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Challenges in understanding the co-prevalence of eating and substance use problems and responding with integrated services

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Abstract

Disordered eating and substance use problems are significant and often co-occurring mental and physical health issues facing women today (see Chapter 13 of this book). Some suggest that when these two conditions co-exist, it may reflect a more significant emotional struggle than when either problem occurs alone (Singer et al., 1993). Researchers are beginning to argue that such co-occurrence must be taken into consideration in the development of more helpful treatment strategies for women (Holderness et al., 1994). Current research, including our own (Stewart et al., 2006), has explored, and continues to explore, common triggers and underlying motivations for both issues. Findings on this topic could be helpful to identify at-risk women, and could also clarify some of the factors associated with co-prevalence, which would be useful in improving current treatments. Through a brief overview of two key studies, as well as our own recent research, this chapter examines how an understanding of the mechanisms underlying the co-occurrence of disordered eating and substance use problems in women can improve women’s health programming, both in terms of modifying existing treatments and developing preventive measures and early interventions that can help avoid the emergence of more extreme clinical problems. For the past 25 years, the frequent co-prevalence of disordered eating and substance use problems among women has been widely documented. Connections between eating problems, particularly bulimic behavior, among women and the harmful use of alcohol and other drugs have now been strongly established (Krahn, 1991; Singer et al., 1993; see also Goldbloom, 1993; Holderness et al., 1994; Sinha & O’Malley, 2000; and Wilson, 1993, for reviews). Several recent studies, including our own (Stewart et al., 2006), have investigated the possibility that binge eating and problematic substance use may be so highly co-prevalent because they reflect a common mechanism or mechanisms involving emotional regulation: namely, providing emotional rewards (e.g., fulfilling needs and desires) and/or emotional relief from psychological distress (e.g., reducing anxiety or depression).
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Chapter 29
Challenges in Understanding
the Co-prevalence of
Disordered Eating and
Substance Use Problems
and in Responding with
Integrated Services
sherry h. stewart and catrina g. brown
Disordered eating and substance use problems are significant and often co-occurring
mental and physical health issues facing women today (see Chapter 13 of this book).
Some suggest that when these two conditions co-exist, it may reflect a more significant
emotional struggle than when either problem occurs alone (Singer et al., 1993).
Researchers are beginning to argue that such co-occurrence must be taken into consid-
eration in the development of more helpful treatment strategies for women
(Holderness et al., 1994). Current research, including our own (Stewart et al., 2006),
has explored, and continues to explore, common triggers and underlying motivations
for both issues. Findings on this topic could be helpful to identify at-risk women, and
could also clarify some of the factors associated with co-prevalence, which would be
useful in improving current treatments.
Through a brief overview of two key studies, as well as our own recent research,
this chapter examines how an understanding of the mechanisms underlying the co-
occurrence of disordered eating and substance use problems in women can improve
women’s health programming, both in terms of modifying existing treatments and
developing preventive measures and early interventions that can help avoid the emer-
gence of more extreme clinical problems.
For the past 25 years, the frequent co-prevalence of disordered eating and sub-
stance use problems among women has been widely documented. Connections
between eating problems, particularly bulimic behaviour, among women and the
harmful use of alcohol and other drugs have now been strongly established (Krahn,
1991; Singer et al., 1993; see also Goldbloom, 1993; Holderness et al., 1994; Sinha &
O’Malley, 2000; and Wilson, 1993, for reviews). Several recent studies, including our
own (Stewart et al., 2006), have investigated the possibility that binge eating and prob-
lematic substance use may be so highly co-prevalent because they reflect a common
mechanism or mechanisms involving emotional regulation: namely, providing
emotional rewards (e.g., fulfilling needs and desires) and/or emotional relief from
psychological distress (e.g., reducing anxiety or depression).
