Anxiety, in particular, can be complexly intertwined with BN, with either condition potentially leading to the development or maintenance of the other. Studies have shown that as many as 65% of people with eating disorders also have an anxiety disorder.1
Still, some treatments have been developed to help people struggling with concurrent mental health conditions, including those who simultaneously struggle with bulimia nervosa and anxiety.
How Does Anxiety Impact Bulimia Nervosa?
The development of any comorbid—or co-occurring—mental health diagnosis represents a complex chain of causes and effects, though patterns do sometimes emerge in these cases. For example, someone can show signs of BN before developing an anxiety disorder, but more often than not, the anxiety comes first.
70% say their anxiety disorder came before their eating disorder.
One survey found that nearly 70% of respondents said their anxiety disorder was diagnosed before their eating disorder.1 In fact, anxiety is often thought of as a potential risk factor for developing any type of eating disorder.2
Why Does Anxiety Come First?
There are any number of reasons why people may experience an anxiety disorder before developing eating disorder behaviors. But one of the biggest may be the fact that, for many people, bulimia nervosa develops as a maladaptive coping mechanism.
Sometimes, exerting control over what, when, and how much someone eats helps them feel they have more control over their lives. This is often the case when it comes to extreme dieting behavior or the limited food intake of anorexia nervosa.
With bulimia nervosa, behavior like binge eating may manifest as a way to deal with stress and anxiety that are otherwise not being addressed. Purging can then develop as a way to cope with the stress or perceived guilt or shame of binge eating. Eventually, these responses develop into a vicious cycle, trapping someone in this destructive pattern.
Eating also activates the parasympathetic nervous system. While this mechanism is at work, the body directs much of its active energy toward digestion and nutrient absorption, leaving other functions in “energy conservation” mode. The result often feels like a sense of relaxation, which many people may rely on, subconsciously or not, to alleviate feelings of stress.
Types of Anxiety Disorders
There are many different types of anxiety disorder, all of which have their own dynamic with and relationship to bulimia nervosa.
Some of the most common anxiety disorders include:
- Generalized anxiety disorder (GAD): This involves persistent feelings of fear, dread, or worry to the point that they interfere with daily life. Usually, anxiety related to GAD is more generalized rather than triggered by or directed at certain situations or things.
- Social anxiety disorder: Also known as SAD, this disorder involves persistent and intense fear of social situations, primarily driven by a fear of being watched or judged by others. It can often result in self-imposed isolation.
- Panic disorder: Symptoms include recurring, frequent, and/or unexpected panic attacks. Specific situations or things usually trigger these, but they can also happen in a broader sense.
- Phobia-related disorders: This involves aversion to or intense fear of specific situations or objects, which is disproportionate to their actual potential for danger.
- Post-traumatic stress disorder (PTSD): This disorder is signified by recurring and intrusive thoughts after witnessing or being involved in a traumatic event or experience.
- Obsessive-compulsive disorder (OCD): Symptoms include uncontrollable obsessions (recurring thoughts) and compulsions (behaviors) that are repeated over and over. When someone is not able to respond to their obsessions by performing compulsions, it can be a deep source of anxiety.
Bulimia and Anxiety as Comorbid Disorders
Bulimia nervosa can co-occur with any type of anxiety disorder. Again, the condition often develops as a maladaptive coping mechanism for the deeply unpleasant feelings involved in anxiety disorders and other mental health concerns.
Overall, however, OCD is one of the most common anxiety disorders to co-occur with any type of eating disorder.3 This may be due to the mechanisms involved in OCD, e.g., the “obsessions” and “compulsions” that drive the disorder.
In a society fixated on “achieving the perfect body,” it can be easy for someone to substitute food or body image as an obsession and develop compulsive rituals connected to these thoughts, such as purging after binging in order to prevent weight gain.
Women who struggle with PTSD are also at a particularly high risk of developing BN.4 Sadly, a history of trauma is a very common experience for people with all types of eating disorders, and the comorbidity with bulimia nervosa is particularly strong.
Treating Anxiety and Bulimia Nervosa Together
Typically, when someone experiences co-occurring mental health disorders, the conditions are best treated simultaneously. With how deeply interconnected most of these conditions are, not addressing both can make long-term recovery particularly difficult.
The type of comprehensive care needed to treat bulimia and anxiety often includes courses of therapy—both individual and in a group, nutritional counseling, meal support, medical treatment, and medication when needed. Still, some therapeutic approaches lend themselves better than others to treating BN and anxiety at once.
Cognitive behavioral therapy (CBT) operates on the philosophy that unhelpful behaviors stem from unhelpful thoughts. It aims to change those undesirable behaviors by helping someone understand and, eventually, change their negative thought patterns.
Change is often realized by addressing the root causes behind these thoughts and identifying potential triggers. Patients are also taught healthier coping strategies and emotional regulation techniques to help them overcome their unhelpful thoughts and actions.
Dialectical behavior therapy (DBT) operates on a theory similar to CBT. Patients are still encouraged to change their unhelpful behaviors through recognizing and changing unhelpful thoughts, and therapists teach their patients similar coping strategies.
However, DBT also introduces the idea of dealing with two truths at once. In these cases, patients are shown how they can reach a place of self-acceptance while simultaneously working to change the thoughts and behaviors driving their conditions.
Acceptance and commitment therapy (ACT) goes one step further than DBT when it comes to teaching acceptance.
With ACT, achieving that perspective is the primary goal. Patients are encouraged to find fulfillment by pursuing activities that align with their morals, and therapists also teach them the tenets of mindfulness to help encourage a healthier mindset.
When patients are treated for bulimia nervosa along with an anxiety disorder, additional counseling or therapy around the ideas of food, nutrition, and body image may be included.
Sometimes, pharmaceutical options can also help alleviate one or both conditions. Certain types of medication have been found to help with some symptoms of both anxiety and BN.
Finding Help for Bulimia Nervosa
Recovery from bulimia nervosa necessitates a comprehensive treatment program that also accounts for the treatment of any co-occurring disorders, including anxiety disorders.
If you or a loved one is struggling with signs of either of these conditions, you should reach out for help. When comorbid mental health conditions are treated together, they can be optimally managed for a long and sustained recovery.
Speaking with your primary care physician or therapist can be a great first step toward finding the treatment to help you build a healthier and happier future.
Resources
- Swinbourne J, Hunt C, Abbott M, Russell J, St Clare T, Touyz S. (2012). The comorbidity between eating disorders and anxiety disorders: prevalence in an eating disorder sample and anxiety disorder sample. The Australian and New Zealand Journal of Psychiatry; 46(2):118–131.
- Deboer, L. B., & Smits, J. A. (2013). Anxiety and Disordered Eating. Cognitive Therapy and Research; 37(5):887–889.
- Eating Disorders. (2021, September 28). Anxiety Depression Association of America (ADAA). Retrieved September 21, 2022.
- Brewerton TD. (2007). Eating Disorders, Trauma, and Comorbidity: Focus on PTSD. The Journal of Treatment & Prevention; 15(4):285-304.