This document discusses the comorbidity of eating disorders and alcohol/substance abuse. It finds that binge eating disorder and bulimia nervosa often co-occur with alcohol/drug abuse, with 20-40% of those with bulimia reporting issues with substances. Restricting anorexics generally have lower rates of substance abuse. Personality traits like impulsivity and theories of an "addictive personality" have been linked to both bulimia and substance abuse. Physicians are encouraged to screen patients with eating disorders or substance abuse issues for comorbid disorders as well, as the combination poses greater health risks. More research is still needed to understand the psychobiological mechanisms at play.
This document discusses the comorbidity of eating disorders and alcohol/substance abuse. It finds that binge eating disorder and bulimia nervosa often co-occur with alcohol/drug abuse, with 20-40% of those with bulimia reporting issues with substances. Restricting anorexics generally have lower rates of substance abuse. Personality traits like impulsivity and theories of an "addictive personality" have been linked to both bulimia and substance abuse. Physicians are encouraged to screen patients with eating disorders or substance abuse issues for comorbid disorders as well, as the combination poses greater health risks. More research is still needed to understand the psychobiological mechanisms at play.
This document discusses the comorbidity of eating disorders and alcohol/substance abuse. It finds that binge eating disorder and bulimia nervosa often co-occur with alcohol/drug abuse, with 20-40% of those with bulimia reporting issues with substances. Restricting anorexics generally have lower rates of substance abuse. Personality traits like impulsivity and theories of an "addictive personality" have been linked to both bulimia and substance abuse. Physicians are encouraged to screen patients with eating disorders or substance abuse issues for comorbid disorders as well, as the combination poses greater health risks. More research is still needed to understand the psychobiological mechanisms at play.
This document discusses the comorbidity of eating disorders and alcohol/substance abuse. It finds that binge eating disorder and bulimia nervosa often co-occur with alcohol/drug abuse, with 20-40% of those with bulimia reporting issues with substances. Restricting anorexics generally have lower rates of substance abuse. Personality traits like impulsivity and theories of an "addictive personality" have been linked to both bulimia and substance abuse. Physicians are encouraged to screen patients with eating disorders or substance abuse issues for comorbid disorders as well, as the combination poses greater health risks. More research is still needed to understand the psychobiological mechanisms at play.
with eating disorders A.H. CONASON 1 , A. BRUNSTEIN KLOMEK 2 and L. SHER 1 From the Divisions of 1 Neuroscience and 2 Child Psychiatry, Department of Psychiatry, Columbia University, New York, USA Summary Eating disorders and alcohol/drug abuse are fre- quently comorbid. Eating-disordered patients are already at an increased risk for morbidity and mortality, so alcohol and drug use pose additional dangers for these patients. Restricting anorexics, binge eaters, and bulimics appear to be distinct subgroups within the eating-disordered population, with binge eaters and bulimics more prone to alcohol and drug use. Personality traits such as impulsivity have been linked to both bulimia nervosa and substance abuse. Many researchers have proposed that an addictive personality is an underlying trait that predisposes individuals to both eating disorders and alcohol abuse. Interviewing is generally the most useful tool in diagnosing alcohol and substance abuse disorders in individuals with eating disorders. It is essential for the physician to be non-judgmental when assessing for substance abuse disorders in this population. We discuss interviewing tech- niques, screening instruments, physical examina- tion, and biological tests that can be used in evaluating patients with comorbid eating disorders and substance abuse. More studies are needed to understand psychobiological mechanisms of this comorbidity, and to develop treatments for individuals with comorbid eating disorders and substance misuse. Co-morbidity of eating disorders and substance abuse Eating disorders, in particular bulimia nervosa and binge eating disorder, have long been associated with co-morbid substance abuse. 1 Between 20% and 40% of women suffering with bulimia also report a history of problems with alcohol and/or drugs. 24 For example, in one study, 37.5% of bulimic individuals reported a history of excess alcohol use and 26.8% a history of alcohol abuse or dependence. 2 In another, 39% of a clinical sample and 26% of a non-clinical sample of bulimic patients reported substance abuse or dependence. 5 Females engaged in binging and purging behaviour report higher rates of substance use and greater levels of psychological distress than their non- purging female peers. 6 In a clinical sample, the presence of binge eating predicted later incidence of substance use disorder. 7 In a study among adoles- cents, approximately 1:3 girls with bulimia nervosa smoked tobacco, used marijuana, and were drinking alcohol at least weekly. 8 A school-based study Address correspondence to Dr L. Sher, Division of Neuroscience, Department of Psychiatry, Columbia University, 1051 Riverside Drive, Suite 2917, Box 42, New York, NY 10032, USA. email: ls2003@columbia.edu Q J Med 2006; 99:335339 Advance Access publication 23 February 2006 doi:10.1093/qjmed/hcl030 ! The Author 2006. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org
