The Intersection of Eating and Alcohol Disorders: Detecting and Managing "Drunkorexia"
Drunkorexia is a term referring to limiting food intake prior to alcohol consumption.
“Drunkorexia,” a term introduced by the media in 2008 referring to “limiting food intake before alcohol consumption,”1 is a “trend among college students.”2
Drunkorexia is more typically associated with binge drinking (defined as ≥4 drinks for women and ≥5 drinks for men in ~2 hours) than with moderate drinking.3 Binge drinking is a serious problem on college campuses.4 According to a review of several national datasets examining alcohol use among college students, approximately 70% of college students report using alcohol in the past month and approximately 40% report binge drinking.5 Eating disorders (EDs) are likewise a serious issue on college campuses. For example, one 13-year study of college students found that total EDs increased from 23% to 32% in female students and from 7.9% to 25% in male students during the study period.6
Drunkorexia, which is the intersection of alcohol use and EDs, may affect as many as 46% of college students, according to one study of 3409 students.7 Another study of 1184 college students found that that 8 of 10 were affected.8
Drunkorexia is characterized by food restrictions, extreme exercising, or purging with a goal of either trading food calories for those consumed by drinking alcohol to heighten the inebriating effects of alcohol, or both.8
“We are seeing an increasing number of cases of ‘drunkorexia' at our clinic at Rutgers University,” Petros Levounis, MD, MA, Chair, Department of Psychiatry, Rutgers New Jersey Medical School, told Psychiatry Advisor.
He noted that although this trend may be taking place outside the university, it seems to primarily affect college students and “there are no good epidemiological studies to show how extensive it might be outside of the college setting.”
Who Is Affected?
Some research has suggested that first-year college students are at particularly high risk.4
“It is often quite a common occurrence that many college students are so fearful to gain the dreaded ‘freshmen 15' [pounds] that, in order to save calories and also not to gain weight while consuming alcohol, they try to manage eating behaviors by drinking more instead of eating,” Alison Chase, PhD, CEDS, Regional Managing Clinical Director, Eating Recovery Center, and Insight Behavioral Center, Austin, Texas, told Psychiatry Advisor.
Drunkorexia tends to affect women more than men, especially if they were already engaging in restrictive eating behaviors. One study of college students found that 80.7% reported some type of drunkorexia behavior during the previous 3 months, of whom 78.0% were male and 82.7% were female.8 Another study of 63 students found that women were more likely than men to engage in drunkorexia because they were more likely to be concerned about weight.1 The greatest risk was found in women who drank more heavily.1
Nevertheless, it is important not to underestimate the impact of this disorder on men, Dr Chase cautioned.
“People have stereotypes about eating disorders — especially those with anorexia — that they are primarily female and white, but our centers get a diverse population of males and a variety of ethnicities,” she said.
Although the more typical reason for drunkorexia is fear of weight gain, one reason that Dr Levounis has noticed is that “some college students have difficulty affording food and find it cheaper to get their calories through cheap alcohol rather than food, so there is a poverty component, apart from the strictly psychiatric one.”
Dr Levounis admitted that this is “not the major component of the problem, nor does it even affect the majority of people, but it has been brought up more than once in our clinic and practitioners should be aware and alert for this potential situation.”
Interviewing is generally the most important tool in diagnosing alcohol use disorders [AUDs] and substance use disorders in people with EDs.9 Components include:
- Personal history (including lifetime and current substance use as well as heaviest period of use)
- Information from third-party sources, if possible
- Physical signs of alcohol or substance use
- Urine toxicology screening to determine drug use
- Liver function tests (especially glutaryl transaminase and mean corpuscular volume in the complete blood count maybe elevated in patients with AUDs)
Screening tests may be helpful as well, including the CAGE10 detecting alcohol use, the SCOFF11 for detecting Eds, and the Drunkorexia Motives and Behaviors Scales.1
“Clinicians working in an academic setting should be vigilant regarding the possibility of drunkorexia and should proactively inquire about students' drinking and eating habits,” Dr Chase said.
General questions are not sufficient, she emphasized.
“Inquire about what the student's eating behaviors are, if they are over-exercising, purging, or restricting their eating,” she advised.
Additionally, “ascertain their drinking behaviors — how much do they drink? When do they drink? How often do they party?”
