Starting the Conversation—College Life, Eating Disorders and Comorbidity

Written by Stephanie Bagby-Stone, MD

When it comes to struggling with an eating disorder, college is a high risk time. The median age of onset for most eating disorders occurs during these years.2 Studies on college campuses report that nearly 1 in 3 women and 1 in 4 men have disordered eating or unhealthy weight control behaviors and these rates have been increasing.4 However, the number of students receiving treatment is low, with only 20% seeking help.

The Time of Your Life

The college years can be an exciting time of identity exploration and growth, and also a time of great stress. Leaving home, new living situations, making friends and more responsibilities regarding school, money and self-care leaves many students feeling isolated and overwhelmed.

Increased social demands from the media and peers constantly promote comparison and send messages how they should look and act. Greek life, sports, dorms, recreation centers and parties are all potentially challenging for students at risk. Even the classroom brings more challenges with academic demands escalating perfectionism and competition.

Food becomes entirely their responsibility… they must choose what, when, where and how or if they will eat. Fear of gaining the mythical “Freshman 15” looms. Their relationship with food and exercise may become a way to cope.

Comorbid Conditions are Common

It is not surprising to see how eating disorders can flourish in this high pressure, high change environment. Anorexia, bulimia and binge eating disorder are secretive by nature and it is often the co-occurring symptoms that are the reason students come to see doctors and therapists. For patients with eating disorders, having one or more additional psychiatric conditions is more likely than not.2

Most Common Comorbidities found in College Students:1

  • Major Depression
  • Generalized Anxiety Disorder
  • Panic Disorder
  • Suicidal ideation
  • Non-suicidal self-injury
  • Binge drinking
  • Marijuana use
  • Cigarette smoking

As a psychiatrist who was worked many years in college mental health, I would often see eating disordered patients coming to clinic with initial concerns about sadness, anxiety, poor concentration, sleep problems, suicidal thoughts or self-harm. The symptoms of the eating disorder would only be revealed by asking directly and sensitively.

It’s Time to Talk about It

Unfortunately far more students are suffering from these disorders than are seeking or receiving treatment and not enough providers are asking about it. Only 6% of college students reported hearing concerns about their weight, exercise or eating patterns from a medical professional.4

SCOFF is an evidenced based screening tool that can help healthcare providers start the conversation.3

S – Do you make yourself Sick because you feel uncomfortably full?

C – Do you worry you have lost Control over how much you eat?

O – Have you recently lost more than One stone (6.35 kg/14 lbs) in a three-month period?

F – Do you believe yourself to be Fat when others say you are too thin?

F – Would you say Food dominates your life?

‘Yes’ to two or more questions deserves further questioning and a more comprehensive assessment.

Asking everyone about eating disordered behavior is vital in the college population as these disorders can be found in students of any race, ethnicity, sex, gender, academic or socioeconomic level.

Finding Help On and Off Campus

College campuses provide many channels for eating disorder education, prevention and intervention. Family, friends, professors, residential life, social organizations, extracurricular activities, counseling and health services can all provide opportunities to express concern and to aid our students in getting appropriate care.

Resources for treatment of these disorders vary greatly among college campuses. Student health and counseling centers are often a good place to start. They may be able to provide treatment or refer to appropriate levels of care off campus. Students can also contact an eating disorder treatment center directly. Starting to have the conversation is the first step toward recovery.


  1. Eisenberg D et al, “Eating Disorder Symptoms among College Students: Prevalence, Persistence, Correlates, and Treatment-Seeking,” Journal American College Health 59, 8(2011): 700-7.
  2. Hudson JL et al, “The Prevalence and Correlates of Eating Disorders in the National Comorbidity Survey Replication,” Biological Psychiatry 61(2007): 348-58.
  3. Reid F, Morgan JF & Lacey JH, “The Scoff Questionnaire: Assessment of a New Screening Tool for Eating Disorders,” British Journal of Medicine 319(1999): 1467-8.
  4. White S, Reynolds-Malear JB & Cordero E, “Disordered Eating and the Use of Unhealthy Weight Control Methods in College Students: 1995, 2002, and 2008,” Eating Disorders 19(2011): 323-34.


Dr. Stephanie Bagby-Stone is board-certified in adult psychiatry and  will be the Medical Director at McCallum Place in Columbia, Missouri, opening Spring 2015. She is an Adjunct Associate Professor of Clinical Psychiatry at the University of Missouri School of Medicine. She received her bachelor of arts in Biology from Central Methodist University. She completed her MD and psychiatry residency at the University of Missouri School of Medicine. She was chief resident during her last year of residency. She came to McCallum Place after over a decade of experience in college mental health during which she served as the Chief of Psychiatric Services at the University of Missouri Student Health Center and was a member of the Eating Disorder Treatment Team.

As a clinician and educator at the University of Missouri, Dr. Bagby-Stone is active in psychiatry residency and medical student education. She has taught numerous courses related to psychotherapy, behavioral medicine and eating disorders. She currently works in the Office of Medical Education as Faculty Liaison for Student Coaching where her focus is to promote medical student health and well-being. She created the medical student course, “Narrative Medicine and the Meaningful Life,” which uses story and Positive Psychology to improve patient care and promote empathy, well-being and resilience. Her clinical approach is also greatly influenced by the Positive Psychology, otherwise known as the Science of Happiness, which seeks to create thriving, meaningful lives for her patients.