I am in the passenger seat of my own body: A qualitative interview study of the relationship between binge eating and concurrent problematic alcohol use

I am in the passenger seat of my own body: A qualitative interview study of the relationship between binge eating and concurrent problematic alcohol use | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article I am in the passenger seat of my own body: A qualitative interview study of the relationship between binge eating and concurrent problematic alcohol use Magdalena Jansson, Lovisa Olsson, Anne-Charlotte Wiberg, Thomas Parling, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8406459/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 16 Mar, 2026 Read the published version in Journal of Eating Disorders → Version 1 posted 9 You are reading this latest preprint version Abstract Background The association between binge eating and alcohol use disorders (AUDs) has been demonstrated in genetic, population-based, and clinical studies. Individuals with binge eating report more binge drinking and heavier alcohol consumption than those with eating disorders (EDs) without binge eating. Co-occurring EDs and AUDs are linked to higher levels of ED symptoms, depression, anxiety, and more severe psychosocial impairment compared with EDs alone. The aim of this qualitative study was to explore how adults with concurrent binge eating and perceived alcohol problems experience these two conditions and their potential interrelationship. Such insight is needed to improve understanding of functional links and perpetuating processes that may complicate treatment. Methods Twelve adults with concurrent binge eating and problematic alcohol use were recruited from a public specialized ED clinic in Stockholm, Sweden, or through an ED patient-organization website between 2024 and early 2025. All interviews were analyzed using reflexive thematic analysis following the principle of Braun and Clarke. Results Four themes were identified. Binge eating and problematic alcohol use were shown to be closely interconnected, as co-occurring emotion regulation strategies, and alcohol being involved before and as part of binge eating situations. Alcohol use maintained the ED, by increasing vulnerability to binge eating, offering short-term relief from ED-related cognitions on restriction, and self-critical views, and being a safety behavior to reduce e.g. body shame in public contexts. Negative responses from healthcare providers regarding concurrent alcohol problems hindered appropriate treatment seeking for both conditions. Conclusions These findings demonstrate the functional relationship between binge eating, and alcohol use, and the maintenance processes of the two conditions. Integrated treatment for both conditions, as well as preventive efforts through earlier identification of alcohol problems in individuals with binge eating difficulties are warranted. Trial registration : The study has not been publicly registered. Binge eating problematic alcohol use emotion regulation difficulties comorbidity integrated treatment PLAIN ENGLISH SUMMARY Studies in both the general population and in patients seeking treatment for eating disorders show that binge eating and alcohol problems often occur together. When they co-occur, people tend to experience more severe eating-disorder symptoms, and treatment can become more challenging. This study explored how adults who struggle with both binge eating and problematic alcohol use understand these difficulties and how they influence one another. The goal was to deepen understanding of how the two conditions may be interconnected and to generate ideas for improving current eating-disorder treatments based on these insights. Twelve adults were interviewed about their experiences with having both binge eating and alcohol problems. They were recruited either at a specialized eating-disorder clinic or through a patient-organization website for eating disorders. The interviews were analyzed to identify themes that represented participants views of the how they experienced the relationship between binge eating and alcohol problems. Participants described binge eating and alcohol use as closely connected. Both were used to cope with difficult emotions, and alcohol often played a role before or during binge-eating episodes. Alcohol use also contributed to being able to maintain the eating disorder, for example, by providing temporary relief from self-critical thoughts and strict food rules, or reducing feelings of body shame in social situations. Participants also reported that negative reactions from healthcare providers to their alcohol use made it harder to seek or receive appropriate help for either problem. These findings demonstrate the need for treatment approaches that address binge eating and alcohol use together, and potential shared underlying aspects that contribute to maintaining both disorders. Such interventions are needed to increase outcomes, and retention in treatment as well as earlier detection of alcohol-related difficulties in people with binge eating problems. BACKGROUND In Western countries, the lifetime prevalence of eating disorders (EDs) among women is approximately 8–18%, with higher rates observed in adolescent and young adults ( 1 , 2 ). Psychiatric comorbidities are highly common in EDs, with up to 70% meeting the criteria for a concurrent diagnosis such as anxiety, depression, neuropsychiatric disorders, or substance use disorders (SUDs) ( 3 , 4 ). Among these, alcohol use disorders (AUDs) are particularly prevalent. The association between binge eating and alcohol use disorders has been identified in genetic, population, and clinical studies ( 3 , 5 – 9 ). Individuals with binge eating report more binge drinking, and heavier alcohol consumption patterns, as compared to individuals with EDs that do not include binge eating. This pattern includes individuals with anorexia nervosa with binge eating and purging, who have a higher frequency of problematic alcohol use, as compared to those with AN without binge eating/purging ( 10 ). Individuals with both EDs and AUDs exhibit higher rates of ED symptoms, depression, and anxiety, as well as more severe psychosocial difficulties and poorer social functioning than those with an ED alone ( 5 , 11 ). Hence, it is particularly important to better understand the clinical implications of treating patients with comorbid EDs and comorbid conditions, in general, and problematic alcohol use in particular. Emotion regulation difficulties are one shared feature that has been explored to understand the more difficult to treat conditions including both EDs and alcohol problems. Such investigations have shown that both binge eating and problem drinking are maintained by their function through negative reinforcement, which is often about relieving negative affects ( 12 – 15 ), such as anxiety, anhedonia, or guilt prior to binge eating, and/or drinking ( 14 ). This may be driven by specific difficulties in regulating emotions, as well as impulsivity which are shared features in EDs and AUDs ( 6 , 14 , 16 – 18 ). More specifically, an impaired inability to identify, being confused, or overwhelmed by feelings, and the tendency to suppress and avoid feelings, have been positively associated with both EDs and SUDs ( 15 , 19 ). Another plausible explanation for the high co-occurrence of binge eating and AUDs, is the limited treatment access and long delays before receiving care for both EDs and AUDs. Reported barriers include failure to recognize the perceived symptoms as mental health problems, fear of stigma, and limited treatment availability and options ( 20 – 24 ). Such barriers may prolong the time with the disorder, contributing to both more severe ED and AUD symptoms and the development of secondary conditions in both directions. Another aspect that may explain the relationship between binge eating and AUDs is that other psychiatric disorders may contribute to the development of comorbid conditions. One proposed link between binge eating and AUDs is the presence of either post-traumatic stress disorder and/or major depressive disorder, as mediators of the relationship between binge eating behaviors and AUDs ( 9 , 25 ). What is still lacking are individual perspectives on how these problems are connected and maintained. To our knowledge, there is no qualitative interview study that has explored how individuals who simultaneously suffer from EDs including binge eating and alcohol problems perceive these conditions, and their potential interconnectedness, and their consequences. The aim of this qualitative study was to explore how adults with concurrent binge eating and perceived alcohol problems, experience these two conditions, and their potential relationship (e.g., whether they potentially maintain each other) from an individual perspective. Such an investigation is warranted for improving our understanding of potential functional relationships and perpetuating processes in binge eating and alcohol use that make them more difficult to treat. It may also generate further hypotheses for developing a novel integrated treatment approach for binge eating and alcohol problems. METHODS Design This was a qualitative interview study including 12 adults who had a concurrent problem with binge eating, and problematic alcohol use. The interviews were conducted in 2024–2025, in Stockholm, Sweden. The current study was approved by the Swedish Ethical Review Authority (No. 2024-05329-01, and amendment: 2024-07895-02). The manuscript is reported in line with Consolidated Criteria for Reporting Qualitative Research (COREQ)( 26 ). Participants and procedure Participants were recruited as a purposive sample at the Stockholm Centre for Eating Disorders, a public clinic specializing in ED treatment, through advertisements in waiting rooms and by handouts from therapists. Advertisements were also posted on the social media account of SHEDO, a Swedish patient organization for individuals with EDs and/or deliberate self-harm. Eligible participants were individuals above 18 years of age, who identified as having both binge eating and concurrent alcohol problems, with no diagnostic procedure included. Exclusion criterion was insufficient proficiency in Swedish. Those who reported an interest in participation were contacted by email, or phone, to schedule an interview appointment. Interviews were conducted either at the Stockholm Centre for Eating disorders, or by video meeting, using an end-to-end encrypted video conferencing platform. In the scheduled meeting, eligible participants received written and oral information about the study and were assessed for eligibility by one of the researchers. After being included, participants reported on their alcohol consumption the previous 30 days, together with the researcher, in line with the timeline follow-back method (TLFB) ( 27 ). The last and the second author performed the interviews, after testing the interview guide, with no changes, after the first interview. All interviews were recorded and transcribed verbatim. No additional notes were taken or included in the data collection, and no follow-up interviews were scheduled. No transcripts were returned to the participants. The participants who came to Stockholm Centre for Eating Disorders (n = 2) filled out questionnaires after finalizing the interview. Those who participated via video meeting (n = 10), received the questionnaires by mail after the interview, filled them out at home, and sent them back to the researcher. No participant withdrew their consent during or after the interview. All participants received two cinema tickets as reimbursement for their participation. Measures Participants reported on the following self-report measures: The Eating Disorder Examination Questionnaire ( 28 ) was used to measure ED symptom severity. The Clinical Impairment Assessment ( 29 ) was used to assess the level of psychosocial impairment due to the ED ( 30 , 31 ). The degree of alcohol problems was measured with the Alcohol Use Disorders Identification Test (AUDIT) (Saunders et al., 1993). Emotion regulation difficulties were assessed with the brief Difficulties in Emotion Regulation Scale (DERS-16) ( 33 ). Depressive and anxiety symptoms were assessed with the Patient Health Questionnaire (PHQ) ( 34 ), and Generalized Anxiety Disorder Scale (GAD-7) ( 35 ). Alcohol consumption was measured with the TLFB ( 27 ), including the previous 30 days. Lastly, participants reported on sociodemographic data, e.g. occupational- and relationship status. Interview guide The interview was semi-structured and included three main questions and allowed for follow-up questions from the researcher. The questions covered; 1) how participants perceived their binge eating and alcohol problem; 2) if they seemed to be somehow connected, and if so, how, and 3) if either the binge eating or alcohol use, maintained the other problem. The researcher encouraged the participants to speak freely and express their opinions on the different topics (Please see supplementary for the complete interview guide). Researchers’ stance The research team brought diverse but complementary clinical and methodological backgrounds to the study. All authors were experienced clinicians from the alcohol, and eating disorder field, which shaped the formulation of the research questions, the conduct of the interviews, and the interpretation of the data. This clinical familiarity facilitated sensitivity to participants’ narratives but also required ongoing reflexive awareness to avoid premature interpretations based on prior professional assumptions. Reflexivity was actively addressed throughout the analytic process by discussing alternative interpretations within the research team. The involvement of researchers at different career stages further supported critical