Other / Co-morbid Conditions

Depression is a common emotional disorder that is experienced by a large number of eating disorder sufferers, though not all. Individuals with depression may feel ‘numb’ of emotions, or may feel distressed and tearful a lot of the time. It is normal for people to feel ‘down’ or ‘flat’ from time to time, but when those feelings last for more than two or three weeks and interfere with work, relationships, school or social activities, it is more likely that you are suffering from depression. Depression can often go hand in hand with anxiety and usually results in social isolation or withdrawal from previously enjoyed activities. There will also usually be a number of physical symptoms such as constant tiredness, lack of appetite and sex drive, over or under eating, broken sleep and aches and pains. Emotional symptoms can range from incessant low spirits to thoughts of suicide. Some eating disorder sufferers experience depression prior to an eating disorder starting, and the eating disorder is used as a way of coping with depression, others will develop depression following the onset of an eating disorder as a direct result of the eating disorder symptoms. In the latter case, the depression usually resolves with effective eating disorder treatment. In the former, the depression will need to be treated alongside or following eating disorder treatment. 

In general, self esteem is used to describe a person’s overall sense of his or her worth or value.  Low self esteem exists when a person holds persistent negative beliefs about themselves, their appearance, their abilities or their emotions. They will see themselves as ‘not good enough’ or ‘defective’ in some way. Low self worth may be associated with body or appearance dissatisfaction since people with low self esteem will often focus on a specific aspect of themselves such as their physical appearance, despite feeling negatively about themselves generally .  Often this can be kept hidden from other people meaning that, to the observer, individuals may seem successful, confident or high achieving. However, underneath this exterior is a core belief that the ‘real you’ is no good, and that every day you risk people finding out that their view of you is not real. Low self esteem is a problem for a large number of people with eating disorders. Eating disorder symptoms often start either as a way of numbing negative feelings, or as a way of improving a person’s sense of self, for example through achieving a desired weight goal or by giving the person an increased sense of control over themselves. Low self esteem is highly distressing to the individual and is not usually resolved by itself.  

 Anxiety is a normal emotion that we all experience at times. When anxiety becomes severe or persistent this feeling can take over and can begin to interfere with everyday life, often leading to avoidance of certain situations or experiences. Symptoms of anxiety can include shortness of breath, dizziness, heart palpitations, ruminations or persistent unwanted thoughts about the past, present or future. There are a number of recognised anxiety disorders including social anxiety, generalised anxiety disorder (GAD), obsessive compulsive disorder (OCD), post traumatic stress disorder (PTSD), panic disorder and phobias. Many of these will coexist alongside an eating disorder, and of course eating disorders themselves are associated with extremely high levels of anxiety about food, weight and shape. When a specific anxiety disorder is diagnosed alongside an eating disorder it will usually need to be treated separately from the eating disorder, either simultaneously or following resolution of the eating disorder symptoms.

OCD has two characteristic elements: obsessions (undesirable, recurrent, intrusive, distressing thoughts and worries) and compulsions (repetitive or ritualized physical or mental behaviors used to combat or ‘neutralise’ the obsessions).

Almost everyone (94% of the population) will experience both obsessive thoughts and compulsions from time to time. However those with OCD will find that these thoughts and compulsions take up a lot of time (over 1 hour per day), interfere with daily life or relationships, and cause a significant amount of stress, anxiety or distress. OCD usually starts in childhood or teenage years.  At its most severe, a person with OCD might spend all day performing ‘compulsions’, preventing them from leaving the house, holding down a job or maintaining relationships.  OCD tends to get worse with time so it is always worth seeking help as early as possible and as soon as the OCD starts to become a problem.

Whilst OCD and eating disorders are different disorders, they can be closely related and often coexist. OCD can precipitate, or even cause, an eating disorder; OCD can be a direct result of low weight and starvation; or an eating disorder may start as a way of ‘distracting from’ or ‘numbing’ the distressing obsessional thoughts.  In the latter case, OCD symptoms may deteriorate as eating disorder symptoms improve, and the OCD will need to be treated independently of the eating disorder.

Perfectionism refers to the setting of excessively high standards. These can either be standards that we set for ourselves, or the standards that we expect others to have of us. Whilst having high standards for ourselves can be healthy, and often helpful, clinical perfectionism is problematic. Clinical perfectionism is accompanied by an overly critical view of the self and a fear of not meeting self imposed standards. Sufferers of clinical perfectionism often describe experiencing intense feelings of failure or worthlessness if they fail to meet their self imposed standards; they find it extremely difficult to feel good about their achievements; and they frequently find that the time and energy taken to ensure these standards are met is detrimental to their emotions, social life and relationships. Clinical perfectionism is known to be a risk factor for anorexia, and other disorders.

Traumatic or distressing events, when not properly processed, can result in memories becoming ‘stuck’ in a part of the brain that keeps these memories feeling very vivid and intense.  In post traumatic stress disorder (PTSD) memories can be re-experienced as if they are happening in the present rather than the past, with associated images, smells, sounds and emotions all being as vivid as they were then.  The associated level of distress of unprocessed memories can be very high, many years after the original traumatic event. Trauma is well known to be a trigger to an eating disorder developing, with the symptoms of an eating disorder often initially used as a way of numbing or avoiding the traumatic memories and their associated emotions.

 Autism spectrum disorder is not a mental health condition, however it is known to commonly exist alongside eating disorders, in particular anorexia. Autism can also result in feeding difficulties in childhood, that can last into adulthood. Autism spectrum disorder (ASD) is a lifelong developmental disorder. It is characterised by difficulties with social interaction and communication. People with autism are likely to find it difficult to understand other people's emotions and feelings, and can often struggle to make eye contact. They are likely to prefer a rigid routine, and may also be over or under-sensitive to sounds, touch, tastes, smells, light or colours. Autism is not an ‘illness’ and cannot be ‘cured’. However there are many interventions that can be helpful for people with autism to enable learning and development. When autism coexists with eating disorders, treatment will need to be adapted in specialist ways in order to ensure it is likely to be effective.

Borderline personality disorder (BPD) is a type of ‘personality disorder’. It is sometimes called Emotionally Unstable Personality Disorder (EUPD). People with BPD struggle to cope with extremely intense emotions, and this can affect their relationships with other people. Around 1 in 100 people have BPD.

The term “personality disorder” can be seen as negative or labelling. However, it does not mean that there is a problem with your personality – instead it is meant to indicate the way in which the difficulties develop (deeply ingrained patterns of behaviour typically apparent by adolescence/early adulthood).

Although not common, BPD has been shown to be more prevalent in those with eating disorders than those in the general population. It is unclear why, but may be due to underlying factors such as traumatic life experiences contributing to both; to the impulsivity seen in BPD making people more vulnerable to bingeing; or due to the stressors stemming from the eating disordered behaviours triggering BPD in those vulnerable to it.