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While you may be having trouble understanding your natural signals now, your body has been sending you all kinds of different cues to help you identify specific needs since the time you were born. Think about babies: when they’re hungry or tired, they cry. Since these tiny humans aren’t able to figure out what they want, crying is their only way of communicating distress. It makes sense, right? But as we move through life, certain obstacles can interfere with this simple system.

 or other traumas can complicate our ability to figure out what our bodies are telling us. However, with time and proper attention to your body, you’ll eventually be able to decipher its messages about hunger and fullness (seriously!). Not only will you be able to tell when you have an appetite, but you’ll be able to discern how hungry you are and if/when that hunger has been satisfied.

Different people have different cues for hunger and fullness. While some may experience hunger as a stomach rumble, others may get a headache or feel weak. Some may feel full sooner than they anticipate and others, depending on the stage of their recovery, may feel uncomfortable with even a slight feeling of hunger 

Identifying these body cues and figuring out when your body is telling you to either eat or stop eating is a process that may involve a lot of trial and error. But as you learn how your body communicates with you, you’ll learn more about yourself and strengthen your connection with your body.

Questions to help you tap into your hunger and fullness cues

As you work with your team, you can think about the following questions:

Where do you feel these sensations in your body? Is it a physical feeling? A mental hunger? Do you feel sensations in the same place every time you are full?

Do you always experience hunger in the same way or does it vary depending on the day or the time of day?

Does your hunger come on gradually or does it arise suddenly?

Does fullness happen at the same time you feel satisfied or are these two different feelings?

What makes you decide whether to start eating or stop eating?

What happens in your body if you do not listen to your hunger? What happens if you do not listen to your appetite?

Do you eat what you truly want? How does your body feel if you don’t eat what you desire?

Does your desire for food change based on how hungry or full you may feel? Does the taste of these foods change because of these factors?

Can you remember the last time you ate and felt satisfied after?

Can you remember the last time you were hungry and listened to those feelings of hunger?

Do your feelings about yourself or your body change depending on whether you feel hungry, full, or satisfied?

A smiling woman at an outdoor restaurant eats a bite of food

Being able to enjoy food is one of life's great pleasures, but for those with eating disorders or disordered eating habits, it can be hard to know when to eat—and when to stop eating.  A dietitian explains how to identify and listen to your body's hunger and fullness cues.

Hunger and Fullness Cues During Eating Disorder Recovery: How to Listen to Your Body

I spent several years of my life living in an energy (calorie) deficit. At the time, I never stepped back to wonder what happens if you don’t eat enough. I didn’t understand how my entire being—mind, body, and emotions—were being affected by living that way. I’m not dramatizing when I say that every part of me was drastically and negatively impacted by undereating. I suffered serious consequences, some of which I’ll share with you today. Fortunately, I committed to healing and recovery over a decade ago, which meant first moving out of an energy imbalance by eating more food, exercising less, and learning how to manage stress.

Today, as an eating disorder dietitian, I see the side effects of not eating enough in my clients and how it infiltrates every facet of their lives every day. Sadly, undereating and setting goals to undereat are normalized and supported across mainstream and social media, without much (if any) regard for the negative impact it might have.

Let’s look at the different ways that undereating can significantly impact you mentally, emotionally, and physically.

In my practice, I notice heightened anxiety is one of the main side effects of undereating, and, personally, I know now that spending years feeling on edge and suffering panic attacks was a direct result of not eating enough food.

Undereating, which often comes with malnutrition and excessive weight loss, can also 

 as well as anxiety due to changes in brain chemistry. 

, RDN, LD, explains that inadequate nutrition can lead to tissue damage in the brain, as well as a lack of nutrients—specifically vitamin B12, folate, and zinc—that 

may cause depression, cognitive decline, and irritability

, RDN, LD. She also notes that malnutrition may also lead to a decrease in production of dopamine and serotonin, two mood-regulating hormones, which can worsen symptoms of anxiety and depression.

