Eating Disorders and Alcoholism: 41% of People With ED Have an Addiction

Author: Susanne Reed, PhD

Alcoholism often co-occurs with other medical and psychological disorders, including eating disorders. While study methodologies make data somewhat inconsistent, many studies show a frequent co-occurrence between eating disorders and alcoholism or another substance use disorder. Studies show a comorbidity rate of 8-41% in individuals with bulimia nervosa and a comorbidity rate between 2-10% in individuals with anorexia nervosa.¹ Co-occurring conditions can increase the behaviors or symptoms associated with each other, worsen the immediate or long-term side effects, and change the indicated treatment plan.

In this article:

How Do Eating Disorders and Alcoholism Co-Occur?

Many people who use alcohol notice that they eat differently when planning to use alcohol (e.g., having a meal in order to decrease the intensity of alcohol’s effects), when using alcohol (e.g., eating snack foods provided in a bar environment in larger amounts than they would when sober), and after using alcohol (e.g., eating specific foods to address hangover symptoms).

For individuals with eating disorders, substance use has an event greater impact on their relationship with food, exercise, and body image—all of which can be encompassed within an eating disorder.

Individuals with an eating disorder experience co-occurring substance use disorders, including alcoholism, at a rate five times higher than the general population. Among people with alcohol and drug dependency, up to 35% have a diagnosable eating disorder—a rate 11 times higher than the general population.²

Research indicates that:^3,4

Some people use alcohol to cope with their eating disorder (e.g., using substances instead of eating disorder behaviors, using substances to cope with the effects of eating disorder behaviors, or using substances to distract from negative feelings related to the eating disorder)
Individuals with co-occurring eating disorders and alcoholism are more likely to exhibit impulsivity
Individuals with binge eating disorder are more likely to consume a larger amount of alcohol in one sitting and to do so more frequently than individuals with other eating dis orders
Binge drinking and eating are more likely to occur in situations that involve unpleasant emotions, social pressures, and physical discomfort or temptations
The intensity of alcohol use and negative consequences associated with drinking correlate with binging behaviors, which are present in several types of eating disorders
Individuals with bulimia nervosa are twice as likely to misuse alcohol as individuals with other eating disorders

What Are the Risk Factors for Co-Occurring Eating Disorders and Alcoholism?

Eating disorders are disturbances in eating and movement behaviors caused by distressing thoughts and emotions. Eating disorders can negatively affect physical, psychological, and social health.¹

Risk factors can be biological, psychological, and sociocultural. Eating disorders are linked to lower dopamine and serotonin neurotransmitters in the brain. Eating disorders can co-occur with mental health conditions—like major depressive disorder and anxiety disorders—in addition to substance use disorders.⁵

Risk factors for developing an eating disorder are the same, regardless of the specific diagnosis. Common risk factors include:⁵

Receiving messages from family, peers, or doctors that your body was unsatisfactory in some way, especially in regards to weight
Having a higher childhood and adolescent weight
Receiving a diagnosis of a mood disorder
Having a focus on perfectionism, especially if it was cultivated by your family or social circle in childhood
Experiencing impulsivity
Enduring significant trauma

While eating disorders are traditionally seen as a condition only girls, teenagers, and women have, people of any gender can develop eating disorders. Research shows that individuals who identify as transgender or nonbinary have the highest rate of past-year eating disorder behaviors—nearly 18%—compared to 1.8% in cisgender women and .2% in cisgender men (women and men who identify with the sex they were assigned at birth).⁶ Eating disorders are also more prevalent among individuals who identify as gay, lesbian, bisexual, or any other non-heterosexual sexuality than among heterosexual cisgender women or men.⁶

The most commonly diagnosed eating disorders—any of which can co-occur with alcoholism—include the following.

Anorexia Nervosa

Anorexia nervosa is a multi-layered disorder. Signs or symptoms of anorexia include:⁷

Intense fear of gaining weight
Distorted body image, which may lead to “body checking” behaviors that attempt to detect any change in the body
Repeated weighing
Food restrictions
Compensatory exercise, including exercise causing extreme fatigue, illness, or injury

The intense emotions relating to body image and potential weight gain can make it difficult for individuals with anorexia to participate in weight restoration and maintain a safe, healthy weight over time, even when they fully understand the health implications of their behaviors and of staying at a very low body weight.

