Co-Occurring Eating Disorder and Psychosis: The Need for Trauma-Informed, Integrated and Personalised Care

In this blog, PhD student and Lived Experience Researcher Rosiel Elwyn highlights the importance of trauma-informed, integrated care when treating someone living with both an eating disorder and psychosis.

Co-Occurrence and Gaps in Treatment

Due to the intersections of my trauma, eating disorder, and psychosis, I experienced significant gaps in my medical and mental health treatment. This included diagnostic overshadowing – meaning that for years, my anorexia nervosa and malnutrition was misattributed as being caused by severe psychosis symptoms.

While in hospital, clinicians did not have the resources or guidance to know how to address my eating disorder, psychosis, and trauma. They would attempt to address either my eating disorder, or psychosis, however the aspects of both were deeply interrelated, and I needed a trauma-responsive treatment approach that was much more holistic. In order to improve clinical understanding of what it can be like to experience psychosis and an eating disorder, I wrote a paper using myself as a case example, in hopes that it might support trauma-responsive, integrated care approaches for others who experience an eating disorder with psychosis. My paper [1] advocates for the need for involving people with lived experience in the co-development of clinical guidelines for treating co-occurring conditions such as psychosis and eating disorders.

My paper is open access, so you don’t have to have a subscription to the academic journal to read it. Just please note that as it is a paper intended for clinicians and researchers to support clinical understanding, it does describe eating disorder behaviours, psychotic symptoms, weight, and other experiences that may be distressing (such as suicidality and difficult experiences of hospital treatment). Please do consider your wellbeing first before reading anything that could be sensitive or triggering for you – your safety is the most important thing.

What Where My Early Symptoms Like?

I first developed my eating disorder at the age of 8, closely related to multiple early traumas. At the age of 12, I started to experience early psychosis symptoms, known as ‘prodromal’ symptoms. This included experiencing unusual beliefs, hearing things other people couldn’t hear, seeing things other people couldn’t see, feeling very withdrawn and not wanting to be around other people. When I was 14 I experienced my first psychotic episode and received treatment for it. This psychotic episode included experiencing a ‘break from reality’, which meant that my perception of reality was very significantly changed, which was a threat to my wellbeing. After this first psychotic episode, there was a fairly long period of time until I had my next psychotic episode, but these periods of time started to get shorter and shorter. In the meantime, my other mental health problems, and my eating disorder, were continuing to get more severe. Over time, I was repeatedly hospitalised with multiple psychotic episodes, and had multiple hospitalisations for my eating disorder. After time, and with treatment, I learned to understand how to manage my psychotic symptoms and to understand the indications of a psychotic episode (such as losing sleep, withdrawing, feeling paranoid, dissociating, experiencing executive dysfunction). Sometimes this was hard to differentiate from my trauma symptoms, neurodivergence, and eating disorder. This was made more difficult when my eating disorder treatment and psychosis treatment was not integrated. There were such huge gaps in my care that I spent years in and out of hospitals, desperate for care that met my needs. This is why I want to increase understanding of psychosis and eating disorder co-occurrence.

There are also multiple presentations of psychosis and eating disorders. Some people may not have a co-occurring psychotic condition, but may experience a transient psychotic episode due to malnutrition because of their eating disorder. Others may have a psychotic condition and may experience disordered eating while they’re in psychosis, or due to their medication. A person’s ‘eating disorder voice’ or the beliefs they have from their eating disorder could also seem similar to a psychotic symptom, and clinicians may be unsure how exactly to treat this. I believe that’s why it’s very important to deepen understanding about these different co-occurrences and to have lived experience involvement in developing clinical guidance and resources to support improved treatment.

What Do We Know from Existing Research?

There is a small, but growing amount of research in this area, but further research is needed. Currently, research has found that:

