The Relationship Between Impulsive Behaviors

and Eating Disorders:

Do anorexics and bulimics differ in their tendency to act rashly?

Jenny McGettigan

INTRODUCTION

This paper focuses on the issue of whether or not there is a discrepancy between those diagnosed with anorexia nervosa and bulimia nervosa in relation to the tendency to demonstrate impulsive behaviors. Impulsive behavior is defined as any of the following: substance abuse, stealing, sexual promiscuity, and self-injury and/or suicide attempts. A large number of studies have been conducted that examine the relationship between these behaviors and those with bulimia, (BN), restricting anorexics (AN-R), and anorexics that binge and purge (AN-BP). This review summarizes the findings of several of these studies.

SUBSTANCE USE AND ABUSE

            An extensive review of alcohol and substance use and abuse was developed by Brooks-Gunn, Holderness, & Warren in 1994, which compared the incidence of each among AN-R, AN-BP, and BN. The following was found:       

Alcohol use "not serious enough to merit the term ‘abuse’" in BN had a median of 23.2%; in AN-R, a mean of 12.93%; and in AN-BP, a mean of 29.5% (8). Street drug use in BN had a median of 26%; in AN-R, 15.3%, and in AN-BP, 34.3%. The authors concluded that substance use is more common in bulimics than anorexics, and more common in bingeing/purging anorexics than in restricting anorexics. A dependency on alcohol/alcohol abuse in BN had a median of 22.9%; in AN-R, 6%; in AN-BP, a median of 26%. A dependency on drugs/drug abuse in BN had a median of 17.05%; in AN-R, 13%; in AN-BP, a median of 25%. The review also includes information about a comparison of the two subtypes of anorexia, which reported that the rates for alcohol abuse and tobacco use was twice as high among AN-BP than in AN-R.

In addition to this review, similar results were found regarding substance abuse and those with eating disorders. In a study examining severity of dieting and the frequency and intensity of use of alcohol, marijuana, and/or tobacco among bulimics and controls, it was determined that the more severe one’s dieting practices, the higher the frequency and intensity of substance use (Demitrack, et al., 1992). Pryor & Wiederman found in their study of adolescent girls with eating disorders that a third with BN smoked cigarettes, marijuana, and drank at least once weekly, whereas those with AN showed a very low incidence of all three of these behaviors.  

Conversely, the study by McGilley, et al., described above, which focused on the differences between the two subtypes of anorexia, found no difference between the two groups regarding drug abuse (1996). A Japanese study also "clearly confirms that there is no general relationship between eating disorders and psychoactive substance use," but the authors attribute this discrepancy from the other literature examining this topic to the differences in "social and cultural values" between Japanese and Western society (Iketani, et al., 2000; 247).

STEALING TENDENCIES IN THE EATING-DISORDERED

A study assessing the importance of stealing in the eating disordered found a positive correlation between bulimic tendencies and history of stealing; it was discovered that 48.7% BN, 35.3% AN-R, and 54.8% AN-BP admitted to having stolen before (Vandereycken & van Houdenhove 1996). These authors also included a comparison to five other studies done on the topic. All of these had similar findings: that "stealing is more likely when the eating disorder includes ‘bulimia-like’ behavior (binge-eating, vomiting, and laxative abuse)"(320).

Similarly, a review published in 1995 by Baum and Goldner investigated the incidence of stealing in the eating-disordered; they found that "although epidemiological data are lacking,…stealing appears to be strongly associated with bulimic symptoms in patients with eating disorders" (Baum & Goldner 1995). Yet third study that explored how eating disorders is associated with stealing reported that those with history of stealing were more dysfunctional in their eating and purging behavior (Drewnowski, et al., 1991).

The authors of all three studies concluded that it seems quite possible that the stealing behaviors of an individual may be an indicator for the severity of the disorder, but this notion needs to be further explored in order to make this a valid statement.

SEXUAL ACTIVITY AND PERCEPTIONS OF SEX

            Overall, most of the literature regarding the sexual experiences of eating-disordered women found that those who binged, whether BN or AN-BP, were more sexually active than AN-R. An exception to this was a study done by McGilley, et al., which compared the two types of anorexics; it found that the two subtypes were no different in masturbation frequency, age at which virginity was lost, and present frequency of intercourse (1996).

Other than this, the other studies found that bingeing/purging behaviors were related to being more sexually active. Pryor and Wiederman found that those who demonstrated bulimic symptoms also exemplified a greater frequency of sexual intercourse (1996). A Japanese study revealed that BN were the most promiscuous (had the largest number of sexual partners not well-known to them) (18%), whereas 11% AN-BP, 2% AN-R, and 2% controls were sexually promiscuous (Iketani, et al., 2000). A study by Morgan, et al., reported that when comparing AN with BN, those with BN were more likely to have had sexual intercourse, had their first experiences at an earlier age, and had a greater interest in sex (1996). In addition to this, it was found for the entire sample that the higher the degree of calorie restriction, the lower the frequency of masturbation.

