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Are Eating Disorders A Risk Factor For Developing Alcohol Disorders In Women?

Mariana Gonzalez

April 28, 2009




††††††††††† By using these globally accepted definitions and diagnosis criteria of both alcohol and eating disorders, we can construct a better conclusion to the question above by examining the degree to which alcohol misuse becomes a problem in the patientís life and its correlation with the onset or worsening of an eating disorder and itís severity.

-- Alcohol Abuse --

††††††††††† According to the DSM-IV, alcohol abuse can be defined as follows: A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period:

1. Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household)

2. Recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use)

3. Recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct)

4. Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights)

-- Alcohol Dependence Ė

As stated in the DSM-IV, alcohol dependence can be defined as follows: A maladaptive pattern of alcohol use, leading to clinically significant impairment or distress, as manifested by three or more of the following seven criteria, occurring at any time in the same 12-month period:

1. Tolerance, as defined by either of the following:

†††† -A need for markedly increased amounts of alcohol to achieve intoxication or desired effect.

†††† -Markedly diminished effect with continued use of the same amount of alcohol.

2. Withdrawal, as defined by either of the following:

†††† -The characteristic withdrawal syndrome for alcohol (refer to DSM-IV for further details).

†††† -Alcohol is taken to relieve or avoid withdrawal symptoms.

3. Alcohol is often taken in larger amounts or over a longer period than was intended.

4. There is a persistent desire or there are unsuccessful efforts to cut down or control alcohol use.

5. A great deal of time is spent in activities necessary to obtain alcohol, use alcohol or recover from its effects.

6. Important social, occupational, or recreational activities are given up or reduced because of alcohol use.

7. 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 the alcohol (e.g., continued drinking despite recognition that an ulcer was made worse by alcohol consumption).

-- Alcohol in the United States --

According to the Centers for Disease Control and Prevention (CDC), more than half of the adult United States population has drank alcohol in the past 30 days, approximately 5% of the total drank heavily, while 15% of the population binge drank. Alcohol use is very common in our society, and drinking alcohol can cause immediate harmful effects and may increase the risk for many harmful conditions. These conditions include liver disease, impaired judgment (can cause drunk driving accidents, and other harmful decisions), and can also contribute to other diseases such as heart disease, sexual dysfunctions, high blood pressure, lowered immune system strength, and malnutrition. The standard measurement of alcohol is as follows: one 12 ounce beer or wine cooler, 8 ounces of malt liquor, 5 ounces of wine, 1.5 ounces of 80 proof distilled liquor. Excessive alcohol use can be defined by drinking more than two drinks a day on average for men and one drink a day on average for women. Another helpful definition is binge drinking in which five or more beverages are consumed in a since occasion for men and four for women. From the years 2001-2005 there were approximately 79,000 deaths annually attributed to excessive alcohol use, in fact is it is the 3rd leading lifestyle related case of death in the United States each year.

-- Anorexia Nervosa --

††††††††††† As stated in the DSM-IV-TR, in order for a person to be diagnosed with Anorexia Nervosa the person must display:

-Refusal to maintain body weight at or above a minimally normal weight for age and height: weight loss leading to maintenance of body weight <85% of that expected or failure to make expected weight gain during period of growth, leading to body weight less than 85% of that expected.

-Intense fear of gaining weight or becoming fat, even though under weight.

-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 denial of the seriousness of the current low body weight.

-The absence of at least three consecutive menstrual cycles (amenorrhea) in women who have had their first menstrual period but have not yet gone through menopause (postmenarcheal, premenopausal females).

Furthermore the DSM-IV-TR includes two subtypes of anorexia nervosa. The first is the restricting type, where during an episode the person has not regularly engaged in using tools such as vomiting and laxatives, but does reduce the amount of her food intake. The second subtype is the Purging Type, where during an episode the person has regularly engaged in binge eating or purging behaviors such as self induced vomiting, over exercise, and laxatives.

Besides the obvious risks of malnutrition, Anorexia Nervosa may also cause the thinning of the bones, brittle hair and nails, yellow skin, mild anemia, lanugo, constipation, low blood pressure, drop in internal body temperature, and lethargy.

-- Bulimia Nervosa --

As stated in the DSM-IV-TR, in order for a person to be diagnosed with Bulimia Nervosa the person must display:

-Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:

        >Eating, in a fixed period of time, an amount of food that is definitely larger than most people would eat under similar circumstances.

        >A lack of control over eating during the episode: a feeling that one cannot stop eating or control what or how much one is eating.

-Recurrent inappropriate compensatory behavior to prevent weight gain, such as: self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; excessive exercise.

-Self-evaluation is unduly influenced by body shape and weight.

-These symptoms occur at least twice a week on average and persist for at least 3 months.

-The disturbance does not occur exclusively during episodes of anorexia nervosa.

              Like Anorexia Nervosa, the DSM-IV-TR has also categorized Bulimia Nervosa into two distinct subtypes. The first, purging type, is when self induced vomiting is used to remove food from the body before it can be digested they can also use laxatives and diuretics. The second subtype is the non-purging type in which bulimics exercise or fast excessively after a binge episode in order to offset the caloric intake of the binge.

