Commentary

Recognizing alcohol and drug abuse in patients

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

a
t

U
n
i
v
e
r
s
i
t
a
t
e
a

L
u
c
i
a
n

B
l
a
g
a
,

S
i
b
i
u

o
n

M
a
r
c
h

2
5
,

2
0
1
4
h
t
t
p
:
/
/
q
j
m
e
d
.
o
x
f
o
r
d
j
o
u
r
n
a
l
s
.
o
r
g
/
D
o
w
n
l
o
a
d
e
d

f
r
o
m

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.

a
t

U
n
i
v
e
r
s
i
t
a
t
e
a

L
u
c
i
a
n

B
l
a
g
a
,

S
i
b
i
u

o
n

M
a
r
c
h

2
5
,

2
0
1
4
h
t
t
p
:
/
/
q
j
m
e
d
.
o
x
f
o
r
d
j
o
u
r
n
a
l
s
.
o
r
g
/
D
o
w
n
l
o
a
d
e
d

f
r
o
m

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

a
t

U
n
i
v
e
r
s
i
t
a
t
e
a

L
u
c
i
a
n

B
l
a
g
a
,

S
i
b
i
u

o
n

M
a
r
c
h

2
5
,

2
0
1
4
h
t
t
p
:
/
/
q
j
m
e
d
.
o
x
f
o
r
d
j
o
u
r
n
a
l
s
.
o
r
g
/
D
o
w
n
l
o
a
d
e
d

