National Eating Disorders Association

Dear Lesley: What is Symptom Substitution?

Dr. Lesley Williams is a certified eating disorder specialist, family medicine physician and positive body image advocate. She co-owns Liberation Center, an eating disorder treatment facility, in Phoenix, Arizona. Dr. Williams is dedicated to ensuring that all women and men that struggle with eating and body image issues receive the help that they need to overcome and live happy, healthy lives.

Dr. Williams regularly educates other healthcare professionals about the diversity and dangers of eating disorders. She has made several media appearances as an eating disorder expert and regularly speaks at national conferences. Her most recent body image advocacy project is writing the children’s book, Free to Be Me. It encourages young girls and boys to love their bodies, no matter what size, and is scheduled to be released later this year.

I struggled with alcohol dependence, self-harm and an eating disorder. Can you speak about symptom substitution--what it means, what it serves, how people can work through it?

Symptom substitution basically means when someone struggles with more than one issue, like an eating disorder and substance abuse, and they improve in one area but the other gets worse. This is a fairly common phenomenon. I frequently see patients who struggle with an eating disorder and co-occurring illnesses. When they go into eating disorder-specific treatment and all of the focus is just on their eating, they find that their urges to engage in other behaviors greatly increase. 

To work through symptom substitution, the main focus needs to be on the underlying function of the disorder. For instance, if we know that the eating disorder, cutting or substance use is a way to numb painful emotions, we need to focus on learning how to tolerate emotional distress.

If we just look at the eating issues and get those under control, when the next painful emotional issue arises, the person will just resort to another coping strategy to numb their feelings. In the past, treatment providers thought it was too overwhelming to address all of someone’s issues at one time.

However, symptom substitution has since taught us that if you don’t address everything at once, you will forever be chasing the symptoms instead of dealing with the root of the problem. That is what is required to achieve long lasting recovery.

Thank you so much for your question. Recognizing that you have these struggles is a huge step. I encourage you to find treatment providers who are well-versed in handling eating disorders, substance use and self-harm simultaneously. Symptom substitution is best addressed with a strong team supporting you.