Lethal Links: Shame and Co-Occurring Eating and Substance Disorders

by Margaret Nagib, PsyD

Accurately diagnosing and treating co-occurring disorders is paramount for long term growth and recovery. A 2003 report issued by the National Center on Addiction and Substance Abuse was one of the first of its kind to study and consider the co-occurrence of eating and substance disorders.  According to the report, substance abuse disorders co-occur in up to 50% of eating disorder treatment recipients while 35% of addiction treatment recipients have a co-morbid eating disorders diagnosis. The authors described the cross-section of eating and substance disorders in this way:

This lethal link between substance abuse & eating disorders sends a signal to parents, teachers and health professionals –- where you see the smoke of eating disorders, look for the fire of substance abuse and vice versa (Califano).

It is vitally important as experts in the field of eating disorders to be competent to assess this comorbidity. We should also be prepared to provide a treatment plan to effectively address both the eating and substance disorders.  As an eating disorder specialist, I had to grow in my knowledge and competency in providing care for substance addictions. In my own work with women seeking residential treatment for these co-occurring disorders, working on a cross-disciplinary team with colleagues skilled in addiction has also been an integral part in providing this treatment.

Shame – The Other Lethal Link

And as I worked to grow in this competency over many years I looked for therapeutic themes common to both. This resulted in identification of another lethal link— shame. Shame was the prevalent feeling I found underlying the individuals I worked with struggling with both eating and substance abuse.  Growing in understanding, identification and treatment of shame has greatly affected my work with more positive outcomes.

Research indicates a deep sense of shame often underlies and drives both eating disorders and substance abuse. When these disorders co-occur, the level of shame intensifies. Two key factors go into effectively addressing shame in treatment: (a) clients who receive psycho-education on shame to help them understand, identify, and know how to address shame in their lives have better treatment outcomes. This can also greatly decrease the magnitude and frequency of relapse. (b) Shame resilience therapy can be utilized to increase and sustain gains made in treatment by providing skills that can be used in treatment and ongoing recovery.

A.      Psychoeducation on shame includes defining the difference between shame and guilt, helping clients identify the voice of shame in their lives, and understanding the different types and reactions to shame. The simplest way to explain shame to clients is to juxtapose it with guilt.  Shame is self-focused and involves thoughts of self disparagement like “I am bad.” Guilt is behavior focused acknowledging the wrongness of a behavior (not the wrongness of personhood), such as “I did a bad thing.”   Guilt is helpful to treatment and recovery while shame is destructive.  With this knowledge clients and clinicians can work together to vigilantly listen for the voice of shame and begin to address and challenge this destructive voice.                                   Educating clients on the two types and reactions to shame can be helpful to promote insight. The two types of shame, internal and external, indicate where the emotion of shame is originating. Internal shame reflects deep and often longstanding shameful internal emotions while external shame is based on an individuals tendency to be hypervigilant, perceiving shame as coming from their environment.  The two common reactions to shame are aversion and proneness. A shame averse client experiences shame as particularly painful and works to avert this feeling with their thoughts and actions. A shame prone client reacts more globally as they experience shame across most situations.

B.      The work of Brene Brown is particularly helpful in understanding how to increase shame resilience. She described shame resilience as having four steps. The first step involves helping clients understand & recognize their shame triggers. The second step is to help them use the skill of reality-checking once they are experiencing the feeling of shame. Step three involves encouraging the client to reach out and share their experience of shame with a trusted individual. And finally, the last step is to develop the practice of vulnerability by being open to discussing shame with friends and significant others when it arises.


  1. B. (2006). Shame resilience theory: A grounded theory study on women and shame. Families in Society: The Journal of Contemporary Social Services (87) 1, pp. 43-52.
  1. Califano et.al. (2003). Food for thought: Substance abuse and eating disorders. New York, NY. The National Center on Addiction and Substance Abuse at Columbia University.


Author Bio:

Margaret Nagib, PsyD, is lead faculty of the Clinical Development Institute at Timberline Knolls Residential Center in Chicago. She has specialized in the field of eating disorders since 1998 and recently authored the book, “Souls Like Stars: Renew Your Mind: Heal Your Heart, Unveil Your Shine”

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