Narcological Characteristics of Young Women with Bulimia Nervosa

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INTRODUCTION

Eating disorder (ED) remains one of the most pressing medical and social problems of the modern life. According to the latest data, ED in Russia affects about 4.0% of the population, with 0.5–3.7% of cases being anorexia nervosa and 1.1–4.2% bulimia nervosa [1].

It is difficult to remain indifferent in the world full of beautiful pictures, ‘successful’ angles, propaganda of thinness under the mask of health and slimness with ‘ideal’ body parameters. Striving for ‘perfection’, even using healthy methods, people often experience strong negative emotional states, which often give rise to eating disorder. To note, disordered eating behaviors are to the highest extent prevalent in women [2], which, following the cherished figures on the scales, create various communities to support each other in keeping to the diets, where the moment of deformation of healthier dietary habits formed in the childhood, often comes unnoticed. Counting calories, harmful restrictions in the diet, strenuous exercises, use of laxatives/diuretics/anorexigenic drugs are not perceived as something wrong and pathological. Driving themselves in a tough framework, girls do not notice how they tip over to the ‘diet-breakdown’ vicious circle, approaching the next whorl of restrictions and compensatory behavior with large numbers on the scale, which gives rise to more worries about their body, weight and appearance. The resulting distress and increasing anxiety-depressive states can in parallel form comorbid conditions including, among other things, the use of various psychoactive substances [3].

There are many studies aimed at identifying and characterizing the course of the disease in patients with anorexia nervosa [4], which cannot be said about patients with bulimia nervosa (BN). Due to the lack of visually striking changes in appearance, encouragement by society, in particular by the loved ones, use of various methods of compensatory behavior in the fight against ‘extra pounds’; an endless internal struggle with negative experiences and concealment of evident internal conflicts, it is hardly possible to identify or at least suspect BN at the early stages.

High prevalence, problems of diagnosis, including identification of predictors, low rate of seeking help from specialists and a number of serious consequences indicate the importance of studying the causes, clinical manifestations and prevention of this spectrum of disorders. Returning to the problem of eating disorder, in particular of BN, comorbidity, it should be noted that the main areas of work are focused on affective pathology, anxiety disorders, high risk of suicidal behavior [5, 6]. Of no less interest is the relationship of ED with substance use disorders, however, the main emphasis in the known research works is anorexia nervosa [3]. Given the current prevalence of substance use pathology [7–9] and the ongoing study of the causes of formation of addictions [10, 11], it only remains to guess about the number of individuals with ED among users of alcohol and other psychoactive substances (PAS).

In a previously conducted pilot study on suicidological characteristics in young women with BN, where the drug use component was considered in the context of autoaggressive behavior [12], attention was drawn to the fact that the problems of the drug use in the study group were quite widespread, requiring further research and specification.

It is known that from the standpoint of suicidology, both ED and alcohol abuse are factors enhancing suicidal risk [5, 6, 12], and studying of the latter undoubtedly deserves special attention in case of a combination of ED (in particular, BN) and alcohol dependence syndrome (ADS), which at the initial stage implies a detailed and close study of the drug addiction characteristics in young women with BN.

The aim of this study to conduct a comprehensive study of the narcological characteristics of young women with bulimia nervosa.

The objectives of this study to narcological characteristics of young women with bulimia nervosa by collecting the narcological history, data of self-reports and specialized test systems: RUS-AUDIT (Alcohol Use Disorders Identification Test) and M.I.N.I. (Mini-International Neuropsychiatric Interview). To clarify the existing theoretical concepts concerning relationship between narcological disorders and bulimia nervosa.

MATERIALS AND METHODS

A total of 195 young women were examined at Ryazan State Medical University from October 2023 to February 2024. The study was approved by the Local Ethics Committee of Ryazan State Medical University (Protocol No. 2 of September 13, 2023). All patients who took part in the study signed voluntary informed consent.

Criteria for inclusion in the study group: established diagnosis of BN according to the criteria of the International Classification of Diseases and Related Health Problems, 10^th revision (ICD-10); absence of other mental disorders according to the criteria of ICD-10 that could have a significant impact on the assessed variables; age from 20 to 27 years, the fact of studying at a higher educational institution at the time of the study.

Criteria for inclusion in the control group: comparable age, comparable socio-demographic characteristics, absence of BN and other eating disorders according to ICD-10 criteria, absence of other established mental disorders according to ICD-10 criteria, no use of psychotropic drugs and drugs that affect appetite (according to the respondent).

