The Relationship Between Eating Disorders & Mood Disorders: Symptoms & Treatment

By Jamie Manwaring, PhD

Mood disorders, such as depression and bipolar disorder, are often linked to eating disorders. Up to 54% of individuals with eating disorders have a co-occurring mood disorder. Negative emotions can drive unhealthy eating behaviors, like overeating or restriction. Both conditions can be treated through psychotherapies like cognitive behavioral therapy, dialectical behavioral therapy and interpersonal psychotherapy to address emotional triggers and improve overall mental health, leading to a more sustainable recovery.

The Link Between Mood Disorders & Eating Disorders

Known as dual diagnosis, most people with eating disorders have co-occurring mental health diagnoses. Research demonstrates that up to 95% of people diagnosed with an eating disorder also receive a diagnosis for at least one more psychiatric disorder.1 Up to 54% of patients with an eating disorder also have a mood disorder, the second most common co-occurring group of diagnoses.1

Some of the most common co-occurring mood disorders in those with eating disorders are major depressive disorder and bipolar disorder. "Eating disorders and mood disorders often coexist," Kamila Cass, PhD, CEDS, ACUTE clinical psychologist explains, "Depression and bipolar disorder can fuel restrictive or purging behaviors, while the physical and emotional consequences of disordered eating can worsen mood instability."

Major depressive disorder

Major depressive disorder, commonly referred to as clinical depression, is one of the most common co-occurring diagnoses with eating disorders, with 50-75% of those struggling with an eating disorder also experiencing symptoms of depression.2 Major depressive disorder consists of a depressed mood and/or loss of interest alongside other symptoms, like:

  • Loss in appetite or weight loss
  • Fatigue or loss of energy
  • Feeling of worthlessness or excessive or inappropriate guilt
  • Diminished ability to think or concentrate, or indecisiveness
  • Recurrent thoughts of death or suicidal ideation3

Major depression & eating disorders

Eating disorders and clinical depression have significant overlap in emotional presentation. Eating disorders and mood disorders similar traits, such as:4

  • Pessimism
  • Self-criticalness
  • Self-dislike
  • Worthlessness
  • Loss of pleasure
  • Indecisiveness

Those with binge eating disorder often experience low self-worth, shame, guilt and hopelessness — all of which are shared with depression.

Changes in appetite

Changes in appetite are common in mood disorders like major depression, which may contribute to the development of disordered eating behaviors.4

Many individuals with eating disorders use maladaptive coping mechanisms, like disordered eating behaviors, to regulate feelings of depression. They may restrict food, purge or binge in an attempt to feel better and/or alleviate feelings of loneliness, isolation, shame or guilt.

Order of onset

It can be difficult to determine whether major depressive disorder or an eating disorder develops first. Some may experience depression first and use disordered eating behaviors to cope, while others engage in eating disorder behaviors and experience subsequent depressive symptoms due to malnutrition.

Bipolar disorders

Two common bipolar disorders associated with eating disorders are:3

  • Bipolar I Disorder (BD-I), when a patient experiences at least one manic episode that requires hospitalization or marked impairment in social or occupational function, with or without being preceded or followed up by hypomanic or depressive episodes
  • Bipolar II Disorder (BD-II), when a patient experiences one hypomanic episode and at least one major depressive episode and no manic episodes

The link between bipolar disorders & eating disorders

Both BD-I and BD-II have notable comorbidity rates with eating disorders. Systematic reviews suggest that comorbidity varies across different eating disorder diagnoses:5

  • Binge eating disorder (BED) has the highest comorbidity rate with bipolar disorders at 12.5%.
  • Bulimia nervosa has a comorbidity rate of 7.4%.
  • Anorexia nervosa has a comorbidity rate of 3.8%.

Patients with bipolar disorder (BD) are much more likely than the general population to meet the criteria of an eating disorder.5,6 Some studies suggest that the comorbidity of BD and eating disorders are closely linked to bingeing and purging since it is more prevalent in binge-purge eating disorder types.7

Shared traits

BD, BED and bulimia nervosa all share impulsivity.8 During manic or hypomanic episodes, those who binge and/or purge can go into an impulsive state and struggle with self-control and have difficulty listening to their body’s hunger cues. Mania or hypomania may also cause the individual to become hyper-focused and fixated on certain activities, like exercise.

In a depressive episode, food might be used as a coping mechanism. Food can stimulate dopamine release in the brain, and during a depressive episode, individuals who binge and/or purge may continue to eat past the point of fullness to prolong this feeling.

For patients who restrict, manic, hypomanic and depressive states can all trigger a loss of appetite, which can disrupt their diet and turn into consistently disordered eating behaviors.

Impact on treatment

Patients with comorbid bipolar disorder have significantly poorer clinical outcomes, lower quality of life and higher rates of alcohol abuse, which may impact eating disorder treatment outcomes and rates of eating disorder relapse.9,10

Effective Therapies for Co-occurring Mood Disorders & Eating Disorders

Multiple therapies have been shown to help people with mood disorders and eating disorders recover, including cognitive behavioral therapy (CBT), dialectical behavioral therapy (DBT), and interpersonal psychotherapy (IPT).

Cognitive behavioral therapy

CBT is a form of psychotherapy that focuses on challenging and changing cognitive distortions and their associated behaviors to improve emotional regulation and develop effective coping mechanisms.

