Personality and Substance Abuse in Eating Disorders

It’s a proverbial dual-edged sword: Drug and alcohol abuse is more common in women with eating disorders than in the general population, and women with anorexia nervosa (AN) or bulimia nervosa (BN) and substance abuse problems take longer to recover from their eating disorders and also have higher mortality rates than do women with eating disorders without substance abuse.

A history of substance abuse appears to be the most important predictor of future substance abuse in women with eating disorders, according to results of a recent study from Massachusetts General Hospital and Boston Hospital (Int J Eat Disord 2008; 41:203). Heather Thompson-Brenner, PhD and colleagues recently investigated associations between personality and substance use among 213 individuals with AN and BN; the longitudinal study assessed substance use at regular follow-up visits every 6 months over 9 years.

Five personality subtypes

The researchers had earlier identified five personality subtypes in a mixed sample of patients with eating disorders. They note that individuals with just one or two of these subtypes may be prone to substance abuse: (1) an avoidant-insecure subtype, with anxious, depressed, and socially avoidant tendencies and (2) a behaviorally dysregulated subtype, with more antisocial and impulsive dysregulated behavioral traits than emotional symptoms.

The patients were interviewed with the LIFE-EAT-II questionnaire, which assesses symptoms, comorbid psychopathology, treatment and psychosocial functioning. At every follow-up interview, participants were asked about potential alcohol and drug misuse since the previous interview. The Structured Interview of DSM-III-R Personality Disorders, or SIPR, was administered to assess Axis II in participants 18 years of age, at baseline.

A history of substance abuse was most important

According to the authors, personality scores did not show significant longitudinal relationships to substance abuse disorders. Only the history of substance abuse appeared to influence the models of personality and longitudinal substance abuse patterns. The obsessional-sensitivity score negatively predicted future drug use disorder episodes, and this negative relationship was significant after the history of substance abuse episodes was included.

Dr. Thompson-Brenner and colleagues note that the results of their study show that personality subtypes are meaningfully associated with substance abuse variables. Persons with eating disorders who have a more obsessional (perfectionistic) personality seemed to be unlikely to abuse substances at the time of the initial assessment or later in their disorder. In contrast, individuals with a behaviorally dysregulated style, characterized by several forms of impulsivity, risk-taking, and self-harm, are more likely than those with other personality typesincluding the emotionally dysregulated style–to begin or continue abusing alcohol. In contrast, the disorder itself, whether AN or BN, did not appear to explain longitudinal patterns of substance abuse. The results also indicate that patients with behavioral dysregulation, unlike those with emotional dysregulation, may show specific vulnerability to alcohol or drug abuse.

The study results also failed to support earlier studies finding that avoidant-insecure or perfectionist patients were also particularly vulnerable to substance abuse (J Clin Psychiatry 2004; 65:1000; Psychol Med 2005; 35:649).

Concern about social acceptance may play a role

Additional research may help clarify the type of perfectionism that is associated with substance abuse in eating disorders, and possible moderating factors. It is possible that individual patients may find that giving up control or taking risks with substances is frightening or aversive because of their concern about doing things right, staying in control, and wanting to appear to be perfect. And, even though risk-taking and impulsivity are often associated with substance abuse, there may be other reasons why drugs and alcohol are appealing to this portion of the eating disorders populationthis subgroup seems to be concerned with social acceptance and may find that drinking and using drugs ease their social concerns.