Eating Disorders & Substance Abuse

By Team RehabAid

Last Updated March 21, 2024

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An eating disorder is a serious medical and mental health condition. Involving extreme behaviors around food that range from deliberate starvation to binging, eating disorders can lead to serious health problems that include obesity, organ failure, brain damage, and even death.

According to the National Association of Anorexia Nervosa and Associated Disorders (ANAD), 70 million people in the world have an eating disorder — 30 million of which live in America. Additionally, the National Center on Addiction and Substance Abuse (CASA) reports that up to 50% of people with an eating disorder also abuse alcohol or drugs.

While eating disorders range in terms of their behavioral symptoms, they all revolve around an unhealthy obsession with food. Whether it’s eating too much or too little, these individuals struggle with feelings of low self-worth and/or excessive concerns about their weight and appearance. These feelings can be accompanied by mental health conditions such as anxiety, depression, and substance use disorder.

However, hope and recovery options are available. In this article, we outline what eating disorders are, how they relate to substance abuse, and what types of treatments are out there.

What Are Eating Disorders?

Eating disorders are considered serious medical illnesses that are characterized by severe disturbances in a person’s eating behaviors. This includes everything from purging, restricting food, and exercising excessively. Individuals with eating disorders will often display obsessions with food, appearance, and body weight and shape. Unsurprisingly, these behaviors greatly affect a person’s health and lead to dangerous consequences.

Who Is at Risk?

Eating disorders can affect people of all ages, backgrounds, and genders. Although they are most often attributed to women in their teen or young adult years, men, and older individuals (into their 40s) can also develop eating disorders.

While the exact cause of eating disorders is not known, several risk factors are thought to contribute to these conditions. They include:

• Genetics and biochemical imbalances in the brain.
• Environmental factors, such as media influences and peer pressure.
• Co-existing anxiety, depression, or low self-esteem.
• Abuse, neglect, and/or other traumatic childhood experiences.

Types of Eating Disorders

There are three main types of eating disorders: anorexia nervosa, bulimia nervosa, and binge eating disorder.

Anorexia Nervosa

Perhaps the most well-known of all eating disorders is anorexia. This condition is characterized by a severe restriction of food, where a person eats far less than is considered healthy. People who are anorexic will also exercise excessively and burn huge amounts of calories, which means they expend far more energy than they take in.

The two sub-types of this condition are restrictive (severely restricting the type and amount of food a person eats) and binge-purge (severely restricting the type and amount of food, accompanied by binge eating, purge eating, and/or using laxatives).

Individuals with anorexia also have an unrealistic view of their bodies — which can present as a co-occurring disorder known as body dysmorphic disorder — that causes them to think they are much heavier than they are.

Signs & Symptoms of Anorexia

• Strict eating regimes.
• Weighing food or cutting it into sections.
• Only eating specific types of food.
• Constantly weighing themselves.
• Excessive exercise between meals.
• Extreme thinness (emaciation).
• A relentless pursuit of perceived “thinness.”
• Intense fear of gaining weight.
• Distorted body image and a sense of self-esteem that is heavily dependent upon perceptions of body weight and shape.
• Denial about the seriousness of low body weight.

Over time, the health consequences of anorexia may result in:

• Thinning or brittle bones (osteopenia or osteoporosis).
• Mild anemia and muscle wasting and weakness.
• Brittle hair and nails.
• Dry and yellowish skin.
• Growth of fine hair all over the body (lanugo).
• Severe constipation and stomach problems.
• Low blood pressure, including slowed breathing and pulse.
• Damage to the structure and function of the heart.
• Low internal body temperature.
• Constant lethargy, sluggishness & fatigue.
• Multiple organ failure, including brain damage.

Bulimia Nervosa

Bulimia consists of eating large amounts of food followed by activities like forced vomiting. Individuals with bulimia are often able to maintain a healthy weight (or be overweight), but they struggle with constant feelings of shame about their binging. Many people with this condition also struggle to eat in public or will refuse to eat around other people.

