RESEARCH ARTICLE

Eating Disorders, Substance Use Disorders, and Impulsiveness

among Disordered Gamblers in a Community Sample
Kristin M. von Ranson1*, Laurel M. Wallace1, Alice Holub2 & David C. Hodgins1
1
2

Department of Psychology, University of Calgary, Calgary, AB, Canada

Alberta Childrens Hospital, Calgary, AB, Canada

Abstract
Disordered gambling and many eating disorders (EDs) involve recurrent loss of impulse control. We examined rates of specic EDs, ED
psychopathology, substance use disorders, and their interrelationships with impulsiveness among community members with disordered
gambling. Community-recruited adults with pathological (n = 95) or problem (n = 9) gambling (N = 104; 51% female) completed
structured interviews and questionnaires. We observed high rates of substance dependence, lifetime EDs, and current ED psychopathology; 20.8% of women (vs 1.9% of men) had a DSM-IV ED, and 37.8% (vs 3.9%) had an ED according to proposed DSM-5 criteria.
Although disordered gambling severity was not associated with ED diagnosis or severity of ED psychopathology, greater disordered
gambling severity and an ED diagnosis were both associated with increased impulsiveness. These ndings suggest that impulsiveness
might constitute a common personality characteristic that underlies disordered gambling and EDs. Copyright 2012 John Wiley & Sons,
Ltd and Eating Disorders Association.
Keywords
pathological gambling; comorbidity; personality; impulsiveness
*Correspondence
Kristin M. von Ranson, Department of Psychology, University of Calgary, 2500 University Drive NW, Calgary, AB T2N 1N4, Canada. Tel: +1-403-220-7085, Fax: +1-403282-8249.
Email: kvonrans@ucalgary.ca

Published online 19 October 2012 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/erv.2207

The comorbidity of disordered gambling (DG) and eating pathology matters for theoretical as well as clinical reasons. DG and
eating pathologyparticularly eating pathology that involves
binge eating, purging, or bothshare a recurrent failure of
impulse control. The conceptualization of DG centres on impulsiveness; as a diagnosable disorder, pathological gambling (PG)
is classied as an impulse control disorder in DSM-IV (American
Psychiatric Association, 2000). Although eating disorders (EDs)
are not considered to be primarily disorders of impulse control
in current diagnostic schemes, impulse control clearly plays a role
in EDs. Specically, a critical element of the DSM-IV denition of
binge eating, which is a central symptom of bulimia nervosa (BN)
and binge eating disorder (BED), is loss of control over eating
(American Psychiatric Association, 2000).
Two interrelated theories have been proposed to explain a
possible association between EDs and PG, centring on mechanisms
underlying recurrent loss of impulse control across these symptom
domains. First, PG and certain other problem behaviours, possibly
including some EDs, have been proposed to lie on an impulsive
compulsive continuum (Frascella, Potenza, Brown, & Childess,
2010; Grant, Potenza, Weinstein, & Gorelick, 2010). Both PG and
EDs have also been associated with impulsive personality characteristics (Alvarez-Moya et al., 2007; Waxman, 2009) and have been
hypothesized to share neurological pathways (Alvarez-Moya et al.,
2007). Likewise, both PG and excessive eating have been described

148

as involving a similar compulsive pursuit of nonsubstance rewards

(Frascella et al., 2010), and purging in anorexia nervosa (AN) has
been associated with increased compulsiveness (Hoffman et al.,
2012). Second, both EDs and PG have been conceptualized
as behavioural addictions that are comparable with substance use
disorders (SUDs) (Frascella et al., 2010; Goodman, 2008).
One difculty with the conceptualization of addiction to certain
behaviours has been that although addiction implies a loss of
control over behaviour, the boundaries of addictive disorders have
not been clear (Cassin & von Ranson, 2007). However, with the
proposal that PG join substance-related disorders in a new
category, Addictions and Related Disorders, in DSM-5 (Petry,
2010), convergence on the view that PG is an addiction may be
emerging. Nevertheless, the view of EDs as addictions remains
controversial (Cassin & von Ranson, 2007), as has the related argument that certain foods, such as sugar, have addictive properties
(Corsica & Pelchat, 2010).
Pathological gambling and EDs are frequently comorbid with
SUDs. Very high rates of alcohol and illicit drug use disorders
have been described among pathological gamblers in community
studies (Petry, Stinson, & Grant, 2005). Elevated rates of SUDs
have been observed among community-based women with EDs
(Baker, Mitchell, Neale, & Kendler, 2010), too, although rates
were lower than among pathological gamblers. Behaviour genetic
research has suggested that both PG and EDs share variance with

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K. M. von Ranson et al.