CBT helps build awareness of negative thought patterns that can be present in those with co-occurring eating disorders and mood disorders. CBT helps patients learn how to identify and challenges these thoughts so they can respond to irrational thoughts in a more effective way and foster more productive thought patterns.

Dialectical behavioral therapy

DBT can be used to address eating disorders and other conditions, like bipolar disorder. DBT is a form of psychotherapy that focuses on mindfulness, interpersonal relationships, distress tolerance and emotional regulation. It can be especially helpful for individuals who engage in self-harm behavior, have difficulties with emotion regulation, and have a difficult time in relationships.

Interpersonal psychotherapy

IPT addresses depression by focusing on the impact and improvement of interpersonal relationships. It addresses four main areas - grief, interpersonal role disputes, role transitions, and interpersonal deficits – by collaborating with the individual to identify the pertinent interpersonal problems and develop strategies to address them. IPT has also been adapted to work with eating disorders and found to be effective.11

Other therapies

Everyone’s journey to recovery is unique. Some patients benefit from certain therapies more than others. There are a variety of effective psychotherapies that can help with eating disorders and other co-occurring conditions.

Find Help for Dual Diagnosis

Living with both an eating disorder and a mood disorder can feel especially overwhelming, but you don’t have to navigate it alone. Integrated care that addresses both conditions at the same time is essential for lasting recovery. With the right support team and evidence-based treatment, recovery is possible.

References

  1. Hambleton, A., Pepin, G., Le, A., Maloney, D., Aouad, P., Barakat, S., Boakes, R. A., Brennan, L., Bryant, E., Byrne, S. M., Caldwell, B., Calvert, S., Carroll, B., Castle, D. J., Caterson, I. D., Chelius, B., Chiem, L., Clarke, S., Conti, J., . . . Maguire, S. (2022). Psychiatric and medical comorbidities of eating disorders: findings from a rapid review of the literature. Journal of Eating Disorders, 10(1). https://doi.org/10.1186/s40337-022-00654-2
  2. Harney, M. B., Fitzsimmons-Craft, E. E., Maldonado, C. R., & Bardone-Cone, A. M. (2013). Negative affective experiences in relation to stages of eating disorder recovery. Eating Behaviors, 15(1), 24–30. https://doi.org/10.1016/j.eatbeh.2013.10.016
  3. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
  4. Voderholzer, U., Hessler, J. B., Lustig, L., & Läge, D. (2019). Comparing severity and qualitative facets of depression between eating disorders and depressive disorders: Analysis of routine data. Journal of Affective Disorders, 257, 758–764. https://doi.org/10.1016/j.jad.2019.06.029
  5. Craba, A., Mazza, M., Marano, G., Rinaldi, L., Sani, G., & Janiri, L. (2021). Which comes first? New insights on comorbidity between eating disorders and bipolar disorders. Emerging Trends in Drugs Addictions and Health, 1, 100023. https://doi.org/10.1016/j.etdah.2021.100023
  6. McAulay, C., Mond, J., Outhred, T., Malhi, G. S., & Touyz, S. (2021). Eating disorder features in bipolar disorder: clinical implications. Journal of Mental Health, 32(1), 43–53. https://doi.org/10.1080/09638237.2021.1875401
  7. Thiebaut, S., Godart, N., Radon, L., Courtet, P., & Guillaume, S. (2018). Crossed prevalence results between subtypes of eating disorder and bipolar disorder: A systematic review of the literature. L Encéphale, 45(1), 60–73. https://doi.org/10.1016/j.encep.2018.06.001
  8. McElroy, S. L., Kotwal, R., Keck, P. E., & Akiskal, H. S. (2005). Comorbidity of bipolar and eating disorders: distinct or related disorders with shared dysregulations? Journal of Affective Disorders, 86(2–3), 107–127. https://doi.org/10.1016/j.jad.2004.11.008
  9. Thiebaut, S., Jaussent, I., Maimoun, L., Beziat, S., Seneque, M., Hamroun, D., Lefebvre, P., Godart, N., Renard, E., Courtet, P., & Guillaume, S. (2018). Impact of bipolar disorder on eating disorders severity in real-life settings. Journal of Affective Disorders, 246, 867–872. https://doi.org/10.1016/j.jad.2018.12.128
  10. Seixas, C., Miranda-Scippa, Â., Nery-Fernandes, F., Andrade-Nascimento, M., Quarantini, L. C., Kapczinski, F., & De Oliveira, I. R. (2012). Prevalence and clinical impact of eating disorders in bipolar patients. Revista Brasileira De Psiquiatria, 34(1), 66–70. https://doi.org/10.1016/s1516-4446(12)70012-0
  11. Zhang, K., Xie, Q., Fan, C., Hu, X., Lei, J., Kong, J., ... & Li, X. (2024). The effectiveness of interpersonal psychotherapy versus cognitive behavioural therapy for eating disorders: A systematic review and meta‐analysis. Clinical Psychology & Psychotherapy, 31(1), e2953

ACUTE Earns Prestigious Center of Excellence Designation from Anthem
In 2018, the ACUTE Center for Eating Disorders & Severe Malnutrition at Denver Health was honored by Anthem Health as a Center of Excellence for Medical Treatment of Severe and Extreme Eating Disorders. ACUTE is the first medical unit ever to achieve this designation in the field of eating disorders. It comes after a rigorous review process.

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