Among all the mental disorders, both eating disorders and substance abuse disorders are associated with the highest risk of mortality. When both disorders coexist, the stage may be set for a particularly dangerous course.

Until recently, little had been written about the effects of one condition upon the other, according to Dr. Debra L. Franko and her colleagues at the Harvard Eating Disorders Center in Boston (Int J Eat Disord 2005; 38:200).

Study design

In a prospective study, Dr. Franko and co-workers studied 136 women diagnosed with anorexia nervosa (AN) and 110 women diagnosed with bulimia nervosa (BN). The women were tested for signs of alcoholism, or alcohol use disorders (AUD) every 6 to 12 months for up to 9 years. After a brief telephone screening, individuals who met study criteria were scheduled for an in-person interview with a trained research assistant. The research assistants confirmed the present of full-syndrome eating disorders and assessed subjects for current or lifetime psychiatric disorders. Every six months thereafter, the women were assessed with the Eating Disorders with the Longitudinal Interval Follow-up Evaluation (LIFE-EAT-II); these interviews were conducted in person whenever possible. The LIFE-EAT II is a semi-structured interview that assesses eating disorders symptoms (such as binge eating, compulsive exercise, etc.), comorbid psychopathology, treatment received, and psychosocial functioning.

At each follow-up interview, the participants were also asked about how often they drank alcohol and any potential alcohol misuse since the previous interview. If a subject reported going through a period when she believed she drank too much or had a family member or others object to her drinking or was unable to stop drinking when they wanted since the last interview, she was assessed for AUD. The subject met the criteria for AUD when she reported three or more of the symptoms (see Table 1) for at least 4 weeks.

Alcoholism affected a quarter of subjects

When the study began, 42 (17%) of the women reported a history of AUD. Eleven of the women with a history of AUD before entering the study developed a new episode of AUD during the study. By 9 years of follow-up, 24 of those with no history at intake had developed AUD, resulting in a total of 66, or 27%, reporting a lifetime history of AUD. Of these 66 women, 33 had AN and 33 had BN.

Although AUD did not predict or influence recovery from symptoms of an eating disorder, a number of eating disorder symptoms did predict both the onset and recovery from an episode of AUD. Unique predictors for AUD among women with AN were depression, overconcern with body image, and vomiting. Recovery from AUD was improved by group therapy and hospitalization for women with AN and by individual therapy and exercise for women with BN.

For patients with AN and BN, hospitalization shortened the time to recovery, suggesting that intensive treatment in a hospital setting is useful. The authors also found that both inpatient teams and outpatient clinicians could effectively treat alcohol problems in this group. Problems with alcohol did not appear to impede recovery from the eating disorder.

Because the combination of alcoholism and eating disorders appears to be potentially dangerous or even deadly, patients with both disorders should be treated aggressively, according to the authors.

Table 1. Criteria for Alcohol Use Disorder Subject thinks she drinks too much. Others complain about her drinking. She admits she often can’t stop drinking even when she wants to. Frequent drinking before breakfast. Frequently missed work, had impaired performance on the job or unable to take care of household responsibilities. Job loss—drinking was the primary reason for this, according to the subject. Frequently has difficulty with family members, friends, or associates because of drinking. Divorce or separation primarily caused by drinking, according to the subject. Alcoholic benders (on 3 or more occasions drank steadily for 3 or more days). Physical violence associated with drinking on at least 2 occasions. Traffic difficulties due to drinking (e.g., reckless droving, accidents, or speeding). Picked up by police due to behavior associated with drinking (other than traffic difficulties, as above). Frequent blackouts (memory loss for events that occurred while conscious during drinking episodes), Frequent tremors most likely due to drinking. Delirium tremens Hallucinations after stopping drinking on at least 2 occasions. Withdrawal seizures in a non-epileptic person, limited to periods when she stopped drinking. Cirrhosis, gastritis, or pancreatitis attributed to alcohol, verified by a physician. Polyneuropathy most likely due to drinking. A diagnosis of Korsakoff syndrome (confusion and severe memory loss, especially for recent events; patients often make up stories to compensate for this).