Misuse of alcohol and anorexia may appear together as an individual uses a liquid—in this case alcohol—as a food replacement or uses the effects of alcohol to cope with negative emotions, especially if underlying trauma is present.

Bulimia Nervosa

Bulimia nervosa is characterized by a strong need to take in—or binge on—large amounts of food, often food that the individual otherwise restricts from their diet, such as processed foods or pastries. These binges can cause extreme guilt or shame afterward and create an urge to eliminate the food and calories consumed from the body. Binge eating may be followed by forced vomiting, using laxatives, excessive exercising, or fasting as purging behaviors.⁵

Signs and symptoms of bulimia nervosa include:⁵

Intense fear of gaining weight
Distorted body image, which may lead to “body checking” behaviors that attempt to detect any change in the body
Repeated weighing
Compensatory exercise, including exercise causing extreme fatigue, illness, or injury
Inflamed sore throat
Swollen glands in the neck area
Acid reflux disorder
Tooth damage or decay
Severe dehydration
Illness related to chronic purging, such as aspiration bronchitis

Alcohol use may co-occur with bulimia during binge cycles, during purging behaviors to induce vomiting, or as a coping tool to minimize feelings of shame or mask underlying causes of the eating disorder.

Binge Eating Disorder

Binge eating disorder involves periods of binge eating, which are clinically similar to the binges observed in individuals who have bulimia nervosa. However, individuals with binge eating disorder do not experience purging urges despite feeling similar guilt, shame, and disappointment following a binge.⁵

Binge eating disorder symptoms include:⁵

Eating excessively large amounts of food in a short period
Eating even though you are full or not hungry, or well past the point of fullness
Eating in secret to conceal how much you eat from other people
Feeling a lack of control over what or how much you eat during a binge
Binging at least once a week for a period of three months or longer
Experiencing binge eating disorder symptoms independently of restrictive (e.g., avoiding specific types of food) or compensatory (e.g., over-exercising) behaviors

Individuals with binge eating disorder are most likely to misuse alcohol during binge periods, but may also use alcohol as a coping mechanism to manage the negative emotions related to the eating disorder.

Other Specified Feeding or Eating Disorder (OSFED)

This category of eating disorders encompasses eating disorders that fall outside the diagnostic criteria of other eating disorders, but still constitute a clinical eating disorder.⁸

Examples include:⁸

Atypical anorexia nervosa
Low frequency or limited bulimia or binge eating disorders
Night eating syndrome
Purging disorder

Multiple physical, behavioral, and emotional symptoms can appear with OSFED. Any or all of the symptoms of eating disorders can be present, as well as the following:⁸

Hoarding or hiding food
Feeling intense fear of eating in public
Drinking excessive amounts of water or other fluids as a food replacement
Constantly using of mints or mouthwash
Fainting
Becoming sick often due to the impact that eating disorder behaviors have on your immune system

Disordered eating behaviors do not necessarily constitute a clinical diagnosis. Many people struggle with one or more disordered eating behaviors that do not rise to the clinical threshold of an OSFED or other eating disorder diagnosis. However, all disordered eating behaviors that co-occur with a substance use disorder can have an impact on your health.²

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What Are the Health Risks of Co-Occurring Eating Disorders and Alcoholism?

Eating disorders cause physical damage to the body, which can become life-threatening.⁹ A person with an eating disorder may develop:¹⁰

Thyroid disease
Hypoglycemia
Alopecia, or hair loss
Hepatitis
Respiratory failure
Cerebral atrophy
Mitral valve prolapse

Alcohol use disorder can affect any part of the body and your life. Side effects of misusing alcohol can include:¹¹

Slurred speech
Malnutrition
Sexual dysfunction
Hallucinations
Blackouts
Interpersonal problems
Professional problems
Financial difficulties

Alcohol and eating disorders can damage your health over time. The most common health problems associated with alcohol include:¹¹

Infectious diseases
Cancer
Diabetes
Neuropsychiatric
Diseases
Cardiovascular disease
Liver damage, which may lead to cirrhosis
Pancreas disease
Unintentional and intentional injury

The combination of alcohol and eating disorders makes health issues related to nutrition—such as complications of Vitamin B1 (thiamine) deficiency—more likely to develop.

