Behavioral Health Is Essential To Health • Prevention Works • Treatment Is Effective • People Recover 

ADVISORY

1 Issue • 10 Volume • 1 201 February 

CLIENTS WITH SUBSTANCE USE AND 

EATING DISORDERS 

Eating disorders (EDs), which cause serious health 

problems and can be fatal, frequently co-occur with 

substance use disorders (SUDs). There are numerous 

psychosocial consequences of EDs (e.g., problems 

with family, friends, school, or work; lowered 

perceived happiness).1 When SUDs and EDs cooccur, the consequences, assessment, treatment, and 

recovery are more complicated for both disorders 

than for either disorder alone.2 

Although researchers have called for integrated 

treatment of SUDs and EDs,3, 4 few programs provide 

such treatment, and no research exists on the best 

ways to provide simultaneous treatment for both 

disorders. An analysis of National Treatment Center 

Study data found that, of 351 publicly funded SUD 

treatment programs surveyed, only 16 percent offered 

treatment for co-occurring EDs.5

 Furthermore: 

● Only half the programs screened for EDs. 

● Only 14 percent of those that did screen used a 

standardized instrument. 

● Only 3 percent had formal referral arrangements 

with ED treatment providers. 

SUD treatment counselors are in a good position to 

help their clients with undiagnosed EDs by being 

aware of the disorders, screening clients for EDs in 

the SUD treatment setting, and/or supporting their 

recovery from SUDs and EDs. Counselors need to 

understand EDs and their treatments so they can: 

● Identify clients with possible EDs. 

● Make appropriate referrals for evidence-based ED 

treatments. 

● Help clients with both EDs and SUDs attain and 

maintain recovery by understanding the effects of 

EDs on SUDs and vice versa. 

The goals of this Advisory are to raise counselors’ 

awareness of EDs and their relationship to SUDs and 

provide an overview of screening and evidence-based 

treatments for EDs. The Advisory does not provide 

comprehensive, how-to information for treating 

clients with EDs. Resources for more information are 

listed throughout the document and in the Resources 

section. 

What are eating disorders? 

EDs are characterized by disturbed eating patterns 

and dysfunctional attitudes toward food, eating, and 

body shape. The primary features of EDs are similar 

to those of SUDs: compulsive use or behavior, loss 

of control, and continuing behavior despite negative 

consequences. Genetics and other biological factors, 

as well as environmental factors, appear to be involved 

in the etiology of EDs, although exact mechanisms 

remain unknown.6, 7 The median age range for the 

onset of EDs is between ages 8 and 21,8

 although EDs 

can begin earlier or later in life. 

The Diagnostic and Statistical Manual of Mental 

Disorders, Fourth Edition, Text Revision (DSM-IVTR),9

 describes three diagnostic categories for EDs: 

anorexia nervosa (AN), bulimia nervosa (BN), and 

eating disorder not otherwise specified. Healthcare 

providers often consider compulsive overeating an ED 

as well; however, this disorder is included in DSMIV-TR only as a possible symptom of other behavioral 

health disorders. 

Anorexia Nervosa 

Primary characteristics of AN are an extreme desire to 

be thin and failure to maintain minimal body weight 

(defined as 85 percent of that expected based on age 

and height, using standard weight tables). A stricter 

indicator of AN is a body mass index (BMI) of 17.5 

or less, according to DSM-IV-TR and based on the 

World Health Organization’s (WHO’s) International 
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ADVISORY
 

Exhibit 1. Body Mass Index10, 11 

BMI is a number derived from a calculation based on 

a person’s weight and height. For most people, BMI 

correlates with their amount of body fat. Measuring 

BMI is an inexpensive and easy alternative to a direct 

measurement of body fat percentage and is a useful 

method of screening for weight categories that may 

lead to health problems. BMI categories are: 

Underweight: BMI score of less than 18.5 

Severe thinness BMI score of less than 16 

Moderate thinness BMI score between 16.00 and 16.99 

Mild thinness BMI score between 17.00 and 18.49 

Normal range: BMI score between 18.5 and 24.9 

Overweight: BMI score between 25.0 and 29.9 

Obese: BMI score of 30.0 or more 

BMI in children and adolescents is calculated 

somewhat differently from BMI in adults. More 

information and BMI calculators for adults and children/ 

adolescents are on the Centers for Disease Control 

and Prevention (CDC) Web site: http://www.cdc.gov/ 

healthyweight/assessing/bmi 

Classification of Diseases-10 diagnostic criteria (Exhibit 

1). However, these are guidelines only. Low body weight 

alone is not enough for a diagnosis of AN; a person may 

be severely underweight because of severe malnutrition 

from addiction or from illness. 

Although anorexia literally means lack of appetite, people 

with AN do experience hunger and appetite, but they 

severely restrict food intake regardless of hunger. DSMIV-TR criteria for AN are listed in Exhibit 2. 

ED workgroups for the fifth edition of the Diagnostic and 

Statistical Manual (DSM-5) currently in development have 

recommended changes in the diagnostic criteria for AN. 

