Eating Disorders & Co-Occurring Psychiatric Disorders

Eating Disorder Psychiatric Comorbidities

Research demonstrates that 55-95% of people diagnosed with an eating disorder also receive a diagnosis for at least one more psychiatric disorder. The most common psychiatric disorders that co-occur with eating disorders include mood disorders, anxiety disorders, substance use disorders, personality disorders and neurodevelopmental disorders. Non-suicidal self-injury and suicidality are also common in patients with eating disorders.

Anxiety Disorders

The most prevalent psychiatric comorbidities of eating disorders are anxiety disorders, with 62-74% of individuals with an eating disorder also experiencing an anxiety disorder.

Generalized Anxiety Disorder

Generalized anxiety disorder (GAD) is excessive anxiety and worry about a number of events or activities with difficulty controlling the worry. The anxiety and worry are associated with the following symptoms:

• Restlessness or feeling on edge
• Being easily fatigued
• Difficulty concentrating or mind going blank
• Irritability
• Muscle tension
• Sleep disturbance

GAD and Eating Disorders

Approximately 22.5% of individuals with eating disorders have generalized anxiety disorder. There may also be a relationship between the severity of disordered eating behaviors and GAD, with a higher prevalence of GAD in patients who restrict, excessively exercise or have a low body mass index (BMI).

There are several clinical features and risk factors that are found in both eating disorders and in GAD. Intense, persistent and overwhelming anxiety is the defining feature of generalized anxiety disorder, and this is mirrored in the psychopathology of eating disorders like anorexia nervosa and bulimia nervosa which feature an intense fear or anxiety regarding weight gain and body shape.

Perfectionism, rigidity of dailyliving and meticulousness are also found in both individuals with eating disorders and individuals with GAD. Studies find around 71% of patients with an eating disorder note that an anxiety disorder preceded their eating disorder, suggesting that anxiety disorders may contribute to the development of an eating disorder.

Post-Traumatic Stress Disorder

Post-traumatic stress disorder (PTSD) is a psychiatric disorder that occurs in people who have experienced or witnessed a traumatic event. PTSD involves one or more of the following:

• Recurrent, involuntary and intrusive distressing memories or dreams related to the traumatic event
• Dissociative reactions in which the individual feels or acts as if the traumatic event(s) were recurring
• Intense or prolonged psychological distress or physiological reactions due to exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event

PTSD also involves a persistent avoidance of stimuli associated with the traumatic event:

• Avoidance of or efforts to avoid distressing memories, thoughts or feelings about or closely associated with the traumatic event
• Avoidance of or efforts to avoid external reminders that arouse distressing memories, thoughts or feelings about or closely associated with the traumatic event

Another characteristic of PTSD is negative alteration in cognitions and mood associated with the traumatic events through:

• Inability to remember an important aspect of the traumatic event
• Persistent and exaggerated negative beliefs or expectations about oneself, others or the world
• Persistent, distorted cognitions about the cause or consequences of the traumatic event that lead the individual to blame oneself or others
• Persistent negative emotional state
• Markedly diminished interest or participation in significant activities
• Feelings of detachment or estrangement from others
• Persistent inability to experience positive emotions

Finally, those with PTSD experience marked alterations in arousal and reactivity associated with the traumatic events, beginning or worsening after the traumatic events, including:

• Irritable behavior and angry outbursts, typically expressed as verbal or physical aggression toward people or objects
• Reckless or self-destructive behavior
• Hypervigilance
• Exaggerated startle response
• Problems with concentration
• Sleep disturbance

PTSD & Eating Disorders

Individuals with an eating disorder are significantly more likely to develop PTSD or meet the criteria for PTSD diagnosis. The lifetime prevalence of PTSD in adults is 6.8% while prevalence of PTSD in anorexia nervosa and bulimia nervosa patients hovers around 24.3%. Numerous studies also suggest higher prevalence of PTSD in patients who purge than those who do not.

At least 52% of those with an eating disorder diagnosis have a history of trauma, with traumatic events often taking place before the onset of an eating disorder. The symptoms of PTSD and an eating disorder may also be reciprocal, with higher PTSD symptomology associated with more severe eating disorder symptoms. Traumatic events can also have a negative impact on treatment outcomes, with eating disorder patients who have experienced traumatic events demonstrating an increased likelihood to drop out of treatment, an increased likelihood of relapse and poorer outcomes.

