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The Relation Between Alcohol and Eating Disorders
Many studies have been done on the comorbidity between eating disorders and depression or other psychological problems, but an inadequate amount has been performed on the comorbidity between alcohol use and misuse and eating disorders. There is a strong correlation between alcohol use and eating disorders, particularly for Bulimia Nervosa and the binge-purge subtype of Anorexia Nervosa. Also, the correlation is much stronger for the younger groups of women. Additionally, the idea of youth substance use and eating disorders is increasing tremendously. 7.1% of middle schoolers are either vomiting or using laxatives to influence weight loss, and those that use alcohol are much more likely to do this than are others. Due to increased mortality associated with alcohol use disorder and eating disorders and the effectiveness of it, hospitalization should be more readily chosen as a form of treatment for those patients that exhibit both alcohol use disorder and eating disorders. Finally, prevention could be an effective method of decreasing the prevalence of eating disorders considering how easily regular dieting can escalade into problem dieting.
Eating disorders are at best a misunderstood problem. Daily, more people suffer from the effects associated with the development of eating disorders, and the negative consequences continue to mount. Much more work in this field is needed to determine efficient ways to prevent the onset of eating disorders and also to hasten and improve the recovery process. One way to do this is through determining and assessing the comorbidity between eating disorders and other physiological, social or psychological problems. Much research has been performed on the association between parental disorders with eating, depression, and various other psychological problems with eating disorders. Another issue, which in and of itself is particularly detrimental, could have severe implications on the onset and recognition of eating disorders: alcohol disorders. The object of this systematic research of the available research is to determine the affects that alcohol misuse and abuse has on eating disorders, and finally how the knowledge of these relationships could affect and improve treatment for eating disorders.
First, the general relationship between alcohol abuse and eating disorders should be noted, and later more specific relationships will be delineated. To begin, in a study by Franko, a sample of 246 women with eating disorders was undertaken. They were diagnosed at the beginning of the study with either Anorexia Nervosa (AN = 136) or Bulimia Nervosa (BN = 110). The participants were then routinely checked up on over the succeeding 8-9 years and the information was recorded. At the beginning of the study, over one fourth of all the participants had or were currently suffering from alcohol use disorders (AUD). Additionally as the study progressed, another 10% of the sample began to experience AUD (Franko, 2005).
In another study, this time in Japan, taken from a hospital dedicated to the treatment of alcohol abuse disorders, the prevalence of eating disorders for women was exceptionally high. In a sample of over 300 women, 11% also exhibited problems with eating disorders. Additionally in the portion of the sample for women under the age of 30, 72% of women experienced eating disorders (Higuchi, 1993). These values are significant because the average prevalence of Anorexia Nervosa in Japan is around 0.025%, and the values for this study were much higher. Additionally, the average prevalence of Bulimia Nervosa in Japan is around 2.9%, but this study had the prevalence at 10 times that for women under 40, and 24 times that for women under 30 (Higuchi, 1993). In another study by O’Brien, 22% of women with Bulimia Nervosa exhibit heavy drinking defined as at least 36 drinks per week, and 28% of these women also exhibited other drug use such as marijuana, amphetamines and tranquilizers (2003). Also found by O’Brien was that 41% of a group of women who went in for substance abuse treatment also had eating disorders and 28% of adolescent females with substance abuse also exhibited eating disorders (2003).
Additionally, when related to mortality, the prevalence of eating disorders made a large difference. In Franko’s study, of the 246 women, 4 committed suicide over the course of the study, all suffering from Anorexia Nervosa. This means that 7.4% of the sample with Anorexia Nervosa committed suicide, a drastically increased number from the general average (SMR = 56) (Franko, 2005). Additionally, in this study the association between increased mortality and severity of alcohol use remained severe (Franko, 2005). Another important factor that should be noted is that many times, eating disorders lead to psychosocial problems. These psychosocial problems typically lead to increases in alcohol use and abuse. And finally, due to their relation, the increase in alcohol use and abuse may lead to increased mortality. For this reason, eating disorders can typically lead to a relationship with alcohol, thus complicated issues further.
Primary Nature of Eating Disorders
To continue this idea that eating disorders lead to other issues, the primary nature of eating disorders should be discussed. In the study by Higuchi, eating disorders were never replaced by alcohol use disorders, rather the alcohol use disorders were just tacked on to the problems. The most common forms of the pairing were those subjects who exhibited alcohol use disorders and Bulimia Nervosa (Higuchi, 1993). Additionally, there was a very short time between the reported beginning of the effects of the eating disorder and the beginnings of problems with alcohol use. To be more specific, the average gap between these two times was 4.5 years for women and 2.5 years for men (Higuchi, 1993). Finally, according to O’Brien, food deprivation has been shown to lead to substance use and abuse (2003). Obviously, eating disorders lead to food deprivation, whether through restriction or purging. And since food deprivation leads to substance use and abuse, consequently, eating disorders may often lead to substance use and abuse (O’Brien, 2003).
