Bulimia nervosa and alcohol use disorders frequently co-occur. A review of the literature, however, reveals a paucity of information on treatment of patients with these comorbid conditions. We present a case report of a 34-year-old Caucasian female with a 20-year history of bulimia nervosa with co-occurring alcohol dependence, who participated in a randomized placebo-controlled medication augmentation trial for bulimia nervosa. The patient served as a pilot subject who met the exclusionary criterion of alcohol dependence, but received all the assessment and intervention procedures of the clinical trial for bulimia nervosa. Despite double-blind random assignment to a placebo condition, the patient's symptoms of bulimia nervosa substantially improved over the course of the 5-week efficacy trial. We hypothesize that this improvement was due to concurrent abstinence from alcohol rather than a placebo effect.
Eating disorders and alcohol use disorders frequently co-occur in clinical samples Holderness, Brooks-Gunn, & Warren 1994 and Katz 1992. High rates of alcohol use disorders have been observed in patients with eating disorders (e.g., Bulik 1987 and Mitchell, Hatsukami, Eckert, & Pyle 1985), and high rates of eating disorders have been documented in patients with alcohol use disorders (e.g., Grilo, Levy, Becker, Edell, & McGlashan 1995, Higuchi, Suzuki, Yamada, Parrish, & Kono 1993 and Taylor, Peveler, Hibbert, & Fairburn 1993). Although the specific nature of the association between eating and alcohol use disorders remains somewhat ambiguous Bulik et al. 1997, Katz 1992, Krahn 1991 and Wilson 1993, the pragmatic clinical issues posed by patients with both disorders represents a well-known challenge. For instance, patients with co-occurring eating and alcohol use disorders are psychiatrically more complicated in terms of additional psychiatric and personality disturbances than those without the co-occurrence Bulik et al. 1997, Grilo, Becker, Levy, Walker, Edell, & McGlashan 1995, Lacey 1993 and Suzuki, Higuchi, Yamada, Mizutani, & Kono 1993 and may be at heightened risk for medical morbidity and mortality (Catterson, Pryor, Burke, & Morgan, 1997).
Clinicians often encounter the very perplexing phenomenon of co-occurring bulimia nervosa and alcohol use disorders in their practice. Although common clinical practice is to recommend abstinence from alcohol use Mitchell, Specker, & Edmonson 1997 and Wilson 1993, we found no reports in the literature describing the clinical outcomes of this conventional clinical wisdom for bulimia nervosa. Due to the idiosyncrasies of efficacy studies, clinical research has not provided sufficient guidance for how to help patients with these co-occurring conditions (Grilo, Devlin, Fahy, & Yanovski, 1997). Options include treating the alcoholism first, the eating disorder first, or a dual-diagnosis approach in which both problems are treated concurrently. Indeed, clinical research is lagging behind clinical practice. Thus, decisions are made on clinical grounds because there is insufficient empirical data available to guide treatment decisions.
Excluding patients with disorders of alcohol or drug use from controlled clinical efficacy trials is a nearly universal practice among eating disorder researchers. Similarly, clinical trials for alcoholism rarely include measures to assess for changes in eating disorder pathology, even if present. A recent workshop sponsored by the National Institutes of Health highlighted research priorities for the field of eating disorders (Grilo et al., 1997). One area of consensus was for clinical researchers to examine treatment interventions for patients with “comorbid” conditions, such as co-occurring alcohol use disorders.