A significant proposed change is to eliminate criterion D, 

amenorrhea. The reason for the proposed change is that 

some individuals exhibit all other symptoms and signs 

of AN but report at least some menstrual activity. Also, 

amenorrhea is limiting as a criterion because it cannot be 

applied to premenarcheal females, females taking oral 

contraceptives, postmenopausal females, or males.12 

There are two subtypes of AN: restrictive and binge eating/ 

purging. People with the restrictive subtype maintain a 

low body weight by restricting food intake and, often, 

exercising to excess. People with the binge eating/purging 

subtype also maintain a low body weight by restricting 

eating but have episodes of binge eating (an inability 

to control eating to the point of discomfort or pain) 

followed by purging (self-induced vomiting and/or using 

laxatives and diuretics). Both subtypes can have many 

serious medical consequences, including delayed puberty 

and/or slowed growth, bone mass reduction, nutritional 

deficiencies, serious cardiac problems, and severe anemia. 

The mortality rate for AN is high; more than 10 percent 

of those diagnosed with the disorder die from it. Death 

typically is caused by starvation, suicide, or electrolyte 

imbalance.9 

Exhibit 2. DSM-IV-TR Diagnostic Criteria for Anorexia Nervosa 

A. Refusal to maintain body weight at or above a minimally normal weight for age and height (e.g., weight loss 

leading to maintenance of body weight less than 85% of that expected; or failure to make expected weight gain 

during period of growth, leading to body weight less than 85% of that expected). 

B. Intense fear of gaining weight or becoming fat, even though underweight. 

C. Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or 

shape on self-evaluation, or denial of the seriousness of the current low body weight. 

D. In postmenarcheal females, amenorrhea, i.e., the absence of at least three consecutive menstrual cycles. 

(A woman is considered to have amenorrhea if her periods only occur following hormone, e.g., estrogen, 

administration.)
	

Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, (Copyright 2000). 

American Psychiatric Association. 

2 
 

 

Clients With Substance Use And Eating Disorders 

February 2011, Volume 10, Issue 1 

Bulimia Nervosa 

Binge eating and purging after a binge eating episode 

are the primary characteristics of BN. Periods of fasting, 

misuse of laxatives and diuretics, use of enemas, and 

excessive exercise are common. People with BN typically 

are of normal or higher than normal weight. DSM-IV-TR 

criteria are listed in Exhibit 3. 

BN also has two subtypes: purging and nonpurging. People 

with the nonpurging subtype use other compensatory 

behaviors (e.g., fasting, excessive exercise). 

Medical consequences of either subtype include potentially 

dangerous fluid and electrolyte imbalances, nutritional 

deficiencies, and menstrual irregularity and other 

reproductive system problems.9

 Rare but potentially fatal 

complications include esophageal tears and gastric rupture 

from purging, as well as cardiac arrhythmias. Erosion of 

tooth enamel (from stomach acid) is common with the 

purging subtype. People with purging BN are more likely 

than those with the nonpurging type to experience severe 

medical problems. 

Exhibit 3. DSM-IV-TR Diagnostic Criteria for Bulimia Nervosa 

A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: 

1. Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger 

than most people would eat during a similar period of time and under similar circumstances 

2. A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or 

control what or how much one is eating) 

B. Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting; 

misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise.
	

C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for
	

3 months.
	

D. Self-evaluation is unduly influenced by body shape and weight. 

E. The disturbance does not occur exclusively during episodes of Anorexia Nervosa. 

Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, (Copyright 2000). 

American Psychiatric Association. 

Eating Disorder Not Otherwise 

Specified: Binge Eating Disorder 

DSM-IV-TR includes binge eating disorders (BEDs) in 

EDs not otherwise specified. The proposed revisions for 

DSM-5 include BED as a separate diagnostic category 

(Exhibit 4, see next page). 

Unlike individuals with BN, those with BED do not 

purge and they tend to be obese. Medical consequences 

are typically those of obesity such as type 2 diabetes, 

high blood pressure and high cholesterol, stroke, cancers 

(e.g., endometrial, breast, colon), osteoarthritis, liver and 

gallbladder disease, and gynecological problems (e.g., 

abnormal menses, infertility).14 

Compulsive Overeating 

Although compulsive overeating is a primary 

characteristic of both BED and BN, compulsive 

overeating without purging or binge eating or with 

infrequent binge eating is common. Compulsive 

overeating is characterized by eating large amounts of 

food to cope with emotions and often eating without 

regard to hunger or feelings of fullness.15 Compulsive 

overeating is a serious problem that can lead to obesity 

and associated medical consequences. 

How common are eating 

disorders? 

