Young female alcoholics with and without eating disorders: a comparative study in Japan

Survey of eating disorder symptoms among women in treatment for substance abuse

A strong association between substance use disorders (SUDs) and eating disorders (EDs) in women has been established. Yet, little is known about the rates and impact of ED symptoms in women presenting to addiction treatment. The current investigation assessed the prevalence of ED symptoms and their effect on treatment outcomes in a sample of substance abusing women with co-occurring posttraumatic stress disorder (PTSD) enrolled in outpatient substance use programs. Participants were 122 women who participated in a multisite clinical trial comparing two behavioral treatments for co-occurring SUD and PTSD. The Eating Disorder Examination-self report, and measures of PTSD and SUD symptoms were administered at baseline, during treatment and at four follow-up points. Two subgroups emerged; those reporting binge eating in the 28 days prior to baseline (Binge group; n = 35) and those who reported no binge eating episodes (No Binge group; n = 87). Women in the Binge group endorsed significantly higher ED, PTSD, and depression symptoms at baseline than those in the No Binge group. Although all participants showed significant reductions in PTSD symptoms and improvements in abstinence rates during the study period, the improvements for the Binge group were significantly lower. These findings suggest that a subgroup of women with co-occurring PTSD and SUDs, who endorsed binge ED symptoms, responded differently to SUD/PTSD group treatment. Identification of ED symptoms among treatment-seeking women with SUDs may be an important element in tailoring interventions and enhancing treatment outcomes.

Lifetime psychiatric comorbidity of alcohol dependence and bulimia nervosa in women

Previous work from our group revealed two groups of women with bulimia nervosa (BN), one with, and one without alcohol dependence (AD). The current study sought to determine whether women with lifetime BN and AD (BN+AD+) were more similar to women with BN and no AD (BN+AD-) or to women with AD and no BN (BN-AD+) in terms of lifetime psychiatric comorbidity and psychological functioning. Data on BN and AD from 407 female relatives in a family study of alcoholism were used to create three mutually exclusive groups: BN+AD+ (n=30), BN+AD- (n=55), and BN-AD+ (n=322). Bivariate analyses revealed fewer differences between BN+AD+ and BN-AD+ women than between BN+AD+ and BN+AD- women. BN+AD+ women were more likely than BN+AD- women to have drug dependence, conduct disorder, and suicidality, and were more likely to have major depression, lower GAF scores, and to engage in unsafe sex than both BN+AD- and BN-AD+ women. After adjusting for other psychopathology and demographic variables, BN+AD+ women were more likely than BN+AD- women to have major depression, drug dependence, and tobacco dependence and more likely than BN-AD+ women to have major depression and obsessive-compulsive disorder. These results suggest that BN+AD+ women exhibit more severe psychopathology than either BN+AD- or BN-AD+ women and may represent a distinct subgroup within bulimia nervosa or alcohol dependence.

Comparative study of attitudes to eating between male and female students in the People's Republic of China

OBJECTIVE

This study was conducted to compare eating attitudes and lifestyles of male and female college students in China (Beijing).

SUBJECTS AND METHODS

The subjects of this study consisted of 217 male and 177 female college students. They were asked to fill out the Eating Attitudes Test-26 (EAT-26) and a lifestyle questionnaire.

RESULTS

The percentages of those above the cutoff point on the EAT-26 for abnormal eating attitudes were 4.7% of male and 6.2% of female students. Body perception of being fat (distorted body image) was the factor most associated with abnormal eating attitudes.

DISCUSSION

Weight related concern was prevalent amongst the Chinese students. This suggests that the culture of the beauty of thinness is common among young students in Beijing, particularly female students.

Dispositional correlates of addictive behaviors in college women: binge eating and heavy drinking

Binge eating and alcohol abuse are often conceptualized as addictive behaviors. As these behaviors are relatively common among undergraduate college women, we examined whether common dispositional variables underlie their occurrence. Three hundred and thirty-five undergraduate women completed self-report questionnaires about their eating and alcohol use habits as well as dispositional measures of impulsivity, tolerance of deviance, self-esteem, rejection sensitivity, extraversion-introversion, conscientiousness, and emotional stability. Multiple regression analyses showed that women who either binge eat or abuse alcohol, but not both, have similar dispositional characteristics. Both groups exhibited a high degree of impulsivity and endorsed socially deviant attitudes; thus, both groups could be viewed as "externalizers." In contrast, women who admitted to both addictive behaviors, i.e., binge eating as well as alcohol abuse, were not particularly impulsive or socially deviant, but manifested a high degree of emotional instability ("neuroticism"); thus, these women might be considered "internalizers." The theoretical and clinical implications of these findings are discussed.

