Relationship Between Alcohol Use and Eating Disorder Purging
Patients with bulimia nervosa and other eating disorders involving purging behaviors have significantly higher rates of alcohol use and alcohol-related problems compared to those with restrictive eating disorders, with the combination of binge eating and purging representing the highest risk profile for problematic alcohol use.
Evidence of the Association
Purging Behaviors Strongly Predict Alcohol Use
Patients with bulimia nervosa use alcohol and other substances at significantly higher frequencies compared to those with anorexia nervosa-restricting type, binge eating disorder, and other eating disorder presentations 1
Patients with anorexia nervosa-binge eating/purging type are dramatically more likely to use alcohol and substances than those with restricting type, with an odds ratio of 3.58 for alcohol use and 30.14 for substance use 1
Higher frequencies of both binge eating and purging behaviors are directly associated with higher frequencies of substance use, creating a dose-response relationship 1
Severity and Consequences
Female college students who purge report both more frequent alcohol consumption and significantly more negative alcohol-related consequences than matched controls without purging behaviors 2
Among college women with eating disorders, those with bulimia nervosa and binge eating disorder are significantly more likely to endorse using alcohol as a coping mechanism for negative affect, compared to non-eating disordered controls 3
The binge eating disorder group specifically reports greater weekend alcohol consumption and higher rates of binge drinking than other eating disorder presentations 3
Clinical Mechanism and Risk Profile
Distinct Subgroups Within Eating Disorders
Restricting anorexics, binge eaters, and bulimics represent distinct subgroups within the eating disorder population, with binge eaters and bulimics being substantially more prone to alcohol use 4
Restricting anorexics demonstrate low rates of comorbid substance abuse, in stark contrast to those with binge-purge behaviors 4
Binge Eating as Independent Risk Factor
Within disordered eating symptoms, binge eating appears as an independent determinant of binge drinking severity, but purging behaviors themselves do not independently predict alcohol use severity when controlling for binge eating 5
This suggests binge eating may represent a general vulnerability factor for emotional dysregulation that is shared across behavioral and addictive disorders 5
Assessment Implications
Screening Requirements
The American Academy of Pediatrics recommends determining types and frequency of purging behaviors (vomiting, laxatives, starvation) as part of the initial evaluation to establish baseline severity 6, 7
Screening for comorbid psychiatric conditions including depression, anxiety, and obsessive-compulsive disorder is crucial, as these often co-occur with both eating disorders and substance use 6, 7
History of physical or sexual abuse and suicidal ideation should be assessed, as these factors may exacerbate both eating disorder symptoms and substance use 6
High-Risk Behaviors
Among bulimic adolescents, substance use is related to increased likelihood of high-risk behaviors including attempted suicide, stealing, and risky sexual behavior 4
Some negative consequences of alcohol use in purging patients are severe and require immediate attention 2
Treatment Considerations
Integrated Approach Required
Patients who manifest both binge eating and purging behavior are at higher risk of substance use, which has important treatment implications requiring concurrent management 1
Cognitive-behavioral therapy has been effective in treating alcohol use and eating disorders individually and may be an effective combined treatment for comorbid presentations 4
Opioid antagonists such as naltrexone may be useful in treating both eating and alcohol use disorders, as both may share underlying neurobiological mechanisms 4
Serotonin reuptake inhibitors may be effective treatment for comorbid presentations, given their efficacy in both conditions 4
Hospitalization Criteria
The American Psychiatric Association recommends hospitalization for patients who cannot control compulsive purging behaviors despite outpatient interventions 8
Severe comorbid psychiatric conditions including depression and anxiety that impair ability to participate in outpatient treatment warrant hospitalization 8
Common Pitfalls
Do not assume that restricting eating disorder patients have the same alcohol use risk as those with binge-purge presentations - the risk profiles are dramatically different, with purging behaviors conferring substantially higher risk 1, 4
Do not assess only alcohol consumption quantity without evaluating negative consequences - patients with purging behaviors may experience severe negative consequences even at lower consumption levels 2
Do not overlook alcohol use as a maladaptive coping mechanism - individuals with eating disorders may turn to alcohol use as a way of coping with problems caused by their eating disorder, similar to how they use binge eating to regulate negative affect 4, 3
Do not delay assessment of substance use when purging behaviors are present - the combination represents a high-risk profile requiring immediate comprehensive evaluation 1