Differences in eating disorder symptoms and affect regulation for residential eating disorder patients with problematic substance use

  • Megan L. MichaelEmail author
  • Adrienne Juarascio
Brief Report
Part of the following topical collections:
  1. Food and Addiction



The aim of the current study was to investigate differences in treatment outcomes for residential eating disorder (ED) treatment patients diagnosed with comorbid substance use disorders (SUDs), particularly differences in ED pathology and affect dysregulation.


Secondary data analysis was conducted on data from a previous study of 140 patients at a residential ED facility. SUD was diagnosed by a staff psychiatrist upon admission, and SUD diagnosis was extracted from electronic health records for the current study. Self-report measures of eating pathology and affect dysregulation from pre-treatment and post-treatment assessments were analyzed.


20.1% of the sample (n = 29) were diagnosed with a substance use disorder at the start of treatment. Contrary to hypotheses, those with comorbid SUD did not significantly differ in eating pathology severity, depression symptoms, emotion dysregulation, or psychological acceptance at baseline. Also contrary to hypotheses, individuals with comorbid SUD and ED evidenced slightly larger improvements in certain areas of eating pathology and affect dysregulation throughout treatment than those with ED diagnosis only.


These findings suggest that residential ED treatment is an appropriate treatment choice for individuals with comorbid SUD. The observed improvements in affect dysregulation combined with a period of forced abstinence from maladaptive affect regulation behaviors may explain these positive results, though more research is needed to test the mechanisms of action of residential treatment for this population.

Level of evidence

IV, multiple time series analysis.


Addiction Eating disorder Residential treatment Substance use disorder  



The authors have no acknowledgements.

Compliance with ethical standards

Conflict of interest

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethical approval

The current study was a secondary data analysis of data from a previous study [25]. The previous study was approved by the Institutional Review Board at Drexel University and by the Core Research Committee at the Renfrew Center.

Informed consent

Informed consent was obtained from all individuals included in the study.


