Comorbidity of Bulimia Nervosa and Substance Abuse: Etiologies, Treatment Issues, and Treatment Approaches

Article excerpt

Recently the comorbidity of substance abuse and eating disorders has become a concern. Treating these disorders is particularly important for bulimia nervosa, which is characterized by "binge eating and inappropriate compensatory methods to prevent weight gain" (American Psychiatric Association, 2000, p. 589). In this article we explore common pathways to the development of bulimia nervosa and substance abase, how treatment is begun, and treatment options (cognitive behavioral therapy/coping skills training and dialectical behavioral therapy). A case study shows the application of coping skills training and dialectical behavioral therapy in clinical practice.


An important area of concern for mental health counselors is effective treatment of substance abuse in the presence of co-occurring conditions like personality, mood, and thought disorders (Accordino, Keat, & Guerney, 2003; Caton et al., 2006; Holdcraft, Iacono, & McGue, 1998; Linton, 2005). Recently the comorbidity of substance abuse and eating disorders has become a particular concern. Substance abuse and eating disorders have the highest mortality risks of all mental disorders (Harris & Barraclough, 1998), and half of all clients with eating disorders abuse alcohol or illicit drugs (Center on Addiction and Substance Abuse [CASA], 2004). Given the rate of co-occurrence of these two potentially deadly conditions, effective treatment is essential.

Characterized by "binge eating and inappropriate compensatory methods to prevent weight gain" (American Psychiatric Association, 1994, p. 589), bulimia nervosa co-occurs with alcohol use disorders in 18%-50% of those affected (Bulik & Sullivan, 1993; Daniels, Masheb, Berman, Mickely, & Grilo, 1998). Because these disorders co-occur so often (Herzog, Franko, Dorer, Keel, Jackson, & Marnzo., 2006; Holderness, Brooks-Gunn, & Warren, 1994), identifying the reasons for their comorbidity could be beneficial in exploring treatment options.

Common Etiologies of the Disorders

According to the literature, psychological, environmental, and biological mechanisms are all factors in the linkage of bulimia and substance abuse (Holderness et al., 1994). For example, those affected might be more impulsive or more easily able to develop an addiction, or might live in family environments conducive to the development of both disorders.

While the literature does not provide a clear explanation for the relation between bulimia and substance abuse, there are several hypotheses, which Wolfe and Maisto (2000) categorized as hypotheses of either shared etiology or causal etiology. Each contains indicators, such as family history or self-medication tendencies, that may help clarify how the disorders are connected.

Shared Etiologies

Shared etiology hypotheses view the relation between the disorders as the result of a common predisposition (i.e., risk factors common to the development of both bulimia and substance abuse). Such shared etiological factors include specific personality type, common family history, similar developmental issues, and specific biological vulnerability (Baker, Mazzeo, & Kendler, 2007).

Specific personality type is key to the shared etiology hypothesis because both diagnoses share addiction traits that may be related to personality (Baker et al., 2007). For example, personality traits common to persons with bulimia and substance abuse are lack of control, craving, and denial (Pearlstein, 2002). In research that has identified eating disorder personality subtypes, one subtype, behaviorally dysregulated, was found to have a tendency to abuse substances (Thompson-Brenner, Eddy, Franko, Dorer, Vashchenko, & Herzog, 2008). The behaviorally dysregulated subtype displays social anxiety and hypersensitivity; shows impulsivity or unpredictability in at least two areas that are self-damaging; has a desire for affection and acceptance; engages in physically self-damaging acts; is prone to suicidal threats, gestures, or attempts; and displays antisocial behavior. …