ating disorders like binge eating disorder, atypical anorexia nervosa, and bulimia nervosa often co-occur with substance use disorders. These conditions, when they occur on their own, can cause significant impairment in many aspects of a person’s life—and when they occur together, the physical, mental, and social consequences are often compounded.
Having a substance addiction can complicate eating disorder treatment outcomes and vice versa, which is why it’s essential that individuals receive comprehensive treatment that addresses both conditions.
What is a Substance Addiction?
An addiction, or substance use disorder, is a chronic relapsing condition in which an individual engages in compulsive drug or alcohol use despite the negative effects it may have on their life.
While everyone’s substance use disorder may affect them differently, some common features of a drug or alcohol addiction may include: (1)
- Failing to quit or control use
- Neglecting previously enjoyed hobbies in favor of substance use
- Using substances in hazardous situations
- Experiencing intense cravings for drugs or alcohol
- Spending a significant amount of time obtaining, using, or recovering from the effects of substances
- Continuing use despite physical or mental health conditions caused or worsened by use
- Continuing use despite occupational or social issues caused or worsened by use
- Requiring higher amounts of drugs or alcohol to feel desired effects (increased tolerance)
- Experiencing unpleasant or distressing symptoms when they cut down or stop use (withdrawal)
Which Eating Disorders Commonly Co-Occur with Addiction?
Certain eating disorders are more likely to co-occur with substance use disorders than others. The purging subtypes of bulimia nervosa are most frequently associated with co-occurring drug and alcohol use. (2) These individuals are reported to to use alcohol and other substances more frequently than patients with anorexia nervosa-restricting type and binge eating disorder.
Patients with anorexia nervosa-binge eating/purging type are also more likely to misuse substances than those with the restricting type. (3) Generally, higher frequencies of binge eating and purging are associated with greater frequencies of drug and alcohol use. (3)
Individuals with a restricting subtype of anorexia nervosa may be at higher risk for use of alcohol, although this is more an anecdotal observation, and in need of further research.
Moreover, although people with eating disorders may use a range of substances, alcohol is most commonly associated with co-occurring eating disorders and addiction. (2) Other commonly used substances include: (5)
- Diet pills
Prevalence of Comorbidity
The prevalence of co-occurring eating disorders and substance use disorders varies greatly from study to study. A review of 51 case reports on comorbidity found a range of co-occurrence from 0% to 55%. (2)
A nine year longitudinal study concerning women with eating disorders found that 30% of women with bulimia nervosa and 18% of women with anorexia nervosa were diagnosed with an addiction for the first time over the course of the study. (4)
And yet, other research estimates that 50% of people with an eating disorder misuse or are dependent on drugs or alcohol compared to 9% of the general population. In addition, among people with a substance addiction, over 35% have an eating disorder. (5)
Proper Diagnosis of Comorbidity
The existence of either an eating disorder and/or a substance use disorder can be highly predictive of an underlying mental health diagnosis. Such a diagnosis places a person at a higher risk for both eating disorders and substance use.
It is vital that a thorough psychiatric assessment take place as early as possible in the course of either a substance use issue or eating disorder, so that treatment of what can be seen as the underlying issue may be treated comprehensively.
Missing the diagnosis of an underlying mental health condition can intensify substance use and eating disorder symptoms, and may lead a person to feel that they have failed treatment. In fact, treatment providers are prone to failing patients if they inadvertently focus on the outward behavior of the substance use condition or eating disorder symptoms without properly ensuring their patient has had appropriate diagnosis and treatment of their mental health condition.
A common occurrence is inadequate diagnostic process and inadequate psychopharmacologic interventions. This is no different than under treatment of high blood pressure leading to progressively worsening hypertension.
Why Do Eating Disorders and Addiction Commonly Co-Occur?
