British Journal of Addiction (1992) 87, 913-920
RESEARCH REPORT
Eating disorders and alcohol abuse in women DAVID S. GOLDBLOOM, CLAUDIO A. NARANJO,' KAREN E. BREMNERi & LISA K. HICKS Department of Psychiatry, The Toronto Hospital; and • Clinical Pharmacology Program, Addiction Research Foundation, Departments of Psychiatry, Pharmacology, and Medicine, University of Toronto, Canada
Abstract Theory and empircal evidence support a relationship between the eating disorders (anorexia nervosa and bulimia nervosa) and alcoholism. This study examines the co-prevalence and characteristics of these disorders among two populations of adult women: those presenting for treatment of alcoholism and those referred to a specialized eating disorders programme. Twenty-two of 73 females (30.1%) with alcohol problems met psychometric cut-off scores for eating disorder, while 25 of the 96 eating disorder females (26.9%) gave psychometric evidence of alcohol dependence. These rates exceed general population norms. While certain clinical and psychometric features distinguish subgroups with both disorders, the basis for co-prevalence and the implications for treatment are unknown.
Introduction In the last decade, research on the eating disorders anorexia nervosa (AN) and bulimia nervosa (BN) has included not only the distinctive characterizations of these illnesses but also their links with other psychiatric disturbances, including alcoholism and mood disorders. While this linkage carries the risk of reductionism, it also allows investigation of dimensional rather than categorical abnormalities and recognizes the co-morbidity that exists among eating disordered or alcholic patients and their families. At a theoretical level, Szmukler and Tantum parallel the development and progression of eating disorders and alcohol abuse from a model of dependency.' In this paradigm, dieting and drinking are behaviours normally under conscious and mod' Address correspondence to: David S. Goldbloom, Eaton 8N-219, The Toronto Hospital, 200 Elizabeth Street, Toronto, Ontario, Canada M5G 2C4.
erate control that anorexics and alcoholics practice to uncontrollable excess. These behaviours become desired sources of tension relief and control despite some initial discomfort. Cognitive and behavioural preoccupation and subjective awareness of the compulsion are common to both disorders. Increased tolerance to the behaviours develops and attempts at cessation are met with withdrawal symptoms such as distress. Serious psychosocial and physiological sequelae occur, and the development of dependence occurs only in a minority of individuals exposed to drinking or dieting behaviour. At a psychodynamic level, Brisman and Siegel compare BN and alcoholism.^ Individuals with these disorders are seen as developmentally deficient in ego functions such as self-protection (signal anxiety, self-soothing) and affect regulation. Food and alcohol are used in pathological attempts to minimize the distress and sense of incompleteness associated with such deficits. Later development of
913
914
David S. Goldbloom et al.
the other disorder is viewed as symptom substitution. At a biological level, a theoretical link exists between alcoholism and both AN and BN with regard to disturbed hypothalamic neuroregulation of consummatory behaviour. Recent attention has focused on the brain neurotransmitter serotonin (5HT) in both alcoholism' and eating disorders,'*'' and their clinical expression may reflect the cultural shaping of a common biological diathesis. Further, drugs that increase brain serotonin activity may reduce aberrant drinking and eating behaviour.'"' What is the empirical evidence thus far for comorbidity? Clinical observations over 20 years ago noted a vulnerability to alcoholism among patients with AN who included binge eating and vomiting in their behavioural repertoire.' A more systematic evaluation of 105 AN patients generated a prevalence rate of 6.7% for alcohol abuse and dependence.' A smaller study of 15 AN patients using alcoholism self-report measures showed 33% of subjects scoring 'likely' for alcoholism.'" A vulnerability to substance abuse has been noted in all clinical descriptions of BN since its initial characterization in 1979."''