Comorbidity of Eating Disorders and Substance Use Disorders

Comorbidity rates in patients with substance use disorders (SUD) have slowly increased

in the past decade. Nearly 50% of patients with a SUD has a co-occurring mental illness.

Specifically, there has been much research on the relationship between patients with an eating

disorder (ED) and SUDs. According to the National Eating Disorder Association (NEDA), half

of all patients with an ED will abuse alcohol or illicit drugs, which is five times greater than the

general population. The most common EDs include anorexia nervosa (AN), bulimia nervosa

(BN), and binge eating disorder (BED). These mental disorders are characterized by abnormal

feeding or eating behaviors, such as binging and purging. In the US, about 8.9% of the

population is diagnosed with an eating disorder, most commonly in Caucasian females. There is

much interest in the relationship between EDs and SUDs because research has shown overlap in

risk factors between these two disorders. Patients who have either disorder have similar

biological, psychological, social, and genetic risk factors. For example, patients with either an

ED or SUD have shown to have Cluster B personality traits; this includes compulsive behavior,

perfectionist qualities, and emotional dysregulation (Bahji, Mazhar, Hudson, Nadkarni, MacNeil,

& Hawken, 2019). Additionally, patients diagnosed with either disorder are more likely to have

suffered from childhood trauma and self-harm. An ED or SUD can be a result of patients finding

a way to cope with negative situations. Furthermore, the goal of this paper is to dive into recent

research concerning the comorbidity of EDs and SUDs, as well as determining possible

etiologies and what healthcare professionals can do to treat these individuals.

In a recent meta-analysis, Bahji et al., 2019 aimed to measure lifetime and current

prevalence of patients with comorbid SUDs and EDs in order to gain more insight on the specific

types of EDs and SUDs involved, as well as creating a call to action for clinicians treating either
disorder. With a thorough extraction of 805 publications, 43 remained after duplications and

exclusion criteria. Results showed that overall lifetime prevalence of any SUD in individual with

ED is 25.4% (+/- 16.1%), with varied rates depending on specific substances. Bahji and

colleagues also found that lifetime SUD prevalence in ED patients were significantly higher in

all female studies (26%), primarily white samples (24%), and those with BED and BN. Current

prevalence data showed that cocaine (28.% +/- 28.8%) was the leading substance that ED

patients abused, followed by cannabis, tobacco, and opioids. Overall, this study concluded that

certain ED types are associated with specific behaviors (e.g., binging and purging), which are

linked with a higher prevalence of SUD. Moreover, clinicians should pay attention to potential

SUD in white females with these behaviors to diagnose a possible ED comorbid with their

existing SUD condition. Evidence-based treatment should be utilized to effectively treat one

disorder before commodity can occur. Although this meta-analysis provided a thorough

understanding of these two disorders, there are a few limitations that must be considered.

Quantitatively, high standard deviations were prevalent in the study which may lead to

misinterpretation of data. Additionally, there were not many studies focused on men, even

though we know that men can develop EDs (according to NEDA, 25% of individuals with AN

are men). Lack of gender representation may affect the understanding of the broad spectrum of

EDs. Finally, due to the large range of articles and the years they were published, some studies

used criteria from the DSM III, and other used DSM IV. Different criteria used could have

caused misdiagnosing patients.

Fouladi et al., 2015 sought to research the prevalence of alcohol and other substance use

in patients with EDs. The Eating Disorder Questionnaire (EDQ) was handed out to 2966 ED

patients in treatment facilities at five different sites in the US between 1975-2004. The EDQ is a
screening tool used to determine the severity of the ED, as well as other behaviors and

demographic information. It is important to note that since the results were taken, there has been

an updated version of this questionnaire called the Eating Disorder Examination Questionnaire

(EDE-Q). When analyzing the data, researchers assigned each patient to a different type and

subtype of ED (e.g. type is AN, subtype is binge) to determine if there is a relationship between a

specific ED and a specific substance. Similar to the previous study, patients were mainly female

(94.2%) and white (91.4%), with an average age of 28.6. Interestingly, results showed that 80%

of individuals with BN engaged in alcohol use, and 50.3% also used other substances. Most

common substances used, aside from alcohol, included sedatives, marijuana, and caffeine pills.

Overall, the EDQ displayed higher rates of depression, impulsiveness, borderline personality

traits, and self-defeating behavior among individuals with BN with heavy alcohol use.