f
r
o
m

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. Co-morbidity of
eating disorders and substance abuse review of the literature.
Int J Eat Disord 1994; 16:134.
2. Beary MD, Lacey JH, Merry J. Alcoholism and eating
disorders in women of fertile age. Br J Addict 1986;
81:6859.
3. Hall RC, Beresford TP, Wooley B, Tice L, Hall AK. Covert
drug abuse in patients with eating disorders. Psych Med
1989; 7:24755.
4. Mitchell JE, Hatsukami D, Eckert ED, Pyle RL. Characteristics
of 275 patients with bulimia. Am J Psychiatry 1985;
142:4825.
5. Hudson JI, Pope HG Jr, Yurgelun-Todd D, Jonas JM,
Frankenburg FR. A controlled study of lifetime prevalence
of affective and other psychiatric disorders in bulimic
outpatients. Am J Psychiatry 1987; 144:12837.
6. Ross HE, Ivis F. Binge eating and substance use among male
and female adolescents. Int J Eat Disord 1999; 26:24560.
7. Wiederman MW, Pryor T. Substance use among women with
eating disorders. Int J Eat Disord 1996; 20:1638.
8. Wiederman MW, Pryor T. Substance use and impulsive
behaviors among adolescents with eating disorders. Addict
Behav 1996; 21:26972.
9. Stock SL, Goldberg E, Corbett S, Katzman DK. Substance use
in female adolescents with eating disorders. J Adolesc Health
2002; 31:17682.
10. Walsh BT, Roose SP, Glassman AH, Gladis M, Sadik C.
Bulimia and depression. Psychosom Med 1985; 47:12331.
11. Kennedy SH, Goldbloom DS. Current perspectives on drug
therapies for anorexia nervosa and bulimia nervosa. Drugs
1991; 41:36777.
12. Walsh BT. Psychopharmacologic treatment of bulimia
nervosa. J Clin Psychiatry 1991; 52:(Suppl.):348.
13. Frank ES. Shame and guilt in eating disorders. Am J
Orthopsychiatry 1991; 61:3036.
14. Potter-Efron RT. Shame, guilt and alcoholism: Treatment
issues in clinical practice. New York, Haworth Press, 1989.
15. Pilkonis PA, Feldman H, Himmelhoch J. Social anxiety and
substance abuse in affective disorders. Compr Psychiatry
1981; 22:4517.
16. Striegel-Moore RH, Silberstein LR, Rodin J. The social self in
bulimia nervosa: public self-consciousness, social anxiety,
and perceived fraudulence. J Abnorm Psychol 1993;
102:297303.
17. Strober M. The significance of bulimia in juvenile anorexia
nervosa: an exploration of possible etiologic factors. Int J Eat
Disord 1981; 1:2843.
18. Gershon ES, Schreiber JL, Hamovit JR, et al. Clinical findings
in patients with anorexia nervosa and affective illness in their
relatives. Am J Psychiatry 1984; 141:141922.
19. Hudson JI, Pope HG Jr, Jonas JM, Yurgelun-Todd D. Family
history study of anorexia nervosa and bulimia. Br J Psychiatry
1983; 142:4289.
20. Loxton NJ, Dawe S. Alcohol abuse and dysfunctional eating
in adolescent girls: the influence of individual differences in
sensitivity to reward and punishment. Int J Eat Disord 2001;
29:45562.
21. Brisman J, Siegel M. Bulimia and alcoholism: two sides of the
same coin? J Subst Abuse Treat 1984; 1:11318.
22. Sinnett ER, Judd B, Olson MA. Food, drugs, and alcohol-a
common temporal pattern of use. Percept Mot Skills 1983;
57:3759.
23. Adams WL, Barry KL, Fleming MF. Screening for problem
drinking in older primary care patients. JAMA 1996;
2776:19647.
24. Brienza RS, Stein MD. Alcohol use disorders in primary care:
do gender-specific differences exist? J Gen Intern Med 2002;
17:38797.
25. Johnson JG, Spitzer RL, Williams JB, et al. Psychiatric
comorbidity, health status, and functional impairment
associated with alcohol abuse and dependence in primary
care patients: findings of the PRIME MD-1000 study. J
Consult Clin Psychol 1995; 63:13340.
26. Erinoff L, Anthony JC, Brown GK, et al. Overview of
workshop on drug abuse and suicidal behavior. Drug
Alcohol Depend 2004; 76(Suppl.):39.
27. Erinoff L, Compton WM, Volkow ND. Drug abuse
and suicidal behavior. Drug Alcohol Depend 2004;
76(Suppl.):12.
28. Sher L, Quendo MA, Galfalvy HC, et al. The relationship
of aggression to suicidal behavior in depressed
patients with a history of alcoholism. Addict Behav 2005;
30:114453.
29. Roy A, Linnoila M. Alcoholism and suicide. Suicide Life
Threat Behav 1986; 16:24473.
30. Murphy GE, Wetzel RD. The lifetime risk of suicide in
alcoholism. Arch Gen Psychiatry 1990; 47:38392.
338 A.H. Conason et al.

a
t

U
n
i
v
e
r
s
i
t
a
t
e
a

L
u
c
i
a
n

B
l
a
g
a
,

S
i
b
i
u

o
n

M
a
r
c
h

2
5
,

2
0
1
4
h
t
t
p
:
/
/
q
j
m
e
d
.
o
x
f
o
r
d
j
o
u
r
n
a
l
s
.
o
r
g
/
D
o
w
n
l
o
a
d
e
d

