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How to Recognize Eating Disorders In the Substance Use Disorder Population
Presented by Robyn Cruze and Linda Lewaniak, LCSW, CAADC
November 14, 2018
Thomas Durham, PhD
Director of Training
NAADAC, the Association for Addiction Professionals
www.naadac.org
Produced ByNAADAC, the Association for Addiction Professionals
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www.naadac.org/eating-disorder-and-SUD-webinar
Cost to Watch:Free
CE Hours Available:1.5 CEs
CE Certificate for NAADAC Members:Free
CE Certificate for Non-members:$20
To obtain a CE Certificate for the time you spent watching this webinar:
1. Watch and listen to this entire webinar.
2. Pass the online CE quiz, which is posted at
www.naadac.org/eating-disorder-and-SUD-webinar
3. If applicable, submit payment for CE certificate or join NAADAC.
4. A CE certificate will be emailed to you within 21 days of submitting the quiz.
CE Certificate
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� Control Panel
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Robyn [email protected]
Linda Lewaniak, [email protected]
Webinar Presenters
YourEating Recovery Center
Webinar Learning Objectives
Recognize the similarities and differences between substance use disorders and eating disorders.
Differentiate between eating disorder behaviors and substance use behaviors.
Identify how the brain is affected by substance use.
1 32
“This desire to ‘switch the witch for the bitch’ was always there. Just because I was making inroads to recovery didn’t
mean I didn’t have a deep desire to numb my feelings. Drinking alcohol often took the place of my disordered
eating in times when my food was ‘under control.’ It became the thing I used to numb myself so as not to feel my
emotions. So I had to say no to that, too.”
Making Peace with Your Plate (p.29)
─ Up to 30 million people of all ages and genders suffer from an eating disorder within the USA.
─ Between 30 and 50 percent of individuals with bulimia and 12-18 percent of those with anorexia abuse or are dependent on alcohol/drugs, compared to approximately nine percent in the general population.
─ Up to 35 percent of individuals who abuse or are dependent on alcohol/drugs also have an eating disorder, compared to up to three percent in the general population.
Co-Occurring Stats
─ People who suffer from substance abuse are 10 times more likely to have an eating disorder than the general population.
─ OSFED (but not AN or BN) was significantly more common in people with SUD than without SUD
─ Eating Disorders have the highest mortality rate out of any mental illness
─ AN and SUD comorbidity have a higher suicide rate.
Co-Occurring Stats (Cont’d)
• Lifetime rates of substance use disorder in the various eating disorder subgroups are as follows:
AN, 27.0%
BN, 36.8%
BED 35%
• AN women are 19 times more likely to die from SUD
• Approximately 57% of males with BED will experience SUD
• Individuals who undergo bariatric surgery are at risk for developing SUD
Co-Occurring Stats (Cont’d)
Anorexia Nervosa: Characterized by self-starvation, and excessive weight loss. AN is divided into to diagnostic categories, restrictive anorexia and binge/purge anorexia.
Bulimia Nervosa: Characterized by a cycle of bingeing and compensatory behaviors, such as self-induced vomiting, laxative abuse or exercising, designed to compensate for the effects of binge eating.
Binge Eating Disorder: Characterized by recurrent binge eating without the regular use of compensatory measures to counter the binge eating.
Other Specified Feeding or Eating Disorder (OSFED): Refers to abnormal eating or feeding without all the symptoms needed to be diagnosed with anorexia, bulimia or binge eating disorder.
Eating Disorder Diagnoses
Eating Disorder Treatment Disparity
2913
1400
224
Accute Beds / One MillionUS Residents
Psych Beds / One MillionPsych Population
E.D. Beds / One MillionE.D. Population
Only 224 eating disorder beds available for every one million people
Source: US Census Bureau, American Hospital Association, Wall Street research, as of 2014
1,400 psychiatric beds available for every one million people diagnosed with a psychiatric disorder.