On top of that, undereating makes it more difficult to deal with tough emotions and hard life experiences and relate to other people. “People who frequently underfuel often describe an increase in irritability, a decrease in patience, and a tendency to have diminished capacity for emotional regulation,” explains 

, MS, RD, CEDS. “They tend to experience mood swings, with less tolerance for ‘riding emotional waves’ throughout the day.”

When I was undereating, I remember feeling like I was abnormal because most of my mental space was taken up by thoughts of food. It was hard for me to stay present in conversations or to pay attention to my work and studies. Now, it’s one of the first concerns clients who are undereating share with me when we start work together: they believe they’re uniquely obsessed with food, when in fact their bodies are simply trying to survive. “Your body doesn't understand that this ‘famine’ is self-inflicted, so it's going to be on high alert to increase its ability to survive and find food,” explains Equip Nutrition Director Erin Reeves, RD. “Therefore, you might be thinking about food more or feel more out of control when you do eat because your body can't trust there won't be a famine again.”

In one famous landmark study (called the 

 on Human Starvation by researcher Ancel Keys), a group of men were intentionally underfed over an extended period. 

 the earliest and most present symptom of their starvation experience was a fixation on and thoughts about food. All the men said they experienced “intellectual inefficiency,” including decreased concentration and rate of learning, or poor judgment. Additionally, some men responded by gathering recipes and cookbooks, eating faster than normal, and dreaming of food, and some said they wanted to watch others eat often while others said they couldn’t bear doing so.

When you aren’t eating enough food, Burkholder says, “much of the ‘airtime’ in your mind is consumed by thoughts of food, leaving little room for other things. This is one of the non-physical effects of not eating enough that I find scariest: without room or energy for life outside food and body, it’s impossible to live in alignment with your true core values. In other words, it’s impossible to be yourself.

In the landmark study I mentioned, the men reported 

 alongside emotional issues like increased irritability. These personality changes included social introversion, loss of sexual interest, decrease in self-initiated activity, and lethargy. Underfueling can also lead someone to become a 

 than they are when they’re eating enough.

In my work with clients who aren’t eating enough, the changes that I observe over our time together can be mind-blowing. As they work toward fueling their body adequately, it’s as if they’re re-emerging from a dark haze that was keeping them disconnected from themselves, their lives, and the people around them. Their sense of humor and mental flexibility returns, their voices become more authentic, hobbies are more interesting, their ability to access life’s pleasures come back, boundaries become easier to set and relationships richer, and their genuine paths in life often become clearer.

Another common side effect of undereating is a decreased basal metabolic rate (BMR), or the amount of energy your body needs to perform basic functioning. The simplest way to think about this is that your body is focused on survival, so if you’re not adequately fueling your body, it will slow down all of its processes in order to conserve energy and survive with less energy. “There are no tricks around this by eating a certain spicy food or doing a certain workout,” explains Reeves. “Your metabolism will slow down if you aren't giving it enough."

This is one of the reasons that so many people who spend years yo-yo dieting to lose weight often end up at higher weights than when they started: their bodies get thrown off by undereating and try to recalibrate by adjusting metabolic speed, only to get confused again, and the cycle continues.

 (or loss of period for more than three months) was my body’s main indicator of not yet being fully recovered from my own eating disorder. It’s a common side effect of undereating and can lead to a myriad of issues, including infertility and osteoporosis. Food restriction, anxiety, depression, emotional stress, excessive exercise, energy imbalance, and malnutrition are associated with development of amenorrhea, according to 

The Journal of Clinical Endocrinology & Metabolism

 concluded that low energy availability from undereating can suppress all reproductive hormones. “In females, levels of estradiol and progesterone—two important reproductive hormones—decrease. Estradiol is responsible for bone growth and remodeling, so low estradiol levels can quickly diminish bone density,” Burkholder explains. “In males, low energy availability disturbs testosterone levels and leads to fatigue, low sex drive, sexual dysfunction, and low bone mineral density.” Essentially, when you don’t eat enough, your body prioritizes vital functions, like heartbeat and lung expansion, and shuts down processes it deems non-essential. “Your body downregulates to conserve as many calories as possible, and that means forfeiting reproductive function,” Burkholder adds.

