Eating Disorders and Co-occurring Psychiatric Diagnoses

It’s uncommon for an eating disorder to exist in a vacuum. Most people with an eating disorders qualify for one, or more co-occurring mental- and physical diagnoses.

The presence of multiple diagnoses or conditions can complicate accurate diagnosis, treatment efforts, and the path to recovery. In today’s blog post we’ll consider the most commonly observed co-occurring conditions with eating disorders, and hopefully understand better how they influence each other.

Eating Disorders and Mood Disorders

Approximately 50% of individuals with eating disorders also qualify for a diagnosis of major depressive disorders. Depression can be experienced before the onset (primary depression), together with, or after the onset (secondary depression) of an eating disorder. Many of the criteria used to diagnose clinical depression are also the consequences of restriction, binge-eating, and/or engaging in compensatory behaviours like purging or excessive exercising.

In most cases, as treatment unfolds, depressive symptoms will improve with the normalization of eating patterns and the elimination of compensatory behaviours. However, if the person experiences primary clinical depression, the use of psychotropic medications can often be very useful in relieving depressive symptoms, helping them participate better in their psychotherapy treatment for their eating disorder.

Eating Disorders and Suicide

There is a complex and interconnected relationship between eating disorders and suicide, although it’s important to note that not everyone with an eating disorder will experience suicidal thoughts or behaviours.

Many factors can contribute to an increased risk of suicide or attempted suicide among people with eating disorders. Some of these factors may include:

• A history of multiple mental health comorbidities (i.e. anxiety- and  mood disorders).
• A history of previous suicide attempts.
• Social isolation.
• Family issues and conflicts.
• Family history of suicide.
• Substance misuse.
• Adverse or traumatic childhood experiences (e.g. abuse, bullying etc.).
• A sense of being a burden on others. Feelings of excessive guilt and shame.
• Self-harm behaviours.
• Hospitalization and treatment history.
• Tolerance for high risk and impulsive behaviours.
• Difficulty regulating emotions.

Statistics highlight suicide to be one of the top causes of death for young people aged 10 to 24 years old. Suicide is also the second leading cause of death among individuals with anorexia nervosa, and suicidal behaviour is elevated in those struggling with bulimia nervosa and binge eating disorder.

Approximately one-quarter to one-third of people with anorexia nervosa, bulimia nervosa, or binge eating disorder admit to having thoughts about suicide; with one-quarter to one-third of people with anorexia and bulimia having previously attempted suicide. Those with anorexia are 18 times more likely to die by suicide and those struggling with bulimia are 7 more times likely to die by suicide.

Eating Disorders and Anxiety Disorders

Overall, research findings highlight anxiety disorders to be highly comorbid with eating disorders. Approximately 48% of adults with anorexia nervosa, 81% of adults with bulimia nervosa, and 65% of adults with binge-eating disorder have at least one co-occurring anxiety disorder. These include anxiety disorders like generalized anxiety disorder, social anxiety, and panic disorder. Anxiety disorders most frequently precede the onset of an eating disorder and often persist after recovery.

Eating Disorders and Obsessive-Compulsive Disorders

Approximately 15-18% of individuals with eating disorders also qualify for a diagnosis of Obsessive-Compulsive Disorder (OCD). The prevalence OCD in the general population is about 2%. Roughly 1 in 6 people with an eating disorder also have OCD, nearly 8 times more than the general population. In general, OCD is more common in individuals with anorexia nervosa than in people with bulimia nervosa or binge eating disorder.

There are a number of similarities between OCD and eating disorders that could account for this high rate of co-occurrence. For example, both conditions involve intrusive thoughts, image or impulses, which are unwanted and distressing. These phenomena can focus on food, weight, body image, contamination, self-harm, or perceived mistakes. People with OCD and those with eating disorders also engage in repetitive compulsive behaviours as a response to these thoughts. These behaviours aim to reduce the anxiety experienced.

Fear of losing control is another likeness. Individuals with eating disorders fear gaining weight and losing control around food, similarly to those with OCD who may fear losing control of their thoughts, actions, or emotions. These issues are compounded by their strong need for perfection, causing them to engage in rigid and inflexible thinking and behaviours. Another similarity is that OCD and eating disorders can be triggered by stress or anxiety. Once again, ritualistic and compulsive behaviours may be used as their main coping strategies. However, these behaviours only bring temporary relief, and may actually increases overall anxiety in the long run.