The study did not include individuals with other mental disorders at the time of the study; those suffering from somatic diseases with symptoms as secondary eating disorders.

The study group included 40 girls with the established diagnosis of BN (girls with BN, GwBN), the control group included 155 young women without eating disorders (GwtBN). The mean age of women in the study group was (21.9±0.8) years, and of women in the control group — (22.1±1.2) years.

The following diagnostic tools were used: a clinical and anamneustic questionnaire to identify autoaggressive behavior (including questions to detect substance use) [13], RUS-AUDIT test [14], M.I.N.I. mini-international neuropsychiatric interview [15].

Mathematical data processing was performed using the SPSS program (IBM SPSS Statistics, USA). Differences were considered statistically significant at p <0.05. Statistical analysis of the results and data processing were performed using nonparametric methods of mathematical statistics using χ² criteria. For nonparametric criteria, the description of the data is presented as n (%) the absolute number of the characteristic in the group and its percentage to the total number of group members. The boundaries of the confidence interval (CI) for the odds ratio are indicated as the lower fiducial limit (LFL) and upper fiducial limit (UFL).

RESULTS

The analysis of the RUS-AUDIT clinical and anamneustic questionnaire data demonstrated statistically significant results concerning the criteria of harmful alcohol consumption, which was identified almost 4 times more often in the study group and accounted for about a third of young women with BN (Table 1). Of attention is also the presence of individuals in the study group with a probable ADS determined using RUS-AUDIT (5% of respondents), with the absence of this tendency in the control group. The same pattern was observed among young women in groups with a low risk of developing ADS; as follows from the table, the control group is much more favorable. The data of the Mini International Neuropsychiatric Questionnaire (M.I.N.I.) regarding the section ‘Alcohol dependence, present at the moment’ are presented in the same table. According to this diagnostic tool (filled out jointly with the physician-researcher), the percentage of people with probable ADS in the group of young women with BN was significantly higher and amounted to 15% of those in the study group (three times more than in the RUS-AUDIT test, filled out by the participants independently). This is already a fact in itself, deserving an interest in the context of potential diagnostic work with the study contingent of people.

 

Table 1. Results of RUS-AUDIT and M.I.N.I. tests

Criterion	GwBN	GwtBN	ꭓ2	р	OR	CI
						LFI	UFI
Quantity, n	40	155	–
RUS-AUDIT
Relatively low risk, n (%)	25 (62.5)	142 (91.2)	21.91	< 0.0001	0.153	0.065	0.359
Harmful alcohol consumption, n (%)	12 (30)	12 (7.7)	14.59	0.0001	5.107	2.083	12.522
Probable alcohol dependence syndrome, n (%)	2 (5)	0 (0)	7.83	0.0051	Infinity	NaN	Infinity
Mini International Neuropsychiatric Questionnaire M.I.N.I.
Alcohol dependence at the present time	6 (15)	0	23.99	< 0.0001	NaN	NaN	NaN

Notes: UFL — upper fiducial limit, GwtBN — girls without bulimia nervosa, CI — confidence interval, GwBN — girls with bulimia nervosa, LFL — lower fiducial limit, OR — odds ratio, Infinity — absence of upper fiducial limit, M.I.N.I. — Mini-International Neuropsychiatric Interview, NaN — not-a-number, RUS-AUDIT — Alcohol Use Disorders Identification Test

 

Summarizing the data obtained at this stage, it can be stated that young women with an eating disorder in the form of BN, from the standpoint of drug addiction practice, represent a very specific cross-section of this age group. The test systems used in the study have proven themselves to be excellent in identifying existing features and disorders.

Let us proceed to the results of self-reports regarding subjective assessment of excessive alcohol consumption obtained from the clinical and anamneustic questionnaire aimed at identifying autoaggresive behavioral patterns. Of course, this diagnostic tool, used as a semistructured interview with respondents, has a different focus, but, for the purpose of a comprehensive assessment of autoaggressive potential of the respondent, the latter is offered a number of statements concerning ‘narcological vector’ of self-destructing behavior including the question ‘Do you think you are abusing alcoholic drinks?’. This question not only has a specific focus that interests us at this stage, but also permits to determine one’s own, subjective attitude to probable drug use problems, which permits to understand the level of devaluation of problems or paraalcoholic denial mechanisms identified in the study of the characteristics of the group at the first stage (assessment using RUS-AUDIT and M.I.N.I.). The indicated data, along with other discovered parameters of a drug-related character, identified at the second stage of the work, are presented in Table 2.