  1. 1.
    Fouladi F, Mitchell JE, Crosby RD, Engel SG, Crow S, Hill L, Steffen KJ (2015) Prevalence of alcohol and other substance use in patients with eating disorders. Eur Eat Disord Rev 23(6):531–536. CrossRefPubMedGoogle Scholar
  2. 2.
    Keski-Rahkonen A, Mustelin L (2016) Epidemiology of eating disorders in Europe: prevalence, incidence, comorbidity, course, consequences, and risk factors. Curr Opin Psychiatry 29(6):340–345. CrossRefPubMedGoogle Scholar
  3. 3.
    Mann AP, Accurso EC, Stiles-Shields C, Capra L, Labuschagne Z, Karnik NS, Le Grange D (2014) Factors associated with substance use in adolescents with eating disorders. J Adolesc Health 55(2):182–187. CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Gratz KL, Roemer L (2004) Multidimensional assessment of emotion regulation and dysregulation: development, factor structure, and initial validation of the difficulties in emotion regulation scale. J Psychopathol Behav Assess 26(1):41–54. CrossRefGoogle Scholar
  5. 5.
    Harrop EN, Marlatt GA (2010) The comorbidity of substance use disorders and eating disorders in women: prevalence, etiology, and treatment. Addict Behav 35(5):392–398. CrossRefPubMedGoogle Scholar
  6. 6.
    Levin ME, MacLane C, Daflos S, Seeley JR, Hayes SC, Biglan A, Pistorello J (2014) Examining psychological inflexibility as a transdiagnostic process across psychological disorders. J Contextual Behav Sci 3(3):155–163. CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Schulte EM, Grilo CM, Gearhardt AN (2016) Shared and unique mechanisms underlying binge eating disorder and addictive disorders. Clin Psychol Rev 44:125–139. CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Buckholdt KE, Parra GR, Anestis MD, Lavender JM, Jobe-Shields LE, Tull MT, Gratz KL (2015) Emotion regulation difficulties and maladaptive behaviors: examination of deliberate self-harm, disordered eating, and substance misuse in two samples. Cognit Ther Res 39(2):140–152. CrossRefGoogle Scholar
  9. 9.
    Elmquist J, Shorey RC, Anderson S, Stuart GL (2018) Experiential avoidance and bulimic symptoms among men in residential treatment for substance use disorders: a preliminary examination. J Psychoactive Drugs 50(1):81–87. CrossRefPubMedGoogle Scholar
  10. 10.
    Courbasson CM, Smith PD, Cleland PA (2005) Substance use disorders, anorexia, bulimia, and concurrent disorders. Can J Public Health 96(2):102–106CrossRefGoogle Scholar
  11. 11.
    Joormann J, Stanton CH (2016) Examining emotion regulation in depression: a review and future directions. Behav Res Ther 86:35–49. CrossRefPubMedGoogle Scholar
  12. 12.
    Gibbs EL, Kass AE, Eichen DM, Fitzsimmons-Craft EE, Trockel M, Wilfley DE, Taylor CB (2016) Attention-deficit/hyperactivity disorder-specific stimulant misuse, mood, anxiety, and stress in college-age women at high risk for or with eating disorders. J Am Coll Health 64(4):300–308. CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Killeen T, Brewerton TD, Campbell A, Cohen LR, Hien DA (2015) Exploring the relationship between eating disorder symptoms and substance use severity in women with comorbid PTSD and substance use disorders. Amer J Drug Alcohol Abuse 41(6):547–552Google Scholar
  14. 14.
    Arias JE, Hawke JM, Arias AJ, Kaminer Y (2009) Eating disorder symptoms and alcohol use among adolescents in substance abuse treatment. Subst Abuse 3:SART-S3354. CrossRefGoogle Scholar
  15. 15.
    Yule AM, Carrellas NW, Fitzgerald M, McKowen JW, Nargiso JE, Bergman BG, Wilens TE (2018) Risk factors for overdose in treatment-seeking youth with substance use disorders. J Clin Psychiatry. CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Franko DL, Keshaviah A, Eddy KT, Krishna M, Davis MC, Keel PK, Herzog DB (2013) A longitudinal investigation of mortality in anorexia nervosa and bulimia nervosa. Am J Psychiatry 170(8):917–925. CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Suzuki K, Takeda A, Yoshino A (2011) Mortality 6 years after inpatient treatment of female Japanese patients with eating disorders associated with alcoholism. Psychiatry Clin Neurosci 65(4):326–332. CrossRefPubMedGoogle Scholar
  18. 18.
    Bonfa F, Cabrini S, Avanzi M, Bettinardi O, Spotti R, Uber E (2008) Treatment dropout in drug-addicted women: are eating disorders implicated? Eat Weight Disord 13(2):81–86. CrossRefPubMedGoogle Scholar
  19. 19.
    Elmquist J, Shorey RC, Anderson SE, Temple JR, Stuart GL (2016) The relationship between eating disorder symptoms and treatment rejection among young adult men in residential substance use treatment. Subst Abuse 10:SART-S33396. CrossRefGoogle Scholar