People with bulimia nervosa have recurrent episodes of consuming unusually large amounts of food and feeling a lack of control over these episodes. This binge-eating is followed by behaviors that compensate for overeating, such as forced vomiting, excessive use of laxatives or diuretics, fasting, and/or excessive exercise. Unlike those with anorexia nervosa, people with bulimia nervosa may maintain a normal weight or be overweight.

Signs and Symptoms of Bulimia

• Binge eating, followed by vomiting, using diuretics or laxatives, excessive exercise, and/or fasting.
• A chronically inflamed and sore throat.
• Swollen salivary glands in the neck and jaw area.
• Worn tooth enamel, sensitive and decaying teeth (due to exposure to stomach acid).
• Acid reflux and other gastrointestinal problems.
• Intestinal inflammation from chronic laxative use.
• Severe dehydration (from excessive purging).
• Electrolyte imbalance (low or high levels of sodium, calcium, potassium, and other minerals). This can lead to stroke or heart attack.

Binge Eating Disorder

Binge eating disorder consists of a lack of control over one’s eating. Unlike bulimia, people with this condition do not engage in vomiting, fasting, or excessive exercise. Instead, individuals with a binge eating disorder eat unusually large amounts of food during a specific period (e.g., at least once a week over three months or longer). As a result, these people are often obese or overweight.

Signs and Symptoms of Binge Eating Disorder:

• Eating unusually large amounts of food in a set period.
• Eating noticeably fast during a binge episode.
• Eating even when full or not hungry.
• Eating until uncomfortably full.
• Eating alone or in secret to avoid embarrassment.
• Feeling distressed, ashamed, or guilty about eating.
• Frequently dieting, possibly without weight loss.

Co-Occurring Conditions With Eating Disorders

Aside from substance abuse, eating disorders are also concurrent with many other mental health conditions. Below are some of the main ones.

Major Depressive Disorder (MDD) and Eating Disorders

Depression is a common co-occurring mental health condition with eating disorders. For example, some studies show that rates of eating disorders among bipolar patients are around 20%. Other studies show high rates of depression in clients with anorexia (some are as high as 90%). Individuals with binge eating disorder also struggle with depression, and rates for these occurrences are around 50%.

The relationship between depression and eating disorders is a complex one. Anorexia, for example, can lead to depression because lack of food can alter neurotransmitters in the brain that are responsible for mood. Conversely, people with eating disorders often struggle with low self-esteem and feelings of guilt and shame, which can lead to the development of clinical depression.

Obsessive-Compulsive Disorder (OCD) and Eating Disorders

Obsessive-compulsive disorder (OCD) is an anxiety disorder that is characterized by obsessive, recurring, and uncontrollable thoughts and behaviors. OCD is often linked with eating disorders because both involve food rituals and obsessive thoughts about food and calories. Individuals who are struggling with OCD and eating disorders will often engage in behaviors like choosing food based on color, weight, and shape, or dividing their food symmetrically. Another trait these conditions share is an anxiety-driven quest for perfection.

Body Dysmorphic Disorder (BDD) and Eating Disorders

Body dysmorphic disorder (BDD) is a condition where an individual experiences a persistent preoccupation with perceived defects in their appearance. People with BDD will experience emotional distress and worry about their supposed flaws, which is why it often appears alongside eating disorders. People with BDD typically engage in behaviors such as obsessive mirror checking, exhibiting ongoing distress over minor or nonexistent flaws, and constantly comparing themselves to models in magazines or celebrities on social media. Some individuals with BDD go on to develop an eating disorder, or sometimes they emerge together.

Trauma (PTSD) and Eating Disorders

Most mental health conditions are the result of post-traumatic stress disorder (PTSD) in a person’s life, and this also applies to eating disorders. Some studies have shown that many individuals with anorexia, bulimia, and binge eating disorder have reported histories of interpersonal trauma and child sexual abuse. While rates of PTSD among women with bulimia and binge eating disorder hover around 10% – 20%, most research supports the notion that rates of eating disorder are generally higher in people who have experienced trauma and/or PTSD.