6. Nutrient deficiencies & muscle breakdown

Another serious side effect of undereating is the development of nutrient deficiencies, which can lead to health conditions like anemia (often a result of iron deficiency), cold intolerance, hair loss, skin problems, insomnia, bone issues, and a weakened immune system. “Your immune system will be depressed, causing an increase in infection, cold and flu or other illnesses,” says Reeves. “Your heart rate slows, there’s less oxygen flow, dizziness and fatigue.”

Undereating can also cause catabolism, or when the body breaks down lean tissue like muscle for fuel, which can lead to loss of muscle mass and muscle wasting. “Your muscles will get broken down faster because there are neither the energy nor the building blocks—amino acids and protein—available to maintain itself,” Reeves explains. Since the heart is largely made of muscular tissue, it will also start to weaken with chronic underfueling, and vital signs like blood pressure and heart rate can fall dangerously low. “This weakening of the heart reduces the ability to pump blood throughout the body, which can lead to fatigue and shortness of breath,” Grimes explains. “Malnutrition also disrupts the electrical activity of the heart, the power behind the heart’s contractions, which can be fatal.” And without enough blood sugar circulating in your blood, which can occur when you’re regularly undereating and have depleted all the glucose stores in your liver and muscles, you can experience hypoglycemia, which can also be deadly. 

Plus, if you’re engaging in physical activity while undereating, your muscles will have a harder time recovering and you’re likely to experience decreased athletic performance, according to Burkholder.

Grimes explains that in addition to affecting heart tissue, malnutrition can result in the breakdown of tissue in the digestive tract, which can, over time, lead to a weakening of muscles in the stomach and intestines. In fact, 

 shows malnutrition and weight loss from undereating can slow down the gastrointestinal (GI) tract, which can cause general 

 (or slowed movement or motility of stomach muscles), constipation, reflux, heartburn, bloating, and diarrhea. Reeves explains that undereating will also decrease the amount of enzymes your body makes that help break down food, leading to further GI symptoms. In my practice, I’ve observed GI disturbances from undereating that cause significant disruptions in clients’ day-to-day functioning and overall quality of life.

 I mentioned, the men reported that once the restriction period ended, they felt an initial loss of control around food during the refeeding period. Some of them reported wanting to eat continuously, while others said they binge ate (and never had before the experiment). More than half of them reported overeating.

In my work, I’ve noticed that most of my clients are surprised when they realize their bingeing or overeating is often rooted in undereating. The thing is, when we’re underfed, our bodies will do everything possible to get us to reclaim a state of equilibrium, and that can sometimes manifest in out-of-control eating, binge eating, or an inability to listen to and honor your hunger and fullness cues. Additionally, undereating and 

“Some people find themselves in chronic deficits unintentionally—their lives are busy, schedules are packed, perhaps their physical activity is high, or they’re struggling with a low appetite,” Burkholder says. “Others may find their chronic deficit has deeper roots: body image concerns, pressure from family members or coaches to maintain a low weight, or an internalized list of rigid food rules.” Also, several of my clients presented with undereating that stems from trauma, and they’re using restriction to cope, numb, disassociate, and indirectly express hard feelings.

The effects of not eating enough are widespread and serious. But there’s good news: most can be reversed with adequate nourishment. Since I stopped undereating and now live within energy balance, my anxiety is manageable, I feel generally more at ease, my focus and ability to stay present with others is good, I have ample brain space for life outside of food, and my reproductive system is fully functioning.

However, it’s tough to get there on your own. Establishing or re-establishing energy balance and reversing the effects of undereating usually takes professional guidance from a team of providers (usually at least a therapist and a dietitian). “Learn from a non-diet dietitian how much your body really needs. It's difficult to use online calculators or providers that endorse weight loss, because you will likely get a calorie goal that is far too low,” Reeves says. “Stay in your lane: don't compare yourself to others or ask your friends how many calories they eat. Your body is its own unique machine, and looking at a snapshot from a peer or someone's 'what I eat in a day' is not going to give you the personal guidance you need to thrive.”