Eating disorders don’t always develop with the intent to control body weight or shape but can also develop as a maladaptive coping mechanism to stress or trauma. When a person experiences a traumatic event, they may develop eating disorder behaviors to manage overwhelming feelings, like sadness, loneliness, guilt, shame or powerlessness.

Obsessive-Compulsive Disorder

Obsessive-compulsive disorder (OCD) is the presence of obsessions, compulsions or both. Obsessions or compulsions are time consuming or cause clinically significant distress or impairment in important areas of functioning. Compulsions are defined as:

• Recurrent and persistent thoughts, urges or images that are experienced, at some time during the disturbance, as intrusive, unwanted and that in most individuals cause marked anxiety or distress
• Individual attempts to ignore or suppress such thoughts, urges or images or to neutralize them with some thought or action

Compulsions are defined by:

• Repetitive behaviors or mental acts that the person feels driven to perform in response to an obsession, or according to the rules that must be applied rigidly
• Behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation, but these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive

OCD & Eating Disorders

Between 15-33% of individuals with an eating disorder also have OCD. The relationship between OCD and eating disorders may be reciprocal, with studies suggesting that OCD symptom improvement follows eating disorder symptom improvement. The pathological presentation of OCD is mirrored in anorexia nervosa. Repetitive behaviors to perform certain acts, obsessive and persistent thoughts and compulsive behavior to reduce stress are also present in disordered eating behaviors.

Patients with an eating disorder may persistently and obsessively think about weight loss or preventing weight gain. They may repeatedly measure their weight, perform body checks or recheck portion sizes, calories or micronutrients. Individuals with an eating disorder may exhibit ritualistic behaviors while eating, like cutting food into small pieces, arranging food a specific way on the plate, eating foods in a specific order, weighing and measuring food in certain quantities, disassembling food or becoming anxious if they are unable to eat a specific way.

Mood Disorders

The second most common group of comorbid psychiatric disorders are mood disorders. Up to 54% of patients with an eating disorder experience a co-occurring mood disorder.

Major Depressive Disorder

Major Depressive Disorder, commonly referred to as clinical depression, is one of the most common co-occurring diagnoses with eating disorders, with 50-75% of those that struggle with an eating disorder also experiencing symptoms of depression. Major depressive disorder consists of either or both:

• A depressed mood
• Loss of interest or in pleasure

Alongside 3 (if experiencing both above) or 4 (if experiencing one of the above) of the following in a 2-week period:

• Loss or increase in appetite nearly every day or significant weight loss when not dieting or weight gain
• Slowing down of thought and a reduction in physical movement
• Fatigue or loss of energy nearly every day
• Feeling of worthlessness or excessive or inappropriate guilt nearly every day
• Diminished ability to think or concentrate, or indecisiveness nearly every day
• Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, a specific plan for committing suicide or suicidal ideation

Major Depression & Eating Disorders

Eating disorders and clinical depression have significant overlap in emotional presentation. Anorexia nervosa shares low self-esteem and body dissatisfaction with depression. Bulimia and major depressive disorder share similar emotional and cognitive symptoms, such as low self-worth, loneliness and isolation, feeling out of control, anger, irritability and inadequacy. Both clinical depression and bulimia also share impaired social and occupational functioning. Those with binge-eating disorder experience low self-worth, shame, guilt and hopelessness — all of which are shared with depression.

It can be difficult to determine whether major depressive disorder or an eating disorder develops first. Some may experience depression first and use disordered eating behaviors to cope; others might engage in eating disorder behaviors and experience subsequent depressive symptoms due to malnourishment or hopelessness.

Bipolar I Disorder

Bipolar I Disorder (BD-I) is when a patient experiences at least one manic episode that requires hospitalization or marked impairment in social or occupational function, with or without being preceded or followed up by hypomanic or depressive episodes. Manic episodes are composed of:

• Distinct period of abnormally and persistently elevated, expansive or irritable mood and abnormally and persistently goal-directed behavior or energy
• A noticeable change from usual in the form of 3 or 4 (if mood is only irritable) of the following:
  • Inflated self-esteem or grandiosity
  • Decreased need for sleep
  • More talkative than usual or pressure to keep talking
  • Flight of ideas or subjective experience that thoughts are racing
  • Distractibility
  • Increase in goal-directed activity or psychomotor agitation
  • Excessive involvement in activities that have a high potential for painful consequences

Bipolar II Disorder

Bipolar II Disorder (BD-II) is when a patient experiences one hypomanic episode and at least one major depressive episode and no manic episodes.

