Trigger Warning: This blog touches on abuse, trauma, addiction, drug abuse, suicide and self harm.
Eating Disorders rarely come out of nowhere and infrequently turn up without bringing or aggravating other issues.
It’s vital to recognise this, if we treat eating disorders as an isolated issue and do not support the whole person, or get to the root of the issue then it is much more likely that relapse will occur.
“The eating disorder isn’t the problem, it is a symptom of the problem”
Although eating disorders can be influenced by external factors such as social media, media and social pressures these are not the causes. If they were every person would have an eating disorder! Eating disorders often run very deep and are accompanied by traumatic experience and/or a host of comorbid issues.
Some suggest that eating disorders are an over inflated and maladaptive coping mechanism. So the disorder was performing a function: to protect and to help you cope. But now the disorder itself has become the issue and is causing the most harm, by this point it has also stopped working as a coping mechanism.
Eating disorder bedfellows
Comorbid: Relating to or denoting a medical condition that co-occurs with another.
Anxiety is the most commonly occurring comorbid disorder with eating disorders. One study showed that 60% of individuals with an eating disorder also had an anxiety disorder. In around 90% of individuals with an eating disorder the anxiety actually predates the eating difficulties. It is a widely held view that eating disorders and anxiety should be confronted at the same time during recovery.
Unlike with anxiety it is unclear if depression is a risk factor for an eating disorder. Although depression can result in individuals feeling negatively about themselves, their bodies or appearance and therefore make them more susceptible to disordered eating behaviour. On the flip side, those who experience an eating disorder are much more likely to experience depression, particularly if they are experiencing starvation, malnutrition or chemical imbalances.
Body Dysmorphic Disorder
There is overlap between characteristics of Body Dysmorphic Disorder (BDD) and eating disorders including, body image dissatisfaction and disturbance, rituals and behaviours relating to appearance, and a tendency to compare. Unfortunately, if BDD is observed, it is not always diagnosed when the individual is presenting with an eating disorder. This can leave the BDD unchallenged. Also, because of a reluctance to diagnose BDD and an eating disorder together, there is no conclusive figures on how many individuals with an eating disorder also have BDD or vice verse.
Individuals with eating disorders will often suffer from body dysmorphia, displaying an overly negative body image or self-esteem. It is not uncommon for a person with an eating disorder to obsess over their physical appearance and engage in extreme body changing behaviours, and/or compare their physical appearance with others.
BDD and an eating disorder can be a truly devastating combination. In one study, 16 patients with both BDD and Anorexia Nervosa were compared to 25 women with anorexia alone. Those who had anorexia plus BDD had been psychiatrically hospitalised more often (6.3 vs. 3.8 times), and had more suicide attempts (63% vs. 20%).
Personality disorders and eating disorders frequently occur together. Of all the personality disorders, eating disorders are more commonly found in people with Boarderline Personality Disorder (BPD): 53.8% of individuals who have BPD also meet criteria for an eating disorder and 26.6% of individuals with other personality disorders meet eating disorder criteria.
Not all people with an eating disorder have a personality disorder, for the majority of people this is not the case. However, there is a large common risk factor for both eating disorder and personality disorders (in particular BPD) which is childhood trauma including physical, emotional and sexual abuse.
Bipolar is commonly seen alongside bulimia but this is not to say the other eating disorders are not also an issue. In fact, 20% of people coping with bipolar also met the criteria for an eating disorder. Unfortunately, the further research into this is limited.
Obsessive traits and symptoms have been reported in between 3% and 83% of eating disorder cases (based on differing criteria). 21% of eating disorder patients were found to have comorbid Obsessive-Compulsive Disorder (OCD), further to this, 37% of anorexia nervosa patients had comorbid OCD. It has also been suggested that the effects of starvation and malnutrition can exaggerate existing obsessive traits in those with eating disorders.