Clinicians who encounter a potential substance use disorder should also inquire about eating habits, and those who encounter potential EDs should inquire about drinking habits, “since there is so much crossover,” she added.
This index of suspicion should be maintained if a student is receiving help for one of the disorders and appears to be improving, she cautioned.
“As one disorder improves, it's not unusual for the other issue to pop up or worsen, since the person may turn to one unhealthy behavior to manage the feelings they were trying to manage through the other unhealthy behavior.”
Chicken and Egg?
EDs frequently occur comorbidly with other psychiatric conditions, including depression, anxiety, posttraumatic stress disorder , attention-deficit/hyperactivity disorder , body dysmorphic disorder, and other underlying conditions, and people often try to self-medicate with alcohol, Dr Levounis noted.
For this reason, it is difficult to determine which is the primary and which is the secondary disorder, he continued.
“However, we are no longer worried about which is the chicken and which is the egg, because these types of considerations and deliberations are not relevant to treatment.”
Instead, he recommended, “treat both conditions independently and together at the same time.”
Pharmacotherapies for Treating Drunkorexia
“The primary treatments for eating disorders are psychosocial, but there nevertheless is some role that medication can play even for anorexia and certainly for alcohol abuse,” Dr Levounis declared.
He noted that there are 3 oral agents (naltrexone, acamprosate, and disulfiram) that are approved by the US Food and Drug Administration for treatment of AUD.12
Some evidence points to selective serotonin reuptake inhibitors as promising treatments for EDs,9,13 “enabling us to kill two birds with one stone, so to say, by addressing the depression and anxiety that so often drive these behaviors,” he said.
Additional pharmacotherapies that have shown utility as adjunctive therapies in anorexia nervosa are atypical antipsychotics — specifically olanzapine — and zinc supplementation.14
Dr Chase agreed that medication has a role to play in drunkorexia treatment. “Medication can be very useful in helping manage the symptoms that exist with eating disorders, particularly managing mood and anxiety issues. Once those symptoms are stabilized, it is easier to manage working through the other aspects of the eating disorder.”
“Most of the evidence-based treatment approaches for treating disorders that we use at our centers are based in some fashion on cognitive behavioral therapy (CBT) approaches,” Dr Chase said.
“We use third waves of evidence-based CBT, including dialectical behavior therapy , acceptance and commitment therapy , and exposure plus response prevention,” she said.15-19
CBT has also been found affective in treating alcohol disorders,20 “making it a treatment of choice for these comorbid conditions,” Dr Levounis said.
He added that motivational interviewing can often be an important precursor to CBT in this population “because some patients might not even be motivated to participate in CBT interventions, since some of them do not see their behavior as problematic.”21,22
In addition, Dr Chase noted that their work with adolescents always includes family-based treatments, since EDs do not take place in a vacuum and often include issues of self-esteem that can have a basis in family relationships. This holds true even for college students, many of whom are no longer living with their families.
Tips for Psychiatrists
Both experts stressed the critical importance of approaching individuals with AUD and/or EDs nonjudgmentally because many encounter judgment and blame both in and out of medical settings. People who feel judged or blamed are less likely to open up and trust their providers and less likely to participate in treatments. It is important to recognize that these individuals are experiencing low self-esteem, depression, anxiety, or other issues that drive their behaviors and to demonstrate the same compassion toward them as would be demonstrated toward any other patient with a mood or other psychiatric disorder.
Engage in multidisciplinary collaboration
The most effective interventions include several professionals, including psychiatrists, psychotherapists, dietitians, and others who may play a role in addressing the multiple complex components of this condition.
“It is important to collaborate and make sure all treatment professionals are working together,” Dr Chase emphasized.
Consider recommending support groups
Twelve-step support groups can be helpful for individuals with both EDs and AUD, Dr Chase noted.
SMART Recovery® is another support forum for individuals recovering from addiction as an adjunct or alternative to more traditional 12-step approaches (https://www.smartrecovery.org).
The ready availability of alcohol on college campuses and high prevalence of student drinking23 has many serious risks, including increased risk for comorbid EDs. Education, proactive screening, early intervention, and multidisciplinary collaboration are essential in addressing this serious and growing problem.
- Eisenberg MH, Fitz CC. “Drunkorexia”: exploring the who and why of a disturbing trend in college students' eating and drinking behaviors. J Am Coll Health. 2014;62(8):570-577.