Patients with Bulimia Nervosa suffer from symptoms as sever as electrolyte imbalance, gastrointestinal problems, and severe dehydration, they may also exhibit chronically inflamed and sore throat, swollen glands in the neck, decaying teeth, kidney problems, and damage to the esophagus.

-- Eating Disorders Statistics --

The prevalence of eating disorders in the United States has steadily climbed the past few years. One in every five women will struggle with an eating disorder or disordered eating, and up to 24 million people struggle with an eating disorder in the United States. It is actually said that nearly half of all Americans personally know someone with an eating disorder. The age group being most greatly affected are women from ages 12 to 25. Nearly 95% of all cases arise within this demographic group. 25% of college aged women engage in binging and purging techniques to control their weight, and 80% of 13 year old girls have attempted to lose weight on top of the 50% of girls between the ages of 11 and 13 that seem themselves as overweight. The media images, cultural standards, and fashion magazines have promoted thinness to a critical extent. The body type portrayed in advertising as the ideal is possessed naturally by only 5% of American females. So much that in the United States, eating disorders have the highest mortality rate of any mental illness and 20% of people suffering from an eating disorder will prematurely die from complications related to their disorder including suicide and heart problems. With this huge risk of mortality, still only one in every ten people suffering from an eating disorders receive treatment and only 35% of those who enter treatment go to a specialized facility for eating disorders.


Coexistence of Alcohol Problems and Eating Disorders: Studies

††††††††††† The first study was conducted by Robert Peveler and Christopher Fairburn (1990) in which their target sample consisted of women between the ages of 17 and 40 with the mean being 30.2 years of age. These women were all consecutive first attendees, in and out patients, at the Chilton Clinic in Oxford, an alcohol treatment unit. All subjects, after withdrawal symptoms had subsided, completed two self-report questionnaires. The presence of an eating disorder was assessed using the EDE-Q and the severity of alcohol dependence was measured using the 20-item Severity of Alcohol Dependence Questionnaire, SADQ. The statistics were as follows: 36% of the sample reported symptoms of binge eating, 26% fulfilled diagnostic criteria for a probable clinical eating disorder, and 19% had a history of probable anorexia nervosa. Peveler and Fairburn concluded that the findings suggest that eating disorders are over represented in women receiving treatment for alcoholism. They are also critical of their finding suggesting that it can not be generalized to say that there is a specific cause and effect relationship due to the finding is similar studies that predicts all patients with other psychiatric problems have a high coexistence rate with eating disorders as well. They are also critical of the fact that there may or may not be bias in their sample due to the fact that they all were currently seeking treatment for a disorder which may or may not effect the sample statistics.

††††††††††† This study is useful because it shows the high rate of coexistence of alcohol problems and eating disorders, but it does not address which one causes which, let alone says their coexistence may not be a cause- effect relationship. I also agree with both psychologists when they say that this study cannot be generalized due to the sample and where they pulled the participants. More research must be conducted in the community and with different groups of people in order to really establish true prevalence of comorbidity between the two psychological problems.

††††††††††† The second study conducted by M.D. Beary and others entitled Alcoholism and Eating Disorders in Women of Fertile Age (1986) also examines the coexistence of both conditions. Beary used a sample size of 40 patients. 20 patients were alcoholic women who were assessed by two psychiatrists and deemed alcohol dependent and were attending an alcoholism unit in London. The other 20 patients were patients that were assessed to have bulimia nervosa at an eating disorders clinic also in London. The control group consisted of women who were taken from the family planning clinic in Putney and were asked about their history, ideal weight, and their measurements were taken. A second part of the study took 112 patients attending another Eating Disorders clinic who suffered from bulimia nervosa and they were used to study the correlation between alcohol use and severity of the eating disorder. All the women were below the age of 40. All groups of women were interviewed and then their interviews were compared to one another. The statistics were as follows: 35% of the alcoholics had a pervious major eating disorder, 50% of the bulimics in the first group either abused (40%) or used alcohol in excess (10%). They also figured out that the alcoholism presented itself many years after the onset of Bulimia Nervosa in most cases. On the second group, reported alcohol abuse increased with age by 50% at the age of 35. It was also noticed that there was no huge weight difference in the control group to the groups of women affected by alcoholism and eating disorders. Therefore the conclusions that they came up with are that the onset of alcoholism comes after bulimia and that alcoholism may interrupt the eating disturbances of the individual replacing it for some time but ultimately the patient suffers from two disorders.

††††††††††† This study, although the sample size was relatively small, shows a timeline for the coexistence of eating disorders and alcoholism. It is a small step and many more studies with a larger and more diverse sample size need to be conducted in order to be able to generalize their findings, but nonetheless the study had some remarkable findings and warns clinicians to be careful of future alcoholism with patients diagnosed for an eating disorder.

