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Evidence Supporting a Relationship Between Eating Disorders and
The relationship between eating disorders and alcoholism has become a widely researched topic only in the last fifteen years. Since 1985, there have been an increasing number of research and case studies substantiating a correlation between these two behavioral and addictive disorders. Alcoholism affects nearly 14 million United States citizens (http://silk.nih.gov/silk/niaaa1/publication/booklet.htm ). The four basic elements of this disease include a craving for, loss of control over, physical dependence on, and tolerance to alcohol (http://silk.nih.gov/silk/niaaa1/publication/booklet.htm). Unfortunately, there is no cure for alcoholism, although various forms of treatment have become available. Eating disorders also affect a vast number of people: approximately 1% of female adolescents have anorexia nervosa and 4% of college-aged women have bulimia nervosa (http://www.anred.com/stats.html ). Men experience eating disorders less than women and encompass only 5-10% of the populations of eating disorder patients (http://www.anred.com/stats.html ). There is no cure for eating disorders. However, varieties of medicinal and psychotherapy treatments have allowed for improvements in patients and critical debates. The following paper analyzes five research studies that examined the possible correlation between eating disorders and alcohol abuse. Each report provides a summary of the procedures, results, and discussions formulated by the researchers. Finally, a critique of the overall findings from each study will offer possible changes that might help concretize conclusions to the many unanswered questions concerning eating disorders and their tendency to result in alcohol abuse.
The first report includes data for a random sample of 27 females drawn from two alcoholic units (Lacey et al., 1986). The mean age of the subjects was 32 years and 7 months and they were equally divided among the upper two social classes. The goal of this research was to examine the past and present eating habits of female alcoholics to determine whether or not a correlation between the two disorders existed. Two methods of research were used to evaluate the subjects: an interview and a questionnaire. One of the authors interviewed each subject individually. The interview consisted of two parts: (1) a detailed assessment of past and present eating behaviors and (2) an evaluation of drinking patterns. The first part of the interview based eating disorders on a variety of patterns, including binge-eating behaviors that lasted for at least 6 months. The second part of the interview used a pre-determined interview created by Stockwell et al. to determine levels of alcohol dependence. The questionnaire consisted of the Eating Attitudes Test, which is "a standardized measure of anorectic and bulimic behavior" (Lacey et al., 1986: pp. 390).
The results of this study supported a correlation between past or present eating disorders and alcoholism. The sample had mild to moderate dependence on alcohol, ranging from continuous to fluctuating intake. 11 members of the sample had experience with binge eating. Nine of the patients had a history of purging to deter weight gain. All of the patients were menstruating and all but one were in normal weight ranges (Lacey et al., 1986). Although six patients described characteristics of anorexia nervosa, none had been diagnosed in the past. Bulimic alcoholics were younger, experienced problems with drinking at earlier ages, and scored higher on the EAT test than the patients who lacked experience with binge eating behaviors. Overall 40% (11 of 27) of the patients reported past or present problems with binge eating (Lacey et al., 1986). The researchers asserted that this prevalence was much higher than the prevalence of binge eating in the general female population at the time of this study (between 3% and 6%). The researchers attributed this correlation to common aspects of each disorder, including depressed emotional states, low self-esteem, high levels of anxiety, and using food as a displacement for boredom. They also suggested that the abuse of alcohol could result from the patients' earlier abuse of and obsession with food (Lacey et al., 1986).
The second study compared 20 consecutive alcoholic women with 20 women diagnosed with bulimia nervosa and 17 control women with neither alcohol abuse or eating disorder symptoms (Beary et al., 1986). This study also analyzed the assessments of 112 consecutive patients attending the St. George's Eating Disorders Clinic diagnosed with bulimia nervosa. The first three groups consisted of women aged 40 years and under. First, the researchers assessed the prevalence of past or present eating disorders in the 20 alcoholic patients with an interview used by the St. George's Eating Disorders Clinic. The researchers selected the second group from patients who had attended the St. George's Eating Disorders Clinic for bulimia nervosa. The control group consisted of 17 consecutive patients attending a family planning clinic. They gave the control group a questionnaire, the Eating Attitude Test (EAT), and weighed and measured each member individually. In the third part of this study, the researchers assessed the 112 patients with bulimia nervosa and made a correlation between alcohol abuse and age (Beary et al., 1986).
