Chemical Dependency and Eating Disorders: Are They Really so Different?

STEWART E. COOPER

A biopsychosocial perspective is developed to help counselors integrate assessment, treatment, evaluation, and research with chemical dependency and eating disorders addictions. Although different in content and symptoms, the underlying similarities between these clinical syndromes are clearly seen through this paradigm.

t is unusual to discuss chemical dependency and eating disorders in the same article. After all, one daily hears or sees advertisements for treating the "disease" of alcoholism, yet eating disorders are seldom thought of in this way. Similarly, eating disorders seem to be highly prevalent only in a few specific groups of our society, while alcohol and drug problems exist in almost every strata. The two syndromes are not only listed in completely different sections of DSM-IIIR (APA, 1987), but it is also very rare for a client to receive both diagnoses.

However, this article posits that both of these disorders share very similar underlying processes and that assessment, intervention, and evaluation steps can be planned through a single overriding model. Similar ideas have been proposed by both the National Academy of Sciences (Levinson et al., 1983) and the National Institute of Drug Abuse (NIDA, 1979). To arrive at this point, the commonalities in symptoms, etiology, assessment, and treatment will be explored.

COMMONALITIES OF SYMPTOMS

Both chemical dependency and eating disorders share four typical characteristics. First, the person usually experiences uncontrollable self-destructive behavior (personally and socially). Second, the person often exhibits an initial denial of the extent of compulsive patterns and will also fail to acknowledge the current or future consequences of these patterns. Third, for a significant subgroup of individuals who evidence behaviors of chemical abuse or anorexia and bulimia, deterioration of symptoms and functioning will occur until intervention is begun. Last, the great majority of families of those who have chemical dependency or eating disorder problems are very affected and involved in the patterns (Cooper, 1983; Johnson & Maddi, 1986; Zucker & Gomberg, 1986). In addition, earlier family dysfunction has often played a key role in the development of these self-destructive patterns, with those closest to individuals in these two groups almost always evidencing either pathological involvement or pathological distancing from the identified client (Duke & Nowicki, 1986).

COMMONALITIES OF ETIOLOGY

Jellinek's work in the early 1950s is probably the largest source for the so-called disease model of chemical dependency. Specifi-

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cally, Jellinek (1952) proposed a common pattern of behavioral and physiological symptom formation and recovery with the idea of a disease being loosely defined as a medical phenomenon with a known course. Since that time, multiple researchers (e.g., Tarter, Altemann, & Edwards, 1985; Vaillant, 1983; Wilkinson & Carlen, 1981) have greatly explored and expanded on this viewpoint. In the field of eating disorders, Mitchell and Bandle (1983), Rowland (1970), and Ordman and Kirschenbaum (1985) have summarized a similar disease concept detailing likely physiological symptoms, expectation of their onset, and a description of medical tests that can provide corroborating evidence.

The disease orientation toward etiology has been the single most important factor in helping the public view these disorders as treatable, but there are two major problems with this perspective. One negative problem as far as long-term recovery is concerned is the lack of control over symptomatic behavior that having a "disease" creates. Those programs that are most successful in treating either chemical dependency or eating disorders prepare clients for dealing with possible lapses and for taking responsibility for their improvement (Brownell, Marlatt, Lichtenstein, & Wilson, 1986; Cooper, 1983; Garfinkel & Garner, 1982). A second problem with the disease concept is that it provides a better fit for clients who are more toward the severe end of the symptom continuum. Those who have only mild or moderate difficulties may lose more than they gain given the research on the effects of both primary and secondary labeling, what an individual given a psychiatric label comes to believe his or her own behavior should be, and how others react to persons with that diagnosis (Goldstein, Baker & Jamison, 1980). In other words, clients who buy into the disease concept will see themselves through that perspective, which, in turn, may affect their self-esteem and their future behavior. They may paradoxically come to lose more control because that is the way they believe that people with these addictions act (Critchlow, 1986; Ordman & Kirschenbaum, 1985).

The genetic perspective has investigated the contribution of family of origin to the likelihood of developing either a chemical addiction or eating disorder problem. Goodwin (1984) and McClearn and Erwin (1982) have summarized several studies showing that chemically dependent persons are much more likely to have the disorder present somewhere in their genetic family network. Similarly, Pope and Hudson (1982) reported that first-degree blood relatives of eating disorders clients were 53% likely to have an affective disorder. This, combined with the effectiveness of antidepressant medication in the treatment

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of bulimics and anorexics/bulimics, (Bratman, Herzog, & Woods, 1984; Mendels, 1983), also suggests a moderately strong genetic contribution. The advantage of the genetic etiological perspective is the power of including family history in making a diagnosis, and it should be an important part of the assessment process. The problem with the correlations reported in these studies, as in many other areas of genetic contributions to psychopathology, is that the majority of people with a genetic predisposition do not develop the disorder and that many people who do develop these problems do not have a family history that would suggest genetic involvement.

