Eating Disorders and Their Comorbid Conditions

Lives are lost to eating disorders every year, not just from the disorders themselves but also from the deadly conditions that often accompany them. Heart failure, suicide, and severe depression are harsh realities for many battling these illnesses. These co-occurring issues, called comorbidities, aren’t just complications; they’re life-threatening.

Recovery isn’t just about treating the eating disorder. It requires addressing the physical and emotional conditions that fuel the cycle of harm. So is essential that we understand how an eating disorder affects the whole mind and body.

Understanding Comorbidity in Eating Disorders

When we talk about comorbidity, we’re describing a situation where someone experiences more than one medical or mental health condition at the same time. For example, a person with an eating disorder (ED) might also struggle with depressive disorders, anxiety disorders, or physical health issues, like heart problems or a loss of bone density.

These conditions aren’t just happening alongside each other by coincidence; they also often interact, making each one harder to manage and complicating treatment plans.

How Common Are Co-Occurring Conditions in Eating Disorders?

Co-occurring conditions are extremely common in people with eating disorders. Most individuals with an ED also face one or more additional challenges, such as:

• Psychiatric disorders, like anxiety, depression, obsessive-compulsive disorder (OCD), or substance use disorders ^[7].
• Physical health complications, including heart issues, gastrointestinal problems, and osteoporosis.
• Trauma histories, such as past abuse or neglect, can contribute to the development or maintenance of an eating disorder ^[1][2][3][4].

it’s more unusual to find someone with an eating disorder who doesn’t have a co-occurring condition than one who does.

Why Does Recognizing Comorbidities Matter?

Identifying and addressing comorbid conditions is absolutely critical for effective treatment. Here’s why:

1. The symptoms of one condition often feed into another. For instance, anxiety might drive restrictive eating, or malnutrition might worsen depression.
2. People who receive care for their eating disorder and their co-occurring conditions are more likely to recover fully.
3. Untreated comorbidities can increase the risk of serious complications, including suicide, physical health deterioration, or relapse.

So, let’s look at the number and types of co-occurring conditions that can develop alongside an eating disorder.

Psychiatric Comorbidities

The table below gives an overview of the mental battles that all too often tend to accompany a disorganized and distorted relationship with food ^[7][8][9].

Mental Health Condition	How It Relates to Eating Disorders
Anxiety Disorders	Anxiety is very common in people with eating disorders. For example, 65% of those with eating disorders also have an anxiety disorder, such as social anxiety. Social anxiety is especially common in bulimia nervosa (85%) and binge eating disorder (75%). Many report anxiety started before their eating disorder.
Depression	Depression occurs in over half of people with anorexia and bulimia nervosa. It can worsen symptoms of eating disorders, like restricting food or binge eating. Other types of depression, such as post-natal depression have also been liked with disruptive eating behavior.
Bipolar Disorder	Bipolar disorder, which involves extreme mood swings, is often seen in people with binge eating or bulimia nervosa (BN). Rates can range from 2% to 36%, depending on the study.
Personality Disorders	More than half of people with eating disorders also have personality disorders, which affect how they think about themselves and others. Common ones include borderline personality disorder and obsessive-compulsive personality disorder [5].
Substance Use Disorders	Around 28% of people with eating disorders also struggle with substance use, like alcohol, tobacco, or drugs. This is more common in BN or binge eating disorders.
Post-Traumatic Stress Disorder (PTSD)	Many people with eating disorders have experienced trauma, like abuse, and may also have PTSD. Rates are highest in bulimia (up to 66%).
ADHD (Attention Deficit Hyperactivity Disorder)	People with attention-deficit hyperactivity disorder (ADHD), especially those with impulsivity, are more likely to develop binge eating or bulimia nervosa. ADHD is found in about 31% of people with eating disorders.
Autism Spectrum Disorder (ASD)	People with autism are more likely to have eating disorders, especially anorexia. Around 23% of those with eating disorders show autism traits like sensory sensitivities.
Obsessive-Compulsive Disorder (OCD)	People with eating disorders often have traits like perfectionism and rigid thinking, which are also common in OCD. About 18%-33% of people with eating disorders also have OCD, with the highest rates in anorexia nervosa.
Body Dysmorphic Disorder (BDD)	People with BDD obsess over specific parts of their appearance, like facial features, and this often overlaps with eating disorders, like anorexia nervosa (AN). Rates in eating disorders range from 26% to 62%.

