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Are anorexics and bulimics more likely to abuse substances than others?

Morgan Levitt

May 4, 2010


            If substance abuse and eating disorders are both diseases of the mind and the body, is a person who suffers from one of these diseases more likely to suffer from the other than is a person without any previous illness? Once a person has developed an illness is it easier for them to fall victim to another obsession? In account of the fatal tendencies of both substance abuse and eating disorders, it is crucial to determine whether or not there is a link between them and to try to figure out why that might be.


What is an eating disorder?

            An eating disorder (ED) is characterized by extreme behaviors such as overeating or binge eating. A person’s mind begins to obsess over something specific such as fatty cookies or inhalants, dieting, drastic dieting, vigorous exercising, and compensatory acts including, vomiting, and the use of laxatives and diuretics. These extreme behaviors stem from an intense fear of weight gain or the dissatisfaction with one’s shape and size. When fear becomes the motivation, a person is no longer just a health conscience individual. Eating disorders frequently develop during adolescence or young adulthood and in women more often than men. Due to the early development of the obsessive relationship with food, EDs commonly co-exist with other pathological illnesses such as depression, anxiety, self-mutilation, and substance abuse. Sufferers channel their problems into fears and attempt to use their control over food as a way to control other problems. In a sense, food becomes the scapegoat for other, more profound problems. The two most familiar eating disorders are anorexia nervosa and bulimia nervosa.


Anorexia Nervosa

            Anorexics are constantly battling an intense fear of weight gain and thus they attempt to combat the fear by maintaining an extremely low body weight. Anorexics eat very small portions if at all. They may diet and fast in order to restrict their caloric intake or exercise excessively to work off what they consumed. They may also vomit, or purge after eating. For an anorexic, the food they do eat is fixated upon. Often times, they plan out their meals and obsess over numbers, certain foods, and portions sizes. Physically, anorexics are emaciated. Their distorted self-image drives them down to unhealthy weights, which can cause amenorrhea, the lack of menstruation in women.


Bulimia Nervosa    

            Bulimics are also constantly concerned with their bodies and relentlessly induce vomiting. They may partake in extreme amounts of exercise or improper use of laxative and diuretics to purge themselves of the unusually large amounts of foods they consume during a binging episode. During a binging episode, bulimics feel a loss of control and compensate through purging. These cycles of uncontrollable overeating and vomiting only further perpetuate the behavior and can lead to ever increasing amounts of shame and anxiety. Unlike Anorexics, bulimics can be overweight and thus amenorrhea does not occur in some sufferers.


Substance abuse

            Substance abuse includes the improper use of any chemical that can alter the body’s functions such as caffeine, alcohol, and illicit drugs. These substances have addictive properties that can cause dependency and cause the development of tolerance and thus withdrawal symptoms. Once the addiction has formed, users have a difficult time quitting and often use the habit as a way to numb themselves of their problems. Substance abuse is similar to eating disorders in that it gives the addict or sufferer something else to focus their attention on other rather than their pre-existing problems.

            The DSM-IV lists the following criteria for substance abuse:

Substance dependence is defined as 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, or home.

2. Recurrent substance use in situations in which it is physically hazardous

3. Recurrent substance-related legal problems

4. Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance

*Alternatively, the symptoms have never met the criteria for substance dependence for this class of substance.



Studies relating substance abuse and eating disorders

            The purpose of this study was to examine the frequency of substance and alcohol abuse among anorexics and bulimics, subcategorized as anorexia nervosa-restrictive, anorexia nervosa-binge eating/purging, and bulimia nervosa (Krug, Pinheiro, Bulik, Jimenez-Murcia, Granero, Penelo, et al 2009). Researchers sampled 371 eating disorder patients questioning them about their own substance/alcohol. They found that there were substantial differences between the results in each subcategory. Anorexia nervosa-restrictive patients suffered from substance/alcohol abuse less frequently than either of the subcategories that exhibited purging behaviors (anorexia nervosa-binge eating/ purging, and bulimia nervosa patients).

            Although this study did not have a control group, their sample size was rather large when the frequency of reported eating disorders is taken into account. The results are reliable because the sample size was so intensely scrutinized thanks to the separation of different subcategories and each individual was questioned personally rather then through other’s testimonials. 

            A study was developed by Ramacciotti, Bianchi, Coli, Polese, Bondi, Massimetti, et al. (2010) to determine whether or not eating disorder patients abuse caffeine more often than the rest of the population, as well as to compare the level of abuse among different types of ED. Researchers used either a dimensional perspective or a categorical approach with the DSM-IV-TR as the basic diagnostic criteria. They studied 15 anorexia nervosa (AN), restricting and binge-eating/purging types, 26 bulimia nervosa (BN) purging type/nonpurging types, and had 15 control subjects. They were all given the Eating Disorder Inventory-2 (EDI-2), the Clinical Global Impression (CGI) and the Caffeine Use Test. The data was analyzed in the original groupings as well as new groupings determined by the presence or absence of purging behaviors. The results lined up with previous studies concluding that most ED patients consume normal amounts of caffeine under binging pretences. The researchers felt that a significant portion of their ED patients qualified as caffeine dependent and thus the case needs additional exploration.

