What do most people misunderstand about eating disorders? Why do eating disorders often cooccur with major depressive disorder? Is it possible to overcome both illnesses at the same time? In this podcast episode, Dr. Cristina Castagnini speaks about mental health awareness, treatment, and eating disorders.


  • Why mental health and eating disorders are connected
  • Distinguishing major depressive disorder
  • A full recovery is possible!

Why mental health and eating disorders are connected

The most important thing that someone has to understand about eating disorders is that they are mental health illnesses.
Eating disorders also typically co-occur with other mental health diagnoses, and this is what I want to talk about and bring awareness to all of you today. (Dr. Castagnini)
Eating disorders often are symptomatic in themselves, meaning that they develop as an external symptom of an unresolved internal issue or problem. These problems could stem from past traumatic experiences or emotional turmoil that has not yet been addressed or resolved. Between 50 and 75% of people that struggle with an eating disorder will also experience symptoms (or share a diagnosis) with depressive disorder.

Distinguishing major depressive disorder

Even though there is a distinction between “going through a rough patch” and experiencing depression, the line is thin. So, if you are in a tough place and you are not sure which way to go, seek professional help.
I always encourage [people] to at least go in and get an assessment to know for sure. I [often see] people dismiss or discount what they’re experiencing rather than getting the help that they need. (Dr. Castagnini)
The criteria for someone to be formally diagnosed with major depressive disorder states that someone needs five or more of the following symptoms to have been present during the same two-week period which is different from previous functioning:
  • Depressed mood and loss of interest or pleasure
  • Marked diminished pleasure in all or almost all activities in the day
  • Significant weight loss or weight gain without an intentional shift in eating habits
  • Hypersomnia or insomnia
  • Psychomotor agitation or retardation every day
  • Fatigue or loss of energy every day
  • A feeling of worthlessness or excessive delusion or guilt
  • Diminished ability to think or concentrate or make decisions every day
  • Recurrent thoughts of death or suicidal ideation
What is crucial to note is that these symptoms should also be noticed by people around you and not only self-diagnosed. Additionally, these symptoms should be based on what someone is experiencing when they are sober. Meaning, without any substance or reaction to a medication, because then those would be considered side effects. In a more everyday sense, these symptoms would look like:
  • A sudden loss of interest in previously beloved activities
  • Mental fatigue and sluggishness
  • Trouble concentrating, understanding, comprehending, and explaining
  • Constantly zoning out and disassociating
  • Having trouble making decisions, even the small ones
  • Either constantly sleeping without feeling rested or struggling to sleep at all
Eating disorders are complex illnesses and there’s no one cause for why someone [experiences] one. They’re [typically] caused by a complex interaction of genetic, biological, behavioral, psychological, and social factors. And, depressive symptoms and behaviors can contribute to eating disorder development … but again, there’s no one cause why someone gets an eating disorder. (Dr. Castagnini)

A full recovery is possible!

Often, a person that is experiencing an eating disorder may be diagnosed with depression, or a person that is struggling with depression may develop an eating disorder. In any case, treatment is possible.
In treating cooccurring eating disorders and depressive symptoms, neither one is more or less urgent than the other, and they both must be treated together. (Dr. Castagnini)
However, in the case that the eating disorder is so severe that the person is medically unstable and is experiencing major physical consequences, becoming medically stable again is the first priority. After that, in step-down and in a lower level of treatment, then treatment for depression can begin. Listen to this episode for more information.
Recovery is possible! Do not let anyone tell you that you will always have your eating disorder to some degree in your life [because it’s not true] and you can achieve full recovery. (Dr. Castagnini)



  I am a licensed Psychologist and Certified Eating Disorder Specialist. While I may have over 20 years of clinical experience, what I also have is the experience of having been a patient who had an eating disorder as well. One thing that I never had during all of my treatment was someone who could look me in the eye and honestly say to me "hey, I've been there. I understand". Going through treatment for an eating disorder is one of the hardest and scariest things to do. I remember being asked to do things that scared me. Things I now know ultimately helped me to get better. But, at the time, I had serious doubts and fears about it. If even one of my providers had been able to tell me "I know it's scary, but I had to go through that part too. Here's what will probably happen...." then perhaps I would not have gone in and out of treatment so many times. My own experience ultimately led me to specialize in treating eating disorders. I wanted to be the therapist I never had; the one who "got it". I will be giving you my perspective and information as an expert and clinician who has been treating patients for over 2 decades. But don't just take my word for it...keep listening to hear the truly informative insights and knowledge guest experts have to share. I am so happy you are here!


