Comparing Co-Occurring Disorders in U.S. and International Countries

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The relationship between co-occurring disorders and eating disorders has been well researched, including the differences in how these issues are addressed in the United States versus internationally.

Eating disorders are known to frequently have co-occurring mood, anxiety, and trauma-based issues. Studies show that lifetime prevalence of bipolar disorder in the eating disorder population is as high as 34.8 percent in outpatient settings, and as high as 64 percent in residential settings [1].

Co-Occurring Disorders in the United States

There are some differences between the subtypes of eating disorders and co-occurring disorders. In a recent study that looked at participants who had co-occurring eating disorders and mood disorders in the U.S., 19 percent of those with bipolar also have diagnosed eating disorders; those with Binge Eating Disorder (BED) typically have higher rates of hypomania episodes[1].

Those with bipolar I or II tended to have greater body weight and increased suicidality, greater affect lability, impulsive behavior, and a higher rate of alcohol use disorder than those individuals with co-occurring mood disorders [1]. They did not show significant differences from those participants with a secondary bipolar II diagnosis of panic disorder and alcohol use disorders.

In this same study, those with eating disorders and bipolar I were shown to have the most severe BED, depression, affect lability, impaired intelligence and working memory issues.

Those with eating disorders and bipolar I had the lowest intelligence quotient and working memory issues compared to the other groups. Those with co-occurring mood disorders had higher severity of mood shifts, impulsiveness, higher body weight, and binge-eating/purging severity [1].

Those participants with bipolar I had a two-fold higher co-occurrence rate of panic disorders, severe depression, mood lability, and higher rate of severe role impairment than those with mood disorders.

Development of Co-Occurring Disorders Overseas

Internationally, eating disorders in non-Western countries have been on the rise [2]. The Middle East and People’s Republic of China have seen such a rise, and studies suggest that the prevalence of eating disorders presents differently due to varying cultures and diagnostic criteria that is based on Western norms of mental health.

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One reason for the increase in reported diagnoses is the increase in social pressure of standards of beauty brought from Western cultures, and the sprawl of urbanism in areas of non-Western countries due to population increase.

In a study that looked at eating disorders in non-Western countries, the researchers looked at 3 groups, East Asian countries, South Asian or Islamic countries, and African countries.

In South Asian/Islamic countries, 39.5 percent of female college students had abnormal eating attitudes, which was the highest rates in the study [2]. In Japan, in 1999, a study that looked at eating pattern in females showed that high school students had higher rates of abnormal eating than adult females, and in 2003 when reevaluated, 11.2 percent of high school girls had abnormal eating attitudes.

Another longitudinal study from 1985 to 1992 looked at the effects of westernization in Japan, finding that BMI decreased from 21.5 to 20.5 by 1995. The researchers suggested that this reflected a young person’s desire to diet and balance of environmental pressures [2].

The higher rate was also associated with increased urbanization; prior to 1985, most reported eating disorders came from cities that had a population size of 60,000 to 250,000.

In comparison, an Iranian survey reported women in Tehran who were more interested in Western culture were more likely to be satisfied with their body shape and suggested that the hypothesis of cultural effects on eating disorders could be limited [2]. Even though there is limited research in the area of eating disorders and its effects in non-Western countries, it is agreed that rates of eating disorders are increasing.

Cultural Variances in Eating Disorders and Body Image

North European Caucasian women tend to have greater body dissatisfaction compared to Asian and African American counterparts, and are more likely to diet [3].

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An Australian university study looked at Hong Kong-born females and found that they were more apt to have positive eating attitudes than Australian-born women, suggesting that Asian women had lower risk of eating pathology. In the U.S., a cross sectional study in public schools, with five different ethnic groups, found that there were no differences in eating pathology.

Another study in Taiwan comparing Taiwanese women, both in Taiwan and the U.S., finding that Taiwan women identified significantly stronger with Taiwanese culture than the U.S. but also showed significantly higher body dissatisfaction and eating disturbances [3].

These studies show that culture may not be a protective factor to the development of eating disorders or co-occurring disorders.

It is known, through prior research, that eating disorders are often about the underlying need for control. Dietary restriction can give a false sense of being in control, which may be encouraged by Western societies.

Western cultures tend to emphasize internal control, while Japanese culture emphasizes external control. European Americans, and those with higher socioeconomic status, report more internal control then Hispanic cultures, who tend to have an external locus of control of beliefs [3]. In East Asia, the cultural view of control is to conform to the reality within the society, while Western cultures tend to conform to the self.

Psychological factors in the development of eating disorders is important both in Western and non-Western societies to understand the development of disorders and how they may function differently.

Another study that looked at 6 countries and co-occurring disorders found that lifetime prevalence of eating disorders was higher in France, Belgium, and Italy, compared to the Netherlands, Germany, and Spain [4]. Eating disorders were found to be significantly associated with other co-occurring disorders.

In conclusion, there is a similar comorbidity rate of eating disorders and other mental health disorders among those in the U.S. and international countries. The differences lies in the presenting symptomatology of the disorders, as well as cultural influence within each society.


Image of Libby Lyons and familyAbout the Author: Libby Lyons is a Licensed Clinical Social Worker and Certified Eating Disorder Specialist (CEDS). Libby has been practicing in the field of eating disorders, addictions, depression, anxiety and other comorbid issues in various agencies. Libby has previously worked as a contractor for the United States Air Force Domestic Violence Program, Saint Louis University Student Health and Counseling, Saint Louis Behavioral Medicine Institute Eating Disorders Program, and has been in Private Practice.

Libby currently works as a counselor at Fontbonne University and is a Adjunct Professor at Saint Louis University, and is a contributing author for Addiction Hope and Eating Disorder Hope. Libby lives in the St. Louis area with her husband and two daughters. She enjoys spending time with her family, running, and watching movies.


[1] Tseng, M. M., Chang, C., Liao, S., & Chen, H. (2017). Comparison of associated features and drug treatment between co-occurring unipolar and bipolar disorders in depressed eating disorder patients. BMC Psychiatry,17(1). doi:10.1186/s12888-017-1243-0
[2] Makino, M., Tsuboi, K., & Dennerstein, L. (2004). Prevalence of Eating Disorders: A Comparison of Western and Non-Western Countries. MedGenMed,6(4), 49th ser. Retrieved May 02, 2017, from  
[3] Soh, N. L., Touyz, S. W., & Surgenor, L. J. (2006). Eating and body image disturbances across cultures: a review. European Eating Disorders Review,14(1), 54-65. doi:10.1002/erv.678
[4] Preti A et al. The epidemiology of eating disorders in six European countries: Results of the ESEMeD-WMH project. Journal of Psychiatric Research (2009), doi:10.1016/j.jpsychires.2009.04.003 (Bijl et al., 1998)

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 June 26, 2017.
Reviewed By: Jacquelyn Ekern, MS, LPC on June 26, 2017.
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