Eating Disorders & Substance Use: Co-Occurring Disorders

Eating disorders commonly occur alongside substance use disorders. This is often referred to as a “dual diagnosis.” Approximately 27% of individuals with Anorexia Nervosa, 36.8% of those with Bulimia Nervosa, and 23.3% of those with Binge Eating Disorder (BED) are diagnosed with a substance use disorder [1]. Each of these disorders, whether separate or comorbid, have severe impacts on the mind and body that worsen if left untreated. Understanding how these diagnoses relate to one another as well as the most appropriate methods of treatment is key to reducing long-term consequences.

Substance Use Disorder Definition

Substance Use Disorders fall under the “Substance-Related and Addictive Disorders” diagnostic section of the Diagnostic and Statistical Manual of Mental Illness, Fifth Edition (DSM-5). According to the DSM-5, Substance Use Disorders are “a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues using the substance despite significant substance-related problems [2].” The DSM-5 specifies the following 10 “classes” of substances: Alcohol, Caffeine, Cannabis, Hallucinogens, Inhalants, Opioids, Sedatives, Stimulants, Tobacco, and Other [2]. The DSM-5 provides criteria for diagnosis of a use disorder for all of these substances.

Substance Use Disorder: What are the Signs?

In substance use disorders, individuals become dependent on a substance despite negative impacts on their daily life. Secrecy is common and individuals will go to extreme lengths in attempts to hide their addiction from those around them. Despite this, there are many warning signs that can indicate someone has a problem and they will not be able to hide these red flags long-term:

  • Changes in appetite or sleeping patterns.
  • Deterioration of personal grooming habits [3].
  • Tremors, slurred speech, impaired coordination [3].
  • Bloodshot eyes, pupils larger and/or smaller.
  • Runny nose or sniffling [3].
  • Unusual odors on breath, body, or clothing [3].
  • Engaging in secretive behaviors.
  • Hiding substance.
  • Engaging in substance use alone or in secret.
  • The substance negatively impacts one’s relationships and/or job performance.
  • Daily life choices revolve around use of substance.
  • Increased financial problems.
  • Borrowing or stealing money.
  • Sudden change in friends, favorite hangouts, and hobbies [3].
  • Using drugs under dangerous conditions (driving while using drugs, using dirty needles, having unprotected sex) [3].
  • Using the substance to avoid withdrawal symptoms.
  • Loss of control.
  • Increased legal trouble.
  • Continued use despite harmful consequences.
  • Lack of motivation.
  • Appearing anxious, withdrawn, and/or paranoid [3].
  • Periods of unusual increased energy, nervousness, or instability [3].
  • Sudden mood swings [3].
  • Severe or unexplained change in personality or attitude [3].

What are the Causes of Substance Use Disorder?

Substance use disorders are biological, psychological, and social disorders that have many contributing factors. Some aspects that increase one’s risk for substance use disorders are:

  • Family history of addiction.
  • Genetics (40-60% of substance use disorder risk is explained by genetic influence [1]).
  • Comorbid mental health diagnosis (Major Depressive Disorder, Generalized Anxiety Disorder, etc.).
  • Experiences of trauma.
  • Adverse childhood experiences.
  • Engaging in a chaotic lifestyle.
  • Turbulent life events.
  • Emotion dysregulation.
  • Lack of effective coping skills.
  • Using/experimenting with drugs at an early age.
  • Genetic predisposition to addictive behavior patterns.
  • Struggles with peer pressure.
  • Low self-esteem.
  • Lack of family involvement and/or parental attachment.
  • Experiencing chronic pain.
  • Financial difficulties.
  • Relationship issues.

Eating Disorders & Substance Use Comorbidity

The relationship between substance use disorders and eating disorders cannot be denied, as 50% of those that struggle with a substance use disorder will also experience an eating disorder compared to 9% of the general population [4]. How individual eating disorder behaviors relate to individual substance use behaviors can differ.

Anorexia nervosa is an eating disorder characterized by severe restriction of food intake and distorted body image. For some, excessive use of substances, or development of addiction to these substances, can occur through intended use of the substance for weight loss. Substances such as methamphetamines or cocaine are often used in this way as these drugs cause lack of appetite and lead to restricting behaviors. Risk factors that make one vulnerable to anorexia nervosa, such as rigidity or perfectionism, also make one susceptible to substance use as individuals may use substances to reduce these tendencies. Low self-esteem and self-worth and difficulty combating peer pressure also make one more at risk for both anorexia nervosa and substance use disorders.

It is important to note that anorexia presentations interact differently with substance use disorders, with more substance use disorders being found in those that engage in Anorexia Nervosa Binge Type than Restrictive Type [4]. Additionally, studies show that the more severe caloric restriction an individual engages in, the more likely they are to abuse psychostimulant substances [5].

Related Reading

Finally, many researchers actually consider anorexia nervosa an addictive behavior in-and-of-itself, noting that “The relentlessness with which individuals with anorexia nervosa pursue starvation despite profound negative physical, emotional, and social consequences is similar to the maladaptive cycle seen in individuals with addiction [5].” Substance use disorders and anorexia nervosa are also similar in that “individuals with anorexia nervosa behave similarly to individuals with substance abuse by narrowing their behavioral repertoire so that weight loss, restricting food intake, and excessive exercise interfere with other activities [5].”

