Eating Disorders and Substance Use: When Two Struggles Overlap
Eating disorders and substance use problems often show up in the same person, tangled around the same pain. Understanding why they overlap, and why they should be treated together, can change the course of recovery.
- Co-occurrence is common. The National Eating Disorders Association notes that substance use problems occur at substantially elevated rates among people with eating disorders, and the reverse is true as well.
- They often share roots. Trauma, anxiety, depression, impulsivity, and difficulty tolerating painful emotions can drive both conditions.
- Symptoms can swap. When one condition is treated alone, the other often intensifies to fill the same emotional function.
- Integrated treatment is the standard. SAMHSA and eating disorder practice guidelines both support treating co-occurring conditions together rather than in sequence.
- Help exists right now. SAMHSA's National Helpline (1-800-662-4357) and the 988 Suicide & Crisis Lifeline are free and available around the clock.
How often eating disorders and substance use overlap
Clinicians who treat eating disorders learn quickly to ask about alcohol and other substances, and clinicians who treat addiction learn to ask about food. The overlap between these conditions is one of the most consistently observed patterns in mental health care. The National Eating Disorders Association notes that people with eating disorders misuse substances at rates well above the general population, and that people with substance use disorders show elevated rates of eating disorders in turn.
The pattern is not limited to one diagnosis. People with bulimia nervosa and binge eating disorder show particularly notable rates of substance use problems, likely because both conditions involve struggles with urges and emotional regulation. People with anorexia nervosa, especially those who binge and purge, are also affected. Substances involved range from alcohol and cannabis to stimulants, which are sometimes misused specifically to suppress appetite, as well as laxatives, diet products, and other compounds used in the service of the eating disorder itself.
The National Institute of Mental Health notes that eating disorders frequently co-occur with other mental health conditions, and substance use disorders sit high on that list. If you are living with both, you are not unusual, you are not uniquely broken, and you are exactly the kind of person integrated treatment was designed for.
Why these conditions travel together
There is no single explanation, but several well-supported threads help make sense of the overlap.
- Shared emotional function. Restricting, bingeing, purging, and substance use can all serve as ways to numb, escape, soothe, or feel a sense of control. When the underlying pain is untreated, the mind reaches for whatever works fastest.
- Trauma. Histories of abuse, neglect, and other traumatic experiences are elevated in both conditions. Our guide to eating disorders and trauma explains how trauma can shape a person's relationship with food, body, and self.
- Shared temperament and biology. Traits like impulsivity, sensitivity to reward, perfectionism, and high anxiety, along with genetic and family factors, appear to raise risk for both.
- Co-occurring mood and anxiety conditions. Depression, anxiety disorders, and obsessive-compulsive patterns commonly accompany both eating disorders and addiction, as we describe in eating disorders and anxiety, depression, and OCD.
- Direct functional links. Some substance use begins in direct service of the eating disorder, such as stimulants for appetite suppression or alcohol used to quiet food guilt.
Understanding these links matters because it reframes both conditions. They are not moral failures competing for blame. They are often two expressions of the same underlying distress.
The risks of treating them separately
Historically, people with both conditions were bounced between systems. Addiction programs declined clients with active eating disorders, eating disorder programs declined clients with active substance use, and the person in the middle got neither. Even when care was available, it often came in sequence: get sober first, then we will deal with the food, or the reverse.
Sequential treatment carries a well-known risk that clinicians call symptom substitution or symptom swapping. When one coping mechanism is removed and the underlying pain remains, the other coping mechanism frequently intensifies. Someone newly sober may find bingeing or restricting escalating sharply. Someone whose eating stabilizes may find themselves drinking more. This is not weakness or self-sabotage. It is the predictable result of removing a survival strategy without healing what made it feel necessary.
There are safety issues as well. Substance use can mask or worsen the medical complications of eating disorders, including electrolyte disturbances and cardiac strain, which we outline in our guide to the health effects of eating disorders. Withdrawal, malnutrition, and purging each stress the body on their own; together they compound. This is why thorough medical assessment, including labs and ongoing monitoring, belongs at the front door of treatment, and why the American Psychiatric Association's 2023 practice guideline stresses assessing for co-occurring substance use in every eating disorder evaluation.
What integrated treatment actually means
The Substance Abuse and Mental Health Services Administration, the federal agency focused on behavioral health, has long championed integrated treatment for co-occurring disorders: one team, one plan, both conditions addressed at the same time. In practice, integrated eating disorder care includes several elements.
- Comprehensive assessment. Screening for substance use in every eating disorder intake, and vice versa, along with psychiatric evaluation and medical labs to understand the whole picture.
- A unified formulation. Rather than treating two separate problems, the team maps how food behaviors and substance use interact, what functions they serve, and what they are protecting the person from feeling.
- Skills that serve both recoveries. DBT skills for distress tolerance, urge management, and emotion regulation apply directly to food urges and substance cravings alike. CBT addresses the thought patterns feeding both cycles.
- Trauma work at the right pace. Because trauma so often underlies both conditions, therapies such as EMDR and somatic approaches, delivered when a person is stable enough to benefit, address the root rather than only the symptoms. Our trauma-integrated treatment page describes this in depth.