^ Large surveys of bulimic behaviours and alcohol use have shown considerable overlap in prevalence'^'*'' and controlled studies have revealed increased prevalence of alcohol abuse and dependence in women with BN," with rates of 48.6 and 22.9%, respectively. Familial vulnerability to alcoholism among BN probands is an important reflection of a diathesis that generates co-morbidity. Chart reviews of family history of alcoholism in patients with both BN and AN led to a 21.9% prevalence rate for alcoholism in adult first-degree male relatives.'* More rigorous studies employing structured family history interviews have generated prevalence rates of 12.8-60% for alcoholism among the relatives of BN probands."'"'" Further, a study of identified adult children of alcoholics revealed that 29% of the 106 subjects met DSM-III" criteria for bulimia by using a semi-structured interview.^" The prevalence of eating disorders in a population identified for alcoholism has only recently attracted attention. Twenty consecutive female referrals to an alcoholism treatment unit were evaluated and 25% gave a history of DSM-III bulimia while 10% had previously experienced AN,^' with the eating disorder typically preceding the alcohol abuse. A second survey of 27 female alcoholics reported binge eating in 40% of the e.^^ A more recent and rigorous study of 31
women in treatment for alcoholism using self-report questionnaires revealed a 'probable' diagnosis of AN in 7%, BN in 7%, and a further 14% with variants of BN^' according to DSM-III-R diagnostic criteria.^'' Many of these studies have suffered methodological limitations with regard to sample size and inadequate psychometric and clinical evaluation. There has been little consideration of associated psychopathology or other disturbances to further characterize that subpopulation which is vulnerable to development of both alcoholism and an eating disorder. We report parallel surveys of the co-prevalence of alcoholism and eating disorders among women referred to specialized treatment centres for either disorder in Toronto.
Methods These surveys were carried out simultaneously at the Program for Eating Disorders, The Toronto Hospital, and the Addiction Research Foundation. The surveys were approved by the ethics committees of both clinical facilities and all subjects provided written informed consent for their participation.
Survey A One hundred consecutive females referred to the Program for Eating Disorders, The Toronto Hospital, for assessment of eating difficulties participated in this study. In addition to clinical semi-structured evaluations by psychiatrists with expertise in eating disorders, all subjects completed a psychometric battery of measures of eating and alcohol problems. Demographic, weight, and family history data were also collected.
Survey B Eighty-three females, aged 19-45 years, who were seeking treatment for alcohol-related problems and did not abuse other psychoactive substances, were recruited for this study from various treatment programmes at the Addiction Research Foundation. Psychometric data identical to that in Survey A was collected with regard to eating and alcohol problems. Results of both surveys led to appropriate clinical referrals when indicated.
Eating disorders and alcohol abuse
915
Table 1. Survey A (a = 96): current clinical eating disorder diagnoses Anorexia nervosa Anorexia nervosa and bulimia nervosa Bulimia nervosa Eating disorder not otherwise specified EAT-26 total scores
Measures Eating disorder pathology was gauged by the 26-item version of the Eating Attitudes Test (EAT26),^' as well as the Eating Disorder Inventory (EDI).^' In addition to a semi-structured clinical interview, further personal and family data relevant to eating disorders were collected via the Diagnostic Survey of Eating Disorders (DSED)." Alcoholrelated pathology was measured by the Recent Drinking History Form,^' which is intervieweradministered, as well as two established self-report measures: the Michigan Alcoholism Screening Test (MAST)" and the Alcohol Dependence Scale (ADS).'" Student's f-tests and x^ tests were used within each survey to differentiate subgroups.