If you’re concerned that you’re not eating enough, we’re here to help. 

Reach out to our team for a free consultation

Issue 59 I The Starved Brain – Can What We Eat Determine How We Think?

https://nedc.com.au/eating-disorder-resources/find-resources/show/issue-59-i-the-starved-brain-can-what-we-eat-determine-how-we-think#:~:text=Restricted%20eating%2C%20malnourishment%2C%20and%20excessive

Lachance, L., & Ramsey, D. (2015). Food, mood, and brain health: implications for the modern clinician. 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6170050/#:~:text=Several%20nutritional%20deficiencies%2C%20such%20as

Eckert E.D. et al. (2018). A 57-Year Follow-Up Investigation and Review of the Minnesota Study on Human Starvation and its Relevance to Eating Disorders. 

https://www.researchgate.net/publication/324507398_A_57-YEAR_FOLLOW-UP_INVESTIGATION_AND_REVIEW_OF_THE_MINNESOTA_STUDY_ON_HUMAN_STARVATION_AND_ITS_RELEVANCE_TO_EATING_DISORDERS

. (2023, May 9). Duke Department of Psychiatry & Behavioral Sciences. 

https://psychiatry.duke.edu/blog/starvation-experiment

. (n.d.). Mayo Clinic. Retrieved April 1, 2024, from 

https://www.mayoclinic.org/diseases-conditions/eating-disorders/symptoms-causes/syc-20353603#:~:text=Dieting%20and%20starvation.&text=Starvation%20affects%20the%20brain%20and

Gordon, C. M., Ackerman, K. E., Berga, S. L., Kaplan, J. R., Mastorakos, G., Misra, M., Murad, M. H., Santoro, N. F., & Warren, M. P. (2017). Functional Hypothalamic Amenorrhea: An Endocrine Society Clinical Practice Guideline. 

Montani, J. (2021). Ancel Keys: The legacy of a giant in physiology, nutrition, and public health. 

Wasserfurth, P., Palmowski, J., Hahn, A., & Krüger, K. (2020). Reasons for and Consequences of Low Energy Availability in Female and Male Athletes: Social Environment, Adaptations, and Prevention. 

https://doi.org/10.1186/s40798-020-00275-6

Iwasa, T., Minato, S., Imaizumi, J., Yoshida, A., Kawakita, T., Yoshida, K., & Yamamoto, Y. (2021). Effects of low energy availability on female reproductive function. 

National Centre for Eating Disorders. (2011). 

The Effects Of Under-Eating | National Centre for Eating Disorders

https://eating-disorders.org.uk/information/the-effects-of-under-eating/

Cost, J., Krantz, M. J., & Mehler, P. S. (2020). Medical complications of anorexia nervosa. 

Mathisen, T. F., Heia, J., Raustøl, M., Sandeggen, M., Fjellestad, I., & Sundgot‐Borgen, J. (2019). Physical health and symptoms of relative energy deficiency in female fitness athletes. 

Scandinavian Journal of Medicine & Science in Sports

https://www.mayoclinic.org/diseases-conditions/gastroparesis/symptoms-causes/syc-20355787

‌Eckert E.D. et al. (2018). A 57-Year Follow-Up Investigation and Review of the Minnesota Study on Human Starvation and its Relevance to Eating Disorders. 

What Happens If You Don’t Eat Enough? 8 Ways Undereating Affects Your Body and Mind

 for my eating disorder, I was surprised to learn just how many forms of therapy my program included. There were, of course, solo sessions with my assigned therapist, where we mostly used cognitive behavioral therapy (CBT), as well as group therapy with other program participants and facilitators. But my particular program also mandated regular meetings with a dietitian, weekly art projects, thrice-weekly group meals, and a form of therapy I’d never heard of before: DBT. As I’d later learn, DBT for eating disorders is a widely used and well-studied approach, but at the time, it was completely new to me.

