Running head: THE HUNGER DRUGS

Riker 1

The Hunger Drugs

Evaluating Treatment for Comorbid Eating Disorders and Substance Abuse
Giselle Riker
Wayne State University

Author Note
This paper was prepared for SW 3810 section 002, taught by Dr. Jessica Camp.

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Introduction to the Problem

More and more often, we are finding mental disorders rarely act alone and it is not
uncommon for an individual to display symptoms from several different diagnoses. These type
of co-occurring, or comorbid, disorders are becoming an increasingly challenging issue for
clinicians and clients alike. Within recent years, many research studies have found strong
evidence linking eating disorders (EDs) and substance use disorders (SUDs). In fact, studies
have found that up to 50% of clients with EDs will abuse alcohol or illicit substances (as cited in
Gregorowski et al p. 2). Being a young female in todays society, I personally understand the
pressures women face when it comes to maintaining the ideal body, a task that is next to
impossible for most of us. I know how frustrating and all-encompassing the weight loss process
can be, so it really makes sense as to why so many women are now turning to psychoactive drugs
to help them control their weight. I have also closely witnessed several of my loved ones struggle
with drug and alcohol addictions, and within these people, I have recognized self-destructive
mindsets and characteristics similar to those associated with EDs.
Various research has found that comorbid ED/SUD diagnoses have many negative
implications and risks including severe medical complications, longer recovery times, poorer
functional outcomes, more frequent and/or severe psychiatric comorbidity, higher rates of
suicide/suicide attempts and higher mortality rates (as cited in Gregorowski et al, 2013, p. 7). It
should also be noted that an individual does not have to have both a full-blown ED and fullblown SUD to be considered in this category. One of the biggest challenges associated with this
comorbidity is determining the correct form of treatment that effectively addresses both the ED
and SUD symptoms. The following articles describe different concurrent treatment interventions
designed for women struggling with aspects of both disorders.

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Intervention #1: Changing the Way We Talk

The first article that I reviewed focuses primarily on co-morbid bulimia nervosa and
substance abuse. Authors Carbaugh & Sias (2010) begin the article by discussing the shared
etiologies between bulimia and substance abuse, and then move on to explaining various
approaches to treatment for this population, namely cognitive behavioral therapy (CBT) with a
significant focus on coping skills training, and dialectical behavioral therapy (DBT) (p. 131).
CBT is widely used in mental health counseling for a variety of different issues and it is designed
to change the way the client thinks about themselves and the world (in this case changing
thoughts related to substance abuse or bulimia) so he or she can reach positive emotional and
behavioral change. Coping skills training is a common CBT technique that involves teaching
skills for the client to improve their functioning on a day-to-day basis. Specifically for comorbid
bulimia and substance abuse, coping skills training would include things like teaching effective
stress management techniques instead of turning to binging and purging or drug use when faced
with triggers and intense emotional states (Carbaugh & Sias, 2010, p. 131). DBT, which was
originally developed to treat borderline personality disorder, is useful because it works well with
the unique needs of the client and focuses on awareness of problems and choices, mood
regulation techniques, and coping skills (as cited in Carbaugh & Sias, 2010, p. 132). DBT
involves a series of different exercises and strategies that help the client change their
dysfunctional behaviors and put their newly learned skills into real life (Carbaugh & Sias, et al,
2010, p. 133).
Following the review of treatment options, a case study is then presented describing
Susan, a 20 year old white female and her experience with alcohol dependence, mild cocaine
abuse and bulimia and how these issues were treated. Following an arrest for her substance use

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issues, Susan was enrolled in an intensive outpatient program that included group counseling
three times a week, individual sessions every two weeks, and a psychoeducational group for
Susan and her family to attend weekly (p.135). However, during the second individual session,
Susan admitted to her counselor that she was binging and purging three times a week, so her
treatment was adjusted to address both of her needs. Susan used some very specific DBT
methods including diary cards to record the times she felt compelled to use, drink, binge, or
purge and discuss the emotions she felt at these times (p. 136). Through coping skills training,
Susan was able to identify high risk situations that would trigger her ED or SUD behaviors,
avoid negative self talk, practice new coping mechanisms, and increase her self esteem (p. 130).
Although she did relapse a few times, she was eventually able to obtain a full time job and move
out of her parents home. Susans personalized mix of treatments seemed to work well for her
own comorbid diagnoses, but because the results are limited to one person it is hard to determine
how well this treatment would translate to women with similar but more severe diagnoses.
Intervention 2: DBT- A Key Principle for Success
The second intervention published by Courbasson et al (2011) further addresses DBT as a
treatment modality for comorbid EDs and SUDs, but this time by testing a larger group of 21
female participants who had been consecutively referred for treatment of concurrent EDs and
SUDs (p. 437). The study randomly split the participants into two groups, 13 receiving DBT,
which consisted of a combination of mindfulness teaching, CBT skills training and treatment
strategies and continued emphasis on dialectics (p. 438) and the other 8 participants receiving
treatment as usual (TAU) which primarily consisted of motivational interviewing, CBT, and
relapse prevention strategies (p.438). The effectiveness of the two treatment methods was
evaluated every 3 months during the yearlong treatment and throughout the year following the