SUDs (Lobo & Kennedy, 2009; Wade, Bulik, Prescott, & Kendler,
2004), supporting the theory that these problems are interrelated.
Thus, it is important to consider SUDs when investigating
relations between EDs and PG.
To date, very few studies have investigated the comorbidity of
PG and EDs, only one of which used interview-based diagnosis
of both PG and ED (Fernandez-Aranda et al., 2006). Researchers
have found elevated rates of PG symptoms among individuals
with BN (Fernandez-Aranda et al., 2006) and BED (Yip, White,
Grilo, & Potenza, 2011); others reported elevated rates of EDs
among pathological gamblers but did not specify ED diagnoses
(Dannon et al., 2006). Only one study (Black & Moyer, 1998)
has examined rates of specic ED diagnoses, and it included just
30 adults with PG behaviour, mainly men. It is critical to ascertain
specic ED diagnoses among people with PG to improve our
understanding of comorbidity of these disorders and to explore
common characteristics that may inuence or account for comorbid presentations.
The present study involved a large sample of community-based
men and women with DGthat is, both clinically diagnosable
and subclinical PG. Note that subclinical gambling problems are
associated with gambling-related harms (Currie, Miller, Hodgins,
& Wang, 2009) and that lowering the number of diagnostic
criteria required to be met for a diagnosis of PG improves classication accuracy (Stincheld, 2003; Stincheld, Govoni, & Frisch,
2005), suggesting it is appropriate to combine these groups.
This study had three aims. First, we examined the prevalence of
specic EDs and related pathology, using both interviews and selfreport questionnaires. Second, we examined relationships among
DG severity, lifetime EDs, current ED psychopathology, and SUDs.
A better understanding of associations may inform our conceptualization of these constructs, which may inform prevention and
treatment of DG and EDs. Third, we hypothesized that impulsiveness would be positively associated with DG severity, lifetime EDs,
current ED psychopathology, and lifetime SUDs. We hypothesized
that disordered gamblers with comorbid eating or substance use
pathology would show above-average impulsivity.

Methods
Ethics approval was granted by an institutional review board.
Participants were recruited via local media advertisements and by
contacting individuals from a research participant pool who had
reported concerns and/or problems with gambling and expressed
interest in further research participation. All participants were
recruited in a large city in western Canada. Eligibility criteria were
minimum age 18 years and meeting criteria for problem or PG in
the past year on the Problem Gambling Severity Index (PGSI) of
the Canadian Problem Gambling Index (Ferris & Wynne, 2001),
measured by a score of eight or greater. The PGSI assesses
gambling-related cognitions, behaviours, and consequences over
the past 12 months and is rated on a 4-point Likert scale. In a
face-to-face interview, an interviewer completed sections of the
Structured Clinical Interview for DSM-IV Disorders (SCID)(First,
Spitzer, Gibbon, & Williams, 1997) to assess for lifetime EDs and
SUDs, and administered Stinchelds DSM-IV Questions for Pathological Gambling (Stincheld, 2003), which paraphrases 10
DSM-IV diagnostic criteria for current PG as 19 yes/no questions.

