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Eating Disorders & Co-Occurring Psychiatric Disorders (Dual Diagnosis)

By Kamila Cass, PhD, CEDS

Eating disorders frequently co-occur with psychiatric conditions such as anxiety, depression, OCD, PTSD, and personality disorders, which can exacerbate symptoms. Understanding dual diagnosis is essential for those seeking treatment, as co-occurring conditions often share underlying traits like impulsivity and obsessive behaviors. Comprehensive treatment approaches, including psychoeducation and psychotherapy, can help individuals manage both their eating disorder and coexisting mental health conditions for improved outcomes.

Eating disorders & Psychiatric Comorbidities

Research demonstrates that 55-95% of people diagnosed with an eating disorder also receive a diagnosis for at least one other psychiatric disorder, also known as dual diagnosis. The most common psychiatric disorders that co-occur with eating disorders include:

  • Anxiety disorders, affecting up to 74% of those with eating disorders
  • Mood disorders, affecting up to 54% of those with eating disorders
  • Trauma- and stress-related disorders
  • Obsessive-compulsive and related disorders
  • Substance use disorders, affecting up to 37% of those with eating disorders
  • Personality disorders
  • Neurodevelopmental disorders.

Non-suicidal self-injury and suicidality are also common in patients with eating disorders and can be compounded by multiple psychiatric diagnoses.

Anxiety Disorders (generalized anxiety disorder)

Up to 23% of those with eating disorders have co-occurring generalized anxiety disorder (GAD). Eating disorders and GAD share similar clinical features, like overwhelming anxiety which may present in eating disorders around weight gain and body shape.

Mood disorders

Major depressive disorder

Major depressive disorder (clinical depression) is one of the most common co-occurring diagnoses with eating disorders, with up to 75% of those that struggle with an eating disorder also experiencing symptoms of depression. 

Eating disorders and clinical depression have significant overlap in emotional presentation, including:

Bipolar disorder

Two common bipolar disorders associated with eating disorders are:

  • Bipolar I Disorder, 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
  • Bipolar II Disorder, when a patient experiences one hypomanic episode and at least one major depressive episode and no manic episodes

During manic or hypomanic episodes, individuals can go into an impulsive state and struggle with self-control and have difficulty listening to their body, either by ignoring hunger cues or exercising to the point of exhaustion.

In a depressive episode, food might be used as a coping mechanism, bingeing to stimulate dopamine release in the brain and eating past the point of fullness to prolong this feeling.

Trauma and Stress-related Disorders (post-traumatic stress disorder)

Post-traumatic stress disorder (PTSD) is an anxiety disorder that can develop after experiencing or witnessing a traumatic event, such as:

  • Combat
  • Natural disasters
  • Serious or life-threatening accidents
  • Assault or abuse

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. Those with eating disorders may use disordered eating behaviors as a way to cope with their trauma.

Obsessive-Compulsive & Related Disorders (obsessive-compulsive disorder)

Obsessive-compulsive disorder (OCD) is characterized by persistent, unwanted thoughts (obsessions) and repetitive behaviors or mental acts (compulsions) that patients feel compelled to perform.

Obsessions or compulsions are time consuming and often cause distress, significantly impacting quality of life. The symptomology of OCD can be frequently seen in eating disorders, like:

  • Obsession around weight loss
  • Repeated measuring, weighing or body checking
  • Food-related rituals

Personality Disorders

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.

Many of the characteristics of OCPD are mirrored in eating disorder pathology. A preoccupation with details, rules, order and schedules reinforces disordered eating behaviors like:

  • Strict calorie and micronutrient counting
  • Rigid exercise schedules
  • Precision dieting
  • Extreme dedication to achieving lower weights or specific measurements.

Borderline personality disorder

Borderline personality disorder (BPD) is a pervasive pattern of instability of interpersonal relationships, self-image and affects with marked impulsivity. Similar to OCPD, the prevalence of BPD is more common in patients with anorexia nervosa binge purge subtype (AN-BP) and bulimia nervosa, at 25% and 28% respectively.

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 bingeing behavior, where one is both physically filling oneself, but may also be used to soothe emotions, including a feeling of emptiness.

Substance Use Disorders

Both disordered eating and substance use can be utilized to cope with negative emotion states. Substance use disorders (SUDs) are significantly more common in individuals who participate in purging behaviors, who may turn to substance use or disordered eating to deal with difficult emotions. Patients may also turn to substance use, particularly methamphetamines or cocaine, to lose weight because some drugs can suppress appetite and make restriction easier.

