Dual Diagnosis: Eating Disorders and Substance Abuse 

Eating disorders and substance use disorders frequently occur together. The conditions operate through similar genetic, biological, and environmental mechanisms, and often work in complex ways to maintain one another. 

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A dual diagnosis can be helpful, clearing the path for someone to pursue a number of different treatment options. Though finding appropriate programs that cater to both of these conditions can be tricky.

Still, in order to ensure the best chances of sustained recovery, it’s imperative for someone struggling with these co-occurring conditions to treat them both—and treat them simultaneously, if possible.

What Are Substance Use Disorders?

Substance use disorders (SUDs), sometimes called substance abuse disorders, are complex conditions, but at their core, they’re generally characterized by a compulsion to use certain substances, such as alcohol, drugs, or tobacco.

Someone struggling with a substance use disorder will engage in this behavior despite the negative impacts it may have on their physical health, mental health, and/or important relationships. And the hyper-focus on using or obtaining these substances often impairs someone’s ability to function normally in day-to-day life.

Causes of Substance Use Disorder

Like all mental health disorders, substance use disorder can stem from any number of causes. Often, there are multiple driving factors at play, and they interact with or impact each other in various ways, working to maintain the condition.

Genetics usually plays a large role. Someone may be at a higher risk of developing a substance use disorder thanks to inherited traits such as impulsivity and certain physiological reactions to stress, among other factors.

Stress that is introduced or present in someone’s environment is also very frequently a major driver of substance use, regardless of someone’s specific biology.

Once the body has been repeatedly exposed to certain substances, a physical dependency can also develop, which introduces a number of other factors that can drive the behavior.

Signs of Substance Use Disorder

Substance use isn’t always obvious, even in serious cases of substance abuse. Often, people learn how to hide the effects of their condition or use or abuse substances in private.

Still, there are some signs that may indicate someone is genuinely struggling with these behaviors, including:1

  • Deterioration in appearance and hygiene habits
  • Sudden changes in behavior, hobbies, and/or friend group
  • Unexplained mood changes, including paranoia, depression, anxiety, or social withdrawal
  • Regularly missing important obligations, such as school or work
  • Sudden, unexpected, or unexplained money problems

Society has also normalized substance use to some extent, particularly when it comes to alcohol. In these cases, someone may be able to hide their behavior in more “socially acceptable” forms of substance use or abuse.

But if someone starts obviously prioritizing alcohol, partying, or pursuing other substances over other hobbies, events, and obligations, they may have crossed the line into substance abuse.

What Are Eating Disorders?

Eating disorders are a group of mental health conditions characterized by disordered behaviors and attitudes around eating, weight maintenance, and body image.

In almost all cases, people with these conditions struggle with chronic low self-esteem, and a history of trauma is common. Co-occurring anxiety disorders and depressive disorders are also very frequent.

Combined, these factors manifest as a warped perception of one’s own body and a fixation on achieving a certain body shape or weight. In pursuit of this goal, people may partake in a range of disordered eating behaviors that can be extreme, dangerous, and sometimes deadly.

Causes of Eating Disorders

As with substance use disorder, the exact causes of eating disorders aren’t completely understood, but they’re thought to be varied and often interlocking.

Genetics is, once again, thought to play an outsized role. Impulsivity, stress response, and sensitivity to certain chemical reactions in the brain, among other factors, can all have an effect on triggering or perpetuating disordered thoughts and behaviors.2

Biology can also directly impact the onset of disordered eating behaviors, with the changes taking place during puberty found to have a particularly strong correlation with the development of eating disorders.2

The circumstances of someone’s environment can also play a part, including any trauma or abuse they may have experienced, other forms of stress or instability they’re dealing with, or disordered eating behavior that was modeled to them growing up.

Eating Disorder Signs and Symptoms

The exact signs that may signal an eating disorder will vary by the disorder. But some of the more common signs include:

  • Hesitation or anxiety around situations involving food
  • Hyper-focus on nutritional information, including calories and fat content
  • Extremely restricted eating, including cutting out entire food groups
  • Eating alone, eating in secret, or avoiding social situations that include food
  • Frequently going to the bathroom after a meal or using laxatives when it is not medically necessary
  • Significant changes to body weight and shape, especially in a short amount of time
  • A fixation on body image, whether their own or others and an unfairly negative assessment of their own image

Just as those with substance use disorder may be able to hide their condition within socially normalized behaviors around drinking and partying, those with eating disorders may be able to mask the true extent of their condition as a drive to “eat healthily,” “eat clean,” or otherwise participate in highly normalized diet culture behavior.

With an eating disorder, the emphasis is commonly on weight loss, with someone setting unrealistic and unhealthy goals that may continue to shift as they lose weight.

The Connection Between Substance Use & Eating Disorders

While on the surface, eating disorders and substance use disorders may seem disparate, there are actually strong connections between the two.

