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Eating Disorders and Cocaine Abuse

Ariel Kanter

May 4, 2010

Introduction and Background

            Over the years, a lot of research has been performed in order to take a closer look at what researchers call “a dual diagnosis”. More specifically, a great deal of time and experimenting has been devoted to examining eating disorders, and some of the other factors that have been found to be associated with them. “It is estimated that about 12-18% of people with anorexia nervosa abuse alcohol, tobacco, or other drugs”, and therefore, the topic was explored even further (Pisetsky, Chao, Dierker, May, & Striegel-Moore, 2008). After completing a lot of research on the subject and perusing scholarly reviews and literature, there is definitely a conclusion to be drawn about whether there exists an association between both anorexia nervosa and bulimia nervosa and the substance abuse of cocaine. Part of the reason people have drawn a connection between the two is because cocaine is known for its appetite suppressant quality, and previous research has found many female cocaine users name weight control as an important motivation for use of the substance. Also, researchers believe that self-deprivation of food increases susceptibility to frequent drug use. One of the first studies conducted on the subject with significant results was the 1987 survey of 259 callers to a cocaine abuse hotline, in which 32% of the female callers had an eating disorder according to the DSM-III (Cochrane, Malcolm, & Brewerton, 1998). In light of all of this information, and the studies that will be analyzed below, one can say that there is, in fact, a strong, significant correlation between these two eating disorders and the abuse of cocaine, particularly in females.


Description of Scientific Literature


            The first study dealing with the question of the connection between anorexia nervosa, bulimia nervosa and cocaine use took place at The Medical University of South Carolina. Its purpose was to replicate previous findings on the comorbidity of cocaine dependence and eating disorders, as well as extend the study to evaluate alcohol abuse in this population. The demographic was forty men and thirty-seven women between the ages of 18 and 48, who endorsed cocaine as their primary substance of abuse. The primary instruments utilized to obtain results were first, the Diagnostic Survey for Eating Disorders-Revised, which essentially is a shortened version of a multi-item self-report survey, that measures the clinical features of eating disorders including drugs used to control weight. The investigators added a short four-question survey to the DSED that asked the cocaine users about reasons for beginning and maintaining cocaine use. Also, participants were asked to check off as many reasons as he or she believed to be applicable for using cocaine initially and for continuing use. Weight control, decreasing appetite, and losing weight were listed as reasons for initiating and continuing cocaine use. Along with the survey, the Eating Disorder Inventory, BMI and Percent Average Body Weight, and data analysis were used to conduct the study (Cochrane et al., 1998).

            The study revealed the following. First, women were significantly more likely to endorse using cocaine to decrease appetite for beginning cocaine use, continuing cocaine use, for losing weight for beginning cocaine use, and continuing use. However, only 13% of the 40 men endorsed using cocaine for weight-related reasons. This finding of a large percentage of women with and without eating disorders using cocaine to control or lose weight replicates the results of Jonas et al. (1987), who found that 32% of the female callers to a cocaine hotline had eating disorders and that many of these women used cocaine to control weight or ameliorate their eating disorder (Cochrane et al., 1998).

Evaluation of Study

            This scientific study, without a doubt, reveals a lot about the supposed association between cocaine abuse and its relation to anorexia and bulimia nervosa. Clearly, the research was very sound because they utilized a balance of tools to measure both substance abuse and eating disorders, and then to connect them through data analysis. This, in correlation with a very specific and organized study helped to generate very significant research and results on the topic. However, in regards to the extension of the study which included alcohol abuse, there’s still more research to be done about whether this factor is still connected. Altogether, though, the sample of women is almost evenly split between having either an eating disorder first and a substance abuse disorder first. From this, we can conclude that either factor can come first, but they are certainly related (Cochrane et al., 1998).

Description of Scientific Literature

One study focused more specifically on the comorbidity of eating disorders and substance use in our youth. Based on previous studies, doctors hypothesized that certain illicit substances may be particularly likely to be consumed by individuals with eating disorders or body image concerns because of their anorexic properties, or because they are specifically used to alter body shape and size. Cocaine was one of ten substances that was tested amongst the participants. Essentially, the study capitalized upon the availability of data from a large, nationally representative sample of both male and female high-school students in the United States, and its association with disordered eating, and the use of the 10 substances as mentioned before. Disordered eating was defined as fasting, diet product use, or purging, and the 10 substances included cigarettes, alcohol, marijuana, cocaine, inhalants, heroin, methamphetamines, ecstasy, steroids, and hallucinogens (Pisetsky et al, 2008).