Repetitive self-mutilation among Japanese eating disorder patients with drug use disorder: comparison with patients with methamphetamine use disorder

Repetitive self-mutilation and drug use disorder are less prevalent in Japan, although the prevalence of eating disorder is comparable with rates in Western countries. However, repetitive self-mutilation has not previously been described in relation to eating disorder and drug use disorder in Japan. Subjects consisted of 19 patients with eating disorders and drug use disorders (ED+DUD) and 12 patients with methamphetamine use disorders (MAP). Subjects were drawn from 180 patients who were referred because of eating disorders and 22 patients who were referred because of methamphetamine-related problems. All subjects underwent a semistructured interview. Repetitive self-mutilation tended to be more prevalent among ED+DUD patients than MAP patients. Conversely, history of oppositional defiant disorder and antisocial personality disorder tended to be more prevalent in MAP patients than in ED+DUD patients. The low prevalence of repetitive self-mutilation appears to be due to low risk factors in Japan, even though the pathogenesis of these behaviors seems to be universal.

Weight and eating concerns in outpatient men and women being treated for substance abuse

This study examined the specific features of weight and eating concerns, and explored gender differences, in a racially diverse group of outpatients (45 men and 39 women) currently being treated for substance abuse but abstinent from substance use. Overweight was prevalent and similarly distributed across gender: 60% of the men and 69% of the women were overweight. Most of the overweight participants did not identify themselves as such. No significant gender differences were observed in terms of the behavioural features of eating disorders: 8% of the men and 11% of the women reported binge eating on at least one day per week; inappropriate weight compensatory behaviours were reported by 8% of the men vs 16% of the women, but the women had significantly higher attitudinal scores than the men. Our findings suggest that, in patients recovering from substance abuse, overweight and features of eating disorders are common in both men and women, and occur in poor and minority groups.

Characteristics of bulimic patients whose parents do or do not abuse alcohol

OBJECTIVES

This study attempts to understand the effects of a parental history of alcohol abuse on the psychopathology and symptoms of bulimia nervosa (BN).

METHOD

The study involved 121 female BN patients consecutively admitted to the Eating Disorders Unit of the University Hospital of Bellvitge. The sample was divided post hoc into two subgroups on the basis of the presence (PAA, n=25) or not of parental abuse of alcohol (NPAA, n=96). All of the patients fulfilled the DSM-IV criteria for BN.

EVALUATION

The assessment measures were the Eating Attitudes Test (EAT-40), the Eating Disorders Inventory (EDI), the Bulimic Investigatory Test Edinburgh (BITE), the Body Shape Questionnaire (BSQ) and Beck Depression Inventory (BDI), as well as clinical and psychopathological variables.

RESULTS AND CONCLUSIONS

Only 7.4% of the patients reported current alcohol abuse and this correlated positively with the presence of other impulsive behaviours (p<0.001). Furthermore, PAA was observed in 20.7% of cases. When the PAA and NPAA subgroups were compared, no significant differences were found in the symptomatological or psychopathological variables, but the PAA group showed more frequent parental obesity (p<0.001) and its members lived less frequently with their parents (p<0.001). The results of this study suggest that there is little correlation between parental abuse of alcohol and the severity of BN.

Disordered eating and substance use in an epidemiological sample: I. Associations within individuals

OBJECTIVE

This study examined the strength of associations between disordered eating and eating disorders and substance use and substance use disorders (SU/SUDs) in an epidemiological sample.

METHODS

672 adolescent girls and 718 women completed structured interviews of lifetime eating disorders and substance use and misuse, as well as self-reported current disordered eating attitudes and behaviors.

RESULTS

Although effect sizes were small, eating attitudes and disorders were associated modestly with nicotine, alcohol, and drug use, and with nicotine dependence in adolescent girls. Alcohol use and misuse were related to eating attitudes and pathology in women. SU/SUDs were associated with restricting and bulimic behaviors and no prominent differences in associations were observed between substance classes. In contrast to findings in clinical populations, these community-based results were positive but generally weak, suggesting there is no strong, overarching relationship between eating and substance use problems.

