That boy you are treating for cocaine dependence might have an eating disorder. He might be using the cocaine as an appetite suppressant to facilitate his desire for an ultra skinny, waif-like body, or to numb himself from the shame of having a “woman's problem.”
Anorexia nervosa and bulimia nervosa are typically viewed as women's disorders. As a result, males with eating disorders often live in lonely silence and frequently rely on substances to relieve their internal pain. Healthcare professionals will encounter the combination of eating disorders and substance abuse more often in males as the prevalence of eating disorders increases in men and boys.
According to experts, the ratio of males to females with eating disorders has gone from 1 in 10 to 1 in 6.1 A recent Harvard study even suggested that one-quarter of adults with eating disorders are men.2 The National Institute of Mental Health (NIMH) suggests that roughly 1 million boys and men currently suffer from eating disorders.3 Even if these estimates were high, it still would be reasonable to believe that hundreds of thousands of males have anorexia, bulimia, eating disorder not otherwise specified, or binge eating disorder, with a significant percentage experiencing substance abuse issues as well.
Substances of abuse
A study of 135 male eating disorder patients at Massachusetts General Hospital revealed that across all diagnoses 37% had a comorbid substance use problem, with alcohol abuse the most common problem (seen at a rate roughly three times that of cocaine abuse).4 More specifically, 61% of patients with bulimia had a co-occurring substance abuse problem-they are three times more likely to have this problem than are those with anorexia. A primary reason for this differential is that many patients with anorexia will not drink alcohol or smoke marijuana because of caloric implications.
It is important to note, however, that some patients with most symptoms of anorexia maintain average weight by obtaining most of their calories through alcohol. If they were to stop drinking, their weight loss would reveal a full anorexic picture. More often, though, anorexic patients abuse cocaine or crystal meth because of the effect of decreased appetite. Yet overall, individuals with bulimia are much more likely to abuse substances than are those with anorexia. The remainder of this article will therefore focus on the bulimic end of the eating disorder continuum.
Persons participating in binge eating behavior appear to be two times more likely than their non-bingeing counterparts to experience severe substance use issues.5 Binge eating disorder (BED) is the most commonly diagnosed eating disorder in males, with 40% of male eating disorder patients having this single diagnosis.2 Approximately 57% of males with BED appear to have lifelong substance abuse problems.6
The substances abused by men who binge eat appear to vary, depending on whether the individuals engage in some form of purging behavior as well. Ross and Ivis5 pointed out that men who binge eat without purging are more likely to use alcohol or tobacco, but those who binge eat and purge not only drink and use tobacco products but also use marijuana, barbiturates and hallucinogens. Furthermore, males who binge and purge exhibit an increased number of drunken episodes compared with men who evidence no compensatory behaviors. This might result from the fact that drunkenness frequently results in vomiting, which is a mechanism to eliminate calories-a desired outcome. It also appears that cocaine use itself might be a precursor to bulimia nervosa in males4 and that men who binge eat have a substantially increased likelihood of cocaine abuse compared with binge eating females.7
It is not uncommon to find persons with eating disorders misusing or abusing diuretics, laxatives, ipecac, or diet pills to manipulate their weight. Men with eating disorders seem to use laxatives less often than women with the disorders8, and likely abuse the other over-the-counter products less often as well. Men are much more likely to increase exercise8 than to use “diet products” since the concept of dieting is not as normative for men. However, the focus on exercise can lead to the abuse of yet another substance: steroids. There is a subset of men with eating disorders whose body image obsession is on muscularity. Muscle dysmorphia, an irrational focus on muscle gain (being “ripped”), can result in steroid abuse, since the desired muscle gain usually cannot be attained through natural means.
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