“Drunkorexia” Treatment Strategies for Co-Occurring Eating Disorders and Alcohol Use Disorders

Dorie McCubbrey, MSEd, PhD, LPC, CEDS Creator, Eating Disorder Intuitive Therapy (EDIT)™ Owner & Clinical Director, Positive Pathways

Eating Disorder Intuitive Therapy 165 Cook Street • Suite 10 EDIT™ Certified Counselors Denver CO 80206 720-606-3242 PositivePathways.com Learning Objectives

1. Review recent research regarding “drunkorexia” and describe the specific DSM-5 behaviors indicative of a co-occurring Eating Disorder (ED) - Alcohol Use Disorder (AUD)

2. Discuss an integrative treatment approach called Eating Disorder Intuitive Therapy (EDIT)™ featuring evidence-based practices

3. Evaluate EDIT™ treatment strategies using case studies of clients in recovery from co-occurring ED-AUD In Memory of Laurence Freedom, LPC, LAC

April 9, 1954 - November 13, 2016 About the Presenter: Dr. Dorie McCubbrey

• PhD – Biomedical Engineering (University of Michigan) • MSEd – Clinical Counseling (University of Akron) • LPC – Licensed Professional Counselor (#2532) • CEDS – Certified Eating Disorder Specialist (IAEDP) • LAC (expected in 2017) – Licensed Addiction Counselor • Owner & Clinical Director – Positive Pathways, Ltd • Bestselling Author – two books; currently writing third book • Media Features – Denver 7 News, FOX News, Shape Magazine, & many more • Creator, Trainer & Supervisor – Eating Disorder Intuitive Therapy (EDIT)™ What is “Drunkorexia”?

Co-Occurring Alcohol Abuse & Eating Disorder Behaviors

• 39th Annual Research Society on Alcoholism (June, 2016) • Rinker et. al. – 1200 college students’ drinking behaviors • 80% combined drinking with eating disorder behaviors • equal number of men / women with “drunkorexia” behaviors • ED behaviors included fasting, self-induced vomiting • binge drinkers more likely to engage in ED behaviors • desire to reduce calories and increase alcohol’s effects “Drunkorexics” Are Thinking…

If I throw up I won’t gain weight

I can’t wait for happy hour – to heck with appetizers, I wanna get buzzed!

I’m on the “alcohol diet”– if I get hungry, just do a shot! If I throw up then I can drink more Drunkorexia Quiz

1. I skip one or more meals if I know I’m going out drinking later. 2. When I drink, I always have at least 3 drinks, and usually more. 3. I’m trying to lose weight, or worried about gaining weight. 4. I make myself throw up after eating and/or drinking, to save calories. 5. I like to drink on an empty stomach so I get buzzed more quickly. 6. If alcohol is not available when I want to drink, I feel agitated and upset. 7. I track my calories (i.e., using a fitbit), to stay below a target number. 8. I try to exercise before draining to compensate for the calories in alcohol. 9. I avoid eating while I’m drinking to keep my calories consumed lower. 10. I use laxatives to get rid of food I eat before or during drinking.

Scoring: count the number of questions answered YES 0: Body-Accepting Socializer – low risk of eating disorders / alcoholism 1-3: Dieting Drinker – medium risk or eating disorders / alcoholism 4-6: Weight-Obsessed Partier – high risk of eating disorders / alcoholism 7-10: Drunkorexic – you probably have an eating disorder and/or alcoholism DSM-5: Anorexia Nervosa (AN)

A. Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health. Significantly low body weight is defined as a weight that is less than minimally normal or, for children and adolescents, less than minimally expected.