DISCUSSION

These results have implications for the addiction model of eating disorders.

Drug use disorders in Japanese eating disorder patients

A previous questionnaire study suggested that drug use disorder (DUD: abuse/dependence on drugs, other than alcohol) in Japanese eating disorder (ED) patients was less prevalent than in Western countries, although eating and drug use disorders have spread simultaneously in Western countries. However, the precise prevalence and comorbidity features remain unknown. Subjects consisted of 62 patients with anorexia nervosa restricting type; 48 patients with anorexia nervosa binge eating/purging type; and 75 patients with bulimia nervosa purging type. The Japanese version of the Structured Clinical Interview for DSM-III-R; the Structured Clinical Interview for DSM-III-R Personality Disorders; and the supplement module of the Schedule for Affective Disorders and Schizophrenia-Lifetime version were used for the interview. Sixteen (8.6%, 95% CI = 4.6-12.7%) patients had lifetime diagnoses of DUD. Drugs were solvent fumes or benzodiazepines, and only one patient had been dependent on methamphetamine. More than half of the patients with lifetime DUD diagnoses were multi-impulsivitists. On multivariate analysis, DUD was significantly linked with childhood parental loss, history of conduct disorder and borderline personality disorder. Thus, the prevalence of DUD in Japanese ED patients was indeed lower than that in Western countries. However, similar comorbidity was found in ED patients with DUD compared with that of those in Western countries. The current study suggests that ED and DUD have different origins, although they share the feature of impulsivity. Further study in the general population is needed to clarify these issues.

Eating disorders and substance use. An examination of behavioral associations

The association between the eating disorders of anorexia nervosa (AN) and bulimia nervosa (BN) and substance use disorder (SUD) has been widely investigated, however, our understanding of the relationship between the disorders remains unclear. Explanatory models have tended to focus on behaviors, yet, little is currently known about the patterns of association among disordered eating and substance use behaviors. In this exploratory study, a behavioral approach was used to investigate the cooccurrence of seven disordered eating and three substance use behaviors in women meeting current DSM-III-R criteria for AN (n=12), subthreshold AN (n=14), BN (n=29), and subthreshold BN (n=24). Results suggest that disordered eating behaviors are differentially associated with substance use behaviors. The most robust finding was that diuretic use positively predicted the current level of alcohol use regardless of diagnostic group. The findings for marijuana and tobacco use were less consistent. Results suggest that rather than being pervasive in all eating disordered women, higher levels of alcohol use may be found in those women who use diuretics.

Eating disorders in the Far East

OBJECTIVE

To investigate eating disorders (EDs) prevalence rates among Asian populations and identify characteristics that distinguish them from their Western counterparts.

METHOD

Potential references were identified through an English-language literature search using Medline, Psychinfo, Dissertation Abstracts (1966 to 1999) and through extensive manual searching of textbooks, reviews and reference lists.

RESULTS

The majority of studies related to EDs were conducted in Japan and China and a few were conducted in Singapore, Malaysia, Taiwan, and Korea whereas there was none in the Philippines, Laos, Vietnam, Cambodia, Myanmar, Indonesia and Thailand. Prevalence rates in Japan range from 0.025 to 0.030% for anorexia nervosa (AN) and from 1.9 to 2.9% for bulimia nervosa (BN). Community studies in China have found the AN prevalence to be 0.01% and BN rates ranging from 0.5% to 1.3%. These rates are lower than ED rates in the West (particularly the U.S. and Britain). Body dissatisfaction (BD) and dieting rates, however, were similar to those in the West. BD rates ranged from 68% (Taiwan) to 81% (Korea) and dieting rates ranged from 34% (Taiwan) to 68% (Japan). Sociocultural and developmental risk factors were relevant to this population.

CONCLUSIONS

EDs in Asian populations have received little attention because they have been predominantly viewed as associated with Western culture. Classified by many as a "culture-bound syndrome" of the West, they may really be a culture-change syndrome.