With concern to the methods used in the study, data was taken by the Youth Risk Behaviors Surveillance System (YRBSS), which utilizes a three-stage cluster sample design to obtain a nationally representative sample of 9th to 12th grade students enrolled in both public and private schools in the country. All of the participation was voluntary and anonymous, and the students were differentiated amongst by gender, racial, and ethnic background. They were asked whether they engaged in a number of behaviors in order to lose weight or keep from gaining weigh. Also, focusing more specifically on cocaine use, which was defined as using the substance one or more times in the past 30 days. Data was taken statistically using logistic regression models, and the effect size reported was Number Needed to Take, which ultimately answers the question “How many cases do you have to see to find one more ‘failure’ than if you had observed their matched controls?” Looking particularly at cocaine, results revealed that cocaine was the substance used by the fewest students: less than 5% reported any cocaine use in the past month. And, looking at its association with disordered eating, results were also weak compared to substances such as alcohol or cigarettes, but still significant (Pisetsky et al., 2008).

Evaluation of Study

Looking at this study, there are a lot of conclusions that we can draw from it. To begin, all associations between disordered eating and use of substances were statistically significant for both female and male students, however, cocaine overall was statistically weaker. This could be attributed to the fact that many high school students aren’t at the age where cocaine is easily accessible, or appealing, like alcohol and cigarettes typically are. Therefore, if the students were barely using it, it makes sense that there wouldn’t be that significant of an association between the two. Also, the study had some limitations to be noted; for example, this study was cross-sectional, but perhaps a longitudinal study would’ve indicated the temporal order of the adoption of disordered eating, substance use, depression, and impulsive characteristics. Also, frequency of disordered eating might have been something that could be included in the study because a person who purged once in the past month, for example, may be clinically different than a person who purged at a higher frequency. But, despite these few limitations, the study on the whole supported the association between cocaine abuse and bulimia nervosa and anorexia nervosa, although the sample of youth probably wasn’t the demographic to truly support this hypothesis (Pisetsky et al., 2008).

Description of Scientific Literature

            Another related study was conducted at the Massachusetts General Hospital, and looked more in depth at a smaller sample size of people. It solely included patients who were female, 12 years or older, and met the full criteria for anorexia nervosa and/or bulimia nervosa. It focused on illicit drug abuse and dependence in a clinical sample of women with eating disorders, examining reports of drug use in terms of its frequency and severity. Conducted longitudinally, the data was gathered from clinical interviews conducted at frequent follow-up intervals from a large sample of treatment-seeking women with anorexia nervosa and bulimia nervosa. Trained clinical interviewers used the LIFE-EAT-II to evaluate the participants, which assesses eating disorder symptomology, comorbid psychopathology, treatment, and psychosocial functioning. And, at every follow-up interview, the participants were asked about the frequency of their alcohol and drug consumption since the previous interview (Herzog, Franko, Dorer, Keel, Jackson, & Manzo, 2006).

            Assessment of drug use during the period before entry into the study indicated that cocaine, an appetite suppressant, was one of the most commonly abused illicit drugs, and the lifetime Drug Use Dependence (DUD) was found in 17% of the sample of treatment-seeking women with the two eating disorders. Numbers also suggested the DUD was more common in patients with anorexia nervosa binge/purge subtype than anorexia nervosa- restricting subtype, which is consistent with other studies and might be related to a greater likelihood of engaging in risky and/or impulsive behaviors in those with bulimic symptomatology. To conclude overall, the study found a very strong association between cocaine abuse and women with bulimia and anorexia nervosa (Herzog et al., 2006).

Evaluation of Study

            This study was very helpful because it took a very controlled sample and tested them thoroughly to further confirm the association between cocaine use and anorexia and bulimia nervosa. Although having a very small and controlled sample group is definitely beneficial, it might have altered the results unfortunately; for example, the finding of few differences between the frequency of DUD and the types of drugs used by the women with intake diagnoses of anorexia nervosa or bulimia nervosa might just be due to having the limited power to detect differences because of the small sample size. But, overall, the finding that affective disorder was very likely to occur in participants with anorexia and bulimia nervosa with a prospective DUD onset confirms the relationship being questioned (Herzog et al., 2006).

