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On their own, eating disorders are serious mental illnesses. But they are often accompanied by co-occurring mental health disorders, which can contribute to and complicate the conditions.
The causes and symptoms of many of these disorders can be similar, which may be why they tend to exist together at such a high rate. This can also make it hard to discern which is the primary condition and which is the secondary issue, which may impact treatment recommendations.
Still, experts are continuing to research and work on different methods that could help people dealing with more than one mental health condition at once.
Co-occurring, or comorbid, disorders refer to when a person experiences two or more mental health conditions at once. And when it comes to eating disorders, there are some conditions that seem to have a higher rate of comorbidity.
Eating disorders and depression
Eating disorders are deeply connected to mood disorders, including depression. One study of 2,400 individuals found 94% of participants with eating disorders had a co-occurring mood disorder, and 92% of those affected struggled with a depressive disorder.1
Further research has reported a co-diagnosis of major depressive disorder with:1
32-39% of people with anorexia nervosa (AN)
36-50% of people with bulimia nervosa (BN)
33% of people with binge eating disorder (BED)
In fact, the two conditions are so closely linked, research has found eating disorders and depression—as well as anxiety—can all be traced back to a shared etiology, or set of common causes.2 Other research has suggested that most eating disorders are offshoots of depression itself, representing “variant” forms of depression, rather than their own condition, though these theories are more controversial.3
Whatever the cause, the unfortunate reality is that when these conditions occur together, symptoms are often more severe, prognosis is often poorer, and the burden of illness is often greater.2
Eating disorders and anxiety
Anxiety disorders are the most commonly occurring types of mental health disorders in the United States, but this class of condition is particularly prevalent among people struggling with eating disorders.
Further research has reported a co-diagnosis of major depressive disorder with:1
Other studies have shown that having an anxiety disorder increases the likelihood of having or developing an eating disorder—or vice versa—thanks to many related underlying factors in both conditions.4
Anxiety disorders and eating disorders both frequently evolve as dysfunctional mechanisms for coping with unpleasant feelings or traumatic events, a powerful shared trait that ties the conditions tightly to one another. This close relationship may also explain, or at least suggest, why symptoms of anxiety sometimes persist even after an eating disorder goes into remission, increasing the risk of relapse.2
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Eating disorders and obsessive-compulsive disorder (OCD)
Research has estimated that anywhere from 11-69% of people with eating disorders also have OCD, while 10-17% of people primarily diagnosed with obsessive-compulsive disorder also struggle with an eating disorder.6 And another study found that women who had experienced OCD in childhood had a higher likelihood of developing an eating disorder later on in life.5
The biggest overlapping trait between the two conditions may be the way they affect someone’s perspective. Eating disorders often involve a fixation on ideas like body weight, food, and eating, and OCD is also propelled by a narrow field of focus.
“Obsessions,” as they’re understood in obsessive-compulsive disorder, describe frequent and recurrent thoughts or impulses, which eventually become intrusive upon daily life. “Compulsions” are the behaviors or thoughts performed in response to obsessions.
In cases where someone’s obsession or compulsion involves food, health, or body image, it could manifest as disordered eating behaviors. If this occurs, OCD can act almost as a turbine, powering the behaviors of an eating disorder. The key, in both cases, is that obsessions often lead to rising levels of anxiety that can only be alleviated by performing ritualistic compulsions.6
Eating disorders and post-traumatic stress disorder (PTSD)
When someone is struggling with PTSD, they are often affected by unresolved trauma, which can leave them particularly vulnerable or sensitive to any additional stress and all its worst effects, including the development of eating disorders.
Unfortunately, the numbers seem to bear out this observation, with several studies finding lifetime comorbidity rates of PTSD and eating disorders anywhere between 38-44%.7
Perhaps the biggest link between these issues is the maladaptive coping mechanisms often involved in both.
