Co-occurring Substance Use Disorders with Eating Disorders
By: Deanna McMichael
Published: September 11, 2023

Facts Behind Eating Disorders and Substance Abuse 

Co-occurring substance use disorders (SUDs) and eating disorders (EDs) can present significant challenges for individuals seeking treatment and recovery. Over their lifetime, about 29% of people with an ED will experience a co-occurring substance use disorder, with 7% experiencing symptoms from both psychological disorders simultaneously.   

Substance use disorder, is a chronic condition characterized by the continued use of licit or illicit substances, resulting in physical and psychological dependence with negative consequences, such as health problems, social problems, and difficulties with work or school. Eating disorders are serious mental health conditions that involve unhealthy eating behaviors and beliefs around food and body image. EDs also have serious negative consequences, many of which overlap with those of SUD. Both are serious mental illnesses and can be life-threating, so it is important to find a treatment facility where both disorders can be treated simultaneously. 

Common licit substances which are misused by those with EDs include: 

  • Alcohol 
  • Tobacco 
  • Caffeine
  • Laxatives 
  • Emetics 
  • Diuretics 

Examples of illicit substances that may be used by those with a co-occurring ED include: 

  • Amphetamines 
  • Heroin 
  • Cocaine 

Risk Factors and Causes of Eating Disorders and Addiction 

Eating disorders and substance use disorders share many common risk factors. This overlap is believed to contribute to their high rate of co-occurrence. Risk factors do not determine whether or not  a person develops an ED or SUD, but are contributing factors that may play a role in the development and/or maintenance of these disorders.   

Some common risk factors shared by both eating disorders and substance use disorders include:  

  • Brain chemistry (neurotransmitter availability and neuroreceptor functionality) 
  • Family history and genetic predisposition 
  • Low self-esteem 
  • Co-occurring depression, anxiety, personality disorders or other illnesses 
  • Social pressures  
  • Compulsive behavior 
  • Social isolation 
  • Risk of suicide and self-harm 

Signs of Co-occurring Eating Disorders and Addiction 

Signs and symptoms of substance use disorders and eating disorders can be difficult to identify, especially because there are so many different disorders that fall under these large umbrella terms. While each SUD and ED may have specific identifiers, they do have some signs and symptoms that are common to many disorders within the various diagnoses. If you or a loved one shows any signs or symptoms of an ED or SUD, please reach out and seek advice from a trained medical professional or a treatment team, such as Koru Spring 

Some signs that are common to many eating disorders include

  • Preoccupation with body shape and size, food, nutritional values, dieting, etc. 
  • Not wanting to eat when other people are around 
  • Restrictive eating and/or eating until uncomfortably full 
  • Bingeing and/or purging 
  • Distorted body image 
  • Social withdrawal and isolation 
  • Depression, anxiety, self-harm or suicidal thoughts 
  • Dry skin and brittle hair and nails 
  • Problems with sleep 
  • Mood swings 
  • Gastrointestinal pain or problems 
  • Continued eating behaviors or restrictions, despite negative consequences 

Substance use disorders are characterized by

  • Inability to control the use of the substance 
  • Social impairments (such as isolating themselves or poor work or school performance) 
  • Using substances in risky environments or situations 
  • Continued use of the substance despite negative consequences 
  • Tolerance and withdrawal 

Prevalence of Substance Use Disorders with Co-occurring Eating Disorders 

The relationship between addiction to substances and eating disorders is complex and may be bidirectional. People experiencing an eating disorder use alcohol or other illicit drugs at a rate that is about 5 times higher than that of the average population. About 50% of people with an ED misuse substances. About 35% of those with a substance use disorder also experience an ED (which is a rate that is about 11 times higher than that of the general population).   

One study found that those who were diagnosed with an eating disorder most often misused: 

  • Tobacco  
  • Caffeine  
  • Alcohol  

Researchers have noted that some behaviors associated with specific ED subtypes (such as binge eating) were also associated with different substance use behaviors or choices of substance used. For example, those who engage in binge eating, such as subtypes of bulimia nervosa (BN) and lifetime anorexia and bulimia (ANBN), were more likely to use both licit and illicit substances. Increased frequency of bingeing and purging behaviors were also associated with increased substance use. 

The NCS-R reports that, within the US, between 23% -36% of people diagnosed with anorexia, bulimia or binge eating disorder also have a substance use disorder. Current research tends to focus on co-occurring substance use disorders in individuals with anorexia nervosa, bulimia nervosa and binge eating disorder, leaving room for future research into other EDs and the misuse of specific substances. To understand the complex relationship between an eating and substance use disorder, it is important to remember that the person has developed these unhealthy behaviors as maladaptive coping mechanisms, not as a choice.  

Co-occurring Anorexia Nervosa and Substance Use Disorders 

Sometimes further categorized into anorexia nervosa restrictive type (AN-R) and anorexia nervosa bingeing/purging type (AN-BP), anorexia is most often characterized by: 

  • Low body mass 
  • Persistent restricted food intake 
  • Distorted body image 
  • An intense fear of gaining weight 

As such, substances associated with appetite suppression or increased metabolism might be taken with the initial intention of changing body weight or shape. Misuse of nicotine, prescription pills (such as Adderall), cocaine and methamphetamines can lead to physical dependence on these substances and the development of associated substance use disorders.  