Overview of Relevant Literature
Very little of the research into the underlying mechanisms contributing to the
co-prevalence of eating and alcohol use problems in women has studied this issue from
a women-centred perspective. With a few exceptions—such as Taylor et al., 1993
there is little evidence in the literature of the voices of women themselves. Among
the many results of Taylor and colleagues’ women-centred study was the suggestion
that both heavy alcohol use and binge eating in women may reflect difficulties in
regulating impulses. This finding is consistent with a common mechanism (i.e.,impul-
sivity) contributing to the co-prevalence. It is also noteworthy that the participants
in this study described their disordered eating and problem alcohol use as being
“intimately connected.
Filstead et al. (1988) examined the nature of the intimate connections between
binge eating and substance misuse in 54 people (mainly women) receiving inpatient
concurrent treatment for both disordered eating and problem substance use. They
found some evidence for common triggers for the two behaviours. Situations involv-
ing negative emotional states posed the highest risk for engaging in binge eating as well
as for engaging in substance misuse. Moreover, how often the participant reported
drinking or using other drugs when in an unpleasant emotional state significantly
predicted how often she or he reported binge eating when experiencing unpleasant
emotions. Similar evidence for common triggers for binge eating and heavy alcohol
or other drug use was found for situations involving pleasant emotional states, the
testing of personal control and interpersonal conflicts.
Two notable limitations to the Filstead et al. (1988) results must be mentioned.
First, the authors did not comment on the degree of relation between conceptually
distinct triggers for each behaviour. For example, they did not report whether there
was any relationship between substance misuse in response to pleasant emotional
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Section 5 Responding with Programs
states and binge eating in response to interpersonal conflict. Second, their sample
included both men and women, but the groups were too small to allow for reliable
gender comparisons.
Jan Baker (1998) replicated and extended this study using two samples of university
women. She found significant correlations between binge eating and frequency of
binge drinking, but only in the larger of the two samples (where n = 121; in the other
sample n = 75). She found that while binge eating emerged as primarily a coping- or
relief-motivated behaviour, binge drinking appeared to be primarily a rewarding,
socially motivated behaviour. This pattern of findings led Baker to conclude that
these behaviours seem to serve different functions. Given the typical social context
of drinking among university students (Carrigan et al., 1998), it remains to be deter-
mined whether findings would be similar in an older, non–university student sample
of women.
Our Research
methodology
Using both quantitative and qualitative methodologies, we recently conducted a study
to replicate and extend the initial findings of Filstead et al. (1988) and Baker (1998). We
investigated these issues in a sample of women receiving treatment for an alcohol
problem at one of the programs offered through Addiction Prevention and Treatment
Services at the Capital District Health Authority in Nova Scotia, and examined the
prevalence and characteristics of binge eating behaviours among these women. We
also tried to determine whether we could reliably distinguish women with alcohol
problems who self-identify as having a history of binge eating from women with
alcohol problems who do not self-identify as binge eaters. Finally, we looked for
common underlying motivations for binge eating and drinking that might help
explain their co-prevalence.
In the quantitative portion of the study, standardized questionnaires assessing
the severity and context of heavy alcohol use and binge eating were administered
to 58 women receiving alcohol treatment. All the women scored above the cutoff
point indicating likely alcoholism on the 10-item Brief Michigan Alcoholism
Screening Test (bmast) (Pokorny et al., 1972), which was included in order to
validate the women’s self-identification as problem drinkers. The women also
completed the 12-item Binge Scale (Hawkins & Clement, 1980), which was included
to identify binge eaters and to assess the severity of the behaviour. All the women
also completed the 42-item Inventory of Drinking Situations, which was used as
the measure of typical heavy drinking situations. This inventory also quantified
each woman’s degree of heavy drinking in several different categories of situations:
those where drinking might serve a “relief function (e.g., relief from conflict with
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Chapter 29 Challenges in Understanding the Co-prevalence of Disordered Eating and Substance Use Problems
others), those where it might serve more of a “reward” function (e.g., enjoying
pleasant times with others) and those where heavy drinking might be triggered by
sudden “temptations” (Annis et al., 1987; Carrigan et al., 1998; Stewart et al., 2000).