B. Intense fear of gaining weight or becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight.

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 persistent lack of recognition of the seriousness of the current low body weight. DSM-5: Anorexia Nervosa (AN)

The ICD-10-CM code depends on subtype: Restricting Type: During the last 3 months, the individual has not engaged in recurrent episodes of binge eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas). This subtype describes presentations in which weight loss is accomplished primarily through dieting, fasting, and/or excessive exercise. Binge-eating/purging type: During the last 3 months, the individual has engaged in recurrent episodes of binge eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas). DSM-5: Anorexia Nervosa (AN)

Specify current severity: The minimum level of severity is based, for adults, on current body mass index (BMI) or, for children and adolescents, on BMI percentile. The ranges below are derived from World Health Organization categories for thinness in adults; for children and adolescents, corresponding BMI percentiles should be used. The level of severity may be increased to reflect clinical symptoms, the degree of functional disability, and the need for supervision. Mild: BMI ≥ 17 kg/m2 Moderate: BMI 16-16.99 kg/m2 Severe: BMI 15-15.99 kg/m2 Extreme: BMI < 15 kg/m2 DSM-5: Bulimia Nervosa (BN)

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 what most individuals would eat in a similar period of time 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). DSM-5: Bulimia Nervosa (BN)

B. Recurrent inappropriate compensatory behaviors in order to prevent weigh gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise.

C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months.

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

E. The disturbance does not occur exclusively during episodes of anoxia nervosa. DSM-5: Bulimia Nervosa (BN)

Specify current severity: The minimum level of severity is based on the frequency of inappropriate compensatory behaviors. The level of severity may be increased to reflect other symptoms and the degree of functional disability. Mild: An average of 1-3 behaviors per week Moderate: An average of 4-7 behaviors per week Severe: An average of 8-13 behaviors per week Extreme: An average of 14 or more behaviors per week DSM-5: Binge-Eating Disorder (BED)

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 what most individuals would eat in a similar period of time 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). DSM-5: Binge-Eating Disorder (BED)

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 feeling embarrassed by how much one is eating. 5. Feeling disgusted with oneself, depressed, or very guilty afterward. DSM-5: Binge-Eating Disorder (BED)

C. Marked distress regarding binge eating is present.

D. The binge eating occurs, on average, at least once a week for 3 months.

E. The binge eating is not associated with the recurrent use of inappropriate compensatory behavior as in bulimia nervosa and does not occur exclusively during the course of bulimia nervosa or anorexia nervosa. DSM-5: Binge-Eating Disorder (BED)

Specify current severity: The minimum level of severity is based on the frequency of inappropriate compensatory behaviors. The level of severity may be increased to reflect other symptoms and the degree of functional disability. Mild: 1-3 binge-eating episodes per week Moderate: 4-7 binge-eating episodes per week Severe: 8-13 binge-eating episodes per week Extreme: 14 or more binge-eating episodes per week DSM-5: Alcohol Use Disorder (AUD)

A. A problematic pattern of alcohol use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:

1. Alcohol is often taken in larger amounts or over a longer period than was intended. 2. There is a persistent desire or unsuccessful efforts to cut down or control alcohol use. 3. A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects. 4. Craving, or a strong desire or urge to use alcohol. DSM-5: Alcohol Use Disorder (AUD)

5. Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home. 6. Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol. 7. Important social, occupational, or recreational activities are given up or reduced because of alcohol use. 8. Recurrent alcohol use in situations in which it is physically hazardous. 9. Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol. DSM-5: Alcohol Use Disorder (AUD)

10. Tolerance, as defined by either of the following: a. A need for markedly increased amounts of alcohol to achieve intoxication or desired effect. b. A markedly diminished effect with continued use of the same amount of alcohol. 11. Withdrawal, as manifested by either of the following: a. The characteristic withdrawal syndrome for alcohol (refer to Criteria A and B of alcohol withdrawal). b. Alcohol (or a closely related substance, such as a benzodiazepine) is taken to relieve or avoid withdrawal symptoms Specify current severity: Mild: Presence of 2-3 symptoms Moderate: Presence of 4-5 symptoms Severe: Presence of 6 or more symptoms Co-Morbidity of ED-SUD