The results of this study confirmed the possible association of eating disorders and alcohol abuse. Seven of the 20 (35%) alcoholic patients reported suffering from either bulimia nervosa or anorexia nervosa in their pasts or during the time of the study. None of the control group members gave a history of an eating disorder (Beary et al., 1986). They also scored below 15 on the EAT, indicating their lack of eating disorders. Fifty per cent of the bulimia nervosa patients reported previous alcohol abuse and thirty per cent reported previous bouts with anorexia nervosa. Of the 112 bulimia patients, those who reported alcohol abuse showed a direct correlation between increasing age and severity of alcohol abuse. The researchers concluded that their results confirmed a relationship between bulimic eating disorders and alcohol abuse in younger women. They suggested that patients with eating disorders substitute their obsession with food to alcohol as a possible response to depression. They also asserted that the eating disorders seemed to start much earlier than alcohol abuse. Therefore, the researchers concluded that further research is necessary to confirm whether bulimia nervosa serves as a possible pre-cursor to alcoholism (Beary et al., 1986).
The third study analyzed the prevalence of eating disorders in 52 women hospitalized for various forms of alcohol abuse (Taylor et al., 1992). The researchers invited all women between the ages of 17 and 45 attending the Regional Alcohol Treatment Unit in Oxford to participate in their study. They used a general population sample as their control group, consisting of 243 women. The ages of the alcohol clinic patients were significantly older than the control group with a mean age of 34.1 years compared to 26.6 years of the control group. The demographics of the two groups did not substantially differ. The researchers used the Eating Disorder Examination (EDE) to assess both participant groups. The EDE is "a standardized validated investigator-based interview that measures the behavior and attitudes characteristic of clinical eating disorders" (Taylor et al., 1986: pp.148). Each group was also given a structured interview to assess histories of eating disorders and menstrual cycles. The severity of alcohol dependence was assessed in the patient group using the Severity of Alcohol Dependence Questionnaire (SADQ).
The results of this study were consistent with the conclusions of the previous two studies: a relationship appeared to exist between eating disorders and alcohol consumption. 33% of the alcohol clinic patients scored greater than 30 on the SADQ, categorizing them as having a severe dependence on alcohol. The researchers used nonparametric analyses to conclude that the proportion of subjects that that indicated symptoms of eating disorders (based on the EDE) was significantly greater in the alcohol abuse sample. 11.5% of the alcohol clinic sample verses 1.7% of the control sample had a history of anorexia nervosa. There was no significant difference between the two samples and the prevalence of bulimia nervosa. However, 17.3% of the alcohol clinic subjects verses 7.0% of the control subjects experienced a lifetime struggle with bulimia nervosa. The alcohol clinic patients that had experience with eating disorders were significantly younger than the alcohol clinic patients with no indication of eating disorders. This group also had a younger age of onset of alcohol abuse than the group void of eating disorders (21.8 years vs. 28.5 years). The researchers concluded that the results of their study support a correlation between eating disorders and alcohol abuse. They also provided evidence that women abuse alcohol earlier if they struggle with eating disorders. Finally, the researchers suggested that the relationship could result from feelings of dysphoria and isolation commonly felt by eating disorder patients, leading to the abuse of alcohol (Taylor et al., 1992).
The fourth study examined a large sample group consisting of 3592 patients (336 females and 3256 males) at the National Institute of Alcoholism between January 1982 and December 1988 (Higuchi et al., 1993). The goal of this study was to determine the prevalence of eating disorders among male and female Japanese alcoholic populations and to assess clinical treatment of people with both eating disorders and alcoholism. The mean age of the female sample was 44.8 years and the mean age of the male sample was 46.0 years. The patients were given physical examinations upon entrance into the hospital. They were also interviewed by social workers for their family histories and backgrounds. Psychiatrists assessed the patients to determine the severity of their alcohol abuse and the possible presence of additional psychotic illnesses. The researchers made two additional assessments for patients that indicated eating disorders in their initial evaluation. These two assessments were based on a classification form and occurred directly after withdrawal symptoms dissipated and three months before the patients were released from the hospital.
The results of this study provided a significant correlation between eating disorders and alcohol abuse in the female patients. 11% of the female alcoholics had eating disorders. Most of these women were younger then those with no problems associated with eating. 72% of the women who were younger than 30 had eating disorders. The male alcoholics presented insignificant results, since only 5 members of the total sample had symptoms of eating disorders. The authors of this study noted that it is important to acknowledge that "all of these patients had both disorders at the time of referral" (Higuchi et al., 1993; pp. 404). However, the results indicated that most of the patients experienced their eating disorders before the onset of alcohol abuse. The researchers referred to previous studies to assert possible interpretations of their data. They offered that addictive behavioral tendencies, a regression in the oral phase of development, feelings of loss of control and compulsion, or genetics contributed to the co-development of these two disorders in women (Higuchi et al., 1993).