Finally, people with OCD and those with eating disorders often have prevailing and enduring low self-esteem. Although there could be multiple reasons for the low self-esteem, it’s perpetuated by negative thoughts about themselves, their weight, or their body image.

Eating Disorders and Trauma

Posttraumatic Stress Disorder (PTSD) is a serious mental health condition that develops when someone is exposed to one or more, or enduring traumatic events. According to the Diagnostic and statistical manual of mental disorders (DSM-5 TR), traumatic events include situations where there is a real or perceived threat of death, serious injury, and/or sexual violence. These events can include those that are directly experienced by someone, witnessing someone else being exposed to the trauma, and/or repeatedly listening to details of other people’s traumatic experiences (e.g., first responders).

Despite research showing a strong correlation between PTSD and eating disorders, it remains unclear exactly how these two conditions are related and why there is such a high co-occurrence between them. One possibility is that eating disorders and their associated symptoms may predispose someone to develop PTSD after experiencing trauma. Several studies have indicated that people with eating disorders are more likely to have:

• A pre-existing anxiety disorder.
• More easily perceive threat or hostile intent from others.
• Are preoccupied with negative consequences.
• Are sensitive to punishment.
• Have difficulty adapting to change.
• Have a heightened reaction to stress and trauma.

All the afore-mentioned components may increase the individual’s risk of developing PTSD after experiencing trauma.

Some researchers have also proposed that eating disorders may develop as a way to self-medicate and cope with the unmanageable feelings associated with their PTSD. It’s been shown that binge eating and/or purging behaviours can help individuals manage their PTSD symptoms by decreasing feelings of anxiety, hyperarousal (extreme anger, paranoia and irritability), and by allowing them to numb or avoid intrusive thoughts about the traumatic event(s).

Others have argued that PTSD related negative thinking may cause or exacerbate symptoms of low self-esteem, perfectionism, and poor body image which then lead to engaging in disordered eating behaviours. Studies have also shown that the traumatic events and subsequent PTSD symptoms often occur before someone shows signs of an eating disorder, which supports evidence that trauma and PTSD may have a causal relationship to the development of eating disorders.

Conversely, other researchers have suggested that rather than one disorder causing the other, the symptoms of both PTSD and eating disorders maintain or exacerbate each other. For example, avoidance of PTSD symptoms such as hyperarousal by binging, purging, and/or restriction may serve to maintain both eating disorders and co-occurring PTSD. Since these behaviours can reinforce each other, it can be difficult to break this cycle of disordered eating and avoidance of PTSD related symptoms. As a result, traumatic experiences and their harmful consequences are not effectively processed and can continue to cause harm. In this way, trauma, PTSD, and eating disorders can be very much intertwined.

Substance Abuse

Substance misuse and eating disorders frequently co-occur, with up to half of individuals with eating disorders also using alcohol or illicit drugs – a rate 5 times more than the general population. Each of these illnesses alone significantly increases mortality rates and when they occur together can lead to serious physical and mental health consequences.

Below is a short video focussing on the dual diagnosis of eating disorders and substance abuse, and what treatment should look like to address these as effectively as possible.

Conclusion

As discussed, eating disorders have close and significant comorbidities with a range of psychiatric conditions. This is partly why eating disorders treatment can be complicated and difficult, because you’re attending to multiple problems of thought, emotions and behaviours at the same time.

For these reasons you should access treatment that addresses all your issues, by someone who has the capacity to assist with most, if not all, of your diagnoses present. This is one of the founding principle behind Reverence Recovery, and a central principle to everyone treated there. We don’t shy from difficult and complex cases, and comorbidities are not barriers to treatment.

If you struggle with any of these conditions described, share these with your treatment team and family. Struggling with an eating disorder is already difficult, but keeping silent on any other issues your experiencing does not help. Treatment needs to be tailored specifically to help, focussing not only on some of your issues, but all of them.

In the next few blog posts we’ll consider some of the comorbid diagnoses in detail, and try to uncover the links with eating disorders better.