The final measure used was the Inventory of Binge Eating Situations (Baker, 1998),
which is a modified version of the 42-item Inventory of Drinking Situations. It was
used as the measure of typical binge eating situations for those women who reported
binge eating. It taps two motives for binge eating: emotional relief and emotional
reward. These two motivations for binge eating are separable but interconnected (see
Stewart et al., 2006).
quantitative findings
Self-reports of binge eating were very common in our sample: 71 per cent of the
women self-identified as binge eaters, with the very large majority of these evidencing
“severe” binge eating patterns. We also found that women with alcohol problems who
engaged in binge eating could be reliably distinguished from women with alcohol
problems who were not binge eaters. The binge eating women were younger, more like-
ly to be unemployed, more frequent drinkers and more likely to drink for emotional
relief purposes than the non-binge eaters. Like Filstead et al. (1988), we found overlap
in the circumstances prompting binge eating and drinking in those women who
engaged in both behaviours. The women who scored high on a drinking motives factor
involving relief from distress were also those who reported binge eating to relieve
emotional distress, and those women who scored high on a drinking motives factor
involving emotional reward also reported binge eating for reasons related to emotional
reward. Our results thus suggest that binge eating and heavy drinking serve similar
functions in a given woman (Stewart et al., 2006).
qualitative findings
A subsample of 28 women with alcohol use problems who participated in the quanti-
tative portion of the study were eligible (i.e., reported binge eating) and agreed to par-
ticipate in a qualitative interview or a focus group. We were able to contact and arrange
individual interviews with 18 of these women. The interviews and the focus group
explored the women’s own perspectives on the relationship (if any) between their
binge eating and heavy drinking behaviour, and established a profile of the needs and
experiences of women who deal with both of these problems.
The women’s narratives of the situations in which they engage in problematic eat-
ing and alcohol use, as well as the emotional antecedents of these behaviours and the
outcomes they hope to gain from them, echoed the results from the quantitative data
(i.e., relief from negative emotions or enhancement of positive emotions), but provided
a substantially enriched picture. The two behaviours were often referenced in the inter-
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Section 5 Responding with Programs
views and focus group as a means of escape from painful or difficult emotions, such as
depression, anxiety, shame, guilt and anger. Common antecedents included issues
with relationships, fear of intimacy,fear of failure, feelings of low self-esteem and inad-
equacy, feeling hurt by others and conflict with others. In addition, the women reported
heavy drinking and binge eating in response to feeling lonely, bored or powerless (in
relation to their male partners). Women repeatedly described both binge eating and
heavy drinking as forms of emotional retreat, ways to “shut down, to dissociate and to
numb themselves.
Some women reported experiencing positive emotions as a consequence of binge
eating and heavy drinking. For example, they described feeling happy, confident or
euphoric when engaging in one or the other of these behaviours. Some women men-
tioned enjoying the sugar rush from binge eating “junk food, and likening the feeling
to the high they desired from heavy drinking (Stewart et al., 2003). In these cases, both
binge eating and drinking were described as serving emotional reward functions.
In the course of the interviews and focus group, many women spontaneously
reported histories of abuse, in particular sexual abuse, in their childhood or adoles-
cence, or reported having witnessed abuse of their mothers. Many also reported expe-
riences of rape and physically abusive relationships in adulthood. Many women
described both heavy drinking and binge eating as behaviours they used to cope with
the trauma they had experienced. Many also connected both behaviours to family
dynamics (e.g., their mother commenting on their weight; food being associated with
reward, punishment or nurturing as a child; or alcohol problems in the family)
(Stewart et al., 2003).
The qualitative data largely supported the quantitative findings that binge eating
and heavy drinking are associated with similar triggers and serve similar purposes for
many women. However, the interviews also revealed that the context in which the two
behaviours occur may be different, adding novel, useful information beyond that
obtained in the quantitative portion of the study. For example, some women found it
more socially acceptable to drink heavily than to eat a lot in public, so their binge eat-
ing was typically done alone. The women also reported that there was often an inverse
relationship between the two behaviours, so that when one was problematic, the other
was hardly noticeable, and if one improved, the other got worse (Stewart et al., 2003).
implications
Many women reported having sought treatment for each of the two problems exclu-
sively, and they expressed frustration and disappointment that issues relating to eating
were not addressed in the substance use treatment programs they were familiar with.
