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While most forms of therapy were originally designed to treat a specific type of mental health disorder, some psychotherapy approaches have been found beneficial for addressing the interlocking causes and contributions of a dual diagnosis.
Cognitive behavior therapy (CBT) has long been the leading form of therapy used to combat eating disorders—particularly bulimia nervosa—as well as a number of common comorbid conditions, such as anxiety, depression, and substance use disorder. This may be due to the extensive research done on CBT, compared to other methods of "talk" therapy.
The practice focuses on helping a patient first identify, and then change, negative thought patterns they may experience as part of their disorder(s). The goal of CBT is for these changes to become automatic until, eventually, the patient no longer experiences these negative thoughts at all. Alternatively, patients should become at least aware of their negative thought patterns. And, in either case, they are given tools to help manage their emotions and deter destructive cycles.
The keystone belief of cognitive behavioral therapy—that a person’s thoughts and feelings play a fundamental role in their behavior—makes this practice highly adaptable and suitable to treat a number of mental health disorders, including in cases of comorbid conditions. And the tools CBT offers can be used in a wide range of scenarios, both in the therapist’s office and at home.1
As its name may suggest, acceptance and commitment therapy (ACT) teaches that acceptance is the healthiest and most beneficial way to deal with the unhelpful thoughts, feelings, symptoms, or circumstances involved with mental health disorder(s). And that broad approach is part of what makes this method adaptable to treating a dual diagnosis.
ACT works almost in an equal and opposite way to CBT. Rather than proactively catching and redirecting unhelpful thoughts, this method promotes the idea of reducing the effort or energy spent on attempting to control these thoughts in the first place.
Rather, ACT implores its patients to let these thoughts come and go, with the idea that this will reduce their impact. To aid in that effort, patients are taught strategies like mindfulness, to help them focus on the present moment, and cognitive diffusion, which helps separate the idea of oneself from one's inner experiences.2
And rather than spend energy on redirecting thoughts, patients are encouraged to get past unhealthy patterns and fixations by actively engaging in activities that are both meaningful to them and consistent with their personal values.
Technically a modified version of cognitive behavior therapy, dialectical behavior therapy (DBT) has been adapted to address a wide range of conditions, including a number of eating disorders, as well as substance use disorder, bipolar disorder, generalized anxiety disorder, major depressive disorder, obsessive-compulsive disorder, borderline personality and PTSD.
The reason this method is so effective for so many conditions may lie in its foundational goals: to help patients learn to live more in the moment, develop healthy strategies for coping with stress, regulate their emotions in a more balanced way, and improve their relationships with others.
Taking such a view, or working toward it, can help promote cognitive flexibility, or the ability to adapt to new, emerging, or unplanned events.3 And this can help directly counteract the cognitive rigidity that works to uphold many eating disorders.4
The method also works to bring about a sense of self-assurance and, subsequently, self-acceptance. This helps a person feel they can rely on themselves to handle any situation without resorting to unhealthy coping mechanisms.5
Exposure therapy is another method whose name explains its core purpose: offering a person some level of exposure to a thing or experience they fear.
That exposure doesn’t have to be a direct or physical experience. Patients undergoing exposure therapy use a number of different techniques, including visualization and virtual reality, to achieve these encounters. Regardless, exposure therapy entails the repeated confrontation with a feared object or scenario to help desensitize a person to the issue and give them vital insight into what, exactly, it is about the thing or circumstance they’re reacting to, as well as build effective coping strategies.
This therapeutic practice is commonly used to help people struggling with post-traumatic stress disorder, OCD, social anxiety, and generalized anxiety, among other mental health conditions.
And while there’s little empirical evidence on how exposure therapy can be specifically used to help people with eating disorders, some aspects of the method are already used in other popular forms of treatment for these conditions, including CBT, which sometimes “assigns” patients to expose themselves to things or situations that cause anxiety.6
Emotion-focused therapy (EFT) aims to help individuals better regulate their emotions, build resilience, and strengthen relationships. To do this, patients are taught a battery of skills that can help them:7
EFT is relatively new, and research on its effectiveness is still emerging. But these techniques have been found especially useful in helping people with binge eating disorder, particularly since the experience of negative emotions is a predictor of binge eating behavior.8
Psychotherapy, or “talk therapy,” is just one component of treating mental health disorders. Many patients also find help through experiential therapies, or methods that help them get out of their head and tap into their body to look for paths toward healing.
There are many reasons why it may be difficult for someone to speak about their feelings in a way that feels sincere, helpful, or satisfactory. But alternative modes of expression can create different avenues for communication, and may even help people discover feelings they didn't realize they were dealing with.
Utilizing different artistic mediums can allow someone to tap into their “right brain,” the side more responsible for imagination, intuition, and the senses. This can help them “turn off” their conscious brain, letting them access deeper feelings that may be beyond verbal expression. Channeling feelings through paint, music, acting or other artistic mediums can also help someone develop different perspectives about their experiences.9
Somatic therapy focuses more intensely on the mind-body connection, helping patients establish a sense of mental relief through physical release.
There are different types of somatic therapy, but many involve walking patients through different meditation-type exercises to help them turn off their "conscious" brain and locate feelings that may be "trapped" in different areas of their body. They're then instructed in different methods for releasing this tension or unwanted energy.
The thought is that releasing these build-ups can help ease the body out of a fight/flight/freeze response and free someone to more fully engage with the present moment. Practitioners say that releasing negative emotions, such as anger, frustration, or despair, that may be trapped in the body can also help release a patient from the past experiences that produced these emotions.10
While the practices of mindfulness and meditation are an ancient Eastern tradition, they have become increasingly popular in mainstream Western societies as a way to reduce stress and improve well-being.