In accordance with these findings, a study done by Evans, et al., also found that AN-R lost their virginity at a later age than BN, AN-BP, and the controls (1995). AN-R also had the lowest number of partners and were the least positive about sexual relationships, although all subjects with eating disorders were less positive about sexuality than the controls. Finally, this study differed from the one conducted by Morgan, et al., in that this study found no difference among eating disorder subtypes concerning masturbation. Another study reported that bulimics were more likely than controls to rate their libido as "above average," which may explain the increased sexual activity, but contradicts the negative perception of sexuality reported in the Evans, et al., study (Abraham, et al., 1985).

SELF-INJURY AND SUICIDE ATTEMPT

Studies exploring the relationship between self-injurious behaviors and eating disorders discovered that those who purged in some form are more likely to demonstrate these behaviors. One study by Favaro and Santonastaso examined the number of methods used to purge in association with the tendency to demonstrate self-injurious behaviors (1996). It was reported that indeed, "there are more serious psychiatric symptoms in purging than in non-purging ED subjects," and that in both AN and BN, the more purging methods used to control weight (vomiting and/or laxatives and diuretics), the higher the likelihood of self-injurious behavior (103). Those who used both purging methods were most likely to engage in more serious self-injurious behaviors (48.3%), while 33.3% of those using only one method and 8.6% of AN-R were self-injurious. A similar trend was seen in suicide attempts. Those who used the rate of suicide attempts was also much higher in those who used at least one method of purging (15.4% of one method-users, 41.4% both method-users) as compared to AN-R (5.7%).

A different study had findings that both supported and contrasted the one above (Pryor & Wiederman 1996). This study also found a positive correlation between bulimic symptoms and suicide attempts. However, in contrast to Favaro and Santonastaso’s study, it was found that there was no relation between type of eating disorder and frequency of self-injurious behavior.

Finally, the Japanese study also investigated the relationship between self-injurious behavior and eating disorder type (Iketani, et al., 2000). It found that 44% BN, 26% AN-BP, and 10% AN-R reported a history of suicide attempts in the questionnaire they filled out. Self-mutilation was reported by 33% BN, 26% AN-BP, and 7% AN-R. Clearly, these results also show a higher incidence of self-injury and suicide attempt among those who demonstrate bingeing/purging behaviors.

CONCLUSIONS

Overall, the majority of the literature examined found that bulimic symptoms in an individual with an eating disorder were positively correlated with impulsive behaviors. However, limitations in the literature do exist. The review exploring eating disorders and alcohol and substance abuse by Brooks-Gunn, et al., discusses some of these. For example, several of the studies they reviewed did not distinguish between AN-R and AN-BP, or between drug abuse and alcohol and drug abuse, etc., which made data interpretation complicated and often inconclusive. Also, some of the studies conducted did not include a group of normal controls with which the behaviors of the eating-disordered could be compared. This further complicated the true relationship between substance abuse and eating disorders. As a second example of a significant limitation, one of the studies discussed in this review was conducted using Japanese subjects; therefore, cultural and societal differences may have caused results that should not be strictly compared to studies conducted in Western society involving similar topics.

With regard to the findings on substance abuse and eating disorders, due to discrepancies between studies examining which type of eating disorder is most positively related with drug abuse, it would be beneficial to conduct further research on the correlation between the two.  However, all of the literature examined concerning alcohol abuse and eating disorders concluded that those with bulimic symptoms were more likely to have a problem with alcohol dependency compared to AN-R.

A limitation with the literature on stealing and sexual activity is that the results are self-reported, and therefore, may not be entirely truthful, especially because some subjects may be ashamed to admit having stolen before, or to reveal the nature of their sexuality. In addition to this, anorexics tend to be introverted, whereas bulimics tend to "fit into the dramatic personality spectrum and may exaggerate their experiences" (Evans, et al., 1995; 416). To try to control for this self-reporter caveat, the study carried out by Vandereycken and van Houdenhove used a questionnaire instead of an interview, expecting that subjects would be less embarrassed to admit to stealing on paper rather than face-to-face.

Aside from the self-reporter confound, all studies mentioned showed a significantly greater likelihood to steal in those who exhibited bulimic symptoms; it therefore seems probable that among those with eating disorders, those who demonstrate bingeing/purging activities do indeed also exhibit the tendency to steal more than those who restrict.