• A meta-analysis of 16 studies indicated that eating disorder and psychotic disorders co-occurrence across clinical and community populations is 8% [2]
• 3-10% of eating disorder patients are estimated to have schizophrenia [3]
• 10–30% of individuals with anorexia nervosa experience delusions [4-7]
• 10-15% of eating disorder patients experience transient psychotic episodes [8]
• Past-year eating disorder is associated with co-occurring diagnosed psychotic disorder (odds ratio: 12.92) and probable psychotic disorder (odds ratio: 28.42) [9]
• Compared to the general population, schizophrenia patients have a higher prevalence of co-occurring anorexia nervosa [10]. There were mixed findings for the prevalence of schizophrenia in AN patients [10].
• Patients with psychotic-spectrum disorders have 2 to 4 times higher rates of disordered eating (10 – 41.5%) [2, 11]
• Binge-eating is experienced by 4.4–45% [11, 12]
• One study indicated that psychosis may be a specific risk for the onset of an eating disorder, with the presence of any psychotic symptoms at age 13 associated with 1.5 increased risk
  for disordered eating behaviour and eating disorder severity at age 18 [13]
• Higher cumulative lifetime and psychotic symptoms over 12 months have also been linked with greater likelihood of meeting criteria for an eating disorder, and having an eating disorder diagnosis at some point over a person’s lifetime [14]
• Psychotic experiences have been associated with later onset of both bulimia nervosa and binge-eating disorder [17]
• Psychotic experiences, such as hearing things other people cannot hear, have been found to be associated with binge-eating [19, 20]
• Paranoia has been linked to disordered eating symptoms [21]
• Patients with anorexia nervosa may report more psychotic symptoms, such as a paranoia, compared to patients with bulimia nervosa [22]
• Symptoms of paranoia have been found to be associated with having concerns about body weight and shape [18]
• People with eating disorders may be more vulnerable to developing a co-occurring psychotic disorder [23] or developing a psychotic disorder in the future [24]
• People with early psychotic-like experiences may be more vulnerable to developing disordered eating [13, 17]

What Does This Mean?

• Eating disorders and psychosis may co-occur in a variety of presentations
• Psychosis symptoms may indicate development of or increased risk for development of disordered eating or an eating disorder. Disordered eating or an eating disorder may indicate development of or increased risk for development of a psychotic disorder. They may have shared mechanisms. More research is needed.
• Due to risk for co-occurrence and overlap, there is need for clinical guidance (screening and treatment).
• Currently there are very little resources for clinicians to use for screening for these co-occurrences. However, the shortest version of the Eating Attitude Test (EAT-7) has been validated as a first-step screening tool to detect disordered eating in patients with first-episode schizophrenia [15]. Further research is needed in this area, with lived experience involvement.

Without clinical guidance on how to treat co-occurring eating disorders and psychosis, there may be significant risk for:

• Delayed diagnosis
• Diagnostic overshadowing/missed diagnosis
• Inappropriate treatments
• People receiving harmful or traumatic experiences in their care
• Lived experience involvement is critical in the co-development of clinical resources

What Did I Suggest for Integrated, Personalised Treatment?

Using my case example [1], I provided a number of specific examples of how my eating disorder symptoms, psychosis, and trauma interrelated, how this affected me, and my treatment. I then made suggestions for what could have been helpful for me in these circumstances.

Broadly, these suggestions included:

1. Compassion, understanding, and patience for the person’s experience of complex symptoms and distress. Including their psychotic-based and eating-disorder based perceptual, sensory, and cognitive disturbances.
2. Reassurance and a focus on helping the person feel safe, reaffirming sense of trust, and reminding them of the reason and need for them to be in hospital. This may be particularly helpful for treatment engagement where psychosis and eating disorder co-occurrence may heighten vulnerability for difficulty recognising and accepting need for treatment.

3. A strong trauma-informed approach incorporating simple somatic care to reduce dissociation, interoceptive, exteroceptive, and body image disturbances, and increase body connection (e.g., grounding exercises, sensory soothing). Including occupational therapists may be particularly beneficial, especially for individuals with depersonalization and derealisation symptoms.

6. Collaboration in treatment and shared medication decision-making to help a person understand their treatment options, support autonomy, and build trust.
7. Consistent, firm and compassionate affirmation that the team wants to provide care and safety, and that the individual deserves safety and support. This may help to reduce paranoia, and encourage treatment engagement, especially for those with anosognosia as part of their ED and psychotic symptoms and strong eating disorder-related cognitions (e.g., belief they are undeserving or not ‘sick enough’ for treatment, and/or that their needs are ‘too much’).
8. Personalised development of a ‘reminder list’ (with an example in the paper) with the person to help them understand the need and purpose of their treatment, reduce disorientation, and increase a sense of safety during care. This may be particularly helpful if the person is experiencing cognitive and perceptual disturbances during psychosis and/or malnutrition.

While Gaps Exist, What Helped Me in My Own Treatment?