Eating Disorders in Community Disordered Gamblers

Eating disorder diagnoses were derived by consensus after

review of SCID symptoms by two authors (KMvR and LMW).
In addition to making DSM-IV diagnoses (narrow diagnoses),
we considered broad denitions corresponding to recently
proposed DSM-5 criteria for AN, BN, BED, and ED not
otherwise specied (broad diagnoses; American Psychiatric
Association, 2012). For broad BN and BED diagnoses, the
minimum frequency of binge episodes was once a week
(versus twice a week) for 3 months; for broad AN, amenorrhea
was not required.
Participants completed three questionnaires. The 36-item
Eating Disorder Examination Questionnaire (EDE-Q; Fairburn
& Beglin, 1994) assesses current ED psychopathology over the
past 28 days and has four subscales describing dysfunctional eating-related attitudes (Restraint, Eating Concern, Shape Concern,
and Weight Concern), a global score, and questions about the
presence and frequency of specic behaviours (e.g. bulimic
episodes, laxative use, and vomiting). The Barratt Impulsiveness
Scale (BIS-11; Patton, Stanford, & Barratt, 1995) includes
30 items for which frequency is rated on a 4-point Likert
scale and contains three subscales to measure different dimensions of impulsiveness: Non-Planning Impulsivity, Motor Impulsivity, and Attentional Impulsivity. The Eysenck Impulsiveness
Questionnaire (I7) of the Eysenck Personality Scales (Eysenck &
Eysenck, 1991) is a 54-item, dichotomously scored (yes/no) measure that conceptualizes impulsiveness overall (I7) and as having
two distinct factors: Impulsiveness (I7i) and Venturesomeness
(I7v). A third I7 subscale, Empathy, which was designed to provide
buffer items in the measure, was not analyzed for the present
study. All scale and subscale scores displayed adequate reliability
in this sample (a > .7). Missing EDE-Q scale data (0.32%) were
prorated using the participants scale mean; no other measure
was missing data. Variables with non-normal distributions were
transformed to approximate normality for parametric tests;
however, to ease interpretation, untransformed results are
presented in the next section.

Results
Of 175 potential participants screened, 129 were eligible and invited to participate, and 104 (80.6%) participated in the study.
At screening, participants mean PGSI score was 14.4 (SD = 4.8),
indicating moderately severe PG. On average, participants
endorsed 7.1 (SD = 1.8) of 10 DSM-IV criteria. Nine participants
(8.7%) endorsed fewer than the ve criteria required for a PG
diagnosis; however, scores indicated that all participants experienced signicant gambling-related impairment. We found no
sex differences in PGSI scores or DSM-IV criteria for PG. Table 1
describes sample demographics. On average, women reported
having engaged in 6.25 (SD = 3.76, range = 115) types of gambling. The most problematic types of gambling were reported to
be electronic gambling machines, that is, slot machines and video
lottery terminals (60.0%, n = 30), followed by bingo (12.0%,
n = 6) and card/table games (10.0%, n = 5).
Rates of lifetime EDs in this sample were high (Table 2) relative
to general population norms (Hudson, Hiripi, Pope, & Kessler,
2007). When using narrow DSM-IV diagnostic criteria, we found
that 20.8% of women and 1.9% of men met criteria for a lifetime

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149

K. M. von Ranson et al.

Eating Disorders in Community Disordered Gamblers

Table 1 Demographic characteristics of the sample (N = 104)

Table 3 Eating disorder psychopathology and prevalence and frequency of

weight-control behaviours in the past 28 days

Variable
Sex
Age (years)
Ethnicity

Marital status

Education

Employment
Net annual income

Female
Male
M (SD); range
Caucasian
Aboriginala
Other
Married/common law
Single
Divorced/separated/widowed
High school diploma
Trades certicate/diploma
Bachelors degree
Full time
Unemployed or part time
Median
Range

51.0%
49.0%
43.5 ( 13.2); 1975
72.1%
20.2%
7.7%
38.5%
28.8%
31.7%
47.1%
42.3%
7.8%
47.1%
52.9%
$30 000
$070 000

Note: The only gender difference found in demographic characteristics was that net
annual income for men (M = $34 811.36, SD = 1.8) was higher than for women
(M = $22 695.65, SD = 1.5), t(88) = 3.53, p < .01. aThe Aboriginal group was dened
as North American Indian, Inuit, or Metis.