reflection and methodological rigor in the thematic analysis. Analytical framework The chosen method for the analysis was reflexive thematic analysis according to the principles outlined by Braun and Clarke ( 30 , 36 ), in which themes relevant to the research questions were identified through a six-step process. The analytical procedure was as follows, each author independently read the interview transcripts to become familiar with the material. The first, second, and last author separately identified codes, i.e. specific words, sentences or sections which were of interest to the research questions. Both explicit and latent codes were used. A preliminary codebook was created by the first and second author independently, and these were reviewed, discussed, and revised in collaboration with the last author. Together, they organized the codes into themes. These themes were then reexamined and refined through ongoing discussions with the rest of the research team. This process continued until the themes were clearly defined. In the final stages, SIH took primary responsibility for drafting the manuscript, with input and feedback from the other authors. Statistical analyses Statistical analyses included basic descriptive statistics to describe the study participants in terms of background variables and clinical characteristics. The participants’ weekly alcohol consumption was calculated as the total number of weekly standard drinks in the 30-day period, divided by the number of weeks (4.29). Analyses were performed using SPSS version ( 37 ). Sample size estimation The interview study planned for 30 participants as the maximum but had no further estimation of the expected number of interviews beforehand. When reaching 12 participants, we deemed the information power in the material to be high, i.e. that the data material contained rich, in-depth information with the ability to answer the research questions ( 38 ). RESULTS The study included 12 participants, 10 women, one man, and one person who identified as non-binary, and their mean age was 39.7 years. The interviews lasted 23–70 minutes (mean 43.5 minutes). All participants had sought treatment for the ED, and two participants had experience from addiction treatment (not displayed in table). Three participants were on sick leave, and the rest were either students or employed (See Table 1 ). Table 1 Sociodemographic and clinical characteristics of the interview sample (n = 12) Gender (% female) 83.3% M SD Range Age 39.67 13.01 22–60 N (%) Educational status Up to secondary school 3 ( 25 ) Post-secondary school 2 (16.7) University studies 3 years 4 (33.3) Employment status N (%) Employed/self-employed 5 (41.7) Sick leave 4 (33.3) Unemployed 1 (8.3) Student 2 (16.7) Relationship status N (%) Single 7 (58.3) Partner/married 5 (41.7) M SD Range EDE-Q 3.97 0.9 2.16–5.07 CIA 34.42 9.77 12–47 Weekly number of drinks (TLFB 30) 7.13 7.61 0-19.63 AUDIT 12.58 7.01 0–22 GAD-7 14.00 6.38 5–21 PHQ-9 16.17 4.88 7–22 DERS-16 61.17 12.86 36–76 Notes = EDE-Q = Eating Disorder Examination Questionnaire; CIA = Clinical Impairment Assessment; TLFB = Timeline follow back 30 days; AUDIT = Alcohol Use Disorder Identification Test; GAD-7 = Generalized Anxiety Disorder Assessment; PHQ-9 = Patient Health Questionnaire; DERS-16 = Difficulties in Emotion Regulation Scale - Brief version. The analysis resulted in four identified themes. For a schematic overview of the themes see Table 2 . Table 2 Schematic overview of themes, examples of codes and quotes of the respective themes. Theme Code (example) Quote (example) Binge eating and alcohol are alternating ways to handle strong emotions Escape from painful feelings Get into the bubble Numb myself Well, I've realised, for me, it's an escape. /… / It has been my refuge when I can't stand it, can't take it anymore. I just want to get into my bubble; I just have to cut myself off from everything and everyone." Taking a break from control Dared to let go of control when intoxicated Could enjoy eating when being drunk “One can let go of the eating disorder, when drunk. Well, it was less of a priority, once being drunk to a certain level, I could let it go. And when I was drunk enough, I could just eat and enjoy it.” From binge eating to drinking alcohol – managing to keep on with the ED Alcohol was used to handle shame of being overweight "I didn't have a problem with alcohol until I started binge eating again. /… / And I guess that's my way of getting my feelings out and getting some comfort. It was so hard to deal with, because I saw the change in my body. So, then I started drinking. To try to escape it.” Problem drinking as a barrier to appropriate treatment Participant felt misunderstood when remitted to dependency care "They thought that I should get help with it (the alcohol) first. And then I was just disappointed and sad and then I ditched it all. Because it's the same problem, I think. But it's the binge eating that is my foundation, my comfort blanket that I've had for so very long. It felt like the completely wrong end to start” Binge eating and alcohol are alternating ways to handle strong emotions All participants mentioned binge eating or drinking alcohol as ways to handle difficult and negative emotions. Participants typically described processes of emotional build-up of negative feelings, such as anxiety, sadness, depressive moods, anger, shame, guilt, or pain. They described similar processes of emotions building up stronger and stronger, and that eating and drinking made it possible to escape from these feelings. There were also several examples of binge eating and drinking similarly serving as ways to handle both acute emotionally triggering events, such as interpersonal conflicts, or more general long-term strain due to stressful life situations, or traumatic life events. Several participants described the start of binge eating as a process of giving in to either, the urge, or strong emotion, and stepping into a bubble, or a safe space, where the preceding emotions subside, and nothing else is present, or matters. Just before the start of binge eating, when reaching the decision to binge eat, participants experienced a relief of negative emotions, or being calm. Further, when engaging in eating, participants described eating as relaxing, all feelings from before disappearing, and being in a private safe space, or room, where no demands or expectations from the outer world are present. Being in the bubble involved drinking for many of the participants, although both behaviors were not always mixed. "Well, I've realised, for me, it's an escape. /… / It has been my refuge when I can't stand it, can't take it anymore. I just want to get into my bubble; I just have to cut myself off from everything and everyone." (Participant 10) ” I don't have to think and feel, I can sit and eat and watch TV and then I push everything else aside. And then I don't have to have the feeling of loneliness or that I have needs that I think I’m not allowed to have. That helps me push things aside." (Participant 4). Emotional buildup that resulted in binge eating and/or drinking could also be characterized as physical experiences, such as an itch, or physical tension. Such physical tension were experienced, sometimes following periods of stricter food restriction. “I get restless. Extremely restless. It's like my body itches. Often, I've been annoyed with someone at work /... / or it has been several days without me binge eating. It’s like it's building up. It's like it's stored somehow, and then I must let go. Or, that it has to ooze out somehow. /… / all the negative feelings. Stress and irritation, and it doesn't go away if I don't binge eat or drink." (Participant 2) Some participants described binge eating and alcohol as alternating problem behaviors, depending on the situation, or as something they noticed were changing over time. For example, trying to change one behavior, resulted in an increase of the other. One participant noticed changes when e.g. initiating treatment for the ED. When focusing specifically on regular eating, this initially increased drinking alcohol, as the eating was no longer a way of releasing emotional tensions. The process could also be over longer periods of time, where others experienced periods in life to be more dominated by the ED, and in other times, problematic alcohol use, but that both binge eating and drinking still served the purpose of suppressing intolerable emotions. One participant described more frequent changes in problem behaviors, with a typical pattern with alternating behaviors, depending on her family situation. Alcohol could be involved or a distinct problem behavior, but in most participants, both alcohol and binge eating were involved in the same problem situations. “They went very hand in hand in some way, I did both, I ate and drank at the same time, ate a lot of sweets and stuff and drank wine at the same time, it wasn't one or the other there, but they were together those years, I think. It was a double way to numb myself in some way and go into this bubble then /... / when I wanted to just disappear a bit." (Participant 10). In contrast to their role in relieving negative affect, some participants also described binge eating and alcohol use as comforting and rewarding, and sometimes actively anticipated behaviors. Alcohol was more often associated with social occasions, rewarding oneself after hard work, or a stressful work situation, and sometimes even as a reward for maintaining food restriction. Likewise, several participants described the anticipation and ritual of binge eating, including planning, purchasing or preparing food, as something pleasurable that they could look forward to. For some, the positive emotions were intensified by the intention to purge afterward. Planning to purge afterwards created a sense of not having to worry about consequences but also allowing them to feel less conflicted about indulging in both food and alcohol. One participant explained that it was not always negative emotions leading up to binge eating; sometimes eating was associated with feelings of happiness, wanting to get a thrill, having a good time and celebrating herself and reinforcing those feelings. Another common description was the use of food and alcohol to create space for oneself. These moments were described in the sence that initially, eating and drinking served comforting or rewarding purposes. After a while, this could change, and become an episode of binge eating. Taking a break from control Participants described that alcohol and the EDs were connected in the way that drinking was a way to cope with the mental strain of the EDs. Constant worrying about eating, planning, as well as comparing oneself to others, negative thoughts related to appearance, or self-doubt were triggers to drinking as alcohol provided a temporary escape from these thoughts. Drinking provided a temporary break from the “control regimen”, but it could also result in letting go and eating more than expected. Alcohol was used both as something that preceded or followed upon binge eating. Several participants described their view of themselves as harsh, critical, or punishing, and that drinking let them both enjoy eating, without being self-critical, or being able to eat without compensating afterwards. “One can let go of the eating disorder, when drunk. Well, it was less of a priority, once being drunk to a certain level, I could let it go. And when I was drunk enough, I could just eat and enjoy it.” (Participant 1). Alternating between restrictive eating and binge eating, abstaining, and losing control over eating and drinking were perceived as somewhat similar experiences. One common example was eating more than intended, or breaking a specific eating rule, which commonly resulted in loss of control over eating. Further, several participants described that they never had been able to limit alcohol, and that both alcohol and eating resulted in loss of control regarding the other problem. “When I do binge eat, it doesn't feel like I'm in control, it feels like I'm sitting in the passenger seat of my own body. And it becomes black in front of my eyes, it’s like, everything is consumed even though in the beginning I thought, of course that I don't want this. Of course, I don't want to eat so much that I feel ill and of course I don't want those feelings that come after. But once you're in it, it doesn't stop. Until it's done. /… / And then with the alcohol it's a bit similar, I usually always think; God, I don't want to drink so much, so that I feel ill or that I embarrass myself because it's just awful. But once I've started, I think it's kind of the same thing.” (Participant 8). Some participants described mixing binge eating and alcohol intensely, which seemed to amplify the feelings of impaired control, and that binge eating got more intense and longer when drinking. One typical chain of losing control was drinking, which commonly lead to drinking more than intended, and then eating more than intended, which in turn would lead to binge eating. Such episodes were sometimes followed by drinking as the binge eating proceeded and lastly, drinking after purging to regulate emotions of guilt and shame and be able to sleep. Such days were then followed by a new day with increased control and restriction to compensate for the impaired control in both eating and drinking, which in turn would increase the risk of binge eating again. It often happened that I felt I had a good day when it came to food. I hadn’t eaten too little or too much. Then I was going out to dinner with my family, and maybe I’d have a glass of wine or two, just because I was happy and it tasted good. But after a third glass, I would sometimes start to feel like I had eaten too much. I don’t really know if that was true every time, but