Comorbidity Eating Disorders and Substance Abuse - Essay Example

Running Head: COMORBIDITY EATING DISORDERS AND SUBSTANCE ABUSE Comorbidity Eating Disorders and Substance Abuse Name] Comorbidity Eating Disorders and Substance Abuse Introduction The co-occurrence of eating disorders and substance use and abuse has been well documented in both clinical (e.g., Corcos et al., 2001, Stock et al., 2002) and non-clinical (Saules et al., 2004, Stewart et al., 2000, Von Ranson et al., 2002) samples. Several reviews of the research literature regarding the association between eating disorders and substance related disorders have been published (e.g., Corcos et al., 2001). The study of comorbidity between disordered eating patterns and substance use in non-clinical female populations has included community, high school, and university samples. In non-clinical community-based adult populations, associations have been found between the syndrome of bulimia nervosa and alcohol drinking, cigarette smoking, marijuana use, amphetamine use and tranquilizer abuse. Using a behavior specific approach in a community-based sample, Piran and Robinson (2005) found that as disordered eating behaviors became more severe, or were clustered together, the number of substance classes used increased. In addition, particular eating disordered behaviors were differentially related to the use of various substance classes. The study of the comorbidity between disordered eating and substance use in middle and high schools samples tended to focus on the association between attitudes toward eating, weight, and shape and tobacco smoking, alcohol drinking, and marijuana use (Field et al., 2002). Nonetheless, several school-based studies have also reported on associations between tobacco smoking, alcohol drinking, and marijuana use in relation to bingeing, purging and dieting behaviors (Lock et al., 2001 and Tomori et al., 2001). However, only a few investigations have included a broader range of substance classes while investigating associations between disordered eating attitudes and behaviors and substance use in school-based studies (Von Ranson et al., 2002). Tomori et al. (2001) found an association between binge eating, with compensatory behaviors, and the use of alcohol as well as one or more of a list of licit and illicit drugs, while Von Ranson et al. (2002) found an association between the revised EDI subscales of Binge Eating, Body Dissatisfaction, and Compensating Behaviors, and the use of a wide range of illicit drugs. There are a small number of studies that have examined the relationship between problematic eating patterns and substance use in university samples (Anderson et al., 2005, Dunn et al., 2002, Krahn et al., 2005, Saules et al., 2004,). Several of these studies have focused on the relationship between bulimic symptomatology and substance use (Dunn et al., 2002 and Krahn et al., 2005). For example, Dunn et al. (2002) found no difference in patterns of alcohol use among college-age non-treatment seeking females with and without bulimia nervosa. The investigators did, however, find differences between the groups in their reported use of marijuana, opiates, and barbiturates. Krahn et al. (2005) found that the quantity and frequency of alcohol consumption were positively associated with a measure that assessed the combined severity of engagement in bingeing, dieting, and purging behaviors. In their study, smoking cigarettes, even at very low levels, was also related to the measure of combined disordered eating behaviors. Other university-based studies have explored the relationship between disordered eating attitudes and behaviors as measured on the Eating Disorder Inventory (EDI) and substance abuse. Krahn et al. (2005) reported a positive significant, albeit small, association between problematic alcohol use in female undergraduate students and the EDI subscales of Bulimia and Interoceptive Awareness, but no such correlation with the other EDI subscales. No significant relationships were found between EDI subscales and use of other substances, including: marijuana, nicotine, cocaine, amphetamines, tranquilizers, and psychedelics. Similarly, Benjamin and Wulfert, (2005) examined the relationship between alcohol abuse and disordered eating among female undergraduate students. They found that females who scored higher on measures of alcohol abuse scored significantly higher on the EDI Bulimia and Interoceptive Awareness subscales, but not on the EDI Body Dissatisfaction or Drive for Thinness, compared with females who scored lower on measures of alcohol abuse. Only a handful of university-based studies have followed a behavior specific approach in studying relationships between particular eating