ED. Using broad ED denitions that included subthreshold variants of DSM-IV diagnoses, we found that ED rates were even
higher: 37.8% of women and 3.9% of men met criteria for a lifetime ED. Use of broad denitions of eating pathology acknowledges that the current diagnostic criteria for formal EDs may be
too strict, as they exclude very similar states; loosening the current
diagnostic criteria has been recommended (American Psychiatric
Association, 2012). Consistent with this recommendation, subsequent analyses that refer to ED diagnoses include all participants
with broadly dened EDs (n = 22 females and 2 males), unless
otherwise specied. The average age of onset for an ED was
23.50 years (SD = 10.63; range = 1447 years). We did not collect
age of onset for other disorders.

Scale score or
behaviour

Males (n = 51)
Mean  SD

EDE-Q Total**
0.84  .95
EDE-Q Restraint*
0.86  1.33
EDE-Q Eating Concern**
0.30  .57
EDE-Q Weight Concern** 1.01  1.18
EDE-Q Shape Concern**
1.19  1.25
Self-induced vomiting
2.00  .00
Laxatives

Diuretics
20.00  .00
Excessive exercise
11.44  8.52

Females (n = 5253)

Frequency

Mean  SD

Frequency

2.0%
0.0%
2.0%
17.6%

2.19  1.38
1.68  1.67
1.33  1.31
2.60  1.52
3.12  1.82
100.5  140.71
8.50  4.95
16.50  16.26
4.57  3.87

3.8%
3.8%
3.8%
13.2%

Note: Asterisks denote signicant sex differences in mean scores; *p < .01; **p < .001.
Behaviour means indicate the average number of times in the past 28 days that the
indicated behaviour was engaged in by participants who had engaged in the
behaviour at least once in the past 28 days.

Current self-reported ED psychopathology (Table 3) was

higher in women with DG than in the general population (Mond,
Hay, Rodgers, & Owen, 2006), even though women in the current
sample were substantially older (M = 44.62 years, SD = 14.87 vs
M = 30.26 years, SD = 7.22) and so might be expected to report
fewer concerns. Analyses of ED psychopathology are based on
EDE-Q data, which are continuous scores provided by all participants in the sample (n = 53 females and 51 males), not just those
with an ED diagnosis. EDE-Q norms for similar-aged men were
unavailable, but EDE-Q scale scores for male participants were
comparable with norms for much younger male undergraduate students (age M = 42.4 years, SD = 11.2 vs M = 19.02 years, SD = 1.41)
(Lavender, De Young, & Anderson, 2010). As only two men had
an ED diagnosis and men had relatively low rates of self-reported
current ED psychopathology (Table 3), subsequent analyses
examined women only. In addition, as only small subsamples of

Table 2 Rates of lifetime, current, and past eating disorder diagnoses (N = 104)
Eating disorder
Anorexia nervosa

Bulimia nervosa

Binge eating disorder (BED)

EDNOS (excluding BED)
Any eating disorder

Diagnosis type

Lifetime N (%)

Current N (%)

Past N (%)

Broad

6 (5.8)

4 (3.8)

2 (1.9)

Narrow

3 (2.9)

2 (1.9)

1 (1.0)

Broad

6 (5.8)

3 (2.9)

3 (2.9)

Narrow

2 (1.9)

0 (0.0)

2 (1.9)

Broad
Narrow
Broad
Narrow
Broad
Narrow

12 (11.5)
7 (6.7)
1 (1.0)
1 (1.0)
22 (21.2)
12 (11.5)

8 (7.7)
3 (2.9)
0 (0.0)
0 (0.0)
15 (14.4)
5 (4.8)

4 (3.8)
4 (3.8)
1 (1.0)
1 (1.0)
8 (7.7)
8 (7.7)

Lifetime Subtype/type: N
Restricting: 1
Binge purging: 5
Restricting: 1
Binge purging: 2
Non-purging: 3
Purging: 3
Non-purging: 0
Purging: 2
N/A
N/A
Purging disorder: 1
Purging disorder: 1

Note: All diagnoses occurred in female participants, with the exception of one male participant with current bulimia nervosa (as assessed by broad criteria, as proposed
for DSM-5) and one male participant with past binge eating disorder (as assessed by narrow DSM-IV criteria). EDNOS, eating disorder not otherwise specied; N/A,
not applicable.

150

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K. M. von Ranson et al.

