a mental health disorder.
The definition of a disorder or disordered behavior indicates that there are both qualitative and quantitative differences in the behavior that set it apart from the same type of behavior that occurs within normal conditions. So-called “normal behaviors” are associated with a broad range of functioning and sometimes may consist of rather extreme departures of what many people consider to be “normal.” When clinicians consider the types of behaviors that represent departures from normal behavior, they must also consider behaviors that vary due to differences in individuals, as a result of cultural or normative beliefs, and/or the influence of numerous social factors or conditions.
When a behavior becomes disordered in clinical terms, this means that the behavior:
- Is extreme in its presentation, such that it represents a clinically significant excessive action or a clinically significant deficient action
- Is not flexible, as disordered behaviors are often very resistant to change when situations require change (almost as if the person cannot control them)
- Results in negative ramifications for the person who engages in it
When individuals engage in disordered behaviors that are extreme, unchangeable, and lead to negative consequences, and they continue to perform or engage in these behaviors, they may be diagnosed with a mental health disorder. Even relatively basic activities like eating and socially acceptable activities like the use of alcohol can become disordered when they meet the general guidelines outlined above.
Disorders of Feeding and Eating
The older clinical term, eating disorders, has been replaced by a broader category in the Diagnostic and Statistical Manual for Mental Disorders – Fifth Edition (DSM-5) from the American psychiatric Association (APA). The new category is titled Feeding and Eating Disorders. These disorders consist of eating or eating-related behaviors that are characterized by altered consumption or absorption of food that results in significant impairment in physical health or social (psychosocial) functioning.
The diagnostic criteria for these disorders will not be displayed here as only a licensed and trained mental health professional can make a formal diagnosis of any of the feeding and eating disorders. These disorders include:
- Pica: This involves eating nonnutritive or nonfood substances that occurs for at least a period of one month, is inappropriate to the individual’s level of physical and cognitive development, and is not acceptable according to the individual’s culture norms or values.
- Rumination disorder: This is repeated regurgitation of food over a period of at least one month that is not attributed to some medical condition, is an appropriate for the person’s level of development, and is not some other eating disorder or psychiatric disorder.
- Avoidance/restrictive food intake disorder: This involves a lack of interest in eating or in food, and results in either significant weight loss (or failure to gain weight in children), nutritional deficits, and dependence on some other outside source like supplements or enteral feeding. It markedly interferes with the person’s social functioning.
- Anorexia nervosa: This is an extreme restriction of food intake, leading to significantly reduced body weight. Anorexia is accompanied by a distorted body image, such that individuals always views themselves as overweight. They have an intense fear of gaining weight or becoming heavy even if they are painfully thin.
- Bulimia nervosa: This involves recurrent episodes of binge eating and inappropriate compensatory behaviors in order to prevent weight gain, such as purging, vomiting, the use of laxatives, etc. These behaviors occur at least once a week and have been occurring for at least three months.
- Binge eating disorder: This consists of recurrent episodes of binge eating that are associated with marked distress in the person. This distress leads to isolation, depression, embarrassment, etc., and occurs at least once a week over a period of at least three months.
- Unspecified eating disorders: These behaviors do not quite meet the formal diagnostic criteria for one of the above eating disorders, but still suggest that the person has a feeding or eating disorder.
There are special provisions for particular presentations of anorexia, bulimia, and binge eating disorder that are specified in the diagnostic criteria for these disorders. For example, even though bulimia is a disorder that includes cycles of binging and purging episodes, some individuals with anorexia may display this type of behavior to some extent. Only experienced and trained clinicians can diagnose these orders and distinguish between them.
The Comorbidity of Substance Use Disorders and Eating Disorders
The term comorbidity is used to describe a situation where an individual has two or more different disorders at the same time. The disorders pica and rumination disorder do not have high morbidities with substance use disorders and often have accompanying developmental disorders or other issues. By its very nature, avoidance/restrictive food intake disorder is not typically comorbid with an alcohol use disorder or significant alcohol abuse.
The eating disorders that have the highest comorbidities with substance abuse are anorexia, bulimia, and binge eating disorder. These disorders are more commonly diagnosed in women and also often comorbid with other mental health disorders, including obsessive-compulsive disorder, bipolar disorder, personality disorders, anxiety disorders, trauma- and stressor-related disorders, and major depressive disorder.
Research indicates that close to half of the individuals diagnosed with one of these three disorders also have some type of comorbid substance abuse issue or substance use disorder. The rates of substance abuse issues are estimated to be 5-10 times more prevalent in individuals with these eating disorders than in the general population; however, the actual figures are quite variable from study to study. Research does indicate that alcohol is one of the most common substances abused by individuals who are diagnosed with one of these three disorders.
Numerous explanations have been put forth to account for why individuals with eating disorders are also susceptible to issues with substance abuse. Some of these explanations attempt to explain how the development of a substance use disorder is directly related to the behavior observed in an eating disorder (e.g., the abuse of stimulants to restrict one’s appetite in order to lose weight or the use of alcohol to self-medicate one’s issues with anxiety and depression).
Other explanations highlight social factors as having causal effects on the development of these disorders. For instance, many theorists implicate relationship and family issues as potential significant driving forces for the development of anorexia, bulimia, and even binge eating disorder. Many forms of successful treatment for these disorders often involve the use of family therapy, and concentrate on identifying and then trying to balance the power structure within the family. Therapists address issues with the relationship structure in the family in an effort to both treat the individual with the eating disorder and to strengthen the overall family unit. These forms of interventions can be quite effective in treating these disorders.
