Plus One: When an Eating Disorder and Other Problem Co-occur

Can a person struggling with bulimia nervosa also suffer from a substance use disorder? How often is someone with binge eating disorder also depressed? If a person has anorexia nervosa and obsessive compulsive disorder, how will treatment be affected?

It is not unusual at all for those struggling with an eating disorder to simultaneously experience symptoms of – or meet full diagnostic threshold for – other disorders. These are called “co-occurring” or sometimes “comorbid” conditions. Below we review the most common co-occurring disorders in people with eating disorders and how this might impact treatment.

Mood Disorders

• Although rates differ from study to study, a large proportion of individuals with anorexia, bulimia, and binge eating disorder are also depressed. Why are the rates so high? There is no conclusive answer, but it has been suggested that for people with anorexia, the state of starvation significantly contributes to feeling depressed. Therefore, a crucial, necessary step in treating depressed mood for individuals with anorexia is to eat and restore weight to a healthy range. In fact, gaining weight to a healthy range has been associated with mood improvement.
• For individuals with bulimia nervosa or binge eating disorder, depressive thoughts are often but not always related to distress around eating. Many therapies, such as cognitive behavioral therapy and interpersonal psychotherapy, can be helpful in addressing both the eating disorder and depression. Additionally, there are anti-depressant medications that can help with mood symptoms. For individuals with anorexia nervosa these medications are indicated in instances where a healthy weight has been achieved and maintained for a while, and mood symptoms persist. For people with bulimia nervosa or binge eating disorder, these medications may be useful earlier in treatment.

Anxiety Disorders

For a subset of individuals with anorexia and bulimia, a diagnosis of an anxiety disorder precedes the onset of the eating disorder. Of these, obsessive compulsive disorder (OCD) and social phobia are some of the most frequent.

• In OCD, people often experience ­obsessions, or intrusive, persistent thoughts that tend to be distressing. For example, they might continually worry that they are contaminated by germs. People with OCD may also experience compulsions which are behaviors they feel they have to do again and again (e.g., repetitive hand-washing, counting, checking, etc.).

Of note, many people with anorexia have obsessive thoughts about food, eating, body shape and weight, and may feel compelled to engage in food rituals at meal times; these tend to worsen at low weight (and improve with better nutrition and weight restoration) and are considered a part of the eating disorder, not an indicator of a separate diagnosis of OCD. Other examples of compulsive behaviors that would be more in line with anorexia than OCD are repeated body-checking, weighing, food-measuring, and hand-washing as a way to remove residue from feared foods. For someone with anorexia, an additional diagnosis of OCD could be considered if the obsessions and compulsions occur outside of food, eating, shape or weight. For example, needing to write and re-write items a certain number of times, repeatedly checking to make sure the stove is turned off, and ordering/straightening household items until they “feel right” are compulsions that are likely unrelated to an eating disorder.

The good news is that OCD has some very effective treatments, one of which is a psychotherapy called Exposure and Response Prevention (ExRP). There is also some evidence that ExRP could be helpful for individuals with anorexia.

• Social phobia (aka social anxiety disorder) is also quite common for people with eating disorders. Social phobia is marked by a very strong fear or anxiety of being negatively evaluated by others in social situations (e.g., talking in class, meeting new people).  This fear or anxiety is distressing and people may avoid situations in which they think others will negatively judge them.

Sometimes people with eating disorders have a lot of anxiety about eating in front of others. If this were the only thing that someone with anorexia or bulimia nervosa were afraid to do in front of others, then an additional diagnosis of social phobia might not be given because the social fears would fall under the umbrella of the eating disorder. However if an individual was also very anxious about participating in a class discussion or speaking up in a meeting for fear that others would judge her as stupid, or if someone avoided meeting new people, this could be a sign that a separate diagnosis is also present.

Treatment for social phobia often includes cognitive-behavioral therapy and/or medication.

• More research is needed to understand the relationship between anxiety disorders and avoidant restrictive food intake disorder (ARFID). For some individuals with ARFID, worry about consequences of eating, such as experiencing a choking sensation or vomiting, might constitute a specific phobia. However, ARFID is diagnosed when this fear leads to changes in eating behavior that have clear consequences on nutrition and overall physical health.

Alcohol and Substance Use Disorders

Problems with drugs and alcohol are also fairly common in individuals with anorexia and bulimia. Comorbidity rates seem to be higher in bulimia and the binge-purge subtype of anorexia than in the restrictive subtype of anorexia and this has been linked to higher levels of impulsivity among those groups. Of note, many individuals with eating disorders may abuse stimulants (caffeine, amphetamines, etc.) in an attempt to curb appetite, and many individuals abuse laxatives, diuretics, and diet pills as an attempt to get rid of calories consumed.

• In deciding if and how to modify treatment if someone has an eating disorder and a substance use problem, the severity of each problem is typically first assessed. In particular, it is important to evaluate the extent to which a co-occurring substance use might interfere with treatment of the eating disorder. For example, if a patient is frequently intoxicated, this will greatly impede progress in eating disorder treatment and suggests a need for substance use treatment prior to eating disorder treatment.

• For some individuals, a structured, dual diagnosis program in which both problems are treated simultaneously may be the best way to effect lasting change.

Getting to 1+1=0

Generally speaking, individuals who struggle simultaneously with an eating disorder and another psychiatric problem may have a longer road to recovery and require a multi-faceted relapse prevention plan than those with an “uncomplicated” eating disorder. Eating disorders are unlikely to improve spontaneously, so it is important to seek out treatment no matter what other issues may or may not be present. Finally, there are some specialized treatment programs that exist specifically for individuals who suffer from a particular combination of issues (e.g., OCD and anorexia, or substance use and an eating disorder). Speaking with a professional who is knowledgeable in this area can help point you in the direction of suitable resources.

If you or someone you know is struggling with an eating disorder, we encourage you to speak with a clinician, or contact the National Eating Disorder Association or a program like ours, for referrals.

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