Elsevier

Eating Behaviors

Volume 1, Issue 2, December 2000, Pages 173-189
Eating Behaviors

Eating disorders and substance use: An examination of behavioral associations

https://doi.org/10.1016/S1471-0153(00)00017-9Get rights and content

Abstract

The association between the eating disorders of anorexia nervosa (AN) and bulimia nervosa (BN) and substance use disorder (SUD) has been widely investigated, however, our understanding of the relationship between the disorders remains unclear. Explanatory models have tended to focus on behaviors, yet, little is currently known about the patterns of association among disordered eating and substance use behaviors. In this exploratory study, a behavioral approach was used to investigate the cooccurrence of seven disordered eating and three substance use behaviors in women meeting current DSM-III-R criteria for AN (n=12), subthreshold AN (n=14), BN (n=29), and subthreshold BN (n=24). Results suggest that disordered eating behaviors are differentially associated with substance use behaviors. The most robust finding was that diuretic use positively predicted the current level of alcohol use regardless of diagnostic group. The findings for marijuana and tobacco use were less consistent. Results suggest that rather than being pervasive in all eating disordered women, higher levels of alcohol use may be found in those women who use diuretics.

Introduction

The eating disorders of anorexia nervosa (AN) and bulimia nervosa (BN) are widely believed to be systematically associated with substance use disorder (SUD). The SUD diagnosis includes substance abuse which is a maladaptive pattern of use and substance dependence, which indicates impaired control over use (American Psychiatric Association (APA), 1994). A considerable amount of research effort has been devoted to clarifying the nature of the relationship between the eating disorders and SUD in an effort to develop more effective prevention and treatment strategies (see Goldbloom, 1993, Holderness et al., 1994, Krahn, 1991 for reviews). Despite this ongoing effort, however, the nature of the relationship between the disorders remains unclear.

Research on the association between the eating disorders and SUD has been primarily in the form of comorbidity studies. Generally, comorbidity studies focus on cases in which individuals simultaneously meet diagnostic criteria for two disorders. The primary purpose of comorbidity studies is to answer important questions about etiology and course of illness, however, methodologic limitations associated with this type of study often result in inconsistent findings Belfer, 1993, Caron & Rutter, 1991, Miller, 1994, Wittchen, 1996. Studies that have focused on the comorbidity of eating disorders and SUD are no exception. Because many studies fail to use a standardized diagnostic classification system, it is often difficult to discern the specific characteristics of the samples. In addition, because studies vary widely in the timing of the assessment relative to the age of onset and progression of each disorder, comparison across studies is difficult (Wonderlich & Mitchell, 1997). As a result of these methodological issues, findings from existing studies vary widely with the magnitude of comorbidity ranging from 5% to 50% (cf. Holderness et al., 1994, Krahn, 1991), complicating efforts to interpret the pattern of results.

Although the exploration of the relationship between the eating disorders and SUD has been primarily at the general level of cooccurring diagnoses, models of etiology have tended to focus on the cooccurrence of specific behaviors. That is, specific behaviors comprising the disorders are conceptualized as stemming from a single common cause. For example, some investigators argue that bingeing, purging, and abuse of substances such as alcohol or illicit drugs represent expressions of the underlying personality trait of impulsivity Fahy & Eisler, 1993, Favaro & Santonastaso, 1995, Garfinkel et al., 1980, Hatsukami et al., 1986, Keel et al., 2000, Lacey, 1993, Lacey & Evans, 1986, Lacey & Moureli, 1986, Taylor et al., 1993, Timmerman et al., 1990, Toner et al., 1986, Weiderman & Pryor, 1996a. Others argue that bingeing, purging, and alcohol and drug abuse reflect a collection of behavioral attempts to regulate affective disturbances Brisman & Siegel, 1984, Hudson et al., 1983, Hudson et al., 1987. Still, others suggest that eating disorder and SUD behaviors stem from a single type of perturbation in neurophysiologic systems such as altered function of the central nervous system reward pathways Krahn, 1991, Sinha et al., 1996, alterations in endogenous opioid activity (Marrazzi & Luby, 1986), or altered serotonin function (Kaye & Wisniewski, 1996).

