What are co-occurring disorders? According to the National Alliance on Mental Illness (NAMI), co-occurring disorders, or dual diagnosis, refer to “when someone experiences a mental illness and a substance use disorder simultaneously” (Greenstein, 2017). However, when it comes to eating disorders, there are also many disorders in addition to the eating disorder with which our patients struggle. In fact, in one study of adults seeking treatment for eating disorders, approximately 70% of the patients also met the criteria for another mental health diagnosis (Ulfvebrand et al., 2015).

The treatment team at Virtue Recovery Eating Disorders is prepared to help you or your loved one make changes to both the eating disorder and the other mental health struggles you or they may be having. We know that eating disorders can have impacts throughout someone’s life and do not just occur around food.

Bipolar and Depressive Disorders

One of the most common co-occurring disorders with eating disorders is bipolar and depressive disorders. In one study, between 40%-43% of people seeking treatment for eating disorders met the criteria for a mood disorder as well (Ulfvebrand et al., 2015). The American Psychiatric Association (APA) categorizes disorders like major depressive disorder and bipolar disorder in the categories of bipolar and depressive disorders (5th ed.; DSM-5; American Psychiatric Association, 2013).

According to the DSM-5, symptoms of major depression can include:

  • depressed mood most of the day, nearly every day;
  • markedly diminished interest or pleasure in all, or almost all activities most of the day, nearly every day;
  • Significant weight loss or weight gain, or decrease or increase in appetite
  • Insomnia or hypersomnia (sleeping too little or too much)
  • Psychomotor agitation or retardation
  • Fatigue or loss of energy
  • Feelings of worthlessness or excessive or inappropriate guilt
  • Diminished ability to think or concentrate, or indecisiveness
  • Recurrent thoughts of death

*Note that malnutrition can also lead to fatigue, diminished ability to think, and weight loss

Bipolar disorder is characterized by manic and hypomanic symptoms. According to the DSM-5, symptoms of mania can include:

  • Inflated self-esteem or grandiosity
  • Decreased need for sleep
  • More talkative than usual or pressured to keep talking
  • Flight of ideas or subjective experience that thoughts are racing
  • Distractibility
  • Increase in goal-directed activity (for example, starting many new projects or activities)
  • Excessive involvement in activities that have a high potential for painful consequences

We at Virtue Recovery Eating Disorders are ready to help you to better understand your symptoms. We want to help you to have a more stable mood and to learn to love yourself again.

Anxiety Disorders

Anxiety disorders are the most common disorder that co-occurs with eating disorders (Ulfvebrand et al., 2015). In the same study as previously mentioned, approximately 53% of adults seeking treatment for an eating disorder also met the criteria for an anxiety disorder. The APA currently considers disorders like Generalized Anxiety Disorder, Social Anxiety Disorder, and Panic Disorder to fall into the category of Anxiety Disorders (2013).

According to the DSM-5, symptoms of Generalized Anxiety Disorder include:

  • Excessive anxiety or worry more days than not
  • Difficulty controlling the worry
  • Restlessness or feeling keyed up or on edge
  • Being easily fatigued
  • Difficulty concentrating
  • Irritability
  • Muscle tension
  • Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep)

Social Anxiety symptoms include:

  • Marked fear of anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others
  • The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated
  • Social situations almost always provoke fear or anxiety
  • Social situations are avoided or endured with intense fear or anxiety
  • Fear or anxiety is out of proportion to the actual threat posed by the social situation
  • Fear, anxiety, or avoidance is persistent
  • Fear, anxiety, or avoidance causes significant distress or impairment in social, occupational, or other important areas of functioning

*Note that some individuals with eating disorders will avoid social situations because of fears about eating around others or because of fear that others will evaluate their body

According to DSM-5, Panic Disorder symptoms can include:

  • Recurrent, unexpected panic attacks, which may include the following symptoms:
    • Palpitations, pounding heart, or accelerated heart rate
    • Sweating
    • Trembling or shaking
    • Sensations of shortness of breath or smothering
    • Feelings of choking
    • Chest pain or discomfort
    • Feeling dizzy, unsteady, light-headed, or faint
    • Chills or heat sensations
    • Numbness or tingling
    • Derealization or depersonalization
    • Fear of losing control or going crazy
    • Fear of dying

Substance Use Disorders

Approximately 10% of adults that sought treatment for an eating disorder met criteria for some kind of substance use disorder (Ulfvebrand et al., 2015). The most common substance of abuse in the study was alcohol. However, it is not uncommon for individuals with eating disorders to use stimulants as a means of controlling weight.