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found significant associations between bulimic behaviours and various measures of alcohol, ciga- rette, and other drug use and abuse. 6 Amongst bulimic adolescents, substance use is also related to an increased likeliness of high-risk behaviours such as attempted suicide, stealing, and sexual intercourse. 8 Some authors report that in contrast with bulimics and binge eaters, restricting anorexics have low rates of co-morbid substance abuse. 9 Stock et al. concluded that adolescents with restrictive eating disorders use significantly less alcohol, tobacco, and cannabis than the general adolescent population. 9 They also found that adolescents with binging and purging symptoms did not use substances significantly more than the general adolescent population. 9 However, in other studies, dieting severity was positively associated with the preva- lence, frequency, and intensity of substance use. 7 Thus, the literature regarding the associations between eating disorders and alcohol and drug use is somewhat unclear. However, it does appear that restricting anorexics, binge eaters, and bulimics represent distinct subgroups within the eating- disordered population, and that binge eaters and bulimics are more prone to substance use. Psychological theories for co-morbidity of eating disorders and alcohol/drug abuse Personality traits such as impulsivity have been linked to both bulimia nervosa and substance abuse. 8 The literature indicates that there may be a subgroup of multi-impulsive bulimics who engage in a variety of impulsive behaviours in addition to binge eating and purging. This subgroup of bulimics is at a higher risk for substance abuse, and responds poorly to treatment. 8 Studies of clinical populations have reported high rates of chemical dependency and clinical depres- sion among adult bulimics. 4,10 It is possible that both eating-disordered individuals and substance- abusing individuals are self-medicating their clinical depression. Eating-disordered patients, mainly bulimics, have been successfully treated with antidepressant medications. 11,12 Individuals suffering with co-morbid eating disorders and substance abuse may simply be self-medicating with two techniques: overeating and substance abuse. Guilt is one of the emotions associated with both eating and alcohol abuse. 13,14 Both eating- disordered patients and alcohol-abusing patients suffer from underlying feelings of guilt. Individuals suffering from eating disorders and individuals suffering from substance abuse both have high rates of social anxiety. 15,16 Substance use may provide relief from anxiety, depression, and other psychosocial problems to which bulimics appear susceptible. 17 Family dysfunction may also be an underlying cause of both eating disorders and alcohol use. Many first-degree relatives of eating disordered women suffer from either eating dis- orders or affective disorders themselves, 18,19 leading to increased family dysfunction, which may lead their children to either develop an eating disorder or use substances, or both. Loxton and Dawe 20 concluded that girls who abuse alcohol and have disordered eating may share a vulnerability to heightened sensitivity to reward, but do not share a heightened sensitivity to punishment. Many researchers have proposed that an addic- tive personality is an underlying trait that predis- poses individuals to both eating disorders and alcohol abuse. Eating disorders, in addition to alcoholism, are often conceptualized as addictive disorders. 21 Individuals who develop an addiction to one substance may develop psychological and behavioural patterns that leave them vulnerable to developing addictions to other substances. In this theory, food and drugs are functional equivalents. 22 However, empirical evidence about the existence of an addictive personality is inconclusive. 1 Diagnosing co-morbidity General practitioners are often the first point of contact for patients suffering with eating disorders and substance abuse. 2325 Physicians must be made aware of the high levels of co-morbidity of these two disorders. If a physician suspects that a patient has an eating disorder, he/she should also screen that patient for substance use disorders. Patients present- ing with substance use disorders should also be screened for eating disorders. It is important for physicians to diagnose sub- stance abuse in all of their patients, especially their eating-disordered patients, because high drug and alcohol use is related to high morbidity and mortality, medical illness, accidents, and homicidal behaviour. Alcohol and drug abuse are also associated with both suicide attempts and com- pleted suicide. 2628 Eating-disordered patients are already at an increased risk for morbidity and mortality, so alcohol and drug use pose additional dangers for these patients. Alcohol dependence is a risk factor for suicidal behaviour: lifetime mortality due to suicide in alcohol dependence may be as high as 18%. 29 336 A.H. Conason et al.
