Eating Disorders: The Hidden Gateway Drug
Uncovering the Link Between Disordered Eating and Substance Abuse
As an addictions counselor and a person in recovery from addiction, people often ask me if marijuana is a “gateway drug”. What they mean is, “does using marijuana lead to substance abuse and addiction?”. I have many things to say on that subject, but this is not the blog post for that. What we need to be asking is whether or not eating disorders are behaviors to addiction.
At its very basis, addiction surrounds the concept of “I feel one way and, if I use this or do this, I will feel differently”.
And then the person continues to engage in the behavior or use the substance until they become dependent on it. As we all know, humans can be addicted to almost anything, including lip balm. When a person is addicted to a behavior, it is often referred to as a “process addiction”. Examples of process addictions include: gambling, sex, debt, eating, and shopping. Eating disorders are absolutely an addiction and can lead to substance abusing behavior. There is also a high rate of people who have an eating disorder who are also diagnosed with another mental health condition, such as depression or bipolar; this compounds the potential for substance abuse.
Eating disorders [EDs] are challenging to navigate and often start at a young age. They are full of shame, depression, low self-worth, and they are lethal. With a five to twenty percent mortality rate, anorexia (nervosa) has consistently been reported the second deadliest mental health condition after opioid addiction (American Addiction Centers, 2020). Research suggests over ten thousand Americans die as a direct result of an ED each year (National Association of Anorexia Nervosa and Associated Disorders [ANAD], 2021). That is one person every 52 minutes! They truly are a slow suicide. They are hard to treat and they are very hard to recover from.
Humans must eat food to survive. This is a hard fact. We don’t have to drink alcohol, use drugs, gamble, or even have sex, but we do have to eat food. We also live in world where many environments revolve around food, which compounds the issue. If they so choose, a recovering alcoholic does not ever have to walk into another liquor store or bar in their lives after they get sober, but a recovering bulimic WILL have to go to the grocery store. They will more than likely go to restaurants and they will certainly be inundated with social situations where food is the center of attention.
Eating disorders are often less about losing weight and more about gaining control. We, for the most part, can control what we put into our bodies; or we can forcibly remove things we have consumed. This is part of the reason EDs often first manifest in teens and young adults. Other reasons for engaging in disordered eating as a teen include: distorted body image, the immense changes of puberty, and social media. Research suggests the average onset for EDs is around age 19, but many people start at a much younger age. I was one of those people.
Bulimia was my first addiction. At the age of eleven or twelve, I forced myself to purge (throw up) for the first time and found a huge sense of relief. In retrospect, it was a lot like the rush of the very first high using drugs. My life felt like it was full of chaos and I was consistently bullied for being overweight. Binging and purging was the one thing I had full control over and the preliminary result was weight loss.
I have what some people call an “addictive personality”. I don’t do unhealthy things partway. It’s just not my style. If it's going to mess up my body, my life, and my relationships, sign me up…twice! Binging and purging quickly became a cornerstone of my life and the secret double life of addiction. Many people with addictions hide it, as well as they can, for as long as they can. The foundation of this is oftentimes shame. I didn’t want anyone to know. Who wants to tell their friend and family they just threw up their nice homecooked dinner into a Tupperware container that is now stashed under their bed? Who wants to tell their parents that are struggling to put food on the table they are basically throwing money in the trash? Just writing these words brings up all sort of emotions for me. Interestingly enough, research suggests teenagers identifying as female from low-income families are 153 percent more likely to be bulimic than their wealthy counterparts (NEDA, n.d.).
I started heavily using alcohol a few years later, which brought a new sense of “relief” and furthered my deep dive into substance abuse. That did not mean my eating disorder stopped. Eventually my parents were apprised of my bulimia (not my alcohol abuse) and they forced me to seek outpatient treatment. According to the National Institute of Health [NIH], approximately 33 percent of people with EDs will seek treatment; this number is significantly lower for teens (n.d.). As with any other addiction, when left untreated these conditions get progressively worse.
Research suggests nine percent of Americans (28.8 million) will have an eating disorder in their lifetime and about 66 percent will achieve long-term recovery (ANAD, 2021). Recovery from any addiction is a beautiful thing, but it needs to be attended to for a lifetime. Approximately 40 percent of people with an ED will relapse within the first two years of recovery (Eating Recovery Center, 2019). A return to treatment is highly recommended by professionals in these situations so the individual can get the support they need.
The risk factors for eating disorder include, but are not limited to: trauma, heredity, a history of dieting, perfectionism, and co-occurring mental health condition(s). Therapists use the term co-occurring disorder to describe a client who presents with, at least, two mental health conditions. This can be any combination. Some examples are: depression and alcohol addiction; bipolar and anorexia; Post-Traumatic Stress Disorder [PTSD], opioid addiction, and bulimia. There are many people who struggle with an eating disorder, substance abuse, and severe mental illness all at the same time.
