The high rate of comorbid substance abuse in women with bulimia nervosa (BN) has remained consistent in the literature. This article reviews the prevalence of substance abuse in BN and summarizes treatment approaches for persons with BN and comorbid substance abuse.
Studies conducted in community and clinical settings continue to demonstrate that the prevalence of substance use disorders is higher among women with BN than in women with other eating disorder diagnoses and in women in the general population.1-3 Dansky and colleagues2 reported on the prevalence of alcohol(Drug information on alcohol) use disorders and BN in a national sample of 3006 women; approximately 31% of the women with BN had a history of alcohol abuse. In comparison, 21.7% of women who did not have an eating disorder reported this history.
More recently, Blinder and associates1 examined the point prevalence of psychiatric comorbidity in 2436 female inpatients who had been admitted to an eating disorder program with varying primary eating disorder diagnoses. Significant differences between eating disorder diagnostic groups and comorbid substance use disorders were found during assessments performed at admission and discharge. In particular, inpatients with BN were twice as likely to have alcohol abuse/dependence (26%) than those with anorexia nervosa restricting subtype (3%), anorexia nervosa binge-purge subtype (14%), and eating disorder not otherwise specified (14%). Moreover, inpatients who had BN were 3 times more likely to have polysubstance abuse/dependence than women with anorexia nervosa restricting type (10% vs 2%, respectively).
These results are similar to those of an earlier study conducted in a clinical setting, in which 24% of women with BN and 17% of women with anorexia nervosa were found to have a DSM-III-R lifetime alcohol use disorder.3
The Table summarizes studies that have examined comorbid substance use/abuse/dependence and eating disorders.
Typical substances of abuse
Women with BN abuse an unusually wide range of substances. Substances commonly abused by this population include alcohol, street drugs (eg, cocaine and marijuana), prescribed medications, and non-psychoactive substances (eg, laxatives, emetics, diuretics, and diet pills). Young women with BN are at greatest risk for abusing substances and experimenting with many types of substances.
The literature concerning alcohol use disorders and BN has been quite consistent. Findings suggest that alcohol use disorders tend to co-occur more often in women with bulimic symptoms (eg, women with BN or anorexia nervosa binge-purge subtype) than in women with restricting symptoms (eg, those with anorexia nervosa restricting subtype).1,3
Similarly, rates of illicit drug use have generally been found to be higher in women with BN than in women with anorexia nervosa. Wiederman and Pryor4 found that more women with BN reported having used amphetamines (18%), barbiturates (10%), marijuana (24.7%), and cocaine (12.5%) than women with anorexia nervosa (3%, 2.2%, 5.2%, and 1.5%, respectively).
Women with BN may become physically and/or psychologically dependent on prescription medications, such as tranquilizers, benzodiazepines, and hypnotics, at therapeutic doses. Women with BN self-medicate and increase their doses of psychotropic drugs significantly more than women with anorexia nervosa restricting subtype.5 Moreover, the use of non-psychoactive substances, which initially may be used in an attempt to control or modify body weight or shape, later develops into an addictive pattern in most women with eating disorders.
The literature suggests that the association between BN and substance use disorder may be more specific. That is, substance use disorders may be associated with bulimic symptoms, such as bingeing or purging, rather than simply BN.
Causality of comorbid bulimia nervosa and substance abuse
Why do women with BN have such high rates of substance use and misuse? One possible explanation is that such women may have underlying impulsive personality traits. Such traits may be unique to a subset of so-called multi-impulsive bulimics. These women engage in other impulsive behaviors, such as gambling, shoplifting, promiscuity, and substance use, in addition to their impulsive eating disorder behaviors.6 The origin of such impulsivity is not known.
However, the observation of high rates of physical and sexual abuse in patients with BN may offer some clues.7 Higher rates of substance abuse are known to occur in individuals with posttraumatic stress disorder. Similarly, bulimic behaviors, such as bingeing and purging and alcohol and drug use, may be a means of regulating emotional disturbances. These emotional disturbances could be related to a history of childhood trauma.