            Here, it is clear that this study was conducted soundly following strict criteria written in the DSM. Though the sample sizes were rather small, the patients were still categorized specifically by their disordered behaviors and a control group was included. The data was measured by multiple credited tests, which further indicated the validity of the study.

            Jonas, Gold, Sweeney, and Pottash (1987) interviewed 259 National Cocaine Hotline callers to determine how many of them met the criteria published by the DSM-III for an eating disorder. Following the DSM-III guidelines, they found that nearly one third of all of the callers could be diagnosed with an ED of anorexia, bulimia, or both. These statistics compared to the percentage of the drug-free population with and ED were outstanding. This study shows that it is not merely a coincidence that people who abuse cocaine may also suffer from and eating disorder. Similarly, these researchers also concluded that further studies should be conducted on the relationship between drug abuse, namely cocaine, and eating disorders.

            This study had a large sample size that was randomly selected. The interviews were conducted consecutively to minimize possible bias. In light of the nature of the study, a control group could not have been utilized; however, because the sampled population was similar in that they were cocaine abusers, their responses can be easily compared to one another without separating the callers into subgroups.

            In an attempt to solidify previous study’s conclusions, a compilation of 51 studies on co-morbidity of ED and substance abuse was put together and reviewed (Holderness, C. et al., 1994). The researchers noted any information concerning the rates of co-morbidity and found similar results in all of the studies; substance abuse was found to occur more often in bulimic women and anorexic women who demonstrate bulimic behaviors than women who are restricting anorexics. Furthermore, this study also urged more research to be done in the future.

            Because this study did not directly deal with people rather other studies, it cannot be criticized for its methodology. Regardless, the question researched here was specific and the number of studies included was quite large for a compilation of statistics.

            In the past decade, a multitude of similar studies have been recorded such as a study done by Sinha and O’Malley (2000) to establish whether or not drug use is more prevalent in the eating disordered population. Similar to the previous studies, they also found that bulimics were at a higher risk to abuse drugs. In a study done by Calero-Elvira, Krug, David, Lopez, Fernandez-Aranda, and Treasure (2009) they also found that bulimics were more likely to suffer from substance abuse problems than others with eating disorders as well as the ED free population.


Are they really linked?

            The literature clearly shows that co-morbidity of eating disorders and substance abuse exists. Researchers conclude study after study that these two diseases often appear in the same individuals. The studies also indicate that bulimics and anorexics that exemplify purging behaviors more commonly struggle with drug abuse than do restricting anorexics. This could possibly have to do with the different mentalities present. If an anorexic practices restriction, they would not want to overindulge themselves with anything whether it is food, alcohol, or drugs--it is a compulsive behavior. In contrast, bulimics and purging anorexics often indulge themselves and use compensatory behaviors like purging to rid themselves of the indulgence.


Are further studies needed?

            Further studies are needed to determine exactly what the link is between substance abuse and eating disorders. Currently, research is moving towards genetic causes for an eating disorder. It could be possible that a genetic component makes a person more likely to obsess over their habits or possibly, it is has to do with personality like an addictive trait. If scientists can pinpoint the link between these two fatal diseases, they can form more effective treatment plans. Addictions are so hard to treat because often times, the patients do not know why it started.










Literature Cited

Calero-Elvira, A., Krug, I., Davis, K., Lopez, C., Fernandez-Aranda, F., & Treasure, J. (2009). Meta-analysis on drugs in people with eating disorders. European eating disorders review : the journal of the Eating Disorders Association, 17(4), 243-259.

Holderness, C., Brooks-Gunn, J., & Warren, M. (1994). Co-morbidity of eating disorders and substance abuse review of the literature.. The International Journal of Eating Disorders, 16(1), 1-34.

Jonas, J., Gold, M., Sweeney, D., & Pottash, A. (1987). Eating disorders and cocaine abuse: a survey of 259 cocaine abusers.. The Journal of Clinical Psychiatry, 48, 47-50.

Krug, I., Pinheiro, A. P., Bulik, C., Jimenez-Murcia, S., Granero, R., Penelo, E., et al. (2009). Lifetime substance abuse, family history of alcohol abuse/dependence and novelty seeking in eating disorders: Comparison study of eating disorder subgroups . Psychiatry and Clinical Neurosciences, 63(1), 82-87.

O'Malley, S., & Sinha, R. (2000). Alcohol and eating disorders: implications for alcohol treatment and health services research.. Alcoholism, Clinical and Experimental Research, 24(8), 1312-1319.

Ramacciotti, C., Bianchi, M., Coli, E., Polese, L., Bondi, E., Massimetti, G., et al. (2010). Caffeine consumption among eating disorder patients: epidemiology, motivations, and potential of abuse.. Eating and weight disorders : EWD, 14(4), 212-218.

Voorhees, B. V. (2009, January 15). Drug abuse: MedlinePlus Medical Encyclopedia. National Library of Medicine - National Institutes of Health.


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