Results Survey A Of the 100 female patients referred for evaluation of a possible eating disorder and assessed in this survey, four subjects were excluded from data analysis for the following reasons: no clinical evidence of eating disorder, age greater than 45 years, or missing clinical or psychometric data. The mean age of the remaining 96 subjects was 25 years (SEM = 0.5). The clinical eating disorder diagnoses and mean EAT scores are summarized in Table 1. Further clinical description of the sample indicated that self-harm (29%) or suicide attempts (26%), stealing (45.8%), and cigarette smoking (49%) were common behaviours in this group. The Recent Drinking History Form evaluated alcohol intake in the 3 months preceding the interview. Using a cut-off of an average of five or more drinks per day, 3.1% of the sample was identified as having recent alcohol difficulties. However, this measure also revealed that 16.7% of the sample had drunk 10 or more drinks on at least one day in the preceding 3 months and that 27.1% of the sample recalled a period of at least 28 drinks per week in the past. Using an accepted cut-off score of > 6 , the MAST identified 12.5% of the sample as
8.3% 14.6% 71.9% 5.2% 36.2 ± 1.5 (x + SEM)
having problems with alcohol. The ADS, using an accepted cut-off score of > 13, labelled 26.9% of the sample as having features of alcohol dependence. The alcoholic subgroup of eating disorder patients, as identified with the ADS, was compared with the ADS-negative subgroup in terms of current clinical diagnosis and related clinical and psychometric features (Table 2). They were also compared with regard to family history as assessed by selfreport on the DSED (Table 3). The only significant differences that emerged were in higher rates of stealing food and a family history of drug abuse among the ADS-positive eating disorder subjects.
Survey B Of the 83 women seeking treatment for problems related to alcohol consumption who were assessed in this survey, 10 subjects were excluded from data analysis because their MAST scores were below the cut-off of six, indicating less than clear evidence of such problems. The mean age of the remaining 73 subjects was 30.3 years (SEM = 0.9). These 73 subjects were then divided into subgroups on the basis of alcohol dependence (low versus moderate-to-severe), as refiected by the ADS (Table 4), or eating disorder pathology, as refiected by an EAT-26 total score of S=20 (Table 5). Among subjects with ADS-defined moderate-to-severe dependence on alcohol, there were greater problems around oral control, interoceptive awareness, and maturity fears as refiected by the EAT and the EDI (Table 4). Twenty-two of the 73 subjects met or surpassed the EAT-26 cut-off score but only four accepted or complied with referral for clinical evaluation by an eating disorders specialist; three had clinical diagnoses of BN and one had an eating disorder not otherwise specified. This subgroup (n = 22) of alcohol-dependent women with psychometric disturbance in eating attitudes and behaviours also displayed significantly greater disturbances in the principal alcoholism measures than those women free of eating disorder pathology (Table 5). Of note, the two subgroups were
916
David S. Goldbloom et al. Table 2. Subgroups of eating disorder patients: clinical and psychometric features
Clinical diagnosis Anorexia nervosa Anorexia nervosa and bulimia nervosa Bulimia nervosa Eating disorder not otherwise specified Clinical features Suicide attempt Self-harm attempt Stealing Food Other Psychometric features EAT-26: total (x + SEM) Factor 1: dieting Factor 2: bulimia Factor 3: oral control EDI subscales (x + SEM) Drive for thinness Bulimia Body dissatisfaction
Table 3. Subgroups of eating disorder patients; family history of psychiatric disorder ADS-positive (« = 25)
ADS-negative ^"(%)''^
Depression Alcoholism Drug abuse Anorexia nervosa Bulimia nervosa Suicide
63.2 35.7 33.3 9.1 9.1 15.4
51.2 39.0 9.1* 6.3 6.5 11.4
p < 0.05. indistinguishable on the basis of body mass index (BMI) (kg/m^) despite psychometric differences with regard to attitudes toward weight and shape.
Discussion At the outset, these psychometric surveys provide evidence for significant co-prevalence of eating and alcohol use pathology in samples of young adult women identified primarily for either disorder. The ADS identified 26.9% of an eating disorder sample as having features of alcohol dependence, while the EAT-26 identified 30.1% of a sample with problems related to alcohol use as endorsing the psychopathological features characteristic of eating disorders.