2,913 acute care hospital beds for every one million U.S. residents.
Co-occurring population tends to be characterized by:
Harm avoidance:• Self-consciousness and hypersensitivity
• Result: anxiety management
Self-directedness:• Strong feelings of insecurity, inadequacy, fragile ego
• Result: uncertainty, disconnect with values
Novelty seeking:• Higher among SUD population; seen with BN
• Result: boredom, quick with emotions
Underlying Personality Characteristics
Similarities:• Increase in behaviors needed for
some effect to remove from current reality.
• Behaviors used to regulate emotions
• Coping does not involve social supports
• Avoidant behaviors that perpetuate and intensify negative emotions (isolation)
Differences:• Stigma• Addiction to the product vs. the
process• Physiological addiction vs.
psychological learned behavior• Relationship with triggers• Can avoid drugs/cannot avoid food• Food is a part of culture, family,
and social relationships
Substance Use and Eating Disorders: Comparison of Experience
www.drugabuse.gov
Drug Addiction is a Complex Illness
Dopamine - produces pleasure through the “reward system”; multiple functions including controlling movement, regulates hormonal responses, important to cognition and emotion.
Serotonin - plays a role in sleep; involved in sensory perception; and involved in controlling emotional states such as anxiety and depression.
Dopamine
• Exercise
• Food
• Sex
• Excitement
• Comfort
Natural Rewards
Dopamine Pathways
Nucleus accumbens
AmphetaminesOpiatesTHCPCPKetamineNicotine
Alcohol benzodiazepines barbiturates
VTA
Natural Rewards Elevate Dopamine Levels
Di Chiara et al., Neuroscience, 1999.,Fiorino and Phillips, J. Neuroscience, 1997.
0
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% o
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Food Sex
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n (%
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SampleNumber
1 2 3 4 5 6 7 8
Female Present
Effects of Drugs on Dopamine Release
0100200300400500600700800900
10001100
0 1 2 3 4 5 hr
% o
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elea
seDADOPACHVA
AccumbensAmphetamine
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% o
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AccumbensCocaine
Time After Drug
Morphine
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% o
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Di Chiara and Imperato, PNAS, 1988
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se0
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Accumbens
0.51.02.510
Dose mg/kgmg/kg
mg/kgmg/kg
Scientific research has shown that other neurotransmitter systems are also affected:
SerotoninRegulates mood, sleep, etc.
GlutamateRegulates learning and memory, etc.
But Dopamine is only Part of the Story
Addictive Properties
Nicotine .35
Heroin .27
Crack/cocaine .26
Cannabis .09
Alcohol .08
MP Induced Changes in [11C]Raclopride (DA Marker) in Marijuana Abusers and Negative Emotionality
Volkow et al., PNAS 2014
Reduced DA reactivity in VS in Marijuana abusers is associated with negative emotionality (NEM)
Marijuana Abusers (N=24) PL > MP
Healthy Controls (N=24) PL > MP
Alcohol Damages the Cerebellum
Image from Susan Tapert, PhD, University of California, San Diego
“…that it is important for clinicians to consider and screen for subthreshold levels of Eating Disorders in addition to formal Eating Disorder diagnoses. Moreover, assessment of co–occurring subthreshold eating problems may facilitate earlier
intervention to prevent later development of the full–blown disorder.”
http://pubs.niaaa.nih.gov/publications/arh26-2/151-160.htm#.VA4QNdegjcs.email
Studies Suggest:
• Many patients who suffer from substance abuse exhibit eating disorder behaviors that can often remain undetected by his or her treatment team.
• Initially substance abuse may mask eating disorder behaviors, or be utilized as part of the eating disorder pattern.
• As individuals with addictions and/or compulsive tendencies enter into abstinence, they may reach toward other numbing mechanisms such as eating disorder behaviors to help them cope with the emotions that re-emerge.