f
r
o
m

31. Kessler RC, Borges G, Walters EE. Prevalence of and risk
factors for lifetime suicide attempts in the National
Comorbidity Survey. Arch Gen Psychiatry 1999; 56:61726.
32. Rossow I, Romelsjo A, Leifman H. Alcohol abuse and
suicidal behaviour in young and middle aged men:
differentiating between attempted and completed suicide.
Addiction 1999; 94:1199207.
33. Schottenfeld RS, Pantalon MV. Assessment of the patient. In:
Galanter M, Kleber HD, eds. Textbook of substance abuse
treatment. Washington DC, American Psychiatric Press,
1999:109.
34. Sobell LC, Agrawal S, Sobell MB. Factors affecting agreement
between alcohol abusers and their collaterals reports. J Stud
Alcohol 1997; 58:40513.
35. Mayfield D, McLeod G, Hall P. The CAGE questionnaire:
validation of a new alcoholism screening instrument. Am J
Psychiatry 1974; 131:11213.
36. Chan AW, Pristach EA, Welte JW, Russell M. Use of the
TWEAK test in screening for alcoholism/heavy drinking
in three populations. Alcohol Clin Exp Res 1993;
17:118892.
37. Russell M, Martier SS, Sokol RJ, Mudar P, Jacobson S,
Jacobson J. Detecting risk drinking during pregnancy: a
comparison of four screening questionnaires. Am J Public
Health 1996; 86:14359.
38. Selzer ML. The Michigan alcoholism screening test: the quest
for a new diagnostic instrument. Am J Psychiatry 1971;
127:16538.
39. Ross HE, Gavin DR, Skinner HA. Diagnostic validity of the
MAST and the alcohol dependence scale in the assessment
of DSM-III alcohol disorders. Journal Stud Alcohol 1990;
51:50613.
40. Skinner HA. The drug abuse screening test. Addict Behav
1982; 7:36371.
41. Brown RL, Leonard T, Saunders LA, Papasouliotis O. A
two-item screening test for alcohol and other drug problems.
J Fam Pract 1997; 44:15160.
42. Sobell LC, Kwan E, Sobell MB. Reliability of a drug history
questionnaire (DHQ). Addict Behav 1995; 20:23341.
43. Anton RF, Litten RZ, Allen JP. Biological assessment
of alcohol consumption. In: Allen JP, Columbus M, eds.
Assessing alcohol problems: A guide for clinicians and
researchers. Treatment handbook Series 4. Bethesda MD,
National Institute on Alcohol Abuse and Alcoholism,
1995:3140.
44. Grant BF, Dufour MC, Harford TC. Epidemiology of
alcoholic liver disease. Semin Liver Dis 1988; 8:1225.
45. National Institute on Alcohol Abuse and Alcoholism.
Alcohol and the liver (Alcohol Alert 19). Rockville MD,
NIAAA, 1993.
46. Eckardt MJ, Ryback RS, Rawlings RR, Graubard BI.
Biochemical diagnosis of alcoholism. A test of the
discriminating capabilities of gamma-glutamyl transpepti-
dase and mean corpuscular volume. JAMA 1981; 246:
270710.
47. Donovan D. Assessment strategies and measures in addictive
behaviors. In: McCrady BS, Epstein EE, eds. Addictions: A
comprehensive guidebook. Oxford University Press,
New York, 1999:187215.
48. Carroll KM, Onken LS. Behavioral therapies for drug abuse.
Am J Psychiatry 2005; 162:145260.
49. Agras WS, Rossiter EM, Arnow B, Schneider JA, Telch CF,
Raeburn SD, Bruce B, Perl M, Koran LM. Pharmacologic
and cognitive-behavioral treatment for bulimia
nervosa: a controlled comparison. Am J Psychiatry 1992;
149:827.
50. Wilfley DE, Agras WS, Telch CF, Rossiter EM, Schneider JA,
Cole AG, Sifford L, Raeburn SD. Group cognitive behavioral
therapy and group interpersonal psychotherapy for the
nonpurging bulimic: a controlled comparison. J Consult
Clin Psychol 1993; 61:296305.
51. Sinha R, OMalley SS. Alcohol and eating
disorders: implications for alcohol treatment and
health services research. Alcohol Clin Exp Res 2000;
24:131219.
Alcohol, drug and eating disorders 339

a
t

U
n
i
v
e
r
s
i
t
a
t
e
a

L
u
c
i
a
n

B
l
a
g
a
,

S
i
b
i
u

o
n

M
a
r
c
h

2
5
,

2
0
1
4
h
t
t
p
:
/
/
q
j
m
e
d
.
o
x
f
o
r
d
j
o
u
r
n
a
l
s
.
o
r
g
/
D
o
w
n
l
o
a
d
e
d

f
r
o
m