Imagine holding an alcohol detox program in a bar. It would be pretty hard to resist the temptation to drink, right?
Unfortunately, that's the situation many people with eating disorders find themselves in when trying to lick a substance abuse problem. Surrounded by vending machines and encouraged to participate in meals that celebrate sobriety, these patients' recovery is often hindered by the availability of seemingly harmless treats that offer solace to other substance abusers.
There are more than 5 million Americans — mostly women — who suffer from eating disorders, such as bulimia, which is characterized by compulsive bingeing and purging. Of those, experts estimate about half also have a substance abuse problem. Although the link between the two is still unclear, some scientists believe there is a connection and that ignoring it makes it impossible for sufferers to recover.
"We know bulimics are more likely to have substance abuse issues than anorexics," Dr. Steven Hyman, director of the National Institutes of Mental Health, told physicians, nutritionists and substance abuse experts at a conference earlier this week at the National Center for Addiction and Substance Abuse at Columbia University in New York. "What we don't know well is the order, or what caused what. There are shared risk factors, but we need more information."
Hyman suspects the two may originate in the same area of the brain, saying, "Both are in part disorders of learning."
Karen Eklund, a recovering alcoholic and bulimic, understands the relationship between food and alcohol issues. Sober and abstinent from bulimia for more than 17 years, Eklund works as an in-patient counselor at the Betty Ford Center in Rancho Mirage, Calif. "If the eating disorder is severe, [the alcoholic] will never get sober," she says.
While she did eventually seek treatment for her alcoholism, her struggle with keeping down food remained a secret. After about a year of sobriety, however, Ecklund could no longer sustain her habit of throwing up 40 times a day and sought treatment for bulimia as well. She says she is grateful she survived, but worries that other women won't if experts — from both the eating disorder and substance abuse fields — don't become conscious that these two problems often co-exist and that they present unique treatment problems.
"Treating chemical dependency may be more straightforward, whereas eating disorders are much more ambiguous," says Dr. Karen Spedowfski, a psychologist at the Kaiser Permanente Chemical Dependency Recovery Program in Santa Clara, Calif. Substance abusers, she explains, know they have to abstain from drugs or alcohol in order to get better, "But with food it's much more tricky."
Because eating disorder patients will have to keep ingesting food for the rest of their lives, they have to learn new thinking and eating habits. "With eating disorders it's more of a gradual stepping away from symptoms," says Spedowfski. "It takes longer [than substance abuse problems]."
But as she has seen in some of her own patients with both problems, dealing with chemical dependency alone may leave the person vulnerable to his food problem: Celebratory meals recovering substance abusers often share in order to have "good, clean fun," can be tortuous for eating disorder patients.
In fact, according to outgoing CASA president, Joseph A. Califano, Jr. it's not unusual for non-eating disorder patients to turn to binge eating during substance abuse treatment and early recovery anyway, so counselors need to be especially aware of the prevalence of both problems.
"All women entering a substance abuse program should be screened for an eating disorder and vice versa," agrees Terence Williams, a professor of psychology at Rutgers University in Piscataway, New Jersey.
Still, Williams is not sold on the hypothesis that eating disorders and substance abuse are necessarily linked.
There are superficial similarities, such as craving and lack of control, he says, but it's dangerous to lump all eating disorders in one category, since there are major differences in the characteristics of anorexics, who starve themselves, compared to bulimics who binge eat. Additionally, because the treatment model for addiction focuses narrowly on the substance, a regular addiction treatment program will not help someone with an eating disorder deal with her body image and self-evaluation issues, Williams says.
The NIMH's Hyman admits the connection is "an unproven hypothesis," but believes that further gene research will lead to the link. In the meantime, he says, it's critical to raise awareness and intervention among counselors so that people seeking treatment get appropriate help. "We're not going to succeed by picking out a single target at a time," he said.