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Feeding and Eating Disorders in a Dual Diagnosis with Substance Use

Understanding the complex relationship between substance abuse and feeding or eating disorders highlights the need for specialized, comprehensive care strategies. It underscores the importance of considering the holistic needs of individuals affected by these co-occurring conditions to facilitate effective treatment and recovery.

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Feeding And Eating Disorders: A DSM-5 Overview

The DSM-5 categorizes Feeding and Eating Disorders as complex conditions that encompass a range of severe and often life-threatening behaviors surrounding food intake, body weight, and body shape concerns. These disorders can have significant psychological, physical, and social repercussions. Understanding the specific characteristics of each disorder is crucial for early identification and intervention. 

Feeding and Eating Disorders are severe and can be fatal if not treated. They often co-occur with other mental health disorders such as anxiety, depression, and substance abuse. Early detection and treatment are key to recovery. If you or someone you know exhibits behaviors associated with these disorders, seeking professional help from a healthcare provider specializing in eating disorders is crucial.

Arches at Burning Tree Ranch in Kaufman, TX
These disorders encompass a range of severe and often life-threatening behaviors surrounding food intake, body weight, and body shape concerns.

Feeding & Eating Disorders in the DSM-5:

Anorexia Nervosa

Characterized by restricted food intake leading to significantly low body weight, an intense fear of gaining weight, and a distorted body image. Individuals with anorexia nervosa may excessively limit their calorie intake or engage in other behaviors to lose weight, such as excessive exercise.

What to look for: Dramatic weight loss, preoccupation with calories, dieting and thinness, avoidance of meals, and excessive exercise.

Bulimia Nervosa

Involves recurrent episodes of binge eating followed by compensatory behaviors to prevent weight gain, such as self-induced vomiting, misuse of laxatives, fasting, or excessive exercise. Individuals often feel a lack of control over their eating during binges.

What to look for: Evidence of binge eating, frequent trips to the bathroom after meals, signs of purging, and expressions of guilt or shame about eating.

Binge-Eating Disorder

Characterized by recurrent episodes of eating large quantities of food in a short period, a sense of lack of control during the episodes, eating until uncomfortably full, and eating large amounts when not physically hungry. Unlike bulimia, binge-eating disorder does not involve regular use of compensatory behaviors.

What to look for: Episodes of eating unusually large amounts of food, eating in secret, and feelings of distress, guilt, or embarrassment about eating.

Avoidant/Restrictive Food Intake Disorder (ARFID)

Unlike anorexia nervosa, ARFID does not involve distress about body shape or size or the pursuit of thinness. It is characterized by an apparent lack of interest in eating or food, avoidance based on the sensory characteristics of food, or concern about the aversive consequences of eating.

What to look for: Limited variety in diet, avoidance of certain textures or types of food, significant weight loss, or failure to achieve expected weight gain in children.


Involves eating non-nutritive, non-food substances over at least one month. The behavior is inappropriate for the developmental level of the individual.

What to look for: Consumption of paper, soap, cloth, hair, string, soil, chalk, metal, or pebbles.

Rumination Disorder

Characterized by repeated regurgitation of food, which may be re-chewed, re-swallowed, or spit out. This behavior occurs for at least one month and is not due to an associated gastrointestinal or medical condition.

What to look for: Frequent regurgitation of meals, which does not seem to be due to an aversion to food or a gastrointestinal issue.

Who is Affected? Dispelling Misconceptions About Eating Disorders

Feeding and eating disorders are often surrounded by misconceptions that can lead to stigma and hinder individuals from seeking help. 

Understanding these misconceptions is crucial for providing support and reducing the stigma surrounding feeding and eating disorders. Recognizing the wide range of individuals affected by these conditions emphasizes the importance of accessible and effective treatment options for everyone.

Misconception: Eating disorders only affect young, white females

Reality: Eating disorders do not discriminate by age, race, sex, or socioeconomic status. They can affect anyone, including men, women, children, adolescents, and older adults across all ethnic and racial groups. Studies have shown that eating disorders are increasingly recognized in boys and men, as well as in diverse racial and ethnic groups. The prevalence rates among different demographics indicate that societal pressures, genetic predispositions, and individual psychological factors contribute to the development of these disorders, making them complex and multifaceted conditions.