ADS-positive (« = 25)
ADS-negative (« = 71)
8.0% 16.0% 76.0% 0 %
6.2% 13.8% 73.8% 6.2%
28.0% 44.0%
24.6% 26.2%
60.0% 64.0%
24.6%* 42.6%
35.8 ± 21.3 ± 10.5 ± 3.5 ±
2.4 1.6 1.0 0.6
14.3 ± 1.1 10.8 ± 1.2 17.4 ± 1.4
37.1 21.9 10.7 4.4
± ± ± ±
1.8 1.2 0.6 0.6
15.0 + 0.7 11.0 ± 0 . 8 17.7 ± 1.0
In the eating disorder sample, the only features that distinguished the alcohol-prone subgroup were a past history of stealing and a family history of drug abuse. A recent survey of stealing behaviour among 181 consecutive eating disorder subjects indicated a prevalence rate of 28.2%; this stealing subgroup had mean MAST scores of 8.3 ± 2.0 versus a mean of 5.1 ± 0.9 among non-stealing eating disorder subjects.^' While this difference was not statistically significant it is noteworthy that the mean MAST scores for the stealing subgroup exceeded the cutoff score for the MAST used in our study, while that of the other subgroup did not. High familial rates of substance abuse have previously been identified among eating disorder probands." In the alcohol use sample, moderate-to-severe alcohol dependence as defined by the ADS was associated with greater difficulty around oral control as reflected by the EAT-26 and heightened maturity fears and problems with interoceptive awareness as indicated by the EDI (Table 4). Further, the presence of eating pathology was associated with more severe problems with alcohol use as reflected by increased MAST and ADS scores (Table 5). Methodological limitations to these surveys must be acknowledged. Neither survey used a control group, although normative data exist for all the principal measures used in this study. The ADS has been tested among women aged 18-45 years pre-
Eating disorders and alcohol abuse
917
Table 4. Subgroups of alcohol patients (ii = 73) ADS-positive (« = 60) ADS MAST EAT-26 Factor 1: dieting Factor 2: bulimia Factor 3: oral control EDI subscales Drive for thinness Bulimia Body dissatisfaction Maturity fears Interoceptive awareness
ADS-negative (" == 13) X SEM
X
SBM
27.6 15.3
1.1 0.5
10.2 10.0
0.5** 0.8**
10.9 2.6 4.1
1.1 0.5 0.6
7.8 1.3 1.7
2.0 0.8 0.5**
8.7 4.0 13.9 5.2 9.4
0.9 0.6 1.1 0.6 1.1
6.8 1.8 11.1 2.3 3.9
1.6 0.8 2.4 0.5** 1.9*
*/>
RESEARCH REPORT
Eating disorders and alcohol abuse in women DAVID S. GOLDBLOOM, CLAUDIO A. NARANJO,' KAREN E. BREMNERi & LISA K. HICKS Department of Psychiatry, The Toronto Hospital; and • Clinical Pharmacology Program, Addiction Research Foundation, Departments of Psychiatry, Pharmacology, and Medicine, University of Toronto, Canada
Abstract Theory and empircal evidence support a relationship between the eating disorders (anorexia nervosa and bulimia nervosa) and alcoholism. This study examines the co-prevalence and characteristics of these disorders among two populations of adult women: those presenting for treatment of alcoholism and those referred to a specialized eating disorders programme. Twenty-two of 73 females (30.1%) with alcohol problems met psychometric cut-off scores for eating disorder, while 25 of the 96 eating disorder females (26.9%) gave psychometric evidence of alcohol dependence. These rates exceed general population norms. While certain clinical and psychometric features distinguish subgroups with both disorders, the basis for co-prevalence and the implications for treatment are unknown.
Introduction In the last decade, research on the eating disorders anorexia nervosa (AN) and bulimia nervosa (BN) has included not only the distinctive characterizations of these illnesses but also their links with other psychiatric disturbances, including alcoholism and mood disorders. While this linkage carries the risk of reductionism, it also allows investigation of dimensional rather than categorical abnormalities and recognizes the co-morbidity that exists among eating disordered or alcholic patients and their families. At a theoretical level, Szmukler and Tantum parallel the development and progression of eating disorders and alcohol abuse from a model of dependency.' In this paradigm, dieting and drinking are behaviours normally under conscious and mod' Address correspondence to: David S. Goldbloom, Eaton 8N-219, The Toronto Hospital, 200 Elizabeth Street, Toronto, Ontario, Canada M5G 2C4.