Anorexia nervosa (AN) may be one of the most researched eating disorders. Based on a systemic research review, about 16% of those people with anorexia also have a substance use disorder, including: 

  • Alcohol use disorder (AUD) in 10% of those with anorexia 
  • Cannabis use disorder in 6% of those with anorexia 
  • Amphetamine use disorder in 5% of those with anorexia 
  • Cocaine and polysubstance use disorder in 3 % of those with anorexia 
  • Narcotic and sedative/hypnotic use disorder in 1% of those with anorexia 
  • Other substances made up for 4% of substances misused by those with AN 

The reinforcing effects of alcohol (or other drugs) can be enhanced by food restriction and can result in severe short- and long-term consequences, including the development and maintenance of eating disorders and substance use disorders. Risk factors of high rigidity and perfectionism are found for both AN and SUDs. 

Co-occurring Bulimia Nervosa and Substance Use Disorders 

Bulimia nervosa is characterized by episodic binge eating that is followed by behaviors that are believed to compensate for the high intake of food. These behaviors can include vomiting, using diuretics or laxatives and excessive exercise. While co-occurring bulimia and SUD has been less researched than a dual diagnosis of AN and SUD, bingeing/purging subtypes of eating disorders are the most likely to co-occur with a substance use disorder.  

Of those who have a dual diagnosis of an ED and a substance use disorder in the US: 

  • Alcohol use disorder (AUD) was found in 34% of those with bulimia 
  • Other substances where misused by 37% of the patients diagnosed with bulimia 
  • Illicit drugs (such as cocaine, tranquilizers, amphetamines, barbiturates and marijuana) were more often used by individuals with bulimia, with the highest reported use found in those with BN who engaged in bingeing and purging. 

Misused substances may be used to support or increase the effects of compensatory purging behaviors, such as laxatives, diuretics, restricting medications (such as injected insulin) and emetics. In those with co-occurring bulimia and substance use disorders, the misuse of substances and bingeing behaviors may both be linked to increased impulsivity and low self-directedness. 

Co-occurring Binge-Eating Disorder and Substance Use Disorders 

Binge-eating disorder is often linked to body size and shape dissatisfaction, leading to binge eating. This may lead to weight gain and feelings of shame or self-hatred. Binge-eating episodes are characterized by the person experiencing three (or more) of the following: 

  • Eating faster than usual 
  • Eating until they feel uncomfortably full 
  • Eating large amounts of food when they don’t feel hungry 
  • Eating alone to hide how much they are eating and associated feelings of shame 
  • Feeling ashamed, depressed or extremely guilty after a binge-eating episode  

Binge eating disorder is three times as common as anorexia and bulimia combined, making it the most common eating disorder in the US. Co-occurring substance use disorder (SUD) has been reported in 23%-68% of those people diagnosed with binge-eating disorder (BED). Both share common symptoms including the loss of control over food or substance intake and the continued use of both despite negative consequences. BED and addiction also share mechanisms which may contribute to the development of co-occurring BED and SUD, such as 

  • Reward dysfunction 
  • Cravings 
  • Emotion dysregulation 
  • Impulsivity 

Alcohol use disorder (AUD) seems to be the most common dual diagnosis found with binge-eating disorder, with a systematic review reporting that about 20% of those with BED also have a lifetime prevalence of AUD. This is 1.5 higher than in those people without a binge-eating disorder. Scientists believe that both binge-eating and alcohol misuse might trigger a reward-response in the brain, which may lead to the development of BED and AUD. They may also use this reward system as an unhealthy coping mechanism to numb or reduce negative emotions or feelings.  

Despite many similarities between addiction to substances and binge-eating, it is important to remember that they are not the same disorder and have key differences. Binge-eating is not simply “food-addiction” and must be treated as a separate disorder from SUD. 


The adverse effects of both eating disorders and substance use disorders can be severe, including malnutrition, electrolyte imbalances, heart-failure and death. Co-occurring disorders require specialized treatment that may include detoxification, medical management of either or both disorders and a holistic and integrated treatment plan. 

Co-occurring ED and SUD can increase the complexity of treatment, as both disorders may require different treatment approaches and strategies. Unique to SUDs and EDs, is that they can be interconnected both physiologically and psychologically. For example, the eating disorder behaviors of restrictive eating may increase the reinforcing effects of the substance. Treating both disorders simultaneously can improve the chances of successful and lasting recovery. 

Some important considerations in the treatment of a dual diagnosis of an ED and SUD include 

1. Addressing underlying issues: Both eating disorders and substance use disorders can be linked to underlying issues or risks, such as trauma, anxiety and depression. Treating these underlying issues may be necessary for long-term recovery. Treatment for SUD and other psychiatric disorders has been shown to be more successful when both disorders were treated simultaneously with an integrated approach. Inpatient centers that offer gender-responsive treatment and trauma-informed care, such as Koru Spring, create integrative treatment spaces where many of the common underlying issues for both ED and SUD can be explored in a safe and supportive space.    

2. Comprehensive treatment: Treating dual diagnosis requires a comprehensive treatment approach that addresses both the eating disorder and the substance use disorder. This may involve a combination of therapies, such as individual therapy, group therapy, and medication management. This may require going to multiple treatment centers or finding a residential treatment program that offers access to many medical professionals on a single campus, such as Koru Spring. 

3. A strong support system: Having a strong support system, including family, friends, and professionals, is important for individuals with co-occurring disorders. Support groups, such as Eating Disorders Anonymous and SMART Recovery, can also be helpful for individuals with ED or SUD. 

Overall, dual diagnosis can significantly impact the treatment of eating disorders and substance use disorders and often results in poorer prognosis and higher rates of dropping out of treatment. To combat this, it is important to seek help from professionals who have experience treating both. A comprehensive and integrated approach to treatment that addresses common underlying issues and accounts for both psychological and physiological treatment is crucial to a successful recovery journey. 

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