the feeling came anyway. And sometimes I did eat more than I had planned, clearly so. In those moments, it could feel like my “good day” was ruined, and that I needed to compensate for it afterwards. (Participant 11). In other cases, binge eating came first, but led to excessive drinking during, and after, to handle the emotional responses after binge eating. The ongoing process of maintaining control over eating, and the ED related cognitions, sometimes resulted in intentionally losing control over alcohol. Also, participants described losing control with alcohol as a way of letting go of trying to control stressful life situations or perfectionistic attitudes toward oneself. Some participants reflected on how this surrender of control felt necessary, even if it was unwanted. With binge eating, it’s about losing control. Or letting go of control. In a way, it is a choice. It’s different with alcohol Then I wanted to let go. And it could be more of a social thing, to socialize with friends. “…” “I think it tastes like crap, but once you feel a sense of well-being. When you get drunk, you want it more. Once I've gotten into that little bit of drunkenness, shit, then I want more. And drank before I had eaten anything. Because I wanted the intoxication to come faster as well. ” (Participant 1). Another aspect described by most participants was the feeling of not being able to stop or ever being able to interrupt a binge or drinking episode. Episodes usually continued until they physically could not eat or drink any more. The most frequent description of how a binge or drinking episode would come to an end was by passing out, falling asleep, or vomiting. Further, the tendency to let go, also had negative consequences of the day after, where participants experienced a stronger tendency to let go of control of eating, due to tiredness or hungover. From binge eating to drinking alcohol – managing to keep on with the ED All participant described how their EDs preceded their alcohol problems. Many had not had contact with alcohol until they were young adults whilst their ED had emerged in childhood or early teenage years. This relationship between the ED and alcohol use, was explained in different ways. For some, alcohol soon became a way to handle secondary consequences of the ED, including shame about weight gain, and/or guilt caused by eating behaviors, or a general sense of self-loathing, shame, negative feelings about oneself, or loneliness. "I didn't have a problem with alcohol until I started binge eating again. /… / And I guess that's my way of getting my feelings out and getting some comfort. It was so hard to deal with, because I saw the change in my body. So, then I started drinking. To try to escape it." (Participant 8) Others described alcohol use as a response to emotional or situational overload, where their ED alone was no longer sufficient to manage all the emotions or life circumstances. Another participant reflected on how alcohol came into the picture after a long-standing reliance on binge eating to handle negative feelings and life situations. One participant described it as a general vulnerability where alcohol and the ED in general were just parallel symptoms of being unable to cope with the underlying problems. “If you have an alcohol abuse, there is usually something underneath that has started that addiction, I think. In my case, it is binge eating. That you have to have something all the time. And then I happened to get into alcohol" (Participant 7). Participants also noticed that the alcohol problem arose due to the negative consequences of the ED, such as weight gain. Being able to keep on maintaining food restriction such as drinking to reduce hunger, were also short-term effective ways to use alcohol. Further, alcohol was also used to manage social situations. For instance, they drank alcohol to be able to break isolation, to be able to go out with friends, or meet with a romantic partner, without being completely preoccupied with their appearance. “Alcohol helps me do what I want, even when I feel the way I do. After being isolated for a couple of days, sitting at home and eating, something starts smoldering inside me. I start to feel that I want to belong too — to have fun, laugh, and hang out with people. When I’m sober, I feel like I can’t do that because of how I look, and then alcohol becomes my solution. It helps me get what I want, even though I don’t think I can manage it when I’m sober — at least not completely, not the way I’d like to.” (Participant 4). Problem drinking as a barrier to appropriate treatment Several participants described that they had stopped drinking alcohol after experiencing too many negative consequences, affecting their social and personal life or safety. This contrasted to their experience with the ED, which none of the participant believed they would be able to recover from on their own. Participants had primarily received treatment for their binge eating problem, and only one participant had gone through treatment for alcohol use. Commonly, the reason for not seeking care was not seeing alcohol as their major problem, not being asked about it in other healthcare settings or being too ashamed to talk about their problematic drinking. "Well, I've known for a long time that this is a problem. And it becomes double embarrassing in some way when you do, both things /... / and I think there are many who feel that you might have the courage and have the energy to seek help for one of them. But it's like, it's too much. Too sick. To have both things at the same time. But I have really thought several times that I would like to dare to talk about alcohol in particular." (Participant 11) Among the ones who tried to bring up alcohol as a topic with their healthcare providers, the response was often, that they could not receive ED treatment if they had an alcohol problem. One participant explained how she was seeking care for her ED but was denied because of her problematic drinking. "They thought that I should get help with it (the alcohol) first. And then I was just disappointed and sad and then I ditched it all. Because it's the same problem, I think. But it's the binge eating that is my foundation, my comfort blanket that I've had for so very long. It felt like the completely wrong end to start” (Participant 2). One participant who were in treatment for her ED felt punished, as she was told to stop drinking to be able to continue receiving treatment. "My therapist told me that you have to stop drinking or you can't continue here. Since I identify so strongly with my addictions, it felt like, rejecting that part of me meant rejecting me. You may not be able to face everything at once or break free from everything immediately, but that shouldn’t mean you get punished for it. Just because you haven’t stopped doing something yet doesn’t mean you should be denied treatment." (Participant 4). Taken together, participants felt they did not receive adequate support in managing their problematic behaviors. They described feeling hesitant to bring up their alcohol use in healthcare settings. They also perceived that healthcare providers often failed to recognize alcohol use as relevant to their care and instead referred them to specialized addiction care, or other healthcare providers, regardless of what the patients considered their main problem. DISCUSSION The overall aim of this qualitative interview study was to investigate the experiences and perspectives of patients who struggle with both binge eating behaviors and problematic alcohol use. The study was done to more thoroughly understand how these problems are experienced, and whether they are perceived as interconnected and/ormaintained by each other. We concluded that binge eating, and problematic alcohol use were functionally connected through shared emotional antecedents. In addition, alcohol use contributed to maintaining the ED, as it was used to alleviate negative emotions both related to binge eating, but also creating short term relief from ED related cognitions, e.g. maintaining restriction, perfectionist attitudes towards oneself, thoughts of body shame, and physiological sensations of e.g. being full or hungry. Four themes were identified. Theme one described how binge eating and alcohol use served as emotion-regulation strategies. Theme two described the interplay between exerting control and experience of impaired control in both eating and drinking. The third theme addressed how the ED preceded the alcohol problem and how alcohol contributed to maintaining the ED. Finally, theme four captured how negative responses from healthcare providers on having a concurrent alcohol problem with the ED hampered adequate treatment seeking for both the ED and the alcohol problems. All participants repeatedly described binge eating and alcohol use were preceded by strong emotions as antecedents, such as sadness, anhedonia, anxiety, stress, and irritability. More general descriptions were also used, such as general discomfort, and physical tension. These findings suggest that both binge eating and alcohol use are used as strategies to avoid and suppress negative affect. The later descriptions may indicate aspects of emotional unclarity, and difficulties identifying the actual affect. These findings are in line with previous research on the close relationship between binge eating as well as alcohol use being strategies for handling negative affect, and the role of negative reinforcement in maintaining both behaviors ( 13 – 15 , 18 , 39 ). However, some participants also described how their eating and drinking episodes were triggered and sometimes maintained by positive affect, such as moments of celebration or as a form of self-reward. Whilst anticipating rewards or pursuing positive affect has been associated with alcohol use, the emphasis on alleviation of negative affect has been more prominent in explanations of binge eating ( 12 , 15 ). Ecological momentary assessment studies have demonstrated that negative emotions, and specifically guilt, increase just prior to a binge eating episode ( 15 ). This study’s findings indicate that antecedents to binge eating may also be more neutral or positive feelings on some occasions. The closely connected patterns of binge eating and alcohol consumption were characterized by the participants’ cyclic process between control and impaired control over both alcohol and eating, as described in theme two. Although participants reported having an ED before they had an alcohol problem, most reported longstanding difficulties limiting their alcohol intake, often drinking rapidly or with the occasional intention of losing control. Difficulties to limit, and drinking more than intended on a specific occasion, is a known predictor for developing more severe alcohol problems ( 40 , 41 ). Therefore, it is warranted to reach individuals with problem drinking, who may be at risk of developing more severe alcohol problems—and offer treatment in the context of their ongoing ED care. Addressing the alcohol problem when patients already sought treatment for their ED may reduce time to treatment, due to the stigma-related barrier of seeking treatment in the addiction services ( 20 , 21 ). Another complicating factor of the interaction of the ED and alcohol use was that loss of control over eating seemed to be more profound and resulted in longer and more intense binge episodes when drinking before or during the binge eating episode. The short-term effects of alcohol, which increase impulsivity, may therefore contribute to the severity of these situations and lead to even stronger post-binge eating reactions such as guilt, shame, and self-loathing. It may be hypothesized that such interactions between alcohol use and binge eating, contribute to the heavier symptom burden in individuals with a comorbid ED and alcohol problems, as compared to those who have only an ED. The third theme addressed how alcohol use came after the ED, and served as a maintainer of the ED. This is a novel finding with implications for prevention and treatment. Preventive efforts directed toward binge eating may reduce the risk for a subsample of this population to engage in dysfunctional consumption of alcohol. As explained by the participants drinking was as a way of handling ED-related cognitions, and its related consequences. Typically, these situations were not related to binge eating. Instead, participants’ examples illustrated how alcohol functioned as avoidance of thoughts (e.g., self-critique and self-focus in social and intimate situations). Further, alcohol was used to create temporary “breaks” from intrusive thoughts about restricted eating. As these problem situations were not directly coupled with binge eating, it may be easier to miss from a clinician’s point of view. Awareness of drinking habits of patients and extending their daily monitoring of eating to alcohol use may provide functional insights into maintaining mechanisms perpetuating the ED and problematic alcohol use. Focus on triggers and functions of alcohol consumption may also help identifying cognitions and emotions that are related to eating, shape and weight, or self-worth that might otherwise not be as easily identified by the patient and the therapist. The perspective and experiences provided by the participants in this study also points to the importance of increasing focus on positive emotions in treatment and using stimulus control to ensure that positive emotions are experienced through activities that are incompatible with binge eating or dysfunctional alcohol use. The efficacy of focus on positive valence has been shown in other areas ( 42 , 43 ). In light of the findings from the current study, it’s time to develop and evaluate the incremental effect of a module focusing on increasing positive valence beyond the work