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Drunkorexia: Where Eating Disorder Meets Substance Use

By Asma Farooq, MD

Eating Disorders and Comorbid Substance Use Disorder

Drunkorexia is a non-medical term and is not a DSM-5 Diagnosis. Drunkorexia refers to the combination of disordered eating and unhealthy alcohol use. Substance use disorders (SUDs) are highly prevalent. According to a United States national survey, approximately 14.5 percent of individuals age 12 or over had a diagnosable SUD in the past year, including approximately 10.2 percent with an alcohol use disorder and 6.6 percent with an illicit drug use disorder. Illicit drug use and nonmedical use of medications alone or in combination with alcohol are associated with a substantial proportion of emergency department visits in the United States. The United States Centers for Disease Control and Prevention's National Center for Health Statistics estimated that there were 105,752 overdose deaths in the 12-month period ending October 2021.

The essential feature of a substance use disorder is the presence of a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues using the substance despite significant substance-related problems. An important characteristic of SUDs is an underlying change in brain circuits that may persist beyond detoxification, particularly in individuals with severe disorders. The behavioral effects of these brain changes may be exhibited in the repeated relapses and intense drug craving when the individuals are exposed to drug-related stimuli. The diagnosis of a substance use disorder is based on a pathological pattern of behaviors related to use of the substance.

On the surface it can seem as though eating disorders and substance use disorders are completely different. But underneath the surface, they can develop for similar reasons. Both eating disorders and substance use disorders can develop as a result of trying to escape pain, anxiety, depression or stress. Because of this, we see a high comorbidity between substance use disorders and eating disorders. Both also share a significant amount of common risk factors, including brain chemistry, family history, low self-esteem, depression, anxiety and social pressures.

About 30% of people with bulimia nervosa and anorexia nervosa-binge eating/purging type also meet criteria for alcohol abuse, while this is less common in the restricting type of anorexia nervosa. This is not a good combination—the two most lethal psychiatric disorders are substance use disorders (number 1) and anorexia nervosa (number 2). SUDs have an additive effect on excess mortality in patients with eating disorders—mortality from anorexia nervosa is 6x higher than that in the general population, and when you combine anorexia nervosa with alcohol abuse, the mortality jumps to nearly 12x higher than the general population. The prevention and treatment of SUDs in this patient group is thus imperative to reduce mortality.

Blacking Out with Drunkorexia

Drinking on an empty stomach will cause an individual to get drunk faster, leading to a quicker spike in blood alcohol content in a shorter amount of time. This can pose great risk and cause an individual to go from feeling fine to blacking out quickly. Blacking out refers to the temporary loss of memory due to excessive alcohol consumption.

During a blackout, an intoxicated person can still function normally, but due to lowered inhibitions may participate in behaviors they might not have otherwise. Many people who black out later learn that they participated in risky behaviors, including drugs use, driving, dangerous stunts and vandalizing property.

Alcohol can also affect autonomic responses, including the gag reflect. A person who’s blacked out is at risk for vomiting while sleeping, and due to loss of reflex control, may choke or suffocate on their vomit. Loss of coordination is also common, making it likely for an intoxicated person to fall or injure themselves, which can be particularly dangerous for individuals with eating disorders suffering from low bone mineral density.

Chronic alcohol consumption can cause neurological complications including irreversible cognitive dysfunction, Wernicke encephalopathy, Korsakoff syndrome, alcoholic cerebellar degeneration, and others. It also is a major risk factor for development of refeeding syndrome.

Dehydration and Malnutrition

Excessive alcohol consumption can cause dehydration. Alcohol is a diuretic (substance that increases production of urine), causing your body to increase urine production. If not enough water is being drunk alongside alcohol, you can become dehydrated quickly. Dehydration can exacerbate existing complications of an eating disorder and malnutrition:

  • Tiredness
  • Headache or confusion
  • Dizziness, weakness or light-headedness
  • Hypotension
  • Constipation and other gastrointestinal complaints
  • Electrolyte complications

How Much Alcohol is Too Much?

According to the National Institute on Alcohol Abuse and Alcoholism, alcohol consumption is divided into three levels:

  • Moderate Drinking: limiting alcohol intake to two drinks or less in a day for men or one drink or less in a day for women.
  • Binge Drinking: a pattern of drinking alcohol that brings blood alcohol concentration (BAC) to 0.08% or higher. For a typical adult, this pattern corresponds to consuming 5 or more drinks (men), or 4 or more drinks (women), in about 2 hours.
  • Heavy Drinking: drinking more than four drinks on any or more than fourteen drinks per week (men) or drinking more than three drinks on any day or more than seven drinks per week (women)

Treating Eating Disorders and Alcoholism

As a patient begins to address behaviors related to their eating disorder, alcohol addiction problems can increase since they may be trying to “replace” their eating disorder with another maladaptive coping mechanism or reduce the stress associated with recovery, treatment and life change. Indeed, people with eating disorders are significantly more likely to receive their SUD diagnosis within a year of being diagnosed with their eating disorder.

If a patient is experiencing severe complications because of their eating disorder, it is imperative to refer the individual to a specialized medical stabilization unit for eating disorders that can also address alcohol withdrawal symptoms. In this case, medical stabilization is the first step in recovery before a patient can be transferred to a lower level of care where they can continue both their eating disorder and substance use recovery.

The management of alcohol withdrawal is directed at alleviating symptoms and identifying and correcting metabolic derangements. Benzodiazepines or similar medications are used to control psychomotor agitation and prevent progression to more severe withdrawal. Supportive care, including intravenous fluids, nutritional supplementation, and frequent clinical reassessment including vital signs, is important.

Resources

Last Reviewed: October 2023 by Dennis Gibson, MD, FACP, CEDS

Related Resources

ACUTE Earns Prestigious Center of Excellence Designation from Anthem
In 2018, the ACUTE Center for Eating Disorders & Severe Malnutrition at Denver Health was honored by Anthem Health as a Center of Excellence for Medical Treatment of Severe and Extreme Eating Disorders. ACUTE is the first medical unit ever to achieve this designation in the field of eating disorders. It comes after a rigorous review process.

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