Neurodevelopment 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 and/or hyperactivity that are inappropriate for developmental level.

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.

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.

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.

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 specific characteristics of foods and rigid brand preference can cause those with ASD to become underweight. 

Effective treatment for eating disorders & co-occurring conditions

Dual diagnosis treatment is crucial because it can help treat conditions that may be contributing to an eating disorder. Eating disorders and co-occurring diagnoses can compound each other, making it equally important to treat all diagnoses. By treating both conditions simultaneously, individuals can learn healthier ways to manage their symptoms and improve their outcomes.

Psychoeducation

Psychoeducation can help those with dual diagnoses understand the connection between their multiple diagnoses. Psychoeducation is a therapeutic intervention that teaches patients about their mental health conditions and treatment. Being able to understand one’s diagnoses and learning how conditions can be managed empowers patients to be an active and informed participant in their care.

Psychotherapy

Psychotherapy is a critical intervention for those with dual diagnoses. Research continually shows around 75% of those who receive psychotherapy experience some symptom relief. Psychotherapy has been shown to improve emotional and psychological wellbeing and is linked with positive changes in the brain and body.

Learn more about psychotherapy options for eating disorders.

References

  • Hambleton, A., Pepin, G., Le, A., Maloney, D., Aouad, P., Barakat, S., Boakes, R. A., Brennan, L., Bryant, E., Byrne, S. M., Caldwell, B., Calvert, S., Carroll, B., Castle, D. J., Caterson, I. D., Chelius, B., Chiem, L., Clarke, S., Conti, J., . . . Maguire, S. (2022). Psychiatric and medical comorbidities of eating disorders: findings from a rapid review of the literature. Journal of Eating Disorders, 10(1). https://doi.org/10.1186/s40337-022-00654-2
  • Swinbourne, J., Hunt, C., Abbott, M. J., Russell, J., St Clare, T., & Touyz, S. (2012). The comorbidity between eating disorders and anxiety disorders: Prevalence in an eating disorder sample and anxiety disorder sample. Australian and New Zealand Journal of Psychiatry, 46(2), 118–131. https://doi.org/10.1177/0004867411432071
  • American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
  • Thornton, L. M., Dellava, J. E., Root, T. L., Lichtenstein, P., & Bulik, C. M. (2011). Anorexia nervosa and generalized anxiety disorder: Further explorations of the relation between anxiety and body mass index. Journal of Anxiety Disorders, 25(5), 727–730. https://doi.org/10.1016/j.janxdis.2011.03.010
  • Schaumberg, K., Reilly, E. E., Gorrell, S., Levinson, C. A., Farrell, N., Brown, T. A., Smith, K. E., Schaefer, L. M., Essayli, J. H., Haynos, A. F., & Anderson, L. (2021). Conceptualizing eating disorder psychopathology using an anxiety disorders framework: Evidence and implications for exposure-based clinical research. Clinical Psychology Review, 83, 101952. https://doi.org/10.1016/j.cpr.2020.101952
  • Tagay, S., Schlottbohm, E., Reyes-Rodríguez, M. L., Repic, N., & Senf, W. (2014). Eating Disorders, Trauma, PTSD, and Psychosocial Resources. Eating Disorders, 22(1), 33–49. https://doi.org/10.1080/10640266.2014.857517
  • Post-Traumatic Stress Disorder (PTSD). (n.d.). National Institute of Mental Health (NIMH). https://www.nimh.nih.gov/health/statistics/post-traumatic-stress-disorder-ptsd
  • Brewerton, T. D. (2007). Eating Disorders, Trauma, and Comorbidity: Focus on PTSD. Eating Disorders, 15(4), 285–304. https://doi.org/10.1080/10640260701454311
  • Rodríguez, M. M., Pérez, V. a. F., & García, Y. (2005). Impact of traumatic experiences and violent acts upon response to treatment of a sample of Colombian women with eating disorders. International Journal of Eating Disorders, 37(4), 299–306. https://doi.org/10.1002/eat.20091
