Substance Abuse in Women With Bulimia Nervosa

Assessment and treatment

Women with BN endure a wide range of severe and debilitating symptoms. The addition of a comorbid substance use disorder not only exacerbates medical and psychiatric complications but also hinders clinical assessment and treatment. Often, women only seek treatment for either BN or a substance use disorder. However, expertise at treatment centers tends to fall into either the addiction or eating disorder fields, but rarely both. Consequently, many treatment centers may lack the expertise to treat both disorders concurrently. The adequate assessment of these comorbid disorders, especially in younger women, who are at greater risk for both disorders, is key to planning appropriate psychoeducation and treatment strategies.

The literature examining the influence of a history of substance use disorders on treatment outcomes in women with BN is scarce, and the findings from the few studies that do exist are mixed.^9,10 Strasser and coworkers⁹ conducted a clinical trial using desipramine to treat 75 women with BN. The women with a history of substance abuse responded better to the treatment and displayed fewer eating disorder symptoms than those who did not report a history of substance abuse. More recently, a history of substance abuse was found to predict a poorer response in a sample of 120 women with BN who were treated with psychotherapy and/or medication.¹⁰

This divergence in findings in treatment outcome studies, along with the lack of research comparing treatment outcomes in women with BN with and without substance use problems, reveals the need for more research in this area. Sequential, simultaneous, and integrated strategies for women with BN and comorbid substance use disorders all exist.¹¹

Sequential treatments involve treating each disorder separately in a stepwise approach. Such treatment often improves the symptoms of the disorder being treated and, in the process, worsens the symptoms of the second disorder. For example, if BN is first treated in a woman with comorbid alcohol abuse, her eating disorder symptoms may improve; because the alcohol problem has not been addressed, however, she may consume more alcohol to self-medicate.

Simultaneous treatments address both the eating disorder and the substance use disorder at the same time. Although the 2 disorders are treated contemporaneously, treatment occurs in 2 separate tracks. Consequently, the patient may not be taught to link the 2 disorders and thus understand how they influence one another.¹¹

Courbasson and Smith¹¹ have found integrated treatment to be most effective for persons with comorbid eating and substance use disorders. This approach incorporates a single treatment that addresses both the eating disorder and the substance use disorder. Unfortunately, there is a lack of treatment outcome studies on integrated treatment and there are few integrated treatment programs.

Practitioners in outpatient practice may not have training or expertise to treat comorbid substance abuse. In these situations, clinicians should attempt to arrange for the patient to have access to specialized substance use services. In some cases, patients may need residential treatment for their substance use before being able to use outpatient services for the eating disorder effectively.

Psychotherapy—both group and individual—is beneficial for women with BN and women with substance use disorders. Cognitive-behavioral therapy (CBT), in particular, has been found to be highly effective in persons with BN and those with substance use disorders.^12,13 It might therefore be useful to incorporate CBT into treatments for women with comorbid BN and substance abuse.

Empirical data are lacking concerning the effects of specific pharmacological treatments for women with BN and comorbid substance use disorders. However, opioid antagonists have been found to decrease both binge eating and cravings for substances of abuse.¹⁴ Research suggests that SSRIs may be helpful for patients with comorbid substance use disorders and eating disorders.¹⁵

Summary

Women with BN frequently have comorbid substance use disorders. The range and occurrence of substance use problems in these women far exceed those in women with other eating disorder diagnoses and in the general population. The association between BN and substance abuse could be explained by their inherent similarities. For example, both have been described as impulsive and addictive disorders frequently associated with other comorbid Axis I and II disorders. There is a lack of research examining treatment outcomes in women with comorbid eating disorders and substance use disorders and few integrated treatment programs exist for this population.