- Medication management when appropriate. Psychiatric providers can address depression, anxiety, and cravings thoughtfully within the whole treatment plan.
Some people also need dedicated addiction services, such as detoxification or a substance-focused program, before or alongside eating disorder treatment. A good team helps you sequence care honestly rather than pretending one program fits every situation. Our overview of levels of care can help you understand the options.
How Empowered Treatment approaches co-occurring recovery
At Empowered Treatment, our intensive outpatient program in Austin treats adults whose eating disorders are entangled with other struggles, because in our experience, most eating disorders are entangled with something. Our care model, described fully on our what we offer page, combines group therapy, weekly individual therapy, nutrition counseling with a registered dietitian, supported meals, psychiatric evaluation, labs and medical monitoring, and medication management when appropriate.
For clients navigating substance use alongside an eating disorder, several parts of our program matter most. DBT groups build concrete skills for riding out urges of every kind. CBT targets the beliefs and rituals that keep both cycles turning. IFS-informed and somatic therapies help clients understand the protective roles these behaviors have played, and EMDR is available when trauma processing is clinically appropriate. We coordinate openly with addiction specialists, prescribers, and outside therapists so that no one has to manage the seams between systems alone, and our continued-care planning addresses both recoveries from the first week, not the last.
Honesty is the entry requirement, not sobriety perfection. We ask clients to be truthful about what they are using and why, so the plan can reflect reality. Shame thrives in secrecy, and both of these conditions run on shame.
Getting help now
If you recognize yourself in this guide, there are concrete places to start today.
- Call Empowered Treatment at (512) 882-4599 to talk through an assessment for eating disorder treatment that takes substance use seriously.
- Call SAMHSA's free, confidential National Helpline at 1-800-662-4357, available every hour of every day, for treatment referrals anywhere in the country, or visit samhsa.gov.
- Use our levels of care guide to think through the right level of support, and our insurance verification page to check coverage.
- If you are in crisis, thinking about suicide, or worried about an overdose, call or text 988 for the Suicide & Crisis Lifeline, or call 911 immediately.
Living with two conditions can feel like double the shame and half the hope. The evidence says otherwise. Both conditions respond to treatment, and treating them together, with one team that sees the whole of you, is not a luxury. It is the standard you deserve.
Frequently asked questions
Do I have to stop using substances before starting eating disorder treatment?
Not necessarily, though it depends on safety. Some situations, such as withdrawal risk, require medical or addiction-specific care first. Many people, however, can and should address both conditions at once in an integrated program. An honest assessment conversation, which you can start by calling (512) 882-4599, is the way to find out what sequence is safe for you.
Why did my eating disorder get worse when I got sober?
This pattern is common enough to have a name, symptom substitution. When a coping mechanism is removed and the underlying distress remains, another coping mechanism often intensifies. It is not a personal failure. It is a sign that the deeper drivers, often including trauma and difficulty tolerating emotions, need direct treatment. Our guide to eating disorders and trauma explains more.
Which eating disorders overlap most with substance use?
Research suggests the overlap is especially pronounced in conditions involving binge eating or purging, such as bulimia nervosa and binge eating disorder, though it occurs across all diagnoses. Shared struggles with urges, impulsivity, and emotion regulation likely explain part of this pattern.
Is misusing diet pills, laxatives, or stimulants to control weight a substance problem or an eating disorder?
It can be both, and the honest answer is that the distinction matters less than getting help for the whole pattern. These behaviors carry serious medical risks and are best addressed by a team that understands eating disorders, with psychiatric and medical support involved.
Where can I find help immediately?
SAMHSA's National Helpline, 1-800-662-4357, is free, confidential, and available around the clock for treatment referrals. For emotional crisis or thoughts of suicide, call or text 988 to reach the 988 Suicide & Crisis Lifeline. For medical emergencies, including suspected overdose, call 911. For eating disorder assessment in Austin, call Empowered Treatment at (512) 882-4599.
Related reading
Eating Disorders and Trauma
How traumatic experiences shape eating disorders and how integrated care heals both.
Read →Trauma-Integrated Treatment
Our approach to treating eating disorders and trauma together.
Read →Anxiety, Depression, and OCD
Understanding the mental health conditions that commonly co-occur with eating disorders.
Read →References
- Substance Abuse and Mental Health Services Administration. samhsa.gov
- Substance Abuse and Mental Health Services Administration. SAMHSA National Helpline. samhsa.gov/find-help/national-helpline
- National Eating Disorders Association. Eating Disorder Statistics. nationaleatingdisorders.org/statistics
- National Institute of Mental Health. Eating Disorders. nimh.nih.gov/health/topics/eating-disorders
- American Psychiatric Association. Practice Guideline for the Treatment of Patients with Eating Disorders, 2023. doi.org/10.1176/appi.books.9780890424865
- National Eating Disorders Association. What Are Eating Disorders? nationaleatingdisorders.org/what-are-eating-disorders
- MedlinePlus, U.S. National Library of Medicine. Eating Disorders. medlineplus.gov/eatingdisorders.html
- 988 Suicide & Crisis Lifeline. 988lifeline.org
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