An application of integrative medicine: nutritional and other therapies can assist with co-occurring substance use and eating disorders.

Eating disorders (EDs) such as bulimia nervosa and anorexia nervosa involve many features similar to those present in substance use disorders (SUDs). Both involve a preoccupation with a substance and with the behaviors accompanying the addiction. Both involve some impulse control issues and the inability to stop doing something that is harmful or addictive. In individuals with bulimia, impulse control issues might include sexual promiscuity, bingeing and the use of drugs and alcohol. Individuals with anorexia exert excessive control to the point of self-starvation and are unable to stop their impulse to restrict.

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A review of studies on the co-occurrence of eating disorders and substance use disorders showed that 23% of individuals with bulimia reported alcohol abuse, with 26% reporting drug abuse. For anorexics, the prevalence of drug use was 19%. Of those with a SUD, 8 to 20% have a current or past history of bulimia and 2 to 10% have a current or past history of anorexia. (1)

Between 50 and 70% of individuals with bulimia have a SUD. Binge eating is associated with heavier use of substances as well as higher rates of depression and low self-esteem. (2) Those with bulimia and alcohol dependence have higher rates of suicide attempts and anxiety disorders and are more likely to use other drugs and have borderline or histrionic personality disorders. (3) SUDs appear to be higher in ED patients than in healthy controls. (4)

Integrative medicine is a healing-oriented discipline that takes into account the whole person--body, mind and spirit--including all aspects of lifestyle. It emphasizes the therapeutic relationship and makes use of both conventional and alternative therapies. While integrative therapies have not been considered part of a traditional approach to the treatment of either eating disorders or substance use disorders, they can be beneficial in the treatment of these co-occurring disorders. The remainder of this article will discuss some of the most promising therapies.

Nutritional strategies

Nutritional therapies are essential in treating EDs but also have a place in SUD treatment. Individuals with SUDs often eat poorly, which limits absorption of vitamins and minerals needed to maintain essential body functions. Approximately 80% of ED clients and two-thirds of those with SUDs will experience depression in their lifetime, and individuals with depression also have nutritional deficits. Several categories of nutritional therapies are potentially useful.

Omega-3 fatty acids are essential fatty acids because the body cannot manufacture them. EPA (eicosapentaenoic acid) and DHA (docosahexaenoic acid) are omega-3 fatty acids found in cold-water fatty fish (such as salmon, tuna, mackerel and sardines) and fish oil. Vegetarian sources of fatty acids come from algae or from walnuts and flaxseeds (which must be fresh ground) and contain a precursor to DHA and EPA called alpha-linolenic acid (ALA). Populations with the highest seafood intake have the lowest levels of illnesses such as major depression and bipolar disorder. Omega-3 fatty acids have been shown to decrease the risk of and/or treat depression and schizophrenia and to decrease aggression and hostility in borderline personality disorder. (5)

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Typical dosages range from 2 to 5 grams per day. One note of caution: There is a theoretical risk of bleeding in individuals who are taking blood thinners, although there have been no reported cases.

B-vitamins, including B-12, folic acid and B-6 (pyridoxine), are required for the synthesis of neurotransmitters in the brain. Individuals with depression and alcoholics have low levels of B-12 and folic acid as well as other B-vitamins. Supplementation with folate may increase the effectiveness of antidepressants (6) and low levels of folate are implicated in poor response to antidepressant therapy. (7)

A B-complex vitamin taken once a day can be used to obtain adequate amounts of all the B-vitamins.

Vitamin D is important because alcoholics and some individuals with EDs are at higher risk for bone loss and osteoporosis. Vitamin D is an important nutrient for bone health. Sources for vitamin D besides conversion in the skin by sunlight include foods such as cereals or milk products. Another source is cod liver oil. Egg yolks, beef liver and cheese contain small amounts as well. There is some newer preliminary evidence supporting the use of Vitamin D-3 (cholecalciferol) over Vitamin D-2 (ergocalciferol).

