Managing Eating Disorders and Addiction: A Case Study

Will My Insurance Pay for Rehab?

Sponsored Legal Stuff - This is an advertisement for Service Industries, Inc., part of a network of commonly owned substance abuse treatment service providers. Responding to this ad will connect you to one of Service Industries, Inc.’s representatives to discuss your insurance benefits and options for obtaining treatment at one of its affiliated facilities only. Service Industries, Inc. Service Industries, Inc. is unable to discuss the insurance benefits or options that may be available at any unaffiliated treatment center or business. If this advertisement appears on the same web page as a review of any particular treatment center or business, the contact information (including phone number) for that particular treatment center or business may be found at the bottom of the review.

Managing Eating Disorders and Addiction: A Case Study

By Amelia Davis MD 06/30/16

Interdisciplinary care for a young woman dually-diagnosed with addictive and eating disorders.

Image: 
Managing Eating Disorders and Addiction: A Case Study
Many treatment facilities can't treat both eating disorders and addiction.

Many clients suffering from eating disorders present with concomitant addictive disorders as well, and the reverse is also true. As these are both disorders of impulse control, mood dysfunction and self-esteem, there are obvious benefits to working on both simultaneously, but this is typically not the approach taken. And there are advantages to treating both disorders in a controlled environment. Here, Amelia Davis, MD, describes a case in which a young woman with a significant history of problems in both realms received care for both, highlighting the benefits of an integrated and comprehensive approach to the treatment of the dually-diagnosed…Richard Juman, PsyD

My experience evaluating and treating the psychiatric conditions of patients with eating disorders has taught me that people suffering from anorexia, bulimia and binge eating disorder often suffer from more than one clinical disorder, whether anxiety, depression, PTSD or, commonly, substance use disorders.

Unfortunately, many treatment facilities—those that treat eating disorders and those focused on addiction treatment—are ill-equipped to handle the co-occurring eating disorder/substance use disorder patient, as that person’s treatment often requires a highly specialized, multidisciplinary team, trained in the treatment of both disorders.  

Recognizing the overlap of a patient’s eating disorder and substance use disorder is critical to developing an individualized recovery model that addresses both conditions simultaneously, which may include weight restoration and detox occurring in tandem. 

As the following case study illustrates, treating patients with co-occurring eating disorders and substance use disorders is challenging and requires multiple modalities, but addressing them together gives the patient a better chance at preventing relapse of either disorder. 

Jennifer: At Presentation  

“Jennifer” was a 30-year-old Caucasian female I initially met when she was transferred to the Rosewood Centers for Eating Disorders’ inpatient eating disorder treatment program from another facility where she was receiving treatment for an eating disorder and other mental health conditions.  

When she initially presented to treatment, she was exhibiting signs and symptoms of mania, which included hyperverbal speech, flight of ideas, mood lability, psychomotor agitation and room pacing. Additionally, she made threatening remarks to staff when she was told she would not receive Adderall. Since she was difficult to redirect, her initial psychiatric evaluation was challenging. 

During the first 48 hours of admission at Rosewood, Jennifer repeatedly asked to receive Adderall, stating that doctors at the previous facility had diagnosed her with bipolar disorder. However, she didn’t believe she had bipolar disorder, but insisted the Adderall was needed to treat her ADHD. 

Records from the previous treatment facility noted a history of manic symptoms and demanding stimulant medications. The facility had initially discontinued stimulants, but later she was given Adderall, as she was taking the medication prior to admission. 

A History of Dieting and Drug Abuse

As Jennifer worked through treatment, her parallel histories of addiction—to prescription, illicit and over-the-counter drugs—and dieting, which ultimately lead to bulimia nervosa, became clear. 

At age 18, she reported being obese (weighing 220 pounds, height 5'4" and a BMI of 37.8) and began dieting. At this time she took Ephedra, a diet pill that is chemically similar to amphetamines and methamphetamines that was banned from the U.S. in 2004.

When she could no longer obtain Ephedra, Jennifer began purging by self-induced vomiting at around age 19, and continued purging daily for six years. During this time period, she reported losing 80 pounds and continued to lose weight, dipping as low as 105 pounds two years prior to admission. Through interviews, she denied binge eating, but said she was addicted to sugar and was vegetarian.

In terms of her substance use history, Jennifer reported her cocaine use started at age 20, and she smoked crack cocaine daily starting at age 27. She also reported using marijuana, LSD and mushrooms in the past. She had also been taking benzodiazepines for many years as treatment for anxiety, and took multiple different psychotropic medications, including Depakote, Seroquel, Ambien, Remeron, Effexor and Clonazepam. All told, she had been hospitalized seven times in the past six years for psychiatric reasons.

