When I was living with an eating disorder as a child, the obsessive thoughts driving how I felt about my body looked a lot like OCD. The anxiety that followed me to the dinner table didn’t go away when I left multiple rounds of treatment; it went dormant and waited. It took years before any clinician helped me see the full picture, and longer before I had the language to name it.
I wasn’t the exception. Research consistently shows that more than half of patients with an eating disorder also meet criteria for anxiety, OCD, depression, ADHD, or a trauma-related diagnosis, with some studies putting that number as high as 95%. Among Equip’s own patient base, 73% present with at least one co-occurring condition.
And yet behavioral healthcare was built around the opposite idea. Specialty programs revolve around a primary condition, and clinical guidelines for one disorder address co-occurring conditions only tangentially, if at all. It represents a stark research-practice gap. Standard treatment manuals are designed for isolated diagnoses, with little instruction on how to blend protocols when a patient presents with multiple complex conditions. For patients, this rigid approach produces a whack-a-mole effect: Address the eating disorder, and untreated anxiety surfaces. Stabilize the mood, and severe OCD behaviors escalate. Manage the OCD, and the eating disorder, never really gone, comes back louder.
FRAGMENTED CARE
Even the evidence base behind eating disorder treatment was built by studying patients without comorbidities. The American Psychiatric Association’s most recent practice guideline acknowledges that many studies of eating disorders excluded those with co-occurring conditions, leaving clinicians with evidence-based protocols that may not reflect the patients they actually see.
The result of all this is fragmented care, and patients pay for it. A patient with severe anorexia and active trauma symptoms might find themselves stuck in a systemic loop, shuttled between disparate providers who don’t talk to one another. Or, a patient with active suicidality may get admitted to inpatient psychiatric care, but their eating disorder behaviors go untouched while the acute crisis is stabilized. Families become the care coordinators by default: a residential stay here, an outpatient therapist there, a psychiatrist somewhere else. There is no shared treatment plan and no one accountable for the whole person.
The cost is measurable. Relapse rates in eating disorder care hover around 30 to 50% within the first year after treatment, and untreated co-occurring conditions are one of the strongest predictors of relapse. We have known this for decades, and we have largely kept treating one diagnosis at a time anyway.
CARE DESIGN
Designing care around complexity should look like this: From the first appointment, clinicians screen for everything that might be going on, including anxiety, OCD, ADHD, and trauma, instead of waiting for those to surface months later. One multidisciplinary team treats the whole person, in the same place, with one chart and one plan, so nothing gets lost in handoffs between providers. Therapists, psychiatrists, and dietitians must be trained to see neurodivergence, trauma, and mood disorders as part of the eating disorder picture. They should treat them at the same time as the eating disorder rather than waiting their turn. The field still argues over whether to treat the trauma first or the eating disorder first; for most patients, the real answer is both, by the same team, at the same time.
Building this kind of care also requires the entire ecosystem to move together. Providers, payers, and researchers all have a role in shifting toward models that reimburse and reward integrated treatment, rather than ones that incentivize narrower, single-condition care. None of us can fix this alone, and the patients caught in the middle can’t wait for us to.
Kristina Saffran is CEO of Equip.