Anxiety Disorder and Eating Disorders

Anxiety is also highly prevalent among individuals with eating disorders. Some studies reveal that around 2/3 of individuals with an eating disorder also have anxiety and that 42% of them developed it in their childhood. In some cases, a person with severe anxiety can go on to develop an eating disorder because they experience fear around issues such as weight and body image. Other anxiety issues related to feelings of control (or loss of it) can lead to an eating disorder due to the relief that is experienced through acts like purging, exercising, or restricting food. Whatever the cause, an underlying anxiety condition can exacerbate an eating disorder and vice versa.

Eating Disorders & Substance Abuse Statistics

• The National Association of Anorexia Nervosa and Associated Disorders (ANAD) reports that eating disorders affect roughly 9% of the U.S. population (around 28.8 million Americans will have an eating disorder in their lifetime).
• Eating disorders are one of the most fatal mental illnesses, second only to opioid overdose.
• 10,200 deaths each year are the direct result of an eating disorder (roughly 1 death every 52 minutes).
• Approximately 50% of individuals with eating disorders also abuse alcohol or illicit drugs. And, up to 35% of people who are dependent on substances have also had eating disorders.
• About 80% of people receiving treatment do not obtain adequate help in the long run to achieve full recovery.
• About 50% of all people suffering from eating disorders also have depression, closely followed by anxiety.
• Only 1 in 10 people with an eating disorder receive treatment. Within that population, roughly 35% of them receive treatment at a specialized facility.

The Relationship Between Substance Abuse and Eating Disorders

It is no secret that eating disorders — particularly anorexia — can cause severe malnourishment. Depriving the body of essential nutrients not only causes extreme thinness, but it can also lead to brittle bones, hair, and nails, loss of muscle mass, and a slowed pulse. In extreme cases, anorexia can cause organ failure and brain damage.

While slightly less damaging, bulimia can also cause long-term health issues. For example, it can deprive the body of fluids and weaken tooth enamel due to constant purging. Other issues such as regular vomiting and laxatives can cause gastrointestinal problems and acid reflux, while imbalances in minerals like calcium and sodium can increase the risk of a heart attack.

Therefore, people with anorexia and a co-occurring substance use disorder are at an even greater risk of damaging their health. Substances like alcohol will enter the bloodstream much faster in a person who is malnourished or is not eating regularly. Also, consuming alcohol or drugs on a severely empty stomach can increase the risk of blackouts, overdoses, alcohol poisoning, damage to the stomach lining, memory loss, brain damage, and alcohol-related injuries.

Some of the side effects that a person with anorexia can experience with regular alcohol or drug use include:

• Fatigue
• Abnormal heartbeat
• Anxiety
• Depression
• Increased blood pressure
• Trouble breathing
• Hair loss
• Teeth loss
• Mood swings
• Gastrointestinal issues
• Stroke
• Death

Similarities Between Eating Disorders and Addiction

There are often clinical similarities between eating disorders and substance use disorders, which is why the conditions resemble each other. In some cases, for instance, eating disorders are considered a type of addiction because the characteristics are similar to the diagnostic criteria for substance use disorder, as outlined below:

• Obsessive preoccupations, cravings, and rituals surrounding an addictive behavior.
• An escalation in frequency or intensity of addictive behaviors over time.
• Sacrificing other interests to spend time on an addictive behavior or substance.
• An inability to stop a destructive behavior despite repeated attempts.
• Expressed concern by loved ones about a particular behavior.
• Continued use of a substance/behavior, despite any negative consequences.

Another similarity between eating disorders and addiction is that their root causes can be similar. Some research suggests that several risk factors are involved in eating disorders, including social pressures, genetics, and personality traits like impulsivity. Some of the other shared characteristics between substance abuse and eating disorders are:

• Shared brain chemistry.
• A common family history (e.g., a history of substance abuse or eating disorders).
• Low self-esteem, depression, and/or anxiety.
• A vulnerability to messages or information from advertising and media.
• A history of trauma or childhood abuse.

Why People With Eating Disorders Engage in Substance Abuse

People with eating disorders abuse drugs and alcohol for several reasons.

To Self-Medicate

Self-medication is one of the primary reasons that individuals turn to substances, especially if they’re struggling with mental health issues. Drugs and alcohol provide a gateway to help numb or escape feelings of shame, anger, and sadness. Also, as many people with eating disorders struggle with anxiety, substances like alcohol or sedatives can ease those feelings. However, the problem with using substances to achieve relief is that it not only leads to addiction, but it can also exacerbate symptoms of an eating disorder, particularly as withdrawal can increase feelings of depression and anxiety.