The purpose of this study is to extend the previous research by investigating the cooccurrence of specific disordered eating behaviors and substance use behaviors in women with AN or BN. Patterns of behavioral association among seven disordered eating behaviors including bingeing, vomiting, restricting, exercising, and laxative, diet pill, and diuretic use, and three substance use behaviors including alcohol, marijuana, and tobacco use are examined. This is important because inferences to behavior that are based simply on the cooccurrence of the eating disorder and SUD diagnoses can lead to erroneous conclusions because of the behavioral heterogeneity within the diagnostic categories Hunt, 1993, Walsh & Kahn, 1997. In addition, the behavioral approach enables consideration of the full continuum of level of involvement in specific behaviors, as well as exploration of the full range of disordered eating and substance use behaviors.

One advantage of the behavior-specific approach for examining the relationship between the eating disorders and SUD is that this approach can address the behavioral heterogeneity inherent in the eating disorder and SUD diagnostic categories. Even if standardized diagnostic criteria are used, the same diagnosis can involve different combinations of symptoms Hunt, 1993, Walsh & Kahn, 1997. For example, an individual who meets DSM-IV diagnostic criteria for AN may do so through self-induced vomiting, use of other purgatives such as laxatives or diuretics, excessive exercise, extreme dietary restriction, or any combination of these behaviors. The DSM-IV diagnosis of bulimia nervosa can be met through various combinations of purging or restricting behavioral responses to recurrent bingeing. In the same way, only a subset of an extensive collection of behavioral symptoms is required for a SUD diagnosis, yet, numerous unique combinations of symptoms can result in the same diagnosis (Grant, Chou, Pickering, & Hasin, 1992). For example, any three or more of the following symptoms can result in a DSM-IV diagnosis of substance dependence: (1) tolerance; (2) withdrawal symptoms; (3) taking substance in larger amounts or over a longer period than was intended; (4) persistent desire or unsuccessful efforts to cut down or control substance use; (5) spending a great deal of time in activities necessary to obtain, use, or recover from the substance; (6) giving up important social, occupational, or recreational activities because of substance use; or (7) continuing substance use despite knowledge of persistent or recurrent physical or psychological problems as a result of substance use (APA, 1994). Similarly, the DSM-IV substance abuse diagnosis can be met by any one of four indicators of a maladaptive pattern of use. Because of the behavioral heterogeneity in these diagnoses, it is not surprising that the findings of existing studies are mixed; some have concluded that the prevalence of SUD is greater among individuals with BN compared to AN Bulik, 1987, Schuckit et al., 1996, Suzuki et al., 1993, Wilson, 1993, while others suggest high levels of SUD among individuals with AN Fichter & Quadflieg, 1996, Strober et al., 1996.

Another advantage of the behavior-specific approach for examining the relationship between the eating disorders and SUD is that it enables consideration of the disordered eating and substance use behaviors on a continuum of level of involvement — from normal or experimental involvement to levels of involvement that put one at risk for grave physical and psychological consequences. This is important because cutoff points along the continuum from mild to severe disordered eating or from substance use to substance abuse and dependence have been arbitrarily determined Walsh & Kahn, 1997, Woody et al., 1993. For example, there is no clear distinction between healthy and extreme restriction of fat and calories and healthy and excessive amounts of exercise. Bingeing and purging may occur monthly, weekly, or multiple times daily. Similarly, while alcohol use is considered a normative behavior in adults, the boundary line indicating alcohol abuse or dependence is vague. Even with controlled substances, level of involvement provides important information that can distinguish experimentation from regular and high levels of use. It is therefore essential to examine the full continuum of level of involvement in disordered eating and substance use behaviors in order to observe patterns of relationship among specific behaviors.

A third advantage of the behavioral approach is that the full range of disordered eating and substance use behaviors can be explored. Studies to date have tended to select a priori, specific behaviors for study while common cooccurring behaviors remain unexamined. In a 10-year prospective study examining the effects of binge eating and dietary restraint among anorexics, the investigators concluded that binge eating during the acute phase of anorexia predicts an increased risk of developing SUD (Strober et al., 1996). The investigators further suggest that there may be a shared biologic mechanism in substance abusers and acutely ill anorexics who binge eat. This study raises important questions about the relationship of substance use to other compensatory behaviors that often cooccur with bingeing such as vomiting, the use of laxatives or diuretics, or excessive exercising. A comprehensive approach, which includes the entire range of disordered eating and substance use behaviors, increases the likelihood that true associations will be revealed.