Eating Disorder Patients 50 50% Alcohol or Illicit 37.5 Substance Abusers 35% 25

General

% POPULATION % 12.5 Population General 9% Population 3% 0 Meet Criteria for SUD Meet Criteria for ED Natl Ctr on Addiction & Substance Abuse at Columbia Univ (2003), Accessed: 20.02.13 Co-Morbidity of ED-SUD/AUD

• More recent literature review revealed co-morbidity rates between 17-46% Harrop et. al. (2013), Addict Behav, 35 • Co-morbid AN/BN and SUDs may be more prevalent – purging behavior more associated with SUDs Root et. al. (2010), Intl J ED, 43 • Alcohol abuse more common in AN (purging type), BN, BED Piran et. al. (2006), Addict Behav, 31 • Having an ED was more likely to lead to the development of an AUD than the reverse Franko et. al. (2005), Intl J ED, 38 What is the Cause of ED-AUD?

• Psychological (trauma, affective instability, impulsivity)

• Cognitive-Behavioral (abstinence leading to binges)

• Neurobiological (dopamine, serotonin, GABA, opioids)

• Hormonal (ghrelin, leptin, insulin, cortisol)

• Genetic (separate genetic factors seem to contribute)

• Other Psychopathology (ADHD, PTSD, GAD, MDD)

Research indicates separate etiologies and courses for each disorder, but what causes both to occur together? What is the Purpose of ED-AUD?

Let’s ask people with EDs, “Why do you drink alcohol”?

• Relax

• Sleep

• Socialize

• Endure pain

• Numb intense emotions

• Control ED behaviors (reduce binges/purges) What is the Purpose of ED-AUD?

Let’s ask people with AUDs, “Why do you skip meals, etc.”?

• Feel effects of alcohol more quickly

• Consume less alcohol for desired effect

• Be less likely to be confronted about use

• Lessen the effects of hangovers

• Control AUD behaviors What is the Purpose of ED-AUD?

The combination of ED-AUD allows people to…

• Avoid some negative consequences, i.e., weight gain

• Numb the pain of one by using the other

• Control symptoms of one while using the other

• Amplify the effects of either ED or AUD alone

We need to guide our clients to discover: what is your true hunger/thirst/craving? “Hungry Ghosts”

“The inhabitants of the hungry ghost realm are depicted as creatures with scrawny necks, small mouths, emaciated limbs, and large, bloated, empty bellies. This is the domain of addiction, where we constantly seek something outside ourselves to curb an insatiable yearning for relief or fulfillment. The aching emptiness is perpetual because the substances, objects, or pursuits we hope will soothe it are not what we really need.” Gabor Maté, MD In the Realm of Hungry Ghosts Case Study I: “Alice”

• was initially AN (restricting) • shifted to AN (binge/purge) • started substituting alcohol for food (days w/o eating) • developed significant alcohol withdrawal symptoms • began measuring alcohol for controlled use all day Case Study II: “Betty”

• was initially BED (had gastric bypass surgery) • developed BN ~ 2 yrs after bariatric procedure • typically skips meals before consuming alcohol • began experiencing “blackouts” while drinking Case Study III: “Carl”

• past history of AN and BN • currently alternates periods of dieting with binge eating (BED) • tends to pair binge drinking with binge eating on weekends • has food and wine delivered to his home during binge episodes Case Study IV: “Debbie”

• long history of AN (restricting) • binge drinker in college • sober 20+ years; resumed drinking after husband’s death • early remission of AUD ~1mo • recurrence of AN (binge/purge) Case Study V: “Edith”

• long history of AUD • currently in sustained remission of AUD; sober 5+ yrs • developed BED in early sobriety • “sugar is my new drug” Outpatient Treatment for Eating Disorders & Addiction

• Dorie McCubbrey, LPC • Rebecca Sculley, LPC • Janelle Hunt, RD • Share Holland, LPCC • Beth Letourneau, LPCC • Whitney Geenen, LPCC • Abby Hansen, BA • Kristen Ales, BA

