Assess for a hidden eating disorder

Treatment of co-occurring eating disorders and substance use disorders can present challenges that most addiction treatment programs are ill-equipped to handle. Often, persons with eating disorders experience shame, denial and/or ambivalence regarding treatment of their eating disorder. They may choose not to disclose their eating disorder, or they may not even be aware that they have one.

It is estimated that 7 to 17% of patients admitted for addiction treatment have a co-occurring eating disorder, yet only 44% of addiction treatment programs screen all admissions for eating disorders. The following case illustrates the challenges of working with this patient population.

Complexity of issues

“Sarah” is a 22-year-old woman who initially was treated in an inpatient psychiatric facility following a suicide attempt. She was hospitalized for nine days for stabilization and alcohol detox and then was transferred door-to-door to a residential facility for treatment of her mood and anxiety issues, borderline personality disorder, and alcohol use disorder.

Sarah began using alcohol at age 14, and at the time of admission she was drinking one to two bottles of wine or a pint of vodka at a time at least five days a week. She also reported some drug use, including marijuana, LSD and cocaine. She had been treated once before in a residential substance use treatment program, but left against medical advice after two weeks.

In addition, Sarah reported a constellation of psychological symptoms, including:

• Worsening symptoms of depression, lack of motivation, inability to concentrate, insomnia, and anhedonia;

• A previous diagnosis of bipolar disorder, though at the time of assessment the diagnosis was unclear;

• Having panic attacks once a week;

• Symptoms consistent with borderline personality disorder; and

• A history of rape at age 16, with additional reports of physical, sexual and emotional abuse by an ex-boyfriend.

During the course of her treatment, staff reported that Sarah would leave group early to use the restroom, and her roommate reported hearing Sarah purge in the bathroom. Staff did not find any vomit, and suspected she was purging in the shower and sink so that it could not be traced. When confronted, Sarah reported that she had been binge eating and purging one to two times a day, and up to five to 10 times a day in the past. She also reported purging eight times over the weekend while in treatment, and said she typically purged everything she ate. She then disclosed that her eating disorder had begun around age 12.

After Sarah was confronted about her eating disorder, staff began monitoring her bathroom use as well as her food intake, and Sarah made an effort to eat normally. At day 11 of treatment, she had gone two days without binge eating or purging and was transferred to an inpatient eating disorder treatment facility.

Screening options

Sarah showcases the problem with diagnosing and treating a comorbid substance abuse disorder and eating disorder. She had undergone no previous treatment of her eating disorder and did not disclose it when she was admitted to the psychiatric facility or to the addiction treatment facility. Non-disclosure of eating disorders is common, and there are multiple reasons why this occurs:

• Many individuals experience shame or embarrassment about their eating disorder behaviors and hide their behaviors from friends, family members and professionals;

• Some individuals may not realize they have an eating disorder or may be in denial about their eating disorder; and

• Some individuals may be interested in treatment for their substance use disorder or other mental health disorders, but do not feel ready or are ambivalent about addressing their eating disorder.

Regardless of the reasons why someone does not disclose an eating disorder, this can complicate treatment, as the eating disorder behaviors can worsen as the substance use stops. Recovery from substance use or other behavioral health disorders is unlikely when the eating disorder remains unaddressed. Therefore, it is important to screen all patients.

It is also important to remember that eating disorders occur in boys and men, in a wide age range of individuals, in various socioeconomic classes, and in different races. Males often go overlooked, but men account for an estimated 10 to 25% of individuals with eating disorders. Also, eating disorders can manifest at different weights.

A brief and validated screening tool, such as the SCOFF questionnaire, should be used for all patients on admission to an addiction treatment facility. These are the SCOFF questions:

• 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 pounds) 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?

As patients may get defensive or reluctant to disclose their eating disorder, it may be helpful to preface questions about eating disorder behavior by explaining that eating disorders commonly co-occur with substance use disorders and that it is important to address both in order to promote the person’s overall health.

While the SCOFF questionnaire has a high sensitivity, patients still may try to cover up an eating disorder, so staff should maintain high clinical suspicion during treatment.

Other ways to address eating disorders in an initial interview include asking about any previous eating disorder treatment when inquiring about previous behavioral health treatment programs. Also, when asking for a list of medications, ask about the use of laxatives, diuretics, or diet pills, which can be used as a way to lose weight.

Treatment considerations

If possible, treatment of a substance use disorder and eating disorder should occur concurrently. As this is not always possible, treatment decisions and referral considerations should be discussed with the treatment team, patient and family, including the options of concurrent treatment vs. subsequent treatment and what resources are available to the patient. The treatment of eating disorders in general involves a specialized multidisciplinary team that requires weighing the patient daily, meal planning, and bathroom monitoring that is not standard at most addiction treatment facilities.

Some patients can be treated on an outpatient basis, whereas others necessitate a higher level of care such as a partial hospitalization program, residential treatment, or inpatient level of care. Consulting with a trained eating disorder professional may help determine the appropriate level of care.

Amelia Davis, MD, is the Medical Director of Wickenburg, Ariz.-based Rosewood Centers for Eating Disorders, where she is directly involved in the psychiatric, medical and neurological evaluation of patients for a range of eating disorders and other conditions.