disordered behaviors and substance use (Anderson et al., 2005, Benjamin and Wulfert, 2005, Saules et al., 2004). These investigations have revealed associations between bingeing, purging, and dieting and problematic alcohol use and cigarette smoking. However, none of these studies included a broader range of substance classes in their investigations. Benjamin and Wulfert (2005) found a positive association between frequency of binge eating episodes and frequency of drinking in the past month in a sample of undergraduate women. Saules et al., (2004) also reported moderate associations between bingeing as well as dietary restraint and the use of alcohol among female undergraduates. They found no associations between indices of disordered eating and cigarette smoking. Anderson et al., (2005) reported that a measure of restrained eating, including dietary restraint (chronic attempts to restrict food intake due to concerns about body weight) and dietary disinhibition (history of body weight fluctuations), among undergraduate women, was significantly associated with drinking quantity, composite measure of drinks per week, binge drinking, and yearly excessive drinking. However, no relationship was found between measures of restrained eating and drinking frequency. Saules et al. (2004) found that dieting concerns, as well as depression and alcohol-related problems among college-aged women, were predictive of smoking initiation. Anderson et al. (2005) compared 20 female college students who purged and 20 students who did not exhibit such behaviors and described that students who purged reported greater alcohol use. Overall, out of the university-based studies reviewed, only two, a study using the EDI, and a study of the syndrome of bulimia nervosa (Dunn et al., 2002), included a wider range of substances, in addition to alcohol, tobacco, and marijuana, in their examination of the relationship between disordered eating and substance use and abuse. The present study aimed to add to the existing literature by studying various patterns of disordered eating behaviors and examining their relationship, in comparison to a non-eating disordered group, to the consumption of a broad range of substances, both licit and illicit. The investigation included a breakdown of individual disordered eating behaviors as well as various clusters of disordered eating behaviors in the analyses. Such a behavior specific analysis allows for the examination of the intricate nature of the relationship between particular types of eating disturbances and the use of numerous substances and has been advocated by such researchers as Zacny et al. (2003). In addition, in light of growing evidence of increasing rates of illicit prescription drug use among adolescents and young adults (Johnston et al., 2004, McCabe and Boyd, 2005 and Zacny et al., 2003), the study included the abuse of various prescription drugs. Examining discrete eating disorder behaviors in relation to substance use revealed a marginally significant association between severe levels of alcohol consumption and binge eating. These findings are comparable with the results of several other university-based studies reporting generally significant, but sometimes low level, associations between rates of alcohol consumption and disordered eating, measured by bulimia scales or through the frequency of binge eating (Benjamin & Wulfert, 2005). Not employing a measure of binge eating severity in the present investigation may have accounted for the lower level of association between binge eating and severe alcohol consumption, as well as for the non-significant associations between varied disordered eating clusters that included bingeing and severe alcohol use. Further, this study employed a more stringent definition of severe alcohol use that considered both the frequency and quantity of alcohol consumed, while recent studies have suggested the importance of assessing the quantity of consumption per drinking occasion, rather than the frequency of alcohol consumption (Wechsler and Nelson, 2001). The relationship between severe levels of alcohol drinking and binge eating has been explained in different ways. Based on the pattern of scores on varied personality scales of women who engaged in both bingeing and drinking, versus women who only engaged in one of these behaviors, Benjamin and Wulfert (2005) suggested that women who engaged in both behaviors displayed a high degree of emotional instability and likely used both behaviors to avoid negative feelings and to escape from aversive stimulation. On the other hand, other researchers such as Kane, Loxton, Staiger, and Dawe (2004) have suggested the role of impulsivity in co-occurring bulimia and alcohol problems in