Substance abuse and dependence
Reported rates of substance abuse in AN vary widely
and are significantly associated with AN subtype (binge/
purge), with rates as high as 35% in those who cross over
to Bulimia Nervosa (BN) after weight restoration [94]. In
general, the presence of any bulimic symptomatology
significantly increases the likelihood of co-morbidity involving
a variety of substances, both illicit and legal
[95,96]. The sequencing of co-morbid alcohol problems
and AN shows no distinctive pattern [97]. However the
concurrent presence of alcohol misuse and AN should
prompt enquiry into wider psychopathology given the
increased odds of this in this subpopulation [98] and the
known increased mortality [2].
Other substance abuse and dependence problems include
the use of diet pills, laxatives, diuretics and other
illicit stimulants for appetite suppression and increased
metabolic effects [99]. Opioid and sedative use is also
significantly elevated. In short, the assessment of substance
misuse should cast a wide net, seeking information
about illicit and over-the-counter drugs, including
common substances containing high levels of caffeine.
The assessment should also include patient understandings
about how these substances maintain AN symptoms
(for example, warding off normal signals of hunger) or
manage other psychological symptoms or distress.