Individuals with eating disorders very often also have another psychiatric condition. In one study, 97% of female inpatients with eating disorders were found to have one or more comorbid diagnoses.1 Recognizing and treating these comorbidities improves outcomes for the eating disorders and treating an eating disorder can significantly improve other conditions as well.
Failure to recognize and treat comorbidities can have catastrophic repercussions. In anorexia nervosa, in particular, mortality is 18 times higher when another significant psychiatric disorders such as depression is present.2
The most frequent comorbid psychiatric disorders are depression, anxiety, and substance abuse disorders. Depression stands out as the most common comorbidity, affecting 94% of patients with eating disorders in the study. Depression appears to equally affect patients with anorexia nervosa, bulimia or eating disorder not otherwise specified.
Anxiety disorders co-occur in more than half (56%) of eating disorder cases, with no difference in prevalence seen by type of eating disorder. Anxiety disorders are associated with increased intensity of weight- and appearance-related concerns and more severe eating disorder symptoms. The presence of anxiety disorders is also associated with both binge-eating and purging.3
Those rituals associated with eating disorders share many characteristics with behaviors seen in obsessive compulsive disorder, which affects up to 56% of individuals with eating disorders and is especially common in anorexia. The fear that serves as the base of OCD may also lead those with eating disorders to strive for perfection, whether in figure, weight or control via highly structured rules around food, exercise or purging. The emergence of an eating disorder as a coping mechanism is given further support by research that indicates that OCD and other anxiety disorders arise during childhood, predating the development of eating disorders in the majority of cases.4
Substance abuse is also higher among individuals with eating disorders, affecting nearly a quarter of all patients. In some instances, substance abuse may be used to suppress appetite, particularly among anorexics. Substance abuse occurs more commonly among bulimics, however, with alcohol abuse twice as likely in bulimics and polysubstance abuse three times more likely in this sub-group than among other eating disorders. Substance abuse may serve a self-medicating function, as an attempt to alleviate the anxiety and distress that often underlies disordered eating.5
Because psychiatric comorbidities occur so often with eating disorders, it is critically important to properly diagnose and understand the relationship between these mental health issues to ensure a lasting recovery. The high prevalence of these conditions means that treatment should include a comprehensive screening for a range of mental health disorders and a plan for addressing multiple diagnoses.
Eating disorders and mood and anxiety disorders share many similarities, including a frequent history of trauma, maladaptive behaviors often including substance abuse, a desire for control and a high risk of suicide. Individuals with these disorders respond well to therapeutic programs that build trust, provide safe, low-stress environments, offer one-on-one and group counseling that is sensitive to issues of trauma, abuse and addiction. They also recognize the need to help patients develop the tools necessary for social interaction as well as emotional expression. Because each patient brings a different mix of issues into treatment, programs that offer multiple types of therapy and staff that understand the importance of meeting patients where they are in their journey to health will offer the best chance for success.
Failure to recognize comorbidities may place an individual who has recovered from an eating disorder at greater risk of relapse when faced with acute stress or trauma. It may also lead to development of other dangerous coping behaviors if the fundamental issues of fear, trauma, shame and control are not addressed. With so many patients needing assistance with multiple disorders, integrative therapy provides the best option for long-term physical and mental health.
1. Blinder BJ, Cumella EJ, Sanathara VA. Psychiatric comorbidities of female inpatients with eating disorders. Psychosom Med. 2006 May-Jun;68(3):454-62.
2. Bernstein BE, Pataki C. Anorexia Nervosa. Medscape. Updated December 14, 2014.
3. Spindler A, Milos G. Links between eating disorder symptom severity and psychiatric comorbidity. Eat Behav. 2007 Aug;8(3):364-73. Epub 2006 Dec 8.
4. Kaye WH, Bulik CM, Thornton L, Barbarich N, Masters K. Comorbidity of anxiety disorders with anorexia and bulimia nervosa. Am J Psychiatry. 2004 Dec;161(12):2215-21.
5. Kaye W, Wisniewski L. Vulnerability to Substance Abuse in Eating Disorders. NIDA. 1996;159:269-311.