Experts explain the complex link between eating disorders and anxiety.

Eating disorders and anxiety disorders occur together more often than not. An astonishing two-thirds of people with an eating disorder also suffer from an anxiety disorder.

Obsessive-compulsive disorder (OCD) seems to have the strongest association with eating disorders in general, while people with post-traumatic stress disorder (PTSD) are most prone to bulimia. But the link between anxiety and eating disorders can be found in people with a range of both types of conditions, including anorexia, bulimia, and binge eating disorder, as well as social anxiety, panic disorders, and depression.

In most cases, people say the anxiety came first. And although no one can say with 100% certainty why the link exists, most thinking points to a need for a sense of control. You could almost think of the eating disorder as a symptom of the anxiety.

“In anxiety and also depression, there’s a loss of some sense of control,” says bariatric psychologist Paul Davidson, PhD, director of behavioral services at the Center for Metabolic and Bariatric Surgery at Brigham and Women’s Hospital in Boston. “The ability to have a sense of control over eating behavior can reduce the anxiety momentarily.”

Restricting food–as in anorexia–especially confers the sense of control, experts say. “The way patients describe it is they feel really anxious and when they do something under their control–doing well on a test, restricting calories, putting their mind to something and doing that something very well–that makes them feel better,” adds Ingrid Barrera, PsyD, director of the eating disorders program at the University of Miami Miller School of Medicine.

With bulimia and binge eating, overindulgence in food may temporarily reduce control–but also provide momentary comfort thanks to a release of feel-good chemicals in the brain after eating. Anxiety and stress cause the brain to produce stress hormones like cortisol, which brings on the fight-or-flight response. High-fat or high-carb foods in particular may counteract those negative feelings temporarily. People with bulimia may then regain the feeling of control by purging, says Davidson.

But why turn to eating habits in the first place? “Think about what kinds of behaviors are always available for you,” says Davidson. “We can’t stop breathing, but we can control how much fluid we take in or what we eat. It’s that constant reminder: Am I under control or not?”

Like any addiction or habitual behavior–be it gambling, smoking, shopping, drugs, or sex–the coping mechanism can turn into the danger. Eating disorders can lead to multiple serious health conditions and even death. In fact, more people die from anorexia nervosa than any other psychiatric illness. Eating behaviors might also serve as a distraction, meaning you don’t address other mental and emotional issues.

But the intertwining of eating and anxiety disorders means they both need to be treated together and on multiple fronts. For starters, treatment might first involve nutrition, namely making sure you’re hydrated and your blood sugar is stable. “You have to level out the blood sugar so you don’t feel the biological pull for the wrong kinds of foods,” says Davidson. Specialists will help you eat more satiating protein and fiber instead of simple carbs, he says.

Making these dietary changes can help you practice safer ways of managing your anxiety, Davidson continues. “When the brain is deprived of proper nutrition, it leads to a decreased ability to concentrate,” he says. “You’re no longer able to think things through as carefully, so you have to work on coping skills that are going to allow you to think more clearly.”

Anxiety may also be treated with calming strategies like breathing exercises, meditation, visualization, and journaling. Medications are also sometimes needed.

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Two types of therapy in particular have been shown to be effective in treating both anxiety and eating disorders: cognitive behavioral therapy (CBT) and acceptance and commitment therapy (ACT). Both focus on changing patterns of behavior and thinking. “Generally, therapy is time-limited, maybe eight to 12 sessions or six months to a year,” says Barrera. “These are two pretty severe illnesses,” she adds, “and both have to be dealt with.”