Eating Disorders in Community Disordered Gamblers

Women with a lifetime ED tended to be more impulsive than

women without (Table 5). Eating Concern was the only form of
current ED psychopathology associated with facets of impulsiveness. Likewise, lifetime drug dependence correlated positively
with all impulsiveness scores except I7v. However, we observed
no differences in impulsiveness according to lifetime alcohol
dependence diagnosis.

participants endorsed vomiting, excessive exercise, and use of

laxatives and diuretics in the past 28 days, these behaviours were
not examined further.
Severity of current ED psychopathology was uncorrelated with
either measure of DG severity (i.e. PGSI and Stinchelds DSM-IV
criteria). Likewise, DG severity did not differ dependent on the
presence or absence of a lifetime ED (broad or narrow) or pastmonth objective binge eating episode (OBE). Of those with an
OBE (n = 16), OBE frequency was uncorrelated with PGSI scores
but was negatively correlated with Stinchelds DSM-IV criteria
(r = .61, p < .05). In sum, DG severity and disordered eating
tended to be unrelated, except that recent, more frequent binge
eating was related to one measure of DG severity.
Rates of lifetime SUDs were high relative to norms (American
Psychiatric Association, 2000): 20 (37.7%) had alcohol dependence and 11 (21.2%) had drug dependence, for a total of
23 women (43.4%) with lifetime substance dependence (i.e. alcohol and/or drug dependence). Of participants who reported the
substances that they used, the substance most commonly used
was marijuana (61.3%, n = 19), followed by cocaine (19.4%,
n = 6), nicotine (19.4%, n = 6), and hallucinogens (9.7%, n = 3).
However, DG severity did not differ between women with and
without either lifetime alcohol or drug dependence. Likewise,
EDE-Q scores did not differ for women with or without lifetime
alcohol or drug dependence. Women with a lifetime ED were
more likely to report lifetime drug dependence (40.0% vs 9.1%;
X2 (1) = 6.92, p < .01), although rates of lifetime alcohol dependence did not differ in women with versus without a lifetime ED.
Women reported high levels of impulsiveness relative to norms
(Eysenck, Pearson, Easting, & Allsop, 1985; Spinella, 2007).
Measures of impulsiveness intercorrelated somewhat inconsistently (Table 4). Both DG measures correlated moderately positively with I7 and I7i, but not with I7v scores. In addition,
Stinchelds DSM-IV criteria correlated moderately positively
with three of the four BIS scores; PGSI scores correlated moderately positively with the BIS Non-Planning subscale only.

Discussion
We observed higher than expected rates of lifetime EDs and
current ED psychopathology (i.e. self-reported eating restraint
and concerns about eating, shape, and weight) among community-dwelling women and men selected for having DG. About
one-fth of women met narrow DSM-IV criteria for a lifetime
ED, and more than one-third met broad draft DSM-5 criteria
for a lifetime ED. EDs were approximately 10 times as common
among women as among men in this sample, consistent with
previous reports (American Psychiatric Association, 2000); however, the current gure is based on only two men diagnosed with
EDs. Rates of ED psychopathology among all 51 middle-aged men
with PG were similar to that of community-based men who
were 20 years their junior (Lavender et al., 2010). If one would
expect eating-related problems to diminish with age, then men
with DG were experiencing elevated ED psychopathology.
However, this conjecture requires further study given the absence
of age-matched norms.
Disordered gambling severity was not consistently related to
lifetime EDs and current ED psychopathology. An exception
was that among women with past-month binge eating, frequency
of OBEs was unexpectedly negatively correlated with DSM-IV criteria for PG. One interpretation is that both behaviours may be used
as coping mechanisms, and so participants who engage in binge
eating may not need to engage in gambling as frequently, and vice
versa. Alternatively, as both behaviours can be time-consuming,
perhaps those with more severe DG were too preoccupied with

Table 4 Intercorrelations, means, and standard deviations of womens gambling, eating disorder psychopathology, and impulsiveness scores (N = 5153)
Measure
1. PGSI
2. Stincheld
3. EDE-Q Total
4. EDE-Q Restraint
5. EDE-Q Eating
6. EDE-Q Weight
7. EDE-Q Shape
8. I7
9. I7i
10. I7v
11. BIS-11
12. BIS Attentional
13. BIS Motor
14. BIS Non-Planning