DBT, which stands for dialectical behavior therapy, is a therapeutic modality that helps people shift harmful behaviors and build a skill set that enables them to thrive in recovery. It was first developed in the 1970s to treat personality disorders and address interpersonal conflict, but 

 shows that it’s also an effective approach to treating eating disorders.

Read on to learn more about DBT for eating disorders, how it works, its benefits and drawbacks, and more.

At its core, DBT is a form of talk therapy designed for people coping with very intense emotions. While the approach is based on the structured, goal-oriented form of talk therapy known as CBT, DBT is distinct in that it focuses not only on helping people accept the reality of their specific situations and behaviors, but also on learning strategies to change unhelpful patterns. “DBT is a specific therapeutic approach aimed at helping people find balance with managing their emotions and relationships,” explains Jessie Menzel, PhD, clinical psychologist and VP of Program Development at Equip.

, a psychologist and researcher who has lived experience with borderline personality disorder (BPD). Due to Linehan’s own experience and research, DBT is often referenced as 

, a mental disorder characterized by patterns of impulsiveness and unstable, intense relationships, among other things. “While DBT is considered the gold-standard treatment for BPD, it has been used in applications far beyond it,” Menzel says. “DBT is now used in the treatment of substance use, 

 and self-harm, PTSD, and eating disorders.”

The word “dialectical” refers to the integration of opposing ideas. By helping people both accept 

 change their unhelpful behaviors, DBT offers space for two opposite truths to exist simultaneously—and introduces the possibility that there is more than one way to perceive a specific situation.

Why is DBT used in eating disorder treatment?

The goal of all DBT practices is to help people learn to regulate their responses to challenging emotions in an adaptive way. Because problems with emotion regulation and awareness can be common in eating disorders, using 

 was a natural expansion of its original purpose.

“DBT has been used in eating disorder treatment largely because of the prominent role that emotions play in maintaining eating disorder behaviors,” Menzel explains. “Many eating disorder behaviors are triggered by difficult emotions and may even be used as a way to help people cope with difficult emotions.”

Indeed, people struggling with eating disorders often use disordered behaviors to regulate emotions in the short-term—for instance, restricting to numb difficult feelings, or bingeing to quiet distressing thoughts—but doing so actually increases emotional dysregulation in the long-term. Because of this, the emotion-regulation skills of DBT not only serve as healthy replacements for disordered coping strategies, but also help people better navigate the ups and downs of life and connect with those around them.

“By teaching patients how to manage their emotions effectively and in a way that isn’t harmful, we can help them reduce their vulnerability to difficult emotions and their need to rely on eating disorder behaviors as a way to cope,” Menzel says.

What does the research say about DBT for eating disorder treatment?

There are several studies examining the effectiveness of DBT for eating disorder treatment, and the results indicate largely positive effects. 

 found that 89% of participants who were taught DBT skills didn’t binge eat as compared with only 12.5% in the waitlist control condition. A 

 on BED found that 40% of DBT participants abstained from binge eating as compared to 3.3% in the waitlist control condition.

“DBT can be very effective as a treatment for eating disorders,” Menzel says. “There have been studies that support the success of DBT particularly in 

 Clinically, DBT is also a great treatment choice for individuals with more complex eating disorders or eating disorders with multiple co-occurring problems, such as self-harm or suicidal ideation and substance use.”

But research on DBT and eating disorders isn’t limited to BED. There is also 

 that people diagnosed with binge/purge behaviors (like people with 

) who were assigned to once-weekly individual DBT treatment had higher rates of abstinence from binge/purge behaviors as compared to a waitlist control group after 20 weeks (28.6% versus 0%). And 

 on women with anorexia found that after an average of 21.7 weeks of DBT, 35% of patients were in full remission, an additional 55% were in partial remission, and there was also a significant increase in post-treatment BMI.

Potential drawbacks to using DBT in eating disorder treatment

While research suggests that DBT can have a significant impact on treatment success, Menzel does caution that the protocol requires serious commitment. “Traditional DBT is a very time-intensive treatment,” she says. “It requires weekly individual therapy and weekly skills groups. Patients are also asked to commit to treatment for a minimum of 6 months or up to a year. While these aspects of DBT may seem overwhelming, they’re part of what makes DBT so effective.”