From the women’s perspective, the symptom-focused treatment approaches failed to
adequately address the underlying psychological issues that contributed to their
alcohol and eating problems (e.g., depression, anxiety and posttraumatic stress).
Some women had sought separate treatments for both problems simultaneously, while
others had tried to address them sequentially. There was consensus that an integrated
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Chapter 29 Challenges in Understanding the Co-prevalence of Disordered Eating and Substance Use Problems
treatment approach would be preferable (Stewart et al., 2003).This approach is consis-
tent with current best practice guidelines for the treatment of concurrent mental
health and substance use disorders, which emphasize providing integrated care for
those with such concurrent problems (Health Canada, 2002).
This research has important implications for clinical practice in delivering health
services for women. First, there are very high rates of co-occurrence—in both clinical
and community samples—of disordered eating that involves binges together with sub-
stance use problems; this suggests the importance of screening for eating problems in
women presenting for treatment of substance use problems, and vice versa.Second, the
data suggest that an integrated treatment program focusing simultaneous treatment
on both of these interrelated behaviours from the outset would be most preferable.
However, a word of caution is in order. In many areas of addictions, integrated treat-
ment packages are currently being developed, where treatments are applied to
co-occurring problems simultaneously rather than sequentially. In general, such com-
bined treatments appear to be very effective for those who are able to complete the
treatment. However, dropout rates tend to be extremely high (see review by Conrod &
Stewart, 2005). A similar pattern might be expected for combined treatment of
co-occurring disordered eating and substance use problems, given that treatments for
each of these problems alone already tend to be quite demanding.
Given these considerations, there may be merit in focusing treatment on common
mechanisms and motivations for each behaviour (i.e., motives of providing relief from
negative emotions, such as depression or anxiety, or enhancing positive emotions).
Each woman needs to be individually assessed to determine the primary motivation
underlying her binge eating and substance use so that a treatment can be tailored to
meet her needs (Conrod et al., 2000). In the case of women for whom emotional relief
is a primary motivation for both behaviours, for example, treatment could focus on
encouraging and teaching skills for more adaptive ways of coping with difficult emo-
tions. Such an approach might be less demanding than a combined simultaneous
treatment approach addressing the individual symptoms of both problems, and might
thus promote increased program completion and ultimately superior outcomes
among women experiencing these two problem behaviours (Conrod & Stewart, 2005).
Conclusion
A review of the emerging literature on this issue makes it clear that there are high
levels of co-occurrence of, and common underlying motivations for, binge eating and
heavy substance use among women (Filstead et al., 1988; Stewart et al., 2003,2006). To
date, there appears to be little in the way of treatment within the Canadian health care
system that effectively addresses the co-existence of these two issues for women. The
challenges that have already been identified in developing effective integrated
approaches to the treatment of co-occurring mental health and substance use prob-
lems (Conrod & Stewart, 2005) are certainly very applicable to the specific case of
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Section 5 Responding with Programs
disordered eating and substance use problems. Future research is needed to find the
optimal method for treating women struggling with both of these problems if we are
to improve women’s health programming and create appropriate preventive measures.
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... Examining why adolescents repeatedly engage in binging behaviours, it has been argued that these behaviours are associated with common triggers and they serve a similar function and purposes, such as regulating emotions and/or escaping from them and coping with distress and/or dissatisfaction with life (Birch, Sherry, & Brown, 2007;Stewart & Brown, 2005;Stewart, Samoluk, Conrod, Pihl, & Dongier, 2000). Stewart and Brown (2005) found overlap in the circumstances prompting binge eating and drinking in those women who engaged in both behaviours. ...
... Examining why adolescents repeatedly engage in binging behaviours, it has been argued that these behaviours are associated with common triggers and they serve a similar function and purposes, such as regulating emotions and/or escaping from them and coping with distress and/or dissatisfaction with life (Birch, Sherry, & Brown, 2007;Stewart & Brown, 2005;Stewart, Samoluk, Conrod, Pihl, & Dongier, 2000). Stewart and Brown (2005) found overlap in the circumstances prompting binge eating and drinking in those women who engaged in both behaviours. Situations involving negative emotional states posed the highest risk for engaging in binge eating as well as for engaging in binge drinking. ...