.58**
.13
.07
.06
.01
.04
.32*
.28*
.20
.11
.14
.06
.28*

.14
.04
.04
.15
.07
.54**
.49**
.23
.31*
.08
.36**
.31*

.75**
.84**
.88**
.92**
.23
.29*
.11
.11
.22
.01
.09

.54**
.61**
.52**
.07
.62
.01
.08
.15
.23
.08

.77**
.77**
.24
.33*
.12
.24
.33*
.16
.16

.91**
.21
.25
.11
.08
.21
.02
.06

.21
.24
.10
.11
.19
.04
.07

.77**
.63**
.62**
.41**
.57**
.60**

.14
.77**
.52**
.68**
.74**

10

.08
.01
.14
.07

11

.75**
.91**
.90**

12

.53**
.50**

13

SD

.75**

14.83
7.19
2.19
1.68
1.33
2.60
3.12
32.78
11.03
7.08
74.51
18.66
26.96
28.89

4.85
1.78
1.38
1.67
1.31
1.52
1.82
7.79
4.64
4.58
11.16
3.44
4.80
4.71

Note: *p < .05; **p < .01. PGSI, Problem Gambling Severity Index; Stincheld, Stinchelds DSM-IV criteria; EDE-Q Total, Eating Disorder Examination Questionnaire Total
Scale; EDE-Q Eating, EDE-Q Eating Concern subscale; EDE-Q Weight, EDE-Q Weight Concern subscale; EDE-Q Shape, EDE-Q Shape Concern subscale; I7, Eysenck
Impulsiveness Questionnaire; I7i, Eysenck Impulsiveness Scale Impulsiveness subscale; I7v, Eysenck Venturesomeness subscale; BIS-11, Barratt Impulsivity Scale; BIS
Attentional, BIS Attentional Impulsivity subscale; BIS Motor, BIS Motor Impulsivity subscale; Bold values indicates statistical signicant.

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K. M. von Ranson et al.

Eating Disorders in Community Disordered Gamblers

Table 5 Impulsiveness in women with disordered gambling, categorized by presence or absence of a comorbid eating or drug disorder diagnosis
Lifetime eating disorder (N = 5253)

Eysenck Impulsiveness Questionnaire

Eysenck Impulsiveness subscale
Eysenck Venturesomeness subscale
BIS Total Score
BIS Attentional Impulsivity subscale
BIS Non-Planning Impulsivity subscale
BIS Motor Impulsivity subscale

Lifetime drug dependence (N = 5152)

Present (n = 20)

Absent (n = 3233)

Mean  SD

Mean  SD

36.99  7.67
13.79  3.47
7.30  5.28
79.35  8.95
20.25  3.24
31.00  4.12
28.10  4.13

30.26  6.72
9.31  4.48
6.94  4.16
71.58  11.45
17.70  3.23
27.61  4.64
26.27  5.09

Present (n = 11)

Absent (n = 4140)

Mean  SD

Mean  SD

3.38**
3.81***
.28
2.59*
2.79**
2.70*
1.36

38.07  8.87
14.07  4.24
7.91  4.93
83.55  13.65
22.45  4.46
31.45  4.89
29.64  5.07

31.67  6.92
10.22  4.44
6.85  4.51
72.15  9.32
17.66  2.32
28.22  4.54
26.27  4.58

2.69*
2.58*
.68
3.25**
3.45**
2.07*
2.12*

Note: BIS, Barratt Impulsivity Scale. *p < .05; **p < .01; ***p < .001.