Another potential obstacle to be aware of when considering DBT for eating disorder treatment is accessibility. Firstly, there’s a limited number of trained and experienced clinicians who specialize in using DBT to treat eating disorders. And secondly, DBT treatment isn’t always covered by insurance. “Treatment that is truly adherent to DBT may be very difficult to find and harder to access if a provider or clinic doesn’t accept insurance,” Menzel says. “Because DBT is so intensive and a big commitment, it isn’t typically recommended as a frontline treatment for most eating disorders.”

At Equip, DBT is incorporated into our treatment approach (more on that below), and Equip is in-network with most insurance plans.

What does DBT look like and what can you expect?

While the specifics of DBT will vary depending on the provider, the program, and the patient, there are some elements that remain consistent. Menzel explains that DBT treatment has four components:

Weekly individual therapy sessions typically last about 40-60 minutes. During these sessions, patients and their therapist will work toward creating goals around:

Minimizing self-harm behaviors (if applicable)

Learning skills to replace maladaptive behaviors

“For patients, treatment also relies heavily on doing work out of sessions,” Menzel explains. “Patients are expected to complete a daily log of their emotions, behaviors, urges, and skills use, as well as completing weekly practice of skills learned during group therapy.”

Equip treatment incorporates DBT in a specific and thoughtful way. “At Equip, we focus on one component of DBT: skills group therapy,” Menzel says. “While skills are just one component of DBT, we believe that they are a very important component.”

 that just the skills group therapy piece of DBT alone—especially when combined with other types of care—can be an effective way of supporting those struggling with eating disorders. In general, 

Each of these four skills categories includes a number of different specific skills, all of which can be employed in different moments to help people manage distressing emotions or situations without turning to disordered behaviors. According to Menzel, learning skills seems to be essential for getting the most out of treatment.

“We’ve woven skills into our treatment in a few ways,” Menzel says. “First, we offer weekly skills group sessions for our teens and adults. We also provide weekly skills videos to our patients and their supports because we believe that our patients have the best chance for recovery if their loved ones are learning skills, too. Finally, all of 

 are trained in how to teach DBT skills so that they can support our patients in using these skills in their everyday lives as they recover.”

You can find all of our weekly DBT skills videos 

. If you’re struggling with an eating disorder or supporting someone who is, try watching a few different videos until you find a skill that resonates. DBT skills can be truly game-changing for stopping disordered eating as well as other patterns and behaviors that aren’t serving you. Below is an example of one of our videos that talks about distress tolerance skills for eating disorder recovery.

And if you want to learn more about DBT for eating disorders at Equip, 

. We’re here to answer any questions you have and to talk through next steps.

Blackford, Jennifer Urbano, and Rene Love. 2011. “Dialectical Behavior Therapy Group Skills Training in a Community Mental Health Setting: A Pilot Study.” International Journal of Group Psychotherapy 61 (4): 645–57. 

https://doi.org/10.1521/ijgp.2011.61.4.645

Chapman, Alexander L. 2006. “Dialectical Behavior Therapy: Current Indications and Unique Elements.” Psychiatry (Edgmont) 3 (9): 62–68. 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2963469/

Cleveland clinic. 2022. “Cognitive Behavioral Therapy (CBT).” Cleveland Clinic. Cleveland Clinic. August 4, 2022. 

https://my.clevelandclinic.org/health/treatments/21208-cognitive-behavioral-therapy-cbt

Lynch, Thomas R, Katie LH Gray, Roelie J Hempel, Marian Titley, Eunice Y Chen, and Heather A O’Mahen. 2013. “Radically Open-Dialectical Behavior Therapy for Adult Anorexia Nervosa: Feasibility and Outcomes from an Inpatient Program.” BMC Psychiatry 13 (1). 

