The research literature indicates that, in general, adult women with bulimic symptoms are more likely to use or abuse a variety of substances relative to their peers with anorexic symptoms or no eating disorder symptoms at all. In other words, it appears that bulimia may be an indicator of increased likelihood to use drugs, or vice versa. There have been few studies involving adolescent girls, and most of those that have been conducted have used nonclinical samples. With these samples of high school or college students, the presence of bulimic behavior is typically related to increased substance use. Still, what about girls who meet diagnostic criteria for an eating disorder? Is substance use among adolescents with eating disorders best explained by particular eating disorder symptoms or by certain clinical and personality characteristics which are associated with disordered eating?

To address these issues, my colleague Tamara Pryor and I studied more than 100 adolescent girls who were presented for evaluation at an eating disorders clinic and met diagnostic criteria for either anorexia nervosa or bulimia nervosa. We hoped to learn whether substance use differed among the girls as a function of their diagnosis, their symptom presentation and severity, or related personality traits.

Participants and Methods

We collected data from 59 girls with anorexia nervosa and 58 girls with bulimia nervosa. These girls ranged in age from 12 to 17 years, with an average of age 15.4 years. All but three of the girls were non-Hispanic, White. In the process of completing measures during the intake evaluation at the university-based clinic, the girls indicated whether they had ever used each of eight substances: alcohol, amphetamines, barbiturates, hallucinogens, marijuana, tranquilizers, cocaine, and cigarettes. They were also asked whether they had ever experienced several problematic behaviors: attempted suicide, physical self-harm, stealing, and sexual intercourse. Nearly all of the girls completed the Eating Disorders Inventory (EDI). The EDI is a widely-used instrument designed to measure several characteristics which often accompany disordered eating, including: drive for thinness (fear of fat), bulimia (or loss of control over eating), body dissatisfaction, sense of personal ineffectiveness, perfectionism, interpersonal distrust, maturity fears (or the desire to remain a child), and relative lack of interoceptive awareness (confusion and apprehension in recognizing and accurately responding to emotional states).

Research Results

Among the anorexic girls, alcohol, cigarettes, and marijuana were the only substances reported. Even so, less than 20% of the girls reported having ever ingested alcohol, the most common substance among this group. The bulimic adolescents, in contrast, reported having taken each of the eight substances, with prevalence ranging from a low of 3.4% for tranquilizers to a high of 67.2% for alcohol (29.3% of the bulimic girls used alcohol at least weekly). The bulimic girls reported having taken an average of 1.70 different substances in contrast to the anorexic girls who reported having taken an average of .38 different substances. Of the 59 anorexic girls, 13 experienced bulimic symptoms. However, most of their substance use occurred within this small subgroup. Of the 11 anorexic girls who indicated ever having used alcohol, 6 had bulimic symptoms. Clearly, bulimic symptoms were associated with increased likelihood of substance use among these adolescents with clinical eating disorders.

Next we looked at whether increased substance use was related to other problematic behaviors. We found that the adolescents who had taken a greater number of different substances were substantially more likely to have engaged in sexual intercourse, stealing, or attempted suicide, although not more likely to have engaged in physical self harm (without the intent of suicide).