Stopping Stimulant Use in Eating Disorder Recovery

The last complication to cover in the treatment of ADD and eating disorders is how and when to stop prescribing stimulants.

There are so many reasons people start taking stimulants: as an appetite suppressant, when given them by friends, for depression or for previously diagnosed ADD. So stopping the medications often take a complex, winding road.

First, if stimulants work for a clear ADD diagnosis then there is no reason to stop taking these medications. As explained in previous posts, the key is to be sure both diagnoses are treated and that any potential side effects are attended to.

In other situations, stopping stimulants is more nuanced. For people clearly abusing these medications, the best step is to stop them and work on addiction as part of the treatment. Since stimulants are easily accessible, treatment must include attention to addiction and cravings otherwise a prescription isn’t necessary to continue the medication use. The addiction can vary from severe abuse to relying on these medications as an eating disorder coping mechanism. 

In addition to focusing on addiction, it means focusing on the eating disorder symptoms as well. Without the physiological and psychological crutch these medications offer for appetite suppression and weight loss, patients become very scared of continuing eating disorder recovery without stimulants. So the craving is both an addiction and a fear related to the eating disorder. 

It’s necessary to monitor food carefully during this process and work on countering eating disorder myths about food and weight while processing that stopping stimulants is a necessary step in recovery. It’s enlightening to see how little these medications actually affect food and weight and how the psychological impact is a much larger component of their power.

Stimulant discontinuation can be a marker of significant progress in recovery. Realizing that the steps forward come from one’s internal change rather than the stopping a medication is eye opening. It reveals how recovery comes from within and reflects true steps towards self awareness rather than loss of the power of a medication. Stimulant discontinuation can be a marker for positive change.

How Indecisiveness can Derail Eating Disorder Recovery

A common symptom of ADD and some learning disorders is indecisiveness. For a number of reasons, the process of making decisions, even seemingly inconsequential ones, can be very difficult. The issue is not in the actual decision itself but instead the process of choosing one and committing to it.

Often therapists try to work through the internal emotional struggle around decision making and instead attribute the issue to perfectionism or ambivalence about recovery. More often, the difficulty is related to organization, processing and prioritizing.

Symptoms of ADD lead a person to get stuck on one task for too long and to struggle to prioritize tasks in a timely manner to be able to accomplish them. Medication and CBT (cognitive behavioral therapy) are very effective in managing many ADD symptoms.

The same can be said about decision making. The most important initial step is to recognize that making the decision is much more important than the actual decision that is made. If the goal is to assess the options, make a decision and move forward, it becomes clear that the focus of the learning process is to make the decision and not worry about which decision is correct. 

In eating disorder recovery, decision making is imperative. Patients who struggle to make decisions find choosing food to eat six times per day in their meal plan to be onerous. Often decisions become so difficult that it becomes easier to avoid the decisions and not eat. Despite the desire to recover, decision making can derail recovery.

For people in this situation, a few steps can make a big difference in success with eating.

First, a much more specific and clear meal plan makes a very big difference. That means a plan with exact times to eat and exact amounts of food to eat. By taking decision making out of the equation at first, the goal is simply to follow the plan. 

The transition to creating a new plan not set completely by the team needs to involve only a few decisions per day with a few options. The goal is to practice meal planning and recognize that making a decision matters and the actual decision is less critical.

The biggest worry is that the team mistakes difficulty making decisions with the lack of motivation to get well. This incorrect assessment can be very demoralizing and also can miss the actual obstacle to getting better.

The Muddy Waters between the Diagnoses of an Eating Disorder and ADD

Diagnosing and treating ADD for people with eating disorders is incredibly complicated. For the majority of these patients, they have not been diagnosed with ADD as children. The lack of a formal and reliable process to diagnose ADD in adults creates a seemingly impossible situation.

Eating disorder symptoms often include the most obvious diagnostic criteria of ADD: inattention, difficulty following through with tasks, poor memory and periods of hyper-focus. Food restriction, binging and purging can affect all of these cognitive skills. If someone firsts develops their eating disorder at a young age, then differentiating an eating disorder from ADD is challenging.

Also stimulants, as neuroenhancers, do have a cognitive impact on people who don’t have ADD. That’s why college students share these medications during the most difficult part of the semester. There are nuances between how these medications affect people with and without ADD as I have written about before. But even these criteria are not foolproof.

When eating disorder patients ask about the diagnosis of ADD, which happens with regularity, the psychiatrist is left with a difficult decision. Treating potential ADD symptoms will likely be somewhat beneficial for the patient who will be more productive and effective. Also the psychiatrist and treatment team would need to monitor eating symptoms to see if the medication affects following the meal plan.

Medical monitoring can also allow the psychiatrist to watch for any abuse of the medication and be sure the patient is not misusing it in any way. Stimulant abuse is a common symptom of an eating disorder but harder to identify if the patient is looking elsewhere for the medication rather than working with the team to take it. 

On the other hand, introducing these medications to eating disorder patients can intensify the desire to restrict and perhaps open the door to new behaviors, even precipitating initial thoughts of abuse. 

In the end, there are no easy answers when diagnosing ADD with eating disorder patients and in treating them with stimulants. A clinician needs to consider the best alternatives, monitor with caution and be willing to change course at any time.

Our collective shift towards using medications for personal gain and the acceptance of the ADD diagnosis already complicate how much people should be taking stimulants. Adding an eating disorder to the situation makes it only harder to navigate. 

And so the best alternative is to balance the possible diagnosis, severity of symptoms and risk/benefits of trying this class of medications. The stronger the trust between the patient and treatment team, the higher the likelihood of success.

The Nuances of Determining an ADD Diagnosis

Attention Deficit Disorder has a complicated history in recent decades in psychiatry. This diagnosis used to be considered almost exclusively in children and only for the most obvious cases, largely in boys with hyperactivity. As the clinical approach to this diagnosis has changed and matured, psychiatrists have to consider this diagnosis much more frequently for a variety of reasons. 

First, women often were overlooked and the diagnosis was either missed or instead misdiagnosed as depression, anxiety or laziness. Girls had hyperactivity less frequently and so their symptoms were not noticed often enough. Plus, the internal gender bias in previous generations prioritized girls’ academic success much less. 

Second, psychiatry now considers the diagnosis of ADD much more as a possibility when differentiating possible causes for poor concentration or academic/professional success. So adults who were not diagnosed as children discover ADD may be something they have struggled with for their entire and seek treatment.

Third, stimulants like Adderall and Ritalin, previously seen in a negative cultural light, are now on the border between a medication to treat ADD and a neuroenhancer which enables people to hyper-focus for periods of intense work.

Last, research into the diagnosis of ADD is primarily focused on children. There is no valid standardized testing to diagnose ADD in adults. Although testing can be done, it is far from definitive which leaves the ultimate diagnosis in the hands of the psychiatrist.

Thus, ADD represents a diagnosis that has shifted both in clinical and cultural norms in recent decades. Any psychiatrist is challenged to try to distinguish between the various reasons an adult may be asking to be evaluated for a disorder not easily or clearly diagnosed.

When an eating disorder is present as well, the muddied waters become almost too difficult to navigate. Since eating disorders can cause very similar symptoms to ADD, the process of a formal diagnosis is difficult if not impossible to ascertain.

The diagnosis is based on best guesses using a patient’s history and overall symptoms through childhood and adulthood. Sometimes a trial of a stimulant is the only way to differentiate cognitive deficits caused by an eating disorder from true ADD.

Due to these difficulties, many eating disorder patients end up taking stimulants long term. I’ll discuss how best to manage this complicated scenario in the next post.