gambling to have frequent binge eating episodes, and those

gamblers who frequently binge ate tended to accumulate few
gambling-related problems. The behaviours may also have been
sequential, however, in which case past gambling may have been
linked to current binge eating. Considering the limited sample size
and lack of replication of the association as measured by the PGSI,
associations between binge eating and DG severity need further study.
We observed no direct relationship between eating and
gambling pathology. However, bivariate analyses showed that
each construct was associated with impulsiveness: impulsiveness
was higher than community norms and higher among women
with a lifetime ED, and facets of impulsiveness were moderately
related to both measures of DG severity. These ndings suggest
that impulsiveness might constitute a common personality characteristic underlying both DG and EDs and may account, in part,
for their comorbidity. It is also possible that people with high impulsiveness may develop either form of pathology: ED or PG.
Neither drug nor alcohol dependence was directly associated
with DG severity. However, impulsiveness may have inuenced
the elevated prevalence of drug dependence observed. We
observed a specic relationship between drug dependence and
lifetime EDs: women with an ED reported drug dependence more
frequently than women without an ED. It is possible that some
women abused drugs to control their shape and weight. However,
women with lifetime drug dependence were more impulsive than
women without lifetime drug dependence, suggesting that the
comorbidity between these two disorders may be inuenced, in
part, by elevated impulsiveness.
The present studys ndings largely align with research by
Fischer and Smith (2008), who examined the inuence of aspects
of impulsiveness on PG, binge eating, and problem drinking in an
undergraduate sample, and concluded that urgencydened as
the tendency to act rashly when distressedmay inuence
vulnerability to these behaviours. However, in contrast to Fischer
and Smiths ndings and other consistently reported links
between impulsiveness and alcohol dependence (Ketzenberger &
Forrest, 2000; Lejuez et al., 2010), we did not observe an association of alcohol dependence with impulsiveness (or any other
construct) in the present study. This discrepancy may be attributed to the limited sample size when gender was considered, as
well as the high rates of impulsiveness reported among these
adults with PG. Alternatively, it is possible that associations
152

between impulsiveness and alcohol dependence were obscured

by the high prevalence of EDs, particularly if women with ED
symptoms used drugs instead of alcohol to avoid increased caloric
intake when engaging in substance use.
Findings from other studies have suggested possible shared
genetic variance among PG, EDs, and SUDs (Lobo & Kennedy,
2009; Wade et al., 2004). Taken together with the present results,
it appears that impulsiveness could pose one path of genetic risk
for these disorders. Further behaviour genetic research that
includes examination of relevant aspects of impulsiveness is
needed to parse these associations.
Current ED psychopathology generally did not correlate with
impulsiveness, with the exception of eating concern. Specically,
eating concern was positively correlated with the attention subscale
of one measure of impulsivity and the impulsiveness subscale of
another impulsivity inventory. Although this nding of limited
associations between impulsiveness and eating psychopathology
could relate to the measures distinct time frames (i.e. lifetime ED
versus current ED psychopathology), it may also relate to the fact
that the EDE-Q scales emphasize disordered eating attitudes rather
than behaviours. An association of impulsiveness with disordered
eating behaviours appears to be more prominent than with disordered eating attitudes. Thus, an impulsive person with disordered
eating attitudes may be more likely to engage in disordered eating
behaviour, whereas a less impulsive person may nd it easier to
respond more moderately to these beliefs.
We found that not all measures of impulsiveness intercorrelated signicantly, most notably venturesomeness, which was
uncorrelated with other measures of impulsiveness as well as
other constructs. Furthermore, analysis of impulsiveness measures subscales revealed more consistent relationships between
impulsiveness and eating, gambling, and SUDs. Converging
evidence suggests that impulsiveness is a multidimensional construct and indicates different associations between impulsiveness
and both gambling problems and disordered eating, depending
on how impulsiveness is dened and measured (Fischer & Smith,
2008). It is important to focus future investigations on specic
aspects of impulsiveness. In this study, we found that aspects of
impulsiveness related to rash behaviour and lack of planning were
most strongly associated with gambling and EDs; motor impulsiveness was more specically associated with gambling; and
attentional impulsiveness was more specically associated with

Eur. Eat. Disorders Rev. 21 (2013) 148154 2012 John Wiley & Sons, Ltd and Eating Disorders Association.

K. M. von Ranson et al.

Eating Disorders in Community Disordered Gamblers

EDs. However, with other conicting ndings reported (Rogers,

Moeller, Swann, & Clark, 2010; Waxman, 2009), further examination is needed. We also noted minor differences in associations
with the two measures of DG severity. These differences may be
due to when and how the measures were administered (i.e. the
PGSI was administered via phone during initial screening,
whereas the DSM-IV measure was administered face-to-face
during the assessment), and differences in response formats
(i.e. the PGSI has nine items with a Likert response format,
whereas the DSM-IV has 19 items with a yes/no response format).
It is possible that the greater number of questions included on
Stinchelds DSM-IV criteria led to more accurate measurement
of DG severity.