... Similar evidence for common triggers for binge eating and binge drinking was found for situations involving pleasant emotional states. Some women reported experiencing positive emotions as a consequence of binge eating and binge drinking describing feeling happy, confident or euphoric (Birch et al., 2007;Stewart & Brown, 2005). So, some adolescents may engage in both behaviours because they have not learned more adaptive strategies to enhance positive affect (emotional rewards) whereas some adolescents may engage in both behaviours because they have not learned more adaptive strategies to relieve negative affect (emotional relief). ...
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... Recent findings (Stewart et al. 2000, Stewart and Brown 2005, Birch et al. 2007) have suggested that binge eating and drinking -above all in women -may be associated with difficulties in regulating emotions (dysregulation hypothesis) and ...
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This study was designed to compare risk situations for binge eating vs. heavy drinking among women who struggle with both problems. Participants were 41 women in treatment for an alcohol problem who also self-reported binge eating. Participants completed the Inventory of Binge Eating Situations (IBES; [Baker, J. M. (1998). Binge eating and binge drinking among university women. Unpublished master's thesis, Department of Psychology, Queen's University, Kingston, Ontario, Canada]) and the Inventory of Drinking Situations (IDS-42; [Annis, H. M., Graham, J. M., & Davis, C. S. (1987). Inventory of Drinking Situations (IDS) user's guide. Toronto, Canada: Addiction Research Foundation]) to measure frequency of binge eating and heavy drinking, respectively, in eight categories of situations. A 2 (substance) x8 (situation) repeated measures ANOVA revealed a significant substancexsituation interaction. Further exploration of this interaction indicated that heavy drinking is more likely than binge eating to occur in reward and interpersonal situations involving pleasant emotions, pleasant times with others, social pressure, and conflict with others. In contrast, binge eating and heavy drinking are equally likely to occur in relief situations involving unpleasant emotions, and physical discomfort, as well as in situations involving urges and temptations, and testing control. Implications of findings for the treatment of co-occurring binge eating and heavy drinking in women are discussed.
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Several large-scale studies examining outcome predictors across various substance use treatments indicate a need to focus on psychiatric comorbidity as a very important predictor of poorer SUD treatment involvement and outcome. We have previously argued that current cognitive-behavioral treatments (CBT) approaches to SUD treatment do not focus on the necessary content in treatment in order to effectively address specific forms of psychiatric comorbidity, and thus only provide clients with generic coping strategies for managing psychiatric illness (as would be achieved in other SUD treatment approaches; Conrod et al., 2000). Furthermore, following our review of the literature on dual-focused CBT treatment programs for concurrent disorders in this article, we argue that combining CBT-oriented SUD treatments with specific CBT treatments for psychiatric disorders is not as straightforward as one would think. Rather, it requires very careful consideration of the functional relationship between specific disorders, patient reactions to specific treatment components, and certain barriers to treatment in order to achieve an integrated dual-diagnosis focus in treatment that is meaningful and to which clients can adhere.
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Twenty-eight adolescent bulimics were compared to 201 psychiatrically hospitalized non-eating disordered patients. Non-eating disordered patients were found to be reliably more aggressive, delinquent, and under-controlled than patients with bulimia nervosa. Sexual abuse was found to be less prevalent among bulimic adolescents than comparison adolescents. No significant between group differences were achieved on any measure of alcohol/drug abuse. The behavioral profiles of substance abusing bulimics were highly similar to those of non-eating disordered patients. Three months follow-up of bulimic patients found that they were less depressed, had less somatization, and were less overcontrolled; however, they showed no reliable improvements in eating attitudes/behaviours or drug/alcohol use.