The patient initially told staff she was diagnosed with ADHD at age 15, but collateral information revealed she was not diagnosed with ADHD until after age 22. Additionally, family members said she had not shown symptoms of ADHD growing up and that she had previously done well in school, receiving straight As.

Jennifer’s case is interesting not only because of the complexity and the difficulty in treating her, but also because of the interplay between the eating disorder and substance use disorder. She began taking Ephedra diet pills, which are similar chemically to amphetamines, later started using cocaine daily, and was able to have a provider prescribe her stimulants for treatment of ADHD.  

While one may think she began using cocaine for weight loss, per the patient, she ended up gaining weight on cocaine. In addition, her reaction to not receiving Adderall was similar to someone with a severe substance use disorder in withdrawal—engaging in whatever behavior they can to try to obtain their drug of choice.  

Individuals with some eating disorders and substance use disorders have increased rates of impulsivity, low self-esteem, history of abuse, family history of addiction or eating disorder, depression and anxiety. Jennifer was very impulsive, reported low self-esteem and sexual molestation as a child. Since she was adopted, she did not know if she had a family history of substance use disorders or eating disorders. 

Developing Individualized Treatment

Recognizing the overlap of Jennifer’s eating disorder and substance use disorder, and the role of amphetamines in each, influenced the treatment team’s approach, which included using a direct yet caring manner and an emphasis on building rapport and trust.  

Adderall was discontinued on admission and she was started on clonazepam, which was gradually tapered to wean her off of the benzodiazepines she was taking prior to admission and to treat her acute agitation. She was also weaned off Effexor as this, and the Adderall, were thought to be inducing her manic symptoms.  

Her manic symptoms resolved within the first several days, yet she remained fixated on restarting Adderall and continued to appear impulsive, labile and talkative, though improved from admission.  

The treatment team also worked closely with her family—including an intensive family therapy week—to help encourage Jennifer to remain in treatment. When speaking with her parents, they initially stated that Jennifer was unable to focus without Adderall, but the treatment team asserted their belief that she did not have ADHD and rather had a substance use disorder involving cocaine and amphetamines in addition to her eating disorder.  

Accepting Treatment for Both Disorders

After building rapport and trust with Jennifer, the treatment team met with her and her family to discuss concerns about her amphetamine use and eating disorder behaviors. During this time, she also engaged in group and individual therapy and met regularly with her dietitian. 

At first, she had difficulty abstaining from eating disorder behaviors, but with time and structured support at meals, these behaviors improved. She continued, however, to voice strong cravings for sugar and stole condiments during her treatment.  

While at first resistant to treatment, she gradually engaged more and noted feeling better. The treatment team used a 12-step model in approaching her, which resonated well. She identified her seventh day of treatment as her surrender date when she decided to give up her eating disorder. She attended 12-step meetings for her substance use daily while in treatment. 

While she continued to deny that she had bipolar disorder—holding firm to the belief that she had ADHD—she eventually agreed to take Lamictal.  

Jennifer completed the inpatient program successfully after 36 days and was transferred to a partial hospitalization program where she continued to show improvement. She completed the partial hospitalization program in 21 days and was then transferred back to the intensive outpatient program near her home.  

On the day of discharge, she voiced appreciation for her treatment and appeared motivated in her recovery.

Conclusion

While at first challenging, Jennifer did very well in treatment. By addressing both the eating disorder and the substance use disorder at the same time as well as applying motivational interviewing techniques in addition to a variety of other therapies, she made significant improvements.  

Treatment was delivered by a multidisciplinary team with specialized treatment experience in eating disorders. In addition, family therapy was also very beneficial for the patient as she learned to develop healthy boundaries with her family as well as provided education to the family about the eating disorder. This is one example of how a comprehensive program can successfully treat co-occurring substance use and eating disorders.

Amelia Davis, MD, is the medical director of Rosewood Centers for Eating Disorders in Wickenburg, Ariz. Board certified in psychiatry by the American Board of Psychiatry and Neurology, she is licensed to practice medicine in the state of Arizona, California, and Florida, where she was formerly chief of the eating disorders program at the University of Florida School of Medicine. In addition to her role as medical director, Dr. Davis is a program director for Rosewood’s clinical eating disorders fellowship.

Please read our comment policy. - The Fix
Disqus comments
Disqus comments