erate control that anorexics and alcoholics practice to uncontrollable excess. These behaviours become desired sources of tension relief and control despite some initial discomfort. Cognitive and behavioural preoccupation and subjective awareness of the compulsion are common to both disorders. Increased tolerance to the behaviours develops and attempts at cessation are met with withdrawal symptoms such as distress. Serious psychosocial and physiological sequelae occur, and the development of dependence occurs only in a minority of individuals exposed to drinking or dieting behaviour. At a psychodynamic level, Brisman and Siegel compare BN and alcoholism.^ Individuals with these disorders are seen as developmentally deficient in ego functions such as self-protection (signal anxiety, self-soothing) and affect regulation. Food and alcohol are used in pathological attempts to minimize the distress and sense of incompleteness associated with such deficits. Later development of
913
914
David S. Goldbloom et al.
the other disorder is viewed as symptom substitution. At a biological level, a theoretical link exists between alcoholism and both AN and BN with regard to disturbed hypothalamic neuroregulation of consummatory behaviour. Recent attention has focused on the brain neurotransmitter serotonin (5HT) in both alcoholism' and eating disorders,'*'' and their clinical expression may reflect the cultural shaping of a common biological diathesis. Further, drugs that increase brain serotonin activity may reduce aberrant drinking and eating behaviour.'"' What is the empirical evidence thus far for comorbidity? Clinical observations over 20 years ago noted a vulnerability to alcoholism among patients with AN who included binge eating and vomiting in their behavioural repertoire.' A more systematic evaluation of 105 AN patients generated a prevalence rate of 6.7% for alcohol abuse and dependence.' A smaller study of 15 AN patients using alcoholism self-report measures showed 33% of subjects scoring 'likely' for alcoholism.'" A vulnerability to substance abuse has been noted in all clinical descriptions of BN since its initial characterization in 1979."''^ Large surveys of bulimic behaviours and alcohol use have shown considerable overlap in prevalence'^'*'' and controlled studies have revealed increased prevalence of alcohol abuse and dependence in women with BN," with rates of 48.6 and 22.9%, respectively. Familial vulnerability to alcoholism among BN probands is an important reflection of a diathesis that generates co-morbidity. Chart reviews of family history of alcoholism in patients with both BN and AN led to a 21.9% prevalence rate for alcoholism in adult first-degree male relatives.'* More rigorous studies employing structured family history interviews have generated prevalence rates of 12.8-60% for alcoholism among the relatives of BN probands."'"'" Further, a study of identified adult children of alcoholics revealed that 29% of the 106 subjects met DSM-III" criteria for bulimia by using a semi-structured interview.^" The prevalence of eating disorders in a population identified for alcoholism has only recently attracted attention. Twenty consecutive female referrals to an alcoholism treatment unit were evaluated and 25% gave a history of DSM-III bulimia while 10% had previously experienced AN,^' with the eating disorder typically preceding the alcohol abuse. A second survey of 27 female alcoholics reported binge eating in 40% of the e.^^ A more recent and rigorous study of 31
women in treatment for alcoholism using self-report questionnaires revealed a 'probable' diagnosis of AN in 7%, BN in 7%, and a further 14% with variants of BN^' according to DSM-III-R diagnostic criteria.^'' Many of these studies have suffered methodological limitations with regard to sample size and inadequate psychometric and clinical evaluation. There has been little consideration of associated psychopathology or other disturbances to further characterize that subpopulation which is vulnerable to development of both alcoholism and an eating disorder. We report parallel surveys of the co-prevalence of alcoholism and eating disorders among women referred to specialized treatment centres for either disorder in Toronto.
Methods These surveys were carried out simultaneously at the Program for Eating Disorders, The Toronto Hospital, and the Addiction Research Foundation. The surveys were approved by the ethics committees of both clinical facilities and all subjects provided written informed consent for their participation.
Survey A One hundred consecutive females referred to the Program for Eating Disorders, The Toronto Hospital, for assessment of eating difficulties participated in this study. In addition to clinical semi-structured evaluations by psychiatrists with expertise in eating disorders, all subjects completed a psychometric battery of measures of eating and alcohol problems. Demographic, weight, and family history data were also collected.