To Lose Weight

In some cases, people with eating disorders will abuse substances to lose weight. Stimulants, for example, are notorious for suppressing appetite, which makes it a desirable drug for someone with an eating disorder. Or someone might decide to replace food with alcohol or substances instead.

Because Substance Use Came First

While many individuals with eating disorders will abuse substances to self-medicate or manage their weight, in some cases, the substance abuse issue comes first. In these cases, an eating disorder arises as a coping mechanism for a person’s alcohol or drug addiction. For example, a person may binge from hunger after abusing drugs or alcohol, which then leads them to feel guilt and restrict their eating. If left untreated, these behaviors can become normalized, making recovery difficult.

Types of Substances Abused by Individuals With Eating Disorders

Two of the main substances that are abused by individuals with eating disorders are alcohol and stimulants.

Alcohol & Anorexia

Alcohol is the most abused substance by people with eating disorders. This is most prevalent among young, college-age females who have reported a combination of anorexia and alcohol abuse; however, men are also known to develop this combination, as well. College students are particularly vulnerable due to peer pressure, academic stress, and being away from family.

Another issue with college students is that they are known for engaging in what is colloquially known as “drunkorexia.” This involves restricting food or altering eating patterns to either increase the effects of alcohol or offset the calories that will be obtained from drinking it. While “drunkorexia” is not a clinical condition, it is a common behavior among college-age individuals and can often be accompanied by binge eating and binge drinking. These behaviors can lead to health risks and medical complications, especially if a person increases their alcohol use and disordered eating habits.

Stimulants & Anorexia

Stimulants are well known for their ability to generate energy and suppress a person’s appetite. Diet pills in the 1960s and 1970s, for example, often contained stimulants like amphetamines to curb a person’s hunger. Because stimulants produce these effects, drugs such as cocaine and Adderall are often ingested by people with eating disorders.

Adderall is particularly popular among college students, as this drug is also known to enhance concentration and focus. However, Adderall also comes with unpleasant side effects such as increased anxiety, depression, fatigue, abnormal heartbeat, and increased blood pressure and breathing rates. Therefore, individuals with eating disorders who take stimulants are putting their health at risk, especially as underlying conditions like anxiety and depression can be worsened with Adderall use.

Eating Disorders & Substance Abuse Treatment Options

As eating disorders and substance abuse often occur together, it is recommended that individuals are treated for both conditions. However, the difficulty is that treatment practitioners may be trained to diagnose and treat one condition, but not the other.

Also, eating disorders and substance use disorders often require different types of treatment, even though they share similar traits.

Differences in Treatment

In the case of substance abuse, traditional therapies tend to focus on abstinence and uncovering the root causes of addiction, often through psychotherapy, group counseling, and self-help techniques.

Eating disorders, on the other hand, require a different level of intervention, which involves dietary support, medical management (particularly in life-threatening cases of anorexia), restoring health, and addressing psychological issues such as body image, comfort eating, and perfectionism.

While these conditions require different levels and types of treatment, there are options. In some cases, individuals with severe eating disorders and/or substance abuse problems may need to be treated sequentially (e.g., they receive treatment for the eating disorder first and then the substance use issue). This could also require admittance into multiple types of treatment centers, especially ones that offer dual diagnosis programs.

Dual Diagnosis Programs

Dual diagnosis programs are highly recommended, as they are set up to diagnose and treat concurrent mental health conditions and substance abuse. In the case of eating disorders, it may require some shopping around, as not all dual diagnosis centers will be able to treat this type of condition. However, once you locate a dual diagnosis program that specializes in eating disorders and substance abuse, they are enormously helpful, as clinicians can safely address each condition while an individual withdraws from alcohol or drugs.

Therapies

There are also therapy programs that can be beneficial for both eating disorders and substance abuse. These are sometimes used in combination with each other.