on alternative activities that are incompatible with ED according to the CBT-E manual ( 44 ). In theme four, participants described how their attempts to bring up alcohol in their ED treatment were met with rejection, or a non-validating attitude from health care professionals. Being told that alcohol problems must be addressed first can result in reduced trust, feelings of being misunderstood, and not being seen as a whole person. These experiences resulted in patients either ending their ED treatment or found the therapeutic alliance to be disrupted. It is not known if participants were identified by ED healthcare as having a severe or a more complex AUD, which demands specialized addiction treatment before the ED treatment. However, alcohol is a stigmatized condition, and being subjected to stereotypical views of alcohol problems, can reduce the willingness to seek specialized addiction care ( 20 , 21 ). It may be concluded that remitting patients with either hazardous use, or a mild to moderate AUD to specialized addiction care before being treated for their ED, can both prolong the time with ED, and the alcohol problem. Strengths and limitations There are strengths and limitations worth mentioning regarding the current study. To our knowledge, this is the first qualitative study with the specific aim to explore the functional relationship between binge eating and alcohol problems from patients’ perspective, for the purpose of developing a novel treatment aiming to treat both conditions in an integrated approach. The study contributed important information from patients’ perspectives on the development, relationship between, and the maintenance of EDs and comorbid alcohol problems. The research team involves clinicians with longstanding experience from both the ED and AUD fields. Previous subjective experiences may have influenced the interpretation of the data. To balance the impact of such subjectivity, three researchers were involved in coding the material, and the rest of the team contributed by supporting the process of developing themes that accurately represent the data. Another limitation is the uneven gender distribution, which may have influenced the results, given that males more commonly have alcohol problems. The participants did however mirror the typical distribution of males vs females seeking treatment for their ED. CONCLUSIONS The findings demonstrate that co-occurring binge eating and problematic alcohol use can be expected to be closely interconnected. In our study, alcohol problems typically developed after the eating disorder and contributed to its maintenance, both as an emotion-regulation strategy, as part of the binge eating cycle, and by providing short-term relief from ED-related cognitions. These data support previous suggestions of the need for integrated treatment approaches that address both behaviors simultaneously ( 45 – 47 ). Our results suggest that it is motivated to work, not only simultaneously, but with an integrated treatment that specifically addresses the possibly similar and connected maintenance processes of the conditions. Further, it is needed to focus on preventive efforts through earlier identification of alcohol problems in patients with binge eating problems. Declarations Ethics approval and consent to participate The current study was approved by the Swedish Ethical Review Authority (No. 2024-05329-01, and 2024-07895-02). All participants left verbal and written consent to participate in the study. Funding The study was funded by Systembolaget’s Alcohol Research Council, no: FO2024-0016, and Stockholm county Research Council (No: FoUI-1022229). Author Contribution Conceptualization: SIH, Data curation: SIH, LO, Formal analysis: MJ, LO, ACW, TP, AG, SIH Funding acquisition SIH, TP, AG, Investigation: MJ, LO, SIH, Methodology: MJ, LO, ACW, TP, AG, SIH. Project administration: SIH, Resources: SIH, Supervision: SIH, TP, AG, Visualization: LO, SIH, Writing original draft:​SIH, Writing review & editing: MJ, LO, ACW, TP, AG, SIH. Acknowledgement We would like to thank the participants who shared their valuable experiences, views and insights with us. Data Availability Data can be available upon reasonable request. References Galmiche M, Déchelotte P, Lambert G, Tavolacci MP. Prevalence of eating disorders over the 2000–2018 period: a systematic literature review. Am J Clin Nutr. 2019;109(5):1402–13. Silén Y, Keski-Rahkonen A. Worldwide prevalence of DSM-5 eating disorders among young people. Curr Opin Psychiatry [Internet]. 2022;35(6). Available from: https://journals.lww.com/co-psychiatry/fulltext/2022/11000/worldwide_prevalence_of_dsm_5_eating_disorders.3.aspx Mellentin AI, Skøt L, Guala MM, Støving RK, Ascone L, Stenager E, et al. Does receiving an eating disorder diagnosis increase the risk of a subsequent alcohol use disorder? 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Bjureberg J, Ljótsson B, Tull MT, Hedman E, Sahlin H, Lundh LG, et al. Development and Validation of a Brief Version of the Difficulties in Emotion Regulation Scale: The DERS-16. J Psychopathol Behav Assess. 2016 June;38(2):284–96. Spitzer RL, Kroenke K, Williams JB. Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. Primary Care Evaluation of Mental Disorders. Patient Health Questionnaire JAMA. 1999;282(18):1737–44. Spitzer RL, Kroenke K, Williams JBW, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166(10):1092–7. Braun V, Clarke V. Thematic analysis: A practical guide. 2021. SPSS Statistics. IBM Corp. Malterud K, Siersma VD, Guassora AD. Sample size in qualitative interview studies: guided by information power. Qual Health Res. 2016;26(13):1753–60. Berg KC, Crosby RD, Cao L, Peterson CB, Engel SG, Mitchell JE, et al. Facets of negative affect prior to and following binge-only, purge-only, and binge/purge events in women with bulimia nervosa. J Abnorm Psychol. 2013;122(1):111–8. Tuithof M, ten Have M, van den Brink W, Vollebergh W, de Graaf R. Alcohol consumption and symptoms as predictors for relapse of DSM-5 alcohol use disorder. Drug Alcohol Depend. 2014 July;1:140:85–91. Gruenewald PJ, Caetano R, Mair C. Impacts of impaired control and pharmacological criteria for lifetime alcohol use disorder on relationships between drinking and problems. Drug Alcohol Depend. 2025;276:112910. Craske MG, Dunn BD, Meuret AE, Rizvi SJ, Taylor CT. Positive affect and reward processing in the treatment of depression, anxiety and trauma. Nat Rev Psychol. 2024;3(10):665–85. Sandman CF, Craske MG. Psychological Treatments for Anhedonia. Curr Top Behav Neurosci. 2022;58:491–513. Fairburn, Christopher R, Straebler S, Cooper Z, Murphy R. Cognitive behavioral therapy for eating disorders. Psychiatr Clin. 2010;33(3):611–27. Gregorowski C, Seedat S, Jordaan GP. A clinical approach to the assessment and management of co-morbid eating disorders and substance use disorders. BMC Psychiatry. 2013;13:289. Sysko R, Hildebrandt T. Cognitive-behavioural therapy for individuals with bulimia nervosa and a co-occurring substance use disorder. Eur Eat Disord Rev. 2009;17(2):89–100. Harrop EN, Marlatt GA. The comorbidity of substance use disorders and eating disorders in women: Prevalence, etiology, and treatment. Addict Behav. 2010;35(5):392–8. Additional Declarations No competing interests reported. Supplementary Files COREQchecklistIngessonHammarberg260103.pdf SUPPLEMENTARYFILE1interviewguide.docx Cite Share Download PDF Status: Published Journal Publication published 16 Mar, 2026 Read the published version in Journal of Eating Disorders → Version 1 posted Editorial decision: Revision requested 12 Feb, 2026 Reviews received at journal 11 Feb, 2026 Reviewers agreed at journal 29 Jan, 2026 Reviews received at journal 21 Jan, 2026 Reviewers agreed at journal 20 Jan, 2026 Reviewers invited by journal 20 Jan, 2026 Editor assigned by journal 19 Jan, 2026 Submission checks completed at journal 19 Jan, 2026 First submitted to journal 19 Dec, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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When they co-occur, people tend to experience more severe eating-disorder symptoms, and treatment can become more challenging. This study explored how adults who struggle with both binge eating and problematic alcohol use understand these difficulties and how they influence one another. The goal was to deepen understanding of how the two conditions may be interconnected and to generate ideas for improving current eating-disorder treatments based on these insights.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTwelve adults were interviewed about their experiences with having both binge eating and alcohol problems. They were recruited either at a specialized eating-disorder clinic or through a patient-organization website for eating disorders. The interviews were analyzed to identify themes that represented participants views of the how they experienced the relationship between binge eating and alcohol problems.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eParticipants described binge eating and alcohol use as closely connected. Both were used to cope with difficult emotions, and alcohol often played a role before or during binge-eating episodes. Alcohol use also contributed to being able to maintain the eating disorder, for example, by providing temporary relief from self-critical thoughts and strict food rules, or reducing feelings of body shame in social situations. Participants also reported that negative reactions from healthcare providers to their alcohol use made it harder to seek or receive appropriate help for either problem.\u003c/p\u003e\n\u003cp\u003eThese findings demonstrate the need for treatment approaches that address binge eating and alcohol use together, and potential shared underlying aspects that contribute to maintaining both disorders. Such interventions are needed to increase outcomes, and retention in treatment as well as earlier detection of alcohol-related difficulties in people with binge eating problems.\u003c/p\u003e"},{"header":"BACKGROUND","content":"\u003cp\u003eIn Western countries, the lifetime prevalence of eating disorders (EDs) among women is approximately 8\u0026ndash;18%, with higher rates observed in adolescent and young adults (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Psychiatric comorbidities are highly common in EDs, with up to 70% meeting the criteria for a concurrent diagnosis such as anxiety, depression, neuropsychiatric disorders, or substance use disorders (SUDs) (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Among these, alcohol use disorders (AUDs) are particularly prevalent. The association between binge eating and alcohol use disorders has been identified in genetic, population, and clinical studies (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan additionalcitationids=\"CR6 CR7 CR8\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Individuals with binge eating report more binge drinking, and heavier alcohol consumption patterns, as compared to individuals with EDs that do not include binge eating. This pattern includes individuals with anorexia nervosa with binge eating and purging, who have a higher frequency of problematic alcohol use, as compared to those with AN without binge eating/purging (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Individuals with both EDs and AUDs exhibit higher rates of ED symptoms, depression, and anxiety, as well as more severe psychosocial difficulties and poorer social functioning than those with an ED alone (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Hence, it is particularly important to better understand the clinical implications of treating patients with comorbid EDs and comorbid conditions, in general, and problematic alcohol use in particular.\u003c/p\u003e \u003cp\u003eEmotion regulation difficulties are one shared feature that has been explored to understand the more difficult to treat conditions including both EDs and alcohol problems. Such investigations have shown that both binge eating and problem drinking are maintained by their function through negative reinforcement, which is often about relieving negative affects (\u003cspan additionalcitationids=\"CR13 CR14\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e), such as anxiety, anhedonia, or guilt prior to binge eating, and/or drinking (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). This may be driven by specific difficulties in regulating emotions, as well as impulsivity which are shared features in EDs and AUDs (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). More specifically, an impaired inability to identify, being confused, or overwhelmed by feelings, and the tendency to suppress and avoid feelings, have been positively associated with both EDs and SUDs (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAnother plausible explanation for the high co-occurrence of binge eating and AUDs, is the limited treatment access and long delays before receiving care for both EDs and AUDs. Reported barriers include failure to recognize the perceived symptoms as mental health problems, fear of stigma, and limited treatment availability and options (\u003cspan additionalcitationids=\"CR21 CR22 CR23\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Such barriers may prolong the time with the disorder, contributing to both more severe ED and AUD symptoms and the development of secondary conditions in both directions. Another aspect that may explain the relationship between binge eating and AUDs is that other psychiatric disorders may contribute to the development of comorbid conditions. One proposed link between binge eating and AUDs is the presence of either post-traumatic stress disorder and/or major depressive disorder, as mediators of the relationship between binge eating behaviors and AUDs (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWhat is still lacking are individual perspectives on how these problems are connected and maintained. To our knowledge, there is no qualitative interview study that has explored how individuals who simultaneously suffer from EDs including binge eating and alcohol problems perceive these conditions, and their potential interconnectedness, and their consequences.