The Relationship Between Impulsive Behaviors
and Eating Disorders:
Do anorexics and bulimics differ in their
tendency to act rashly?
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
SUBSTANCE USE AND ABUSE
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:
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.
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.
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
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
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.,
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
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).
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.
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
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%).
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.
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
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.
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.
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.
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.
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
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
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.
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
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.
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