Cognitive-Behavioral Therapy (CBT)

One of the best therapies for co-occurring mental health conditions and substance abuse is cognitive-behavioral therapy (CBT). CBT helps individuals change negative cycles of thought and behavior into more positive ones. In the case of eating disorders, CBT can help identify triggers, as well as where a person’s unhealthy eating habits originate. Clients receiving CBT for addiction also learn how to recognize “automatic thoughts” and dysfunctional thinking patterns, and how to develop a greater sense of self-understanding and self-esteem. This is a great therapy for helping individuals with unhealthy obsessions and thoughts.

Dialectical-Behavior Therapy (DBT)

Dialectical-behavior therapy (DBT) is a type of cognitive-behavioral therapy that focuses on mindfulness, how to live in the moment, cope with stress, and improve relationships. DBT also helps clients better regulate their moods, impulsiveness, and how to develop healthy coping skills. This kind of therapy is useful for people who have co-occurring conditions, especially those who have eating disorders, depression, or anxiety. DBT is also effective for PTSD and for people who exhibit self-destructive behaviors.

Trauma Therapies (EMDR)

Since a history of trauma and abuse are contributing factors to eating disorders, trauma treatments are also effective. For example, eye movement desensitization and reprocessing (EMDR) is led by a therapist who guides an individual through a series of rapid eye movements to help redirect negative or traumatic memories. This redirection helps the person form new connections or associations, so that the memory is less emotionally distressing over time. This therapy is therefore useful for individuals with mood disorders, as it helps them overcome the emotional suffering associated with traumatic events.

Alternative or Holistic Therapies

Holistic therapies are also effective at treating addiction and mental health disorders. These can be especially useful for eating disorders, as many of these therapies help improve a person’s physical, mental, and emotional health.

The purpose of holistic therapies is to treat the whole person and not just the symptoms. These can be incredibly beneficial for providing calmness, spiritual support, emotional expression, improving physical health, and teaching valuable skills. Some of the popular holistic therapies include:

• Relaxation techniques
• Nutritional therapy
• Animal-assisted therapy (e.g., emotional support dogs)
• Massage
• Adventure therapy (e.g., hiking or rock climbing)
• Mindfulness and meditation
• Art therapy and music therapy
• Yoga and Tai-Chi
• Equine-assisted (horse) therapy

Resources

If you or a loved one are struggling with an eating disorder and substance abuse or addiction, you are not alone. Treatment and support are readily available. Contact the Substance Abuse and Mental Health Services Administration (SAMHSA) National Helpline at 1-800-662-4357 for information on support and treatment.

You can also find a list of treatment centers near you on our website to help get you on the path to recovery.

Key Sources

Arcelus, Jon et al. (2011). Mortality rates in patients with anorexia nervosa and other eating disorders. A meta-analysis of 36 studies. Archives of general psychiatry. 68(7), 724-31. https://doi.org/10.1001/archgenpsychiatry.2011.74

Brewerton, T. (2007). Eating Disorders, Trauma, and Comorbidity: Focus on PTSD. Journal of Treatment & Prevention. 15(4), 285-304. doi.org/10.1080/10640260701454311

Deloitte Access Economics. (2020). The Social and Economic Cost of Eating Disorders in the United States of America: A Report for the Strategic Training Initiative for the Prevention of Eating Disorders and the Academy for Eating Disorders. Harvard T.H. CHAN. https://www.hsph.harvard.edu/striped/report-economic-costs-of-eating-disorders.

Lesser, B. (2021). Everything About Eating Disorders. Dual Diagnosis.org. https://dualdiagnosis.org/eating-disorders.

Mitchell K., Mazzeo S., Schlesinger M., Brewerton T., Smith B. (2012). Comorbidity of partial and subthreshold PTSD among men and women with eating disorders in the National Comorbidity Survey-Replication Study. International Journal of Eating Disorders. 45(3),307-315. doi:10.1002/eat.20965.

National Eating Disorders Association (NEDA). (n.d.). Substance Abuse and Eating Disorders. NEDA. https://www.nationaleatingdisorders.org/substance-abuse-and-eating-disorders.

Ross, C. (2015). When Eating Disorders and Drug Addiction Collide. Psychology Today. https://www.psychologytoday.com/gb/blog/real-healing/201511/when-eating-disorders-and-drug-addiction-collide.

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