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Podcast Transcription

[DR. CRISTINA CASTAGNINI] Behind the Bite Podcast is part of a network of podcasts that are good for the world. Check out podcasts like the Full of Shift Podcast, After the First Marriage Podcast and Eating Recovery Academy over at practiceofthepractice.com/network. Welcome to Behind the Bite Podcast. This podcast is about the real life struggles women face with food, body, image, and weight. We're here to help heal, inspire, and create better, healthier lives. Welcome. Well, hello everyone. Welcome to Behind the Bite Podcast. For any of you who are not aware of this, May is Mental Health Awareness month. While I believe that there needs to be more than just one month out of the year where mental health is a focus of our attention, I am glad that there at least is a dedicated time to help break the stigma about mental health illnesses, spread awareness, and help educate people about what mental health illnesses are. And certainly in the time since I started working in this field, I have seen a lot of positive changes in regard to there being much, much more open, honest discussions about mental illnesses. But if I'm being honest, there is still so much more that needs to be done. To me it's really unfortunate that mental illnesses are so misunderstood and there are still so many barriers to treatment. I just don't get it, like why mental health treatment is not just seen as necessary and just as important for treatment as the treatment for physical health illnesses. It's just unacceptable. Our insurance needs to cover the cost to treat all illnesses, not just some. And something else it's sad to me that people are scared or anxious to seek help or mental health illness. I often hear that they're fearful that others will think that they're "crazy" or something they'll, they're going to be really critical of them if they receive a diagnosis or they're worried that they'll be judged, shamed, or maybe even have negative consequences like lose their job and all of these things need to change. For anyone out there listening who does have a mental health illness, I hope you know you're not alone. I know it can oftentimes be so much easier for people to say that they have a toothache or a broken leg and have no problem going to seek help for those things but it can be so much harder to admit to and seek help for those things that we can't touch, see, or feel on the surface, like depression or anxiety. You know you can feel it, you know it's real, and just because nobody else can does not mean that you don't deserve to get the help and the treatment that you deserve. So in light of this being mental health awareness month, I think it's only appropriate to bring awareness to all of you listening here today. So for any of you who do not know, eating disorders have the highest mortality rate of all mental health illnesses, which is why I feel very strongly that people understand much, much more about them and seek treatment as soon as possible. And eating disorders also typically co-occur with other mental health diagnosis and this is what I want to talk about and bring awareness to all of you today. We call that comorbidity when two illnesses co-occur together. So if you hear me say that word, that's just what that means. For instance, between 50% to 75% of those who struggle with an eating disorder will also experience symptoms of and have a co-diagnosis or comorbidity with major depressive disorder. While I often hear people say that they feel depressed, there is a difference between having a "bad day" or "feeling down" and having the diagnosable illness of major depressive disorder. Sometimes it's difficult to know the difference. While I'm going to go through the diagnostic criteria used to diagnose someone with major depressive disorder, I want anyone listening right now to please hear me loud and clear. I don't ever want anyone to feel like they are, what they're feeling or experiencing is not real or that they're not sick enough to seek help. So I always encourage someone to at least go in and get an assessment to know for sure. I find it so easy for people to dismiss and discount what they're experiencing rather than getting the help they need. Okay, so onto the diagnostic criteria. According to the DSM five, which is short for the Diagnostic and Statistical Manual of Mental Illness 5th Edition it specifies the criteria necessary for someone to be formally diagnosed with major depressive disorder. So here's the criteria. I'll try to go slow as I can, quite long. Someone needs five or more of the following symptoms to have been present during the same two week period and represent a change from previous functioning and at least one of the symptoms is either A, depressed nude or B, loss of interest or pleasure. So depressed nude most of the day, nearly every day, as indicated by either subjective report, like feeling sad, empty, hopeless, or observation made by others appears to your goal. Another symptom, markedly diminished interest or pleasure in all or almost all activities most of the day, nearly every day, again, as indicated by either the person's own account or by observation of others, significant weight loss when not dieting or weight gain, which in the diet field they say, change of more than 5% body weight in a month or a decrease or increase in appetite nearly every day. Another symptom is insomnia or hypersomnia nearly every day so not sleeping or sleeping too much nearly every day. Another symptom is psychomotor agitation or retardation nearly every day. This can look like some these really fidgety or restless or that's