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Despite much research, there is little evidence upon which to provide clear guidance on the treatment of comorbid ED and AOD use disorders. Research from single disorder ED suggests that comprehensive assessments conducted by a multidisciplinary team should be followed by psychotherapy as the first line of treatment (CBT-based approaches for both bulimia nervosa and binge eating disorder). Although there is some evidence that pharmacotherapy may be a useful adjunct to the treatment of single disorder ED (particularly binge eating disorder), the evidence is not conclusive and Australian clinical guidelines do not recommend its use in the absence of psychotherapy [893].

Box 20 illustrates the continuation of case study H, following Charlotte’s story after she presented to an AOD service for benzodiazepine and stimulant use. As illustrated, the presence of a comorbid ED and AOD use disorder is not easily identifiable, and can be difficult to treat.

Box 20: Case study H: Treating comorbid ED and AOD use: Charlotte’s story continued

Over the next few weeks, Charlotte continued to attend sessions with the AOD worker, and, although her mother was still driving her to and from appointments, she would remain in the waiting room. The AOD worker had been using MI and CBT approaches, but Charlotte admitted that she had still been using Valium and stimulants.

After several weeks, in a joint session with Charlotte and her mother, Charlotte’s mother mentioned that she was still concerned about Charlotte, particularly about her apparent obsession with running up and down the stairs. When questioned further, Charlotte’s mother said that she had been running up and down the stairs repetitively, every evening, sometimes for an hour or more. She often did this after meal times. Earlier in the week Charlotte’s mother found her in the kitchen in the middle of the night and suspected she had eaten the lasagne and pavlova she had made for the following day’s family meal. She also thought that she had heard Charlotte vomiting soon after eating.

The AOD worker spoke privately with Charlotte, and Charlotte said that she had been exercising to lose weight, as she was unhappy with her size and shape, and had been taking the stimulants to stop feeling hungry. She also said that the stimulants gave her energy throughout the day, although she had trouble sleeping and often felt agitated and on edge. Charlotte said that she liked taking Valium to help her get to sleep and calm down. It also became evident that, instead of going to classes at university, Charlotte had been going to the gym and running on the treadmill. She told the AOD worker that if she was ever unable to get to the gym at her usual time, she felt incredibly anxious and couldn’t stop thinking about it. It was not unusual for Charlotte to spend several hours running on the treadmill at the gym every day.

The AOD worker consulted with an ED specialist, who arranged with Charlotte and her mother to attend an assessment. Charlotte was moderately underweight (with a BMI of 17) and the specialist arranged for a complete physical assessment, including her heart rate, blood pressure, temperature, metabolic tests, assessments for any cognitive changes, and contributing factors. Charlotte’s family were encouraged to maintain involvement with her ongoing treatment, and the specialist devised a plan that included psychoeducation with her family’s involvement, and MI, medical stabilisation, reversal of the cognitive effects of starvation, and psychological treatment. However, because of the complexities involved in Charlotte’s bulimia nervosa, including the use of stimulants and benzodiazepines, the specialist recommended inpatient treatment at a specialised ED facility.

Key points

  • ED can be difficult to identify in people with AOD use disorders.
  • Once an ED has been identified, it is vital that the client receives a comprehensive physical assessment by a medical professional. The primary focus is on stabilising the client’s physical health and restoring cognitive function, and then psychotherapy can begin.
  • The AOD worker should maintain client engagement, even if a referral to an ED specialist is made.