  20. 20.
    Elmquist J, Shorey RC, Anderson S, Stuart GL (2015) Eating disorder symptoms and length of stay in residential treatment for substance use: a brief report. J Dual Diagn 11(3–4):233–237. CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Cohen LR, Greenfield SF, Gordon S, Killeen T, Jiang H, Zhang Y, Hien D (2010) Survey of eating disorder symptoms among women in treatment for substance abuse. Am J Addict 19(3):245–251. CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    O’Malley SS, Sinha R, Grilo CM, Capone C, Farren CK, McKee SA, Wu R (2007) Naltrexone and cognitive behavioral coping skills therapy for the treatment of alcohol drinking and eating disorder features in alcohol-dependent women: a randomized controlled trial. Alcohol Clin Exp Res 31(4):625–634. CrossRefPubMedGoogle Scholar
  23. 23.
    Fernandez-Aranda F, Alvarez-Moya EM, Martínez-Viana C, Sanchez I, Granero R, Penelo E, Penas-Lledo E (2009) Predictors of early change in bulimia nervosa after a brief psychoeducational therapy. Appetite 52(3):805–808. CrossRefPubMedGoogle Scholar
  24. 24.
    Karačić M, Wales JA, Arcelus J, Palmer RL, Cooper Z, Fairburn CG (2011) Changes in alcohol intake in response to transdiagnostic cognitive behaviour therapy for eating disorders. Behav Res Ther 49:573–577. CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Weigel TJ, Wang SB, Thomas JJ, Eddy KT, Pierce C, Zanarini MC, Busch A (2019) Residential eating disorder outcomes associated with screening positive for substance use disorder and borderline personality disorder. Int J Eat Disord 52(3):1–5. CrossRefGoogle Scholar
  26. 26.
    Courbasson C, Nishikawa Y, Dixon L (2012) Outcome of dialectical behaviour therapy for concurrent eating and substance use disorders. Clin Psychol Psychother 19(5):434–449. CrossRefPubMedGoogle Scholar
  27. 27.
    Courbasson CM, Nishikawa Y, Shapira LB (2010) Mindfulness-action based cognitive behavioral therapy for concurrent binge eating disorder and substance use disorders. Eat Disord 19(1):17–33. CrossRefGoogle Scholar
  28. 28.
    Juarascio A, Shaw J, Forman E, Timko CA, Herbert J, Butryn M, Lowe M (2013) Acceptance and commitment therapy as a novel treatment for eating disorders: an initial test of efficacy and mediation. Behav Modif 37(4):459–489. CrossRefPubMedGoogle Scholar
  29. 29.
    Fairburn CG, Beglin SJ (1994) Assessment of eating disorders: interview or self-report questionnaire? Int J Eat Disord 16(4):363–370PubMedGoogle Scholar
  30. 30.
    Luce KH, Crowther JH (1999) The reliability of the eating disorder examination-Self-report questionnaire version (EDE-Q). Int J Eat Disord 25(3):349–351.;2-M CrossRefPubMedGoogle Scholar
  31. 31.
    Goldberg D, Bridges K, Duncan-Jones P, Grayson D (1988) Detecting anxiety and depression in general medical settings. BMI 297(6653):897–899. CrossRefGoogle Scholar
  32. 32.
    Holm J, Holm L, Bech P (2001) Monitoring improvement using a patient-rated depression scale during treatment with anti-depressants in general practice A validation study on the Goldberg Depression Scale. Scand J Prim Health Care 19(4):263–266. CrossRefPubMedGoogle Scholar
  33. 33.
    Forman EM, Herbert JD, Juarascio AS, Yeomans PD, Zebell JA, Goetter EM, Moitra E (2012) The Drexel defusion scale: a new measure of experiential distancing. J Contextual Behav Sci 1(1–2):55–65. CrossRefGoogle Scholar
  34. 34.
    Cardaciotto L, Herbert JD, Forman EM, Moitra E, Farrow V (2008) The assessment of present-moment awareness and acceptance: the Philadelphia Mindfulness Scale. Assessment 15(2):204–223. CrossRefPubMedGoogle Scholar
  35. 35.
    Bond FW, Hayes SC, Baer RA, Carpenter KM, Guenole N, Orcutt HK, Zettle RD (2011) Preliminary psychometric properties of the Acceptance and Action Questionnaire-II: a revised measure of psychological inflexibility and experiential avoidance. Behav Ther 42(4):676–688. CrossRefPubMedGoogle Scholar
  36. 36.
    Fowler JC, Charak R, Elhai JD, Allen JG, Frueh BC, Oldham JM (2014) Construct validity and factor structure of the difficulties in emotion regulation scale among adults with severe mental illness. J Psychiatr Res 58:175–180. CrossRefPubMedGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Center for Weight and Lifestyle SciencesDrexel UniversityPhiladelphiaUSA
  2. 2.Department of PsychologyDrexel UniversityPhiladelphiaUSA

Personalised recommendations