An interesting follow-up on this topic might be to examine the relationship between those with binge eating disorder and their stealing patterns. This could investigate whether it is the act of bingeing or purging that is related to an increased tendency to steal. On one hand, if those with BED showed similar stealing tendencies as those with BN and AN-BP, it may suggest that the compulsion to eat is similar to the compulsion to steal. Vandereycken and van Houdenhove suggest that perhaps both are related in that a loss of control is experienced (1996). On the other hand, if those with BED were more likely to act as controls in their stealing behaviors, it may imply that it is the act of purging exhibited in those with bulimic symptoms that is similar to stealing.

Additional limitations occurred in the studies investigating the sexual activity of those with eating disorders. For example, in the study conducted by Evans, et al., the controls did not fill out a questionnaire about pubertal development and sexual life events; 13% of the controls did not fill out the sexual development questionnaire; the controls were not examined for the presence of an eating disorder; and, as mentioned above, because all results were self-reported, they may not be entirely truthful due to embarrassment or exaggeration. Because of these caveats, some of the results may be a bit distorted.

In addition to this, several discrepancies about the sexual activities of those with eating disorders exist (see "Sexual Activity and Perceptions of Sex" above). Due to these discrepancies, it is important to carry out further research concerning masturbation and attitudes towards sexuality in those with eating disorders to determine the true relationship between them. However, the majority of studies did find that overall, those with BN and AN-BP generally have a greater, more positive interest in sex and are more sexually active than those with AN-R. It might be beneficial to investigate the emotions and degree of regret (if any) after behaving promiscuously in the eating-disordered, for it may provide insight into the issue of self-respect and how those with eating disorders view their bodies and personal worth.

The discrepancies found between studies on self-injury and eating disorders confirm that more investigation on this topic needs to be carried out before a sound conclusion can be reached. Two of the studies discussed in this review found a positive correlation between bulimic symptoms and self-injury, but a third found no difference among eating disorder groups and this type of impulsive behavior. However, all studies reported similar findings regarding bingeing/purging behaviors and suicide attempts; therefore, it would probably be reasonable to conclude that those who exhibit some type of bulimic symptoms are also more likely to have some sort of history of a suicide attempt than restrictors.

Overall, despite the inconsistencies noted above, it appears that the type of eating disorder one has indeed plays a role in whether or not impulsive behaviors are demonstrated by the individual. For all four of the main types of impulsive behavior, there seems to be a trend that those who engage in some form of bingeing/purging activity are more likely to exhibit impulsive behaviors as compared to restrictors. An interesting study to conduct in the future would be one that examined whether or not there is a relationship between what it is that triggers a binge versus what triggers one to demonstrate an impulsive behavior in those that exemplify in both. This may provide some insight as to why there is such a strong relationship between bingeing/purging and the exhibition of impulsive behaviors.

 

References:

JOURNAL ARTICLES

Abraham SF, Bendit N, Llewellyn-Jones D, Mason C, Mitchell H, O’Connor N, Ward J, Young S (1985): The psychosexual histories of young women with bulimia. Australian and New Zealand Journal of Psychiatry 19(1):72-6.

Baum A & Goldner EM (1995): The relationship between stealing and eating disorders: a review. Harvard Review of Psychiatry 3(4):210-21.

Brooks-Gunn J, Holderness CC, Warren MP (1994): Co-morbidity of eating disorders and substance abuse review of the literature. International Journal of Eating Disorders 16(1):1-34.

Demitrack M, Drewnowski A, Krahn D, Kurth C (1992): The relationship of dieting severity and bulimic behaviors to alcohol and other drug use in young women. Journal of Substance Abuse 4(4):341-53.

Drewnowski A, Gosnell BA, Krahn DD, Nairn K (1991): Stealing in eating disordered patients. Journal of Clinical Psychiatry 53(3):112-5.

Evans K, Schmidt U, Tiller J, Treasure J (1995): Puberty, sexual milestones and abuse: how are they related in eating disordered patients? Psychology of Medicine 25(2):413-7.

Favaro A & Santonastaso P (1996): Purging behaviors, suicide attempts, and psychiatric symptoms in 398 eating disordered subjects. International Journal of Eating Disorders 20(1):99-103.

Iketani T, Kawarada Y, Kiriike N, & Nagata T (2000): Multi-impulsivity of Japanese patients with eating disorders: primary and secondary impulsivity. Psychiatry Research 94(3):239-50.

McGilley B, Pryor T, Wiederman MW (1996): Clinical correlates of anorexia nervosa subtypes. International Journal of Eating Disorders 19(4):371-9.

Morgan CD, Pryor T, Wiederman MW (1996): The sexual experience of women diagnosed with anorexia nervosa or bulimia nervosa. International Journal of Eating Disorders 19(2):109-18.

Pryor T, Wiederman MW (1996): Substance use and impulsive behaviors among adolescents with eating disorders. Addictive Behaviors 21(2):269-72.

Vandereycken W & van Houdenhove VD (1996): Stealing behavior in eating disorders: characteristics and associated psychopathology. Comprehensive Psychiatry 37(5):316-21.