Eating Disorders and Dual Diagnosis or Co-Occurring Disorders

Alysa came in for her first therapy session during her 6th week of treatment at an outpatient drug and alcohol rehab program. As she was gaining time in her sobriety, her eating disorder behaviors began to escalate. She became more focused on her weight and began restricting food as well as bingeing and purging.

Many women and men who have eating disorders have co-occurring disorders. The most common co-occurring disorders and behaviors include:

  • Depression
  • Anxiety disorders
  • Obsessive-compulsive disorder (OCD)
  • Body dysmorphic disorder (BDD)
  • Post-traumatic stress disorder (PTSD)
  • Trichotillomania (TTM)
  • Self-injurious Behavior (SIB)
  • Alcohol/Substance Use Disorders (SUDS)

Dual diagnosis is the term used to describe an individual who simultaneously has a mental health issue and substance use disorder. In the case of Alysa, she meets the criteria for dual diagnosis as she has substance use disorder (alcohol and cocaine) and bulimia nervosa. As treatment progressed, it became clear that she also has depression, anxiety and self-injurious behavior.

According to the National Institute of Mental Health, more than 50 percent of individuals with anorexia nervosa have a co-occurring disorder as well as over 90 percent of individuals with bulimia nervosa, and over 75 percent of individuals with binge eating disorder.

Depressive Disorders

Depressive disorders are often characterized by persistent sadness, feelings of emptiness, irritability, and loss of interest in life. This is accompanied by somatic and cognitive changes that significantly compromise the individual’s ability to function and participate in activities of daily living. Major depressive disorders are the most common co-occurring disorders in eating disorders. According to the American Psychiatric Association, the lifetime rate of major depressive disorders in eating disorders ranges from 50 to 75 percent.

Depression can lead to eating disorders and eating disorders can lead to depression. In anorexia nervosa being in a malnourished state can lead to physiological changes that can affect one’s mood. With anorexia and bulimia nervosa, a person’s sense of self and self-worth is significantly dependent on weight, body size and/or shape. The inability to meet one’s desired weight and/or body size and shape can lead to feelings of failure which contributes to depression. Depression can also be exacerbated during recovery as the “ideal” or “desired” weight is no longer in line with recovery. Perfectionism is often seen in individuals with eating disorders. The need for perfection can lead to a focus on food and weight as they may not feel good enough in other areas of their life and see their successes with controlling their food and weight as a means of feeling worthwhile.

…Alysa reported an increase in her depression as she came to the realization that for her to recover from bulimia, she needed to let go of trying to lose more weight. This saddened her as she believed that being at her current weight made her less acceptable.

Anxiety Disorders

Anxiety disorders – especially generalized anxiety disorder and social anxiety disorder— often co-occur in eating disorders. In many cases, the onset of anxiety precedes the development of the eating disorder. In one study, 2/3 of individuals suffering from an eating disorder also experienced an anxiety disorder at some point in their life. In addition, 42% of those individuals reported the onset of anxiety during childhood predating the development of the eating disorder.

Anxiety is managed differently in individuals with anorexia versus those who binge eat (bulimia and binge eating disorder). In anorexia nervosa, eating raises the serotonin and dopamine levels which results in increasing tension and anxiety. This leads the person with anorexia to restrict their food to manage their moods. They feel calmer when they do not eat. On the other hand, individuals who binge eat will have a rise in serotonin and dopamine levels which results in a decrease in anxiety and improvement in mood.

…At the end of a long day at work, Alysa often would look forward to her nightly binge/purge session. Bingeing and purging did so many things for her. It helped her to escape; to numb out; to soothe and comfort herself. When she stopped, she reported feeling more anxious at night as she wasn’t able to numb out by bingeing and purging. She missed the feeling of euphoria after a binge/purge session.

Obsessive-Compulsive Disorder (OCD)

Obsessive-compulsive disorder is characterized by obsessions and compulsive behaviors. The individual has uncontrollable obsessions that manifest as thoughts, urges or mental images that cause intense anxiety that prompts the person to engage in irresistible compulsions to alleviate the anxiety. If you have OCD, you feel that you cannot control these thoughts or behaviors; you spend an excessive amount of time in the cycle of obsessions and compulsions; you don’t feel pleasure in this cycle but you do obtain short-term relief from your anxiety; and it causes significant problems in your life as it interferes with activities of daily living.

Of the anxiety disorders, obsessive-compulsive disorder occurs the most frequently with eating disorders. In these individuals, the obsessions and compulsions are connected to food and weight such as measuring or weighing foods; preparing, presenting and eating foods in a ritualistic manner; and weighing oneself or body checking compulsively.

According to the International OCD Foundation, individuals with eating disorders have a statistically high rate of OCD ranging from 11% to 69%. Eating disorders, particularly anorexia and bulimia nervosa have similar characteristics to OCD. In both cases, there are obsessive thoughts that lead to compulsive or ritualistic behaviors to alleviate anxiety. Due to the similarity, there is a need to distinguish whether the individual has OCD, has an eating disorder, or both.