The Relationship Between Bulimia and Drug Addiction

Bulimia Nervosa is characterized by binge eating episodes followed by compensatory behaviors such as vomiting, excessive exercise, or laxative use. Bulimia nervosa is the most prevalent co-occurring eating disorder with substance use disorders. Individuals that struggle with both bulimia nervosa and/or substance use disorders are found to have difficulty with impulsivity and compulsive behaviors [7]. Additionally, those that have a history of trauma, adverse childhood experiences and/or have difficulties with low self-esteem or coping with peer pressure are at higher risk for development of bulimia nervosa and/or substance use disorders.

Genetics and neurobiology can play a large part in both disorders and research has found that 83% of the phenotype connection between substance abuse and bulimia nervosa was determined by genetic influences [8]. The chemical response of the mind and body to purging or substance use can reinforce these behaviors and lead the individual to want to engage in them repeatedly.

Bulimia nervosa and substance use disorders may also co-occur due to individuals utilizing substances to enhance or support bulimic behaviors.

Binge Eating and Substance Use

Binge Eating Disorder (BED) is characterized by episodes of binge eating that are not followed by compensatory behaviors. Individuals often develop binge eating behaviors as a maladaptive coping skill which may be a connection between BED and substance use, as individuals can engage in substance use behaviors for the same reason. Both BED behaviors and substance use behaviors are also often utilized to cope with negative emotion-states. Additionally, similar to bulimia nervosa, individuals with BED and substance use disorders often struggle with impulsivity and compulsive behaviors.

Struggling with Substance Abuse

Substance Use Disorder Statistics

Substance use disorders are all-too-common and are evolving quickly as we learn more about their effects. Researchers have learned the following about substance use disorders:

  • “According to the National Survey on Drug Use and Health (NSDUH), 19.7 million American adults (aged 12 and older) battled a substance use disorder in 2017 [8].”
  • Approximately 11.7% of people ages 12+ have used illicit drugs in the last month [9].
  •  Approximately 2% of people ages 12+ have recreationally used psychotherapeutic drugs in the last month [9].
  • 74% of those that struggled with a substance use disorder in 0217 struggled with Alcohol Use Disorder [8].
  • 1 out of every 8 adults struggle with both a substance use and alcohol use disorder simultaneously [8].
  • In 2017, 8.5 million Americans struggled with co-occuring mental health and substance use disorders.
  • “Drug abuse and addiction cost American society more than $740 billion annually in lost workplace productivity, healthcare expenses, and crime-related costs [8].”

Eating Disorder and Substance Use Treatment

Eating disorders and substance use disorders can be difficult to treat simultaneously due to the physical impacts of both on the body. Many professionals believe that treating the eating disorder first is most helpful so that an individual can approach substance use treatment less brain-starved and malnourished. However, if an individual is at-risk for withdrawal symptoms due to their substance use disorder, they must first undergo detox at a hospital as this can be a life-threatening process without proper medical support and supervision. Regardless of which specific treatment an individual is in, both disorders should always be considered simultaneously, as they are likely incredibly intertwined with one another.


Medication can be used to treat certain substance use disorders, however, there is currently no medication that can treat eating disorders. For those with eating disorders, the psychiatric medications taken are often treating comorbid mental health diagnoses such as mood or anxiety disorders. It can be helpful for one to use psychiatric medications to reduce substance use, when recommended by a medical treatment professional, as this allows one to maintain sobriety and engage more presently in eating disorders and substance use treatment.

Medications used for treatment of substance use disorders can include the following:

  • Alcohol Use Disorders: Naltrexone, Antabuse, Campral [10].
  • Opioid Use Disorders: Naltrexone, Methadone, Buprenorphine [10].
  • Nicotine Use Disorders: Bupropion, Nicotine Replacement THerapies, Varenicline [10].


Many of the therapeutic modalities that are effective in treating eating disorders are also effective for treating substance use disorders, making it helpful to learn these therapeutic insights and skills because they will be applicable to treating both types of disorders. The most evidence-based treatments for either disorder types include: Cognitive Behavioral Therapy (CBT), Dialectical Behavior Therapy (DBT), exposure therapies, and Family-Based Treatments.

Relapse Prevention and Aftercare Support

The most effective way to treat comorbid eating disorders and substance use disorders is to always consider both simultaneously throughout treatment. The similarities in presentations and risk factors lead to both types of disorders often reinforcing and perpetuating one another. Treatment professionals should support their patients in gaining insights and developing skills that can support recovery from both.

While eating disorders and substance use disorders can result in harrowing consequences if left untreated, they are treatable disorders. Recovery from both is absolutely possible if one follows the recommendations of their treatment team from the beginning and engages in the outpatient maintenance work recommended.

Author: Margot Rittenhouse, MS, LPC, NCC

Page Last Updated & Reviewed By: Jacquelyn Ekern, MS, LPC on August 18th, 2021
Published on, Treatment Resources & Information on Eating Disorders