EDs occur more frequently in women, but men also are 

vulnerable and experience the same types of physical 

and behavioral signs and symptoms as women. However, 

men are less likely to be diagnosed with an ED, 

which is often considered a female disorder.7 Hudson 

and colleagues8

 analyzed a subset from the National 

Comorbidity Survey Replication study that consisted 

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ADVISORY
 

Exhibit 4. Proposed DSM-5 Diagnostic Criteria for Binge Eating Disorder13 

A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: 

1. Eating, in a discrete period of time (for example, within any 2-hour period), an amount of food that is definitely 

larger than most people would eat in a similar period of time under similar circumstances 

2. A sense of lack of control over eating during the episode (for example, a feeling that one cannot stop eating or 

control what or how much one is eating) 

B. The binge eating episodes are associated with three (or more) of the following: 

1. Eating much more rapidly than normal 

2. Eating until feeling uncomfortably full 

3. Eating large amounts of food when not feeling physically hungry 

4. Eating alone because of being embarrassed by how much one is eating 

5. Feeling disgusted with oneself, depressed, or very guilty afterwards 

C. Marked distress regarding binge eating is present. 

D. The binge eating occurs, on average, at least once a week for three months. 

E. The binge eating is not associated with the recurrent use of inappropriate compensatory behavior (for example, 

purging) and does not occur exclusively during the course of Anorexia Nervosa, Bulimia Nervosa, or Avoidant/ 

Restrictive Food Intake Disorder. 

of adults ages 18 and older with an ED. Exhibit 5 

summarizes lifetime prevalence estimates of EDs 

(based on DSM-IV-TR diagnostic criteria) found in the 

Hudson study.8 

Overweight and obesity are common in the United 

States. A 2010 analysis of National Health and 

Nutrition Examination Survey data of adults ages 20 

and older found:16 

●		68 percent of the general population is overweight 

or obese (72 percent of men, 64 percent of women). 

●		34 percent of the general population is obese
	

(32 percent of men, 35.5 percent of women).
	

Exhibit 5. Lifetime Prevalence Estimates 

of EDs (n=2,980)8 

Disorder Women 

(%) 

Men 

(%) 

Anorexia nervosa 0.9 0.3 

Bulimia nervosa 1.5 0.5 

Binge eating disorder 3.5 2.0 

What is the relationship between 

EDs and SUDs? 

A 2010 review found that both clinical and community 

studies have reported high co-occurrence of EDs among 

women with SUDs.3

 For example: 

●		Gadalla and Piran17 found that women with either an 

SUD or an ED were more than four times as likely to 

develop the other disorder as were women who had 

neither disorder. 

●		Gilchrist and colleagues18 examined the co-occurrence 

of EDs and SUDs and reported that 14 percent of 

women with an SUD had AN and 14 percent had BN. 

Behavioral Health Is Essential To Health • Prevention Works • Treatment Is Effective • People Recover 

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Clients With Substance Use And Eating Disorders 

February 2011, Volume 10, Issue 1 

Similarly, Hudson and colleagues8 found that men and 

women with EDs had high rates of co-occurring SUDs 

(Exhibit 6). 

Piran and Robinson19 looked at the relationship between 

EDs and SUDs and found that: 

●		As EDs became more severe, the number of different 

substances used increased. 

●		Severe BED was consistently associated with alcohol 

use. 

●		Attempts to lose weight by purging (with or without 

binge eating) were associated with stimulant/ 

amphetamine and sleeping pill (e.g., triazolam, 

flurazepam) abuse. 

People often use food and substances to help them cope.2 

A person in recovery from an ED often uses substances 

to cope with the stresses of recovery. Similarly, a person 

in recovery from an SUD may use disordered eating 

to cope with or to compensate for the lack of chemical 

reinforcement. 

For a person with AN, treatment typically begins with 

refeeding, a process of incrementally increasing calorie 

intake to achieve a weight gain of 0.5 to 1 pound per 

week. Refeeding and the subsequent weight gain are 

particularly stressful, and a client in this process should be 

monitored closely for relapse to ED and substance use.2 

During this process, the SUD treatment counselor must 

closely coordinate with the ED specialists (e.g., therapist, 

dietitian), psychiatrist, physician, and other professionals 

treating the person for AN. 

As with recovery from SUDs, recovery from EDs can 

be a long process with periods of relapse and recovery,2 

and relapse to one disorder may affect a client’s recovery 

from the other. Relapse prevention counseling is critical to 

recovery from both disorders. For example, peer influences 

are important aspects for people with both EDs and SUDs. 

EDs often occur in clusters among particular groups (e.g., 

sports teams, sororities, cliques),2

 so changes in friends 

and recreational activities to avoid triggers are important in 

ED recovery as well as in SUD recovery. 

Exhibit 6. Lifetime Comorbidity Estimates of EDs and SUDs (n=2,980)8 

Disorder 

Alcohol Abuse or 

Dependence 

(%) 

Illicit Drug Abuse or 

Dependence 

(%) 

Any Substance Use 

Disorder 

(%) 

Anorexia nervosa 24.5 17.7 27.0 

Bulimia nervosa 33.7 26.0 36.8 

Binge eating disorder 21.4 19.4 23.3 

Exhibit 7. Lifetime Comorbidity Estimates of EDs and Other Behavioral Health Disorders 

(n=2,980)8 

Disorder 

Co-Occurring Anxiety 

Disorders 

(%) 

Co-Occurring Mood 

Disorders 

(%) 

Co-Occurring Impulse 

Control Disorders* 

(%) 

Anorexia nervosa 48 42 31 

Bulimia nervosa 81 71 64 

Binge eating 65 46 43 

*Includes intermittent explosive disorder, attention deficit hyperactivity disorder, oppositional-defiant disorder, and conduct disorder. 