Description of Scientific Literature

            The final study to examine is one that focused on the occurrence of sexual abuse and the comorbidity of depression and eating disorders among African American women who use crack cocaine. The sample included 208 subjects, with 148 of them whom, at the time of the interview, were involved in treatment for crack cocaine use and were contacted in treatment facilities; 54 were not in treatment and were actively using crack cocaine. Each subject was interviewed for approximately 2 to 4 hours using the Boyd Substance Abuse Survey for Women. With concern to the eating disorders aspect, only 1 of the women met all of the DSM-IV criteria for anorexia nervosa, whereas 6 met the criteria for bulimia at some point in their lives. 15 met the diagnostic criteria for an Eating Disorder Not Otherwise Specified (Ross-Durow & Boyd, 2000).

Evaluation of Study

            As a result of this study, many of these women exhibited disordered eating with their substance use problems. Supporting research of many previous studies and research, bulimia was found to be more prevalent (2.88%) among these female crack cocaine users than was anorexia nervosa (.48%). This proves to have resonance considering the fact that one of the clinical effects of crack cocaine is appetite suppression. However, there were a few factors that could be improved upon in this study. First, the prevalence of eating disorders among African American women has not been extensively researched. Therefore, it could be possible that the lower rates of occurrence of anorexia nervosa and bulimia among the subjects might be related to the homogeneity of the sample. Yet, once again, although the population studied was more culturally specified, the direct connection between the two eating disorders and cocaine abuse is very apparent (Ross-Durow & Boyd, 2000).

Discussion and Conclusions

            After an in depth analysis on the correlation between bulimia and anorexia nervosa and cocaine abuse, it is clear that a strong connection exists. Both cross-sectional and longitudinal studies have shown a high prevalence of eating disorders in female patients with substance abuse, including cocaine abuse. Therefore, there is an apparent association between clinical eating disorders, and this substance abuse (Krahn, Kurth, Demitrack, & Drewnowski, 1992). After assessing all of this research, explanations have been offered for comorbidity: researchers believe that men and women abuse substances specifically to alter body weight or shape or decrease appetite and eating (Pisetsky et al., 2008). And, even further, one can conclude that patients who are female and diagnosed with bulimia nervosa are most likely to abuse cocaine.

            But, despite the significant results that have shaped from this scholarly review, there are still questions to be asked. First, researchers are not quite sure whether it is having the eating disorder first that provokes the cocaine use, or vice versa. Most would say that it correlates in both ways. And, there are still many prospective studies that need to further explore the associations underlying substance use and disordered eating (Pisetsky et al., 2008). Also, the scientists who studied African American women suggest that in the future, longitudinal, prospective studies of female crack cocaine users would be helpful in establishing the temporal ordering of depression, eating disorders, and substance abuse. Finally, there are many things that doctors and clinicians need to do in the future. With regards to these many studies, clinicians working with adolescent populations need to be mindful that weight control efforts may signal substance use and vice versa. Also, therapists must be aware that eating disorders and substance abuse can coexist, so they should carefully assess patients with symptoms of these problems so that the appropriate treatment can be undertaken. Overall, data indicates that clinicians should take a careful history of drug use when assessing substance use in patients with anorexia nervosa and bulimia nervosa. In accomplishing all of these ideas, doctors can save patients who might be experiencing one side of the equation from experiencing the other side as well.


Works Cited

Cochrane, C., Malcolm, R., & Brewerton, T. (1998). The Role of weight Control as a Motivation for Cocaine Abuse. Addictive Behaviors, 23(2), 201-207.


Franko, D. L., Dorer, D. J., Keel, P. M., Jackson, S., Manzo, M. P., & Herzog,  D. B.     (2008, July). Interacitons Between Eating Disorders and Drug Abuse. The Journal of Nervous and Mental Disease, 196(7), 556-561.


Herzog, D. B., Franko, D. L., Dorer, D. J., Keel, P. K., Jackson, S., & Manzo,
     M. P. (2006). Drug Abuse in Women with Eating Disorders. International
     Journal of Eating Disorders, 39(5), 363-368.


Krahn, D., Kurth, C., Demitrack, M., & Drenowski, A. (1992). The Relationship of
     Dieting Severity And Bulimic Behaviors to Alcohol and Other Drug Use in
     Young Women. Journal of Substance Abuse, 4, 341-353.


Pisetsky, E. M., Chao, Y. M., Dierker, L. C., May, A. M., & Striegel-Moore, R.
     H. (2008). Disordered Eating and Substance Use in High-School Students:
     Results from the Youth Risk Behavior Surveillance System. International
     Journal of Eating Disorders, 41(5), 464-470.


Ross-Durow, P. L., & Boyd, C. J. (2008). Sexual Abuse, Depression, and   Eating Disorders in African American Women who Smoke Cocaine. Journal of Substance Abuse Treatment, 18, 79-81.




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