Misconception: Eating disorders are a choice or a lifestyle

Reality: Feeding and eating disorders are serious mental health conditions that the individual does not choose. They are complex disorders caused by genetic, biological, behavioral, psychological, and social factors. These disorders require professional medical, nutritional, and psychological treatment.

Misconception: People with eating disorders are easy to identify by their appearance

Reality: Individuals with feeding and eating disorders can have a variety of body types. Not all individuals with anorexia nervosa are underweight, nor are all individuals with bulimia nervosa or binge-eating disorder overweight. Many people with eating disorders have an average weight or are of normal appearance, making the disorder less visible but equally serious.

Misconception: Eating disorders are not severe and are merely a phase.

Reality: Eating disorders are among the deadliest mental health conditions, second only to opioid addiction. They can have severe physical and psychological consequences, including heart conditions, bone density loss, gastrointestinal issues, and an increased risk of suicide.

Misconception: Only affluent individuals suffer from eating disorders

Reality: Eating disorders affect individuals across all economic backgrounds. While specific cultural and societal pressures associated with affluence may contribute to the development of these disorders, they are also prevalent in middle and lower socioeconomic groups. Access to treatment and awareness of these conditions may vary by socioeconomic status, but the disorders are not limited to any economic group.

Two Horses Side-by-Side at Burning Tree Ranch
Feeding and eating disorders are often surrounded by misconceptions that can lead to stigma and hinder individuals from seeking help.

Unraveling the Ties: Substance Abuse and Its Impact on Eating Disorders

The prevalence of substance abuse among individuals with feeding or eating disorders is notably higher compared to the general population, with studies suggesting a range of co-occurrences. Specific prevalence rates can vary based on the type of eating disorder and the substance being abused. Still, research indicates that up to 50% of individuals with eating disorders may engage in substance abuse, a rate significantly higher than that seen in the general population.

Substances Commonly Abused:

  • Alcohol: Alcohol is frequently abused by individuals with eating disorders, particularly those with bulimia nervosa or binge-eating disorder, as it may serve as a means to cope with emotional distress or to facilitate binge eating.
  • Stimulants: Stimulants, including amphetamines and cocaine, are commonly abused by individuals seeking to suppress appetite and lose weight. This is especially prevalent among those with anorexia nervosa.
  • Laxatives and Diuretics: Although not traditionally considered under substance abuse, the misuse of laxatives and diuretics is common in individuals attempting to control weight or counteract the effects of binge eating.

Risks and Facts:

  • Dual Diagnosis: The co-occurrence of substance abuse and eating disorders complicates diagnosis and treatment, requiring a comprehensive approach that addresses both conditions simultaneously.
  • Health Consequences: Substance abuse can exacerbate the health complications associated with eating disorders, including electrolyte imbalances, cardiovascular issues, and cognitive impairments, increasing the risk of serious health outcomes.
  • Psychological Impact: Substance abuse can worsen the psychological symptoms of eating disorders, such as anxiety, depression, and body image disturbances, further entrenching both conditions.
  • Treatment Challenges: The dual diagnosis of an eating disorder and substance abuse disorder presents unique treatment challenges. These necessitating integrated treatment plans address both the psychological and physical aspects of these disorders.
  • Prevention and Early Intervention: Early detection and intervention are critical for individuals at risk of or currently experiencing co-occurring substance abuse and eating disorders. Tailored treatment strategies, including behavioral therapies, nutritional counseling, and, when appropriate, medication, are essential for recovery.

Understanding the complex relationship between substance abuse and feeding or eating disorders highlights the need for specialized, comprehensive care strategies. It underscores the importance of considering the holistic needs of individuals affected by these co-occurring conditions to facilitate effective treatment and recovery.