The relationship between eating disorders and substance use: moving beyond co-prevalence research

The frequent comorbidity of eating disorders and substance use has been demonstrated consistently by research. Less is known about the basis of this relationship. A review of the literature indicates that the hypotheses proposed to clarify the etiological relationship between eating disorders and substance use have not been supported sufficiently or consistently by empirical evidence. General criticisms include: a lack of well developed models, a reliance on co-prevalence data, and a lack of integration of knowledge from eating disorder and substance use research. It is suggested that an understanding of the etiological relationship between eating disorders and substance use will be arrived at only after fundamental inquiries into the functional relationship between eating disorders symptomatology and substance use patterns have been conducted. A behavioral assessment approach is offered as a means of evaluating the functional relationship between eating disorder symptomatology and substance use.

Multi-impulsivity of Japanese patients with eating disorders: primary and secondary impulsivity

Several studies have noted that multi-impulsive bulimia nervosa tends to be refractory to treatment. However, it is not known whether these impulsivities are an expression of more fundamental psychopathology or simply the consequence of chaotic eating behaviors. Studies of the temporal relationship between the onset of eating disorder and the occurrence of impulsive behaviors will facilitate a better understanding of these issues. Subjects consisted of 60 patients with anorexia nervosa restricting type (AN-R), 62 patients with anorexia nervosa binge-eating/purging type (AN-BP), 114 patients with bulimia nervosa purging type (BN) and 66 control subjects. Impulsive behaviors and childhood traumatic experiences were assessed by self-report questionnaire. Multi-impulsivity (defined by at least three of the following: heavy regular alcohol drinking; suicide attempt; self-mutilation; repeated shoplifting of items other than food; sexual relationships with persons not well known to the subject) was found in 2% of AN-R, 11% of AN-BP, 18% of BN and 2% of control subjects. Eighty percent of BN patients with multi-impulsivity had a history of suicide attempts or self-mutilation history prior to the onset of bulimia nervosa. In BN patients, there tended to be a relationship between childhood parental loss or borderline personality disorder and multi-impulsivity. In conclusion, primary impulsivity (chronological prior occurrence of impulsive behaviors) does exist even in a very different culture, although the number of patients of this type is very limited.

Body weight in bulimia nervosa

OBJECTIVES

The objectives of this study were to determine: 1) factors associated with body mass index (BMI) in women with bulimia nervosa prior to treatment; 2) changes in BMI during cognitive behavioral therapy (CBT) for bulimia nervosa; and 3) predictors of weight change during CBT treatment.

METHODS

Participants were 94 women with DSM-III-R bulimia nervosa enrolled in a randomized clinical trial of CBT. Eating disorder symptomatology, past and current psychopathology, and BMI were measured prior to treatment and after twelve weeks of treatment.

RESULTS

A significantly lower BMI prior to treatment was independently associated with a history of anorexia nervosa, substance use, cigarette smoking, and a high frequency of vomiting. Reductions in binge eating, purging, and food restriction after treatment did not result in significant changes in BMI. Increasing age, higher maximum lifetime body weight, and a high frequency of binge eating at baseline predicted weight gain during treatment. Weight loss during treatment was predicted by a high frequency of vomiting, and elevated levels of body dissatisfaction prior to treatment.

DISCUSSION

Patients hesitant to engage in treatment for fear of weight gain upon cessation of their bulimic behaviors should be reassured that CBT is not usually accompanied by substantial weight gain. Identification of women at risk of significant weight gain or loss during CBT may enable therapists to focus on its aspects that help to prevent excessive body weight changes.

Substance dependence and eating disorders: impact of sequence on comorbidity

There is a high comorbidity between eating disorders and substance dependence. The sequence of illness may indicate differences in the underlying pathology and could reflect different etiologies and treatment. The present study subjects were 218 inpatients and outpatients with diagnoses of anorexia nervosa binge-purge type (AN-BP), bulimia nervosa (BN), and eating disorder NOS (ED-NOS). Of these 218 patients, 38 had substance dependence predating the eating disorder (SDED), 71 had an eating disorder predating the substance dependence (EDSD), and 109 had only an eating disorder (ED-only). All subjects were administered the Structured Clinical Interview for DSM-III-R, Patient Edition With Psychotic Screen (SCID-P). EDSD patients had an earlier onset of the eating disorder than SDED patients and had the greatest prevalence of comorbid pathology. SDED patients were dependent on more substances. We conclude that the sequence of development of the eating disorder and substance dependence in eating disorder patients influences the amount of comorbid psychopathology. Clinical implications and future research are discussed.