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termination of the treatment. These evaluations used interviews and questionnaires to measure
addiction severity, coping self-efficacy, frequency and number of binge eating/purging episodes,
cognitive vulnerability to ED, (p. 437) and mood regulation and depressive symptoms (p. 438)
amongst both groups. As originally hypothesized, DBT techniques were found to be more
effective and displayed better results than TAU clients, several of whom discontinued treatment
due to lack of effectiveness and in some cases, worsened symptoms (p. 440). Although this study
suggests that DBT is very effective in treating clients with comorbid EDs and SUDs, the weak
and eventually terminated TAU group should be noted because it did not really provide for a very
strong control group, therefore compromising the validity of these results. Even so, the DBT
group had positive effects, and once again it seems to be a vital technique when working with
this type of treatment.
Intervention #3: Body Positive Education and Social Support
The final article focuses on treating comorbid EDs and SUDS by implementing a
supplemental health and body image curriculum into existing substance abuse treatment
programs. Lindsay et al (2012) begin the article by discussing the increased rate of substance use
and abuse by women in the U.S. and how research points to weight loss being one of the main
reasons women begin using (p. 61). The authors suggest four treatment targets that should be
incorporated into substance abuse treatment programs in order to effectively address the issue:
decreasing thin-ideal internalization, decreasing body dissatisfaction, eating pathology (i.e.
eliminate eating disorder symptoms), and increasing global health knowledge and behavior
(p.63). Healthy Steps to Freedom (HSF) is one of the first interventions of this kind and it
consists of twelve 90 minute weekly sessions that include education and discussion about the
following topics: substance abuse and womens health, body image and self esteem, physical

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activity, weight and body composition, basic nutrition, calories and metabolism, eating behaviors
and disordered eating, and cognitive distortions related to weight or appearance (p. 63). This
particular article set out to evaluate the effectiveness of HSF by measuring how well the program
met the four target treatments. A total of 257 female participants were involved in this study and
data about their progress was collected through researcher collected measures and self-report
questionnaires. (p. 64). As the authors had originally hypothesized, results were positive and
suggested that many participants have adopted more healthful attitudes toward their appearance,
weight, and extreme weight control behaviors (p.66) after completing HSF. The program seems
to do well in addressing disordered eating and weight issues in female substance abusers, but as
of this point it is not quite suitable for women with severe, diagnosable EDs. However, the social
support aspect of HSF that comes from the group therapy sessions is definitely an important
factor to emulate in all comorbid ED and SUD treatments, and with further research and
adjustments, many more programs like HSF should be able to be widely implemented across the
existing treatment programs for this population.
My Own Design
All of these interventions were successful in accomplishing the goals they were designed
to achieve, so it is a challenge to pick the one I believe would work best. If I were to design my
own intervention for women with comorbid EDs and SUDs, I think I would attempt to follow a
model similar to that of Susans in article one, but I would also change some things and try to
incorporate elements discussed in the other two articles. My main goal would be to make sure
the treatment plans are as personalized as possible in order to ensure maximum success for each
individual client, and ensuring each client feels a strong level of social support in their recovery
process. Therefore, group counseling would account for a significant portion of treatment. Group

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sessions would include methods to motivate behavioral change, DBT (particularly the group
discussion of individual diary cards) as well as educational pieces similar to those utilized in
HSF in order to promote healthy eating and body image as well as techniques to adapt to a drug
free life. Individual counseling sessions would also be frequent and include quite a bit of CBT,
coping skills training and more DBT. I would prefer my clients to attend an intensive outpatient
program (especially if they already live in a safe and supportive home environment) so they feel
less removed from everyday society during their treatment. However, if a clients diagnosis is
severe enough and has required hospitalization on more than one occasion, I would refer him/her
to receive similar treatment but in a residential program setting.
Conclusion and How Evidence Based Practice Got Me Here
Evidence based practice allowed me to gain a much clearer understanding of why EDs
and SUDs often coexist and how specific treatments work to change these problematic
cognitions and behaviors. One of the biggest shortcomings of evidence based practice with this
type of population is the presence of gender disparity. I did not once see an article that even
mentioned men having this type of comorbidity, which could largely be due to a lack of research
in general, as well as the stereotypical association between women and eating disorders. Another
difficulty with evidence based practice with this population is that it can be hard to pinpoint
exactly what kind of intervention will work for your particular client because there are many
different types of EDs and SUDs with varying effects and symptoms, and many of these pairings
currently do not have any research available. Once more research is done on this population of
growing interest, the evidence based practice process will become much easier and as a result
treatment approaches will improve and become more comprehensive so more and more clients
will be able to eliminate their harmful ED behaviors and substance use once and for all.

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References

Carbaugh, R. J., & Sias, S. M. (2010, April). Comorbidity of Bulimia Nervosa and Substance Abuse:
Etiologies, Treatment Issues, and Treatment Approaches. Journal of Mental Health
Counseling, 32(2), 125-138. Retrieved from

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6534844a0c91f5de

Courbasson, C., Nishikawa, Y., & Dixon, L. (2012). Outcome of Dialectical Behaviour Therapy
for Concurrent Eating and Substance Use Disorders. Clinical Psychology &
Psychotherapy, 19(5), 434-449. doi:10.1002/cpp.748
Gregorowski, C., Seedat, S., & Jordaan, G. P. (2013). A clinical approach to the assessment and
management of co-morbid eating disorders and substance use disorders. BMC Psychiatry, 13,
289. Retrieved from http://go.galegroup.com.proxy.lib.wayne.edu/ps/i.do?id=GALE
%7CA349003667&v=2.1&u=lom_waynesu&it=r&p=HRCA&sw=w&asid=fcc25b12442949
66e2381a86ce5e59f9

Lindsay, A. R., Warren, C. S., Velasquez, S. C., & Lu, M. (2012). A gender-specific approach to
improving substance abuse treatment for women: The Healthy Steps to Freedom
program. Journal of Substance Abuse Treatment, 43(1), 61-69.
doi:http://dx.doi.org/10.1016/j.jsat.2011.10.027