The psychological etiological perspective has focused on the purpose and evolvement of the maladaptive behaviors that comprise these clinical classifications. Kellam et al. (1983), for example, in the addictions arena, presented a model wherein substances are first used to relieve stress or achieve desired emotional or interpersonal goals. Then, either suddenly or more often gradually the individual becomes involved in using chemicals to attempt to deal with negative physical, personal, and social effects of previous alcohol or drug use. Other addictions researchers, such as Jones (1968, 1971), Kammeier, Hoffman, and Loper (1973) and Marshall (1979), have investigated the relationships among personality, expectations, and problem drinking. Rosen and Leitenberg (1984) have developed a very similar model for eating disorders, in which behaviors that were initiated for apparent positive goals, such as thinness, self-control, and drive lead to a physiological condition that greatly increases affective instability leading to increased symptomology. These goals are particularly important to persons with eating disorders, in that they appear to have a great deal of personal vulnerability (Connors, Johnson, & Stuckey, 1984; Lewis & Johnson, 1985; Schneider & Agras, 1985), especially when combined with very high self-expectations (Goodsitt, 1984).

The psychological model has been paramount in emphasizing the need for therapy in addition to medical support and peer groups in the successful treatment of these disorders. This perspective justifies and provides an important role for counselors in helping those who are caught up in these very selfdestructive cognitive-affective-behavioral patterns. The psychological model in and of itself, however, is overly narrow, and it fails to account for either genetic or sociocultural factors.

The emerging perspective in both fields has been labeled the biopsychosocial model. Zucker and Gomberg (1986) in the area of chemical dependency and Johnson and Maddi (1986) in the area of eating disorders have convincingly drawn together reviews of studies that suggest that some combination of genetics, family environment, personality structure, and sociocultural groups account for the development of these disorders.

The specifics for eating disorders and chemical addictions do differ, but more in manifestation than in purpose. For example, chemically dependent individuals are more likely to have histories of antisocial behavior and academic problems, while eating-disordered individuals are more likely to be high achievers and compliant. Those with addiction problems often are members of a wide variety of cultural and subcultural groups that encourage excessive drinking, while the vast majority of anorexics and bulimics are from the affluent White middle class. (Johnson & Maddi, 1986; Zucker & Gomberg, 1986).

Both chemically dependent and eating-disordered individuals, however, tend to score high on the psychopathic deviance scale of the Minnesota Multiphasic Personality Inventory

Substance and Eating Disorder Addictions

(MMPI) (Graham, 1977; Norman & Herzog, 1983), and the interplay of genetics, family history, personality structure, and sociocultural influences are remarkably parallel for both of these compulsive disorders (Levison, Gerstein, & Maloff, 1983; NIDA, 1979).

The biopsychosocial model has the advantage of not only including the genetic, disease, and psychological perspectives but it also adds the importance of family and cultural factors. As such, it provides a very expansive framework for assessment, intervention, and treatment evaluation. Full-scale adoption of this model by professionals, the media, and the public would be helpful in reducing the stigma of having one of these disorders. Further, I contend that each of the previous etiological perspectives has had its usefulness but that clinging to them will inhibit future progress in research and treatment.

The resistance to a change such as this will be very strong. There are millions, perhaps billions, of dollars that are committed to these earlier perspectives, particularly the disease concept. It will take a determined effort by many counselors and psycholgists to effect what Kuhn (1970) would label a major shift in paradigm. The remaining sections of this article will outline the assessment, treatment, and evaluation procedures that emerge from the biopsychosocial perspective.

DIFFERENTIAL ASSESSMENT

Table 1 outlines the four components that should be investigated in the assessment process. The suggestion to include behavioral, affective, cognitive, and environmental factors in treatment and evaluation of these disorders has been emphasized by prominent researchers in chemical dependency (e.g., Cronkite & Moos, 1980; Levison, Geistein, & Maloff, 1983) and eating disorders (Brownell, 1984; Garner & Garfinkel, 1985). With either chemical addictions or eating disorders, the behavioral aspect includes the frequency, intensity, and duration of problematic behaviors. Along the same vein, the counselor would investigate the feelings before, during, and after these behaviors, as well as the cognition, such as beliefs, values, and perceptions, of the client about himself or herself. The environmental aspect consists of gathering a social and genetic history and of evaluating the current family and interpersonal relationships, particularly in how the addiction or eating disorders is affecting and affected by these other people. The assessment process typically requires 3-5 hours. If it is done over an extended time, it permits the collection of daily data on behavior, affect, and cognitions. This information can be very enlightening for both the counselor and the client. An interpretation and reaction to the objective assessment information would also fit into this framework. In an inpatient setting, accurate assessment is often not possible until the client has reached a stable level of psychophysical balance. Often, information from others who are close to the inpatient client is more helpful at the beginning of the process in the chemical dependency and severe eating disorders.

TABLE 1

Assessment Commonalities of Chemical Dependency and Eating Disorders

Component

Behavioral Affective Cognitive Environmental

Specifics

Frequency, intensity, and duration

Antecedents, experiences, and consequences Beliefs, values, and perceptions

Historical, developmental, and current

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