psychomotor or agitation or the retardation is like they look really slow, like everything is just slow moving. Again, that's either, that's observable by other people, not just subjective by the person. Another symptom is fatigue or loss of energy nearly every day. Another symptom is feelings of worthlessness or excessive or inappropriate guilt, which may be delusional, that's in the diagnostic manual, nearly every day and it's not merely self-report or guilt about being sick. So again, feelings of worthlessness or excessive or inappropriate guilt. Another symptom is diminished ability to think or concentrate or indecisiveness nearly every day. Another symptom, recurrent thoughts of death, not just fear of dying, recurrent suicidal ideation without a specific plan or a suicide attempt or a specific plan for committing suicide. These symptoms cause clinically significant distress or impairment in social, occupational, or other areas that are important to the person. Something that we use for the diagnosis is that this episode is not attributable to this physiological effects of a substance or another medical condition. So want to make sure somebody's not having like a reaction to a medication or they have a brain tumor or something else is going on. Again, these are the clinical criteria and again, if you want to go back and listen to those again, I know there was a lot of symptoms, but again, it's five or more of the following symptoms I just went off on and listed off have been present during the same two week period. Those, again, like I said, were the clinical criteria, but a lot of people might be wondering about what some of the common signs and symptoms they want to look out for in and of themselves, or a loved one to know if they might be experiencing depression. So just in the day-to-day, some things to look out for are withdrawing from activities and others or isolating yourself or someone else's isolating, feeling sad, hopeless, helpless or worthless nearly every day. Losing interest in pleasure by activity. So let's say you typically enjoy playing video games or painting, but now when you play or you paint you just feel bored or could care less. You find yourself just wanting to cry or being tearful for what feels like really no reason or you see somebody who typically isn't like that doing that. Again, like I mentioned in the criteria, changes in appetite, so either eating way more or less than usual. Someone may be having angry outbursts or maybe you're feeling like you have really angry outbursts and that's just typically not like you. Lacking motivation and feeling like it's difficult or overwhelming or even get irritable when you think about doing even the simplest of daily activities like getting out of bed or brushing your teeth or getting dressed on. When we talk about problems with focusing or concentrating maybe, maybe watching TV and you might find yourself, you have to keep rewinding the show because your mind dressed off and you miss what was said. Or maybe you try to read something over and over and over, or when you're in conversation with people, you just drift off and get lost and you miss most of what someone else just said. You might also find that like making decisions is really hard. You just keep finding it, it's really difficult to decide if you want to go do something or what you want to eat. A lot of people also describe just being really very tired, fatigued, even if you're sleeping a lot more than usual, so sometimes people say, oh my gosh, I'm sleeping all day, I just want to keep sleeping. That's just not typical. Again, those weren't like the clinical symptoms, but I wanted to just mention those so that you might get a more sense of like what that looks like in the more day-to-day. Because people who have eating disorders are also so often given a diagnosis of depression, I sometimes get asked if depression can be the reason why someone gets an eating disorder. So let me start off by saying that eating disorders are very complex illnesses and there's no one cause for why someone gets one. So they're caused by complex interaction of genetic, biological, behavioral, psychological, and social factors and depressive symptoms and behaviors can contribute to eating disorder development. But again, there's no one cause for why someone gets an eating disorder. People who struggle with depression, they often try to find some way to cope with it, and sometimes they turn to maladaptive behaviors such as eating disorder behaviors of restricting binging or purging. And I just mentioned these different eating disorder behaviors and there are different eating disorder diagnoses associated with each of these different behaviors. Before I mention that depression co-occur with eating disorders but there are different eating disorders. So for simplicity and time’s sake, here I will focus on the most commonly known three, anorexia nervosa, bulimia nervosa, and binge eating disorder. So you may be wondering if someone who has a diagnosis of say anorexia nervosa versus someone who has a diagnosis of binge eating disorder, have the same comorbidity rates with depression and they don't. For instance, 42% of those who have a diagnosis of anorexia nervosa experience comorbid depression. One of the strongest connections researchers find between these two disorders is the common symptoms of low self-esteem and body dissatisfaction. These feelings can lead to the development of either disorder as well as the perpetuation of the disorder if left untreated. So there comes a question of which comes first. And there's not really a clear answer and we probably won't ever have one, but for each