Elsevier

Eating Behaviors

Volume 2, Issue 1, Spring 2001, Pages 27-38
Eating Behaviors

Psychoactive substance consumption in eating disorders

https://doi.org/10.1016/S1471-0153(00)00021-0Get rights and content

Abstract

Research investigating the comorbidity between eating disorders and substance-use disorders have reported positive but contrasting results. The aim of this study was to further explore this association by studying patterns of consumption of the entire range of psychoactive substances (alcohol, specific drugs, prescribed psychotropics) in a large sample (N=271) of eating-disorder DSM-IV subtypes. Results show that subjects suffering from anorexia of the restrictive type show significantly less drug-consumption behaviors and alcohol abuse and/or dependence disorders than purging anorexic and bulimic subjects. No difference was found in the total consumption of psychotropics among the four groups of eating disorders. However, more than half of eating-disorder subjects are regular consumers of psychotropics. Among these regular consumers, bulimics self-prescribe and increase their doses of psychotropics significantly more than anorexics. Features of impulsivity that are associated with purging and bulimic behaviors could play a specific role in these patterns of comorbidity and account for such differences.

Introduction

It is widely recognized that patients suffering from eating disorders have high rates of comorbid psychiatric disorders. The most common major comorbid disorders include personality disorders, mood and anxiety disorders and substance-use disorders Holderness et al., 1994, Wiseman et al., 1999, Wonderlich & Mitchell, 1994, Zaider et al., 2000.

Although these comorbidities have been extensively studied, less is known about the basis of these relationships. Several conceptual models have been proposed to explain the link between eating disorders and comorbid disorders. To test these conceptual models, complex research paradigms are needed, including epidemiological studies, behavior–genetic studies, and longitudinal research designs (Zaider et al., 2000).

Special interest has recently been paid to the comorbidity between eating disorders and substance-use disorders. In fact, several authors have started to consider eating disorders as addictive behaviors Bulik et al., 1992, Davis & Claridge, 1998, Holderness et al., 1994, Jager et al., 1991 and several studies showing a frequent association between eating behaviors and addictive behaviors (alcoholism, drug abuse) have provided support for this hyphotesis Bulik et al., 1992, Hatsukami et al., 1984, Welch & Fairburn, 1996, Wiederman & Pryor, 1996. Addiction corresponds to an extension of the term normally used to describe drug dependencies to other behaviors that Fenichel (1945) called “dependences without drugs.” This term describes a range of behaviors characterised by some repetitive and compulsive actions in which a dependence on a behavior or a substance that is sought after and consumed with avidity predominates. This term covers dependencies on alcohol, drugs or psychotropic medications as well as eating disorders such as bulimia nervosa or behaviors as compulsive buying or pathological gambling. Such addictive behaviors are often associated in the same patients pleading for an overall addictive dimension.

The initial interest in the relationship between eating disorders and substance abuse stemmed from the observations of Crisp, Hsu, Harding, and Hartshorn (1980) who observed that chronic anorexics who developed bulimic behaviors often abused alcohol. More recently, cross-sectional studies of women with eating disorders have documented a prevalence of alcohol and other substance abuse and dependence at a much higher level than that reported in the general female population. Conversely, women with substance-abuse disorders report eating-disorder behaviors more often than the general population (Hudson, Weiss, & Pope, 1992). In the most complete review of the comorbidity between addictive behaviors and eating disorders, Holderness et al. (1994) have shown a stronger association with psychoactive substance consumption and abuse in bulimics and anorexic bulimics than in anorexics. In their review of the lifetime prevalence of drug abuse or dependence in bulimics, Bapt et al., (1999) reported contrasting results: 12% to 71% for alcohol, 10% to 60% for drugs.

These divergent results can probably be explained by modifications in the diagnostic criteria over time and by the existence of different clinical profiles among eating-disorder patients. Authors agree in considering that comorbid conditions can influence psychoactive consumption among eating-disorder patients, and in particular personality disorders and emotional and depressive disorders Hatsukami et al., 1986, Lacey, 1984. Patients presenting impulsive and self-aggressive manifestations and features of comorbid personality disorders, more often associated with bulimic features, would show higher rates of addictive behaviors, including abuse of medications prescribed for therapeutic reasons (Bapt et al., 1999).