\u003c/p\u003e \u003cp\u003eThe aim of this qualitative study was to explore how adults with concurrent binge eating and perceived alcohol problems, experience these two conditions, and their potential relationship (e.g., whether they potentially maintain each other) from an individual perspective. Such an investigation is warranted for improving our understanding of potential functional relationships and perpetuating processes in binge eating and alcohol use that make them more difficult to treat. It may also generate further hypotheses for developing a novel integrated treatment approach for binge eating and alcohol problems.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eDesign\u003c/h2\u003e \u003cp\u003eThis was a qualitative interview study including 12 adults who had a concurrent problem with binge eating, and problematic alcohol use. The interviews were conducted in 2024\u0026ndash;2025, in Stockholm, Sweden. The current study was approved by the Swedish Ethical Review Authority (No. 2024-05329-01, and amendment: 2024-07895-02). The manuscript is reported in line with Consolidated Criteria for Reporting Qualitative Research (COREQ)(\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eParticipants and procedure\u003c/h3\u003e\n\u003cp\u003eParticipants were recruited as a purposive sample at the Stockholm Centre for Eating Disorders, a public clinic specializing in ED treatment, through advertisements in waiting rooms and by handouts from therapists. Advertisements were also posted on the social media account of SHEDO, a Swedish patient organization for individuals with EDs and/or deliberate self-harm. Eligible participants were individuals above 18 years of age, who identified as having both binge eating and concurrent alcohol problems, with no diagnostic procedure included. Exclusion criterion was insufficient proficiency in Swedish. Those who reported an interest in participation were contacted by email, or phone, to schedule an interview appointment. Interviews were conducted either at the Stockholm Centre for Eating disorders, or by video meeting, using an end-to-end encrypted video conferencing platform. In the scheduled meeting, eligible participants received written and oral information about the study and were assessed for eligibility by one of the researchers. After being included, participants reported on their alcohol consumption the previous 30 days, together with the researcher, in line with the timeline follow-back method (TLFB) (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). The last and the second author performed the interviews, after testing the interview guide, with no changes, after the first interview. All interviews were recorded and transcribed verbatim. No additional notes were taken or included in the data collection, and no follow-up interviews were scheduled. No transcripts were returned to the participants. The participants who came to Stockholm Centre for Eating Disorders (n\u0026thinsp;=\u0026thinsp;2) filled out questionnaires after finalizing the interview. Those who participated via video meeting (n\u0026thinsp;=\u0026thinsp;10), received the questionnaires by mail after the interview, filled them out at home, and sent them back to the researcher. No participant withdrew their consent during or after the interview. All participants received two cinema tickets as reimbursement for their participation.\u003c/p\u003e\n\u003ch3\u003eMeasures\u003c/h3\u003e\n\u003cp\u003eParticipants reported on the following self-report measures: The Eating Disorder Examination Questionnaire (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e) was used to measure ED symptom severity. The Clinical Impairment Assessment (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e) was used to assess the level of psychosocial impairment due to the ED (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). The degree of alcohol problems was measured with the Alcohol Use Disorders Identification Test (AUDIT) (Saunders et al., 1993). Emotion regulation difficulties were assessed with the brief Difficulties in Emotion Regulation Scale (DERS-16) (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). Depressive and anxiety symptoms were assessed with the Patient Health Questionnaire (PHQ) (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e), and Generalized Anxiety Disorder Scale (GAD-7) (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). Alcohol consumption was measured with the TLFB (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e), including the previous 30 days. Lastly, participants reported on sociodemographic data, e.g. occupational- and relationship status.\u003c/p\u003e\n\u003ch3\u003eInterview guide\u003c/h3\u003e\n\u003cp\u003eThe interview was semi-structured and included three main questions and allowed for follow-up questions from the researcher. The questions covered; 1) how participants perceived their binge eating and alcohol problem; 2) if they seemed to be somehow connected, and if so, how, and 3) if either the binge eating or alcohol use, maintained the other problem. The researcher encouraged the participants to speak freely and express their opinions on the different topics (Please see supplementary for the complete interview guide).\u003c/p\u003e\n\u003ch3\u003eResearchers’ stance\u003c/h3\u003e\n\u003cp\u003eThe research team brought diverse but complementary clinical and methodological backgrounds to the study. All authors were experienced clinicians from the alcohol, and eating disorder field, which shaped the formulation of the research questions, the conduct of the interviews, and the interpretation of the data. This clinical familiarity facilitated sensitivity to participants\u0026rsquo; narratives but also required ongoing reflexive awareness to avoid premature interpretations based on prior professional assumptions. Reflexivity was actively addressed throughout the analytic process by discussing alternative interpretations within the research team. The involvement of researchers at different career stages further supported critical reflection and methodological rigor in the thematic analysis.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eAnalytical framework\u003c/h2\u003e \u003cp\u003eThe chosen method for the analysis was reflexive thematic analysis according to the principles outlined by Braun and Clarke (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e), in which themes relevant to the research questions were identified through a six-step process. The analytical procedure was as follows, each author independently read the interview transcripts to become familiar with the material. The first, second, and last author separately identified codes, i.e. specific words, sentences or sections which were of interest to the research questions. Both explicit and latent codes were used. A preliminary codebook was created by the first and second author independently, and these were reviewed, discussed, and revised in collaboration with the last author. Together, they organized the codes into themes. These themes were then reexamined and refined through ongoing discussions with the rest of the research team. This process continued until the themes were clearly defined. In the final stages, SIH took primary responsibility for drafting the manuscript, with input and feedback from the other authors.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStatistical analyses\u003c/h3\u003e\n\u003cp\u003eStatistical analyses included basic descriptive statistics to describe the study participants in terms of background variables and clinical characteristics. The participants\u0026rsquo; weekly alcohol consumption was calculated as the total number of weekly standard drinks in the 30-day period, divided by the number of weeks (4.29). Analyses were performed using SPSS version (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eSample size estimation\u003c/h3\u003e\n\u003cp\u003eThe interview study planned for 30 participants as the maximum but had no further estimation of the expected number of interviews beforehand. When reaching 12 participants, we deemed the information power in the material to be high, i.e. that the data material contained rich, in-depth information with the ability to answer the research questions (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e).\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eThe study included 12 participants, 10 women, one man, and one person who identified as non-binary, and their mean age was 39.7 years. The interviews lasted 23\u0026ndash;70 minutes (mean 43.5 minutes). All participants had sought treatment for the ED, and two participants had experience from addiction treatment (not displayed in table). Three participants were on sick leave, and the rest were either students or employed (See Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSociodemographic and clinical characteristics of the interview sample (n\u0026thinsp;=\u0026thinsp;12)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender (% female)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e83.3%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRange\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22\u0026ndash;60\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducational status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUp to secondary school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePost-secondary school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUniversity studies\u0026thinsp;\u0026lt;\u0026thinsp;3 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUniversity\u0026thinsp;\u0026gt;\u0026thinsp;3 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmployment status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmployed/self-employed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (41.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSick leave\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (8.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRelationship status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (58.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePartner/married\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (41.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRange\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEDE-Q\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.16\u0026ndash;5.07\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCIA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12\u0026ndash;47\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeekly number of drinks (TLFB 30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0-19.63\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAUDIT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u0026ndash;22\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGAD-7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5\u0026ndash;21\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePHQ-9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7\u0026ndash;22\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDERS-16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36\u0026ndash;76\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cem\u003eNotes\u003c/em\u003e\u0026thinsp;=\u0026thinsp;EDE-Q\u0026thinsp;=\u0026thinsp;Eating Disorder Examination Questionnaire; CIA\u0026thinsp;=\u0026thinsp;Clinical Impairment Assessment; TLFB\u0026thinsp;=\u0026thinsp;Timeline follow back 30 days; AUDIT\u0026thinsp;=\u0026thinsp;Alcohol Use Disorder Identification Test; GAD-7\u0026thinsp;=\u0026thinsp;Generalized Anxiety Disorder Assessment; PHQ-9\u0026thinsp;=\u0026thinsp;Patient Health Questionnaire; DERS-16\u0026thinsp;=\u0026thinsp;Difficulties in Emotion Regulation Scale - Brief version.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe analysis resulted in four identified themes. For a schematic overview of the themes see Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSchematic overview of themes, examples of codes and quotes of the respective themes.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTheme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCode (example)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQuote (example)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBinge eating and alcohol are alternating ways to handle strong emotions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEscape from painful feelings\u003c/p\u003e \u003cp\u003eGet into the bubble\u003c/p\u003e \u003cp\u003eNumb myself\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eWell, I've realised, for me, it's an escape. /\u0026hellip; / It has been my refuge when I can't stand it, can't take it anymore. I just want to get into my bubble; I just have to cut myself off from everything and everyone.\"\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTaking a break from control\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDared to let go of control when intoxicated\u003c/p\u003e \u003cp\u003eCould enjoy eating when being drunk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;One can let go of the eating disorder, when drunk. Well, it was less of a priority, once being drunk to a certain level, I could let it go. And when I was drunk enough, I could just eat and enjoy it.