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ADVISORY
 

What is the relationship between 

EDs and other behavioral health 

disorders? 

Co-occurring behavioral health disorders (particularly 

anxiety and mood disorders) are common in people 

with EDs.6

 Exhibit 7 (see page 5) lists incidence rates of 

common co-occurring disorders found in the study by 

Hudson and colleagues.8 

DSM-IV-TR links EDs to a range of specific behavioral 

health disorders, such as:9 

●		AN is an associated disorder for major depressive 

disorder and narcissistic personality disorder.
	

●		Both AN and BN are associated disorders for bipolar II 

disorder. 

●		EDs in general (but BN in particular) are disorders 

associated with borderline personality disorder.
	

When and how should SUD 

treatment counselors screen for 

EDs and refer for ED treatment? 

Screening Clients for EDs 

Little is known about ideal screening for EDs in SUD 

treatment programs. Merlo and colleagues2

 recommend 

that SUD treatment programs screen for EDs, along 

with other behavioral health disorders, at intake and 

intermittently during treatment of all clients in SUD 

treatment. An analysis of National Treatment Center Study 

data notes that programs that screen for EDs do so during 

intake and assessment. About half these programs screen 

all admissions for EDs, and half screen only when an ED 

is suspected.5 

Screening for EDs only when one is suspected can be 

complex, because signs and symptoms of EDs can overlap 

Exhibit 8. Possible Indications of Eating Disorders2, 9 

Disorder Indication 

Anorexia nervosa Eating tiny portions, refusing to eat, and denying hunger 

Dressing in loose, baggy clothing (to hide weight loss) 

Exercising excessively and compulsively 

Feeling cold frequently 

Experiencing hair loss, sunken eyes, or pale skin 

Complaining of being fat, even when underweight 

Developing lanugo, fine body hair that develops along the midsection, legs, and arms 

Bulimia nervosa Eating little in public but overeating in private 

Disappearing after eating; spending a lot of time in the bathroom 

Sounding hoarse 

Experiencing bruised or callused knuckles, bloodshot eyes, or light bruising under eyes 

Hiding food wrappers and other evidence of binge eating 

Experiencing severe dental problems (loss of enamel) 

Binge eating disorder Hiding food to eat later 

Eating little in public but overeating in private 

Hiding food wrappers and other evidence of binge eating 

Compulsive overeating History of repeating cycles of losing and regaining body weight (yo-yo dieting) 

Believing that all problems could be solved by losing weight 

Eating little in public but overeating in private 

Hiding food wrappers and other evidence of binge eating 

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Clients With Substance Use And Eating Disorders 

February 2011, Volume 10, Issue 1 

with those of SUDs or with those of other behavioral 

health problems. For example, weight loss, lethargy, 

changes in eating habits, and depressed mood can indicate 

an SUD or an affective disorder. In addition, signs may 

not be readily observable to counselors, because people 

with EDs often go to great lengths to disguise and hide 

their disorder.2

 However, counselors should be aware of 

common red flags for EDs that tend not to overlap with 

those of other behavioral health disorders. Exhibit 8 (see 

page 6) lists some indications (in addition to DSM criteria) 

that an ED may be present. 

Screening all clients for EDs will likely result in 

identification of more clients in need of further assessment 

and treatment. SUD treatment counselors can easily (and 

unobtrusively) incorporate some ED screening into the 

SUD assessment in a number of ways: 

●		As part of the drug use assessment, ask clients 

about their use of over-the-counter and prescription 

laxatives, diuretics, and diet pills.
	

●		As part of taking a medical history, ask clients about 

past hospitalizations and behavioral health treatment 

history, including for EDs. 

●		As part of assessing daily activities, ask clients how 

often and for how long they exercise.
	

●		Ask clients, “Other than those we’ve discussed so far, 

are there any health issues that concern you?” 

Counselors also can use a standardized screening 

instrument. Exhibit 9 lists the five questions in the 

SCOFF questionnaire.20 This screening tool was originally 

developed and validated in the United Kingdom and 

has been validated for use in the United States.21 Other 

validated brief screening instruments include: 

●		The Eating Attitudes Test (a 26-item version of the 

original 40-question Eating Attitudes Test22, 23
	

●		The Bulimia Test—Revised (BULIT—R)24 

Clients in SUD treatment may be confused or defensive 

about being asked questions regarding their eating and 

body image. Counselors can prepare clients by: 

●		Explaining that EDs commonly co-occur with SUDs. 

●		Explaining that it is important to have a clear picture 

of the client’s overall health status. 