How Are Co-Occurring Eating Disorders and Alcoholism Treated?

An integrative treatment plan for persons with both eating disorders and alcoholism can be critical for addressing both. During the evaluation process, the treatment plan is created, the initial assessment is given by a licensed mental health professional.¹²If alcoholism and eating disorders are not addressed together, it is common for substance use behaviors to be used as a replacement for eating disorder behaviors and vice versa.

The evaluation will examine biological, psychological, and physiological factors contributing to both disorders. Depending on your level of alcohol use, detox treatment may be needed to medically stabilize you and help you get a clear mind. Three aspects to treatment are present in every type of treatment setting:¹²

Pharmacotherapy
Behavioral therapy
Recovery support

Pharmacotherapy

Medications are available for both substance misuse and mental health disorders. Working with a psychiatrist or treatment facility doctor, you are assessed for which type of medication may be able to help you with your current behaviors and symptoms. Some individuals need medicine to ease withdrawal symptoms associated with alcohol use disorder, some need medication to rebalance the levels of neurotransmitters in the brain, and some may need both.¹²

Behavioral Therapy

One of the most common therapy modalities used in treating both eating disorders and addiction is cognitive-behavioral therapy (CBT).¹² CBT is a form of talk therapy that can take place in individual and group counseling. You learn to identify thoughts—cognitive—that lead to actions—behavioral—and learn to adjust your thought patterns to lead into actions that are realistic and not negatively focused. CBT can have many sub-therapies to help you deal with specific issues, like past traumas that may have contributed to your alcohol use disorder, eating disorder, or both.

Dialectical behavioral therapy (DBT) is another treatment often combined with CBT for the treatment of eating disorders to help you learn emotional regulation and how to process complex ideas through mindfulness.¹² Your therapist may combine other modalities, such as psychotherapy or somatic therapy—or body awareness therapy—as they find appropriate for your needs and treatment goals.

Recovery Support

While in treatment, you will be introduced to recovery support services like Alcoholics Anonymous (AA) and the 12 Step program. You can continue to attend these groups in the community setting once you are discharged from a higher level of care. Recovery support can include any mutual support program lead by both peers and treatment staff that provide a safe learning and sharing environment for anyone struggling with alcohol use and eating disorders. This includes both in-person and online recovery support programs.¹²

The treatment services you receive must be comprehensive and should include all of the following:¹³

Extensive screening and assessment
Access to a prescribing psychiatrist or physician
Medication monitoring
Psychoeducational classes
Dual recovery support groups
Relapse prevention skills classes
Early recovery skills classes
Family therapy
Aftercare planning

If you are struggling with an eating disorder, alcohol use disorder, or both, we can help you get the right treatment services. Give us a call 800-948-8417 Calls are forwarded to paid advertisers . Our treatment specialists want to share the opportunities available to help you overcome the obstacles you face.

Resources

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National Eating Disorders Association. Substance Abuse and Eating Disorders.
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Schmerling, R.H. (2018). Sorting Out the Health Effects of Alcohol. Harvard Health Publishing.
National Institute on Mental Health. (2021). Mental Health Information. Eating Disorders.
Griffiths, S. & Yager, Z. (2019). Gender, Embodiment, and Eating Disorders. Journal of Adolescent Health, 64(4), 425-426).
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O’Brien, K. M., Whelan, D. R., Sandler, D. P., Hall, J. E., & Weinberg, C. R. (2017). Predictors and long-term health outcomes of eating disorders. PloS One, 12(7),
Mehler, P. S., & Brown, C. (2015). Anorexia nervosa – medical complications. Journal of Eating Disorders, 3,
Arias, J. E., Hawke, J. M., Arias, A. J., & Kaminer, Y. (2009). Eating disorder symptoms and alcohol use among adolescents in substance abuse treatment. Substance Abuse: Research and Treatment, 3, 81–91.
Yule, A. M., & Kelly, J. F. (2019). Integrating treatment for co-occurring mental health conditions. Alcohol Research: Current Reviews, 40(1), arcr.v40.1.07.
Center for Substance Abuse Treatment. (2005). Substance Abuse Treatment for Persons With Co-Occurring Disorders. Rockville (M.D.): Substance Abuse and Mental Health Services Administration (U.S.); Treatment Improvement Protocol (TIP) Series, No. 42.