Individuals with eating disorders have obsessions and compulsions based on concerns regarding their weight, size and/or shape whereas OCD individuals do not. For example, Janie who has an eating disorder, obsesses about the number of calories she eats each day and spends a great deal of time calculating the numbers so as not to exceed a predetermined amount for fear of weight gain. On the other hand, Jim who has OCD spends a great deal of time choosing the foods he purchases for fear of contamination. Jesse who has both an eating disorder and OCD spends time measuring and weighing his food before each meal. When he sits down to eat he goes through an OCD ritual of pulling up his socks 10 times on each side before he can start eating.

Post-Traumatic Stress Disorder (PTSD)

Trauma is an emotional response to a distressing or life-threatening event. Post-traumatic stress disorder occurs when the event overwhelms the individual’s internal resources resulting in symptoms of PTSD. These symptoms include re-experiencing the traumatic event such as memories and flashbacks; hyperarousal including excessive awareness, problems with sleep, being easily irritable, outbursts, and feeling easily startled; avoidance of reminders of the event including avoidance of people, places and situations; negative changes to thoughts and moods; and dissociation.

Individuals who engage in binge behaviors such as bulimia nervosa and binge eating disorder have a higher rate of post-traumatic stress disorder. Recent studies including The National Women’s Study and The National Comorbidity Survey Replication indicated that the highest rates of PTSD were 38% and 44% respectively in individuals with bulimia nervosa. In addition, when factoring in individuals who did not meet the full criteria for post-traumatic stress disorder, the numbers were even higher with well over 50% of the individuals who have bulimic symptoms also having post-traumatic stress disorder symptoms.

Individuals with bulimia and binge eating disorders may use the bingeing and/or purging as a means to numb out from the anxiety and hyperarousal associated with trauma and to help them avoid and/or forget traumatic experiences.

Body Dysmorphic Disorder (BDD)

Body dysmorphic disorder is thought to be a subtype of obsessive-compulsive disorder and is not a variant of bulimia or anorexia. People with BDD are excessively concerned about their appearance and become obsessively focused on perceived flaws. In particular, they may focus on their face, hair, and skin. They are convinced that these flaws exist despite being reassured by friends, family or medical professionals that there is nothing wrong. In both BDD and eating disorders, particularly, anorexia and bulimia, the individuals have intrusive thoughts, worries and anxiety that are alleviated by practicing ritualistic behaviors. For the person with BDD, it may be checking their face for hours on end for any flaws and correcting the flaws with an extensive makeup routine. For the eating disorder, it may be restricting their intake of foods in both calories and in repertoire. In both cases, the belief is that if I can “fix the problem” I will be happier, more accepted, and feel more worthwhile. Another similarity between BDD and eating disorders is that the individuals isolate and do not participate in social activities due to their perceived negative body image.

Studies have indicated that about 1/3 of individuals with BDD also have a lifetime co-occurring eating disorder. In addition, 25% of individuals with anorexia showed symptoms of BDD prior to the onset of the manifestation of eating disorder behaviors.


Trichotillomania (TTM) is a hair-pulling disorder. Hair is pulled from any part of the person’s body but is most commonly pulled from the scalp, eyebrows, eyelids and less frequently the face, pubic and peri-rectal areas. The individual will have recurrent episodes of pulling their own hair which results in hair loss. It can cause inflammation and infection to the site. Hair pulling may occur in brief sporadic episodes or frequent and prolonged, sometimes hours, periods of time.

TTM is classified under the DSM-V (Diagnostic and Statistical Manual of Mental Disorders) as a disorder under the obsessive-compulsive and related disorders due to the individual’s compulsivity to pull their hair out. Individuals with TTM may pull their hair out with conscious intent or it may be automatic. The hair pulling may be preceded by feelings of boredom or anxiety or increased level of tension. After the hair is pulled, the individuals may feel a sense of relief or gratification, decrease in anxiety, or a sense of pleasure. Like eating disorders, TTM appears to be a way to manage an individual’s negative emotions. Like eating disorders, the hair pulling may be accompanied by ritualistic behaviors such as finding the right hair to pull and the manner in which the hair is pulled. They may also engage in visual, tactile or oral behaviors with the pulled hair. Someone may pull their hair out and spend a period of time examining the hair strand. Someone may pull the hair out and play with it including rubbing the hair on their skin or face. Others may pull the hair out and chew on it and even eat it. The prevalence of individuals with eating disorders having a co-occurring diagnosis of TTM is unclear but in one study of individuals with TTM, 20% endorsed an eating disorder.