It can be very difficult to prevent the beginning of eating disorders, and for that reason, recovery could be just as important. For that reason, research on the efficacy of various treatments and methods of improvement based on the factors already present is very important. One such study was noted earlier: Franko’s study of 246 women with eating disorders. Here, it was found that the presence of an alcohol use disorder did not affect recovery time from the eating disorders (2005). Also in this study, regardless of whether the subject was suffering from Anorexia Nervosa or Bulimia Nervosa, hospitalization helped the recovery from alcohol use disorders. Expectedly, drug use hindered this same process (Franko, 2005). There were also some differences on effective treatments between the two disorders. For Anorexia Nervosa, group therapy helped whereas vomiting hurt the process. Conversely, for Bulimia Nervosa, exercise seemed to help with the recovery from alcohol use disorder (Franko, 2005). This could be because the exercise was used as a substitute coping mechanism in place of the alcohol use. Most likely, if exercise were used in the AN group, the effects of the eating disorder would be magnified as an opportunity for purging would be encouraged. One final thought on treatment is that there is the possibility that treatment in specialized settings could be more effective in patients which exhibit both an eating disorder and problems with alcohol use because they share common root problems: behaviors in response to stress or negative effects (Franko, 2005). This is good news considering the high number of people who suffer from both alcohol use problems and an eating disorder.
Differences Among Gender and Various Subtypes
To begin the conversation, the differences between male and female issues with eating disorders and alcoholism are as they would be expected. Men do not show the same correlation between alcohol use and misuse, as do women. For instance, in the Japan study, there were over 3,000 men admitted into this hospital for problems with alcohol use. Only 5 of these men exhibited any eating disorders (Higuchi, 1993). This is not a very high amount of men. Although, it should be noted that each of these 5 men were below the age of 30, thus continuing the trend that young people are at a higher risk for eating disorders. Also, not much research is done regarding men, in fact many of the available studies deliberately only obtain data from women. For this reason, much more research is needed on the male end of the spectrum.
As far as the difference between different types of eating disorders (BN, AN binge-purge subtype and AN restrictive subtype) there are some important ideas. Franko’s study found no significant difference between AN and BN with regards to problems with alcohol use. But this could be because 88% of AN subjects developed BN symptoms throughout the course of the study, thus strengthening the argument that symptoms of Bulimia Nervosa can lead to problems with alcohol use (Franko, 2005). Among BN subjects, more global issues like psychosocial functioning and substance abuse increase vulnerability for developing an alcohol use disorder. On the other hand, among AN subjects, over concern with bodyweight and shape and the use of vomiting to control them seem to increase vulnerability (Franko, 2005). In general, vomiting seems to be a consistent indicator of AUD onset in people with Anorexia Nervosa. It seems that in AN, alcohol use is more closely related to purging than to binging (Franko, 2005). Further explained, vomiting is closely related to AUD (speeds onset and delays recovery) than is binging. This has an important implication in that this could mean that purging disorder (where someone engages in purging without an initial binge) could be more closely related to alcohol use than originally thought (Franko, 2005).
Also, the mortality rates across the types of eating disorders were very different. For example, 7.4% of people in Keel’s study with Anorexia Nervosa died during the study’s duration, and upon further research with the families of the deceased, alcohol played a major role in each of these deaths (2003). Half of these deaths were from each subtype, thus yielding no difference in mortality among the different subtypes of Anorexia Nervosa. Also, the mortality rate was much lower in the Bulimia Nervosa group (only 1 death representing 0.9% of the BN sample). A few final notes on this subject of the variation between the different types of eating disorders is that purging and alcohol use both seem to be compulsive, and for this reason there seems to be a correlation between Bulimia Nervosa or Anorexia Nervosa with the binge-purge subtype and alcohol use disorder while there does not seem to be the same relationship between the AN-restrictive subtype and AUD.
There is a very popular idea that alcohol use is another example of impulsive behavior normally exhibited by Bulimia Nervosa patients or those with Anorexia Nervosa that exhibit some of the symptoms associated with BN. Franko explains this by pointing out that the binge-purge subtype in Anorexia has much more problems with alcohol than does the other subtype, and that the multi-impulsive bulimic personality is very common (one where a subject exhibits 3 or more impulsive behaviors like binging, alcohol use, suicide attempts and kleptomania) (2005). This is important as Higuchi points out because there is a common addictive and impulsive personality shared by people with AUD and eating disorders (1993). It should also be noted that binge eating is very similar to bout drinking. They each exhibit excessive and impulsive actions with a strong lack of control by the subject (Higuchi, 1993).