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFrom binge eating to drinking alcohol \u0026ndash; managing to keep on with the ED\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAlcohol was used to handle shame of being overweight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e\"I didn't have a problem with alcohol until I started binge eating again. /\u0026hellip; / And I guess that's my way of getting my feelings out and getting some comfort. It was so hard to deal with, because I saw the change in my body. So, then I started drinking. To try to escape it.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProblem drinking as a barrier to appropriate treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eParticipant felt misunderstood when remitted to dependency care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e\"They thought that I should get help with it (the alcohol) first. And then I was just disappointed and sad and then I ditched it all. Because it's the same problem, I think. But it's the binge eating that is my foundation, my comfort blanket that I've had for so very long. It felt like the completely wrong end to start\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eBinge eating and alcohol are alternating ways to handle strong emotions\u003c/h2\u003e \u003cp\u003e All participants mentioned binge eating or drinking alcohol as ways to handle difficult and negative emotions. Participants typically described processes of emotional build-up of negative feelings, such as anxiety, sadness, depressive moods, anger, shame, guilt, or pain. They described similar processes of emotions building up stronger and stronger, and that eating and drinking made it possible to escape from these feelings. There were also several examples of binge eating and drinking similarly serving as ways to handle both acute emotionally triggering events, such as interpersonal conflicts, or more general long-term strain due to stressful life situations, or traumatic life events. Several participants described the start of binge eating as a process of giving in to either, the urge, or strong emotion, and stepping into a bubble, or a safe space, where the preceding emotions subside, and nothing else is present, or matters. Just before the start of binge eating, when reaching the decision to binge eat, participants experienced a relief of negative emotions, or being calm. Further, when engaging in eating, participants described eating as relaxing, all feelings from before disappearing, and being in a private safe space, or room, where no demands or expectations from the outer world are present. Being in the bubble involved drinking for many of the participants, although both behaviors were not always mixed.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"Well, I've realised, for me, it's an escape. /\u0026hellip; / It has been my refuge when I can't stand it, can't take it anymore. I just want to get into my bubble; I just have to cut myself off from everything and everyone.\"\u003c/em\u003e (Participant 10)\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026rdquo; I don't have to think and feel, I can sit and eat and watch TV and then I push everything else aside. And then I don't have to have the feeling of loneliness or that I have needs that I think I\u0026rsquo;m not allowed to have. That helps me push things aside.\"\u003c/em\u003e (Participant 4).\u003c/p\u003e \u003cp\u003eEmotional buildup that resulted in binge eating and/or drinking could also be characterized as physical experiences, such as an itch, or physical tension. Such physical tension were experienced, sometimes following periods of stricter food restriction.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I get restless. Extremely restless. It's like my body itches. Often, I've been annoyed with someone at work /... / or it has been several days without me binge eating. It\u0026rsquo;s like it's building up. It's like it's stored somehow, and then I must let go. Or, that it has to ooze out somehow. /\u0026hellip; / all the negative feelings. Stress and irritation, and it doesn't go away if I don't binge eat or drink.\"\u003c/em\u003e (Participant 2)\u003c/p\u003e \u003cp\u003eSome participants described binge eating and alcohol as alternating problem behaviors, depending on the situation, or as something they noticed were changing over time. For example, trying to change one behavior, resulted in an increase of the other. One participant noticed changes when e.g. initiating treatment for the ED. When focusing specifically on regular eating, this initially increased drinking alcohol, as the eating was no longer a way of releasing emotional tensions. The process could also be over longer periods of time, where others experienced periods in life to be more dominated by the ED, and in other times, problematic alcohol use, but that both binge eating and drinking still served the purpose of suppressing intolerable emotions. One participant described more frequent changes in problem behaviors, with a typical pattern with alternating behaviors, depending on her family situation. Alcohol could be involved or a distinct problem behavior, but in most participants, both alcohol and binge eating were involved in the same problem situations.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;They went very hand in hand in some way, I did both, I ate and drank at the same time, ate a lot of sweets and stuff and drank wine at the same time, it wasn't one or the other there, but they were together those years, I think. It was a double way to numb myself in some way and go into this bubble then /... / when I wanted to just disappear a bit.\"\u003c/em\u003e (Participant 10).\u003c/p\u003e \u003cp\u003e In contrast to their role in relieving negative affect, some participants also described binge eating and alcohol use as comforting and rewarding, and sometimes actively anticipated behaviors. Alcohol was more often associated with social occasions, rewarding oneself after hard work, or a stressful work situation, and sometimes even as a reward for maintaining food restriction. Likewise, several participants described the anticipation and ritual of binge eating, including planning, purchasing or preparing food, as something pleasurable that they could look forward to. For some, the positive emotions were intensified by the intention to purge afterward. Planning to purge afterwards created a sense of not having to worry about consequences but also allowing them to feel less conflicted about indulging in both food and alcohol. One participant explained that it was not always negative emotions leading up to binge eating; sometimes eating was associated with feelings of happiness, wanting to get a thrill, having a good time and celebrating herself and reinforcing those feelings. Another common description was the use of food and alcohol to create space for oneself. These moments were described in the sence that initially, eating and drinking served comforting or rewarding purposes. After a while, this could change, and become an episode of binge eating.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eTaking a break from control\u003c/h2\u003e \u003cp\u003eParticipants described that alcohol and the EDs were connected in the way that drinking was a way to cope with the mental strain of the EDs. Constant worrying about eating, planning, as well as comparing oneself to others, negative thoughts related to appearance, or self-doubt were triggers to drinking as alcohol provided a temporary escape from these thoughts. Drinking provided a temporary break from the \u0026ldquo;control regimen\u0026rdquo;, but it could also result in letting go and eating more than expected. Alcohol was used both as something that preceded or followed upon binge eating.\u003c/p\u003e \u003cp\u003e Several participants described their view of themselves as harsh, critical, or punishing, and that drinking let them both enjoy eating, without being self-critical, or being able to eat without compensating afterwards.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;One can let go of the eating disorder, when drunk. Well, it was less of a priority, once being drunk to a certain level, I could let it go. And when I was drunk enough, I could just eat and enjoy it.\u0026rdquo; (Participant 1).\u003c/em\u003e \u003c/p\u003e \u003cp\u003eAlternating between restrictive eating and binge eating, abstaining, and losing control over eating and drinking were perceived as somewhat similar experiences. One common example was eating more than intended, or breaking a specific eating rule, which commonly resulted in loss of control over eating. Further, several participants described that they never had been able to limit alcohol, and that both alcohol and eating resulted in loss of control regarding the other problem.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;When I do binge eat, it doesn't feel like I'm in control, it feels like I'm sitting in the passenger seat of my own body. And it becomes black in front of my eyes, it\u0026rsquo;s like, everything is consumed even though in the beginning I thought, of course that I don't want this. Of course, I don't want to eat so much that I feel ill and of course I don't want those feelings that come after. But once you're in it, it doesn't stop. Until it's done. /\u0026hellip; / And then with the alcohol it's a bit similar, I usually always think; God, I don't want to drink so much, so that I feel ill or that I embarrass myself because it's just awful. But once I've started, I think it's kind of the same thing.\u0026rdquo;\u003c/em\u003e (Participant 8).\u003c/p\u003e \u003cp\u003eSome participants described mixing binge eating and alcohol intensely, which seemed to amplify the feelings of impaired control, and that binge eating got more intense and longer when drinking. One typical chain of losing control was drinking, which commonly lead to drinking more than intended, and then eating more than intended, which in turn would lead to binge eating. Such episodes were sometimes followed by drinking as the binge eating proceeded and lastly, drinking after purging to regulate emotions of guilt and shame and be able to sleep. Such days were then followed by a new day with increased control and restriction to compensate for the impaired control in both eating and drinking, which in turn would increase the risk of binge eating again.\u003c/p\u003e \u003cp\u003e \u003cem\u003eIt often happened that I felt I had a good day when it came to food. I hadn\u0026rsquo;t eaten too little or too much. Then I was going out to dinner with my family, and maybe I\u0026rsquo;d have a glass of wine or two, just because I was happy and it tasted good. But after a third glass, I would sometimes start to feel like I had eaten too much. I don\u0026rsquo;t really know if that was true every time, but the feeling came anyway. And sometimes I did eat more than I had planned, clearly so. In those moments, it could feel like my \u0026ldquo;good day\u0026rdquo; was ruined, and that I needed to compensate for it afterwards.\u003c/em\u003e (Participant 11).\u003c/p\u003e \u003cp\u003eIn other cases, binge eating came first, but led to excessive drinking during, and after, to handle the emotional responses after binge eating.\u003c/p\u003e \u003cp\u003eThe ongoing process of maintaining control over eating, and the ED related cognitions, sometimes resulted in intentionally losing control over alcohol. Also, participants described losing control with alcohol as a way of letting go of trying to control stressful life situations or perfectionistic attitudes toward oneself. Some participants reflected on how this surrender of control felt necessary, even if it was unwanted.\u003c/p\u003e \u003cp\u003e \u003cem\u003eWith binge eating, it\u0026rsquo;s about losing control. Or letting go of control. In a way, it is a choice. It\u0026rsquo;s different with alcohol Then I wanted to let go. And it could be more of a social thing, to socialize with friends.\u003c/em\u003e \u0026ldquo;\u0026hellip;\u0026rdquo; \u003cem\u003e\u0026ldquo;I think it tastes like crap, but once you feel a sense of well-being. When you get drunk, you want it more. Once I've gotten into that little bit of drunkenness, shit, then I want more. And drank before I had eaten anything. Because I wanted the intoxication to come faster as well.\u003c/em\u003e\u0026rdquo; (Participant 1).\u003c/p\u003e \u003cp\u003eAnother aspect described by most participants was the feeling of not being able to stop or ever being able to interrupt a binge or drinking episode. Episodes usually continued until they physically could not eat or drink any more. The most frequent description of how a binge or drinking episode would come to an end was by passing out, falling asleep, or vomiting. Further, the tendency to let go, also had negative consequences of the day after, where participants experienced a stronger tendency to let go of control of eating, due to tiredness or hungover.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eFrom binge eating to drinking alcohol \u0026ndash; managing to keep on with the ED\u003c/h2\u003e \u003cp\u003eAll participant described how their EDs preceded their alcohol problems. Many had not had contact with alcohol until they were young adults whilst their ED had emerged in childhood or early teenage years. This relationship between the ED and alcohol use, was explained in different ways. For some, alcohol soon became a way to handle secondary consequences of the ED, including shame about weight gain, and/or guilt caused by eating behaviors, or a general sense of self-loathing, shame, negative feelings about oneself, or loneliness.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"I didn't have a problem with alcohol until I started binge eating again. /\u0026hellip; / And I guess that's my way of getting my feelings out and getting some comfort. It was so hard to deal with, because I saw the change in my body. So, then I started drinking. To try to escape it.