Exhibit 9. The SCOFF Questionnaire20, 21 

1. Do you make yourself Sick [induce vomiting] 

because you feel uncomfortably full?
	

2. Do you worry you have lost Control over how much 

you eat? 

3. Have you recently lost more than One stone* in a 

3-month period? 

4. Do you believe yourself to be Fat when others say 

you are too thin? 

5. Would you say that Food dominates your life? 

Two or more “yes” responses indicate that an ED is 

likely. 

*14 pounds 

●		Asking the client for permission to pursue ED 

screening (e.g., “May I ask you some questions about 

your eating habits?”). 

Screening does not end at intake. Counselors should 

remain alert for signs of EDs, including changes in weight 

that may appear later in treatment or recovery. 

Referring Clients for Further

Assessment and Treatment 

Ideally, a person with both an ED and an SUD would 

receive integrated treatment from one program.3

 However, 

because such programs are rare, SUD treatment counselors 

generally need to refer clients with EDs to specialized ED 

treatment programs and vice versa. 

After medical stabilization (if necessary), treatment of 

the SUD should generally come first when integrated 

treatment for both disorders is unavailable,2, 4 because a 

client with an active SUD will be less likely to engage 

in and benefit from ED treatment. In addition, many 

specialized ED programs are not prepared to treat a client 

who also has an SUD. 

Treatment decisions (such as whether the SUD and 

ED will be treated sequentially or concurrently or 

on an inpatient or outpatient basis) should be made 

together by the client and family, the SUD treatment 

counselor, the physician, and the ED specialist as part of 

a multidisciplinary team approach. This team approach 

7 
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ADVISORY
 

to treating SUDs and EDs is critical. Counselors should 

consider developing formal referral relationships with 

local evidence-based ED treatment resources to enhance 

the referral process and ongoing treatment of both 

disorders. 

ED treatment resources include specialized programs and 

practitioners, dentists, and nutritionists/dietitians. Possible 

sources of ED treatment referral information include: 

●		American Dietetic Association. A list of registered 

dietitians is at http://www.eatright.org 

●		Families Empowered and Supporting Treatment of 

Eating Disorders (F.E.A.S.T.). A list of treatment 

resources by State and country is at http://www.
	

feast-ed.org/clinics.aspx; a list of active clinical 

trials is at http://www.feast-ed.org/SearchResults.
	

aspx?Search=clinical+trials
	

●		National Association of Anorexia Nervosa and 

Associated Disorders. A list of resources by State is at 

http://www.anad.org/get-help/treatment-centers/ 

●		Community behavioral health centers and other 

behavioral health specialists.
	

●		Hospital psychiatry departments and outpatient clinics. 

●		University- or medical school-affiliated programs 

specializing in EDs.
	

●		Employee assistance programs. 

●		Local medical and/or psychiatric societies. 

What is the treatment for EDs? 

Evidence-based specialized treatment for EDs generally 

includes some combination of: 

●		Medical stabilization. 

●		Nutritional rehabilitation. 

●		Pharmacotherapy. 

●		Psychosocial treatment. 

Medical Stabilization 

Immediate inpatient medical care and stabilization are 

necessary for individuals with AN who are severely 

malnourished or for those with AN or BN with 

dehydration or electrolyte imbalances. Inpatient medical 

care for other physical consequences of EDs also may be 

necessary. For people with less severe malnutrition and 

medical consequences, medical care may be provided on 

an outpatient basis.2 

Nutritional Rehabilitation 

Nutritional rehabilitation is a critical aspect of treatment 

for those with EDs.25 For individuals with AN, nutritional 

rehabilitation begins with a process of refeeding. 

Refeeding is usually initiated in an inpatient setting for 

severe malnutrition. The process must be done slowly and 

must be closely supervised to avoid refeeding syndrome, 

a cluster of possibly severe consequences (including 

cardiovascular problems) associated with a too-rapid 

increase in nutrient intake.25 In less severe cases, refeeding 

may be done on an outpatient basis. 

Nutritional rehabilitation for EDs also includes other 

services, typically provided by a registered dietitian. A 

dietitian may evaluate a client’s nutritional status, provide 

information about risk regarding the ED, educate about 

nutrition, and monitor weight gain or loss. 

Pharmacotherapy 

Pharmacotherapy is often used for BN and BED. No 

medications have been found to be effective for AN. The 

selective serotonin reuptake inhibitor (SSRI) fluoxetine has 

been approved by the U.S. Food and Drug Administration 

for the treatment of BN and is commonly used to 

treat BED. Topiramate may also be effective for both 

disorders.26 Preliminary research has found that:26 

●		Trazodone and desipramine may be effective 

treatments for BN.
	

●		SSRIs (other than fluoxetine), imipramine, and 

sibutramine may be effective treatments for BED.
	

Psychosocial Treatments 

More research on treatment for specific EDs is needed. 