Survey B Eighty-three females, aged 19-45 years, who were seeking treatment for alcohol-related problems and did not abuse other psychoactive substances, were recruited for this study from various treatment programmes at the Addiction Research Foundation. Psychometric data identical to that in Survey A was collected with regard to eating and alcohol problems. Results of both surveys led to appropriate clinical referrals when indicated.
Eating disorders and alcohol abuse
915
Table 1. Survey A (a = 96): current clinical eating disorder diagnoses Anorexia nervosa Anorexia nervosa and bulimia nervosa Bulimia nervosa Eating disorder not otherwise specified EAT-26 total scores
Measures Eating disorder pathology was gauged by the 26-item version of the Eating Attitudes Test (EAT26),^' as well as the Eating Disorder Inventory (EDI).^' In addition to a semi-structured clinical interview, further personal and family data relevant to eating disorders were collected via the Diagnostic Survey of Eating Disorders (DSED)." Alcoholrelated pathology was measured by the Recent Drinking History Form,^' which is intervieweradministered, as well as two established self-report measures: the Michigan Alcoholism Screening Test (MAST)" and the Alcohol Dependence Scale (ADS).'" Student's f-tests and x^ tests were used within each survey to differentiate subgroups.
Results Survey A Of the 100 female patients referred for evaluation of a possible eating disorder and assessed in this survey, four subjects were excluded from data analysis for the following reasons: no clinical evidence of eating disorder, age greater than 45 years, or missing clinical or psychometric data. The mean age of the remaining 96 subjects was 25 years (SEM = 0.5). The clinical eating disorder diagnoses and mean EAT scores are summarized in Table 1. Further clinical description of the sample indicated that self-harm (29%) or suicide attempts (26%), stealing (45.8%), and cigarette smoking (49%) were common behaviours in this group. The Recent Drinking History Form evaluated alcohol intake in the 3 months preceding the interview. Using a cut-off of an average of five or more drinks per day, 3.1% of the sample was identified as having recent alcohol difficulties. However, this measure also revealed that 16.7% of the sample had drunk 10 or more drinks on at least one day in the preceding 3 months and that 27.1% of the sample recalled a period of at least 28 drinks per week in the past. Using an accepted cut-off score of > 6 , the MAST identified 12.5% of the sample as
8.3% 14.6% 71.9% 5.2% 36.2 ± 1.5 (x + SEM)
having problems with alcohol. The ADS, using an accepted cut-off score of > 13, labelled 26.9% of the sample as having features of alcohol dependence. The alcoholic subgroup of eating disorder patients, as identified with the ADS, was compared with the ADS-negative subgroup in terms of current clinical diagnosis and related clinical and psychometric features (Table 2). They were also compared with regard to family history as assessed by selfreport on the DSED (Table 3). The only significant differences that emerged were in higher rates of stealing food and a family history of drug abuse among the ADS-positive eating disorder subjects.
Survey B Of the 83 women seeking treatment for problems related to alcohol consumption who were assessed in this survey, 10 subjects were excluded from data analysis because their MAST scores were below the cut-off of six, indicating less than clear evidence of such problems. The mean age of the remaining 73 subjects was 30.3 years (SEM = 0.9). These 73 subjects were then divided into subgroups on the basis of alcohol dependence (low versus moderate-to-severe), as refiected by the ADS (Table 4), or eating disorder pathology, as refiected by an EAT-26 total score of S=20 (Table 5). Among subjects with ADS-defined moderate-to-severe dependence on alcohol, there were greater problems around oral control, interoceptive awareness, and maturity fears as refiected by the EAT and the EDI (Table 4). Twenty-two of the 73 subjects met or surpassed the EAT-26 cut-off score but only four accepted or complied with referral for clinical evaluation by an eating disorders specialist; three had clinical diagnoses of BN and one had an eating disorder not otherwise specified. This subgroup (n = 22) of alcohol-dependent women with psychometric disturbance in eating attitudes and behaviours also displayed significantly greater disturbances in the principal alcoholism measures than those women free of eating disorder pathology (Table 5). Of note, the two subgroups were
916
David S. Goldbloom et al. Table 2. Subgroups of eating disorder patients: clinical and psychometric features
Clinical diagnosis Anorexia nervosa Anorexia nervosa and bulimia nervosa Bulimia nervosa Eating disorder not otherwise specified Clinical features Suicide attempt Self-harm attempt Stealing Food Other Psychometric features EAT-26: total (x + SEM) Factor 1: dieting Factor 2: bulimia Factor 3: oral control EDI subscales (x + SEM) Drive for thinness Bulimia Body dissatisfaction
Table 3. Subgroups of eating disorder patients; family history of psychiatric disorder ADS-positive (« = 25)
ADS-negative ^"(%)''^
Depression Alcoholism Drug abuse Anorexia nervosa Bulimia nervosa Suicide
63.2 35.7 33.3 9.1 9.1 15.4
51.2 39.0 9.1* 6.3 6.5 11.4
p < 0.05. indistinguishable on the basis of body mass index (BMI) (kg/m^) despite psychometric differences with regard to attitudes toward weight and shape.