Alcohol consumption interferes with the production of vitamin D. Certain medications may lower vitamin D levels as well. These include Dilantin (used for seizures), steroid medications such as prednisone used to reduce inflammation or treat asthma, and Questran (cholestyramine), a cholesterol-lowering medication.

A dosage of 1,000 IU daily is appropriate for Vitamin D-3.

Amino acids also have become more widely used. Research has documented that the dopaminergic system, especially the dopamine D2 receptor, is implicated in the reward cascade stimulated by natural rewards as well as by the use of psychoactive substances. This cascade affects levels of dopamine in the brain, which can be modified by other neurotransmitters such as serotonin, norepinephrine and GABA. Researchers have proposed that defects in this system can result in a reward deficiency syndrome and that adults with this syndrome are at higher risk for abuse of psychoactive substances. (8) Amino acids, the building blocks of protein, are used to manufacture the neurotransmitters listed above.

Many with EDs and SUDs continue to crave their substance or process even after achieving abstinence for an extended period. It is postulated that this might be a result of reward deficiency syndrome and that supplementation of the amino acid precursors to neurotransmitters might reduce these symptoms and decrease relapse.

Eight of the 20 amino acids are essential, meaning they must be consumed in our diet. For example, adrenaline/noradrenaline is made from the amino acids L-phenylalanine and tyrosine; endorphins are made from D- and DL-phenylalanine; serotonin is made from tryptophan or 5-HTP.

Symptoms that may be part of reward deficiency syndrome include anxiety, stress or tension, which may respond to supplementation with GABA, tryptophan, 5-HTP or taurine. Difficulty concentrating, mental fuzziness, memory problems, depression with apathy and low energy may respond to tyrosine. Hypersensitivity to stimuli (light, noise) and chronic pain may respond to DL-phenylalanine. Insomnia or irritability may respond to 5-HTP or GABA or taurine.

Furthermore, clinical observations have demonstrated specific amino acid deficiency symptoms that are particular to the drug of abuse:

* Stimulant abuse: tyrosine.

* Alcoholism: tryptophan, GABA.

* Opiate dependence: D-phenylalanine, GABA and tryptophan or 5-HTP.

* Carbohydrate cravings: tryptophan/5-HTP, tyrosine and DL-phenylalanine.

Amino acids should be taken along with B-vitamins as noted above. (9)

Therapies for stress

Stress is considered a major factor in the initiation, continuation and relapse of SUDs and EDs. The use of body-centered therapies can reduce physiological measures of stress and reduce symptoms of mood and anxiety disorders.

Massage reduces anxiety in anorexic women and reduces withdrawal symptoms in adults trying to quit smoking. Massage during alcohol withdrawal, when combined with conventional treatment, improves engagement in therapy. Massage therapy is also useful in treating depression and eating disorders. (10)

Acupuncture may reduce relapse from alcohol. In one study, 93.75% of participants who received acupuncture and conventional treatment were abstinent, vs. 42.86% of a control group that received conventional treatment alone. (11)

Acupuncture may be helpful in the treatment of co-occurring disorders seen in both EDs and SUDs, such as depression, anxiety and the symptoms of post-traumatic stress disorder (PTSD). Acupuncture has shown promise in research in reducing withdrawal symptoms and cravings in alcoholics, opiate addicts and cocaine addicts.

Relaxation therapies include guided imagery, biofeedback, meditation and breath work, which may be helpful in treating depression and anxiety. Meditation may reduce drug use (12), and guided imagery may reduce bingeing and purging in BN. (13)

Sleep aids

Sleep problems are common in individuals with SUDs and EDs. Difficulty sleeping may have a negative impact on treatment and on relapse risk.

The use of progressive relaxation training reduced complaints of sleep disturbances in alcoholics. (14)

Valerian root was useful in decreasing complaints of sleep problems in an inpatient setting in patients with co-occurring EDs and SUDs, reducing the need for prescription medication from 53% to 13%. (15) Valerian root can cause an increase in sedation when used with benzodiazepines or alcohol, and it has a characteristic "stinky" odor. The dosage for insomnia is 900 mg at bedtime; safety has been established for use up to 28 days.