Treatment may be different for everyone, and what worked for me may not work for others. What did help me, was Schema Therapy. I found this form of therapy very helpful as it was able to take a more holistic approach to the core unmet needs that were common to my eating disorder, psychosis, and trauma. We were also able to approach therapy in a neuroaffirmative way. I’ve learned a lot of skills that have supported me to work on managing my eating disorder, psychosis, and PTSD and CPTSD long-term, especially while studying my PhD.

Co-occurring Conditions – Advocating for Your Needs in Care

I was part of two teams that helped co-design resources to support people to advocate for their needs in treatment. It can sometimes be difficult or overwhelming to ask for or describe the kind of help you need, especially when you’re unwell. We hope these resources can support you:

• Zirnsak T, Elwyn R, Sherrin M, Burge M, Dasvarma A, Drake J, English L, La Paglia Reid H, Rayner A, Roberts R & Maylea C (2024) “Taking Charge of Your Care: Consumer Resource”, Equally Well, <https://www.equallywell.org.au/consumer-resource/>
• Keep Safe, Be Heard, You Matter Resource: https://wedge-octopus-z5d3.squarespace.com/

 

About the Author

My name is Rosiel Elwyn (they/them), I am a PhD student and Lived Experience researcher. I am neurodivergent, and have lived and living experience of PTSD and complex PTSD, anorexia nervosa and ARFID, psychosis, and suicide survival.

Get Support

Learn more about psychosis and get support

• Rosiel is part of the @psychosis_understood team on Instagram, aiming to increase understanding of the early signs of psychosis. This is a resource young people, families, and clinicians can access.
• headspace – Early psychosis support: Free and confidential support for young people who are experiencing an early episode of psychosis or are at risk of developing psychosis.
• Kids Helpline provides phone and online counselling for young people aged 5 to 25. Call 1800 55 1800.
• Lifeline provides online and phone crisis support. Call 13 11 14.

Get support for an eating disorder

If you’re struggling with an eating disorder or body image concerns, reach out for help from professionals that understand eating disorders. 

• For confidential and free counselling, call the Butterfly National Helpline on 1800 ED HOPE (1800 33 4673) or chat online or email, 7 days a week, 8am-midnight (AEDT).
• Find an eating disorder professional – search Butterfly’s National Referral Database to find eating disorder practitioners closest to you.

References

[1] Elwyn, R. (2025). Co-occurring eating disorder and psychosis: a lived experience case exploration with examples and suggestions for personalized integrated treatment approach. Journal of Eating Disorders, 13(1), 164. https://doi.org/10.1186/s40337-025-01270-6

[2] Drymonitou, G., McCulloch, A., Parry, S., Gough, R., Moreira Cruz, R., Mostoufi, M., Jawad, M., Newman, C., Harding, D., Salazar de Pablo, G., & Jewell, T. (2025). The association between disordered eating and psychosis in clinical and non-clinical populations: a systematic review and meta-analysis. Psychological Medicine, 55, e160, 1–20 https://doi.org/10.1017/S003329172500114X

[3] Yum SY, Caracci G, Hwang MY. Schizophrenia and eating disorders. Psychiatr Clin North Am. 2009;32(4):809–19.

[4] Konstantakopoulos G, Varsou E, Dikeos D, Ioannidi N, Gonidakis F, Papadimitriou G, et al. Delusionality of body image beliefs in eating disorders. Psychiatry Res. 2012;200(2):482–8.

[5] Mountjoy RL, Farhall F, Rossell JL. A phenomenological investigation of overvalued ideas and delusions in clinical and subclinical anorexia nervosa. Psychiatry Res. 2014;220(1):507–12.

[6] Phillipou A, Mountjoy RL, Rossell SL. Overvalued ideas or delusions in anorexia nervosa? Australian New Z J Psychiatry. 2017;51(6).

[7] De Young K, Bottera A, Kambanis E, Mancuso C, Cass K, Lohse K, et al. Delusional intensity as a prognostic indicator among individuals with severe to extreme anorexia nervosa hospitalized at an acute medical stabilization program. Int J Eat Disord. 2022;55(2):215–22.

[8] Sarró S. Transient psychosis in anorexia nervosa: review and case report. Eating and weight Disorders – Studies on anorexia. Bulimia Obes. 2009;14(2):e139–43

[9] Rodgers E, Marwaha S, Humpston C. Co-occurring psychotic and eating disorders in England: findings from the 2014 adult psychiatric morbidity survey. J Eat Disorders. 2022;10(1):150.