The relationship between eating disorders and substance use disorders is complex, and researchers are still not entirely certain why they frequently co-occur, though there are likely several psychosocial and biological influences. (4)
There are often different progressions of co-occurring eating disorders and substance use disorder development. For instance, some people in recovery from an eating disorder may substitute drugs or alcohol for disordered eating symptoms, such as binge eating or purging. (4) Similarly, someone who is recovering from an addiction may engage in disordered eating behaviors to cope with or compensate for the absence of substances. (6)
Others report that they used stimulants or diet pills to control or decrease their weight, and that this stimulant misuse eventually progressed into an addiction. Meanwhile, some patients have reported developing an eating disorder after substances have suppressed their appetite. Moreover, patients with bulimia nervosa or anorexia nervosa may “self-medicate” with substances in order to cope with the distress of disordered eating behaviors. (7)
Genes are also thought to play a major role in the development of eating disorders and co-occurring addictions. That means a family history of either eating disorders or substance addictions may increase a person’s risk for the development of either or both disorders. One study suggested there was a link between binge eating and compensatory behaviors in bulimia nervosa and alcoholism. (7) Another study found that 83% of observable traits between bulimia nervosa and illicit drug use/dependence was accounted for by genetic influences. (4)
Other factors that can lead to the correlation between eating disorders and addictions include: (7)
- Childhood trauma
- Childhood sexual abuse
- Common traits, such as impulsivity, novelty-seeking, and emotional dysregulation
- Witnessing important persons in one’s life engaging in disordered eating or substance use
- Shared symptoms, such as binging more amounts than intended, continuous binging/use despite negative consequences, and avoiding enjoyable activities due to binging/using.
- Shared brain chemistry (disturbances in serotonin, dopamine, gamma amino-butyric acid, and endogenous opiates)
Comprehensive Treatment for Co-Occurring Disorders
The presence of a substance addiction can lead to greater severity of disordered eating behaviors, an increase in risk in life-threatening consequences, and may complicate assessment, treatment, and recovery. (2,7)
When a clinician sees the presence of either an eating disorder or a substance use disorder, and especially when seen together, there should be a high suspicion of an underlying mental health condition. A thorough psychiatric assessment (and assessment of family psychiatric history) should commence and in so doing, the patient can be guided to an appropriate treatment plan to address their condition in an integrated and comprehensive manner.
For these reasons, integrated treatment that fully addresses both the eating disorder and addiction is necessary for positive treatment outcomes. Further, if both conditions exist, it is highly likely that an underlying mental health condition exists, and it is vital that treatment include addressing this condition in a meaningful way.
Unfortunately, a study of 351 publicly funded substance use treatment programs found that only 16% offered treatment for comorbid eating disorders. What’s more is only 50% of the programs even screened for eating disorders and a mere 3% of programs had formal referral arrangements with eating disorder treatment programs. (7)
At Within, our goal is to meet all of our patients where they are at. And to do that, our clinicians conduct a biopsychosocial evaluation, which takes many factors of a person’s life into account—including the psychological, social, and biological factors. As part of our first steps in treatment, we screen for eating disorders as well as co-occurring substance use disorders and mental health conditions.
If you or a loved one are looking for help healing from an eating disorder, our clinical care team is here for you. Call our team to learn about our virtual treatment and care programs which include comprehensive treatment for any co-occurring disorders.
- American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
- Gordon, S. M., Johnson, J. A., Greenfield, S. F., Cohen, L., Killeen, T., & Roman, P. M. (2008). Assessment and treatment of co-occurring eating disorders in publicly funded addiction treatment programs. Psychiatric services (Washington, D.C.), 59(9), 1056–1059.
- Fouladi, F., Mitchell, J.E., Crosby, R.D., Engel, S.G., Crow, S., Hill, L, et al. (2015). Prevalence of Alcohol and Other Substance Use in Patients with Eating Disorders. European Eating Disorders Review 23(6).
- Baker, J.H., Mitchell, K.S., Neale, M.C., Kendler, K.S. (2010). Eating disorder symptomatology and substance use disorders: Prevalence and shared risk in a population based twin sample. International Journal of Eating Disorders 43(7), 648-658.
- Root, T. L., Pisetsky, E. M., Thornton, L., Lichtenstein, P., Pedersen, N. L., & Bulik, C. M. (2010). Patterns of co-morbidity of eating disorders and substance use in Swedish females. Psychological medicine, 40(1), 105–115.
- Substance Abuse and Mental Health Services Administration. (2011). Clients with Substance Use and Eating Disorders.
- Eskander, N., Chakrapani, S., & Ghani, M. R. (2020). The Risk of Substance Use Among Adolescents and Adults With Eating Disorders. Cureus, 12(9), e10309.