However, some psychosocial treatments have been found 

to be more effective than others for particular EDs and/ 

or age groups. Two extensive reviews of the literature 

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Clients With Substance Use And Eating Disorders 

February 2011, Volume 10, Issue 1 

Exhibit 10. Overview of Evidence-Based Psychosocial Treatments for EDs26, 27 

Population Anorexia Nervosa Bulimia Nervosa Binge Eating Disorder 

Preadolescents/adolescents 

(ages 10–17) 

Maudsley Approach 

Manual-guided self-help 

Maudsley Approach Inconclusive evidence 

Older adolescents/young 

adults 

(ages 18–20) 

Maudsley Approach 

(if client is still living at 

home) 

CBT 

Manual-guided self-help 

CBT 

Manual-guided self-help 

Inconclusive evidence 

Adults 

(ages 21 and older) 

Nonspecific individual 

psychotherapy 

CBT (after near-normal 

weight is gained) 

CBT 

IPT 

CBT 

IPT 

found that the most promising of these treatments include 

Maudsley Approach family therapy, cognitive–behavioral 

therapy (CBT), Interpersonal Psychotherapy (IPT), and 

self-help approaches.26, 27 Exhibit 10 provides an overview 

of the psychosocial treatments that have been found to be 

most effective for particular EDs and age groups. 

Maudsley Approach Family Therapy 

Maudsley Approach family therapy is based on family 

systems theory and is a mainstay of AN treatment 

for adolescents. It also has been adapted for use with 

adolescents with BN.27 The therapy has three phases: 

●		Phase 1: With coaching by a clinician with specialized 

training in ED treatment, parents of an adolescent with 

AN take control of the adolescent’s eating (i.e., what, 

when, how much he or she eats). When the adolescent 

has BN, parents disrupt his or her ED behaviors (e.g., 

binge eating, purging). 

●		Phase 2: After significant weight gain is achieved 

(or ED behaviors have significantly decreased), 

control over eating behavior is carefully returned to 

the adolescent. At the same time, the family explores 

issues related to the ED. 

●		Phase 3: The ED clinician and family work to restore 

normal and age-appropriate developmental processes 

and relationships within the family. 

Cognitive–Behavioral Therapy 

CBT approaches, used widely in SUD treatment, have 

been tailored for treating EDs. For EDs, cognitive 

approaches address distorted thought processes related to 

body shape and image that drive ED behaviors. Behavioral 

approaches are directed at altering the food restriction 

of AN, compulsive overeating, or binge/purge behavior. 

These approaches appear to be most effective when 

combined.26 CBT appears to be most effective for clients 

with BN or BED. It also appears to reduce relapse in adult 

clients with AN, but only after the client has reached nearnormal weight.26 

Interpersonal Psychotherapy 

IPT focuses on interpersonal problems rather than 

intrapsychic processes. IPT has been found effective in 

treating BN or BED and is sometimes combined with 

CBT. When IPT is used to treat EDs, the premise is that 

negative interactions may lead to negative emotions that 

then lead to ED behaviors. During IPT sessions, clients 

with BN or BED focus on how to cope with the tension 

and frustration that can result from negative interpersonal 

interactions and learn to improve their relationship skills. 

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ADVISORY
 

Self-Help Approaches 

Self-help approaches show promise for treating EDs.26, 

27, 28 These approaches use highly structured audiovisual 

materials or manuals based on CBT principles. Manuals 

can be used by clients independently, in peer-led groups, or 

with a nonspecialized clinician (guided self-help). 

Are there mutual-help groups for 

EDs? 

Yes. Two mutual-help groups focus on people with EDs; 

both offer face-to-face, online, and telephone meetings: 

●		Overeaters Anonymous (OA) is a well-established 

mutual-help group based on the 12-Step model. OA 

was developed for people with compulsive overeating 

but has since broadened its scope to welcome those 

with other EDs. For example, it offers an informational 

packet titled Focus on Anorexia and Bulimia. More 

information and a meeting locator are available at 

http://www.oa.org/new-to-oa/about-oa.php 

●		Eating Disorders Anonymous (EDA) is appropriate 

for people with any ED. More information and 

an EDA meeting locator are at http://www.
	

eatingdisordersanonymous.org
	

Although research on mutual-help groups for clients with 

EDs is virtually nonexistent, these groups may be useful 

for clients in long-term recovery from EDs. 

