Almost everyone is unhappy with their weight, body shape or other aspect of their appearance at some point.  Individuals may take steps to eat healthier, try a new diet or start an exercise plan to improve their appearance.  However, some people may have eating and exercising habits that go way beyond normal.  They may fast or severely restrict their caloric intake, exercise for hours on end each day or take other actions to prevent weight gain.  They may have an intense fear of gaining weight or becoming fat, even though they are underweight.  These people may be suffering from an eating disorder — a category of medical conditions that commonly co-occur with anxiety disorders.

For people with anxiety disorders, having a co-occurring eating disorder may make their symptoms worse and recovery more difficult.  This makes it essential to be treated for both disorders.  Read on to learn more about the co-occurrence of anxiety and eating disorders.

What is an anxiety disorder?

Anxiety disorders are a unique group of illnesses that fill people's lives with persistent, excessive and unreasonable anxiety, worry and fear. They include generalized anxiety disorder (GAD), obsessive-compulsive disorder (OCD), panic disorder, posttraumatic stress disorder (PTSD), social anxiety disorder (SAD) and specific phobias. Although anxiety disorders are serious medical conditions, they are treatable. Click here to learn more.

What is an eating disorder?

According to the National Mental Health Information Center, an eating disorder is an emotional and physical problem that is associated with an obsession with food, body weight or body shape. Often, a person with an eating disorder diets, exercises and/or eats excessively.  These behaviors can have serious health consequences and can even be life threatening.  The three most common types of eating disorders are anorexia, bulimia and binge eating.  Symptoms of each include:

Anorexia Nervosa

• Refusal to maintain body weight at or above a minimally normal weight for age and height
• Intense fear of gaining weight or becoming fat, even though underweight
• Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight
• Infrequent or absent menstrual periods (more specifically, the absence of at least three consecutive menstrual cycles) in females who have reached puberty

People with this disorder see themselves as overweight even though they are dangerously thin.  The process of eating becomes an obsession.  Unusual eating habits develop, such as avoiding food and meals, picking out a few foods and eating these in small quantities, or carefully weighing and portioning food.  People with anorexia may repeatedly check their body weight, and many engage in other techniques to control their weight, such as intense and compulsive exercise, or purging by means of vomiting and abuse of laxatives, enemas and diuretics. Individuals with anorexia nervosa who regularly engage in binge-eating or purging behavior are considered to have the binge-eating/purging type of anorexia nervosa.

Bulimia Nervosa

• Recurrent episodes of binge eating, characterized by eating an excessive amount of food within a discrete period of time and by a sense of lack of control over eating during the episode
• Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting or misuse of laxatives, diuretics, enemas or other medications (purging), fasting or excessive exercise
• The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for three months
• Self-evaluation is unduly influenced by body shape and weight

Because purging or other compensatory behavior follows the binge-eating episodes, people with bulimia usually weigh within the normal range for their age and height.  However, like individuals with anorexia, they may fear gaining weight, desire to lose weight and feel intensely dissatisfied with their bodies.  People with bulimia often perform the behaviors in secrecy, feeling disgusted and ashamed when they binge, yet relieved once they purge.

Binge Eating Disorder

• Recurrent episodes of binge eating, characterized by eating an excessive amount of food within a discrete period of time and by a sense of lack of control over eating during the episode
• The binge-eating episodes are associated with at least three of the following: eating much more rapidly than normal; eating until feeling uncomfortably full; eating large amounts of food when not feeling physically hungry; eating alone because of being embarrassed by how much one is eating; feeling disgusted with oneself, depressed, or very guilty after overeating
• Marked distress about the binge-eating behavior
• The binge eating occurs, on average, at least two days a week for six months
• The binge eating is not associated with the regular use of inappropriate compensatory behaviors (e.g., purging, fasting, excessive exercise)

People with binge-eating disorder experience frequent episodes of out-of-control eating, with the same kinds of binge-eating symptoms as those with bulimia.  The main difference is that individuals with binge-eating disorder do not purge their bodies of excess calories.  Therefore, many with the disorder are overweight for their age and height.  Feelings of self-disgust and shame associated with this illness can lead to bingeing again, creating a cycle of binge eating.

For more information about these eating disorders, click here.

What differences are there between men and women who have eating disorders?

First it is important to note that while eating disorders are more common in women, men also can suffer from these disorders.  It is estimated that about 10 percent of people who suffer from anorexia or bulimia are men, but the proportion of men with an eating disorder may be even higher, especially among people with binge-eating disorder.  While most of the underlying psychological factors that lead to an eating disorder are the same for men and women, men with eating disorders can have some added difficulties.  They may be less likely to report their symptoms because they think eating disorders are a “woman’s disease” — some may think it reflects negatively on their masculinity or are worried about people questioning their sexual orientation.  Additionally, men may be less likely to seek help because they don’t feel comfortable being the only man (or one of the few) participating in a support group and treatment program for eating disorders, which is often the case.  However, it is just as important for men to seek treatment as women, and men are generally thought to respond to the same types of treatment for eating disorders as women.  For more about men and eating disorders, click here.

How often do anxiety and eating disorders occur together, and which occurs first?

