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355
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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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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