When struggling with PTSD, or unresolved trauma that is triggered by an occurrence that’s similar to the original traumatic event, many people revert to something called avoidant coping. This mechanism is characterized by self-punishing and self-defeating thoughts—for example, I’ll never be okay, so nothing good can come from trying. These same types of thoughts are also risk factors for developing eating disorders.7
Eating disorders and bipolar disorder
Research examining the comorbid connections between eating disorders and bipolar disorder has been less robust. But at least one study found a co-occurring rate of around 33% between the two conditions.8
An earlier study on the topic found a higher rate of comorbidity in cases where women had earlier ages of onset and more severe symptoms of bipolar disorder.9
Still, some theories on why or how the two conditions impact each other have been developed, mostly through examining qualitative data. In the later study, for example, participants reported struggling with different facets of eating disorders, or different eating disorders altogether, during manic and depressive phases.
Generally, mania was related to overeating, while depression was linked to limiting food intake, leading researchers to theorize that some common factors were directing both these mood swings and the various disordered eating patterns that manifested during their onset.8
Eating disorders and substance use disorder
Statistically, substance use disorders and eating disorders co-occur at much higher rates than either condition occurs on its own within the general population.
Up to 50% of people struggling with eating disorders also use alcohol or illicit drugs, a rate that’s five times higher than people without eating disorders. And up to 35% of people with a substance use disorder also have an eating disorder, a rate eleven times higher than the general population.10
As with many other comorbid relationships, the correlation may hinge on a number of shared traits and risk factors between substance use disorder and many eating disorders, including social pressures, family history, genetics, and brain chemistry.10
Mood disorders, like anxiety and depression, are also common contributing factors to both substance use disorder and eating disorders, as well as the types of compulsive thinking associated with OCD.10
Eating disorders and dementia
Eating behaviors can change during the aging process due to the many physiological, psychological, and social changes a person undergoes at that time. And one of the most common conditions to bring about these changes is dementia.
The age-related disorder presents a number of risk factors for developing a comorbid eating disorder, including appetite changes, sleep disturbance, and depression, among other biochemical changes.12
For specific presentations of dementia, like Alzheimer’s, there are further risk factors, including the cognitive changes that may make a patient forget to eat, or forget if they have eaten already.12 Alzheimer’s can also impact a person’s sense of smell and bring on social risk-factors for developing eating disorders, including loneliness, isolation, and depression.12
Shared risk factors of eating disorders and co-occurring disorders
One reason so many people struggle with eating disorders and a co-occurring disorder is that many of these conditions share several overlapping risk factors, from biological and psychological to environmental and sociocultural causes.
Genetic predisposition
It is possible to be born with the predisposition for developing either an eating disorder, a number of different mental health disorders, or both.
Many studies have shown at least some degree of heritability for both bulimia nervosa and anorexia nervosa.14 And a breadth of other work has shown genetic connections to substance use disorder, depression, anxiety, and other mood disorders.
In many of these cases, what gets passed on isn't the disorder itself, but a number of risk factors that may make a person more susceptible to developing the disorder. For example, the way a person reacts to stress—which is often involved in the developing or maintaining of mental health disorders—has been found to be heritable.14
Other key inheritable risk factors include negative emotionality and harm avoidance, which inform personality traits such as shyness, fearfulness, and a tendency to worry.14
Serotonin imbalance
Serotonin is an important neurotransmitter which helps with many bodily processes. Capable of boosting feelings of happiness, it's mostly known as a mood stabilizer, but it can also function as an appetite suppressant, creating the sensation of satiety, or feeling full after eating.
Because it plays a key role in both appetite and emotions, it is a common link between eating disorders and comorbid mental health conditions. And several studies have shown that serotonin dysfunction or imbalance may play a role in developing or sustaining several co-occurring eating disorders and mental health conditions.15
Malnutrition
Regardless of the pattern of a person’s disordered eating, one of the biggest repercussions is an unbalanced diet. And while malnutrition is more of a consequence of eating disorders, rather than a risk factor, it can have a cascading effect on the body that can lead to the development or support of comorbid conditions.