Parental and Child Substance Use
To begin this portion, the parental idea will be discussed first. In a study by García-Vilches of 121 patients with Bulimia Nervosa, only 7.4% exhibited any problems with alcohol (2001). Additionally, 20.7% of the parents of the bulimia nervosa patients were reported to have abused alcohol. The study suggests that there was no difference in the severity of the bulimia nervosa patients according to whether or not their parents abused alcohol (García, 2001). But it is important to note that 20.7% of these patients had parents that abused alcohol, an amount much higher than the average. So, maybe the severity of BN is not affected by parental alcohol abuse, but the prevalence of BN could very well be affected. It should also be noted that the majority of the parents who abused alcohol were also obese, thus warping the child’s perception of image. This could have led to increased development of eating disorders (García, 2001).
As far as children are concerned, much research has been done on the correlation between older adolescents and eating disorders and substance use, but not much research has been done on younger adolescents. In a study of 5,770 middle school students by Garry, 6.0% percent of students had used diet pills and 7.1% had either used vomiting or laxatives to influence weight loss (2002). It was also found that students that who drank alcohol (20.5%) or smoked cigarettes (20.6%) were much more likely to engage in these practices, and those that drank alcohol and smoked cigarettes were at the highest risk (Garry, 2002). It is also pointed out that there is a high correlation between unhealthy weight loss behaviors and substance use such as alcohol and marijuana use by high schoolers. Additionally, studies show that substance use in middle schoolers was associated with higher concern about body weight (Garry, 2002). Also, as was noted earlier, in the study in Japan, 72% of women under the age of 30 suffered from eating disorders (Higuchi, 1993). Overall, youth, especially middle school, is a volatile time. With the beginning of puberty, advanced social interactions and dating, young people are at a high risk of starting dieting behaviors that could escalate to more unhealthy and dangerous behaviors and even eating disorders (Garry, 2002). Finally, earlier it was stated that vomiting is a consistent predictor of alcohol use disorders. Since 7.1% of middle schoolers in a large sample are engaging in vomiting or laxative use, they are at a high risk and should consequently be paid very close attention.
Suggestions and Conclusion
Based on these findings, several suggestions can be made to help those suffering from eating disorders and alcohol use disorders. First, since alcohol use was shown to increase mortality among those with eating disorders, those that have eating disorders and use alcohol should be extra cautious, and should perhaps refrain from alcohol use. Additionally, the hospitalization threshold should be lowered. Considering that hospitalization has been shown to decrease the recovery time of individuals suffering from either of the disorders, particularly those with both of them, and that mortality increases when the two are combined, hospitalization could be used even more effectively if the two are observed together.
Another important idea is that of prevention. Prevention is always cheaper than treatment, particular by way of increasing awareness. Considering the abnormally high amount of young people, middle school students, that engage in unsafe dieting behaviors, more attention should be paid to them. Those that exhibit substance use like alcohol, tobacco, or marijuana use as early as the 8th grade should be paid special attention due to their increased risk of developing an eating disorder. Additionally, it has been shown that one third of normal dieting among women leads to problem dieting, and if this many students are already exhibiting normal dieting or even abnormal dieting, this is a cause for alarm (Garry, 2002). Unfortunately, there are some faults with the available research. For one, there have not been many studies on simply the use of alcohol, instead its misuse. Also, not many studies have been done on any male sample groups. Overall, detecting and increasing awareness of the relationship between alcohol and substance use with eating disorders could prove to limit the effects that eating disorders have been having on the population, and consequently improve and even save many lives.
Franko, D., Dorer, D., Keel, P., Jackson, S., Manzo, M., Herzog, D. (Oct., 2005). How do eating disorders and alcohol use influence each other? International Journal of Eating Disorders. Vol. 38 (3): 200-207.
Garcia-Vilches, A., Badía, F., Fernández, S., Jiménez, V., Turón, J., Vallejo, Katzman, M. (Sep. 2001). Characterisitcs of bulimic patients whose parents do or do not abuse alcohol. Eating and Weight Disorders. 7: 232-238.
Garry, J., Morrissey, S., Whetstone, L. (Dec., 2002). Substance use and weight loss tactics among middle school youth. International Journal of Eating Disorders. Vol 33 (1): 55-63.
Higuchi, S., Suzuki, K., Yamada, K., Parrish, K., Kono, H. (1993). Alcoholics with eating disorders: prevalence and clinical course. A study from Japan. British Journal of Psychiatry. 162: 403-406.
Doi: 10.1192/ bjp. 162.3.403.
Keel, P., Dorer, D., Eddy, K., Franko, D., Charatan, D., Herzog, D. (2003). Predictors of mortality in eating disorders. Archives of General Psychiatry. Vol.60 (2): 179-183.
O’Brien, K., Vincent, N. (Feb. 2003). Psychiatric comorbidity in anorexia and bulimia nervosa: nature, prevalence, and causal relationships. Clinical Psychology Review. Vol. 23 (1): 57-74.
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