Additionally, higher frequencies of binging and purging were associated with higher frequency

of substance use and possible abuse. Interestingly, patients with AN were less likely to use drugs

and alcohol than other ED types. The researchers suggested this was because they displayed high

level of avoidance and obsessional behaviors towards limiting food and drink consumption. The

exception of this is smoking tobacco or marijuana. This may be because of the misperception

that it will aid in weight loss. Fouladi and colleagues also concluded that binge eating can lead to

binge drinking. This is an example of emotional relief and reward-seeking behaviors in both ED

and SUD patients. This study provided ample evidence on the relationship between specific EDs

and substance use. An important limitation to mention is that the data did not allow them to

examine the severity of the problem between ED and SUD because it was unknown if the

individuals with ED were diagnosed with a SUD.

 In a different take, Killeen, Brewerton, Campbell, Cohen, and Hien (2015) explored the

relationship between ED behaviors in women with comorbid PTSD and SUDs. Between 2004

and 2006, the EDE-Q was administered to women with a SUD and PTSD to detect ED behaviors

and if those behavior could be linked to SUD. In addition to the EDE-Q, patients also filled out

the Clinician’s Administered PTSD Scale (CAPS) and the Addiction Severity Index (ASI).

Demographic information in this study included mostly white (42.6 %) or black (32.8%),

divorced/ separated (47.5%) or single (38.6%), with an average age of 38 years. The most

frequently used substances were cocaine (72%), alcohol (66%) and opiates (26%). It was also

found that 93% of women reported lifetime history of physical abuse and 63% reported sexual

abuse. Based on this information, as well as the results of the EDE-Q, CAPS, and ASI, the

researchers were able to come to a few conclusions regarding ED behaviors in PTSD and SUD

patients. First, women in recovery from SUD and PTSD reported concerns about their weight,

shape, and general eating habits at a higher rate that the general population. This may be why

EDs develop with these individuals. Also these women who are participating in certain ED

behaviors (binging or purging) may be more at risk to relapse to substance abuse to cope with

their concerns about weight or eating. Finally, there was a particular interest in the role of opiates

in this study. The data provided about opiate use the past 30 days may indicate that this

substance can act as an appetite suppressant for women with weight and shape concern. Finally,

the researchers called to action of the use of cognitive behavioral therapy to help treat ED

behaviors in PTSD and SUD patients. A critical limitation to take into account is the fact that this

is a secondary analysis article based on a clinical trial through the National Institute of Drug

Abuse Clinical Trials Network.

 In this research update, I wanted to compare recent studies focusing on the comorbidity

of patients with EDs and SUDs to further understand the complexities of their relationship.

Overwhelming evidence points to a high likelihood (nearly 50%) of patients with ED developing

a SUD. More specifically, however, many articles concluded that patients with BN and BED are

most likely to develop a SUD due to a desire for emotional relief and reward-seeking behaviors.

In fact, there has been further research done on the neurobiological similarities between food

addiction and drug addiction (Brewerton, 2011). Similar to drug use, some foods have

reinforcing properties that can alter dopamine levels by increasing the brain’s reward

motivational drive and decreasing the inhibitory control in the limbic system. This can lead to

brain reward deficiencies that can eventually contribute to addiction. Based on all of this

information, there seems to be a need for a treatment that specifically targets patients with ED

and SUD comorbidity. For example, cognitive behavioral therapy seems to be effective for these

situations, however it is not widely used or researched (Claudat et al., 2020). Thus, it would be

beneficial to conduct more research on this type of treatment implementation. Finally, clinicians

who work with patients with either ED or SUD should be able to recognize the prevalence of

substance use or eating disorder behaviors to avoid comorbidity.

 References:

Bahji, A., Mazhar, M. N., Hudson, C. C., Nadkarni, P., MacNeil, B. A., & Hawken, E. (2019).
Prevalence of substance use disorder comorbidity among individuals with eating
disorders: A systematic review and meta-analysis. Psychiatry Research, 273, 58-66.

Claudat, K., Brown, T. A., Anderson, L., Bongiorno, G., Berner, L. A., Reilly, E., ... & Kaye, W.
H. (2020). Correlates of co-occurring eating disorders and substance use disorders: a case
for dialectical behavior therapy. Eating Disorders, 28(2), 142-156.

Fouladi, F., Mitchell, J. E., Crosby, R. D., Engel, S. G., Crow, S., Hill, L., ... & Steffen, K. J.
(2015). Prevalence of alcohol and other substance use in patients with eating disorders.
European Eating Disorders Review, 23(6), 531-536.

Killeen, T., Brewerton, T. D., Campbell, A., Cohen, L. R., & Hien, D. A. (2015). Exploring the
relationship between eating disorder symptoms and substance use severity in women with
comorbid PTSD and substance use disorders. The American journal of drug and alcohol
abuse, 41(6), 547-552.
Brewerton, T. D. (2011). Posttraumatic stress disorder and disordered eating: food addiction as
self-medication.