Genetic connections between substance abuse and eating disorders have also been confirmed in numerous research studies, suggesting that there are at least some inherent factors that may be common to these behaviors. Strong inherent factors may also contribute to the strong comorbidity eating disorders share with many other mental health disorders. They may also account for why many research studies find that areas of the brain that are shown to be involved in substance abuse issues are also the same areas of the brain that appear to be involved in the expression of these types of eating disorders.
However, based on the overall body of research evidence investigating the causes of eating disorders and other mental health disorders, the general conclusion is that these disorders result from a combination of inherent factors and a person’s experience (environment). These factors interact in different ways that are not yet fully understood and are dependent on the specific situation to contribute to the development of these disorders.
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Treatment for Eating Disorders & Alcohol Use Disorders
It is quite clear that having a diagnosis of an eating disorder or alcohol use disorder is associated with having significantly more medical complications, higher levels of reported subjective stress, lower levels of life satisfaction, and increased probability of mortality, including the potential for suicide, than the general population. Treatment outcomes for individuals with eating disorders and substance use disorders are often most positive if the disorder can be identified early in its course. Because many individuals who are formally diagnosed with anorexia, bulimia, or binge eating disorder often begin these behaviors as children or adolescents, it is extremely important to attempt to intervene when these individuals are young. Substance use disorders are more likely to develop in late adolescence to early adulthood.
Attempting to treat an individual who has a serious eating disorder and a comorbid alcohol use disorder is a very complicated situation; however, it is imperative that both disorders are treated at the same time. Treatment will be unsuccessful if providers attempt to focus on one disorder while ignoring the other or attempting to hold it constant.
After a thorough evaluation to identify particular areas of concern and develop a treatment plan, treatment for a co-occurring alcohol use disorder and eating disorder would consist of the following:
- Medical detox: Inpatient treatment is best suited for individuals with co-occurring alcohol use disorders and eating disorders in order to monitor the individual’s progress, have 24-hour medical care on hand in case of emergencies, and ensure that the individual is eating properly.
- Medical care: Medically assisted treatments for withdrawal, cravings for alcohol, and other issues should be strictly supervised and monitored.
- Screenings: Abstinence from alcohol should also be objectively monitored through the use of random alcohol screenings.
- Monitoring: Many individuals with eating disorders have significant suicidal ideations or thoughts, and may have attempted suicide in the past. These situations should be strictly monitored.
- Therapy: Both an eating disorder and an alcohol use disorder are best addressed by the use of psychotherapy, particularly various types of Cognitive Behavioral Therapy. A combination of individual and group therapy sessions works best.
- Family involvement: For eating disorders like anorexia and bulimia, family involvement is often crucial in treatment. Family therapy should be an option for anyone with an eating disorder and co-occurring alcohol use disorder.
- Peer support: There are numerous social support groups for both alcohol use disorders (e.g., Alcoholics Anonymous) and for individuals with eating disorders (e.g., Food Addicts Anonymous). Participation in these groups should be strongly encouraged. Social support groups, such as 12-Step groups, can be the foundation of a long-term aftercare recovery program once an individual has completed the bulk of their formal psychotherapy.
- Complementary therapies: Because complete treatment for these issues should be personalized in order to address the specific needs of the individual, other interventions should be applied as needed in the individual case. These interventions can include vocational training, occupational therapy, tutoring, case management, psychoeducation, etc. They may include complementary and alternative therapies, such as art therapy, music therapy, psychodrama, etc.
- Aftercare: Treatment for both alcohol use disorders and eating disorders should be focused on long-term treatment involvement. Individuals who have these issues will most likely be involved in some form of treatment-related activity for many years and perhaps even over the course of their lifetime. Aftercare can help individuals avoid the repeating cycle of relapse/recovery that often leads to more serious complications, such as health issues, family and relationship issues, and even potential self-harm.
When an individual has a mental health disorder, such as an alcohol use disorder, and a comorbid eating disorder (or any psychological disorder and substance use disorder), the situation is often referred to as a dual diagnosis or as co-occurring disorders . The treatment of co-occurring disorders is implemented by a multidisciplinary team of treatment providers who each specialize in specific areas. These professionals treat the client separately and then meet periodically as a team to assess goals and treatment progress. This is typically designed to be a long-term intervention treatment program that follows and assists the individual for many years.
For people who are diagnosed with a co-occurring alcohol use disorder and an eating disorder, the recovery process is a long-term commitment. The goal of treatment is to engage in the recovery process without experiencing significant relapses or setbacks; however, when relapses or other types of significant setbacks occur, these events can be used to help the individual strengthen their treatment program and commitment to recovery.
In the long run, most people who have comorbid alcohol use disorders and eating disorders can go on to live productive lives and benefit from long-term treatment interventions. This often requires that the individual maintain some level of vigilance regarding the signs of relapse. As mentioned above, one of the best alternatives for long-term aftercare treatment is to be involved in a 12-Step program or social support group that allows the individual to regularly check their behavior, reconnect with their recovery, and give back to others who may need assistance. In addition, periodically checking in with therapists, physicians, and other treatment providers to discuss progress can also be important.