Resources 

Web Resources 

Academy for Eating Disorders 

http://www.aedweb.org 

Alliance for Eating Disorders Awareness 

http://www.allianceforeatingdisorders.com 

American Dietetic Association 

http://www.eatright.org 

American Psychiatric Association 

Treatment of Patients With Eating Disorders, Third Edition 

http://www.psychiatryonline.com/pracGuide/ 

pracGuideTopic_12.aspx 

Eating Disorder Referral and Information Center 

http://www.edreferral.com/index.html 

Eating Disorders Anonymous 

http://www.eatingdisordersanonymous.org 

F.E.A.S.T. 

http://www.feast-ed.org 

International Association of Eating Disorder 

Professionals 

http://www.iaedp.com 

National Association of Anorexia Nervosa and 

Associated Disorders 

http://www.anad.org 

National Eating Disorders Association 

http://www.nationaleatingdisorders.org 

National Institute of Diabetes and Digestive and Kidney 

Diseases, Weight-control Information Network 

http://win.niddk.nih.gov 

National Institute of Mental Health 

http://www.nimh.nih.gov/health/topics/eating-disorders/ 

index.shtml 

National Library of Health, Medline Plus 

http://www.nlm.nih.gov/medlineplus/eatingdisorders.html 

The National Women’s Health Information Center 

http://www.womenshealth.gov/bodyimage/eatingdisorders/ 

Overeaters Anonymous 

http://www.oa.org/new-to-oa/about-oa.php 

Relevant Publications from SAMHSA 

Treatment Improvement Protocol (TIP) 35: Enhancing 

Motivation for Change in Substance Abuse Treatment 

(SMA) 08-4212 

TIP 39: Substance Abuse Treatment and Family Therapy 

(SMA) 08-4219 

TIP 42: Substance Abuse Treatment for Persons With CoOccurring Disorders (SMA) 08-3992 

10 
Behavioral Health Is Essential To Health • Prevention Works • Treatment Is Effective • People Recover 

Women’s Mental Health: What It Means to You (OWH09-

CONSUMER) and the companion publication for 

professionals, Action Steps for Improving Women's Mental 

Health (OWH09-PROFESSIONAL) 

These publications can be ordered from the Substance 

Abuse and Mental Health Services Administration 

(SAMHSA) by calling 1-877-SAMHSA-7 (1-877-726-

4727). Publications also can be ordered or downloaded via 

the SAMHSA Store at http://store.samhsa.gov/home 

Notes 

1 Piran, N., Robinson, S. R., & Cormier, H. C. (2007). 

Disordered eating behaviors and substance use in women: 

A comparison of perceived adverse consequences. Eating 

Disorders, 15, 391–403. 

2 Merlo, L. J., Stone, A. M., & Gold, M. S. (2009). Co-occurring 

addiction and eating disorders. In R. K. Ries, D. A. Fiellin, 

S. C. Miller, & R. Saitz (Eds.), Principles of addiction 

medicine (4th ed.). Philadelphia: Lippincott Williams & 

Wilkins. 

3 Harrop, E. N., & Marlatt, G. A. (2010). The comorbidity of 

substance use disorders and eating disorders in women: 

Prevalence, etiology, and treatment. Addictive Behaviors, 35, 

392–398. 

4 Woodside, B. D., & Staab, R. (2006). Management of 

psychiatric comorbidity in anorexia nervosa and bulimia 

nervosa. CNS Drugs, 20(8), 655−663. 

5 Gordon, S. M., Johnson, J. A., Greenfield, S. F., Cohen, 

L., Killeen, T., & Roman, P. M. (2008). Assessment and 

treatment of co-occurring eating disorders in publicly funded 

addiction treatment programs. Psychiatryonline.org, 59(9). 

Retrieved September 14, 2010, from http://psychservices. 

psychiatryonline.org/cgi/content/full/59/9/1056 

6 Klump, K. L., Bulik, C. M., Kaye, W. H., Treasure, J., & 

Tyson, E. (2009). Academy for Eating Disorders position 

paper: Eating disorders are serious mental illnesses. 

International Journal of Eating Disorders, 42(2), 97–103. 

7 National Institute of Mental Health. (2007 revision). Eating 

disorders. NIH Publication No. 07-4901. Bethesda, MD: 

U.S. Department of Health and Human Services. 

8 Hudson, J. I., Hiripi, E., Harrison, G. P., & Kessler, R. C. 

(2007). The prevalence and correlates of eating disorders in 

the National Comorbidity Survey Replication. Biological 

Psychiatry, 61(3), 348–358. 

9 American Psychiatric Association. (2000). Diagnostic and 

statistical manual of mental disorders (4th ed., text revision). 

Washington, DC: Author. 

Clients With Substance Use And Eating Disorders 

February 2011, Volume 10, Issue 1 

10 Centers for Disease Control and Prevention. (n.d. b). Healthy 

weight: It’s not a diet, it’s a lifestyle. Retrieved September 

14, 2010, from http://www.cdc.gov/healthyweight/assessing/ 

bmi 

11 World Health Organization. (2006). Global database on body 

mass index. Retrieved September 14, 2010, from http://apps. 

who.int/bmi/index.jsp?introPage=intro_3.html 

12 American Psychiatric Association. (2010a). Anorexia nervosa: 

Rationale. DSM-5 Development. Retrieved September 14, 

2010, from http://www.dsm5.org/ProposedRevisions/Pages/ 

proposedrevision.aspx?rid=24# 

13 American Psychiatric Association. (2010b, February 10). 

DSM-5 proposed revisions will include binge eating disorder 

and revisions to other eating disorders criteria. Retrieved 

September 14, 2010, from http://www.dsm5.org 

14 Centers for Disease Control and Prevention. (n.d. a). 

The health effects of overweight and obesity. Retrieved 

September 14, 2010, from http://www.cdc.gov/ 

healthyweight/effects/index.html 

15 American Dietetic Association. (n.d.). Eating disorders. 

Retrieved September 14, 2010, from http://www.eatright.org/ 

Public/content.aspx?id=6819&terms=compulsive+overeating 

16 Flegal, K. M., Carroll, M. D., Ogden, C. L., & Curtin, L. R. 

(2010). Prevalence and trends in obesity among U.S. adults, 

1999–2008. JAMA, 303(3), 235–241. 