We also need to include individuals struggling with binge-eating disorder (BED) and obesity, who face these concerns:

• Higher risks of depression
• Obsessive-compulsive symptoms
• Feelings of inadequacy compared to those with obesity alone^[6]

Medical Comorbidities

Just as serious as the mental disorders that tend to co-occur with an ED are the physical problems. These can affect every part of the body.

System	Associated Medical Conditions
Cardiovascular	Slow heart rate (bradycardia), irregular heartbeats (dysrhythmias), prolonged QT interval (affects heart rhythm), low blood pressure (hypotension), heart failure, mitral valve prolapse (improper valve closure), fluid around the heart (pericardial effusion).
Cancer	Higher mortality from melanoma (skin cancer), cancers of genital organs, and cancers of unspecified sites.
Dermatologic	Yellow skin (from high levels of carotene in the blood), cold blue hands/feet (acrocyanosis), bruising (purpura), fine body hair (lanugo), dry skin (xerosis), hair loss (telogen effluvium).
Skeletal System	Weak or brittle bones (osteopenia or osteoporosis), increased fracture risk.
Gastrointestinal	Constipation, delayed stomach emptying (gastroparesis), difficulty swallowing, structural GI changes, increased risk of esophageal cancer.
Dental	Tooth enamel erosion, swollen salivary glands, red and sore gums (mucosal erythema), gum disease (periodontal disease).
Metabolic/Endocrine	High cholesterol levels (hypercholesterolemia), altered energy use and metabolism, higher risk factors for heart disease and diabetes (metabolic syndrome), low levels of essential electrolytes like potassium and magnesium (electrolyte imbalances).
Renal (Kidney)	Poor kidney function (reduced ability to filter waste), dehydration, kidney disease.
Neurological	Brain shrinkage (enlarged ventricles), memory and focus issues, Wernicke’s encephalopathy (caused by severe vitamin B1 deficiency).
Reproductive	Loss of periods (amenorrhea), irregular periods (oligomenorrhea), miscarriages, complications during pregnancy, growth restriction for babies in the womb (intrauterine growth restriction).
Oral Health	Tooth erosion, swollen salivary glands, increased cavities, and gum disease.
Vitamin Deficiencies	Low levels of calcium, vitamin D, zinc, selenium, B vitamins, and other essential nutrients.
Immune System	Possible increased risk of immune-related disorders, such as autoimmune conditions.
Cognitive Functioning	Problems with focus, decision-making, memory, and processing speed.
Bone Health	Brittle bones, curved spine (scoliosis), long-term thinning of bones.
Refeeding Syndrome	Dangerous shifts in electrolytes and fluids (e.g., low phosphorus levels), can cause respiratory failure, heart failure, and seizures.
Metabolic Syndrome	High blood sugar, high cholesterol, high blood pressure, obesity-related problems.

Impact on Mortality Risk

When considering the above risks, and to fully grasp the dangers of comorbidities in eating disorders, we also consider the very high mortality rate that can come with them.

The table below gives an overview of how co-occurring conditions (like depression and suicidality) contribute to a concerningly high risk of death ^[10].

Aspect	What the Research Says
Suicide Rates in AN	Suicide is a leading cause of death in people with AN, making up 27% of all deaths in one study.
	People with AN are much more likely to die by suicide than the general population.
Suicide Rates in BN	About 27% of people with BN attempt suicide at some point in their lives.
	In severe BN cases, 60% of deaths are due to suicide.
	People with BN attempt suicide more often than those with AN, but fewer die by suicide compared to AN.
Transgender Students with EDs	Among transgender college students with EDs, 75% reported suicidal thoughts, and 74% had attempted suicide, rates that are much higher than other groups.
Risk Factors for Suicide	People with depression, a history of trauma, or impulsive behavior are at even greater risk.
Comparison Between AN and BN	Suicide is more common in people with AN than BN, but BN is associated with more frequent attempts.