women. Furthermore, Ricciardelli, Williams, and Finemore (2001) explored shared issues related to behavioral control in relation to eating and drinking alcohol and suggested that these difficulties relate to a struggle with self-control, especially in the context of behavioral restraint and cognitive rumination. To date, however, studies that aimed at exploring the theoretical links between disordered eating patterns and alcohol drinking have employed correlational designs and thus cannot lead to conclusions about causality. In the present investigation, no significant association was found between dieting and severe alcohol abuse. Zacny et al., (2003) reported that a measure of restrained eating was associated with measures of drinking quantity, but not with drinking frequency. Since the present investigation defined heavy alcohol use in terms of a combined measure of frequency and quantity, the negative findings in this study could relate to the inclusion of frequency criteria in the definition of severe alcohol abuse. Further, the findings of Stewart et al. suggest the importance of assessing drinking frequency and drinking quantity separately in examining the relationship between dietary restriction and alcohol abuse. Examining clusters of eating disordered symptoms in relation to substance use revealed a significant association between dieting and purging (without bingeing) and the use of stimulants/amphetamines as well as a significant association between dieting and purging (with and without bingeing) and the use of cocaine. These results are consistent with those of other studies (Piran and Robinson, 2005). Piran and Robinson (2005) found in a community-based study of young adult women that restriction and purging were associated with significantly higher rates of stimulant/amphetamine use compared with controls. They also found a significantly higher rate of stimulants/amphetamines and cocaine use in women who dieted, purged and binged compared to controls. Similarly, Saules et al., (2004) found in a clinical sample of young adult women that severity of purging was predictive of cocaine, as well as alcohol and cigarette use. They also found that severity of restriction, defined by age of onset, current frequency of fasting, and diet pill use, was positively correlated with the use of amphetamines. The physiological effects of the stimulants/amphetamines and cocaine are basically identical. Both substance classes are central nervous system stimulants whose actions resemble those of adrenaline and have long been taken by users for their stimulant and euphoric effects. Moreover, one of the physical effects of these drugs, especially the stimulants/amphetamines, is loss of appetite. This may explain the significantly increased use of these substance classes among women who are actively engaging in weight loss behaviors, e.g., dieting and purging. An association between bingeing and dieting (with and without purging) and the use of tobacco was also found. Namely, a higher percent of women who binged and dieted smoked tobacco compared with controls. The association between bingeing and dieting, with and without purging, and tobacco smoking can be understood in relation to the use of tobacco as a means to control weight among women with weight concerns (Saules et al., 2004). Interestingly, the abuse of antidepressants and sleeping pills was also higher among women who binged and dieted, but did not purge. These results are comparable to those of Corcos et al. (2001), who described that more than half of the eating disordered women in their study were regular consumers of psychotropic medications (tranquilizers, hypnotics and antidepressants). Moreover, in their study, women with bulimia nervosa were found to self-prescribe these medications significantly more than individuals with anorexia nervosa. According to a study by McCabe and Boyd (2005), prescription medications appeared to be readily available for illicit use among college students. Considering that more of the women in the present investigation who binged and dieted, but did not purge, smoked tobacco as well as abused antidepressants and sleeping pills compared with controls, it is possible that these substances are being used as a means of dealing with adverse emotional states, such as depression. Saules et al. (2004) suggested that escalating depression during the first year of college was a significant risk factor for the onset of smoking. Similarly, in their discussion of smoking in relation to psychosocial risk factors in adolescents, Tomori et al. (2001) suggested that smoking, together with the abuse of other drugs, can be seen as a form of self-medication. However, in a correlational study such as the present