Treating the trifecta – trauma, eating disorders and substance use disorder

By Terry Fassihi

WARNING: This post is about three things none of us really like to think about _ the trifecta of trauma, eating disorders and substance use disorder. Why refer to this as a trifecta?  Because they so commonly occur together.

Trauma, addiction and eating disorders are interrelated and can’t be compartmentalized as separate issues. It is estimated that 25% of people with substance use disorders have an eating disorder. It is estimated that 30 – 50 percent of patients with an eating disorder have substance use disorders, most commonly in patients with bulimia, and 2/3 of patients with bulimia have experienced trauma. It is impossible to establish direct causal relationships, but there is compelling evidence of a positive relationship to early life trauma and substance-related problems later in life. The same can be said of eating disorders and trauma. Early trauma is common for patients with eating disorders and addiction, but especially for patients with both of these. Treatment that includes early intervention for trauma is recommended for this group. It cannot be an afterthought or something that waits until the addiction or eating disorder is under control.

Avoiding any part of the trifecta is not the answer
There is substantial evidence that medical and mental health professionals don’t like to think of these three issues either, especially all three at once. These problems are often referred out by general mental health professionals – if they are identified in the first place. For example, research indicates that many general mental health practitioners do not ask about eating problems in their assessments. Questions about trauma may be cursory. Substance abuse, if identified, is left to the specialists or AA. As treatment providers, we are often the only carriers of hope, the role models of resilience. How do we provide this to our patients if we are avoiding these issues at the outset?

“I just work with one of these”
With such high rates of co-occurrence, it may be surprising that it is difficult to find treatment that addresses the full trifecta. Clinicians who specialize in trauma, addiction or eating disorders, have to do a lot of additional training in various types of interventions. It is a substantial investment in time and money, and this extra effort is laudable. Understandably, given the extra effort it takes and the desire to be fully proficient, it may seem more manageable to say, “I just work with one of these.“

Why high rates of relapse are not surprising
This applies to intensive treatment as well. Most specialty higher level of care programs offer to address just one of these issues, and maybe touch on the others a bit. This leaves many patients in an untenable position. If they only get help for one of their problems, when they have all three, where does that leave them after specialty treatment? Still struggling with the issues that weren’t addressed and vulnerable to relapse on what was treated because they are still in deep suffering. This cherry-picked approach to treatment has to be a factor in the high rates of relapse we see.

Treatment programs need to cater for and cover all three
Clinicians don’t want to fail their patients. We want better outcomes! What obstacles do we face, besides training? Treatment programs for addiction or trauma are typically not equipped to support treatment for an eating disorder. If a patient engages in eating disorder behaviors, they may be discharged for this reason, or, worse, the symptoms may go unrecognized. An active addiction may also disqualify a patient from participation in an eating disorder program.

Reimbursement is also an issue. When insurance coverage is discontinued because patients are in remission from eating issues or substance use, but they have not had a chance to work on the underlying trauma issues, the compartmentalization of the issues often leads to denial of further coverage, leading to harmful interruption in treatment.

Solutions require specialists to unite and work together
I believe these are obstacles we can overcome. In their substantial and groundbreaking work, Eating Disorders, Addictions, and Substance Use Disorders, Dr. Timothy Brewerton and Dr. Amy Baker Dennis* offer understanding and solutions. Basically, their textbook offers a solid foundation for addiction specialists to understand eating disorders, for eating disorder specialists to understand addiction and how to see the role of trauma. Comprehensive treatment strategies are described. Cognitive behavior therapy, mindfulness based interventions, and behavioral treatments are some of the best evidence-based approaches. These are familiar to most of us, and training is available and affordable. Basically, we specialists need to unite and work together.

“Our patients should expect no less”
With thorough assessment, we can identify the presence of all the issues our patients are dealing with. As specialists, we can collaborate and expand our knowledge so we can address each problem fully. And we must advocate to payors that treatment is not complete until treatment of each problem is provided.

Our patients should expect no less.

About Terry:  I am a psychologist practicing in Houston, Texas who has been treating eating disorders since 1998. I was drawn to learn more about eating disorders when I discovered that the vast majority of sufferers were women with underlying issues of poor body image and low self-esteem. Initially, I believed that these challenges had a profound connection to the objectification of women and the obsession with perfection in our culture. I still believe this, but also recognize that there is much greater complexity to these illnesses and also that they do not occur by themselves. I have worked in hospitals, outpatient programs and in private practice. I love to treat patients, but I also devote much of my energy to advocacy for better care. Thanks for taking the time to read my post and to June for inviting me to contribute to her wonderful Diary Healer.

– Terry Fassihi, PHD, FAED, CEDS

* Eating Disorders, Addictions, and Substance Use Disorders: Research, Clinical, and Treatment Perspectives, edited by Timothy D. Brewerton and Amy Baker Dennis: New York, NY: Springer, 2014, 694 pages.