Many behavioral health providers are surprised to learn of the high rates of comorbidity between eating disorders, mental health conditions, and substance use disorders.
In fact, a 2022 review of the Psychiatric and Medical Comorbidities of Eating Disorders, found that in people diagnosed with an Eating Disorder (ED):
- Approximately 60% also had an anxiety disorder
- Up to 50% experienced a mood disorder; and
- 27% had comorbid substance use and post-traumatic stress disorders
The review describes a reciprocal relationship between eating disorders and mental health conditions, stating, “Comorbidities may precede the onset of ED, be co-occurring, or result from symptoms and behaviors associated with the ED.”
Clearly, disordered eating is something all behavioral health clinicians need to maintain an awareness of. And the National Eating Disorders Awareness Week (February 27-March 5, 2023) provides a timely opportunity to refresh your knowledge about this important issue.
Adopting a dual diagnosis lens around eating disorders and general mental health conditions is a priority for two reasons.
Firstly, like the relationship between substance misuse and mental health, the presence of either an eating disorder or mental health condition increases the risk that a person will experience other behavioral health challenges. Therefore, it’s important to screen people with an eating disorder for other mental health concerns, and vice versa.
Secondly, treatment outcomes for one condition influence the other. If a client is experiencing an eating disorder and a substance use disorder, (e.g., anorexia nervosa and stimulant dependence) the management and outcomes of each condition will impact the other.
By utilizing a dual diagnosis, or integrated approach, behavioral health providers can promptly recognize and respond to comorbid mental health issues, substance use disorders, and eating disorders—improving outcomes for their clients.
A common challenge with the integrated approach is clinicians being unsure of what screening questions to ask, and lacking confidence in conducting an initial assessment to refer on for specialist input. To make this easier for your staff, TheraNest provides the ability to create DSM-5-compatible custom assessment forms, session note templates, and referral documents, with full Wiley Practice Planner integration.
Research suggests that the underlying causes of eating disorders are a mix of biological, psychological, and social factors. As such, the relationship between disordered eating habits and mental health is unique for each person. Therefore, an individualized response is required for each client.
It’s also important to note that the abnormal eating habits clinicians might notice in clients won’t always be severe enough to warrant a diagnostic assessment or specialist referral—but that doesn’t mean they should be ignored.
Nutritional psychiatry provides good evidence that diet and mental well-being are related. So addressing potentially unhealthy eating habits can be an important part of mental health and substance use recovery.
To give you an idea of what to look out for in clients, here are some common ways that disordered eating habits and mental health coincide:
Alterations in appetite are a hallmark symptom of depression. Some people experience an increase in appetite and weight gain, potentially causing emotional distress and lower self-esteem. While for others, a decrease in appetite can result in excessive calorie restriction and malnutrition, which can negatively impact mood and be physically dangerous.
Approximately 65% of people with eating disorders meet the criteria for an anxiety disorder. And in most cases, anxiety was present before disordered eating emerged. Some risk factors to be aware of in clients with anxiety are being overly concerned or preoccupied with physical appearance, binging or restricting food as a coping mechanism, and loss of appetite during flare-ups of anxiety.
As a behavioral health clinician, helping clients navigate stressful situations in life is an essential part of the job. In most cases, the focus will be on assisting people to identify solutions to their problems and being a compassionate course of support. But when stress is prolonged, some clients may experience digestive issues, stomach pain, and disruptions in appetite. Stress can also be a triggering event for the relapse of a pre-existing eating disorder.
Childhood abuse and bullying/teasing about physical appearance increase the risk a person will experience an eating disorder. Clinicians working with teens may want to periodically ask about any bullying at school or teasing within the home. And for those providing trauma therapy to adults, it’s important to be mindful of possible connections between disordered eating and childhood abuse or trauma.
Although there is no consistent connection between psychotic illnesses and eating disorders, practitioners often report the co-occurrence of these two issues. The key here is to recognize that the two issues may present together, and provide holistic person-centered treatment. Addressing one issue without attending to the other is likely to result in suboptimal outcomes.
Finally, personality factors can be a factor in disordered eating. Traits like perfectionism, impulsivity, low distress tolerance, reward dependence, and obsessive compulsiveness are associated with eating disorders. Insight-oriented therapy into these factors can help patients recognize and avoid unhealthy patterns of eating.
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Now that we know what to look out for with disordered eating and mental health, let’s explore some strategies for helping clients to build healthy relationships with food.
In many cases, clients may not even be aware of potentially unhealthy or disordered eating patterns—let alone how these might relate to a pre-existing mental health or substance use disorder. When disordered eating is identified, both the client and clinician can start collaboratively addressing the problem. Sometimes just increasing a client’s awareness of disordered eating can be a powerful intervention in itself.
Early intervention leads to improved outcomes in all behavioral health conditions. So to help your clients and clinicians identify disordered eating early on, use practice management software, like TheraNest, that allows you to incorporate custom screening questions for disordered eating into session notes and assessment forms.
- Integrated Care
As with mental health and substance use recovery treatment, a dual diagnosis, or integrated approach to the management of disordered eating is the benchmark for high-quality behavioral health care. It’s important to refer on for specialist input or consultation when required, but behavioral health clients shouldn’t feel an eating disorder precludes them from mainstream treatment providers or vice versa.
The reality is, successful recovery from comorbid eating disorders, mental health conditions, and substance use disorder requires a person-centered, holistic, integrated approach. Treatment providers need to either offer integrated care within their organization, or partner with another provider to deliver shared care.
Education is a very powerful strategy clinicians can use to help clients build healthy relationships with food. By educating your clients, you can help them gain insight into the unhelpful patterns of thinking and behavior that might be driving their disordered patterns eating.
If you need to upskill in this area, the National Center of Excellence for Eating Disorders has a vast amount of free online training for healthcare providers.
A combination of provider-led and self-directed education is likely to achieve the best results. This blog post is an example of some of the educational resources you can direct your clients to, from reputable websites like the National Eating Disorders Association or the Office on Women’s Health.
With the right practice management software, any behavioral health practice can improve its ability to deliver high-quality care to clients with disordered eating. An intuitive, flexible, all-in-one solution like TheraNest Professional can improve outcomes for patients by streamlining early detection and intervention while reducing administrative burden and cognitive load on clinicians. To see how TheraNest can help your practice—get a free 21-day trial today.