Although it can happen, most mental health disorders don’t happen by themselves. There are usually one or more other disorders occurring at the same time, in a phenomenon known as a dual diagnosis. Eating disorders are no different; they are listed in the DSM-5 with other forms of psychiatric illnesses, and they tend to appear in conjunction with disorders like depression, OCD, and PTSD.

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Here we’ll explore some of the types of psychiatric illness that co-occur in a dual diagnosis with eating disorders such as anorexia nervosa, bulimia nervosa, binge eating disorder, and other types of an eating disorder. Common psychiatric treatments and recovery options are also going to be covered here.

Common Psychiatric Disorders That Co-occur With Eating Disorders

These psychiatric disorders may co-occur with an eating disorder, or they may be a cause of one or caused by one. In most cases, the diagnostic team of doctors and psychiatrists will develop a simultaneous treatment program that addresses both. Some of the common psychiatric disorders include:

Depressive Disorders

The DSM-5 (Diagnostic and Statistical Manual for Mental Disorders-5-TR) supports a diagnosis of clinical depression if five or more of the following symptoms are reported by an eating disorder patient:

• Insomnia or hypersomnia (oversleeping and sleeping more than 12 hours a day)
• Anhedonia, or a loss of interest in previously enjoyed activities
• Self-isolation/avoiding social situations
• Cognition difficulties such as memory loss, difficulty concentrating, and trouble making decisions
• Suicidal ideation (contemplating or planning suicide)
• Sadness, lack of motivation, and/or a feeling of emptiness

Depression in Teens

Adolescence is a time of complex changes involving biological, social, and emotional milestones. It can be difficult for parents to recognize early signs of depression in teens because adolescents’ emotions can be turbulent, with mood swings and negative feelings being common. Depression often precedes the development of an eating disorder in adolescents as disordered eating behaviors can alleviate the sadness and anger they feel.

Possible signs an adolescent has clinical depression include:

• Consistent angry or hostile attitude, especially when confronted or questioned about their behavior
• Increased withdrawal from family and friends; socially isolating oneself
• Feelings of worthlessness, low self-esteem, decreased self-worth Disinterest in activities that were once enjoyed
• Increased sleeping or increasing sleeplessness
• Suicide ideation

Anxiety Disorders

Generalized Anxiety Disorder

Characterized by irrational worries, a constant sense of apprehension, and a negative outlook on the future, generalized anxiety disorder (GAD) is commonly co-diagnosed in teens with eating disorders. Anxiety disorders often engender a sense that the person is losing control over their circumstances, which can trigger eating disorders as a way to “regain” control over something. This can become a cycle that exacerbates both the anxiety disorder and the eating disorder. Thankfully, many therapeutic methods effectively treat both kinds of disorders.

Phobias and Panic Disorder

Also on the spectrum of anxiety disorders are phobias and recurring panic attacks. Many people with eating disorders, especially anorexia nervosa and ARFID, have fears about food and eating, resulting in food avoidance or extensive food rituals. People with anorexia nervosa may suffer panic attacks if they are forced by their parent or loved one to eat even a small amount of food they consider fattening or high-calorie. Treating psychiatric disorders such as phobias and panic is an essential precursor to successfully addressing a person’s eating disorder.

Schizophrenia

While co-occurring diagnoses of eating disorders and schizophrenia are relatively rare compared to depression or anxiety, it has been known to happen. A serious, difficult to treat psychiatric disorder, schizophrenia can be managed to an extent with medications and professional counseling, as well as family support and life skills classes. If a person is diagnosed with schizophrenia and an eating disorder, the eating disorder is typically a selective eating disorder like ARFID, pica (eating inedible things like dirt), or overeating disorder not otherwise specified.

Symptoms of schizophrenia include delusions, audio/visual hallucinations, incoherent speech, and inability to understand reality.

Post-Traumatic Stress Disorder (PTSD)

Experiencing traumatic events such as abuse violence, a divorce, loss of a loved one, or even an auto accident can cause a debilitating disorder known as PTSD. Symptoms of PTSD such as extreme anxiety, nightmares, flashbacks to the traumatic event, and difficulty coping with normal life stressors. As with GAD, PTSD can trigger disordered eating behaviors as a coping mechanism and means to take back control.