\"\u003c/em\u003e (Participant 8)\u003c/p\u003e \u003cp\u003eOthers described alcohol use as a response to emotional or situational overload, where their ED alone was no longer sufficient to manage all the emotions or life circumstances. Another participant reflected on how alcohol came into the picture after a long-standing reliance on binge eating to handle negative feelings and life situations. One participant described it as a general vulnerability where alcohol and the ED in general were just parallel symptoms of being unable to cope with the underlying problems.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;If you have an alcohol abuse, there is usually something underneath that has started that addiction, I think. In my case, it is binge eating. That you have to have something all the time. And then I happened to get into alcohol\"\u003c/em\u003e (Participant 7).\u003c/p\u003e \u003cp\u003eParticipants also noticed that the alcohol problem arose due to the negative consequences of the ED, such as weight gain. Being able to keep on maintaining food restriction such as drinking to reduce hunger, were also short-term effective ways to use alcohol. Further, alcohol was also used to manage social situations. For instance, they drank alcohol to be able to break isolation, to be able to go out with friends, or meet with a romantic partner, without being completely preoccupied with their appearance.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Alcohol helps me do what I want, even when I feel the way I do. After being isolated for a couple of days, sitting at home and eating, something starts smoldering inside me. I start to feel that I want to belong too \u0026mdash; to have fun, laugh, and hang out with people. When I\u0026rsquo;m sober, I feel like I can\u0026rsquo;t do that because of how I look, and then alcohol becomes my solution. It helps me get what I want, even though I don\u0026rsquo;t think I can manage it when I\u0026rsquo;m sober \u0026mdash; at least not completely, not the way I\u0026rsquo;d like to.\u0026rdquo;\u003c/em\u003e (Participant 4).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eProblem drinking as a barrier to appropriate treatment\u003c/h2\u003e \u003cp\u003eSeveral participants described that they had stopped drinking alcohol after experiencing too many negative consequences, affecting their social and personal life or safety. This contrasted to their experience with the ED, which none of the participant believed they would be able to recover from on their own. Participants had primarily received treatment for their binge eating problem, and only one participant had gone through treatment for alcohol use. Commonly, the reason for not seeking care was not seeing alcohol as their major problem, not being asked about it in other healthcare settings or being too ashamed to talk about their problematic drinking.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"Well, I've known for a long time that this is a problem. And it becomes double embarrassing in some way when you do, both things /... / and I think there are many who feel that you might have the courage and have the energy to seek help for one of them. But it's like, it's too much. Too sick. To have both things at the same time. But I have really thought several times that I would like to dare to talk about alcohol in particular.\"\u003c/em\u003e (Participant 11)\u003c/p\u003e \u003cp\u003eAmong the ones who tried to bring up alcohol as a topic with their healthcare providers, the response was often, that they could not receive ED treatment if they had an alcohol problem. One participant explained how she was seeking care for her ED but was denied because of her problematic drinking.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"They thought that I should get help with it (the alcohol) first. And then I was just disappointed and sad and then I ditched it all. Because it's the same problem, I think. But it's the binge eating that is my foundation, my comfort blanket that I've had for so very long. It felt like the completely wrong end to start\u0026rdquo;\u003c/em\u003e (Participant 2).\u003c/p\u003e \u003cp\u003eOne participant who were in treatment for her ED felt punished, as she was told to stop drinking to be able to continue receiving treatment.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"My therapist told me that you have to stop drinking or you can't continue here. Since I identify so strongly with my addictions, it felt like, rejecting that part of me meant rejecting me. You may not be able to face everything at once or break free from everything immediately, but that shouldn\u0026rsquo;t mean you get punished for it. Just because you haven\u0026rsquo;t stopped doing something yet doesn\u0026rsquo;t mean you should be denied treatment.\"\u003c/em\u003e (Participant 4).\u003c/p\u003e \u003cp\u003e Taken together, participants felt they did not receive adequate support in managing their problematic behaviors. They described feeling hesitant to bring up their alcohol use in healthcare settings. They also perceived that healthcare providers often failed to recognize alcohol use as relevant to their care and instead referred them to specialized addiction care, or other healthcare providers, regardless of what the patients considered their main problem.\u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe overall aim of this qualitative interview study was to investigate the experiences and perspectives of patients who struggle with both binge eating behaviors and problematic alcohol use. The study was done to more thoroughly understand how these problems are experienced, and whether they are perceived as interconnected and/ormaintained by each other. We concluded that binge eating, and problematic alcohol use were functionally connected through shared emotional antecedents. In addition, alcohol use contributed to maintaining the ED, as it was used to alleviate negative emotions both related to binge eating, but also creating short term relief from ED related cognitions, e.g. maintaining restriction, perfectionist attitudes towards oneself, thoughts of body shame, and physiological sensations of e.g. being full or hungry. Four themes were identified. Theme one described how binge eating and alcohol use served as emotion-regulation strategies. Theme two described the interplay between exerting control and experience of impaired control in both eating and drinking. The third theme addressed how the ED preceded the alcohol problem and how alcohol contributed to maintaining the ED. Finally, theme four captured how negative responses from healthcare providers on having a concurrent alcohol problem with the ED hampered adequate treatment seeking for both the ED and the alcohol problems.\u003c/p\u003e \u003cp\u003e All participants repeatedly described binge eating and alcohol use were preceded by strong emotions as antecedents, such as sadness, anhedonia, anxiety, stress, and irritability. More general descriptions were also used, such as general discomfort, and physical tension. These findings suggest that both binge eating and alcohol use are used as strategies to avoid and suppress negative affect. The later descriptions may indicate aspects of emotional unclarity, and difficulties identifying the actual affect. These findings are in line with previous research on the close relationship between binge eating as well as alcohol use being strategies for handling negative affect, and the role of negative reinforcement in maintaining both behaviors (\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). However, some participants also described how their eating and drinking episodes were triggered and sometimes maintained by positive affect, such as moments of celebration or as a form of self-reward. Whilst anticipating rewards or pursuing positive affect has been associated with alcohol use, the emphasis on alleviation of negative affect has been more prominent in explanations of binge eating (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Ecological momentary assessment studies have demonstrated that negative emotions, and specifically guilt, increase just prior to a binge eating episode (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). This study\u0026rsquo;s findings indicate that antecedents to binge eating may also be more neutral or positive feelings on some occasions.\u003c/p\u003e \u003cp\u003eThe closely connected patterns of binge eating and alcohol consumption were characterized by the participants\u0026rsquo; cyclic process between control and impaired control over both alcohol and eating, as described in theme two. Although participants reported having an ED before they had an alcohol problem, most reported longstanding difficulties limiting their alcohol intake, often drinking rapidly or with the occasional intention of losing control. Difficulties to limit, and drinking more than intended on a specific occasion, is a known predictor for developing more severe alcohol problems (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). Therefore, it is warranted to reach individuals with problem drinking, who may be at risk of developing more severe alcohol problems\u0026mdash;and offer treatment in the context of their ongoing ED care. Addressing the alcohol problem when patients already sought treatment for their ED may reduce time to treatment, due to the stigma-related barrier of seeking treatment in the addiction services (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAnother complicating factor of the interaction of the ED and alcohol use was that loss of control over eating seemed to be more profound and resulted in longer and more intense binge episodes when drinking before or during the binge eating episode. The short-term effects of alcohol, which increase impulsivity, may therefore contribute to the severity of these situations and lead to even stronger post-binge eating reactions such as guilt, shame, and self-loathing. It may be hypothesized that such interactions between alcohol use and binge eating, contribute to the heavier symptom burden in individuals with a comorbid ED and alcohol problems, as compared to those who have only an ED.\u003c/p\u003e \u003cp\u003eThe third theme addressed how alcohol use came after the ED, and served as a maintainer of the ED. This is a novel finding with implications for prevention and treatment. Preventive efforts directed toward binge eating may reduce the risk for a subsample of this population to engage in dysfunctional consumption of alcohol. As explained by the participants drinking was as a way of handling ED-related cognitions, and its related consequences. Typically, these situations were not related to binge eating. Instead, participants\u0026rsquo; examples illustrated how alcohol functioned as avoidance of thoughts (e.g., self-critique and self-focus in social and intimate situations). Further, alcohol was used to create temporary \u0026ldquo;breaks\u0026rdquo; from intrusive thoughts about restricted eating. As these problem situations were not directly coupled with binge eating, it may be easier to miss from a clinician\u0026rsquo;s point of view. Awareness of drinking habits of patients and extending their daily monitoring of eating to alcohol use may provide functional insights into maintaining mechanisms perpetuating the ED and problematic alcohol use. Focus on triggers and functions of alcohol consumption may also help identifying cognitions and emotions that are related to eating, shape and weight, or self-worth that might otherwise not be as easily identified by the patient and the therapist. The perspective and experiences provided by the participants in this study also points to the importance of increasing focus on positive emotions in treatment and using stimulus control to ensure that positive emotions are experienced through activities that are incompatible with binge eating or dysfunctional alcohol use. The efficacy of focus on positive valence has been shown in other areas (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). In light of the findings from the current study, it\u0026rsquo;s time to develop and evaluate the incremental effect of a module focusing on increasing positive valence beyond the work on alternative activities that are incompatible with ED according to the CBT-E manual (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). In theme four, participants described how their attempts to bring up alcohol in their ED treatment were met with rejection, or a non-validating attitude from health care professionals. Being told that alcohol problems must be addressed first can result in reduced trust, feelings of being misunderstood, and not being seen as a whole person. These experiences resulted in patients either ending their ED treatment or found the therapeutic alliance to be disrupted. It is not known if participants were identified by ED healthcare as having a severe or a more complex AUD, which demands specialized addiction treatment before the ED treatment. However, alcohol is a stigmatized condition, and being subjected to stereotypical views of alcohol problems, can reduce the willingness to seek specialized addiction care (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). It may be concluded that remitting patients with either hazardous use, or a mild to moderate AUD to specialized addiction care before being treated for their ED, can both prolong the time with ED, and the alcohol problem.