17 Gadalla, T., & Piran, N. (2007). Co-occurrence of eating 

disorders and alcohol use disorders in women: A meta 

analysis. Archives of Women’s Mental Health, 10, 133–140. 

18 Gilchrist, G., Gruer, L., & Atkinson, J. (2007). Predictors 

of neurotic symptom severity among female drug users 

in Glasgow, Scotland. Drugs: Education, Prevention, and 

Policy, 14(4), 347–365. 

19 Piran, N., & Robinson, S. R. (2006). The association between 

disordered eating and substance use and abuse in women: A 

community-based investigation. Women and Health, 44(1), 

1–20. 

20 Morgan, J. F., Reid, F., & Lacey, J. H. (1999). The SCOFF 

questionnaire: Assessment of a new screening tool for eating 

disorders. British Medical Journal, 319, 1467–1468. Used 

with permission from the primary author, John F. Morgan, 

M.D., M.R.C.Psych. 

21 Parker, S. C., Lyons, J., & Bonner, J. (2005). Eating disorders 

in graduate students: Exploring the SCOFF questionnaire 

as a simple screening tool. Journal of American College 

Health, 54(2), 103–107. 

22 Garner, D. M., & Garfinkel, P. E. (1979). The Eating Attitudes 

Test: An index of the symptoms of anorexia nervosa. 

Psychological Medicine, 9(2), 273–279. 

11 
ADVISORY

SAMHSA Advisory

Clients With Substance Use And Eating Disorders

23 Garner, D. M., Olmstead, M. P., Bohr, Y., & Garfinkel, P. E. 

(1982). The Eating Attitudes Test: Psychometric features and 

clinical correlates. Psychological Medicine, 12, 871–878.

24 Thelen, M. H., Farmer, J., Wonderlich, S., & Smith, M. 

(1991). A revision of the bulimia test: The BULIT—R. 

Psychological Assessment: A Journal of Consulting and 

Clinical Psychology, 3(1), 119–124.

25 American Dietetic Association. (2006). Position of the 

American Dietetic Association: Nutrition intervention in 

the treatment of anorexia nervosa, bulimia nervosa, and 

other eating disorders. Journal of the American Dietetic 

Association, 106, 2073–2082.

26 Berkman, N. D., Bulik, C. M., Brownley, K. A., Lohr, K. 

N., Sedway, J. A., Rooks, A., et al. (2006). Management of 

eating disorders. Evidence Report/Technology Assessment, 

135, 1–166.

27 Keel, P. K., & Haedt, A. (2008). Evidence-based psychosocial 

treatments for eating problems and eating disorders. Journal 

of Clinical Child & Adolescent Psychology, 37(1), 39–61.

28 Peterson, C. B., Mitchell, J. E., Crow, S. J., Crosby, R. D., & 

Wonderlich, S. A. (2009). The efficacy of self-help group 

treatment and therapist-led group treatment for binge eating 

disorder. American Journal of Psychiatry, 166, 1347–1354.

SAMHSA Advisory 

This Advisory was written and produced under contract number 270-09-0307 by the Knowledge Application Program 

(KAP), a Joint Venture of JBS International, Inc., and The CDM Group, Inc., for the Center for Substance Abuse 

Treatment (CSAT), Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of 

Health and Human Services (HHS).

Disclaimer: The views, opinions, and content expressed herein do not necessarily reflect the views or policies of 

CSAT, SAMHSA, or HHS. No official support of or endorsement by CSAT, SAMHSA, or HHS for these opinions or 

for particular instruments, software, or resources is intended or should be inferred.

Public Domain Notice: All materials appearing in this document except those taken directly from copyrighted sources 

are in the public domain and may be reproduced or copied without permission from SAMHSA/CSAT or the authors. 

Citation of the source is appreciated. However, this publication may not be reproduced or distributed for a fee without 

the specific, written authorization of the Office of Communications, SAMHSA, HHS.

Electronic Access and Copies of Publication: This publication may be ordered from SAMHSA’s Publications 

Ordering Web page at http://www.store.samhsa.gov/home. Or, please call SAMHSA at 1-877-SAMHSA-7 

(1-877-726-4727).

Recommended Citation: Substance Abuse and Mental Health Services Administration. (2011). Clients With Substance 

Use And Eating Disorders. Advisory, Volume 10, Issue 1.

HHS Publication No. (SMA) 10-4617

First Printed 2011