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2. Increased Risk of Death for People with Eating Disorders

Aspect	What the Research Says
Overall Death Rates (Crude Mortality Rate, CMR)	People with AN have about a 6% chance of dying over 10 years. Most die from health problems related to their eating disorder or suicide.
	For BN, death rates are lower, at around 0.3% to 1.4%, depending on the group studied.
	People with both AN and BN have very high death rates: around 20% over 12.5 years.
Risk Compared to the General Population (Standardized Mortality Ratio, SMR)	People with AN are 9.5 times more likely to die than the general population within 6-12 years of diagnosis.
	Even after 30 years, people with AN are 3.7 times more likely to die than those without the disorder.
	For BN, the risk of death is 7 times higher than average over 5-11 years.
Impact of Health Problems	Many deaths are linked to severe health issues caused by the eating disorder, such as heart problems or weakened immune systems.
Why These Death Rates Matter	These numbers show that eating disorders are not just psychological issues—they have serious physical effects and long-term risks, even for people who recover.

Diagnosis and Assessment

Diagnosing eating disorders isn’t just about checking symptoms on a list. It’s about understanding the whole person. Eating disorders like AN, BN, and BED are diagnosed using clear guidelines, but the process goes deeper.

Clinicians look at how long the symptoms have lasted, how severe they are, and how much they affect someone’s life and health. Tools like structured interviews and questionnaires help make the diagnosis more accurate and guide the next steps for a treatment plan.

It’s also crucial to identify any other mental health conditions that might be happening at the same time. Nearly half of people with eating disorders also deal with issues like anxiety, depression, or substance use. These can make recovery harder if they’re not addressed. Understanding these connections is key to creating the right treatment plan.

The Assessment Process: More Than a Checklist

The assessment starts by asking, “Where is this happening, and why?” For example, in a school setting, a nurse might use quick screening tools to identify students who need more help. In a mental health clinic, professionals might take more time to conduct detailed interviews to build a full picture of what’s going on.

Each situation calls for a different approach, but the goal is always the same: to get the clearest possible understanding of the person’s needs.

Screening tools are a good first step to spot red flags, but they can’t give the full picture. False positives are common, so people who show signs of a problem often need a deeper evaluation.

This could include more detailed interviews or ongoing assessments during treatment to track progress.

Treatment Approaches

Treating EDs and their co-occurring conditions requires a comprehensive approach of integrated care that combines nutritional help, psychotherapy, medication, and social support ^[12]. It can involve:

• Cognitive-behavioral therapy (CBT), which helps understand thought patterns, emotional responses, and past experiences.
• Dialectical behavior therapy (DBT), is particularly helpful for emotional regulation in those with personality disorders.
• Nutritional counseling, which plays a vital role in restoring healthy eating habits.
• Medications (like SSRIs), which can treat mental health conditions like anxiety or depression.
• Mindfulness-based approaches and techniques, such as learning intuitive eating habits, can support long-term success and recovery.

Prevention and Early Intervention

Eating disorder prevention starts with educating people about body positivity, the dangers of dieting, and healthy eating habits.

Schools and communities play a key role here, shaping how young people think about food and their bodies and reducing the risk for eating disorders.

Families also have a crucial role^[11]. Creating a positive environment around food, where meals are about nourishment and enjoyment rather than restriction, can help prevent disordered eating.

When EDs occur, the earlier they are detected, the better. It’s also best that parents and teachers take note of teenagers showing signs of low self-esteem and closely monitor their behaviors, possibly with extra screenings.

In general, the sooner an eating disorder is caught and treated, the better the outcome. This means quick action is equally important ^[13].

Support and Resources

Recovering from an eating disorder, especially when it is paired with other conditions, is challenging but not impossible. Yet, extensive support systems are critical.

The longer somebody is left alone to struggle with an ED, the more it tends to take hold and invade every area of their lives, including their thoughts and perceptions and their physical health. This means they need help from those around them.

Therapy, whether individual, group, or family-based, provides the emotional tools and coping strategies best suited for recovery.

Some organizations and websites have great directories to find specialists:

• National Eating Disorders Association (NEDA)
• The Academy for Eating Disorders (AED)
• The Eating Disorder Foundation

Peer support groups can help, but they should always be led by professionals to avoid situations where patients might accidentally make each other’s eating habits worse.

Final Words

The sooner an eating disorder is diagnosed, and the quicker it is treated, the fewer comorbidities a patient will likely develop, and better overall mental and physical health outcomes can be expected.

Even so, considering the vast number of comorbidities, both physical and mental, that fuel eating disorders and are caused by the eating disorders themselves, it is absolutely crucial that clinicians look at the whole picture before starting treatment.