Issue 15 | Eating Disorders & Psychiatric Comorbidity

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NEDC e-Bulletin

Issue 15 | September 2013

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Editors Note: 


Welcome to the September edition of the NEDC e-Bulletin. This month we are exploring issues related to eating disorders and co-morbidity. We are also highlighted the latest news from the eating disorders and wider mental health sectors.

We hope you enjoy this month's edition and if you would like to suggest topics or events to be featured in future editions of the e-bulletin, please contact us at


1. Eating disorders & psychiatric comorbidity

2. Medical complications and comorbidity

3Australian eating disorders sector: latest news

4. Opportunities to get Involved


Eating Disorders & Psychiatric Comorbidity – A Common Conundrum

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Psychiatric comorbidity, or dual-diagnosis, is a common issue for those with an eating disorder. Clinical and community studies have reported that between 55% and 98% of individuals with anorexia nervosa and between 88% and 97% of individuals with bulimia nervosa meet the criteria for another psychiatric disorder (Hughes, et al., 2013).

The most common disorders to co-occur with an eating disorder are; mood, anxiety, substance use, and personality disorders. Studies suggest that different kinds of disorders may interact with eating disorders differently.

Some studies have found that early-onset anxiety disorders may represent a genetically-based pathway toward the development of an eating disorder. This has stemmed from the idea that excessive fear about certain events or situations may lead into excessive concerns about eating, shape and weight, and subsequently lead into the development of disordered eating behaviours (Pallister & Waller, 2008).

This is in contrast with research showing that obsessive-compulsive disorder, generalised anxiety disorder, post-traumatic stress disorder, and panic disorder typically occur simultaneously with or following the onset of the eating disorder (Kaye, Bulik, Thornton, Barbarich, & Masters 2004). These findings suggest that eating disorders may exacerbate anxiety symptoms. In particular, the effects of starvation and other weight-loss methods can contribute to obsessive-compulsive behaviours related to food, eating and body-checking.

The effects of starvation may also contribute to depressive symptoms or even the onset of a depressive disorder. Studies of the onset of eating disorders and depression suggest that eating disorders tend to precede the development of depression, and that depressed mood improves with weight restoration (Hughes, et al., 2013). Co-morbid depression may predict a longer course of illness or contribute to the development and intensity of eating disorder symptoms. It is also possible that depressed individuals are more likely to experience their eating disorder symptoms as distressing, or to more readily communicate their distress.

A trans-diagnostic approach to understanding comorbidity may offer a simplistic explanation for co-morbid diagnoses. This approach suggests that shared personality traits or underlying neuro-cognitive processes play a key role in the mediation and maintenance of eating disorder and co-morbid symptoms (Pollock & Forbush, 2013).

Regardless of the course of their development, when eating disorder symptoms do co-occur with other mental health disorders it affects a wide range of functions for each person.

Several studies have reported that individuals with eating disorders and co-morbid diagnoses are more likely to have a poorer prognosis; increased social and psychosocial impairment, decreased health-related quality of life, higher rates of mortality and a more chronic course of illness (Bodell, Brown, & Keel, 2012; Hughes, et al., 2013; Pollock & Forbush, 2013). This link to outcomes may be because the effects of comorbidity hamper recovery, or because the presence of additional mental health issues represents increased severity and complexity of illness.

Individuals with co-morbid diagnoses are more likely to seek treatment than those with a single diagnosis, and yet these patients are often excluded from outcome trials and treatment programs because of the complexity of their presenting problems. Those who seek help frequently only present with one diagnosis, which may leave these complicated cases at risk for medical problems associated with their diagnoses (Courbasson, Nishikawa, & Dixon, 2012). Integrated treatment for clients presenting with an eating disorder and co-morbid psychiatric condition may be a valuable approach.

Comorbidity may complicate the diagnostic picture and treatment process either directly, or as a function of the eating disorder severity. It may be beneficial for treatments to take into account specific areas of functioning being impaired. Determining the priority of symptoms to be treated may depend in part on the onset of the disorders.

Understanding the mechanisms that underlie the co-occurrence between these disorders is of importance, as it may contribute to a better understanding of the development and progression, and aid in the design of new treatments to target shared underlying mechanisms of dysfunction.

Despite empirical evidence for the high rates of comorbidity for those with an eating disorder, clinicians often find making treatment decisions for these individuals very difficult. There continues to be confusion about the best course of assessment and treatment in the presence of more than one diagnosis at one time.

There is a clear need for research investigating comorbidity in order to ensure further assessment and treatment of these disorders.


Bodell, L. P., Brown, T. A., & Keel, P. K. (2012). The Impact of Bulimic Syndromes, Mood and Anxiety Disorders and Their Comorbidity on Psychosocial Impairment: What Drives Impairment in Comorbidity? European Eating Disorders Review, 20(1), 74-79.

Courbasson, C., Nishikawa, Y., & Dixon, L. (2012). Outcome of Dialectical Behaviour Therapy for Concurrent Eating and Substance Use Disorders. Clinical Psychology & Psychotherapy, 19, 434-449.