 

Table 2. Data of clinical and anamneustic questionnaire aimed at identification of autoaggressive behavior patterns (narcological part)

Criterion	GwBN	GwtBN	ꭓ2	р	OR	CI
						LFI	UFI
Quantity, n	40	155	–
Subjective conviction in the existence of alcohol abuse, n (%)	3 (7.5)	3 (1.94)	3.30	0.0692	4.108	0.797	21.182
Consumption of up to approx. 200 ml of alcohol in recalculation for vodka at a time 3–4 times a month, n (%)	7 (17.5)	7 (4.5)	8.04	0.0046	4.485	1.473	13.657
Consumption of approx. 100–200 ml of wine or beer at a time, no more than several times a year, n (%)	12 (30)	85 (54.8)	7.85	0.0051	0.353	0.167	0.745
Tobacco smoking, n (%)	8 (20)	9 (5.81)	8.05	0.0046	4.056	1.453	11.319
Increase in the number of smoked cigarettes in the last two years, n (%)	6 (15)	4 (2.59)	10.08	0.0015	6.794	1.818	25.397

Notes: UFL — upper fiducial limit, GwtBN — girls without bulimia nervosa, CI — confidence interval, GwBN — girls with bulimia nervosa, LFL — lower fiducial limit, OR — odds ratio

 

First of all, of attention is the generally low subjective level of assessment of oneself as a person probably having at least minimal problems with alcohol consumption. Returning to the data of the first table, obtained in RUS-AUDIT test, namely, that 30% of young women with BN have at least ‘harmful forms of alcohol consumption’, and 5% have a significant probability of alcohol dependence (and according to M.I.N.I. data — 15% of respondents in the group), the presented data permit to form a comprehensive idea of the narcological characteristics of the study group. According to the data of diagnostic interviews, alcoholic excesses in individuals of the study group most often occurred with the underlying breakdowns in ‘proper nutrition’, or with pronounced internal stress, often associated with intrapersonal conflicts arising from problems of accepting one's own appearance.

It is easy to see that young women with BN are statistically more inclined to use strong drinks in a rather aggressive style (up to approx. 200 ml of alcohol equivalent to vodka, 3–4 times a month), while respondents of the control group tended to have a milder patterns of consumption (approx. 100–200 ml of wine or beer at a time no more than several times a year). All this characterizes the study group rather unfavorably, demonstrating evident comorbidity of BN and alcohol spectrum disorders. By the way, in the modern narcology, there is a well-known concept of a ‘standard portion’ (‘drink’) of alcohol which is approx. 10 ml of ethyl alcohol [14]. Certainly, we understand that from the point of view somatic health, there is no safe level of alcohol consumption, nevertheless, it is considered that, according to the National Institute on Alcohol Abuse and Alcoholism, risk of the developing addiction is minimal when consuming not more than 28 standard drinks per month [16]. According to our data, young women with BN were most often in the zone of consuming 24-32 standard drinks per month, which greatly distinguishes them from the participants in the control group. Unfortunately, in a significant number of cases, alcohol acts as a ‘tranquilizer’ and is widely used by girls with BN to normalize their condition. By the way, alcohol can aggravate an existing eating disorder, both due to the active use of alcohol calories, and as a result of the depressing effect of ethanol on the central nervous system (up to a pronounced decrease in mood).

The next drug compensator of chronic stress in young women with BN is traditionally believed to be smoking, statistically predominating in the study group (almost four times), as well as increase in the number of cigarettes smoked for the last two years (the years of maximum expression of the severity of the ED). On the one hand, the discovered feature is also associated with attempts to cope with failures in weight control on the other hand, many girls noted ananorexic effect of smoking, that is, use of cigarettes to suppress the appetite, which is the cause of the increase in the number of cigarettes smoked in the last two years.

It should be noted that during the data processing, we did not find statistically significant differences concerning use of substances. However, almost a third of respondents used a number of substances (mainly antidepressants of the group of selective serotonin reuptake inhibitors) to control appetite, purchased independently and often used in maximum dosages.