Eating Disorders can Hide Behind Substance Abuse
Behaviors that May Indicate an Eating Disorder in SUD Population
• Consistently leaving the table within ten minutes after eating a meal
• Stirring or playing with food rather than eating
• Skipping meals consistently
• Skipping a meal then over-eating at another meal
• Consistently tired or fatigued
• Consistently setting and communicating goals around getting physically “healthy”
• Exercising despite physical injuries
• Exercising more than 1.5 hours a day more than 4-5 days a week
• Restricting foods or food groups • Talking about particular foods as “good” or
“bad”• Expressing concerns about being or
becoming fat• Gaining weight in treatment• Inordinate amounts of conversation about
food, weight, the body, and calorie intake • Rigid eating patterns
• Use it as a gentle red flag
• Do not assume client has an eating disorder
• Do a 24-hout food recall
• Keep personal opinions about food and body to yourself
If a Client Displays/Reports Eating Disorder Behavior in SUD Population
DO:• What do you think about your
body?• Do you diet or attempt to lose
weight in other ways?• Do worries about eating or your
body affect your day to day life?• Do you ever try to make up for
or “spend” calories after eating to keep from gaining weight?
• Do you ever feel out of control when eating or eating for reasons other than being physically hungry?
DON’T:• You don’t look like you have an
eating disorder• I could stand to lose some
weight myself• You look good• You look healthy• Just eat healthier foods• You don’t look fat• You are too skinny
What to Say and What Not to Say
The SCOFF has been validated in primary care practices and is a good tool given the short time it takes and ease of application.
• Do you make yourself Sick because you feel uncomfortably full?
• Do you worry that you have lost Control over how much you eat?
• Have you recently lost more than One stone (14 lb) in a 3-month period?
• Do you believe yourself to be Fat when others say you are too thin?
• Would you say that Food dominates your life?
Screening: SCOFF Questionnaire
• Patients suffering from substance abuse and eating disorders may benefit from completing treatment for each condition in immediate succession or simultaneously.
• As a substance abuse treatment professional, if you observe any of the behaviors, consult an eating disorders treatment professional to assess the patient.
• Consult an eating disorders treatment professional to determine the best course of action that complements the patient’s substance abuse treatment plan.
• A comprehensive treatment plan that encompasses both conditions helps patients achieve greater long-term recovery.
How Do We Treat an Eating Disorder?
• Sequential treatment - Focuses on the most acute disorder first treatment is delivered by different providers in different locations
• Parallel treatment - Both disorders addressed at the same time but with different providers or different locations
• Currently no evidence-based integrated treatment for treating co-occurring substance abuse and eating disorders
Current Treatment Approaches
• Reduced substance use
• Improvement in psychiatric symptoms and functioning;
• Decreased hospitalization
• Increased coping skill
• Range for housing, taking meds as prescribed , to getting a job
• Increased job performance
• Improved quality of life
Integrated Treatment is AssociatedWith the Following Positive Outcomes:
• Hope is critical
• Services and treatment goals are consumer-driven
• Unconditional respect and compassion for consumers is essential
• Integrated treatment specialists are responsible for engaging consumers and supporting their recovery
Integrated Treatment Recovery Model
Comprehensive screening for both eating disorders and substance abuse
• Co-occurring psychiatric disorders
• Medical conditions and lab test
• Comprehensive drug testing
• Understanding the independent and combined medical complications of these disorders is crucial in treatment planning and implementation, as evidenced by their prominence in guidelines from the American Psychiatric Association (Yager et al., 2006), the American Society of Addiction Medicine (Mee-Lee & Schulman, 2001), and the National Institute of Clinical Excellence, (2004)
Comprehensive individual treatment plan that encompass both eating disorders and substance abuse
Working definition on Integrative Treatment Approach: Ed and SUD
Source: Chapter 21 integrated treatment principle strategies for patients with eating disorder substance abuse and addictions - Dennis, Pryor, Brewerton