The final study analyzed in this paper examined the relationship between alcohol abuse and eating disorders in 234 high school females (Striegel-Moore & Huydic, 1993). The aim of this study was twofold: (1) to determine the relationship between possible eating disorders and problem drinking and (2) to examine the relationship between the three symptom descriptions of eating disorders and problem drinking. The researchers gathered the sample from a racially and socioeconomically homogeneous high school in Connecticut. 88% of the sample were Caucasian. The mean age of the participants was 15.5 years. Each student was given three separate surveys during one academic period. The students filled out a demographic questionnaire, The Adolescent Drinking Index (ADI), and the Eating Disorder Examination (EDE-Q). The ADI screened for the possibility of significant problem drinking, based on amount of control over drinking as well as reasons and repercussions of drinking. Higher scores on the ADI indicated more severe drinking problems. The EDE-Q examined various aspects of eating disorders prevalent within one month of the test (for example, affective, cognitive, and behavioral symptoms). The students rated each question on a 7-point scale from least to most frequent or severe. The researchers used regression analysis, univariate analyses of variance, and multivariate analysis of variance to correlate the possible relationships between probable eating disorders (and/or their individual symptoms) and problem drinking.
The results of this research were less concrete than the aforementioned studies. The authors suggest a relationship between problem drinking and body image and dietary concerns. They also assert, however, that their data does not provide significant results for an association between drinking and binge eating. 17.5% (41 students) of the sample were identified by their scores on the ADI as problem drinkers. 5.1% (11 students) of the sample were identified by the results of the EDE-Q as possibly having eating disorders (1 subject had symptoms of bulimia nervosa, and 10 had criteria for EDNOS). Of these 11 students, 4 were also problem drinkers, representing 11% of the total group of problem drinkers. The remaining 7 students represented 4% of the total number of students who scored in the normal range of the ADI. Although it seemed likely that there was a pattern between the students with possible eating disorders and problem drinking, the results were too small to form statistically significant conclusions. Problem drinkers, however, provided significant statistical evidence to support the correlation between problem drinking and more severe body image concerns, dieting, and overeating (Striegel-Moore & Huydic, 1993). The researchers argued that dietary and caloric restraint may lead to alcohol abuse to reinforce the basic necessities of the body. They argued that eating disorders could be a predictor of alcohol abuse and that further research on this topic is necessary to determine effective treatments for both disorders.
The five previous reports support the potential relationship between eating disorders and alcohol abuse. However, each report has weaknesses that undermine its reliability and validity. First, three of the five studies used sample sizes that were less than 40 subjects. This limited amount of subjects causes a greater detrimental effect on the statistics if one or two subjects are evaluated incorrectly or provide false information. Thus, larger sample sizes or a more critical evaluation of the statistics could provide results that are more significant. Another problem with studies based on eating disorders and alcohol abuse is the difficulty in diagnosing both disorders. Many of the researchers referred to the DSM for definitions and diagnosis of anorexia nervosa, bulimia nervosa, and EDONS. However, many patients met limited criteria and were not given full psychological assessments and yet they were grouped as having eating disorders. False data further perpetuates misleading studies. Mandating that subjects must have full psychological evaluations and diagnoses would provide a factual and clear report. The methods of assessment in these studies also allow for lack of clarity and conviction when determining the presence of eating disorders and satisfactory measures of alcohol intake. Questionnaires and interviews rely on appropriate questions and honest participants for the formulation of an effective study. Other factors to consider are the social, educational, and economic backgrounds of the subjects. Comparing two demographically different samples leads to misleading data and conclusions. Finally, almost all of the studies consulted for this paper had a selection bias of the subjects. Much of the research done on the correlation of eating disorders and alcohol abuse lack a control group from the general population. Furthermore, choosing subjects from alcohol clinics may hide a true association between the two disorders. For example, subjects with both disorders may seek help for only alcohol abuse because of the social stigmas associated with eating disorders (Taylor et al, 1992). Such an incident would result in the distortion of the selection of subjects.
All five of the reports analyzed in this paper provide data and steps towards understanding the behavioral, cognitive, and affective developments of eating disorders and their relationships with alcohol intake. Of the ten studies consulted throughout the compilation of this paper, all provide evidence for the correlation between eating disorders and alcohol abuse. Each study also asserts that eating disorders appear to result in younger ages of people misusing alcohol. Since the etiologies of these disorders are still unclear, it is difficult to establish common causes or reasons for the apparent correlation. However, the studies in this paper pave the road for future researchers by highlighting inconsistencies and interesting relationships that need to be further researched. Studies will improve with the use of greater population samples, less selection bias, and concrete criteria for diagnoses of these diseases. By forging into unknown territory, researchers offer hope to victims of alcoholism and eating disorders that the future may provide more effective therapies, recognizable symptoms, or even the creation of a cure.
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