A major study conducted by University of Pittsburgh researchers in 2004 found two-thirds of people with eating disorders suffer from an anxiety disorder at some point in their lives.  It also found that a significant number of these people — 42 percent — developed an anxiety disorder during childhood, well before the onset of their eating disorder.  Other studies have also found that anxiety disorders usually precede development of an eating disorder.  Some researchers, including those from 2004 study, noted that early diagnosis and treatment of an anxiety disorder may provide some preventative effect against eating disorders, although this is an area that requires further study. 

Are there specific anxiety disorders that are more often associated with eating disorders?

Although people with eating disorders can suffer from any of the anxiety disorders and vice versa, specific ones are associated with the co-occurrence of eating disorders.  These include:

Obsessive-Compulsive Disorder (OCD). OCD is one of the most common anxiety disorders to co-occur with eating disorders. In fact, the disorders share many of the same features. Women with anorexia may suffer from obsessions with exercise, dieting and food. They often develop compulsive rituals such as weighing every bit of food, cutting food into tiny pieces, repeated checking of weight or mirror checking. There are also similar characteristics between bulimia and OCD.  Like the compulsions in OCD, binges are difficult to resist and hard to control.  While binges provide some immediate relief to the sufferer, like the compulsions characteristic of OCD, this relief is short-lived and temporary.  While similar, eating disorders and OCD also have differences, such as a wider variety of symptoms in OCD and different treatment considerations.

Posttraumatic Stress Disorder (PTSD). In the National Women’s Study of over 3,000 women in the community who were questioned about their history of aggravated and sexual assault, PTSD, bulimia and binge eating disorder, higher rates of sexual and aggravated assault were found in women with bulimia compared to women without bulimia.  The study also found that women with bulimia had higher rates of PTSD compared to those without bulimia.  The odds of developing bulimia are greater for women with PTSD, even if the trauma resulting in the PTSD was not assault. 

Social Anxiety Disorder (SAD). SAD, along with OCD, has been found to be among the most common anxiety disorder to co-exist with eating disorders in many studies.

Panic Disorder.  Panic disorder, unlike many of the other anxiety disorders, has been found in many studies to follow the onset of an eating disorder.

Why do these disorders occur together so frequently?

More research is needed to determine why this is the case.  Many scientists believe a childhood anxiety disorder may contribute to increased vulnerability to a later eating disorder, or that eating disorders and anxiety disorders share common biological/genetic and/or environmental causes.  In both OCD and eating disorders, for instance, levels of the neurotransmitter serotonin (which plays a role in regulating mood, sleep, appetite and other important body functions) are abnormal.  These and other possible factors are areas that are being explored further.

What complications can arise from having both disorders?

People with both disorders may suffer more severe anxiety symptoms and have a more difficult recovery than those with an anxiety disorder alone.  Moreover, having an eating disorder can have serious physical consequences and risks that are not normally present with an anxiety disorder alone, some of which may be life threatening.  Because of the potentially dangerous effects of an eating disorder, it is crucial for people with both disorders to pursue treatment.

Can these disorders be treated together?

Yes.  The same types of therapies used to treat anxiety disorders may be used to treat eating disorders, and the disorders can often be treated at the same time (by one professional or as part of a treatment team).  Recovery from one disorder does not ensure recovery from the other disorder, which is why it is necessary to seek help for both.  Treatment options for both include:

• Psychological treatment (psychotherapy). Cognitive-behavioral therapy (CBT) is a type of therapy in which individuals learn to identify, challenge and gain control over unwanted behaviors and develop more accurate and helpful beliefs.  These therapies have been demonstrated to be effective in both anxiety and eating disorders.  Interpersonal therapy is another type of psychotherapy that may be effective for eating disorders.  Psychological treatments are sometimes provided in an individual format and sometimes in a group.  Family therapy is a type of treatment that uses strategies to reduce the level of distress within the family that may either contribute to or result from the ill person’s symptoms.  It also provides psychoeducation to family members about an illness.

• Medication — Antidepressants such as SSRIs may be used to treat both anxiety disorders and eating disorders.  Other medications may also be helpful for certain disorders.  The choice of medication should be discussed carefully between doctor and patient and will always depend on individual circumstances.

• Self-help/other treatment groups — Individuals with similar needs or experiences meet, and meetings are facilitated by a consumer, layperson or survivor.  Self-help groups for anxiety disorders can be found on ADAA's website here. It is suggested that self-help groups be used in addition to one of the treatments above.

Treatment for eating disorders also includes nutritional management and nutritional counseling.  Sometimes, people experiencing severe symptoms of an eating disorder may require hospitalization to help restore them to a safe and healthy weight. 

For more information about treatment options, click here.

References and Resources

Comorbidity of Anxiety Disorders with Anorexia and Bulimia Nervosa

The Harris Center at Massachusetts General Hospital

National Association of Anorexia Nervosa and Associated Disorders

National Eating Disorders Association

National Institute of Mental Health

Office on Women’s Health (Department of Health and Human Services)

Science Daily — University of Pittsburgh Research Points to Anxiety as a Key Risk Trait for Eating Disorders

Scripps Howard News Service — Anxiety can Balloon to Eating Woes Later

[ Click here for archives ]