Dual Diagnosis & Co-Occurring Disorders

Anxiety Disorder

Anxiety Disorders may well be the most common co-occurring mental health diagnosis with eating disorders. Approximately 47.9 & of those with Anorexia Nervosa, 80.6% of those with Bulimia Nervosa, and 65.1% of those with BED also struggle with an anxiety disorder diagnosis such as Generalized Anxiety Disorder (GAD), Panic Disorder, Phobias, and Separation Anxiety, to name a few [1]. The risk factors for both of these disorders are similar, as both tend to be experienced by individuals that struggle with rigidity in their beliefs and behaviors as well as those with neurotic or perfectionist tendencies. As mentioned above, regardless of which disorder “came first,” they often build on one another and must be treated simultaneously.

Mood Disorders

Like anxiety disorders, depression and other mood disorders (such as Bipolar Disorder) often co-occur with eating disorders. These disorders often lead to the development of eating disorders as an ineffective method of coping, occur due to malnourishment and the impact of eating disorders, and/or both. 42.1% of those with Anorexia Nervosa, 70.7% of those with Bulimia Nervosa, and 46.4% of those with BED also have a diagnosis of a depressive disorder.

Borderline Personality Disorder (BPD)

Like anxiety disorders, depression and other mood disorders (such as Bipolar Disorder) often co-occur with eating disorders. These disorders often lead to the development of eating disorders as an ineffective method of coping, occur due to malnourishment and the impact of eating disorders, and/or both. 42.1% of those with Anorexia Nervosa, 70.7% of those with Bulimia Nervosa, and 46.4% of those with BED also have a diagnosis of a depressive disorder.

Obsessive Compulsive Disorder (OCD)

Similar to anxiety disorders, the traits that put one at risk for eating disorder development also put one at risk for development of OCD. These include attachment to rigidity, meticulousness, or perfectionism as well as difficulty coping with distress related to daily life changes, big or small. Eating disorders often involve both obsessive beliefs and thought patterns as well as compulsive behaviors. Research indicates that “those with eating disorders have significantly higher rates of OCD” development [4].”

Post-Traumatic Stress Disorder (PTSD)

Trauma severely impacts the psychological, neurological, and sociological functioning of individuals that experience it. The relationship between trauma experiences are linked with all eating disorder diagnoses, yet, appears particularly significant in those with Bulimia Nervosa. One study noted that “eating disordered behaviors, particularly purging behaviors, serve to facilitate avoidance of traumatic material and to numb the hyperarousal and emotional pain associated with traumatic memories and thoughts [5].” Additionally, those with a PTSD diagnosis tend to experience an increased disconnect from the body and emotions as well as dissociative states, all of which can also contribute to eating disorder development.

Self-Injury

Self-harming behaviors are frighteningly common in those with eating disorders, with 61% of those that report engaging in self-injurious behaviors also reporting current or past eating disorder behaviors [6]. Self-injury refers to any behaviors in which an individual physically harms themselves. Those with eating disorders often develop this behavior as an ineffective coping skill for uncomfortable mood-states. For some, the eating disorder behaviors themselves are intended to be self-harming.

Trichotillomania

Trichotillomania falls under the DSM-5 category of “Obsessive-Compulsive Related Disorders” and refers to an individual experiencing a compulsive need to pull out one’s hair. Individuals with eating disorders and trichotillomania share many clinical features such as emotion dysregulation, an inability to effectively cope, and/or obsessive-compulsive tendencies.

Substance Use Disorder

Substance use disorders are incredibly common in those with eating disorder diagnoses, with 27% of those with Anorexia Nervosa, 36.8% of those with Bulimia Nervosa, and 23.3% of those with BED experiencing both [1]. These disorders often feed off of one another, with one study determining that women with either an eating disorder or substance were more than 4 times as likely to develop the other disorder as those women that experienced neither disorder [7]. People often use substances and/or eating disorder behaviors to help them cope and, therefore, those struggling are likely to engage in one or both disorders.

Substance Use Disorder

The relationship between alcoholism and eating disorders is included in much of the research on substance use disorder and eating disorders mentioned above. Excessive alcohol use is often seen as a method to numb from uncomfortable emotion-states as well as reinforce, or cause, eating disorder behaviors such as purging or restricting.

Resources

1. Unknown (2017). Eating disorders. National Institute of Mental Health. Retrieved from https://www.nimh.nih.gov/health/statistics/eating-disorders#part_155062.
2. NEDA (2022) Anxiety, Depression, and Obsessive Compulsive Disorder. Retrieved from https://www.nationaleatingdisorders.org/anxiety-depression-obsessive-compulsive-disorder
3. Khosravi, M. (2020). Eating disorders among patients with borderline personality disorders: understanding the prevalence and psychopathology. Journal of Eating Disorders, 8:38.
4. Neziroglu, F., Sandler, J. (2009). The relationship between eating disorders and OCD, part of the spectrum. The OCD Newsletter. Retrieved from https://iocdf.org/expert-opinions/expert-opinion-eating-disorders-and-ocd/.
5. Brewerton, T. D. (2008). The links between PTSD and eating disorders. Psychiatric Times.
6. Levitt, J. L., Sansone, R. A., Cohn, L. (2008). Self-harm behavior and eating disorders. Bruner-Routledge. New York,. NY.
7. Unknown (2011). Clients with substance use and eating disorders. Substance Abuse and Mental Health Services Administration, retrieved from https://store.samhsa.gov/sites/default/files/d7/priv/sma10-4617.pdf.