Eating disorders and SUDs share a number of frequently co-occurring disorders, such as anxiety and depression, which can serve to drive either or both conditions. Environmental stress is another major factor that often influences SUDs and eating disorders. And similar genetic traits can lead to the manifestation of these disordered thoughts and behaviors.

At their core, both eating disorders and SUDs are essentially maladaptive coping mechanisms that people turn to in order to help them deal with stress, trauma, low self-esteem, or other unpleasant experiences.

Eating Disorders and Alcohol Use Disorder

Among the various substance use disorders, alcohol use disorder (AUD) is especially prevalent in people with eating disorders, with alcohol consumption found to influence behaviors associated with bulimia nervosa (BN), anorexia nervosa (AN), and binge eating disorder (BED).4

Researchers have proposed a number of possible reasons for the connections. Alcohol consumption may trigger binge eating episodes in people with both BN and BED. On the other hand, those with AN may use alcohol as an appetite suppressant or meal replacement.4

Some people may substitute a food binge entirely with an alcohol binge. And those who exhibit compensatory behavior as part of their disorder may use alcohol to compensate for a binge, especially if they also deal with feelings of guilt or shame around their behavior.4

Substance use disorders impact up to 50% of women with eating disorders.4

Overall, the link between AUD and bulimia nervosa has been found to be especially high, though one study found substance use disorders of all types impacted up to 50% of women with all types of eating disorders.4

Treating Co-Occurring Substance Use Disorders and Eating Disorders

Since substance use and disordered eating behaviors can be so interwoven, it is imperative to address both of these conditions when seeking treatment. And addressing both of these issues at once is generally thought to be the most effective path to recovery.

Unfortunately, many eating disorder treatment programs screen for people with SUDs, preventing them from entering treatment. And programs primarily directed at substance abuse may not include considerations associated with eating disorders.

This can lead to a confusing and frustrating path to treatment. But there are some types of therapy that may lend themselves to addressing both of these issues at once.

In the case of an eating disorder co-occurring with a substance use disorder, cognitive behavioral therapy (CBT) is likely to be a key component of treatment. This method is considered a primary treatment for both conditions.

Cognitive behavioral therapy operates on the idea that disordered behaviors stem from disordered thoughts. Through a series of highly-structured sessions, patients are taught to recognize their unhelpful thought patterns and given strategies to redirect them, with the ultimate goal of eliminating these thought patterns entirely.

Patients also learn new and healthier coping mechanisms and are given strategies for dealing with future relapses into disordered thinking.

Acceptance and commitment therapy (ACT) operates on the opposite assumption of CBT. Rather than proactively redirect thoughts and feelings, ACT emphasizes the concept of accepting these experiences for what they are.

To deal with these thoughts in a healthier way, patients are encouraged to simply let them pass through, rather than fixate on them. The concept mirrors the tenets of mindfulness, and these practices are a big part of ACT treatment.

ACT also works with patients to help them develop healthier hobbies and interests. The “commitment” aspect of the therapy implores patients to commit to these healthier hobbies, which hopefully works to help naturally move their thoughts away from unhelpful ideas.

Exposure therapy may also be helpful for people simultaneously struggling with SUD and an eating disorder.

This method centers around the effects stress has on thoughts and behavior, which is a common driving factor in both conditions. Exposure therapy is also often helpful for people who struggle with post-traumatic stress disorder (PTSD), which is another common co-occurring disorder with SUDs and eating disorders.

In a controlled and safe environment, patients are repeatedly exposed to concepts or situations that cause them stress to help familiarize and desensitize them to the sensation. As they work out the connection between the situations and their feelings, they’re also given new, healthier coping strategies for dealing with this type of stress.

Finding Help for SUD or an Eating Disorder

If you or a loved one are struggling with a substance use disorder, an eating disorder, or both, it’s important to seek out help. These conditions are dangerous and can be deadly if left untreated.

Reaching out to a doctor, therapist, or other trusted mental health professional is a great place to start. These experts are educated in a number of mental health conditions and may be able to guide you toward the next best steps.

If you’d rather not discuss this sensitive topic face-to-face with someone, there are also a number of mental health hotlines that cater to people struggling with all types of conditions. These services allow you to remain anonymous while delivering information and other resources about where to find help.

Recovery from a dual substance use disorder and eating disorder may seem impossible, but reaching out for help is the first—and most important—step toward making that recovery a reality.


  1. Drug Addiction (Substance Use Disorder). Mayo Clinic. Accessed March 2023.
  2. Berrettini W. (2004). The genetics of eating disorders. Psychiatry; 1(3):18–25.
  3. Eating Disorders. National Institute of Mental Health. Accessed March 2023.  
  4. Eskander N, Chakrapani S, & Ghani MR. (2020). The Risk of Substance Use Among Adolescents and Adults With Eating Disorders. Cureus; 12(9):e10309.

Last Update | 03 - 27 - 2023

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