In co-occurring substance use and eating disorders, the relationship between the two is like a dance. The eating disorder (ED) might have come first, then the addiction swoops in and becomes more prominent. And then the addiction gets addressed the ED rears its head again. It’s an exhausting game of whack-a-mole where two disorders are working in concert to fill the same void – numbing pain and avoiding feelings.
Fifty percent of people with an ED will also abuse substances, which is a rate five times higher than the general population for addiction. When looking at the personality crossover between the two populations, the similarities become apparent. Overlaps in perfectionism, intolerance of feelings, anxiety, maladaptive coping skills, shame and trauma are all high in both disorders. Substances can also be used to serve the needs of an eating disorder by promising fast weight loss through stimulants, or offsetting caloric intake with drinking (often casually referred to as “drunkorexia”).
Another common thread is intense food cravings in the early days of sobriety. When people are heavily using, food often gets pushed to the wayside. Food isn’t the main priority for long periods of time and the body often becomes malnourished during addiction. When the body enters into recovery, sobriety hunger cues wake up. It starts to realize the malnourishment levels and naturally starts craving food. For some people, this is a short-lived phenomenon and their relationship with and thoughts about food will return to normal. For others, this food obsession can snowball into a full-blown eating disorder, even if there wasn’t one present prior to addiction.
The interesting divergence in this heavy overlap of disorders occurs in their treatment. While food can feel quite addicting and out of control, and may feel emotionally addicting, you cannot be biologically addicted to food. This may sound very odd and different from what we hear all the time about sugar addiction. Yet we have to remember that, with an eating disorder, you cannot withhold food or label foods as good and bad. An eating disorder brain works differently when it comes to rigidity with food. Anything hinting at restriction will backfire and delay recovery. You cannot live without food, thus eating disorder recovery cannot utilize abstinence in the way that is essential in substance recovery. This can be a giant reframe in thinking if you’re coming from an abstinence background with addiction. Instead of avoiding certain foods, in eating disorder recovery you have to do the exact opposite and face the foods that are causing distress on a regular basis.
For many individuals, their eating disorder is the issue that holds on the longest, long into sobriety. The ED is difficult to shake because it’s the last leg standing. It’s the coping tool that is still allowing you to check out and not fully face certain emotions. It’s still meeting a need. Because it can be so difficult to recover from the ED even after working incredibly hard with sobriety, it’s important to make sure you have all the support you need. Group therapy is unfortunately not nearly as available for eating disorders as it is for substances, and the community doesn’t have deep roots like 12 step programs. Additionally, eating disorder behaviors and weight loss are often praised in a way that we don’t see with addiction behaviors. Eating disorders can also be very severe without any “obvious” body signs, contrary to the popular belief that only deathly thin people are suffering with food. This means that many people often have to take it upon themselves to get help for ED and not wait for someone to step in.
We can all be more aware of these issues by normalizing how the body will react towards food in early sobriety, and being on alert if this snowballs into an eating disorder. We can be prepared to see our ED again if we had one prior to addiction, and set ourselves up for success with support groups and ED therapy. We can address both disorders at once in treatment, as this is the best predictor of non-relapse and reduces the frustrating whack-a-mole rollercoaster. And we can look out for each other when it comes to food behaviors and check in on our recovery friends.