Hypomanic episodes are composed of:

• Distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently goal-directed behavior or energy
• A noticeable change from usual in the form of 3 or 4 (if mood is only irritable) of the above (see Bipolar I Disorder)
• The episode is associated with an unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic
• The disturbance in mood and the change in functioning are observable by others
• The episode is not severe enough to cause marked impairment in social or occupational functioning³

Major depressive episodes mirror major depressive disorder (see Major Depression).

Bipolar Disorders & Eating Disorders

Both BD-I and BD-II have notable comorbidity rates with eating disorders. Systematic reviews suggest that comorbidity varies across different eating disorder diagnoses, with binge eating disorder (BED) showing the highest comorbidity rate at 12.5%, then bulimia nervosa (7.4%) and finally anorexia nervosa (3.8%). Patients with bipolar disorder (BD) are much more likely than the general population to meet the criteria of an eating disorder. Some studies suggest that the comorbidity of BD and eating disorders are closely linked to bingeing and purging since it is more prevalent in individuals with anorexia nervosa binging/purging subtype (AN-BP), bulimia nervosa and BED.

BD, BED and bulimia nervosa all share impulsivity. During manic or hypomanic episodes, individuals can go into an impulsive state and struggle with self-control and have difficulty listening to their body’s hunger cues. Mania or hypomania may also cause the individual to become hyper-focused and fixated on certain activities, like exercise. Manic energy can cause patients to exercise excessively or to the point of exhaustion.

In a depressive episode, food might be used as a coping mechanism. Food can stimulate dopamine release in the brain, and during a depressive episode an individual with an eating disorder may continue to eat past the point of fullness to prolong this feeling.

For patients with anorexia nervosa restrictive subtype (AN-R), manic, hypomanic and depressive states can all trigger a loss of appetite, which can disrupt their diet and turn into consistently disordered eating behaviors.

Patients with comorbid bipolar disorder have significantly poorer clinical outcomes, lower quality of life and higher rates of alcohol abuse. This may impact eating disorder treatment outcomes and rates of eating disorder relapse.

Personality Disorders

Personality disorders are the third most common comorbid group of psychiatric disorders among eating disorder patients, affecting between 30-37% of those with eating disorders. Individuals with bulimia are more likely to have a personality disorder than those with anorexia nervosa.

Obsessive Compulsive Personality Disorder

Obsessive Compulsive Personality Disorder (OCPD) is a pervasive pattern of preoccupation with orderliness, perfectionism and mental and interpersonal control at the expense of flexibility, openness and efficiency. It is indicated by:

• Preoccupation with details, rules, lists, order, organization or schedules to the extent that the major point of the activity is lost
• Perfectionism that interferes with task completion
• Excessive devotion to work and productivity to the exclusion of leisure activities and friendships
• Overconscientiousness, scrupulousness and inflexibility about matters of morality, ethics, or values
• Inability to discard worn-out or worthless objects even when they have no sentimental value
• Reluctance to delegate tasks or to work with others unless they submit to exactly his or her way of doing things
• Miserly spending style toward both self and others
• Rigidity and stubbornness³

OCPD & Eating Disorders

The prevalence of OCPD is much higher in patients with eating disorders. OCPD is present in 22% of individuals with AN-R, compared to 8% in the general population.

Many of the characteristics of OCPD are mirrored in eating disorder pathology. A preoccupation with details, rules, order and schedules easily facilitates disordered eating behaviors like strict calorie and micronutrient counting, rigid exercise schedules, precision dieting and dedication to achieving lower weights or specific measurements.

The feature of perfectionism in OCPD complements the thin ideal, maintaining a complex eating and exercise regimen and committing to severe dietary restrictions. Excessive devotion to work fuels an obtrusive focus on weight loss at the expense of interpersonal relationships and leisure. Inflexibility on morality on values complements the idealization weight loss, low body weight and self-control characteristic of restriction. Rigidity and stubbornness reflect the uncompromising pursuit of weight loss despite the medical risks.

Borderline Personality Disorder

Borderline personality disorder (BPD) is a pervasive pattern of instability of interpersonal relationships, self-image and affects with marked impulsivity. It is indicated by:

• Frantic efforts to avoid real or imagined abandonment
• Pattern of unstable and intense interpersonal relationships consisting of alternating between extremes of idealization and devaluation
• Identity disturbance
• Impulsivity in at least two areas that are potentially self-damaging
• Recurrent suicidal behavior, gestures, threats or self-mutilating behavior
• Affective instability due to a marked reactivity of mood
• Feelings of emptiness
• Inappropriate, intense anger or difficulty controlling anger
• Transient, stress-related paranoid idea or severe dissociative symptoms3

BPD & Eating Disorders

Similar to OCPD, the prevalence of BPD is more common in patients with AN-BP and bulimia nervosa, at 25% and 28% respectively. This far exceeds the general population's rate of BPD at 6%.