Usually the reward center of the brain is stimulated by good things and pleasant activities. However, it can also be stimulated by chemical input from drugs or alcohol and eating disordered behavior. Stimulation of the reward center through chemical abuse or eating disordered behaviour blocks unpleasant feelings and emotions and this, in very simplified terms, is how an addiction develops. Individuals who struggle with an addiction, in whatever form, may have a personality type that is prone to impulsiveness, extremes, and high anxiety or stress responses and this can result in needing more stimulation of the reward centre for gain.
Up to 35% of individuals who are addicted to alcohol or other drugs have also experienced (or are experiencing) an eating disorder, a rate 11 times greater than the general population.
Again, it should be recognised that addiction is often a coping mechanism, so individuals who suffer with an addiction have often experienced trauma (as with eating disorders). It is difficult to get a clear report but studies estimate that between 25% and 75% of people who survive abuse and/or violent trauma develop an addiction and 10% to 33% of people who have been through accidents, illness or natural disasters report an addiction.
This is related to addiction. Abuse of prescriptions, over the counter medication, recreational drugs and alcohol offer a mechanism for those suffering from eating disorders to numb their pain and anxiety. The use of substances that decrease or suppress appetite or enable purging (such as diuretics and laxatives) in an effort to manage weight are also found in many eating disorder sufferers. Research suggests that 25% of individuals entering treatment an eating disorder will also meet criteria for substance abuse problems and up to 50% of individuals with eating disorders have at some point abused alcohol or illicit drugs, a rate five times higher than the general population.
Self-Harm or Non-Suicidal Self Injury (NSSI)
Often labelled as an addiction, self harm is regularly found in people who suffer from an eating disorder and, indeed, eating disorders are a form of self harm. Self harm is self inflicted pain and suffering and covers a wide range of behaviours including but not limited to: cutting, burning, or picking at one’s skin, bashing, bruising, pinching, digging nails into skin, eating disorders, exercising until injury, substance abuse, high risk behaviour, compulsively getting tattooed or pierced. Although it may seem counter-intuitive, these behaviours work in the same way as drugs and alcohol and light up the pleasure centre of the brain, working as a way to numb unpleasant feelings, self soothe and boost mood; even if only temporarily.
Important side note: Self harm is very, very rarely for attention and it should not be treated as such.
Up to 72% of people with an eating disorder also self harm and up to 54% of people who seek support for self harm report eating disordered behaviour.
Recovery from an eating disorder and comorbid disorders
When embarking on recovery for an eating disorder, whether seeking help professionally or not, it is vital that it’s not just the eating disorder that is being confronted. The history of an individual, the comorbid disorders and issues all must be supported in order for recovery to be successful. Sometimes this will require medical and holistic support.
If you are suffering from one or all of the above… Remember: you are not your disorders or your illness. You deserve love and support to recover.
We currently provide a monthly support group for anyone who struggles or has struggled with eating and body perception difficulties. As a part of this, we have connections to trusted therapists, hypnotherapists and holistic therapy/ wellness practitioners as well as contacts to various support services. So if you feel you need more support we can point you in a direction that might help.
If you would like more information, please do not hesitate to get in contact.
Related blog posts
Resources and references
Bulik et al, 1997. “Eating disorders and antecedent anxiety disorders: a controlled study.”
Dingemans et al, 2012. “Body dysmorphic disorder in patients with an eating disorder: prevalence and characteristics.”
Grant et al, 2002. “Body dysmorphic disorder in patients with anorexia nervosa: prevalence, clinical features, and delusionality of body image.”
Fahy et al, 1991. “Caffeine abuse in bulimia nervosa”
Thornton et al, 1997. “Obsessive compulsive comorbidity in the dieting disorders”
Kaye, W., and Wisniewski, L. 1996. “Vulnerability to Substance Abuse in Eating Disorders.”
Zanarini et al, 2004. “Axis I Comorbidity in Patients with Borderline Personality Disorder: 6-Year Follow-Up and Prediction of Time to Remission.”
Sansone et al, 2007. “Childhood Trauma, Borderline Personality, and Eating Disorders: A Developmental Cascade. Eating Disorders: The Journal of Treatment & Prevention.”