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Elvin Semrad, MD, a famous psychoanalyst, would speak about how important it is for patients to “know what they are up against.” This is especially important in the care and treatment of patients with eating disorders.
When patients are treated for anorexia nervosa or bulimia nervosa, the eating disorder is often the tip of the iceberg, and a thorough evaluation often reveals co-occurring psychiatric disorders.
A recent national survey found that patients with anorexia nervosa had high rates of coexisting mood disorders (42.1%), anxiety disorders (47.9%), substance use disorders (27%), and impulse control disorder (30.8%). This same survey found that patients with bulimia nervosa had even higher rates of co-occurring psychiatric disorders: mood (70.7%), anxiety (80.6%), substance use (36.8%), and impulse control (63.8%).
At first, diagnosing co-occurring conditions might seem disheartening, as this might make an already serious eating disorder diagnosis suddenly seem more complicated. However, hope begins with integrated treatment. When patients understand what they are up against—how each disorder worsens the other—and receive treatment for all their conditions, recovery can move forward.
Eating disorders, for example, worsen depression and vice versa. The malnutrition of anorexia nervosa and erratic eating of bulimia nervosa has a negative effect on the brain, worsening mood and impairing sleep, concentration, and energy. Eating disorders behaviors cause social isolation and are time-consuming. Patients also suffer from distressing negative body image, ruminations about food and body, and shame and stigma that worsen their self-esteem, further lowering their mood. Depression saps motivation for recovery, makes patients feel hopeless, and keeps them stuck. In the case of anorexia nervosa, weight loss can be a slow suicide.
Despite the worsened clinical picture of these combined disorders, treating both the eating disorder and the depression improves both conditions significantly. With treatment, patients can stabilize their eating disorders: restore weight, establish regular eating, stop purging or exercising, and work on better managing the psychological symptoms of their eating disorder.
When patients are on track with eating, the multitude of evidence-based treatments for depression (medications, psychotherapy, electroconvulsive therapy (ECT), and transcranial magnetic stimulation) work better, and patients have more energy and emotional space to find the meaning and enjoyment in life that is integral to recovery from depression.
Similarly, an eating disorder and a substance use disorder feed off each other. Alcohol has calories, and patients restrict to make up for drinking. Drugs and alcohol disinhibit and are associated with bingeing, which is followed by restricting or purging to offset the intake.
The lack of a clear head due to the use of drugs and alcohol makes it hard to stay on track with eating disorder recovery. However, even two weeks of sobriety brings back a clear head, and the awareness of the association of substance use and eating disorder symptoms can allow patients more choice in their recovery.
Trauma, sometimes undiagnosed, often underlies substance use disorders and eating disorders. The constellation of symptoms from trauma can include shame and a negative impact on self-esteem (patients feel the trauma is their fault), a negative impact on self-care, and post-traumatic stress disorder (PTSD).
Patients often drink, take drugs, or use eating disorder behaviors to cope with their trauma symptoms. For example, restricting can provide a sense of control, can be numbing, can be soothing. Bingeing and purging can be an emotional outlet.
Trauma treatment starts with trauma education, including helping patients understand how their old ways of coping can be replaced with more adaptive coping mechanisms.
At first, patients might feel overwhelmed when they are diagnosed with multiple disorders. A college student once said, “I thought I was just partying. Now you are telling me I have a substance use problem on top of my eating disorder!”
But the truth is that patients know what they are up against deep down inside as they live and experience their struggles every day. Making these struggles more explicit, naming them, diagnosing them, explaining how different disorders interact, and most importantly, providing treatment for all problems moves patients into a more complete recovery.
This is a hopeful process.
In the words of a patient, “I am not glad that I got anorexia, but I am glad I came to treatment to get help for everything else that was going on.”
Hudson JI, Hiripi E, Pope HG Jr, Kessler RC. The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biological Psychiatry. 2007;61(3):348-58.
Do you or a loved one need treatment for an eating disorder? McLean Hospital’s Klarman Eating Disorders Center offers world-class treatment for anorexia, bulimia, and other eating disorders. Call us today at 877.209.5860.