Some of the characteristics of BPD are also exhibited in eating disorders that involve binge eating and/or purging. The impulsivity categorized by BPD is easily mirrored in impulsive eating pathology. Impulsivity is exhibited in binge-eating episodes as well as purging methods like self-induced vomiting and misuse of diuretics and laxatives.

Purging can also be perceived as a form of self-injury as it has the possibility of causing significant harm, and at its most severe, can cause serious medical complications which can result in death. Feelings of emptiness may be present in binging behavior, where one is both physically filling oneself, but may also be used to soothe emotions, including a feeling of emptiness.

Substance Use Disorders

Substance use disorders (SUDs) are the fourth most comorbid group of psychiatric disorders in eating disorder patients, affecting up to 27% of individuals with an eating disorder. The most reported substances used by those with eating disorders are caffeine, alcohol, tobacco, cannabis and stimulates.

Substance Use Disorders & Eating Disorders

SUDs are significantly more common in individuals who participate in purging behaviors. A meta-analysis of substance use disorder in eating disorder patients suggests that individuals with AN-BP are over twice as likely (18%) to have substance use disorders than those with AN-R (7%) as well as drug abuse/dependence. Individuals with BED seem to be at highest risk, with almost 25% of individuals with BED reporting lifetime SUD.

SUD and eating disorders, particularly those with binge-eating and purging presentation, share a lack of impulse control. Individuals with BED binge as a coping mechanism, similar to substance use. Both food and substance use can be utilized to cope with negative emotion states. Patients who purge may also become reliant on diuretics and laxatives to purge.

Patients who restrict may turn to substance use, particularly methamphetamines or cocaine, to lose weight. These drugs can suppress appetite and make restriction easier. Similar to patients who binge or purge, patients who restrict may take medications in order to ease negative emotional states brought on by the need for perfection or rigidity.

Neurodevelopment Disorders

Neurodevelopmental disorders are a group of psychiatric disorders that affect the development of the nervous system. Some neurodevelopmental disorders, like attention deficit hyperactivity disorder and autism spectrum disorder, have an increased prevalence in those with eating disorders.

Attention Deficit Hyperactivity Disorder

Attention Deficit Hyperactivity Disorder (ADHD) is a persistent pattern of inattention and/or hyperactivity and impulsivity that interferes with functioning and development. It is characterized by symptoms of inattention that are inappropriate for developmental level, with at least six symptoms of inattention for children up to age 16 or at least five in those older than 17:

• Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities.
• Often has trouble holding attention on tasks or play activities
• Often does not seem to listen when spoken to directly
• Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace
• Often has trouble organizing tasks and activities
• Often avoids, dislikes or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework)
• Often loses things necessary for tasks and activities
• Is often easily distracted
• Is often forgetful in daily activities

It is also categorized by hyperactivity and impulsivity that are inappropriate for developmental level with at least six symptoms of inattention for children up to age 16 or at least five in those older than 17. Symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive:

• Often fidgets with or taps hands or feet, or squirms in seat
• Often leaves seat in situations when remaining seated is expected
• Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless)
• Often unable to play or take part in leisure activities quietly
• Is often “on the go” acting as if “driven by a motor”
• Often talks excessively
• Often blurts out an answer before a question has been completed
• Often has trouble waiting their turn
• Often interrupts or intrudes on others

In addition, the following conditions must be met:

• Several inattentive or hyperactive-impulsive symptoms were present before age 12
• Several symptoms are present in two or more settings
• There is clear evidence that the symptoms interfere with, or reduce the quality of, social, school, or work functioning

There are three presentations ADHD that can occur: combined presentation, predominantly inattentive presentation and predominantly hyperactive-impulsive presentation.

ADHD & Eating Disorders

The prevalence of ADHD symptoms in eating disorder patients is between 5-17%, and the prevalence of eating disorder in those with ADHD is up to 12%. Children with ADHD are also more likely to experience an eating disorder. Eating disorder patients with comorbid ADHD tend to experience poorer clinical outcomes.