investigation, no inferences can be made regarding the directional links between depression, tobacco smoking, and body preoccupation. The behavior specific approach used in this investigation allowed for the examination of particular associations between single disordered eating behaviors as well as clusters of disordered eating patterns, and the consumption of specific substances. Fifthly, this study assessed a broad spectrum of substance classes, both licit and illicit in relation to disordered eating. As such, this approach revealed, in a young female university sample, associations between binge eating and severe alcohol use, dieting with purging and the use of stimulants and cocaine, and dieting with bingeing and tobacco use as well as the abuse of antidepressants and sleeping pills. Moreover, the relationship between dieting and bingeing and the abuse of antidepressants and sleeping pills reinforces the importance of including the abuse of prescription medications in studies that examine the co-occurrence of disordered eating and substance use. Examining a broad range of substance classes, with differing physiological properties and effects, in relation to specific disordered eating behaviors, could contribute to theory development regarding the functions of the specific co-occurring behaviors. Combining this behavior specific approach with varied measures of psychological functioning, such as those that assess affect, impulsivity, or self-control, will further help delineate the specific challenges associated with these particular co-occurring behavioral patterns. This understanding could, in turn, lead to treatment strategies that address the specific presenting needs of these individuals (Benjamin and Wulfert, 2005 and Ricciardelli et al., 2001). Conclusion In light of growing evidence of increasing rates of drug use and the common occurrence of disordered eating behaviors (among adolescents and young adults, understanding more about how these problematic behaviors co-occur has important implications for assessment, treatment, and future research. Regarding assessment, there is a need for screening instruments assessing for both disordered eating behaviors and substance addictions in young women presenting at medical settings, community service agencies, and university counseling centers. These instruments should also aim to assess the compounded range of psychosocial and medical risks that may occur in women with both eating problems and substance addictions. Regarding treatment, there is a need to develop treatment approaches specifically designed to address patterns of both disordered eating and substance use. For that purpose, shared elements applied separately thus far to the treatment of eating disorders and to the treatment of substance use, such as psychoeducation, systematic recording of the context within which particular problem behaviors tend to occur, strategies for enhancing internal awareness and identifying high risk situations, and other relapse prevention strategies could be integrated to address difficulties in both domains. Regarding future studies, research investigating associations between disordered eating and substance use should include measures that assess severity of the particular eating disordered and substance use behaviors. In addition, the measures should evaluate frequency, quantity, consequences of, and attitudes toward the various disordered eating and substance use behaviors in their definitions. The use of categorical as well as continuous measures of engagement could further aid in allowing the results to be more comparable with those of other investigations in this area. Furthermore, such studies should investigate a broad range of substance classes, including various over-the-counter drugs (Gravol, antihistamines, caffeine pills, over-the-counter cold and flu preparations), prescribed stimulants such as Ritalin, and party drugs such as 'MDMA (Ecstasy)' and 'Crystal Methamphetamine (ice)' that were not evaluated in this investigation. Lastly, as this study was conducted in a young university sample, future studies could include participants from different age groups in their investigations to evaluate whether age is an important factor when considering associations between disordered eating and the use of particular substances classes. References Anderson, D.A. Martens, M.P. and M.D. Cimini, Do female college students who purge report greater alcohol use and negative alcohol-related consequences, International Journal of Eating Disorders 37 (2005) (1), pp. 65-68. Benjamin, L. and Wulfert, E. (2005) "Dispositional correlates of addictive behaviors in college women: Binge eating and heavy drinking", Eating Behaviors 6 (3), pp. 