However, most of the studies investigating substance consumption in eating disorders have been imprecise in specifying the nature of the drug, whether this is a street drug (cocaine, heroin, stimulants, tetrahydroxycannabinol derivatives) or a prescribed medication (tranquilizers, hypnotics, antidepressants). It is because of this scarcity of works specifying substance abuse or dependence that hard drugs such as heroin are rarely quoted in eating disorders, whereas amphetamines are the most-quoted illegal psychoactive substances, either separately or within the class of “stimulants” (Table 1). In these studies, rates of amphetamine abuse/dependence vary from 6% to 28% in bulimia or in anorexic-bulimia and lie at 13% in anorexia. Amphetamines are sometimes prescribed at the beginning of the illness for their anorexigenic and antidepressive effects; nevertheless, a prolonged treatment risks establishing a pharmacological tolerance and a pharmacodependence.

As far as other prescribed medications are concerned, tranquilizers (including barbiturates) show a rate of abuse and dependence varying from 5% to 14% in bulimia or in anorexic bulimia and 9% in anorexia Hudson et al., 1983, Hudson et al., 1992. When we consider benzodiazepines (BZD), certain patients exhibit a physical and psychic dependence even at therapeutic doses. The consumption of barbiturates is found in some studies Weiss & Ebert, 1983, Wiederman & Pryor, 1996.

In these studies, antidepressants are not quoted as medications susceptible to abuse or dependence. While the majority of antidepressants are not recognized as inducing dependence, cases of dependence on Amineptine and Tianeptine have been identified Bertshy et al., 1990, Vandel et al., 1999. Addiction to Amineptine would be possible in patients with a past history of alcohol or drug addiction or among patients suffering from eating disorders (Roques, 1999). An increased risk of dependence on Fluoxetine (Menecier, Menecier-Ossia, & Bern, 1997) and of crossed dependence on methadone (Haddad, 1999) has been also described.

The results reported in these studies must be treated with caution given the heterogeneity of the populations (ages, diagnostic criteria, disorder subtypes) as well as the bias in the data-acquisition procedure (current or past consumption, medical or self-prescription).

The aim of this study was to strengthen previous studies highlighting the association between eating disorders and addictive behaviors by studying the lifetime prevalence (whether abuse or dependence) of the entire range of psychoactive substances (alcohol, specific drugs, prescribed psychotropics) in a large sample of eating-disorder DSM-IV subtypes (restrictive anorexia, purging anorexia, purging bulimia, nonpurging bulimia). We expected to find a strong comorbidity with all psychoactive substances coherently with the assumption of an addictive dimension in the eating-disorder behaviors. Moreover, we supposed that such comorbidity would be more important in bulimics and in purging anorexic patients compared to restrictive anorexics, this difference being accounted for by the dimension of impulsivity observed in eating-disorder patients with impulsive features.

Section snippets

Subjects

The participants in this study were selected from a larger research project called “Dependence Network 1994–2000” (Inserm 494013), an international (France, Switzerland, Belgium) multicentric study investigating the common clinical and psychopathological features shared by different disorders (eating disorders, alcoholism, substance-related disorders) gathered together under the heuristic concept of dependence. The complete clinical protocol of the network has been described elsewhere (Final

Alcohol consumption in eating disorders

Alcohol consumption is more significant in bulimics (12.4%) and in purging anorexics (10.9%) that in restrictive anorexics (2.7%)(χ2=15.32 with 3 ddl, P<.005). The results also highlight a greater prevalence of alcohol dependence (current or past) over alcohol abuse in eating disorders, thus introducing an index of severity for this association (Table 2). These results are similar to already published data in the literature Braun et al., 1994, Herzog et al., 1992.

Drug consumption in eating disorders

Statistical analysis

Discussion

In our study, carried out within the framework of the Dependence Network on a population of 271 patients presenting an eating disorder, we found, as expected, a significant association between eating disorders and psychoactive substance consumption (alcohol, drugs, psychotropics). Results concerning the overall psychoactive substance consumption and the lifetime prevalence of alcohol and drug abuse and dependence in our sample of eating-disorder patients confirm data already published in the

Acknowledgements

This work has been conducted within the clinical research project called “Dependence Network 1994–2000” which has received the support of the Institut National de la Santé et de la Recherche Médicale (Réseau Inserm no 494013) and of the Fondation de France. The promoter of the project is the Institut Mutualiste Montsouris.

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