Impulsivity and inattention are shared features of both bulimia nervosa and ADHD, with research suggesting that the occurrence of ADHD is higher in patients with bulimia nervosa. Children with ADHD are at an increased risk for bulimia nervosa symptoms and girls with ADHD are over three times as likely to have an eating disorder than their peers; of those with eating disorders, 30% had a history of exclusively anorexia nervosa, while 70% had a history of exclusively bulimia nervosa or both bulimia nervosa and anorexia nervosa.

Autism Spectrum Disorder

Autism Spectrum Disorder (ASD) is a neurodevelopmental disorder characterized by persistent deficits in social communication and interactions, restricted interests and repetitive behavior. The diagnostic criteria for ASD is as follows:

The first characteristic of ASD is a persistent deficit in social communication and social interaction across multiple contexts. An individual with ASD must present with the following:

• Deficits in social-emotional reciprocity (including abnormal social approach and failure of normal back-and-forth conversation; reduced sharing of interests, emotions or affect and failure to initiate or respond to social interactions)
• Deficits in nonverbal communicative behaviors used for social interaction (including poorly integrated verbal and nonverbal communication; abnormalities in eye contact and body language or deficits in understanding and use of gestures or lack of facial expressions and nonverbal communication)
• Deficits in developing, maintaining and understanding relationships (including difficulty adjusting behavior to suit various social contexts, in sharing imaginative play or in making friends or the absence of interest in peers)

Those with ASD must also demonstrate at least 2 of the following restricted and repetitive behaviors or activities:

• Stereotyped speech, repetitive motor movements, echolalia (repeating words or phrases, sometimes from television shows or from other people) and repetitive use of objects or abnormal phrases
• Rigid adherence to routines, ritualized patterns of verbal or nonverbal behaviors and extreme resistance to change
• Highly restricted interests with abnormal intensity or focus, such as a strong attachment to unusual objects or obsessions with certain interests
• Increased or decreased reactivity to sensory input or unusual interest in sensory aspects of the environment, such as not reacting to pain, strong dislike to specific sounds, excessive touching or smelling objects or fascination with spinning objects.

ASD & Eating Disorders

Research suggests that there is a heightened prevalence of ASD among patients with eating disorders. Almost 23% of individuals with ASD have an eating disorder, compared to 2% of the general population.

Anorexia nervosa and ASD share some symptomology. Restricted and intense focus on specific interests can be limited to or directed toward food and diet and rigid attitudes can manifest through weight-focused repetitive behaviors, like body checking or weighing oneself. Both ASD and AN show social anhedonia (reduced ability to experience pleasure), deficits in emotional intelligence, difficulties on advanced theory of mind tests, rigidity on tests of set-shifting, excellent performance on tests of attention to detail and alexithymia (impaired ability to be aware of, explicitly identify, and describe one's feelings).

ASD and Avoidant/Restrictive Food Intake Disorder (ARFID) also share symptomology. Food selectivity is the most frequent eating problem in children with ASD and being a picky eater, aversions to different aspects of foods and rigid brand preference can cause those with ASD to become underweight. Individuals, both children and adults, with ASD with increased reactivity to sensory input may avoid certain foods based on smell, texture, appearance, temperature or color.

Self-Injury & Suicide

Self-injury and suicide are elevated in individuals with eating disorders. Even though non-suicidal self injury (NSSI) features no suicidal intent, it often precedes suicidal ideation and behavior.

Self-Injury

Non-suicidal self-injury (NSSI) is inflicting intentional harm to one’s body without the intent to die. Self-injury is a maladaptive coping mechanism that frequently occurs alongside an eating disorder, with up to 33% of individuals with eating disorders report engaging in NSSI at some point.

NSSI is associated with higher levels of impulsivity and emotional reactivity in patients with eating disorders, which are both higher in patients with bulimia nervosa than those with anorexia nervosa. NSSI are used to alleviate overwhelming negative emotions, which serves a similar purpose for many of those who suffer from an eating disorder. NSSI can include self-cutting, burning, scratching, banging, hitting, intentionally preventing wound healing, among others, and most of those who utilize NSSI will use multiple methods.

Suicide

Suicide is the leading cause of death for individuals with eating disorders and varies by disorder and subtype. Bulimia nervosa has the highest risk (30%), followed by AN-BP (25-44%) and AN-R (8.6-15%). Depression has a strong association with lifetime suicide attempts, for both bulimia nervosa and anorexia nervosa. There are fewer studies covering suicidality in those with BED, but it is suggested that those with BED experience suicidal ideation, planning and attempts at similar rates to other eating disorders.

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