Can You Have Anorexia and Bulimia at the Same Time?

Is it possible to have two eating disorders at once? What if you restrict and binge and purge? Is that anorexia or bulimia? Both? Neither?

It’s a common question, one that makes sense to ask. Many people do experience a continuum of disordered behaviors within or over the course of their illness, at times restricting, bingeing, and purging. One behavior leads to another in what is often called the eating disorder “cycle.” Trapped in this cycle, people experience symptoms that overlap multiple eating disorder diagnoses. They may be left to wonder: Exactly what, then, is the appropriate diagnosis?

Often we equate anorexia with restricting and bulimia with bingeing and purging, but The Diagnostic and Statistical Manual of Mental Disorders (DSM–5) offers additional specification. The following criteria are used by professionals to diagnose different types of eating disorders. To be diagnosed with either anorexia or bulimia, a person must fully meet the respective criteria below.

DSM-5 Criteria

Anorexia Nervosa

• Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health (less than minimally normal/expected).
• Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain, even at a significantly low weight.
• Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of current low body weight.

There are two subtypes of anorexia:

• Restricting type: During the last three months, the individual has not engaged in recurrent episodes of binge eating or purging.
• Binge-Eating/Purging type:During the last three months, the individual has engaged in recurrent episodes of binge eating or purging.

Bulimia Nervosa

• Recurrent episodes of binge eating. An episode of binge eating is characterized by both:
  • Eating in a discrete period of time (e.g., within a two-hour period) an amount of food that is larger than what most individuals would eat in a similar period of time under similar circumstances.
  • A sense of lack of control over eating during the episodes (e.g., a feeling that one cannot stop eating or control what or how much one is eating).
• Recurrent inappropriate compensatory behaviors to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise.
• The binge eating and compensatory behaviors both occur, on average, at least once a week for three months.
• Self-evaluation is unduly influenced by body shape and weight.
• The disturbance does not occur exclusively during episodes of anorexia nervosa.

Provided they meet the other criteria, a person who engages in bingeing and purging and has a low body weight would likely be diagnosed with anorexia nervosa, binge-eating/purging subtype. A person who engages in bingeing and purging and does not have a less-than-expected body weight would likely receive a diagnosis of bulimia nervosa.

Many eating disorders do not fit within the narrow definition of either anorexia or bulimia. These situations may merit another diagnosis, OSFED.

OSFED

For those who do not meet these strict anorexia or bulimia criteria but do engage in restricting, bingeing, and/or purging, the DSM-5 offers another category: Other Specified Feeding or Eating Disorder (OSFED), formerly known as Eating Disorder Not Otherwise Specified (EDNOS). Despite the representation of OSFED as the “other” and “atypical” eating disorder, this diagnosis describes a real eating disorder in its own right. It should be regarded with the same serious concern as anorexia and bulimia (as well as BED and ARFID).

Within OSFED are a few presentations that closely resemble anorexia and bulimia:

• Atypical Anorexia Nervosa: All criteria for anorexia nervosa are met, except that despite significant weight loss, the individual’s weight is within or above the normal range.
• Bulimia Nervosa (of low frequency and/or limited duration): All criteria for bulimia nervosa are met, except that the binge eating and inappropriate compensatory behavior occurs at a lower frequency and/or for less than three months.
• Purging Disorder: Recurrent purging behavior to influence weight or shape in the absence of binge eating.

Diagnostic Crossover

A person typically has one eating disorder diagnosis at a time, but that diagnosis can and often does change over time; the combination of symptoms fluctuates and with it the appropriate diagnosis. This movement among diagnoses or diagnostic subtypes is called diagnostic crossover, and is especially common in those with anorexia nervosa. Research has shown that about one-third of those with anorexia cross over to bulimia and 14 percent of those with bulimia cross over to anorexia (Eddy, Dorer, Franko, et al., 2008). Between anorexia subtypes, up to 62% of patients with restricting-type anorexia later develop the binge eating/purging-type (Eddy, Keel, Dorer, et al., 2002).

What’s in a Diagnosis?

Diagnoses are primarily clinical tools meant to equip clinicians and researchers with language to clearly discuss, study, and treat eating disorders. Like any classification system, the DSM is useful for organizing information but limited in its ability to perfectly capture individual experiences.

Your experience is more than a set of DSM symptoms. You are more than a diagnosis.

This reminder is especially important for people with eating disorders, illnesses that strongly impact self-identity. Those with eating disorders often do attach their identity to their illness, interpreting a diagnosis not merely as a description of symptoms but of themselves. For many suffering, anorexia exists at the top of a diagnostic hierarchy. It is viewed as more “serious,” more “legitimate,” or otherwise more “important” than the other diagnoses.

In reality, all eating disorders require proper identification, intervention, and treatment. No matter its unique presentation or combination of symptoms, an eating disorder is serious and warrants appropriate attention and care.

Diagnoses are best made by qualified clinicians who specialize in eating disorders. To connect with The Emily Program for an assessment, take a moment to complete our online form or call our admissions team at 1-888-364-5977.