- Ward RM, Galante M. Development and initial validation of the Drunkorexia Motives and Behaviors scales. Eat Behav. 2015 ;18:66-70.
- National Institutes of Health. National Institute on Alcohol Abuse and Alcoholism. Drinking Levels Defined. Available at: https://www.niaaa.nih.gov/alcohol-health/overview-alcohol-consumption/moderate-binge-drinking. Accessed November 14, 2018.
- Burke SC, Cremeens J, Vail-Smith K, Woolsey C. Drunkorexia: Calorie restriction prior to alcohol consumption among college freshman. J Alcohol Drug Educ. 2010;54(2):17-35.
- O'Malley PM, Johnston LD. Epidemiology of alcohol and other drug use among American college students. J Stud Alcohol Suppl. 2002;(14):23-39.
- White S, Reynolds-Malear JB, Cordero E. Disordered eating and the use of unhealthy weight control methods in college students: 1995, 2002, and 2008. Eat Disord. 2011;19(4):323-334.
- Roosen KM, Mills JS. Exploring the motives and mental health correlates of intentional food restriction prior to alcohol use in university students. J Health Psychol. 2015;20(6):875-886.
- Rinker DV, Neighbors C. Examining the association between “drunkorexia,” perceived norms, and drinking motives.” Paper presented at: 39th Annual Research Society on Alcoholism Scientific Meeting; June 27, 2016; New Orleans, LA.
- Conason AH, Brunstein Klomek A, Sher L. Recognizing alcohol and drug abuse in patients with eating disorders. QJM. 2006;99(5):335-339.
- National Institutes of Health. National Institute on Alcohol Abuse and Alcoholism. Screening Tests. Available at: https://pubs.niaaa.nih.gov/publications/arh28-2/78-79.htm. Accessed November 13, 2018.
- Morgan JF, Reid F, Lacey JH. The SCOFF questionnaire: a new screening tool for eating disorders. West J Med. 2000;172(3):164-165.
- National Institutes of Health. National Institute on Alcohol Abuse and Alcoholism. Helping Patients Who Drink Too Much: A Clinician's Guide. Available at: https://pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/PrescribingMeds.pdf. Updated October 2008. Accessed November 14, 2018.
- Marvanova M, Gramith K. Role of antidepressants in the treatment of adults with anorexia nervosa. Ment Health Clin. 2018;8(3):127-137.
- Flament MF, Bissada H, Spettigue W. Evidence-based pharmacotherapy of eating disorders. Int J Neuropsychopharmacol. 2012;15(2):189-207.
- Murphy R, Straebler S, Cooper Z, Fairburn CG. Cognitive behavioral therapy for eating disorders. Psychiatr Clin North Am. 2010;33(3):611-627.
- Jenkins PE, Morgan C, Houlihan C. Outpatient CBT for underweight patients with eating disorders: effectiveness within a National Health Service (NHS) eating disorders service. Behav Cogn Psychother. 2018:1-13.
- Groff SE. Is enhanced cognitive behavioral therapy an effective intervention in eating disorders? A review. J Evid Inf Soc Work. 2015;12(3):272-288.
- Mac Neil BA, Hudson CC. Patient experience and satisfaction with acceptance and commitment therapy delivered in a complimentary open group format for adults with eating disorders. J Patient Exp. 2018;5(3):189-194.
- Steinglass JE, Sysko R, Glasofer D, Albano AM, Simpson HB, Walsh BT. Rationale for the application of exposure and response prevention to the treatment of anorexia nervosa. Int J Eat Disord. 2011;44(2):134-141.
- McHugh RK, Hearon BA, Otto MW. Cognitive-behavioral therapy for substance use disorders. Psychiatr Clin North Am. 2010;33(3):511-525.
- Macdonald P, Hibbs R, Corfield F, Treasure J. The use of motivational interviewing in eating disorders: a systematic review. Psychiatry Res. 2012;200(1):1-11.
- Nyamathi A, Shoptaw S, Cohen A, et al. Effect of motivational interviewing on reduction of alcohol use. Drug Alcohol Depend. 2010;107(1):23-30.
- National Institutes of Health. National Institute on Alcohol Abuse and Alcoholism. College Drinking. Available at: https://pubs.niaaa.nih.gov/publications/CollegeFactSheet/Collegefactsheet.pdf. December 2015. Accessed November 14, 2018.