  • Mahon, J., Bradley, S. N., Harvey, P., Winston, A., & Palmer, R. D. (2001). Childhood trauma has dose-effect relationship with dropping out from psychotherapeutic treatment for bulimia nervosa: A replication. International Journal of Eating Disorders, 30(2), 138–148. https://doi.org/10.1002/eat.1066
  • Fichter, M. M., & Quadflieg, N. (2004). Twelve-year course and outcome of bulimia nervosa. Psychological Medicine, 34(8), 1395–1406. https://doi.org/10.1017/s0033291704002673
  • Mandelli, L., Draghetti, S., Albert, U., De Ronchi, D., & Atti, A. R. (2020). Rates of comorbid obsessive-compulsive disorder in eating disorders: A meta-analysis of the literature. Journal of Affective Disorders, 277, 927–939. https://doi.org/10.1016/j.jad.2020.09.003
  • Mischoulon, D., Eddy, K. T., Keshaviah, A., Dinescu, D., Ross, S. M., Graham, A. K., Franko, D. L., & Herzog, D. B. (2011). Depression and eating disorders: Treatment and course. Journal of Affective Disorders, 130(3), 470–477. https://doi.org/10.1016/j.jad.2010.10.043
  • Voderholzer, U., Hessler, J. B., Lustig, L., & Läge, D. (2019). Comparing severity and qualitative facets of depression between eating disorders and depressive disorders: Analysis of routine data. Journal of Affective Disorders, 257, 758–764. https://doi.org/10.1016/j.jad.2019.06.029
  • Eating Disorders. (n.d.). National Institute of Mental Health (NIMH). https://www.nimh.nih.gov/health/statistics/eating-disorders
  • McAulay, C., Mond, J., Outhred, T., Malhi, G. S., & Touyz, S. (2021). Eating disorder features in bipolar disorder: clinical implications. Journal of Mental Health, 32(1), 43–53. https://doi.org/10.1080/09638237.2021.1875401
  • Seixas, C., Miranda-Scippa, Â., Nery-Fernandes, F., Andrade-Nascimento, M., Quarantini, L. C., Kapczinski, F., & De Oliveira, I. R. (2012). Prevalence and clinical impact of eating disorders in bipolar patients. Revista Brasileira De Psiquiatria, 34(1), 66–70. https://doi.org/10.1016/s1516-4446(12)70012-0
  • McDonald, C. E., Rossell, S. L., & Phillipou, A. (2019). The comorbidity of eating disorders in bipolar disorder and associated clinical correlates characterised by emotion dysregulation and impulsivity: A systematic review. Journal of Affective Disorders, 259, 228–243. https://doi.org/10.1016/j.jad.2019.08.070
  • Godt, K. (2008). Personality disorders in 545 patients with eating disorders. European Eating Disorders Review, 16(2), 94–99. https://doi.org/10.1002/erv.844
  • Sansone, R. A., Levitt, J. L., & Sansone, L. A. (2004). The Prevalence of Personality Disorders Among Those with Eating Disorders. Eating Disorders, 13(1), 7–21. https://doi.org/10.1080/10640260590893593
  • Devoe, D. J., Dimitropoulos, G., Anderson, A., Bahji, A., Flanagan, J., Soumbasis, A., Patten, S. B., Lange, T., & Paslakis, G. (2021). The prevalence of substance use disorders and substance use in anorexia nervosa: a systematic review and meta-analysis. Journal of Eating Disorders, 9(1). https://doi.org/10.1186/s40337-021-00516-3
  • Reinblatt, S. P. (2015). Are Eating Disorders Related to Attention Deficit/Hyperactivity Disorder? Current Treatment Options in Psychiatry, 2(4), 402–412. https://doi.org/10.1007/s40501-015-0060-7
  • Svedlund, N. E., Norring, C., Ginsberg, Y., & Von Hausswolff-Juhlin, Y. (2018). Are treatment results for eating disorders affected by ADHD symptoms? A one-year follow-up of adult females. European Eating Disorders Review, 26(4), 337–345. https://doi.org/10.1002/erv.2598
  • Biederman, J., Ball, S., Monuteaux, M. C., Surman, C. B. H., Johnson, J. S., & Zeitlin, S. (2007). Are Girls with ADHD at Risk for Eating Disorders? Results from a Controlled, Five-Year Prospective Study. Journal of Developmental and Behavioral Pediatrics, 28(4), 302–307. https://doi.org/10.1097/dbp.0b013e3180327917