Mindfulness is the practice of bringing one's attention to the present moment and cultivating an objective awareness of one's experiences and surroundings. Meditation is the practice of being still, focusing on the breath, and bringing attention back to breathing when the mind wanders.
A review of several studies on these practices found that those utilizing meditation and mindfulness techniques showed improvement in emotional and behavioral functioning. These correlated to higher levels of life satisfaction, conscientiousness, vitality, self-esteem, empathy, sense of autonomy, competence, and optimism. Participants in these studies also reported lower levels of depression, neuroticism, absent-mindedness, dissociation, rumination, reactivity, and social anxiety.11
For eating disorders in particular, mindfulness-based eating awareness training (MB-EAT) has shown promise. The technique applies the concept of mindfulness to eating, and it has been found helpful in reducing binge eating episodes, increasing awareness of hunger and fullness cues, and changing eating behaviors for people struggling with BED.12
Unfortunately, the complex and interlocking nature of comorbid conditions can also present a number of challenges for people struggling with multiple mental health disorders to find appropriate treatment.
Many people struggling with a mental health disorder can feel reluctant about seeking out help.
Cultural expectations, financial limitations, and religious beliefs can influence someone's likelihood of seeking out treatment or even believing there is an issue to be treated. On a personal level, shame, guilt, and embarrassment frequently surface around these subjects, and may make someone less likely to reach out about their experiences or seek proper care.
The presentation of depression or anxiety in someone with an eating disorder can make this task especially hard. Anxiety and depression are both often accompanied by avoidant coping mechanisms, which can manifest as efforts to evade the exact type of interpersonal relationships encouraged by therapy.13 Both conditions also typically entail a fear of being negatively evaluated by others, which may further dissuade someone from pursuing treatment.13
The overlapping or similar symptoms of two different mental health conditions can make it difficult to properly diagnose a patient, determine which is the primary condition, or set a course of treatment that may be the most beneficial.
The types of compulsions and obsessions that define OCD, for example, are also expressed as part of many types of eating disorders. This can make it hard to tell whether someone is struggling with food-based obsessions or compulsions as part of their OCD, or an eating disorder whose symptoms carry an obsessive-compulsive quality.
The scenarios may sound interchangeable, but they can make a difference in the recommended course of treatment a clinician may advise.
These gray areas can also lead to the unfortunate situation where a condition isn’t recognized at all, as it can hide behind common symptoms that either get misdiagnosed or overlooked entirely.
Unresolved trauma stemming from a comorbid condition can be another complicating factor in treatment for many people. This specific issue can be a particular problem with people struggling with both an eating disorder and PTSD.
Post-traumatic stress disorder, which is the body and mind’s reaction to unresolved trauma, tends to go underdiagnosed, undiagnosed entirely, or inadequately addressed. More than 33% of participants with PTSD still experience the full symptoms 10 years later, according to one study.14
One of the most harmful symptoms of PTSD are dissociative strategies, or thoughts that allow someone to separate themself from the details of a traumatic event, or even suppress the memory entirely.14 These amnesic responses can present additional challenges when seeking proper treatment for PTSD and any comorbid disorders.
Medication is not always recommended as a course of treatment for mental health disorders, but in cases when it is, it can prove another complicating factor when treating people with multiple conditions.
This balancing act can be particularly tricky for people struggling with both bipolar disorder and an eating disorder.
Antidepressants are one of the most widely-prescribed medical treatments for eating disorders in general. This class of medication, however, is not recommended for people struggling with bipolar disorder, as they can sometimes trigger manic mood swings.15
On the other hand, mood stabilizers or antipsychotics are generally recommended for people with bipolar disorder, but these types of drugs can prompt binge-eating episodes for people with bulimia nervosa or binge eating disorder.15
Like bipolar disorder, each mental health condition tends to respond better or worse to certain medications, and clinicians must be very careful when considering how these drugs may potentially interact with each other, and the patient, when prescribing them.
While some types of therapy may work to treat several types of mental health disorder at once, the same may not be said of some treatment programs for these conditions.
For example, substance use disorder and eating disorders are rarely treated together in the same program. Many eating disorder treatment programs will not accept patients who compulsively use alcohol, illicit drugs, or even over-the-counter medications like laxatives. And many substance use programs will exclude patients struggling with eating disorders.16
As a result, patients hoping to treat both conditions will have to go through different programs individually, which can cost a lot of money and time, be highly disruptive, and cause issues with insurance coverage. It can also leave patients at risk of seeing one disorder intensify while the other is being treated. For example, more symptoms of an eating disorder may present while the person is being treated for substance use, though more empirical data is needed to support this effect.16
Disclaimer about "overeating": Within Health hesitatingly uses the word "overeating" because it is the term currently associated with this condition in society, however, we believe it inherently overlooks the various psychological aspects of this condition which are often interconnected with internalized diet culture, and a restrictive mindset about food. For the remainder of this piece, we will therefore be putting "overeating" in quotations to recognize that the diagnosis itself pathologizes behavior that is potentially hardwired and adaptive to a restrictive mindset.
Disclaimer about weight loss drugs: Within does not endorse the use of any weight loss drug or behavior and seeks to provide education on the insidious nature of diet culture. We understand the complex nature of disordered eating and eating disorders and strongly encourage anyone engaging in these behaviors to reach out for help as soon as possible. No statement should be taken as healthcare advice. All healthcare decisions should be made with your individual healthcare provider.
