The Arc of Eating Disorders: Co-Morbid Diagnoses Contained Within

By: Judy Scheel, Ph.D., LCSW

Eating disorders (Anorexia Nervosa, Bulimia, Binge Eating Disorder) are considered “umbrella disorders.”  Typically, an eating disorder is part of a larger diagnostic picture. There is almost always a co-morbid diagnosis–depression, anxiety or personality disorder in addition to familial issues and interpersonal conflicts.   Sexual or physical trauma, Obsessive Compulsive Disorder or substance use can also accompany an eating disorder. Sometimes the eating disorder is the primary diagnosis; sometimes it is secondary or the consequence of another primary diagnosis like depression. The co-morbid diagnosis likely existed prior to the onset of the eating disorder, though may remain latent until the eating disorder emerges. However, co-morbidity can occur as an outgrowth of the eating disorder and can show improvement with reduction in eating disorder symptoms like weight restoration. Because eating disorders are intertwined within the greater constellation of psychological and psychiatric issues eating disorders cannot or should not be treated as separate and apart from other mental health issues. 

• The most common secondary Axis I (mood disorder) diagnosis with eating disorders is Depression
• Higher rates of Dysthymia among adolescents than other co-morbid diagnoses
• Frequency of Personality Disorders (enduring patterns of maladaptive behaviors & personality traits i.e. Borderline Personality Disorder) varies from 27%-77% in eating disorder population
• Personality disorders typically precede the development of an eating disorder
• Mood Disorders with eating disorders remit more frequently than personality disorders with eating disorders
• Anxiety states more pervasive and unremitting – lower recovery rates
• Males with Bulimia at higher risk for mood and substance use disorders
• Males with Anorexia Nervosa at higher risk for Schizophrenia
• Obsessive Compulsive Disorder predates eating disorder & ED develops at a younger age
• Eating disorders and substance abuse disorders associated with the highest mortality risk across all mental disorders
• Greater prevalence of sexual abuse with Bulimia and alcohol abuse
• Greater risk for other self-destructive acts like cutting among individuals with substance abuse disorders and eating disorder

The percentage of individuals with eating disorders and substance abuse disorder are high; some studies reporting up to 55% of individuals with Bulimia and 23% of those with Anorexia have concurrent substance abuse with alcohol and stimulants being the most commonly abused. A recent New York Times article reported on alcohol abuse and eating disorders, indicating that alcohol is the only “food” of choice among a select group of those diagnosed with Anorexia. Bulimia and alcohol abuse is associated with a higher incidence of Borderline Personality Disorder, a diagnosis that precedes the substance abuse and eating disorder. Borderline Personality Disorder as well as alcohol abuse is associated with dis-inhibition and impulsivity, two personality traits relatively common among individuals with Bulimia.

The causes of eating disorders are complex and varied. Research in eating disorders remains inconclusive, at best, regarding definitive claims to causation.   Genetic research studies are increasing, however, the data remains weak and inconsistent.  It cannot definitively be stated that eating disorders are genetic disorders.  The Academy for Eating Disorders (aedweb.org) states: “Recently there has been considerable interest in both genetic and biological factors which may contribute to the onset of eating disorders. For both anorexia nervosa and bulimia nervosa, behavioral genetic studies using twin designs have indicated that there is a substantial genetic effect for the liability for each of these disorders. Researchers are now examining genetic influences by searching for genes, and some gene candidates have been found to be associated with anorexia nervosa and bulimia nervosa, although this research remains relatively inconclusive in terms of genetic effects. There are also numerous studies indicating that certain brain chemicals, such as serotonin, may be abnormal in eating disordered individuals.”

Focusing exclusively on genetics as causation is inappropriate, at best. The belief that eating disorders are strictly a genetic or biological disorder reinforces for patients and their families that the eating disorder is running on its own track and has little or nothing to do with the individual’s psychological and relational experiences that may have contributed significantly to the eating disorder. Professionals who treat eating disorders need to remain committed to understanding and staying abreast of all the research regarding eating disorders.  Caution must remain, however, regarding those seeking to reduce causation to primarily genetic factors.  There are too many variables that coalesce to create an eating disorder. Solid treatment includes utilizing an experienced team of professionals providing psychotherapy, medical and psychiatric care and nutritional counseling.

Eating disorder sufferers share common traits, like tendency toward people pleasing, perfectionism, and have high self-expectation. Some of these traits are consistent with the eating disorder diagnosis, however, can also be associated with a co-morbid diagnosis like Obsessive Compulsive Personality Disorder and Dependent Personality Disorder.

Eating Disorder treatment varies and needs to be consistent and appropriate with the specifics of the eating disorder diagnosis – including severity of condition and symptoms, length of time of illness, willingness and commitment to recovery. For those who provide eating disorder treatment or those with a loved one who is suffering with an eating disorder, treatment options can be confusing and often driven by insurance limitations and restrictions, particularly when it relates to seeking inpatient care. When a patient has a concurrent substance abuse diagnosis, treatment for the eating disorder may vary from how the substance abuse disorder is treated. Some eating disorder treatment, particularly when the eating disorder is in conjunction with a substance use disorder, may promote a 12-step approach to obtaining sobriety and maintaining recovery. Many times, however, eating disorder treatment may not be consistent with a 12-step approach. Often, eating disorder treatment reflects a combination approach utilizing insight, family systems and/or cognitive/behavioral treatment (CBT). A treatment model, such as 12-step, can be difficult to utilize exclusively in treating eating disorder patients because not only is food not an option to avoid (as is necessary and possible with alcohol and drugs), but also so much of what needs to be changed in the thinking of eating disorder sufferers is the perfectionism and all or nothing thinking that laid the ground work for the disorder. A 12-step model emphasizes behavioral changes and often encourages abstinence of certain food groups, i.e. sugar and white flour. While this treatment approach is effective for some patients, it can also reinforce all or nothing thinking around food for many sufferers – that is, that some food is bad. The goal of eating disorder treatment is generally to help patients integrate all foods into their diet, thereby removing the negative stigma associated with eating foods that are enjoyable but not necessarily nutritional i.e. deserts. Food is pleasurable. There are no good versus bad foods. For many eating disorder sufferers, the absence of pleasure and the presence of self-criticism, perfectionism and rigid self-control dictates life. Depriving oneself of pleasurable foods is a psychological metaphor for these harsh self-imposed expectations.

Taking responsibility for one’s eating disorder so that lasting recovery may occur is the goal of treatment, regardless of the approach one employs to get healthy. It is important, in the end, however, that the type of treatment is appropriate and acceptable to the sufferer and or the family. Different approaches work for different people and sometimes it takes a few types of treatment or therapists before someone is ready to settle in and begin the serious work of recovery. Complicating the picture is often the co-morbid diagnosis, which runs parallel to the eating disorder, and the eating disorder is also a vehicle to express and concretize the co-morbid diagnosis. It is important to remember that an eating disorder is rarely the only diagnosis present and that understanding and treating the conditions that are co-occurring are essential. Although there are similarities in behaviors and personality traits of eating disorder sufferers, the eating disorder and co-morbid diagnoses need to be fully understood and treated as they are unique to each sufferer based on her/his own genetic (nature) and experiential/environmental factors (nurture).