Personality Disorders

Personality disorders can be much more difficult to treat than other forms of mental illness because they form a central aspect of the person’s self-identity. Borderline, obsessive-compulsive, and avoidant personality disorders are some of the most common types of personality disorders diagnosed in people with anorexia nervosa, bulimia nervosa, or binge-eating disorder. Evidence-based talk therapy such as CBT and DBT may help combat personality disorders, as well as certain medications, which may continue long after residential eating disorder treatment has been completed.

Psychiatric Evaluations in Eating Disorder Treatment

A comprehensive psychiatric evaluation allows the treatment team at an eating disorder treatment facility to assess a person’s complete treatment needs. This information is critical to developing an individualized recovery program that can capably treat any and all disorders, giving the individual the best chance at a full recovery.

Standard Questionnaires and Cognitive Assessments

Certain standard questionnaires can get the ball rolling. Because many psychiatric illnesses and eating disorders can both impair cognitive ability, various cognitive questionnaires can be administered to assess their cognitive abilities. For example, tests containing questions that measure a client’s complex attention processes can determine how well they can observe stimuli without being distracted.

The Role of Medical History in Medical Health and Eating Disorders

Although psychiatric illnesses are generally mental health disorders, the individual’s medical history must also be assessed, especially since in cases of eating disorders, there are often severe medical complications that need attention. Does the patient have a history of seizures? Migraine headaches? Recurring infections? Heart disease? Dental issues?

Any prescribed medications and medical allergies should be discussed as well. If the individual has a history of substance abuse, their last usage, and type of drug should be mentioned. While much of this may be something the individual wants to keep secret, it’s essential to their health that all avenues are explored.

Psychosocial and Developmental History in Dual Diagnosis Evaluation

The final component of psychiatric evaluations involves the individual’s developmental and psychosocial history. Developmental history involves a discussion of the individual’s childhood and adolescence and examines important past experiences that have influenced a person’s development. Some things of particular concern to psychiatrists include a history of chronic diseases, physical abuse, or sexual abuse that may have had a profound effect on the patient’s psychological maturation.

Family relationships and those with close friends are explored to get an idea of the individual’s psychosocial baselines. Sexual history, sexual orientation, and cultural beliefs concerning sex are also examined as part of a complete psychiatric evaluation. Every effort should be made to include cultural sensitivity as part of this evaluation, as it will play a central role in the eventual individualized treatment plan.

Treatments for Dual Diagnosis of Eating Disorders and Mental Illness

After the initial psychiatric evaluation, the medial, therapeutic, and psychiatric team at an eating disorder center will design an individual treatment plan. This includes several different types of therapy, each of which is designed to help the individual overcome both the eating disorder and the co-occurring mental health disorder.

Psychotherapy

The basic building block of any recovery program, psychotherapy is a type of “talk” therapy that reinforces how to process their emotions and maintain control over them. Psychotherapists talk with the individual about their thoughts and feelings even if they experience anxiety and fear over acknowledging them. Therapy sessions can also uncover previously repressed feelings and memories, hopefully leading to a “breakthrough,” where new insights can be made.

Cognitive Behavioral Therapy

Decades of evidence-based studies of psychotherapy utilized by eating disorder therapists and psychologists has led to the development of cognitive behavioral therapy (CBT). CBT helps people recognize distorted thoughts and behaviors as being unhealthy via an objective one-on-one dialogue between client and therapist. This has proven to be especially helpful for people diagnosed with borderline personality disorder, depression, eating disorders and anxiety/phobias, CBT challenges false assumptions and rigid thought patterns.

Central to CBT is helping individuals see the way they think objectively and not through the filter of their subjective emotions. For example, a person with an anxiety disorder who reports they are unable to focus on anything because they feel something bad is going to happen to them will be guided by a CBT therapist to systematically and objectively examine these thoughts to see if there is any objective reason to think so. Eventually, after several sessions, the individual might come to realize their fears are not based on solid evidence but are instead irrational.

How Treatment Programs Can Keep an Individual Motivated

Many teens and adolescents who need eating disorder treatment may feel guilty about their disordered eating behaviors, but treatment centers’ programs for family and friends can increase their motivation to get better. Family members and support groups can be of great help to those who may need extra motivation and support when the urge to start engaging in eating disorder behaviors is persistent and overwhelming.

While externally supplied motivation is a necessity to complete an eating disorder recovery program, people in eating disorder treatment, on a residential or day treatment basis, must realize the incentive to enjoying a successful recovery lies primarily within themselves and their desire to live a healthier life with a better relationship with food and eating. No matter the program eventually chosen, securing a psychiatric evaluation and a specialized treatment plan based on that evaluation is the essential first step to a full recovery.

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