According to the DSM-5, symptoms of a substance use disorder include:

  • The substance is often taken in larger amounts or over a longer period of time than was intended
  • There is a persistent desire or unsuccessful efforts to cut down or control use
  • A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects
  • Craving, or a strong desire to use the substance
  • Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home
  • Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the substance
  • Important social, occupational, or recreational activities are given up or reduced because of substance use
  • Recurrent substance use in situations in which it is physically hazardous
  • Substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance
  • Tolerance
  • Withdrawal

Many of us here at Virtue Recovery have experience working with substance abuse populations. We appreciate that relapses in substance use can lead to relapses with eating disorders and vice versa. We are dedicated to helping you to learn to manage both disorders for a happier, healthier life.

Post-Traumatic Stress Disorder

Approximately 4% of adults that sought treatment for an eating disorder also met the criteria for Post-Traumatic Stress Disorder (Ulfvebrand et al., 2015). There are many, many symptoms of PTSD and different individuals can present in very different ways.

According to the DSM-5, symptoms of PTSD can include:

  • Recurrent, involuntary, and intrusive distressing memories of the traumatic event
  • Recurrent distressing dreams in which the content and/or effect of the dream are related to the traumatic event
  • Dissociative reactions in which the individual feels or acts as if the traumatic event(s) were recurring
  • Intense or prolonged distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s)
  • Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s)
  • Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event
  • Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s)
  • Inability to remember an important aspect of the traumatic event(s)
  • Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world
  • Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others
  • Persistent negative emotional state (e.g., fear, horror, anger, shame, or guilt)
  • Markedly diminished interest or participation in significant activities
  • Feelings of detachment or estrangement from others
  • Persistent inability to experience positive emotions (e.g., happiness, satisfaction, or love)
  • Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects
  • Reckless or self-destructive behavior
  • Hypervigilance
  • Exaggerated startle response
  • Problems with concentration
  • Sleep disturbance

Although the statistics would indicate that the co-occurrence of trauma is uncommon, we at Virtue Recovery believe that eating disorders develop as a result of past traumas. We know that it is important to not only to focus on the behaviors in the here and now, but also to look back at experiences from the past to better understand how we are still living with them. We provide several services and are trained in several modalities that are evidenced based for the treatment of PTSD.

Obsessive-Compulsive Disorder

Approximately 4% of adults who sought treatment for an eating disorder also met the criteria for Obsessive-Compulsive Disorder (OCD) (Ulfvebrand et al., 2015). Although this may sound like a small proportion of individuals who seek treatment, many who do seek treatment share traits with those described in the criteria for OCD. The DSM-5 describes two primary characteristics of OCD: obsessions and compulsions.

According to the DSM-5, obsessions are defined as:

  • Recurrent and persistent thoughts urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress
  • The individual attempts to ignore or suppress such thoughts, urges, or images or to neutralize them with some other thought or action

For many who struggle with eating disorders, there can be many obsessions about food and the body. We at Virtue Recovery have worked with many patients that struggle with obsessions about whether or not food is “healthy” or whether or not certain foods will lead to weight gain or illness. Many patients that our staff has worked with in the past have been able to work through these fears and nourish themselves again.

According to the DSM-5, compulsions are defined as:

  • Repetitive behaviors or mental acts that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly.
  • The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessively

Repetitive behaviors can be very common in individuals that struggle with eating disorders for a variety of reasons. Some individuals are overly concerned with gaining weight, which can lead to purging-type behaviors that can consist of exercising, vomiting, laxative use, or taking other medications or supplements designed to prevent weight gain. Other individuals can become significantly concerned with their health or body sensations and will take dietary supplements that do not have empirical evidence of health benefit or, at times, even supplements or other medications that can be harmful to an individual’s health.

We at Virtue Recovery Eating Disorders know that eating disorders do not occur in isolation. Our team is prepared to help you or your loved one with any of the symptoms you may be struggling with. We want you and your loved ones to be able to enjoy your lives without so much hanging over your heads.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Greenstein, L. (2017, Oct 4). Understanding Dual Diagnosis. https://www.nami.org/Blogs/NAMI-Blog/October-2017/Understanding-Dual-Diagnosis

Ulfvebrand, S., Birgegard, A., Norring, C., Högdahl, L., & von Hausswolff-Juhlin, Y. (2015). Psychiatric comorbidity in women and men with eating disorders results from a large clinical database. Psychiatric Research, 230, 294-299.

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