††††††††††† The third study conducted was by Debra L. Franco entitled, How do Eating Disorders and Alcohol Use Disorder Influence Each Other (2005). 544 women at the Massachusetts General Hospital that were currently being treated for eating disorders were asked to participate. Of these 544 women, 246 women decided to participate and passed all the criteria and screenings. 51 women were anorexic restricting type, 85 were anorexic binge purge type, and 110 were bulimic. Each subject was briefly talked to on the telephone, and came in for an interview, interviews were then held every 6 to 12 months for approximately 8.6 years. The results were as follows, Over one fourth of the sample, 27%, reported a history of an alcohol abuse problem, 10% developed an alcohol problem during the study, alcohol abuse did not effect the recovery from eating disorders, and they also came up with a correlation between women who were depressed and the onset of both disorders. Franco concluded through the interview process, that the influence of eating disorders on alcohol problems was much more prevalent than the reverse.

††††††††††† This study is one of the more reliable studies I found because it was conducted with a large sample size, and was reviewed over a long period of time. The only problem with this is that the criteria and definitions of both alcohol dependence disorder and eating disorders have changed within this time thereby maybe skewing the results. But for the most part the conclusions and statistics represent a large portion of the population and the methods they used are very reliable. The combination of psychological self-assessment tests, and interviews double-checked the patientís history and problems, and the ongoing and persistent interview process was a good indicator of change in behaviors and gave a fairly specific timeline of episodes of both eating disorders and alcohol abuse disorders.

††††††††††† The fourth study conducted by Dansky, Brewerton, and Kilpatrick (1998) had 3006 participants. All participants were generated by multi staged geographic sampling procedures and were all basically random women who participated in the third wave of the National Womenís Study. Respondents completed structured telephone interviews of approximately 40 minutes. They were screened for demographic characteristics, trauma history, PTSD, BN, MDD and AUDs. The mean age of the sample was 46.1 years old and the sample was predominately Caucasian with a mostly African American minority. The study came up with the following statistics, 31% of women who have a history of Bulimia Nervosa also had a history of Alcohol Abuse and more than one in eight women (13%) had a history of alcohol dependence. These rates, which were observed in a non-treatment seeking population, are comparable to the prevalence rate of other researchers in samples of inpatients and outpatients therefore broadening the statistics and taking a step to generalizing the findings. But due to the other variables in the study like PTSD and Depression, Dansky and others were unable to find a definite correlation between eating disorders and alcohol disorders. They found that the prevalence of both disorders was also raised with the onset of PTSD and MDD. Therefore with such conflicting problems and other disorders it was unclear which disorder came first, caused one another, and influenced one another.

††††††††††† This study attempted to monitor too may variables and was not specific enough, therefore was not able to find a definite correlation between eating disorders and alcohol disorders. But many good things came from this study too. The fact that the sample size was large and that the participants were not inpatients or outpatients at a treatment facility broadens the findings of many studies that could not be generalized. The fact that ďnormalĒ household women have the same rates or comparable rates as those being treated with a disorder is staggering and prompts more discussion and more specific studies to be started.

††††††††††† The fifth and final study was conducted in Japan by Susumu Higuchi (1993). This study included males, to stick with the topic I have taken out the statistics of all the male participants. This leaves the inclusion of 336 females (mean age of 46.9) who were admitted to the National Institute of Alcoholism located in Kurihama National Hospital and were given either the diagnosis of alcohol abuse or alcohol dependence. They then interviewed all the patients. They used the criteria in the DSM-III-R to diagnosis them. The study found that 11% of the female alcoholics suffered from eating disorders and were substantially younger than the other women in treatment. They also found out that nearly three quarters (72%) of the women below 30 were currently suffering from an eating disorder, the onset of eating disorders was the late teens and on average females progressed from habitual to problem drinking in only 3.5 years. They discovered that the onset between disorders took an average of 4.5 years with the alcohol disorder coming after the onset of an eating disorder.

They attributed both disorders with a commonality of loss of control and compulsion. This study broadens the scope to not only the United States and once again helps broaden the ability to generalize the statistics found in studies of this topic. The sample size was decent but could have been better, and the interview process was not followed by self-assessment, which I think could have strengthened their findings and offered more in depth looks into the disorders.

Which comes first? : Conclusion

Due to varied point of views discussed in the reviews, it is not certain which psychological disorder arises first in a personís life. Although it seems as if the onset of alcoholism has a much higher prevalence to arise after an eating disorder, more specific studies must be conducted. It is also a hypothesis that both binging and alcoholism are compulsions and this is why they coexist in high rates. The high rates of the coexistence may also be due to the types of survey used to date. Most studies use subjects that are being treated for either disorder and this skews the results. But it can also be seen that the results are somewhat generalized due to community survey that have been done as well.

In my opinion, it can be safe to say there is a strong correlation with the onset of an eating disorder and a later onset of alcoholism, but I do agree that more specific and larger survey must be conduced in order to reach a solid conclusion. Most studies that I found confirmed that an eating disorder is a risk factor for developing alcoholism in women but have not gone far enough to confirm a direct causation. The correlation nonetheless is strong and most studies urge clinicians to beware of this high rate and risk factor when treating patients with eating disorders. After further research is done, the next step would be to decide whether or males also exhibit the same correlation. To date, most studies focus on females due to the lack of information and men who report eating disorders in the United States.




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