Evidence-based treatment teams that are trained in evidence-based treatments:
• Motivational interviewing • Motivating people to reduce their substance use (i.e., harm
reduction versus abstinence)• Stages of change treatment interventions
• Acceptance and Commitment Therapy
Behavioral Models and Focus on Recovery Path
Source: Chapter 21 integrated treatment principle strategies for patients with eating disorder substance abuse and addictions - Dennis, Pryor, Brewerton
Dialectical Behavior Therapy
• Mindfulness
• Radically Open-Dialectical Behavior Therapy
• Behavioral Activation
Exposure and Response Prevention
Cognitive Behavioral therapy
Behavioral Models and Focus on Recovery Path
1. Eating disorders, substance abuse, and addictions are complex but treatable conditions that affect brain functioning and behavior
2. No single treatment is appropriate for individuals
3. Treatment needs to be readily available• Individuals with eating disorder and substance abuse are often
reluctant to seek treatment and prevention is important
4. Effective treatment tends to multiple needs of the individual not just the eating disorder or substance use disorder
Guidelines for effective treatment -NIDA (Adapted with eating disorder)
Source: Chapter 21 integrated treatment principle strategies for patients with eating disorder substance abuse and addictions - Dennis, Pryor, Brewerton
5. Remaining in treatment for an adequate period of time is crucial for treatment effectiveness.
6. Counseling individual, family, group nutritional, and other behavior therapies are critical components of effective treatment for both disorders.Family support and intervention
7. Medications are important element of treatment for many patients especially when combined with counseling and other behavioral therapies.This is where relapse prevention medicine is very critical
8. An individual's treatment and service plan must be assessed continually and modified as necessary to ensure that the plan meets the person's changing needs.
Guidelines for effective treatment - NIDA (Adapted with eating disorder)
Source: Chapter 21 integrated treatment principle strategies for patients with eating disorder substance abuse and addictions- Dennis, Pryor, Brewerton
9. Medical detoxification is the first stage of addiction treatment and it by itself does not change long-term drug use, likewise weight restoration, the normalization of eating patterns and the elimination of compensatory behavior is the only first stage of recovery from ED.
10. Treatment does not need to be voluntary to be effective
11. ED–related behaviors and drug use during treatment must be monitored continuously.
12. Patient should be tested for the presence of HIV/AIDS, hepatitis B and C, tuberculosis, and other infectious diseases and targeted risk – reduction counseling should be provided counseling should be provided.
Guidelines for effective treatment –NIDA (Adapted with eating disorder)
Source: Chapter 21 integrated treatment principle strategies for patients with eating disorder substance abuse and addictions- Dennis, Pryor, Brewerton
Why we have implemented the four following modules for treatment:
• Progression of addiction
• Addiction and compulsive behaviors
• Cross tolerance and post-acute withdrawal and other related illnesses
• Impact of substance abuse and mental health in the body
• What is recovery
What is substance use disorder?
• Stages of change
• My values
• Defusion versus fusion
• Grief and substance abuse
• Value-based living
• Recovery skills
Mindfulness-Based Sobriety
• Relapse prevention one
• What is social support, i.e., 12-step
• Relapse inventory
• Relapse prevention two
• Relapse prevention planning
• Medication assisted treatment
Relapse Prevention
• What is codependency
• Boundaries
• Healthy communication
• Family roles and rules
• Embracing vulnerability (shame/guilt and anger/resentment)
• Spirituality
Codependency
www.naadac.org/eating-disorder-and-SUD-webinar
Cost to Watch:Free
CE Hours Available:1.5 CEs
CE Certificate for NAADAC Members:Free
CE Certificate for Non-members:$20
To obtain a CE Certificate for the time you spent watching this webinar:
1. Watch and listen to this entire webinar.
2. Pass the online CE quiz, which is posted at
www.naadac.org/eating-disorder-and-SUD-webinar
3. If applicable, submit payment for CE certificate or join NAADAC.
4. A CE certificate will be emailed to you within 21 days of submitting the quiz.
CE Certificate
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