In this research, we consider a broad range of disordered eating and substance use behaviors including the entire continuum of level of involvement in each behavior. Two research questions were addressed: (1) Are alcohol, marijuana, and tobacco use differentially associated with the disordered eating behaviors of bingeing, vomiting, restricting, exercising, and laxative, diet pill, and diuretic use? and (2) Do the patterns of association among disordered eating and substance use behaviors differ in women with AN or BN?

Section snippets

Participants

Participants were 79 women with a clinically diagnosed eating disorder who participated in a larger study on self-cognitions in eating disorders (Stein & Nyquist, 2000). The DSM-III-R1

Disordered eating behaviors

We began our analyses by examining the extent of current involvement in each of the disordered eating behaviors for all four groups. Table 2 shows the prevalence of disordered eating behaviors in the last month for threshold and subthreshold AN and BN groups; means and ranges for the intensity of involvement computed based on those who engaged in the behavior are also shown. The restrictive type behaviors, food restricting and exercising, were prevalent in all groups; between 79% and 92% of

Discussion

A behavior-specific approach was used to examine patterns of association among disordered eating and substance use behaviors in women with threshold and subthreshold levels of anorexia or bulimia nervosa. As expected, this approach revealed considerable heterogeneity among the disordered eating behaviors across the threshold and subthreshold AN and BN groups, with bingeing, vomiting, exercising, and food restricting occurring in all groups. In addition, results suggest that across groups, there

References (55)

  • M.S Aldenderfer et al.

    A review of clustering methods

  • Diagnostic and statistical manual for mental disorders

    (1989)
  • Diagnostic and statistical manual for mental disorders

    (1994)
  • M.L Belfer

    Substance abuse with psychiatric illness in children and adolescents: definitions and terminology

    American Journal of Orthopsychiatry

    (1993)
  • M.D Berry et al.

    Alcoholism and eating disorders in women of fertile age

    British Journal of Addiction

    (1986)
  • T.D Brewerton et al.

    Comorbidity of Axis I psychiatric disorders in bulimia nervosa

    Journal of Clinical Psychiatry

    (1995)
  • C.M Bulik

    Drug and alcohol abuse by bulimic women and their families

    American Journal of Psychiatry

    (1987)
  • C Caron et al.

    Comorbidity in child psychopathology: concepts, issues and research strategies

    Journal of Child Psychology and Psychiatry

    (1991)
  • C.E Costakis et al.

    The relationship between the stages of exercise adoption and other health behaviors

    American Journal of Health Promotion

    (1999)
  • T Fahy et al.

    Impulsivity and eating disorders

    British Journal of Psychiatry

    (1993)
  • A Favaro et al.

    Purging behaviors, suicide attempts, and psychiatric symptoms in 398 eating disordered subjects

    International Journal of Eating Disorders

    (1995)
  • M.M Fichter et al.

    Course and two-year outcome in anorexic and bulimic adolescents

    Journal of Youth and Adolescence

    (1996)
  • M.B First et al.

    Structured clinical interview for DSM-IV Axis I disorders

    (1997)
  • P.E Garfinkel et al.

    The heterogeneity of anorexia nervosa

    Archives of General Psychiatry

    (1980)
  • D.S Goldbloom

    Alcohol misuse and eating disorders: aspects of an association

    Alcohol and Alcoholism

    (1993)
  • C.C Holderness et al.

    Co-morbidity of eating disorders and substance abuse: review of the literature

    International Journal of Eating Disorders

    (1994)
  • J.I Hudson et al.

    A controlled study of lifetime prevalence of affective and other psychiatric disorders in bulimic outpatients

    American Journal of Psychiatry

    (1987)
  • Cited by (12)

    • Disordered eating behaviors in young adult Mexican American women: Prevalence and associations with health risks

      2013, Eating Behaviors
      Citation Excerpt :

      Purging behaviors (vomiting, diuretics, laxatives, and diet pills) were associated with the number of heavy drinking days. This finding is consistent with other studies that found associations between purging and alcohol use in community samples (Adebe, Lien, Torgersen, & von Soest, 2012) and in women with eating disorders (Baker et al., 2013; Corte & Stein, 2000). In a meta-analysis of 41 studies that examined co-occurrence of DE behaviors and alcohol use in clinical, community, and student samples, Gadalla and Piran (2007) found an overall effect size of .41 for purging and alcohol use.

    View all citing articles on Scopus
    View full text