Masson, Philip C., Kristin M. von Ranson, Laurel M. Wallace, and Debra L. Safer. 2013. “A Randomized Wait-List Controlled Pilot Study of Dialectical Behaviour Therapy Guided Self-Help for Binge Eating Disorder.” Behaviour Research and Therapy 51 (11): 723–28. 

https://doi.org/10.1016/j.brat.2013.08.001

Mayo Clinic. 2019. “Borderline Personality Disorder - Symptoms and Causes.” Mayo Clinic. July 17, 2019. 

https://www.mayoclinic.org/diseases-conditions/borderline-personality-disorder/symptoms-causes/syc-20370237

Pisetsky, Emily M., Lauren M. Schaefer, Stephen A. Wonderlich, and Carol B. Peterson. 2019. “Emerging Psychological Treatments in Eating Disorders.” Psychiatric Clinics of North America 42 (2): 219–29. 

https://doi.org/10.1016/j.psc.2019.01.005

Rahmani, Maliheh, Abdollah Omidi, Zatollah Asemi, and Hossein Akbari. 2018. “The Effect of Dialectical Behaviour Therapy on Binge Eating, Difficulties in Emotion Regulation and BMI in Overweight Patients with Binge-Eating Disorder: A Randomized Controlled Trial.” Mental Health & Prevention 9 (March): 13–18. 

https://doi.org/10.1016/j.mhp.2017.11.002

Telch, C. F., W. S. Agras, and M. M. Linehan. 2001. “Dialectical Behavior Therapy for Binge Eating Disorder.” Journal of Consulting and Clinical Psychology 69 (6): 1061–65. 

https://doi.org/10.1037//0022-006x.69.6.1061

Wisniewski, Lucene, and Denise D. Ben-Porath. 2015. “Dialectical Behavior Therapy and Eating Disorders: The Use of Contingency Management Procedures to Manage Dialectical Dilemmas.” American Journal of Psychotherapy 69 (2): 129–40. 

https://doi.org/10.1176/appi.psychotherapy.2015.69.2.129

DBT for Eating Disorders: What Is Dialectical Behavioral Therapy and How Does It Work?

Alcohol and eating disorders are very connected. 

 with eating disorders have also abused alcohol or illicit drugs. Perhaps even more surprising is what that statistic means: the rate of substance use disorders in people with eating disorders is five times higher than in the general population. The numbers go both ways: 35% of individuals with substance use issues have also had an eating disorder (eleven times higher than the general population). Let's look more closely at the relationship between eating disorders and alcohol use.

Why do eating disorders and alcohol abuse so frequently go together?

"Many people with eating disorders use food restriction and binge eating as a way to regulate emotions, albeit temporarily," says Cara Bohon, PhD and VP of Clinical Programs at Equip. "We see the same thing in substance use disorders, where substances are used to self-medicate from particularly strong negative emotions. And these things work in the moment, but often lead to new emotions of guilt or shame or biological responses of hunger, fullness or chemical dependence and withdrawal. The new emotions then lead to more eating disorder behaviors or substance use, causing a cycle that is difficult to stop without a supportive environment."

 is in recovery from an eating disorder and has 

about “drunkorexia,” meaning the role alcohol played in her anorexia and bulimia. Hall says that people aren’t often aware of the overlap between eating disorders and substance abuse, but based on her own experience, the conditions can coincide for many reasons. “A lot of people worry about calories in alcohol and there are plenty of people deep in an eating disorder who don’t drink for that reason alone,” she says. “But I think there are a lot of us who struggle with anxiety or impulse control or self-destructive behaviors. So we drink to navigate the eating disorder by trying to silence its raging screams in our head that go on all day every day.”