Self-Injurious Behavior (SIB)

Self-injurious behavior is a deliberate act to harm your body. It is not an attempt to commit suicide. Individuals who self-harm do so to find relief from emotional pain such as anger and sadness; or to find relief from negative thoughts; to help resolve interpersonal difficulty; or to bring on a positive mood. It is unclear as to how self-harm can bring on a positive mood but it may be due in part to the body’s release of endorphins which elevates their mood. It may also be due in part to a concept called pain offset relief. According to this concept, when someone experiences an unpleasant physical reaction to a painful stimulus the removal of the stimulus does not return the person to their pre-stimulus state. Instead, it leads them into a short but intense state of euphoria. These changes occur either during or right after the self-injurious behavior.

Self-harm behaviors include the following: scratching, cutting, picking, burning, piercing, carving, hitting, punching, and/or head banging. The most common areas of the body for injury include the frontal area of thighs, the back of the forearms, and the front of the torso. SIB often starts in the early teen or preteen years and can continue for many years. For some, self-injury may occur a few times and then stop, but for others, it becomes a long term chronic problem. Although self-injury may not be an attempt to die, individuals can cause serious harm to themselves including accidental death; therefore, individuals who self-harm should seek help to gain alternative coping skills and address underlying issues.

Self-injurious behavior is often seen in individuals with eating disorders, particularly among those with binge behaviors and even more so in individuals who both binge and purge. Rates are even higher in those who purge via laxatives. Laxatives are both a means of purging as well as a self-injurious behavior.

In two separate studies on eating disorders and co-occurring disorders, it was found that 49% and 40.8% of the girls endorsed self-injurious behavior. In the later study, those patients with SIB were more likely to be female, have bulimic behaviors, have substance use and/or abuse, and mood disorders.

…Alysa admitted that she started cutting again. It was something she hadn’t done for some time. She reported increased feelings of depression and anxiety. She wanted to maintain her sobriety and not engage in her eating disorder so she began to cut to feel a sense of relief.

Alcohol and Substance Use Disorders

Substance use disorders occur when an individual uses alcohol or other substances that lead to problems with their health, job, school, and home life. Substances include opiates and narcotics such as heroin, opium and pain killers; stimulants such as cocaine and amphetamines including ADHD/ADD medications; depressants such as alcohol and benzodiazepines such as Valium, Ativan and Xanax; LSD, and Marijuana.

Alcohol and substance use disorders are frequently seen in individuals with eating disorders, especially in the inpatient treatment setting. The frequency varies widely. Among individuals with bulimia nervosa the range is 8 to 41 percent and in anorexia nervosa it ranges from 2 to 10 percent.

Substance use disorders and eating disorders at first glance may seem like two very different disorders; however, both disorders may offer a means of escaping and numbing out from anxiety, stress, emotionally painful feelings such as sadness, fear and anger, and an escape from trauma. Individuals with these co-occurring disorders may practice both disorders equally at the same time or one may be more dominant than the other. When an individual switches from the eating disorder to substance use (or other behaviors such as gambling or excessive shopping) or vice versa, it is called cross addiction. Cross addiction frequently occurs during recovery.

It is fairly common to see individuals, especially men, who are in substance rehab programs to exercise compulsively as they become sober. As with Alysa, individuals who had a preexisting eating disorder will often engage in their eating disorder and other behaviors as they gain abstinence.


Recovery from an eating disorder can be a long and difficult road and is often complicated by having co-occurring disorders. Treatment for eating disorders co-occurring with other substance and/or mental health issues should occur at the same time. There are many professionals and treatment facilities that can offer treatment for co-occurring disorders. Treatment should include a combination of medical/psychiatric care, medical nutrition therapy, psychotherapy including CBT, and medication management.

Alysa’s road to recovery has been up and down like a roller coaster but she remained committed to her treatment and recovery. After she discharged from her rehab program, she continued to attend weekly therapy sessions. In these sessions, different modalities of treatment were used. Treatment included Cognitive Behavioral Therapy, Dialectical Behavioral Therapy, and Experiential Therapy including exposure work. Alysa also incorporated meditation and started attending a meditation and breath workgroup to augment her therapy sessions. In addition, she attended AA meetings on a regular basis and worked with a sponsor. She took medications to help her with depression and anxiety. Two years into treatment Alysa had maintained her sobriety; experienced more stable moods; developed greater flexibility with food; and gained more freedom in her life. We often say in our sessions together “more freedom from food means more freedom in life.”


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Additional Reading:

Postpartum Depression and Eating Disorders
Support Groups for Eating Disorders
Challenging Diet Mentality
Media and Body Image

About The Author:

Anne H. Lee, MS, RDN, LMFT, CEDS is a Licensed Marriage Family Therapist and Registered Dietitian Nutritionist who specializes in eating disorders and co-occurring disorders. She was the clinical director at Mission Hospital Laguna Beach Eating Disorders Program for over 17 years. She currently is in private practice in Orange County, California, where she treats adolescents and adults.


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Written – 2019