197-209. Corcos, M. Nezelof, S. Speranza, M. Topa, S. Girardon, N. and Guilbaud, O. et al., (2001) "Psychoactive substance consumption in eating disorders", Eating Behaviors 2 (1), pp. 27-38. Dunn, E.C. Larimer, M.E. and Neighbors, C. (2002) "Alcohol and drug-related negative consequences in college students with bulimia nervosa and binge eating disorder", International Journal of Eating Disorders 32 (2), pp. 171-178. Field, A.E. Austin, S.B. Frazier, A.L. Gillman, M.W. Camargo C.A. Jr. and Colditz, G.A. (2002) "Smoking, getting drunk and engaging in bulimic behaviors: In which order are the behaviors adopted", Journal of the American Academy of Child and Adolescent Psychiatry 41 (7), pp. 846-853. Gilbert, N. and Meyer, C. (2005) "Fear of negative evaluation and the development of eating psychopathology: A longitudinal study among nonclinical women", International Journal of Eating Disorders 37 (4), pp. 307-312. Gliksman, L. Adlaf, E.M. Demers A. and Newton-Taylor, B. (2003) "Heavy drinking on Canadian campuses", Canadian Journal of Public Health 94 (1), pp. 17-21. Johnston, L. D., O'Malley, P. M., Bachman, J. G., & Schulenberg, J. E. (2004). Monitoring the future national survey results on drug use, 1975-2003. Volume ii: College students and adults ages 19-45. NIH Publication No. 04-5508. Bethesda, MD. National Institute on Drug Abuse, 267. Kane, T.A. Loxton, N.J. Staiger, P.K. and Dawe, S. (2004) "Does the tendency to act impulsively underlie binge eating and alcohol use problems" An empirical investigation, Personality and Individual Differences 36 (1), pp. 83-94. Krahn, D.D. Kurth, C.L. Gomberg, E. and Drewnowski, A. (2005) "Pathological dieting and alcohol use in college women - a continuum of behaviors", Eating Behaviors 6 (1), pp. 43-52. Kuo, M. Adlaf, E.M. Lee, H. Gliksman,L. Demers, A.e. and Wechsler, H. (2002) "More Canadian students drink but American students drink more: Comparing college alcohol use in two countries", Addiction 97 (12), pp. 1583-1592. Lock, J. Reisel, B. and Steiner, H. (2001) "Associated health risks of adolescents with disordered eating: How different are they from their peers Results from a high school survey", Child Psychiatry and Human Development 31 (3), pp. 249-265. McCabe S.E. and Boyd, C.J. (2005) "Sources of prescription drugs for illicit use", Addictive Behaviors 30 (7), pp. 1342-1350. Patterson, F. Lerman, C. Kaufmann, V.G. Neuner, G.A. and Audrain-McGovern, J. (2004) "Cigarette smoking practices among American college students: Review and future directions", Journal of American College Health 52 (5), pp. 203-210. Piran, N., & Robinson, S. R. (2005). "The association between disordered eating and licit and illicit substance use/abuse: A community-based investigation". Paper presented at the Academy for Eating Disorders International Conference on Eating Disorders, Montreal, Quebec. Quinton, S. and Wagner, H.L. (2005) "Alexithymia, ambivalence over emotional expression, and eating attitudes", Personality and Individual Differences 38 (5), pp. 1163-1173. Ricciardelli, L.A. Williams, R.J. and Finemore, J. (2001) "Restraint as misregulation in drinking and eating", Addictive Behaviors 26 (5), pp. 665-675. Saules, K.K. Pomerleau, C.S. Snedecor, S.M. Mehringer, A.M. Shadle, M.B. and Kurth C. et al., (2004) "Relationship of onset of cigarette smoking during college to alcohol use, dieting concerns, and depressed mood: Results from the Young Women's Health Survey", Addictive Behaviors 29 (5), pp. 893-899. Stock, S.L. Goldberg, E. Corbett, S. and Katzman, D.K. (2002) "Substance use in female adolescents with eating disorders", Journal of Adolescent Health 31, pp. 176-182. Substance Abuse and Mental Health Services Administration, Results from the 2003 National Survey on Drug Use and Health: National Findings (2004, September 9) Retrieved June 8, 2005, from http://oas.samhsa.gov/nhsda.htm. Tomori, M. Zalar, B. Kores Plesnicar, B. Ziherl, S. and Stergar, E. (2001) "Smoking in relation to psychosocial risk factors in adolescents," European Child and Adolescent Psychiatry 10 (2), pp. 143-150. von Ranson, K.M. Iacono, W.G. and McGue, M. (2002) "Disordered eating and substance use in an epidemiological sample: I. Associations within individuals", International Journal of Eating Disorders 31 (4), pp. 389-403. Wechsler, H. and Nelson, T.F. (2001) "Binge drinking and the American college students: What's five drinks", Psychology of Addictive Behaviors. Special Understanding binge drinking 15 (4), pp. 287-291. Zacny, J. Bigelow, G. Compton, P. Foley, K. Iguchi, M. and Sannerud, C. (2003) "College on problems of drug dependence taskforce on prescription opioid non-medical use and abuse: Position statement", Drug and Alcohol Dependence 69 (3), pp. 215-232. Read More