Individual, Couples & Family Counseling • Support & Therapy Groups • 1-on-1 IOP Nutrition Counseling • Art Therapy • Wilderness Therapy • Yoga Therapy Integrative Treatment: ED-AUD

Abstinence Model vs. Moderation Management

• Nutrition Counseling with Intuitive/Mindful Eating for ED

• Motivational Interviewing with Harm Reduction for AUD

• Cognitive Behavioral Therapy (CBT)

• Dialectical Behavior Therapy (DBT)

• Acceptance & Commitment Therapy (ACT)

• Somatic Therapy (Wilderness Therapy, Yoga Therapy)

• Expressive Arts (Art Therapy, Journal Therapy) Eating Disorder Intuitive Therapy (EDIT)™

A Comprehensive and Holistic Treatment Approach Eating Disorder Intuitive Therapy (EDIT)™

ED-AUD EDIT™

false self True Self “hiding” “healing”

A Comprehensive and Holistic Treatment Approach EDITTM theory: EDITTM principles: EDITTM outcomes:

CBT/DBT/ACT Love Your Self Healthy Self-Image Voice Dialogue Be True To Your Self “Normal” Eating Jungian Express Your Self Emotion Regulation Transpersonal Give To Your Self Self-Care Practices Intuitive Eating Believe In Your Self Relapse Prevention EDIT™ Principle #1: Love Your Self

• Body Image Improvement • Values Clarification • Holistic Sense of Self • Compassionate Self-Talk EDIT™ Principle #2: Be True To Your Self

• Intuitive Wisdom • Intuitive Eating • Intuitive Exercise • Intuitive Drinking EDIT™ Principle #3: Express Your Self

• Thoughts-Feelings-Needs • Healthy Coping Skills • Healing Core Issues (Trauma) • Underlying Cause of ED-SUD EDIT™ Principle #4: Give To Your Self

• Proactive Recovery Practices • Routines of Self-Care • Re-parenting Oneself • ED-SUD Behavior Prevention EDIT™ Principle #5: Believe In Your Self

• Relapse Prevention Skills

• Long-Term Recovery

• Know Vulnerabilities

• Monitor “Voice of Addiction” ™ Love Your Self EDIT Worksheet #7: Self-Image #1: ED-IT Dialogue

Are you aware of a critical thought you’ve had recently – maybe one you're thinking right now? That’s the voice of your Eating Disorder (ED), which is like an “inner critic.” You also have an “inner guide” which speaks with compassion – that’s the voice of your Intuitive Therapist (IT). It might seem like ED is the only voice you can hear ED-IT Dialogue in your mind, but as recovery progresses, you’ll be able to turn up the volume of IT. Your EDIT™ Certified practitioner can model the voice of IT for you until you can hear IT clearly within your Self!!

ED’s critical thought (exactly as you say it to yourself):

IT’s compassionate reply (“another possibility is…”): • Explain voices of ED vs. IT

ED’s argument (what you’d say back to IT):

IT’s nonjudgmental observation (“that’s interesting…”): • Role play dialogue with client

ED’s retort (what you think about this “other voice”):

IT’s curious query (“what would happen if…”): • Client can practice at home

If you “get stuck,” ask a friend or your EDIT™ Certified practitioner for help!

©2015 by Dr. Dorie McCubbrey, reprint only with permission • EDIT™ Worksheets (Version 3.0) • purchase your copy at: EDITcertified.com ™ Be True To Your Self EDIT Worksheet #21: Intuitive Eating #1: The Three Reasons WHY We Eat

The reasons why we eat can be categorized into three main areas. Let’s explore each:

1. HUNGER – this is your body’s PHYSICAL NEED for food (to satisfy energy requirements, support nutritional Reasons WHY We Eat needs, sustain the body’s life). What are ways you recognize hunger in your body?