Conclusion

Eating disorders and substance use disorders co-occur at very high rates. The mediating factor may be genetics or possibly mood and anxiety disorders. Research on the use of alternative therapies in individuals with ED or SUD is ongoing. The therapies are often low in risk when used appropriately. Integrative medicine, while not considered part of traditional treatment for ED and SUD, can offer significant benefits in conjunction with conventional therapies.

References

(1.) Holderness CC, Brooks-Gunn J, Warren MP. Co-morbidity of eating disorders and substance abuse: review of the literature. Int J Eat Disord 1994 Jul; 16:1-34.

(2.) Ross HE, Ivis F. Binge eating and substance use among male and female adolescents. Int J Eat Disord 1999 Nov; 26:245-60.

(3.) Bulic CM, Sullivan PF. Lifetime comorbidity of alcohol dependence in women with bulimia nervosa. Addict Behav 1997 Jul-Aug; 22:437-46.

(4.) Krug I, Treasure J, Anderluh M, et al. Present and lifetime comorbidity of tobacco, alcohol and drug use in eating disorders: a European multicenter study. Drug Alcohol Depend 2008 Sep l; 97:l69-79.

(5.) Hutchins H. Symposium Highlights--Omega-3 fatty acids: recommendations for therapeutics and prevention. Medscape CME. Published Oct. 19, 2005.

(6.) Taylor MJ, Carney SM, Geddes J, et al. Folate for depressive disorders. Cochrane Database of Systematic Reviews. 2005, Issue 2.

(7.) Coppen A, Bailey J. Enhancement of the antidepressant action of fluoxetine by folic acid: a randomized, placebo-controlled trial. J Affect Disord 2000 Nov; 60:121-30.

(8.) Comings DE, Blum K. Reward deficiency syndrome: genetic aspects of behavioral disorders. Prog Brain Res 2000; 126:325-41.

(9.) Holford P, Miller D, Braly J. How to Quit Without Feeling S**t: The Fast, Highly Effective Way to End Addiction to Caffeine, Sugar, Cigarettes, Alcohol, Illicit or Prescription Drugs. London: Piatkus Books; 2008.

(10.) Hart S, Field T, et al. Anorexia nervosa symptoms are reduced by massage therapy. Eat Disord 2001 Winter; 9:289-99.

(11.) He-Hon L. A retrospective study on the use of acupuncture for the prevention of alcoholic recidivism. Am J Acupuncture 1996; 23:29-33.

(12.) Gelderloos P, Walton KG, Orme-Johnson DW, et al. Effectiveness of the Transcendental Meditation program in preventing and treating substance misuse: a review. Int J Addict 1991 Mar; 26:293-325.

(13.) Esplen MJ, Garfinkel PE. Guided imagery treatment to promote self-soothing in bulimia nervosa: a theoretical rationale. J Psychother Pract Res 1998 Spring; 7:102-18.

(14.) Greeff AP, Conradie WS. Use of progressive relaxation training for chronic alcoholics with insomnia. Psychol Rep 1998 Apr; 82:407-12.

(15.) Ross C, Herman PM, Rocklin O, et al. Evaluation of integrative medicine supplements for mitigation of chronic insomnia and constipation in an inpatient eating disorders setting. Explore (NY) 2008 Sep-Oct; 4:315-20.

BY CAROLYN COKER ROSS, MD, MPH

Carolyn Coker Ross, MD, MPH, is an author, speaker and expert in the field of eating disorders, addictions and integrative medicine. Now in private practice, she formerly headed the eating disorders program at Sierra Tucson and is now a consultant at The Ranch outside of Nashville, Tennessee. Her e-mail address is [e-mail] and her Web site is www.carolynrossmd.com.