Eating Disorders and the Importance of Understanding Co-occurring Disorders

Contributor: Leigh Bell, BA, writer for Eating Disorder Hope

Eating disorders are rarely only what’s presented on the surface, and more often than not, co-exist with one or more disorders, most commonly depression, anxiety, and obsessive-compulsive disorder. These co-occurring diagnoses and eating disorders share an intricate and perplexing relationship, in which one may cause, feed, or provoke the other.

Treatment needs to address this relationship artfully, realizing symptoms of the co-occurring disorder may increase when the eating disorder is challenged, and vice versa. This is challenging when eating disorders are involved. The lines are grey — malnourishment, incites symptoms similar to co-occurring disorders — the information is vast, and each case is different.

Depression

Depression is the common co-occurring disorder and is almost equally pervasive across each type of eating disorder (Blinder, Cumella, Sanathara, 2006).

It’s normal for people with eating disorders to feel depressed at some point, but most research shows 50-75% of those with eating disorders experience major depressive disorder, which can put them at greater risk for suicide.

Anxiety Disorders

Anxiety disorders are present in the majority of bulimics and anorexics. One study found two-thirds of individuals with eating disorders had one or more lifetime anxiety order; and the rate of anxiety disorders is virtually even among bulimia, restrictive anorexia, and anorexia with the binge/purge cycle (Kaye, Bulik, Thornton, Masters, 2004). OCD was the most common anxiety disorder (41%), followed by social phobia (21%).

Blinder, et. al. found OCD was most prevalent in anorexics (almost 30%) and less common in bulimics (16%). While a debate ensues about whether the eating disorder or the co-occurring disorder appears first, several studies show, in most cases, the onset of anxiety disorders precedes the eating disorder (O’Brien, 2003).

This makes anxiety disorders, especially OCD, a major risk factor for eating disorders.

Post-Traumatic Stress Disorder

Post-Traumatic Stress Disorder (PTSD) is prevalent in people with eating disorders. PTSD follows exposure to a traumatic event, including sexual and physical abuse, which is a risk factor for the development of an eating disorder.

In one report, 74% of 293 women in residential treatment said they had experienced a significant trauma, and more than half reported symptoms consistent with a PTSD diagnosis (Brewerton, 2008). Rates of PTSD in women with restrictive anorexia (10%) is almost equal to the general population; while about 25% of women with binge-purge behaviors exhibit PTSD (Blinder, et. al. 2006).

While sexual abuse and sexual assault are often linked to eating disorders, which can be a coping mechanism, it’s important to realize this type of trauma is not necessarily germane to eating disorders.

Alcoholism and Substance Abuse

Alcoholism and substance abuse is present in about 50% of people with an eating disorder, a rate 5 times greater than what’s seen in the general population, according to the National Eating Disorder Association.

People with bulimia and “bulimic” behaviors, like binging and purging, statistically have a far greater propensity for substance abuse than those with restrictive anorexia. In fact, women who binge-and-purge use/abuse more substances than women with other eating disorders and women, in general (Blinder, et. al. 2006).

It is important to identify and address substance abuse alongside an eating disorder, for research indicates when one disorder is confronted, symptoms of the other may increase.

Borderline Personality Disorder

Borderline Personality Disorder is a serious mental illness causing unstable moods, behavior, and relationships. Most people with BPD have trouble regulating emotions and thought; managing impulsivity and sometimes reckless behaviors; and maintaining healthy relationships.

These traits mirror personality characteristics researchers use to explain high rates of substance abuse in bulimia. It’s no surprise, then, data reveals a strong relationship between BPD and bulimia. One study found almost 40% of individuals with bulimia met criteria for a personality disorder, most frequently BPD (O’Brien, Vincent, 2003).

In another study, 34.7% of bulimics met criteria for BPD, compared to roughly 6% of the general population. Conversely, multiple data show those with BPD are about 50% more likely than most people to develop an eating disorder.

Considering this relationship, when someone presents impulsivity, reckless behavior, and/or irregular moods, it’s important to look further for signs of BPD and/or eating-disordered behavior. Limited data show little to no relationship between anorexia and BPD.

Self-Harm

Self-Harm is intentional, direct injuring of one’s body tissue, usually without suicidal intentions. While little epidemiological studies investigate eating disorders and self-harm behavior, present data shows about 25% of people with eating disorders present non-lethal self-harm behaviors (Sansone, Levitt, 2002).

In another study of 376 patients with eating disorders, 35% said they had injured themselves, and 21% did so within the last six months (Thomas, Schroeter, Dahme, Nutzinger, 2002). While the subject hasn’t been studied intensively and the majority of people with eating disorders haven’t hurt themselves, self-injury is a serious co-occurring disorder not to be overlooked.

Bipolar Disorder

Bipolar Disorder, or “manic depression,” is a mental disorder characterized by constantly changing moods, especially from very high to very low. Reviewed literature leaves little doubt that bipolar and eating disorders — particular bulimia nervosa and bipolar II (not experiencing extreme highs) — are related (McElroy, Kotwal, Keck, Akiskal, 2005).

Still most research studies the vulnerability of bipolar patients to eating disorders, and the result is about 14%. While bipolar disorder occurs less frequently with eating disorders than some of the aforementioned co-occurring disorders, the diagnosis remains pertinent in our understanding of the cause and characteristics of comorbidity.

Community Discussion – Share your thoughts here!

What is your experience with seeking treatment for both Eating Disorders and Co-occurring disorders? Do you have advice to share based on your path to recovery?

---

About the Author:

Leigh Bell holds a Bachelor of Arts in English with minors in Creative Writing and French from Loyola Marymount University in Los Angeles. She is a published author, journalist with 15 years of experience, and a recipient of the Rosalynn Carter Fellowship for Mental Health Journalism. Leigh is recovered from a near-fatal, decade-long battle with anorexia and the mother of three young, rambunctious children.
References:

1. Blinder B.J., Cumella E.J., Sanathara V.A. (2006). Psychiatric comorbidities of female inpatients with eating disorders. Psychosomatic Medicine. 68, 454-462.
2. Brewerton, T. (2008). The links between ptsd and eating disorders. Psychiatric Times. 2008.
3. Kaye, W., Bulik, C., Thornton, L., & Masters, K. (2004). Comorbidity of anxiety disorders with anorexia and bulimia nervosa. American Journal of Psychiatry, 161(12), 2215-2221.
4. Mcelroy, S., Kotwal, R., Keck, P., & Akiskal, H. (2005). Comorbidity of bipolar and eating disorders: Distinct or related disorders with shared dysregulations? Journal of Affective Disorders, 86(2-3), 107-127.
5. Mcelroy, S., Kotwal, R., Keck, P., & Akiskal, H. (2005). Comorbidity of bipolar and eating disorders: Distinct or related disorders with shared dysregulations? Journal of Affective Disorders, 86(2-3), 107-127.
6. Sansone, R., & Levitt, J. (2002). Self-harm behaviors among those with eating disorders: an overview. Eating Disorders, 10(3), 205-213.
7. Thomas, P., Schroeter, K.,Dahme, B., Nutzinger, D.O. (2002). Self-injurious behavior in women with eating disorders. American Journal of Psychiatry, 159(3), 408-411.

Last Updated & Reviewed By: Jacquelyn Ekern, MS, LPC on February 21st, 2015
Published on EatingDisorderHope.com