Discussion At the outset, these psychometric surveys provide evidence for significant co-prevalence of eating and alcohol use pathology in samples of young adult women identified primarily for either disorder. The ADS identified 26.9% of an eating disorder sample as having features of alcohol dependence, while the EAT-26 identified 30.1% of a sample with problems related to alcohol use as endorsing the psychopathological features characteristic of eating disorders.
ADS-positive (« = 25)
ADS-negative (« = 71)
8.0% 16.0% 76.0% 0 %
6.2% 13.8% 73.8% 6.2%
28.0% 44.0%
24.6% 26.2%
60.0% 64.0%
24.6%* 42.6%
35.8 ± 21.3 ± 10.5 ± 3.5 ±
2.4 1.6 1.0 0.6
14.3 ± 1.1 10.8 ± 1.2 17.4 ± 1.4
37.1 21.9 10.7 4.4
± ± ± ±
1.8 1.2 0.6 0.6
15.0 + 0.7 11.0 ± 0 . 8 17.7 ± 1.0
In the eating disorder sample, the only features that distinguished the alcohol-prone subgroup were a past history of stealing and a family history of drug abuse. A recent survey of stealing behaviour among 181 consecutive eating disorder subjects indicated a prevalence rate of 28.2%; this stealing subgroup had mean MAST scores of 8.3 ± 2.0 versus a mean of 5.1 ± 0.9 among non-stealing eating disorder subjects.^' While this difference was not statistically significant it is noteworthy that the mean MAST scores for the stealing subgroup exceeded the cutoff score for the MAST used in our study, while that of the other subgroup did not. High familial rates of substance abuse have previously been identified among eating disorder probands." In the alcohol use sample, moderate-to-severe alcohol dependence as defined by the ADS was associated with greater difficulty around oral control as reflected by the EAT-26 and heightened maturity fears and problems with interoceptive awareness as indicated by the EDI (Table 4). Further, the presence of eating pathology was associated with more severe problems with alcohol use as reflected by increased MAST and ADS scores (Table 5). Methodological limitations to these surveys must be acknowledged. Neither survey used a control group, although normative data exist for all the principal measures used in this study. The ADS has been tested among women aged 18-45 years pre-
Eating disorders and alcohol abuse
917
Table 4. Subgroups of alcohol patients (ii = 73) ADS-positive (« = 60) ADS MAST EAT-26 Factor 1: dieting Factor 2: bulimia Factor 3: oral control EDI subscales Drive for thinness Bulimia Body dissatisfaction Maturity fears Interoceptive awareness
ADS-negative (" == 13) X SEM
X
SBM
27.6 15.3
1.1 0.5
10.2 10.0
0.5** 0.8**
10.9 2.6 4.1
1.1 0.5 0.6
7.8 1.3 1.7
2.0 0.8 0.5**
8.7 4.0 13.9 5.2 9.4
0.9 0.6 1.1 0.6 1.1
6.8 1.8 11.1 2.3 3.9
1.6 0.8 2.4 0.5** 1.9*
*/>