The present correlational ndings raise the question of whether

EDs should join other disorders of impulse control in a class of
behavioural addictions, in light of both the impulsive behaviours
seen in EDs and a shared trait of impulsiveness. Several facts
about EDs need to be reconciled in considering this possibility.
On one hand, contrary to the notion that EDs are behavioural
addictions, symptoms of one form of EDthe restricting type
of ANare characterized by a prominent lack of impulsive behaviour. On the other hand, the majority of EDs involve impulsive
behaviour such as binge eating or purging (American Psychiatric
Association, 2000). In addition, individuals ED symptoms often
vary over time (e.g. Eddy et al., 2010), suggesting that the level
of impulsive behaviours can be temporally unstable among individuals with EDs, including those with restricting AN. We conclude
that ndings from this study are consistent with the notion that
most, but not all, EDs can be described as forms of behavioural
addiction.
We caution that a common thread of impulsiveness does not
equal a common thread of addiction, however. It remains
important to test empirically the assumption that addiction-based
treatments for EDs are effective (Wilson, 2010). Neither PG severity nor alcohol dependence, for which addiction-based treatments
have traditionally been targeted, was consistently related to
current disordered eating pathology or to lifetime ED diagnoses
in this sample. Recognizing that impulsiveness was greater among
women with greater gambling severity, with a lifetime drug
dependence diagnosis, and with a lifetime ED diagnosis, it is possible that impulsiveness is a personality trait that underlies PG,
drug dependence, and EDs. Thus, the effectiveness of transporting
addiction-based treatments to EDs needs to be empirically
evaluated. In addition, future research should address whether
incorporating techniques that target and address elevated impulsiveness into psychotherapeutic approaches for PG, EDs, and drug
dependence benets treatment of the targeted disorder, improves
comorbid psychopathology, and prevents development of later
psychopathology.

Strengths and limitations

Because the likelihood of seeking treatment increases as the number of problems one experiences rises, resulting in a bias toward
higher levels of observed comorbidity in treatment samples
(Berkson, 1946), community samples such as the present one
provide less biased estimates of comorbidity. Additional methodological strengths of this study included the use of both semistructured interviews and self-reports, two measures of gambling
severity, ED psychopathology, and impulsiveness, and the use of
consensus diagnoses of EDs.
Study limitations included the restricted number of participants, particularly men with EDs. The modest sample size may
also have limited the power of analyses to detect small effects. In
addition, all participants included in the study were required to
have scored in the problem range of DG severity on the PGSI,
which resulted in a restricted range of gambling severity that
may have limited detection of associations with other constructs.
Absence of a control group limits conclusions that may be drawn,
as comparisons were made to norms. Finally, the cross-sectional
design prevents the drawing of conclusions regarding causality
and direction of relationships among constructs. Longitudinal
research that investigates the role of impulsiveness in eating,
gambling, and SUDs is needed to improve our understanding of
causal relationships between impulsiveness and these disorders.

Acknowledgements

Conclusion
Lifetime EDs were common in this community sample of disordered gamblers, and indirect evidence suggests that high levels
of impulsiveness may inuence this overlap. Treatment providers
should be mindful of links between EDs and DG, and should
screen for comorbidity. Future research that examines the
chronology of DG and EDs is warranted and may have implications for assessment and treatment planning, as well as possibly
providing clues about the etiology of these problems.

Funding was provided by fellowship awards to Alice Holub from

the Alberta Heritage Foundation for Medical Research and the
Social Sciences and Humanities Research Council, as well as an
operating grant from the Alberta Gaming Research Institute
(The Structure of Impulsivity in Pathological Gambling; #40).
Portions of this research were presented at the International
Conference on Eating Disorders in Baltimore, Maryland (May
2007), and the Eating Disorders Research Society meeting in
Edinburgh, Scotland (September 2011).

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