Bulimia nervosa and alcohol dependence. A case report of a patient enrolled in a randomized controlled clinical trial

Bulimia nervosa and alcohol use disorders frequently co-occur. A review of the literature, however, reveals a paucity of information on treatment of patients with these comorbid conditions. We present a case report of a 34-year-old Caucasian female with a 20-year history of bulimia nervosa with co-occurring alcohol dependence, who participated in a randomized placebo-controlled medication augmentation trial for bulimia nervosa. The patient served as a pilot subject who met the exclusionary criterion of alcohol dependence, but received all the assessment and intervention procedures of the clinical trial for bulimia nervosa. Despite double-blind random assignment to a placebo condition, the patient's symptoms of bulimia nervosa substantially improved over the course of the 5-week efficacy trial. We hypothesize that this improvement was due to concurrent abstinence from alcohol rather than a placebo effect.

Eating pathology among women with alcoholism and/or anxiety disorders

Two hundred one non-treatment seeking women with alcoholism, anxiety disorders, alcoholism and anxiety disorders, or neither alcoholism nor anxiety disorders were interviewed to assess core psychopathology associated with eating disorders using the Eating Disorders Examination and DSM-IIIR psychiatric diagnoses using the Schedule of Affective Disorders and Schizophrenia-Lifetime version. Alcoholic women had significantly higher mean scores on each of the Eating Disorders Examination subscales of Restraint, Overeating, Eating Concern, Shape Concern, and Weight Concern compared with nonalcoholic women. Women with anxiety disorders had significantly elevated scores on subscales of Overeating, Eating Concern, and Weight Concern compared with women without anxiety disorders. Women with both alcoholism and anxiety disorders had higher rates of bulimia nervosa and/or eating disorder NOS compared with women with either disorder alone. Implications of these findings are discussed in the context of the co-morbid association between alcoholism, eating disorders, and anxiety disorders.

Eating disorders with and without substance use disorders: a comparative study of inpatients

We assessed the co-occurrence of DSM-III-R axis I and II disorders and self-reported psychologic distress in inpatients with eating disorders with and without substance use disorders (ED-SUD and ED groups, respectively) and in a matched comparison sample with substance use disorders but no eating disorder (SUD group). The three groups showed similar distributions of axis I disorders but differed in the distribution of axis II disorders. Cluster B personality disorders were diagnosed more frequently in SUD and ED-SUD groups than in the ED group. In contrast, cluster C personality disorders were diagnosed more frequently in the ED group than in SUD and ED-SUD groups. The SUD group reported greater psychologic distress than ED and ED-SUD groups. Possible implications of the observed group differences for psychologic models of why these disorders may be associated are considered.

Eating disorders in female inpatients with versus without substance use disorders

This study assessed the relationship between substance use disorders and eating disorders in female psychiatric inpatients. Structured diagnostic interviews were reliably administered to a series of inpatients with substance use disorders (n = 67) and a comparison sample without substance use disorders (n = 69). Eating disorder diagnoses as a whole, including eating disorder not otherwise specified, were distributed significantly more frequently among subjects with substance use disorders than among psychiatric controls. Frequencies of the specific diagnoses of bulimia nervosa and anorexia nervosa, however, did not differ significantly between groups. The results suggest that eating disorder features may be overrepresented among female inpatients with substance use disorders.

Bulimia nervosa with and without alcoholism: a comparative study in Japan

To characterize females with bulimia nervosa and alcoholism, this study compared the social and family backgrounds, as well as the clinical symptoms of alcoholics with bulimia and patients with bulimia only. The subjects were 22 Japanese female patients with both bulimia nervosa and alcoholism; the comparison group comprised 22 age-matched female patients with bulimia nervosa but without alcoholism. Patients with both bulimia and alcoholism had more borderline personality disorders and pathological symptoms such as stealing, suicide attempts, and liver injuries than the nonalcoholic comparison group. The subjects' average body weight was significantly less than that of the comparison group. Whereas the clinical characteristics of females with bulimia and alcoholism differ in many respects from those with bulimia only, it is suggested that alcoholic bulimia patients form a distinct clinical subgroup among patients with bulimia nervosa.