\u003c/p\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003eThere are strengths and limitations worth mentioning regarding the current study. To our knowledge, this is the first qualitative study with the specific aim to explore the functional relationship between binge eating and alcohol problems from patients\u0026rsquo; perspective, for the purpose of developing a novel treatment aiming to treat both conditions in an integrated approach. The study contributed important information from patients\u0026rsquo; perspectives on the development, relationship between, and the maintenance of EDs and comorbid alcohol problems. The research team involves clinicians with longstanding experience from both the ED and AUD fields. Previous subjective experiences may have influenced the interpretation of the data. To balance the impact of such subjectivity, three researchers were involved in coding the material, and the rest of the team contributed by supporting the process of developing themes that accurately represent the data. Another limitation is the uneven gender distribution, which may have influenced the results, given that males more commonly have alcohol problems. The participants did however mirror the typical distribution of males vs females seeking treatment for their ED.\u003c/p\u003e \u003c/div\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eThe findings demonstrate that co-occurring binge eating and problematic alcohol use can be expected to be closely interconnected. In our study, alcohol problems typically developed after the eating disorder and contributed to its maintenance, both as an emotion-regulation strategy, as part of the binge eating cycle, and by providing short-term relief from ED-related cognitions. These data support previous suggestions of the need for integrated treatment approaches that address both behaviors simultaneously (\u003cspan additionalcitationids=\"CR46\" citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e). Our results suggest that it is motivated to work, not only simultaneously, but with an integrated treatment that specifically addresses the possibly similar and connected maintenance processes of the conditions. Further, it is needed to focus on preventive efforts through earlier identification of alcohol problems in patients with binge eating problems.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e \u003cp\u003eThe current study was approved by the Swedish Ethical Review Authority (No. 2024-05329-01, and 2024-07895-02). All participants left verbal and written consent to participate in the study.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThe study was funded by Systembolaget\u0026rsquo;s Alcohol Research Council, no: FO2024-0016, and Stockholm county Research Council (No: FoUI-1022229).\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eConceptualization: SIH, Data curation: SIH, LO, Formal analysis: MJ, LO, ACW, TP, AG, SIH Funding acquisition SIH, TP, AG, Investigation: MJ, LO, SIH, Methodology: MJ, LO, ACW, TP, AG, SIH. Project administration: SIH, Resources: SIH, Supervision: SIH, TP, AG, Visualization: LO, SIH, Writing original draft:​SIH, Writing review \u0026amp; editing: MJ, LO, ACW, TP, AG, SIH.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe would like to thank the participants who shared their valuable experiences, views and insights with us.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eData can be available upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGalmiche M, D\u0026eacute;chelotte P, Lambert G, Tavolacci MP. Prevalence of eating disorders over the 2000\u0026ndash;2018 period: a systematic literature review. Am J Clin Nutr. 2019;109(5):1402\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSil\u0026eacute;n Y, Keski-Rahkonen A. Worldwide prevalence of DSM-5 eating disorders among young people. Curr Opin Psychiatry [Internet]. 2022;35(6). 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Pathways to help-seeking in bulimia nervosa and binge eating problems: A concept mapping approach. Int J Eat Disord. 2007 Sept 1;40(6):493\u0026ndash;504.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDansky BS, Brewerton TD, Kilpatrick DG. Comorbidity of bulimia nervosa and alcohol use disorders: Results from the National Women\u0026rsquo;s Study. Int J Eat Disord. 2000;27(2):180\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349\u0026ndash;57.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSobell LC, Sobell MB. Timeline follow-back: A technique for assessing self-reported alcohol consumption. Measuring alcohol consumption: Psychosocial and biochemical methods. Springer; 1992. pp. 41\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSysko R, Walsh BT, Fairburn CG. Eating Disorder Examination-Questionnaire as a measure of change in patients with bulimia nervosa. Int J Eat Disord. 2005;37(2):100\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBohn K, Doll HA, Cooper Z, O\u0026rsquo;Connor M, Palmer RL, Fairburn CG. The measurement of impairment due to eating disorder psychopathology. Behav Res Ther. 2008;46(10):1105\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBraun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77\u0026ndash;101.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBraun V. and Clarke V. One size fits all? What counts as quality practice in (reflexive) thematic analysis? Qual Res Psychol. 2021 July 3;18(3):328\u0026ndash;52.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSaunders JJB, AASLAND OG, BABOR TF, DE LA FUENTE JR GRANTM. Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO Collaborative Project on Early Detection of Persons with Harmful Alcohol Consumption-II. Addict Abingdon Engl. 1993;88(6):791\u0026ndash;804.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBjureberg J, Lj\u0026oacute;tsson B, Tull MT, Hedman E, Sahlin H, Lundh LG, et al. Development and Validation of a Brief Version of the Difficulties in Emotion Regulation Scale: The DERS-16. J Psychopathol Behav Assess. 2016 June;38(2):284\u0026ndash;96.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSpitzer RL, Kroenke K, Williams JB. Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. Primary Care Evaluation of Mental Disorders. Patient Health Questionnaire JAMA. 1999;282(18):1737\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSpitzer RL, Kroenke K, Williams JBW, L\u0026ouml;we B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166(10):1092\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBraun V, Clarke V. Thematic analysis: A practical guide. 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSPSS Statistics. IBM Corp.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMalterud K, Siersma VD, Guassora AD. Sample size in qualitative interview studies: guided by information power. Qual Health Res. 2016;26(13):1753\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBerg KC, Crosby RD, Cao L, Peterson CB, Engel SG, Mitchell JE, et al. Facets of negative affect prior to and following binge-only, purge-only, and binge/purge events in women with bulimia nervosa. J Abnorm Psychol. 2013;122(1):111\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTuithof M, ten Have M, van den Brink W, Vollebergh W, de Graaf R. Alcohol consumption and symptoms as predictors for relapse of DSM-5 alcohol use disorder. Drug Alcohol Depend. 2014 July;1:140:85\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGruenewald PJ, Caetano R, Mair C. Impacts of impaired control and pharmacological criteria for lifetime alcohol use disorder on relationships between drinking and problems. Drug Alcohol Depend. 2025;276:112910.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCraske MG, Dunn BD, Meuret AE, Rizvi SJ, Taylor CT. Positive affect and reward processing in the treatment of depression, anxiety and trauma. Nat Rev Psychol. 2024;3(10):665\u0026ndash;85.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSandman CF, Craske MG. Psychological Treatments for Anhedonia. Curr Top Behav Neurosci. 2022;58:491\u0026ndash;513.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFairburn, Christopher R, Straebler S, Cooper Z, Murphy R. Cognitive behavioral therapy for eating disorders. Psychiatr Clin. 2010;33(3):611\u0026ndash;27.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGregorowski C, Seedat S, Jordaan GP. A clinical approach to the assessment and management of co-morbid eating disorders and substance use disorders. BMC Psychiatry. 2013;13:289.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSysko R, Hildebrandt T. Cognitive-behavioural therapy for individuals with bulimia nervosa and a co-occurring substance use disorder. Eur Eat Disord Rev. 2009;17(2):89\u0026ndash;100.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHarrop EN, Marlatt GA. The comorbidity of substance use disorders and eating disorders in women: Prevalence, etiology, and treatment. Addict Behav. 2010;35(5):392\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-eating-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"joed","sideBox":"Learn more about [Journal of Eating Disorders](http://jeatdisord.biomedcentral.com)","snPcode":"40337","submissionUrl":"https://submission.nature.com/new-submission/40337/3","title":"Journal of Eating Disorders","twitterHandle":"@JEatDisord","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Binge eating, problematic alcohol use, emotion regulation difficulties, comorbidity, integrated treatment","lastPublishedDoi":"10.21203/rs.3.rs-8406459/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8406459/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe association between binge eating and alcohol use disorders (AUDs) has been demonstrated in genetic, population-based, and clinical studies. Individuals with binge eating report more binge drinking and heavier alcohol consumption than those with eating disorders (EDs) without binge eating. Co-occurring EDs and AUDs are linked to higher levels of ED symptoms, depression, anxiety, and more severe psychosocial impairment compared with EDs alone. The aim of this qualitative study was to explore how adults with concurrent binge eating and perceived alcohol problems experience these two conditions and their potential interrelationship. Such insight is needed to improve understanding of functional links and perpetuating processes that may complicate treatment.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eTwelve adults with concurrent binge eating and problematic alcohol use were recruited from a public specialized ED clinic in Stockholm, Sweden, or through an ED patient-organization website between 2024 and early 2025. All interviews were analyzed using reflexive thematic analysis following the principle of Braun and Clarke.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eFour themes were identified. Binge eating and problematic alcohol use were shown to be closely interconnected, as co-occurring emotion regulation strategies, and alcohol being involved before and as part of binge eating situations. Alcohol use maintained the ED, by increasing vulnerability to binge eating, offering short-term relief from ED-related cognitions on restriction, and self-critical views, and being a safety behavior to reduce e.g. body shame in public contexts. Negative responses from healthcare providers regarding concurrent alcohol problems hindered appropriate treatment seeking for both conditions.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusions\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThese findings demonstrate the functional relationship between binge eating, and alcohol use, and the maintenance processes of the two conditions. Integrated treatment for both conditions, as well as preventive efforts through earlier identification of alcohol problems in individuals with binge eating difficulties are warranted. \u003cb\u003eTrial registration\u003c/b\u003e: The study has not been publicly registered.\u003c/p\u003e","manuscriptTitle":"I am in the passenger seat of my own body: A qualitative interview study of the relationship between binge eating and concurrent problematic alcohol use","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-22 13:31:26","doi":"10.21203/rs.3.rs-8406459/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-02-13T00:41:01+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-11T16:27:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"119289072044604948279968107753087978711","date":"2026-01-29T21:30:03+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-21T13:11:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"79591247707793201357928960839383512952","date":"2026-01-20T23:36:36+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-20T23:28:06+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-19T09:28:18+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-19T09:23:05+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Eating Disorders","date":"2025-12-19T15:37:21+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-eating-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"joed","sideBox":"Learn more about [Journal of Eating Disorders](http://jeatdisord.biomedcentral.com)","snPcode":"40337","submissionUrl":"https://submission.nature.com/new-submission/40337/3","title":"Journal of Eating Disorders","twitterHandle":"@JEatDisord","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7d5804e3-9662-4ca6-b59a-9edf301cf9a6","owner":[],"postedDate":"January 22nd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-03-23T16:00:54+00:00","versionOfRecord":{"articleIdentity":"rs-8406459","link":"https://doi.org/10.1186/s40337-026-01576-z","journal":{"identity":"journal-of-eating-disorders","isVorOnly":false,"title":"Journal of Eating Disorders"},"publishedOn":"2026-03-16 15:58:24","publishedOnDateReadable":"March 16th, 2026"},"versionCreatedAt":"2026-01-22 13:31:26","video":"","vorDoi":"10.1186/s40337-026-01576-z","vorDoiUrl":"https://doi.org/10.1186/s40337-026-01576-z","workflowStages":[]},"version":"v1","identity":"rs-8406459","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8406459","identity":"rs-8406459","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}