According to the National Center on Addiction and Substance Abuse, people diagnosed with an ED are five times more likely than the general population to abuse alcohol and/or drugs; the most abused substances other than diuretics and laxatives were: cocaine, alcohol, amphetamines, and heroin. (NEDA, n.d.). I have talked with countless people in recovery from substance abuse or who are actively abusing substances that also struggle with an eating disorder currently or have in the past. Reportedly 27% of people with anorexia and 37 percent of people with bulimia are dependent on mood altering substance(s) (NEDA, n.d.). It interesting because many people in recovery openly talk about their co-occurring severe mental health conditions, but are ashamed to talk about their ED. The stigma associated with eating disorders keeps people hidden with their shame and afraid to seek help. I was sober for YEARS before I ever openly shared about my bulimia and is still a very hard subject for me to discuss.
People often ask, “Do you treat the mental health condition or the substance abuse first?”. The answer is that they are best treated simultaneously, which is often referred to as concurrent treatment. Research suggests between half and three quarters of people diagnosed with an eating disorder cope with one or more other mental health conditions (ANAD, 2021). One study of 2400 people hospitalized with an eating disorder found that 97 percent of them had a co-occurring diagnosis. (ANAD, 2021). Mood (including depression), anxiety, and substance abuse disorders were among the most common, as well as approximately one in four people being diagnosed with PTSD (ANAD, 2021).
Eating disorders occur in all types of people and all genders. Individuals identifying as male make up approximately one third of all eating disorder diagnoses, although they often are underreported and go untreated; the shame associated with eating disorders and the false stigma that these conditions are a “female disorder” are cited as barriers to seeking treatment for men (National Eating Disorders Collaboration, n.d.). In the United States, marginalized individuals, such as those in the BIPOC [Black, Indigenous, and People of Color], Latin, and Asian communities are significantly less likely to receive treatment for their ED despite similar rates to Caucasian individuals (National Eating Disorder Association [NEDA], n.d.). With regard to the queer (LBGTQ+) community, research suggests gay, lesbian, and bisexual teens are at a higher risk of EDs than their peers; it is also suggests that transgender individuals experience eating disorders at a much higher rate than those identifying as cisgender (those whose personal identity and gender matches their sex at birth) (NEDA, n.d.).
People with eating disorders are at a much higher risk for suicide and self-harming behaviors, such as cutting or burning oneself. Self-harming can be an indicator of suicidal thoughts and should be addressed immediately. Research suggests anorexia has the highest mortality rate of any mental health condition and people with this diagnosis are 31 times more likely to make a fatal suicide attempt than the general population (O’Melia, 2016). If you, or someone you know has serious thoughts of attempting suicide, please call the National Suicide Prevention Lifeline at 1-800-273-8255 or seek medical treatment immediately. Talking to someone about their (potential) suicidal thoughts DOES NOT increase their risk of completing suicide! It is a very hard subject to talk about with someone we love, but they need our love and support.
Addiction is not a respecter of race, socioeconomic status, gender, employment, education, religion, age, or political party. It can literally affect anyone.
I was once discussing addiction recovery with a family member who said, “it’s [addiction] just about lack of willpower anyway”. Ummm…NO! Addiction, of all types, is a disease. It is a biological, psychological, and sociological illness that has NOTHING to do with someone’s level of willpower. It involves factors like brain chemistry, heredity, and trauma history; things we cannot control
But recovery, from any addiction, is possible. With the right support, we can recover from “a hopeless state of mind and body” (Alcoholics Anonymous [AA] Big Book, 2002, p. xiii). That could mean professional help, such as hospitalization, inpatient treatment, outpatient treatment. That could mean community support groups surrounding substance abuse, eating disorders, or other process addictions. We also need to be willing to change. No one else can make an addict willing to stop their behavior and get help but themselves. We cannot love or force someone into recovery, but we can support them the best we know how.
If you are struggling with an addiction or love someone who is, I encourage you to reach out to me or another therapist for support. You can also check out the “resources” page on this website. It is full of organizations that are dedicated to supporting you in your recovery journey. We are enough!
Addition Recovery Centers. (2020, February 3). What are the health risks of anorexia? What Are the Consequences & Health Risks of Anorexia (americanaddictioncenters.org)
Alcoholics Anonymous [AA] Big Book (4th ed). (2004). Alcoholics Anonymous World Services.
Eating Recovery Center. (2019, November 18). Eating disorder relapse is common. Eating Disorder Relapse is Common | Eating Recovery Center
National Association of Anorexia Nervosa and Associated Disorders [ANAD]. (2021). Eating disorder statistics. Eating Disorder Statistics | General & Diversity Stats | ANAD
National Eating Disorder Association. (n.d.). Statistics and research on eating disorders. Eating Disorder Statistics & Research | Learn | NEDA (nationaleatingdisorders.org)
National Eating Disorder Collaboration. (n.d.). Eating disorders in males. Eating Disorders in Males (nedc.com.au)
National Institute of Mental Health [NIMH]. (n.d.) Eating disorders. NIMH » Eating Disorders (nih.gov)
O’Melia, A. M. (2016, September 17). Managing suicidality in eating disorder patients. Eating Recovery Center. Eating Disorders & Suicidality: Managing Suicidal Thoughts (eatingrecoverycenter.com)