Moreover, comorbid Axis I and II disorders, such as depression and borderline personality disorders, are frequently diagnosed in women with BN or substance use disorders. These additional diagnoses may moderate the association between BN and substance abuse. Again, the connection between the development of Axis II disorders and a history of trauma is not well understood and deserves further attention.
Finally, some research shows elevated rates of substance abuse in the families of individuals who have BN.8 The development of one or the other condition may act as a trigger that precipitates the onset of the second illness, despite each of them being inherited separately.
Assessment and treatment
Women with BN endure a wide range of severe and debilitating symptoms. The addition of a comorbid substance use disorder not only exacerbates medical and psychiatric complications but also hinders clinical assessment and treatment. Often, women only seek treatment for either BN or a substance use disorder. However, expertise at treatment centers tends to fall into either the addiction or eating disorder fields, but rarely both. Consequently, many treatment centers may lack the expertise to treat both disorders concurrently. The adequate assessment of these comorbid disorders, especially in younger women, who are at greater risk for both disorders, is key to planning appropriate psychoeducation and treatment strategies.
The literature examining the influence of a history of substance use disorders on treatment outcomes in women with BN is scarce, and the findings from the few studies that do exist are mixed.9,10 Strasser and coworkers9 conducted a clinical trial using desipramine to treat 75 women with BN. The women with a history of substance abuse responded better to the treatment and displayed fewer eating disorder symptoms than those who did not report a history of substance abuse. More recently, a history of substance abuse was found to predict a poorer response in a sample of 120 women with BN who were treated with psychotherapy and/or medication.10
This divergence in findings in treatment outcome studies, along with the lack of research comparing treatment outcomes in women with BN with and without substance use problems, reveals the need for more research in this area. Sequential, simultaneous, and integrated strategies for women with BN and comorbid substance use disorders all exist.11
Sequential treatments involve treating each disorder separately in a stepwise approach. Such treatment often improves the symptoms of the disorder being treated and, in the process, worsens the symptoms of the second disorder. For example, if BN is first treated in a woman with comorbid alcohol abuse, her eating disorder symptoms may improve; because the alcohol problem has not been addressed, however, she may consume more alcohol to self-medicate.
Simultaneous treatments address both the eating disorder and the substance use disorder at the same time. Although the 2 disorders are treated contemporaneously, treatment occurs in 2 separate tracks. Consequently, the patient may not be taught to link the 2 disorders and thus understand how they influence one another.11
Courbasson and Smith11 have found integrated treatment to be most effective for persons with comorbid eating and substance use disorders. This approach incorporates a single treatment that addresses both the eating disorder and the substance use disorder. Unfortunately, there is a lack of treatment outcome studies on integrated treatment and there are few integrated treatment programs.
Practitioners in outpatient practice may not have training or expertise to treat comorbid substance abuse. In these situations, clinicians should attempt to arrange for the patient to have access to specialized substance use services. In some cases, patients may need residential treatment for their substance use before being able to use outpatient services for the eating disorder effectively.
Psychotherapy—both group and individual—is beneficial for women with BN and women with substance use disorders. Cognitive-behavioral therapy (CBT), in particular, has been found to be highly effective in persons with BN and those with substance use disorders.12,13 It might therefore be useful to incorporate CBT into treatments for women with comorbid BN and substance abuse.
Empirical data are lacking concerning the effects of specific pharmacological treatments for women with BN and comorbid substance use disorders. However, opioid antagonists have been found to decrease both binge eating and cravings for substances of abuse.14 Research suggests that SSRIs may be helpful for patients with comorbid substance use disorders and eating disorders.15
Women with BN frequently have comorbid substance use disorders. The range and occurrence of substance use problems in these women far exceed those in women with other eating disorder diagnoses and in the general population. The association between BN and substance abuse could be explained by their inherent similarities. For example, both have been described as impulsive and addictive disorders frequently associated with other comorbid Axis I and II disorders. There is a lack of research examining treatment outcomes in women with comorbid eating disorders and substance use disorders and few integrated treatment programs exist for this population.
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