Bulimia Nervosa and Co-occurring Mental Health Issues

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Unfortunately, it is common for those with bulimia to experience co-occurring mental health problems.

These disorders often share common risk factors and symptoms with bulimia, resulting in a dangerous combination that can make the recovery process more challenging.

Anxiety Disorders

Studies have shown that “the majority of people with …bulimia nervosa experience one or more anxiety disorders,” most commonly, obsessive-compulsive disorder (OCD), social phobia, and specific phobia [1].

Post-Traumatic Stress Disorder (PTSD) can occur up to three times more frequently in individuals with bulimia than those with anorexia [1].

Additionally, researchers have, more often than not, found that the onset of the anxiety disorder precedes that of bulimia [2].

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Depending on the anxiety disorder, there are numerous overlapping risk factors. For example, individuals with both bulimia and OCD report significant obsessional personality features [3].

Interestingly enough, it also appears that early onset of an anxiety disorder acts as a risk factor to the development of bulimia [4].

In addition to similar risk factors, both disorders share symptomology, particularly, “dizziness, wobbliness in legs, changes in appetite, and lack of interest in sex [5].


Both disorders share common life factors such as low self-esteem, lack of control, feelings of inadequacy, isolation, and body-image issues.

One study found levels of depression and bulimia to both be uniquely related to self-reported body dissatisfaction [6].

In fact, some researchers question whether body dissatisfaction is a central feature of disordered eating or if it is a central feature of depression, with the combination of the two then leading to disordered eating [6].

Regardless of which disorder tends to appear first, there is no denying that the two disorders are linked. One study found that 59% of normal-weight bulimics and 80% of anorexic-bulimics experience major depression at some point in their lives [7].

Women diagnosed as both bulimic and depressed rate themselves as less socially competent and less attractive [8]. Furthermore, patients with bulimia have a higher frequency of suicide attempts as well as depression [7].

Drug and Alcohol Abuse

The comorbidity of substance abuse and eating disorders is incredibly concerning. Both disorders have the highest mortality risks of all mental disorders and statistics show that half of all clients with eating disorders abuse alcohol or illicit drugs [9].

There is no singular reason why these disorders commonly co-occur. However, studies show that common biopsychosocial risk factors predispose individuals to both bulimia and substance abuse.

Some of these factors involve “an addictive personality, a family history of drug abuse, parental characteristics, common developmental issues, and biological vulnerability [9].”

Woman drinking coffeeA dual-diagnosis of bulimia and substance abuse does make treatment more challenging, “however, successful outcomes can be increased through proper diagnosis and early intervention [9].” It is important that substance abuse and eating disorder treatment facilities screen for both problems.

Clinicians and researchers have noted that having a dual-diagnosis can make the recovery process more challenging. This knowledge may seem bleak but has propelled providers and advocates into emphasizing the importance of early intervention and screening for both.

Catching either disorder early on can tackling them together can be the key to securing long lasting recovery.

Image of Margot Rittenhouse.About the Author: Margot Rittenhouse is a therapist who is passionate about providing mental health support to all in need and has worked with clients with substance abuse issues, eating disorders, domestic violence victims and offenders, and severely mentally ill youth.

As a freelance writer for Eating Disorder and Addiction Hope and a mentor with MentorConnect, Margot is a passionate eating disorder advocate, committed to de-stigmatizing these illnesses while showing support for those struggling through mentoring, writing, and volunteering. Margot has a Master’s of Science in Clinical Mental Health Counseling from Johns Hopkins University.


[1] Kaye, W. H., et al. (2004). Comorbidity of anxiety disorders with anorexia and bulimia nervosa. American Journal of Psychiatry, 161, 2215-2221.
[2] Bulik, C. M. et al. (1996). Lifetime anxiety disorders in women with bulimia nervosa. Comprehensive Psychiatry, 37:5, 368-374.
[3] Kuehnel, D. J. (1998). Eating disorders: comorbidities of eating disorders. Retrieved on 25 August 2017 from https://www.healthyplace.com/eating-disorders/articles/eating-disorders-comorbidities-of-eating-disorders/.
[4] Swinbourne, J. M., Touyz, S. W. (2007). The co-morbidity of eating disorders and anxiety disorders: a review. European Eating Disorders Review, 15, 253-274.
[5] Levinson, C. A. et al. (2017). The core symptoms of bulimia nervosa, anxiety, and depression: a network analysis. Journal of Abnormal Psychology, 126:3, 340-354.
[6] Wiederman, M. W., Pryor, T. L. (2000). Body dissatisfaction, bulimia, and depression among women: the mediating role of drive for thinness. International Journal of Eating Disorders, 90-95.
[7] Levy, A., Dixon, K., and Stern, S. (1989). How are depression and bulimia related? The American Journal of Psychiatry, 146:2, 162-168.
[8] Matthews, A., Lynn, S. J. (2008). Subclinical bulimia vs. depression in an interpersonal context. Eating Behaviors, 9, 509-512.
[9] Carbaugh, R. J., Sias, S. M. (2010). Comorbidity of bulimia nervosa and substance abuse: etiologies, treatment issues, and treatment approaches. Journal of Mental Health Counseling, 32:2, 125-138.

The opinions and views of our guest contributors are shared to provide a broad perspective of eating disorders. These are not necessarily the views of Eating Disorder Hope, but an effort to offer discussion of various issues by different concerned individuals.

We at Eating Disorder Hope understand that eating disorders result from a combination of environmental and genetic factors. If you or a loved one are suffering from an eating disorder, please know that there is hope for you, and seek immediate professional help.

Published on October 11, 2017.
Reviewed By: Jacquelyn Ekern, MS, LPC on October 11, 2017.
Published on EatingDisorderHope.com