Hughes, E. K., Goldschmidt, A. B., Labuschagne, Z., Loeb, K. L., Sawyer, S. M., & Grange, D. L. (2013). Eating Disorders with and without Comorbid Depression and Anxiety: Similarities and Differences in a Clinical Sample of Children and Adolescents. European Eating Disorders Review, 21(5), 386-394.

Kaye, W. H., Bulik, C., Thornton, L., Barbarich, N., & Masters, K. (2004). Comorbidity of anxiety disorders with anorexia and bulimia nervosa. The American Journal of Psychiatry, 161(12), 2215-2221.

Pallister, E., & Waller, G. (2008). Anxiety and eating disorders: understanding the overlap. Clinical Psychology Review, 28, 366-386.

Pollack, L. O., & Forbush, K. T. (2013). Why do eating disorders and obsessive–compulsive disorder co-occur? Eating Behaviors, 14(2), 211-215.

If you would like to read further on comorbidity and eating disorders you can search through our online Knowledge Hub.

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Medical Complications and Comorbidity

young girl contemplating mental illness

In addition to the psychiatric comorbidities recognised, eating disorders are frequently characterised be medical complications that can often be severe. Conditions that commonly occur alongside an eating disorder include; bone disease, cardiac complications, gastrointestinal distress, and organ failures associated with starvation and purging. A variety of endocrine changes have also been described, and there appears to be an association with eating disorders and poor control of diabetes.

Understanding how comorbid conditions are intertwined with an eating disorder and treating both the eating disorder and co-occurring illnesses are critical to lasting recovery. It also highlights the important role of both medical and psychiatric physicians in the treatment process.

Comprehensive eating disorders treatment should involve a collection of extensive information regarding past diagnoses and medications, as well as psychiatric and medical screenings upon admission. This information helps the treatment team craft an individualised treatment plan for each patient that recognises the eating disorder and other diagnoses.

However, when comorbidites are present, the initial objective of treatment is psychiatric and medical stabilisation, which must be achieved before patients can meaningful engage in the therapeutic recovery process.

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Australian Eating Disorders Sector: Latest News

Three Australian researchers have been recognised for their achievements at a recent international conference on eating disorders.

At the Eating Disorders Research Society Annual Meeting held in September in the US, researchers Karina Allen, Kristy Zwickert and NEDC steering committee member Tracey Wade all received awards for recent publications.
Professor Tracey Wade received “Best Article by a Senior Author Advancing the Field of Eating Disorders 2013” for the article “The role of perfectionism in body dissatisfaction.”

Kristy Zwickert received “Best Article by a Young Author Advancing the Field of Eating Disorders 2013” for the article “Stigmatizing attitudes towards individuals with anorexia nervosa: an investigation of attribution theory”.

Both of these awards were granted by the Journal of Eating Disorders in association with Ramsey Mental Health in order to support publications and the dissemination of research.

At the same event Australian researcher Karina Allen won the prestigious “Early Career Investigator Award” for the paper “Low maternal Vitamin D levels during pregnancy predict increased eating disorder risk in female offspring during adolescence”.

Congratulations to all three of these very worthy award recipients.


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Opportunities to get Involved

mental health week logo

Mental Health Week

In this month’s e-Bulletin we’ve explored issues of coomorbidity in those with or at risk of developing an eating disorder and it would be appropriate to take the opportunity to highlight the wider Australian mental health sector.

In 2013, Mental Health Week will run from Sunday 6th to Saturday 12th October. World Mental Health Day is marked every year on the same date: 10th of October.

World Mental Health Day is being organised in Australia through the Mental Health Council of Australia. The MHCA are doing quite a bit from a promotional perspective to raise awareness about this day and encourage Australians to take a moment to think about the millions of people with a mental illness.

To find out more watch this address from Frank Quinlan, CEO of the Mental Health Council.

Visit the Mental Health Council Website to find out what’s on and opportunities to get involved.

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See also

Issue 2 | Journal of Eating Disorders

NEDC e-Bulletin Issue Two | August 2012 Contents 1.

Read more

Issue 21 | NEDC Resources

NEDC e-Bulletin Issue 21 | April 2014 Introduction: Welcome to the April edition of the NEDC e-Bulletin.

Read more

Issue 51 | Neurobiology and Eating Disorders

NEDC e-Bulletin Editor’s Note: Welcome to the fifty first edition of the NEDC e-Bulletin, as we kick off what promises to be an exciting year with our continued focus on developing and maintaining a nationally consistent approach to the prevention, treatment and management of eating disorders in Australia.

Read more

Issue 81: Training and Innovation

Editor's Note New: Eating Disorder Core Skills: eLearning for Mental Health Professionals Q&A with Dr Annaleise Robertson Training Approvals – Interview with Dr Amanda Bolton and Dr Sarah Egan Butterfly In the Wings AEDRTC IngnitED Fund Upcoming Training and Events Editor’s noteOne of NEDC’s main objectives is to help build a skilled and competent national workforce that can provide safe and effective care and treatment for people experiencing an eating disorder, across diagnostic presentations and treatment settings.

Read more

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