Prioritizing Care: Deciding Between Addiction and Eating Disorders

Determining whether addiction or a feeding and eating disorder should be treated as the primary condition depends on several factors, including the severity of each disorder, the risk they pose to the individual’s health, and the interplay between the two conditions. Here’s a general guideline for approaching treatment:

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Assess Severity and Immediate Risks

Evaluate which condition poses the most immediate risk to the individual’s physical health or safety. For example, if the eating disorder results in severe malnutrition or life-threatening medical complications, it may need to be stabilized first. Conversely, if substance abuse is leading to an immediate risk of overdose or severe health consequences, addressing the addiction may take precedence.

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Integrated Treatment Approach

Ideally, both conditions should be treated simultaneously whenever possible. Integrated treatment models that address both the addiction and the eating disorder can be more effective than treating one condition in isolation. This approach acknowledges the complex relationship between these disorders and aims to address the underlying issues contributing to both.

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Sequential Treatment

In some cases, a sequential treatment approach may be necessary, starting with the most acute or severe condition. However, even when one disorder is prioritized for initial treatment, the other condition should still be monitored and addressed as part of a comprehensive care plan.

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Personalized Treatment Plan

The decision on which condition to treat first should be made on a case-by-case basis, considering the individual’s specific circumstances, history, and needs. Collaboration among healthcare providers, including mental health professionals, addiction specialists, and nutritionists, is crucial for developing a personalized and effective treatment plan.

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Support and Monitoring

Regardless of which condition is treated first, ongoing support and monitoring are essential to address emerging issues or complications. Relapse prevention strategies should be incorporated for both the addiction and the eating disorder.

In summary, the decision on whether to treat addiction or a feeding and eating disorder as the primary condition is complex and should be guided by clinical judgment, individual assessment, and an integrated approach to treatment. The goal is to provide holistic care that addresses the multifaceted needs of the individual for the best possible outcomes.

Recommended Reading: 5 Books On Feeding and Eating Disorders

Each of these books contributes valuable insights into the nature of Eating and Feeding Disorders, offering hope, understanding, and paths toward healing for those affected.

"Eating Disorders: Journey to Recovery Workbook"

by Laura Goodman and Mona Villapiano

This workbook is designed for individuals recovering from eating disorders. It provides practical exercises and insights to help navigate the recovery process, authored by professionals with extensive experience in treating eating disorders.

"Skills-Based Learning for Caring for a Loved One with an Eating Disorder: The New Maudsley Method"

by Janet Treasure, Grainne Smith, and Anna Crane

This book is aimed at families and caregivers of those with eating disorders. It offers a compassionate and practical approach to supporting loved ones based on the renowned Maudsley method.

"Life Without Ed: How One Woman Declared Independence from Her Eating Disorder and How You Can Too"

by Jenni Schaefer with therapist Thom Rutledge

Jenni Schaefer shares her journey of recovery from an eating disorder, offering hope and strategies to others struggling with similar issues. The book includes insights from her therapist, Thom Rutledge, adding a professional perspective to her story.

"Eating in the Light of the Moon: How Women Can Transform Their Relationship with Food Through Myths, Metaphors, and Storytelling"

by Anita Johnston, Ph.D.

Dr. Anita Johnston uses myths and stories to address the psychological underpinnings of eating disorders and to help women explore their relationship with food and body image in a profound and transformative way.

"The Eating Disorder Sourcebook: A Comprehensive Guide to the Causes, Treatments, and Prevention of Eating Disorders"

by Carolyn Costin

Carolyn Costin, a renowned expert in the field of eating disorders, offers an in-depth look at the causes, treatment, and prevention of eating disorders in adults. Drawing from her extensive clinical experience and recovery from an eating disorder, Costin provides readers with practical advice, the latest research, and compassionate insights into overcoming these complex conditions. This book serves as a valuable resource for individuals struggling with eating disorders, as well as their families and therapists, offering hope and guidance for the journey to recovery.

The Importance of Early Intervention & Care

Final Words for Families Considering Long-Term Treatment

Addressing the intertwined challenges of substance abuse and eating disorders demands a nuanced, integrated treatment approach. Recognizing the substantial prevalence of substance abuse among those with eating disorders underscores the importance of early intervention and specialized care.

Tailoring treatment to the individual’s unique needs while considering the severity and impact of each condition is vital for fostering recovery and ensuring the best possible outcomes for those affected.