Eating Disorders & Substance Use: Treating Both Together

Written by: Jessica Hansford LPC, CAAD
Site Director, The Renfrew Center of Radnor, PA

Over the last year and a half, the world has been under a new level of stress due to COVID-19 and there has been a significant increase in needed support for a variety of mental health issues.

Both substance use disorders and eating disorders have been areas of great concern for a number of Americans. While these may seem like separate areas of struggle, it is important to note that these disorders frequently occur together.

In fact, according to the National Eating Disorders Association (NEDA), up to 50% of individuals with eating disorders abused alcohol or illicit drugs, which is 5 times higher than the regular population. In addition, research shows that people who suffer from substance use disorders are ten times more likely to have an eating disorder than the general population.

Why Eating Disorders & Substance Use Can Overlap

The presence of both a substance use disorder and eating disorder symptoms is known as a co-occurring disorder (more than one mental health diagnosis occurring at the same time).

There are often overlapping risk factors such as genetics, changes in the brain’s reward system and personality traits such as achievement expectations, difficulty with emotional regulation, history of trauma, or environmental/social pressures. Sometimes eating disorders and substance use disorders appear at the same time, serving as a coping method for stressful emotional situations.

In other cases, substance use disorders can occur during or after recovery from an eating disorder as a person sets down one coping skill for another, a phenomenon known in the therapeutic community as symptom substitution. This can lead to a dangerous and frustrating process of “whack-a-mole” treatment – effectively addressing substance use symptoms only to see an increase in eating disorder behaviors and vice versa.

Due to this documented struggle, it is important for those facing an overlap of these two concerns to be aware of the best practices for treatment.

Best Practices for Co-Morbid Treatment

  1. Assess the Safety of the Individual
    The physical safety of the individual needs to be prioritized and assessed first to determine the most appropriate treatment plan. It is essential to assess whether supportive medical care or hospitalization is indicated due to the disordered eating behaviors or substance use.For example, it is possible that the individual may require a medical detoxification program with ongoing monitoring to safely and comfortably withdrawal from certain substances, such as alcohol or benzodiazepines. This type of assessment might occur by a medical or mental health professional during an initial intake screening or a bio-psycho-social assessment. The assessor would inquire about the types and quantity of substances used, length of usage, age, gender, and medical history. Medical labs and an EKG and are generally recommended, as well.

    When assessing the severity of disordered eating, immediate medical intervention and monitoring might be needed if someone is purging multiple times a day, severely restricting fluids, at a very low weight and/or experiencing physical symptoms such as fainting, dizziness upon standing, or low heart rate.

  1. Evaluate Treatment Needs
    Once a screening has been done to determine if immediate medical intervention is necessary, the next step is to appropriately match the recommended level of treatment to the individual’s needs.When diagnosing a substance use or eating disorder and determining the best therapeutic intervention, the clinician will evaluate the level of distress, frequency and duration of symptoms and any risk to the individual or others.

    Treatment for these disorders range from outpatient therapy to residential or more medically based inpatient care. While the importance of not undertreating a person’s needs may be widely accepted, research shows it is also critical not to overtreat; therefore, it is important to seek out an evidence-based therapeutic assessment to ensure the care provided best meets the identified needs.

  1. Determine If Concurrent Treatment is Necessary
    One of the most important elements to consider when addressing substance use and eating disorders is the need for concurrent treatment.Effective co-occurring programs have an appreciation for potential risk of relapse and the need for a potentially longer and a more comprehensive treatment approach. The interaction between substance use disorders and eating disorders is complex and individualized. Substances may be used or abused to cope with the eating disorder, such as using substances to increase appetite. Alternatively, substances may be used in service of the eating disorder such as using substances to purge, decrease appetite or escape thoughts and feelings.
  1. Decide on a Treatment Track
    A person’s choice of substances is often connected to the distressing emotional state they are trying to manage. This can lead to a cycle that is difficult to break. The eating disorder symptoms can lead to an increase in substance use which can potentially result in the ongoing worsening of both diagnoses.Best practice intervention includes treatment with cross-trained staff and integrated supportive care. Beyond the interruption of symptoms, these programs need to address underlying issues such as trauma, anxiety/depression, relational/interpersonal factors, developmental factors, and neurobiological factors. A quality co-occurring treatment program will work to increase understanding of the connection between substance use, eating disorder behaviors and current functioning/quality of life.

    Addressing this complicated collection of symptoms will require work to enhance motivation to change, develop the capacity to tolerate emotions, encourage the development of healthy relationships, and strengthen relapse prevention skills.


Support, hope and healing are possible. If you or someone you know is considering seeking treatment for both substance use and eating disorder behavior concerns, look for a co-occurring reputable and qualified professional or program to identify any required medical intervention and to help recommend the correct level of care needed.

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