Understanding Co-Occurring Issues in Eating Disorders

Contributor: Amy M. Klimek, MA, LCPC, Director of Program Development, Eating Disorder Program Coordinator, Timberline Knolls Residential Treatment Center

Eating disorders manifest in many different ways and one does not look like another. Yet, one thing they often have in common is that they rarely present alone. When two or more disorders or illnesses occur simultaneously in the same individual, it is referred to as co-occurring disorders, also known as co-morbidities in the field of behavioral health.

The question of which came first is irrelevant and historically, an individual often only received treatment for the more recognizable behaviors and never receive the adequate care of the underlying symptoms. This resulted in the individual playing a game of Ping-Pong when it came to treatment, leaving her vulnerable to relapse.

Integrated treatment for co occurring provides the best recovery outcome for the individual. Co-occurring disorders can present themselves differently in each individual and early intervention is essential.

Common Co-occurring Disorders

Substance Use Disorder (SUD)

Eating Disorders, like substance abuse, are influenced by genetic, biological, environmental, and psychological factors. Some individuals may experience suppression of their appetite after consuming a substance, triggering an onset to an eating disorder.

Man abusing AlcoholSome individuals may restrict their calories to feel the high of the substance come on quicker. In a 2003 study at the National Center for Addiction and Substance Abuse (CASA) at Columbia University, research suggested that nearly 50 percent of individuals with an eating disorder were also abusing drugs and/or alcohol.


Those who suffer from ED and depression present similarly. Isolation from family and friends, an increase in irritability, loss of interest in food, and an increase physical health complaints such has fatigue or pain are all too common. An individual who experiences depression may not have the motivation to take care of herself including eating.

This can present as restriction of intake, possibly triggering an onset to an eating disorder. Individuals may engage in binge eating behaviors to number or distract from their depressive state. American Journal of Psychiatry research indicates that 50 percent of those with eating disorders will also experience major depression at some time in their lives.

Self Harm

girl-535877_640x528Self-injuring behaviors may be presented as eating disorder symptoms, such as self-induced vomiting, binge eating behaviors eating until painfully full, and exercising excessively with the intention of inflicting pain or injury to one self. The prevalence of non-lethal self-injury among ED patients is approximately 25%, regardless of the type of eating disorder.


Approximately two-thirds of those with eating disorders also struggle with some type of anxiety. Individuals with eating disorders often report anxiety generally surrounding fear of criticism, fear of being judged in both body shape and size and what they eat. In this, an individual is profoundly afraid of rejection and judgment.

Anxiety can present in a variety of ways and may present in ways of phobias including Agoraphobia, fear of leaving a safe place; Social Phobia, fear of embarrassment or humiliation in social setting and specific phobias such as fear of eating or fear of choking.


Prescription MedicineIn years past, it was standard operating procedure to treat only one disorder or addiction at a time. A woman would receive treatment for alcoholism, but not an eating disorder; another would be treated for anxiety, but not a chemical addiction. That has now changed, and for good reason. Today, treatment centers need to recognize all addictions and disorders and have the ability to address them simultaneously.

The “ability” component is paramount. Treatment for the individual can include medical stabilization, nutrition education, and combination of psychotherapeutic methods. Treating only one issue at a time is inadequate care. The end result is that the individual, though set free from one disorder, will remain in bondage to another. The end result is that additional treatment will be required, thus further delaying the goal of complete and lasting recovery.

Amy Klimek photoAbout the Author: Amy M. Klimek, MA, LCPC, Director of Program Development, Eating Disorder Program Coordinator facilitates supervision for Eating Disorder Specialists, offers support through training to TK staff, and provides education on eating disorders to the community.

Amy started at Timberline Knolls as a Behavioral Health Specialist. As such, she provided support at the milieu level for all residents. She transitioned to Eating Disorder Specialist in 2012, supporting healing in present moment experiences for residents who struggled with eating disorders and body image. Amy earned a Bachelor of Science Degree in Sociology from the University of Illinois. She was awarded a Master’s Degree in Counseling specializing in both community and school counseling from Lewis University.


[1]: The National Center on Addiction and Substance Abuse (CASA) at Columbia University. Food for Thought: Substance Abuse and Eating Disorders. The National Center on Addiction and Substance Abuse (CASA) Columbia University; New York: 2003.
[2]: Mortality in Anorexia Nervosa. American Journal of Psychiatry, 1995; 152 (7): 1073-4.
[3]: Sansone RA, Levitt JL. Self-harm behaviors among those with eating disorders: An overview. Eating Disorder 2002; 10:205.
[4]: http://www.adaa.org/understanding-anxiety/related-illnesses/eating-disorders

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.

Last Updated & Reviewed By: Jacquelyn Ekern, MS, LPC on March 8, 2016
Published on EatingDisorderHope.com