An INSATIABLE HUNGER (need for large amounts of food, or a need to eat very often) can be triggered after periods of fasting, extreme dieting, or ANOREXIA. Has this happened to you? Describe the details::

• Hunger, Appetite, Comfort 2. APPETITE – this is a PHYSICAL DESIRE for food, based on TASTE or SENSES (smell of food, seeing an advertisement for food, etc). Describe your appetite for food, and how this differs from hunger:

An INSATIABLE APPETITE (desire for large amounts of food, or to eat very often) can occur in response to eating specific foods, sometimes called “trigger foods.” The theory is that the “pleasure center” of the brain is stimulated by these “trigger foods,” similar to what occurs in people with alcohol/drug addiction. Hence, the term FOOD ADDICTION is often used to describe this extreme craving. • OK to eat for all 3 reasons Do you seem to have some “trigger foods”? List them here, and what typically happens when you eat these:

3. COMFORT – this is an EMOTIONAL DESIRE for food, based on MOOD (depression, anxiety, etc). Eating creates various biochemical changes in the body, which can have an effect on emotions. Do you have“comfort foods,” which you occasionally eat as a means of self-soothing? Describe: • Extremes related to EDs An INSATIABLE COMFORT CRAVING (desire for large amounts of food, or to eat very often) can occur when the food-mood behavior is used as a means of COPING with emotions on a regular basis, especially as a means of coping with past traumas. This type of behavior is linked to BINGE EATING DISORDER and BULIMIA. Do you use food as a means of coping? How often? What are your emotional triggers?

©2015 by Dr. Dorie McCubbrey, reprint only with permission • EDIT™ Worksheets (Version 3.0) • purchase your copy at: EDITcertified.com ™ Express Your Self EDIT Worksheet #43: Healing #1: Symptoms as Messengers

If you engage in ED behaviors, take this opportunity to learn what ED might be here to teach you. Symptoms as Messengers Remember your foundation of Self-Love as you complete this worksheet with compassion!

STEP 1 – Describe the ED event, specifically noting the type of ED BEHAVIOR you used, and its intensity:

STEP 2 – Identify any possible TRIGGERS for the ED event. Recall where you were, who you were with, • Compassionate perspective and what you were doing right before the ED event:

STEP 3 – Recall your THOUGHTS and FEELINGS leading up to the ED event. Note whether you were aware of having these thoughts and feelings at the time, or if your awareness is only after the fact:

• STEP 4 – Reflect about how the ED event began. Did it seem like you had NO CONTROL over it – Identify triggers of ED event suddenly you were engaged in ED behaviors? Or did you have CONTROL – did you plan it? Describe:

STEP 5 – If you had a DO-OVER, what would you do differently to PREVENT the ED event? Consider actions you could take based on what you described in STEPS 2-4 above. • Interventions and insights STEP 6 – What is your overall MESSAGE from ED? What might ED be here to teach you?

©2015 by Dr. Dorie McCubbrey, reprint only with permission • EDIT™ Worksheets (Version 3.0) • purchase your copy at: EDITcertified.com ™ Give To Your Self EDIT Worksheet #50: Self-Care Routine #4: Recovery Is My #1 Priority!

SELF-CARE is a proactive practice – when you are “filled from within,” you can more effectively give to others Recovery Priority throughout your day, and be better prepared to handle any challenges which come your way,. Reflect about the four aspects of your Self (SOUL-HEART-MIND-BODY) and what SELF-CARE means for each:

SOUL HEART MIND BODY

Now that you know WHAT you intend for Self-Care, consider WHEN/HOW you’ll implement it:

DAILY SELF-CARE INTENTIONS: • Holistic Self-Care WAKING MORNING BREAKFAST LUNCHTIME AFTERNOON DINNERTIME EVENING BEDTIME

• Daily, Weekly Planning WEEKLY SELF-CARE INTENTIONS: SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY • Monthly, Yearly, Long-Term SATURDAY LONG-TERM SELF-CARE INTENTIONS:

MONTHLY QUARTERLY YEARLY

©2015 by Dr. Dorie McCubbrey, reprint only with permission • EDIT™ Worksheets (Version 3.0) • purchase your copy at: EDITcertified.com ™ Believe In Your Self EDIT Worksheet #54: Recovery #1: Winning the War Within

Sometimes it can seem like you have a “war within” – between the positives and negatives of recovery. Sometimes you might feel committed to recovery, while other times you’re not so sure. It’s important to honor all of your Winning War Within thoughts and feelings about recovery, without judgment. Make notes on the “4-Corner Grid” illustration below: NEGATIVES of ED POSITIVES of IT (consequences of quitting recovery) (benefits of staying in recovery)

• Resolving conflicts about recovery

POSITIVES of ED NEGATIVES of IT (benefits of quitting recovery) (consequences of staying in recovery) • Risks and benefits of ED

• Risks and benefits of recovery In which corners of the grid did you write the most? Which corners seem most compelling? What is causing your “war within,” and how can recovery win? Ask your EDIT™ Certified practitioner for help to enhance the wisdom expressed on the top half of the grid, and to address any concerns revealed in the bottom half of the grid. Note your observations and action steps:

©2015 by Dr. Dorie McCubbrey, reprint only with permission • EDIT™ Worksheets (Version 3.0) • purchase your copy at: EDITcertified.com Case Study I: “Alice”

• 30-day residential tx for AUD • meal plan from a dietitian • core issue of parental abandonment • left abusive marriage • mild BED in early sobriety • now 5+yrs sober, ED-free Case Study II: “Betty”

• strategies to reduce alcohol consumption (harm reduction) • reviewed bariatric meal plan, strategies for compliance • core issues of sexual traumas • exploring skills for development of healthy relationships • currently consumes ~6 drinks/wk; BN episodes ~1-3/wk Case Study III: “Carl”

• strategies for “social drinking” (no alcohol at home) • emphasis on diet-free lifestyle, intuitive eating strategies • coping skills for work stress • no binge-eating/drinking past 3 mo; consumes ~4 drinks/wk Case Study IV: “Debbie”

• improvements in body image leading to weight restoration • nutrition counseling, intuitive and mindful meal strategies • core issues of grief/loss • continued remission AUD ~9mo • binge/purge episodes <1x/wk Case Study V: “Edith”

• intuitive/mindful meal strategies to make peace with food • core issues of childhood neglect • re-parenting & inner child work • sustained remission of AUD ~6yr • no binge episodes ~1 yr ED-AUD Treatment Summary

• meet clients where they are and offer customized treatment plan • make accurate diagnosis of the type and severity of ED and incorporate interventions to reduce ED behaviors • assess severity of AUD and use a harm reduction model to guide clients to make“intuitive decisions” about alcohol intake • utilize EDIT™ principles to address body image issues, intuitive and mindful eating skills, emotion regulation, healthy coping skills, healing of core issues, self-care and re-parenting skills, relapse prevention, strategies for long-term recovery Filled from Within: hunger/thirst/craving to be ones True Self Complete Recovery Is Possible Resources at Positive Pathways

Breakthrough Recovery Support Group Tuesdays, 6-7:30pm

Affordable ED-SUD Treatment $35/session – $350/week IOP

Eating Disorder Intuitive Therapy (EDIT)™ Training, Clinical Supervision & Certification

PositivePathways.com/drunkorexia-diet Presentation Slides, Drunkorexia Quiz & Other Resources Dorie McCubbrey, MSEd, PhD, LPC, CEDS Creator, Eating Disorder Intuitive Therapy (EDIT)™ Owner & Clinical Director, Positive Pathways 165 Cook Street • Suite 10 Denver CO 80206 720-606-3242

EDITcertified.com PositivePathways.com [email protected] [email protected]