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The 42-item version of the Inventory of Drinking Situations (IDS-42) assesses relative frequency of drinking behavior across eight categories of drinking situations and was originally developed as a method for identifying high-risk situations in alcoholic samples. This study was designed to examine the psychometric properties of the IDS-42 in a sample of university students in order to assess its suitability as an assessment tool in the non-clinical population. Three hundred and ninety-six students (111 M, 283 F, 2 with missing gender data) completed the IDS-42 and a well established measure of drinking motives, the Drinking Motives Questionnaire (DMQ). Confirmatory factor analysis of the IDS-42 established a hierarchical factor structure with eight lower-order factors and three higher-order factors of negatively-reinforcing situations, positively-reinforcing situations, and temptation situations. The eight lower-order IDS-42 factors demonstrated moderate to high internal consistency and excellent concurrent validity with conceptually-similar DMQ subscale scores. Non-parametric analyses revealed that male students reported a higher drinking frequency overall as compared to female students, particularly in IDS-42 situations involving Social Pressure to Drink, Pleasant Times with Others, Testing Personal Control, and Urges and Temptations. Across the entire sample of university student drinkers, a higher drinking frequency was reported in positively-reinforcing situations as compared to negatively-reinforcing situations and temptation situations, as predicted. Results suggest the IDS-42 possesses good psychometric properties and support its utility as a tool in identifying situation-specific antecedents to drinking among university students.
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Purpose: We investigated the psychometric properties (factor structure, internal consistency reliability, concurrent validity) of the Short Form Inventory of Drinking Situations (IDS-42) in women substance abusers. Methods: A sample of 297 substance-abusing women was recruited from the community. The women completed the IDS-42 and the three-factor Drinking Motives Questionnaire (DMQ). Results: Confirmatory factor analyses of IDS-42 items suggested a hierarchical structure for the scale. Eight factors (corresponding to Marlatt and Gordon's eight heavy drinking situations) provided the best model fit at the lower-order level, and three factors (i.e., Negatively Reinforcing vs. Positively Reinforcing vs. Temptation Situations) provided the best model fit at the higher-order level. Lower- and higher-order IDS-42 subscales were shown to possess adequate-to-high levels of internal consistency. The eight lower-order IDS-42 factors demonstrated excellent concurrent validity with conceptually similar DMQ subscale scores. Across the entire sample of female substance abusers, a higher frequency of heavy drinking was reported in Positively Reinforcing Situations and Unpleasant Emotions Situations, as compared to other heavy drinking situations. Implications: Results support the IDS-42's good psychometric properties and demonstrate its utility as a tool in identifying situation-specific antecedents to heavy drinking among women substance abusers.
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The authors report an abbreviated version of the Michigan Alcoholism Screening Test (MAST). They hypothesized, on the basis of previously published data, that scores based on ten of the questions of the MAST would be as effective in discriminating between alcoholics and nonalcoholics as scores based on all 25 questions. The responses of 60 alcoholic and 62 nonalcoholic psychiatric patients supported their hypothesis.
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Bulimia is an eating disorder purported to comprise binge eating episodes with subsequent depressive moods and self-deprecating thoughts. This study reports the development and preliminary construct validation of a Binge Scale intended to provide more descriptive, quantifiable information about the behavioral and attitudinal parameters of bulimia. Over two-thirds of the females and nearly one-half of the males in the samples reported binge eating occurences. The severity of binge eating was associated with degree of dieting concern (“restraint”) and inversely related to self-image acceptance, particularly among females. Maintaining body weight below “set point” through restrained eating efforts may increase the susceptibility to periodic binge episodes.
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The comorbidity of eating disorders and substance use and abuse has frequently been reported in the past 15 years. To date, however, no synthesis of this literature exists. Here, 51 studies reporting on these associations are reviewed. Studies of substance use and abuse in eating disordered women are considered, as are studies of eating disorders among women classified as substance abusers. The rates of substance abuse among eating disordered women are also examined. This review indicates that associations are stronger with bulimia, and "bulimic" behaviors, than with anorexia nervosa. Analogously, bulimic anorectics report more substance use and abuse than restricters. The prevalence of drug abuse was not found to differ between the relatives of bulimics and anorectics. Several mechanisms explaining the eating disorder-substance use/abuse link are considered, and suggestions for future research made.