According to the National Center on Addiction and Substance Abuse, 50% of individuals with eating disorders have also abused alcohol or illicit drugs. Perhaps what’s even more surprising is what that statistic means: the rate of substance abuse in people with eating disorders is five times higher than in the general population. The numbers go both ways, as well: 35% of individuals with substance use issues have also had an eating disorder (eleven times higher than the general population). Let's look more closely at the relationship between eating disorders and alcohol substance abuse, specifically when it comes to alcohol.
Why do eating disorders and alcohol abuse so frequently go together?
"Many people with eating disorders naturally experience emotions with great intensity, prompting attempts to reduce the burden of those feelings. Food restriction and binge eating, two of the primary symptoms of eating disorders, often serve to regulate emotions, albeit temporarily," says Cara Bohon, PhD and VP of Clinical Programs at Equip. "We see the same thing in substance use disorders, where substances are used to self-medicate from particularly strong negative emotions. And these things work in the moment, but often lead to new emotions of guilt or shame or biological responses of hunger, fullness or chemical dependence and withdrawal. The new emotions then lead to more use of eating disorder behaviors or substance use, leading into a cycle that is difficult to stop without a supportive environment."
Writer and advocate Lindsey Hall is in recovery from an eating disorder and has publicly spoken out about the role alcohol played in her anorexia and bulimia. Hall says that people aren’t often aware of the overlap between eating disorders and substance abuse, but based on her own experience, the conditions can coincide for many reasons. “A lot of people worry about calories in alcohol and there are plenty of people deep in an eating disorder who don’t drink for that reason alone,” she says. “But I think there are a lot of us who struggle with anxiety or impulse control or self-destructive behaviors. So we drink to navigate the eating disorder by trying to silence its raging screams in our head that go on all day every day.”
Hall isn’t alone: research suggests that eating disorders and substance use disorders may frequently co-occur because they share some key risk factors. As one multicenter study found, individuals with eating disorders and alcohol use disorders reported more depressive and anxiety disorders, certain personality disorders, impulsivity, and perfectionism traits. And other research has shown that childhood trauma increases the odds of developing an eating disorder, as well as many other conditions, like alcohol use disorder or substance use disorder. In fact, people with both an eating disorder and substance abuse disorder have higher rates of childhood trauma and post traumatic stress disorder (PTSD) than those with an either disorder alone.
How substance abuse can become intertwined with the eating disorder
Substances and eating disorder behaviors serve a similar purpose, and at some point, these behaviors were effective. If you are feeling difficult emotions—guilt, sadness, frustration, worry—drinking, binging, vomiting, shoplifting, or having a tantrum will provide some instant relief. These are sometimes called “maladaptive” behaviors because while they work, in the long run, they create more problems than they solve.
If someone has found comfort in these maladaptive behaviors and it has worked as a tool to help manage emotions, there eventually comes a time when this “tool” becomes problematic and the person tries to stop. Unfortunately, even if someone stops drinking, they can’t stop hard emotions. And it may become even more difficult to experience hard emotions because the lack of practice. The easiest thing to do is to choose another maladaptive behavior. This becomes “whack-a-mole” like the old arcade game: when one mole goes down, another pops up. People start using substances when they are trying to stop bingeing and purging, or use eating disorder behaviors when they are trying to become sober. It is the definition of a vicious cycle.
Amy Baker Dennis, PhD, FAED, a clinical psychologist who specializes in eating disorders and is the author of Eating Disorders, Addictions and Substance Use Disorders: Research, Clinical and Treatment Perspectives, has explored the thorny relationship between eating disorder and substance use disorders and how they relate to the initiation or lack thereof of treatment.
“Substance abuse programs often do not admit patients with active ED,” she told EDCatalogue.com. “Likewise, ED programs frequently admit patients with over-the-counter (OTC) diet pill, laxative, or diuretic abuse but exclude patients abusing alcohol, benzodiazepines, cannabis, stimulants, or opiates.”
Many people struggling with both an ED and SUD are then bereft of treatment options or continuity of care, let alone choices that help treat their entire self.
“ED and SUD share several behavioral similarities,” wrote Dennis. “There’s a lot of symptom substitution. We find that individuals who are going through eating disorder treatment, once their eating symptoms subside, we often see the resurgence or the beginning of a substance abuse problem.”
How to address co-occurring eating disorders and alcohol abuse
For long-term recovery, eating disorders and substance use disorders (SUDs) need to be treated simultaneously. We know that for many patients, it can be tempting to get treatment for only one. People often choose to get treatment for their addiction, and are less ready to part with their eating disorder, which is reinforced by it being more culturally acceptable. Yet without treating both, people will recover from neither. If you are struggling in these ways, demand that you simultaneously get treatment for both your eating disorder and your substance use. And families: help your loved one to find treatment providers that recognize the two are inextricably linked. In treatment, you will learn skills that combat all your urges, so that in recovery you aren’t replacing drinking with eating disorder behaviors, nor replacing eating disorder behaviors with using substances. In recovery, you will be replacing all the behaviors that don’t serve you, with things that bring you closer to joy and the life that you want to live.
With the knowledge that eating disorders and substance use can be, and often are, interwoven, what can families, friends, and loved ones do to support those in their lives who may be in need of support around one or both complex issues? Being aware of therisk factors at play for both EDs and substance abuse — family history, low self-esteem, anxiety, and depression, to name a few — is one important prevention strategy. But if someone you love is already struggling with an eating disorder, substance use disorder, or both, comprehensive support and evidence-based treatment is key.
1. Killeen, Therese et al. “Exploring the relationship between eating disorder symptoms and substance use severity in women with comorbid PTSD and substance use disorders.” The American journal of drug and alcohol abuse vol. 41,6 (2015): 547-52. doi:10.3109/00952990.2015.1080263
3. Brewerton, T. D., & Brady, K. The role of stress, trauma, and PTSD in the etiology and treatment of eating disorders, addictions, and substance use disorders. In T. D. Brewerton & A. B. Dennis (Eds.), Eating disorders, addictions and substance use disorders: Research, clinical and treatment perspectives (pp. 379–404). Springer-Verlag Publishing/Springer Nature.