individual, the dynamic between depressive and eating disorder symptoms really vary. Some might have well experienced depressive struggles first and use disordered eating to cope while others might engage in eating disorder behaviors and experience subsequent depressive symptoms due to malnourishment or hopelessness. When we look at those who have a diagnosis of, say, binge eating disorder, so this is a different thing, so I said 42% of those with anorexia nervosa have comorbid depression, but 46% who have binge eating disorder have a comorbid diagnosis of depression. So binge eating disorder involves similar feelings of depression, such as low self-esteem, low self-worth, shame, guilt and hopelessness and some may use binge eating behaviors to cope with the emotion dysregulation caused by depression. Yet as people continue to engage in binge eating behaviors, they may feel guilty and experience increased symptoms of worthlessness and helplessness as they may experience depression. Bulimia nervosa occurs with major depressive disorder at the highest rate with 70.7% of people who are diagnosed with bulimia nervosa, who currently having a diagnosis of depression. So bulimia and depression share similar emotional and cognitive symptoms such as low self-worth, loneliness, isolation, feeling out of control, irritability, anger, and inadequacy and these disorders also share the consequences of impaired social and occupational functioning. Additionally, with bulimia nervosa, the impact that purging behaviors have on the brain and body make depressive symptoms much more likely to develop an emotion regulation more difficult for the person who has them. Similar to anorexia and binge eating disorder, there is no distinction of which disorder occurs first only that we understand that the two often interact with each other. So if a person has a diagnosis of both an eating disorder and major depression might be asking how do they seek treatment? If you're out there and you're listening and you're someone who has been diagnosed with both an eating disorder and major depression, you might be wondering, okay, should I seek help for my eating disorder or my depression, separately, together which one to address first? So in treating co-occurring eating disorder and depressive symptoms, neither one is more or less urgent than the other, and they really both must be treated together. That being said, there's one thing if the eating disorder is so severe that you or the person who has one is medically unstable and there's major physical consequences, you must first go to inpatient hospitalization for medical stabilization. So while someone's in the hospital, the primary focus needs to be for the person to achieve medical stabilization and then after the person steps down to a different level of treatment, they can then focus on the more psychological aspects of their eating disorder, which may at that point may include exploration and treatment of their depression as well. When I said different levels of treatment, if anyone has questions about the different levels of care for eating disorders, Dr. Michael Wetter from UCLA was a fantastic guest. He provided such great in-depth information about this on episode 54. So I strongly encourage you to go back find episode 54 and listen to this. He did a great job explaining all these different levels of care. There are different types and forms of treatment offered for both eating disorders and depression, and they're varied and numerous and I could too, I could talk about this for the longest time, but what may work well for one person may not work well for another. And I've had, again, numerous podcasts in the past with expert guests discussing many of these different treatments and modalities. So again, I encourage any of you who have not listened to past shows to go back and listen if you're interested. Typically I will say there is a team approach to treatment so there's typically a therapist, nutritionist, and psychiatrist, but regardless of what approach or type of treatment, I want to say loud and clear. I say this almost every episode, but it is possible to overcome your illnesses. It is possible to overcome both illnesses and live a fulfilling life. Recovery is possible. Do not let anyone tell you that you will always have your eating disorder to some degree in your life. You can achieve full recovery. I say this to you as someone who has achieved it, I will say this in probably every podcast going forward as well, you can achieve full recovery. Okay, but before I end today, I do want to say one more final thing, you are not your illness. I so often hear people saying things like, I am depressed, I am anxious, I'm bipolar. Look, your words are powerful. Again, you are not your illness. You just don't hear people saying, I'm a broken leg or I'm a migraine. That would sound ridiculous. But listen, by starting to become aware of and changing the language, the things we say, we can start to change the stigma around mental illness too. If you have an illness, it is not something that's your fault. It's not something that defines you, it's not something that you caused, it's not something you asked for, but what it is, it is something that's diagnosable, manageable, treatable, and definitely not something you need to be ashamed of. Thank you for listening. This podcast is designed to provide accurate and authoritative information in regards to the subject matter covered. It is given with the understanding that neither the host, the publisher, or the guests are rendering legal, accounting, clinical, or any other professional information. If you want a professional, you should find one.