DISCUSSION

The obtained data permit to state that ED (in this study, BN) is to a significant extent associated with various drug problems, first of all, with disorders related to alcohol consumption. In the study group, both formed patterns of dependence, and to a much greater extent, a variant of harmful (for ADS formation) alcohol use are presented. The results of such a pre-diagnostic section as RS-AUDIT are rather demonstrative, since they reflect exactly the high potential risk of developing alcohol dependence in the future. Often, such patterns of consumption are found with the underlying other probable predictors, most often described in terms of genetic predisposition or some unfavorable emotional background [17]. The latter is to a significant extent represented in the study group and is associated with significant distress as a result of difficulties in maintaining ideal body weight [18].

Since the initial study design did not imply a clinical assessment of the participants from the point of view of addiction (only test systems and self-reports were used), it is certainly impossible to establish a direct diagnosis, however, its probability is a rather alarming moment, especially taking into account the age of participants. With strongly alarming data on the diagnosis of disorders in alcohol consumption control, the level of subjective assessment of the existence of problems remains low, which is necessary to take into account in the narcological work with patients with BN. All this is of undoubted interest for both psychiatric, psychotherapeutic and narcological services. The existing level of actual stress associated with ED, caused by dysmorphophobic problems, numerous breakdowns in healthy eating habits, quite logically lead to an increase in the number of people abusing alcoholic beverages [19] both in terms of the number of consumers, and, probably, in terms of the amount of alcohol consumed by young women with BN. The obtained data are also of undoubted interest for the suicidological service, since the consumption of psychoactive substances (including alcohol) is one of the options for non-suicidal realization of anti-vital aspirations [5, 20].

Smoking continues to be a popular form of addictive behavior in the group of women studied, being a way of coping with existing neurotic experiences, and, in addition, a ‘generally recognized’ means of regulating appetite and losing weight.

CONCLUSION

Young women with bulimia nervosa have very characteristic narcological specifications, significantly different from the control group. The level of subjective assessment of oneself as a person having problems with alcohol consumption in the considered group, is far lower than the actual prevalence of the respective disorders and pre-diagnostic rubrics, in particular, the pattern of harmful alcohol consumption (according to RUS-AUDIT data). Similar features concern nicotine dependence, with no statistically significant differences in relation to narcotic drugs. One should remember about the probability of the existence of ED in the form of bulimia nervosa in patients with harmful consumption of alcohol or with a formed alcohol dependence syndrome.

The obtained data expand the existing knowledge concerning the comorbidity of eating disorders in the form of bulimia nervosa and addictive disorders, which allows for the creation of more individualized therapeutic and prophylactic programs.

ADDITIONAL INFORMATION

Author contributions. E.R. Gurulyova — collection and processing of material, statistical processing, writing the text; A.V. Merinov — concept and design of the study, writing the text, editing; V.V. Novikov — writing the text, editing. All authors approved the manuscript (the publication version), and also agreed to be responsible for all aspects of the work, ensuring proper consideration and resolution of issues related to the accuracy and integrity of any part of it.

Ethics approval. The study was approved from the Local Ethics Committee of the Ryazan State Medical University (Protocol No. 2 of September 13, 2023).

Consent for publication. All participants of study voluntarily signed an informed consent form before being included in the study.

Funding sources. No funding.

Disclosure of interests. The authors have no relationships, activities or interests for the last three years related with for-profit or not-for-profit third parties whose interests may be affected by the content of the article.

Statement of originality. The authors did not use previously published information (text, illustrations, data) when creating this work.

Data availability statement. The editorial policy regarding data sharing does not applicable to this work, and no new data were collected or created.

Generative AI. Generative AI technologies were not used for this article creation.

Provenance and peer-review. This work was submitted to the journal on its own initiative and reviewed according to the usual procedure. Two external reviewers, a member of the editorial board and the scientific editor of the publication participated in the review.

About the authors

Elena R. Gurulyova

Ryazan State Medical University

Author for correspondence.
Email: er46280@gmail.com
ORCID iD: 0000-0002-7406-4563
SPIN-code: 7564-5262
Russian Federation, Ryazan

Aleksey V. Merinov

Ryazan State Medical University

Email: merinovalex@gmail.com
ORCID iD: 0000-0002-1188-2542
SPIN-code: 7508-2691
ResearcherId: M3863-2016

MD, Dr. Sci. (Medicine), Professor

Russian Federation, Ryazan

Vladimir V. Novikov

Ryazan State Medical University

Email: novlad2006@yandex.ru
ORCID iD: 0000-0003-3132-4959
SPIN-code: 9322-7985

MD, Dr. Sci. (Med.), Assistant Professor

Russian Federation, Ryazan

References

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