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However, Murphy and Wetzel reviewed the epide- miological literature, and found that the lifetime risks of suicide among individuals with alcohol dependence treated in out-patient and in-patient settings were 2.2% and 3.4%, respectively. 30 Nonetheless, individuals with alcohol dependence have a 60120 times greater suicide risk than the non-psychiatrically-ill population. High rates of suicide attempts among individuals with alcohol use disorders have also been reported. 31,32 Studies of both general populations and drug abuse treatment populations demonstrate that drug use is also a risk factor for suicidal behaviour. 27 Drugs of abuse have profound effects on mood, which could amplify existing suicide risks. 27 Drugs of abuse also increase impulsivity, which is a risk factor for suicidal behaviour. 8,27 Adolescents may be at a particularly high risk for drug-related suicidal behaviour. 27 Interviewing Interviewing is generally the most useful tool in diagnosing alcohol and substance abuse disorders in individuals with eating disorders. It is essential for the physician to be non-judgmental when assessing for substance abuse disorders in this population. 33 Physicians should obtain a personal history of each patient that includes their lifetime and current substance use, as well as their heaviest period of use. 33 Obtaining information from third-party sources often plays an important role is diagnosing substance use disorders, especially in patients who are unreliable or unwilling to disclose information about their substance use. Use of multiple infor- mants increases the validity of the evaluation. 34 There are several short screening measures that would be useful in a primary care setting. Most screening instruments tend to focus on alcohol use rather than drug use. The CAGE 35 consists of four questions (cutdown, annoyed, guilty, eye-opener) and the TWEAK 36 consists of five questions (toler- ance, worried, eye-opener, amnesia, cutdown). Both of these instruments are short enough to be implemented into routine physical exams or admin- istered if the physician suspects an alcohol use disorder in a patient with eating disorder. The TWEAK appears to have greater sensitivity and specificity than the CAGE for assessing lifetime alcohol abuse and dependence. 37 More detailed questionnaires, such as the Michigan Alcoholism Screening Test (MAST) 38 or the Alcohol Dependence Scale (ADS) 39 may also be useful in assessing alcohol use and dependence, but these scales may be less time-efficient. The Drug Abuse Screening Test (DAST), 40 28-item self-report measure, and the Two Item Alcohol and Drug Screening Questions 41 are good screening measures for drug abuse. The Drug History Questionnaire (DHQ) 42 is a short measure that is useful in capturing information about a patients extent and frequency of drug use. Screening instruments or questionnaires for the diagnosis of substance abuse do not increase the patients rate of disclosure. Therefore, an empathic talk with the patient could be at least as helpful. Physical signs and biological tests There are physical signs of alcohol or substance abuse. 43 Evidence of hepatomegaly, tremor, or mild peripheral neuropathy may indicate early stages of alcoholism. Signs of withdrawal from alcohol or other substances may include lacrimation, rhinor- rhea, papillary dilation, diaphoresis, fever, piloerec- tion, yawning, tachycardia, elevated blood pressure, or tremulousness. 33 Signs of sepsis (fever, pallor, hypotension) or nutritional deficiency (wasted appearance, gingivitis, cheilosis, or ulceration of the skin at the corners of the mouth) may be signs of alcohol or other substance dependence. 46 Evidence of stimulant intoxication includes tachycardia, papillary dilation, diaphoresis, restlessness, nervous- ness, excitement, a flushed face, muscle twitching, psychomotor agitation, and pressured or rambling speech. 33 Opioid intoxication may be detected by pupillary restriction, drowsiness, slurred speech, and impaired attention or memory. Cannabis intoxica- tion may be indicated by conjunctival injection, increased appetite, dry mouth, and tachycardia. Hyperthermia may indicate cocaine use, and seizures may indicate cocaine intoxication. 33 A perforated nasal septum and nasal discharge are signs of a patient who snorts cocaine. Track marks, abscesses, or evidence of subcutaneous injections are signs of intravenous drug use. Pupillary changes are seen in users of a variety of drugs. 33 Liver damage is an indicator of alcoholism, and liver function tests, especially GGPT (glutaryl transaminase), may be elevated in alcoholic patients. 44,45 The MCV (mean corpuscular volume) test in the CBC (complete blood count) can also be elevated in alcoholic patients. 46 Serum magnesium, uric acid, total protein, and folate tests may also sometimes be abnormal in alcoholic patients. 33 Urine toxicology screens may be helpful in deter- mining drug use. Cocaine, amphetamines, opioids, marijuana, and phencyclidine (PCP) can all be detected through urine toxicology screens. 47 Alcohol, drug and eating disorders 337
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Treatment Both psychotherapy and medications can be used to treat patients with comorbid alcohol/substance abuse and eating disorders. Psychotherapeutic approaches such as cognitive-behavioural therapy are successful in treating alcoholism/substance use 48 as well as in treating eating disorders. 49,50 Opioid antagonists such as naltrexone may be useful in treating both eating disorders and alcohol-use disorders. 51 Some data suggest that serotonin re-uptake inhibitors (SSRIs) are beneficial in treating patients with comorbid alcoholism and eating disorders. 51 Conclusion Eating disorders and alcohol/drug abuse are fre- quently comorbid. It is important to recognize alcohol and drug abuse in patients with eating disorders. More studies are needed to understand psychobiological mechanisms of this comorbidity, and develop treatments for individuals with comor- bid eating disorders and substance misuse. References 1. Holderness CC, Brooks-Gunn J, Warren MP. 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