Bulimia and Addiction

Bulimia nervosa, often shortened to bulimia, is an eating disorder characterized by binge eating followed by purging. The National Institute of Mental Health (NIMH) publishes that 1% percent of American adults have a lifetime prevalence of bulimia.¹ Women are more likely than men to suffer from bulimia, and the disorder generally appears by around age 18.¹

In general, the prevalence of eating disorders is higher in urban environments and bulimia appears to be much more common in cities than in rural areas.²

There are two subtypes of bulimia: purging bulimia and non-purging bulimia. With purging bulimia, individuals purge what they consumed by making themselves vomit or by misusing diuretics, laxatives, or enemas. Someone who suffers from non-purging bulimia may try to get rid of the food and calories with excessive exercise, fasting, or unhealthy dieting.³

Bulimia is a serious and potentially life-threatening condition. It may be difficult to recognize, as individuals can maintain a typical body weight, unlike those who suffer from other eating disorders, such as anorexia, for example.² Since bulimia does not just involve unhealthy relationships with food, but also negative body image and low self-esteem, treatment should address healthy eating patterns as well as improvement of self-image. This could include establishing a daily routine, self-monitoring using a food journal, developing structured meal times, ensuring the availability of nutritious and “safe” foods, and limiting exposure to triggers for bingeing or purging.²

Rates and Characteristics of Co-Occurring Bulimia and Addiction

Results of the National Comorbidity Survey Replication study suggest the following lifetime co-occurrence estimates:⁴

• Bulimia co-occurring with alcohol use or dependence is 33.7%.
• Bulimia co-occurring with illicit drug abuse or dependence is 26%.
• Bulimia co-occurring with any substance use disorder is 36.8%

Recent research suggests substance abuse is present in nearly 30-70% of adults with bulimia.⁵

The National Eating Disorders Association (NEDA) reports that individuals battling bulimia and other eating disorders most frequently abuse alcohol, laxatives, emetics, diuretics, amphetamines, heroin, and cocaine.⁶ Dieting and purging are frequently associated with the use of cocaine and other stimulants.²

NEDA also estimates that approximately 37% of individuals with bulimia also have a substance use disorder.⁶ Compared to bulimic women who are not also alcohol dependent, bulimic women who were alcohol-dependent reported a higher rate of suicide attempts, anxiety, personality and conduct disorders and other drug dependence.⁶

There has been limited scientific research examining substance use in adolescents with eating disorders. An estimated two thirds of teens with bulimia report using alcohol.⁵ Another third have used illegal drugs at least once, with marijuana being the most common, followed by cocaine and amphetamines.⁵ Adolescent girls with symptoms of bulimia symptoms (i.e., binge eating/purging behavior) had higher rates of substance use than those who were simply restricting food intake (i.e., dieting).⁵ Furthermore, 30% of girls with bulimia reported that they were smoking cigarettes, using marijuana, and drinking alcohol at least weekly.⁵

Adolescents and adults with eating disorders such as bulimia typically use substances to relieve anger, avoid eating, or to “get away” and relax.⁵

Shared risk factors of both eating disorders and substance abuse include:⁶

• Brain chemistry.
• Family history of eating disorder and/or substance abuse.
• Low self-esteem.
• Depression.
• Anxiety.
• Social pressures.

Social (i.e., peer) pressure can lead individuals to abuse substances as well as be highly sensitive to their weight and attempt to meet unrealistic body size and shape goals. High levels of stress and anxiety may induce a person to try and regain some semblance of control, which may be temporarily mitigated by substance abuse or by bingeing and purging.^2,3

Bulimia can lead to many health issues from the cycle of binge eating and then subsequent purging. These can include:^2,7

• Dehydration from fluid purging, which can lead to kidney failure.
• An imbalance of electrolytes, such as potassium, sodium, and chloride which can lead to irregular heartbeats and possibly heart failure.
• Stomach rupture due to binge eating.
• Rupture of the esophagus due to frequent vomiting.
• Swelling of salivary glands under the jaw and in front of the ears.
• Chronic sore and inflamed throat causing hoarse voice.
• Gastrointestinal issues and acid reflux.
• Intestinal irritation and issues related to misuse of laxatives.
• Pancreatitis, marked by pain, nausea and vomiting.

Menstrual irregularity, constipation and reproductive problems are additional health risks raised by bulimia.²

Social isolation, secrecy, and denial are often hallmarks of both bulimia and addiction, and it may be difficult for a person suffering from both disorders to admit when there’s a problem and seek help.² Likewise, substance use treatment professionals find screening for bulimia and other eating disorders to be complex, because signs and symptoms of eating disorders can overlap with those of substance abuse. Examples of overlapping symptoms include weight loss, lethargy, changes in eating habits and depressed mood.³

Treatment programs for substance use disorders haven’t always been able to adequately manage co-occurring eating disorders and vice versa.⁸ However, as the prevalence of comorbidity has come to light, integrated treatment strategies have been developed.

By treating both disorders at the same time, a multi-disciplinary team of medical, substance abuse, and mental health professionals can employ various psychosocial, behavioral, and pharmacological interventions to minimize relapse and enhance recovery.^1,2

References

1. National Institute of Mental Health. (2017). Eating Disorders.
2. Miller, S. C., Fiellin, D. A., Rosenthal, R. N., & Saitz, R. (2019). The ASAM Principles of Addiction Medicine, Sixth Edition. Philadelphia: Wolters Kluwer.
3. Substance Abuse and Mental Health Services Administration. (2011). Clients with Substance Use and Eating Disorders
4. Hudson, J. I., Hiripi, E., Pope, H. G., Jr, & Kessler, R. C. (2007). The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biological Psychiatry, 61(3), 348–358.
5. Mann, A. P., Accurso, E. C., Stiles-Shields, C., Capra, L., Labuschagne, Z., Karnik, N. S., & Le Grange, D. (2014). Factors associated with substance use in adolescents with eating disorders. The Journal of Adolescent Health: Official Publication of the Society for Adolescent Medicine, 55(2), 182–187.
6. National Eating Disorder Association. (2018). Eating Disorders and Substance Abuse Infographic.
7. National Eating Disorder Association. (2018). Health Consequences.
8. Center on Addiction. (2003). Food for Thought: Substance Abuse and Eating Disorders.