Anxiety and depression, in particular, have been linked to malnutrition, with some studies finding that the absence of certain proteins can promote “anxiety- and depression-like behavior.”16
Maladaptive emotion regulation strategies
Broadly, emotion regulation refers to someone’s awareness and recognition of their emotional state, as well as any attempt to regulate, or modulate, it. And, whether conscious or subconscious, these mechanisms can play a key part in driving eating disorders and commonly co-occurring conditions.
Indeed, many eating disorders, as well as anxiety and depression, can arise as attempts to cope with unpleasant feelings, especially during the onset of puberty or other times in life that see a number of physiological, psychological, and social changes.2
Likewise, higher levels of depression or anxiety can lead to the development of disordered eating behaviors as a maladaptive–or harmful–emotion regulation strategy, and vice versa.2
Low self-esteem
Low self-esteem is frequently a major factor in eating disorders and commonly co-occurring mental health conditions. It can drive the development of these disorders, manifest as the result of these disorders, or both.
The trait has been found to play an especially big role in the relationship between eating disorders and depression, contributing to the negative self-perception and poor sense of self-worth that is often a hallmark in both conditions.2 But overall, low self-esteem has been found to be a key aspect in many mood disorders and eating disorders.
Perfectionism
Perfectionism is more often associated with anxiety, be it generalized anxiety disorder or more specific manifestations of the condition, such as obsessive-compulsive disorder.
The anxious trait generally manifests as setting and pursuing high standards for oneself, and becoming highly critical of oneself if/when failing to meet those goals.
People struggling with a perfectionist aspect of their anxiety disorder are particularly hard on themselves, often for small, exaggerated, or even imagined transgressions. And this level of sensitivity has been noted as a key maintaining factor in many different eating disorders, anxiety disorders, and, to a lesser extent, depression.2
Psychotherapy treatment for eating disorders with co-occurring disorders
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 co-occurring conditions.
Cognitive behavior therapy (CBT)
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.26
Acceptance and commitment therapy (ACT)
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 co-occurring conditions.
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.17
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.
Dialectical behavior therapy (DBT)
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.11 And this can help directly counteract the cognitive rigidity that works to uphold many eating disorders.20
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.27
Exposure therapy
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.28
Emotion-focused therapy (EFT)
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:22
Increase awareness of and identify their emotional state
Better tolerate painful experiences
Express their emotions in healthy ways, rather than suppressing them
Practice regulating their emotions in ways that help them meet their needs
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.21
Experiential therapies for co-occurring disorder treatment
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.
Art Therapies
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.13
Somatic Therapy
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.18
Mindfulness and meditation
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.23
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.24
Potential treatment complications
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.
Aversion to 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.2 Both conditions also typically entail a fear of being negatively evaluated by others, which may further dissuade someone from pursuing treatment.2
Diagnosing difficulties
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
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.7
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.7 These amnesic responses can present additional challenges when seeking proper treatment for PTSD and any comorbid disorders.
Medication complications
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.19
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.19
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.
Lack of comprehensive clinical programs
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.25
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.25
Finding help for an eating disorder
Eating disorders that present with a comorbid mental health condition can cause a number of short- and long-term complications. And the negative effects of these on both mental and physical health tend to get worse with time.
Consulting your primary care physician, therapist, psychiatrist, or another trusted medical professional may be a good place to start. These experts may be able to help you secure an official diagnosis, guide you to successful treatment programs, or otherwise help you determine your next best steps.
Remote treatment is available
At Within Health, we can also help. Our team of multidisciplinary experts can help create a treatment plan that’s tailored to your specific needs, including any considerations for co-occurring conditions.
If you or a loved one are struggling with disordered eating behaviors or other complications, you should seek out help. Treatment is always available and, no matter how difficult the experience may feel, recovery is always possible.
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.
Lapid, M., Prom, M., Burton, M., McAlpine, D., Sutor, B., & Rummans, T. (2010). Eating disorders in the elderly. International Psychogeriatrics,22(4), 523-536.