Eating disorder and alcohol use disorder risk factors

Hall isn’t alone: research suggests that eating disorders and substance use disorders may frequently co-occur because they share some key risk factors. As 

, individuals with eating disorders and alcohol use disorders (AUD) reported, some of the most common risk factors for both eating disorders and alcohol use disorders are:

The relationship between trauma and these disorders is worth highlighting. In fact, people with both an eating disorder and substance abuse disorder have higher rates of childhood trauma and post traumatic stress disorder (PTSD) 

Bulimia nervosa is an eating disorder where someone uncontrollably eats a lot of food at once (called bingeing) and then tries to get rid of the food through vomiting, laxative misuse, or excessive exercise (called purging.) It’s also possible to binge drink, which is defined as 4 or 5 drinks within a short period of time for women and men respectively. Bulimia and alcohol use disorder are some of the most common co-occurring conditions. For people who experience both bulimia and AUD, they may binge on both food and alcohol, and then purge both as well.

Binge eating disorder and alcohol use disorder

Binge eating disorder (BED) is the most common eating disorder in the U.S. It’s defined by persistent “bingeing” behavior, meaning eating a large amount of food with a feeling of being out of control. Unlike bulimia, it doesn’t include purging behaviors. For people with BED and AUD, they may feel like one behavior triggers another. For example, drinking excessively may lead to an intensified craving to binge eat. Alternatively, a binge eating episode often leads to feelings of shame which someone may drink alcohol in an effort to numb those feelings.

Anorexia nervosa is an eating disorder characterized by extreme food restriction and fear of weight gain. There are two subtypes of anorexia: restricting and binge/purge subtype. Those who fall into the binge/purge category may develop alcohol use disorder due to shared risk factors of impulsivity and binge cycles. For those who fall into the restricting subtype, it can be common for people to use alcohol as a way of suppressing appetite.

It’s also worth noting that drinking can change your metabolism, and in extreme cases this can 

 which could exacerbate an existing eating disorder. Vise versa, drinking heavily while restricting food intake can cause the effects of alcohol to be accelerated.

 is a non-diagnosable slang term that refers to the concept of eating less in order to consume more calories through drinking. This practice is incredibly dangerous and can have long-term side effects, including the development of an eating disorder and/or alcohol use disorder. Diet culture and drinking pressures may contribute to the desire to practice “drunkorexia,” and getting to the root of these factors may help in breaking out of this harmful behavior.

Equip offers free resources and events that can help you identify disordered dieting and tools to break free from them. 

Break free from diet culture

How substance abuse can become intertwined with the eating disorder

Substances and eating disorder behaviors serve a similar purpose, and at some point, these behaviors were effective. If you are feeling difficult emotions—guilt, sadness, frustration, worry—drinking, binging, vomiting, shoplifting, or having a tantrum will provide some instant relief. These are sometimes called “maladaptive” behaviors because while they work, in the long run, they create more problems than they solve.

If someone has found comfort in these maladaptive behaviors and it has worked as a tool to help manage emotions, there eventually comes a time when this “tool” becomes problematic and the person tries to stop. Unfortunately, even if someone stops drinking, they can’t stop hard emotions. And it may become even more difficult to experience hard emotions because of the lack of practice. The easiest thing to do is to choose another maladaptive behavior. This becomes “whack-a-mole” like the old arcade game: when one mole goes down, another pops up. People start using substances when they are trying to stop bingeing and purging, or use eating disorder behaviors when they are trying to become sober. It is the definition of a vicious cycle.

How to treat co-occurring eating disorders and alcohol abuse

For long-term recovery, eating disorders and substance use disorders (SUDs) need to be treated simultaneously. We know that for many patients, it can be tempting to get treatment for only one. People often choose to get treatment for alcohol use, and are less ready to part with their eating disorder, which is reinforced by it being more culturally acceptable. Yet without treating both, people will recover from neither. Many people go into treatment for one disorder, and when they come out the other disorder becomes more prominent.

If you are struggling in these ways, it’s important that you simultaneously get treatment for both your eating disorder and your substance use. And families: help your loved one to find treatment providers that recognize the two are inextricably linked. In treatment, you will learn skills that combat all your urges, so that in recovery you aren’t replacing drinking with eating disorder behaviors, nor replacing eating disorder behaviors with using substances. In recovery, you will be replacing all the behaviors that don’t serve you, with things that bring you closer to joy and the life that you want to live.