  • Huke, V., Turk, J., Saeidi, S., Kent, A., & Morgan, J. (2013). Autism Spectrum Disorders in Eating Disorder Populations: A Systematic Review. European Eating Disorders Review, 21(5), 345–351. https://doi.org/10.1002/erv.2244
  • Dell’Osso, L., Carpita, B., Cremone, I. M., Mucci, F., Salerni, A., Marazziti, D., Carmassi, C., & Gesi, C. (2020). Subthreshold Autism Spectrum in a Patient with Anorexia Nervosa and Behçet’s Syndrome. Case Reports in Psychiatry, 2020, 1–6. https://doi.org/10.1155/2020/6703979
  • Dell’Osso, L., Abelli, M., Carpita, B., Pini, S., Castellini, G., Carmassi, C., & Ricca, V. (2016). Historical evolution of the concept of anorexia nervosa and relationships with orthorexia nervosa, autism, and obsessive-compulsive spectrum. Neuropsychiatric Disease and Treatment, Volume 12, 1651–1660. https://doi.org/10.2147/ndt.s108912
  • Beighley, J. S., Matson, J. L., Rieske, R. D., & Adams, H. L. (2013). Food selectivity in children with and without an autism spectrum disorder: Investigation of diagnosis and age. Research in Developmental Disabilities, 34(10), 3497–3503. https://doi.org/10.1016/j.ridd.2013.07.026
  • Postorino, V., Sanges, V., Giovagnoli, G., Fatta, L. M., De Peppo, L., Armando, M., Vicari, S., & Mazzone, L. (2015). Clinical differences in children with autism spectrum disorder with and without food selectivity. Appetite, 92, 126–132. https://doi.org/10.1016/j.appet.2015.05.016
  • Sobanski E, Marcus A, Hennighausen K, Hebebrand J, Schmidt MH. Further evidence for a low body weight in male children and adolescents with Asperger’s disorder. Eur Child Adolesc Psychiatry. 1999;8(4):312–314. 
  • Bölte, S., Özkara, N., & Poustka, F. (2002). Autism spectrum disorders and low body weight: Is there really a systematic association? International Journal of Eating Disorders, 31(3), 349–351. https://doi.org/10.1002/eat.10015
  • Klonsky, E. D., Victor, S. E., & Saffer, B. Y. (2014). Nonsuicidal Self-Injury: What We Know, and What We Need to Know. The Canadian Journal of Psychiatry, 59(11), 565–568. https://doi.org/10.1177/070674371405901101
  • Ripke, S., Kuja-Halkola, R., Thornton, L. M., Runfola, C. D., D’Onofrio, B. M., Almqvist, C., Lichtenstein, P., Sjölander, A., Larsson, H., & Bulik, C. M. (2016). Familial Liability for Eating Disorders and Suicide Attempts. JAMA Psychiatry, 73(3), 284. https://doi.org/10.1001/jamapsychiatry.2015.2737
  • Goldstein, A., & Gvion, Y. (2019). Socio-demographic and psychological risk factors for suicidal behavior among individuals with anorexia and bulimia nervosa: A systematic review. Journal of Affective Disorders, 245, 1149–1167. https://doi.org/10.1016/j.jad.2018.12.015
  • Forcano, L., Álvarez, E. S., Santamaría, J. M., Jiménez-Murcia, S., Granero, R., Penelo, E., Alonso, P., Sánchez, I., Menchón, J. M., Ulman, F., Bulik, C. M., & Fernández-Aranda, F. (2011). Suicide attempts in anorexia nervosa subtypes. Comprehensive Psychiatry, 52(4), 352–358. https://doi.org/10.1016/j.comppsych.2010.09.003
  • Conti, C., Lanzara, R., Scipioni, M., Iasenza, M., Guagnano, M. T., & Fulcheri, M. (2017). The Relationship between Binge Eating Disorder and Suicidality: A Systematic Review. Frontiers in Psychology, 8. https://doi.org/10.3389/fpsyg.2017.0212
Written by
Kamila Cass, PhD, CEDS

Kamila Cass, PhD, CEDS

Dr. Kamila Cass is a Clinical Psychologist at the ACUTE Center for Eating Disorders at Denver Health, providing psychodiagnostic assessment, individual and group psychotherapy, and crisis intervention…
Treatment Type
Psychiatric Treatment
Resource Type
Medical Resource

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ACUTE Earns Prestigious Center of Excellence Designation from Anthem
In 2018, the ACUTE Center for Eating Disorders & Severe Malnutrition at Denver Health was honored by Anthem Health as a Center of Excellence for Medical Treatment of Severe and Extreme Eating Disorders. ACUTE is the first medical unit ever to achieve this designation in the field of eating disorders. It comes after a rigorous review process.

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