[10] Hechinger RM, Javaras KN, Lewandowski KE. Comorbidity of anorexia nervosa and schizophrenia: a systematic review. Schizophr Res. 2025;276:185–93

[11] Sankaranarayanan A, Johnson K, Mammen SJ, Wilding HE, Vasani D, Murali V et al. Disordered eating among people with schizophrenia spectrum disorders: a systematic review. Nutrients. 2021;13(11).

[12] de Beaurepaire R. Binge eating disorders in antipsychotic-treated patients with schizophrenia: prevalence, antipsychotic specificities, and changes over time. J Clin Psychopharmacol. 2021;41(2):114–20.

[13] Solmi F, Melamed D, Lewis G, Kirkbride JB. Longitudinal associations between psychotic experiences and disordered eating behaviours in adolescence: a UK population-based study. Lancet Child Adolesc Health. 2018;2(8):591–9.

[14] Ganson KT, Cuccolo K, Nagata JM. Associations between psychosis symptoms and eating disorders among a national sample of US college students. Eat Behav. 2022;45:101622

[15] Fekih-Romdhane F, Boukadida Y, Cheour M, Hallit S. Validation of the shortest version of the eating attitude test (EAT-7) as a screening tool for disordered eating in patients with first episode schizophrenia. Journal of Eating Disorders. 2025 Feb 7;13(1):20. https://doi.org/10.1186/s40337-025-01210-4

[16] Zirnsak T, Elwyn R, Sherrin M, Burge M, Dasvarma A, Drake J, English L, La Paglia Reid H, Rayner A, Roberts R & Maylea C (2024) “Taking Charge of Your Care: Consumer Resource”, Equally Well, <https://www.equallywell.org.au/consumer-resource/>

[17] McGrath, J. J., Saha, S., Al-Hamzawi, A., Andrade, L., Benjet, C., Bromet, E. J., … Kessler, R. C. (2016). The bidirectional associations between psychotic experiences and DSM-IV mental disorders. American Journal of Psychiatry, 173(10), 997–1006.

[18] Malcolm, A., Phillipou, A., Neill, E., Rossell, S. L., & Toh, W. L. (2022). Relationships between paranoia and body image concern among community women. Journal of Psychiatric Research, 151, 405–410. https://doi.org/10.1016/j.jpsychires.2022.05.007

[19] Koyanagi, A., Stickley, A., & Haro, J. M. (2016). Psychotic-like experiences and disordered eating in the English general population. Psychiatry Research, 241, 26–34. https://doi.org/10.1016/j.psychres.2016.04.045

[20] Mutiso, V. N., Ndetei, D. M., N Muia, E., K Alietsi, R., Onsinyo, L., Kameti, F., … Mamah, D. (2022). The prevalance of binge eating disorder and associated psychiatric and substance use disorders in a student population in Kenya – towards a public health approach. BMC Psychiatry, 22(1), 122. https://doi.org/10.1186/s12888-022-03761-1

[21] Catone, G., Salerno, F., Muzzo, G., Lanzara, V., & Gritti, A. (2021). Association between anorexia nervosa and other specified eating or feeding disorders and paranoia in adolescents: What factors are involved?. Rivista di Psichiatria, 56(2), 100–106. https://doi.org/10.1708/3594.35768

[22] Lysaker, P. H., Chernov, N., Moiseeva, T., Sozinova, M., Dmitryeva, N., Makarova, A., … Kostyuk, G. (2023). Contrasting metacognitive, emotion recognition and alexithymia profiles in bulimia, anorexia, and schizophrenia. The Journal of Nervous and Mental Disease, 211(5), 348. https://doi.org/10.1097/NMD.0000000000001612

[23] Rodgers, E., Marwaha, S., & Humpston, C. (2022). Co-occurring psychotic and eating disorders in England: Findings from the 2014 adult psychiatric morbidity survey. Journal of Eating Disorders, 10(1), 150. https://doi.org/10.1186/s40337-022-00664-0

[24] Zhang, R., Larsen, J. T., Kuja-Halkola, R., Thornton, L., Yao, S., Larsson, H., … Bergen, S. E. (2021). Familial co-aggregation of schizophrenia and eating disorders in Sweden and Denmark. Molecular Psychiatry, 26(9), 5389–5397. https://doi.org/10.1038/s41380-020-0749-x