Four years ago, Lindsey Hall left a wedding with three grilled cheese sandwiches in her pocket. That night, she drank booze but hadn’t taken a bite of food, and she intended to eat and purge her illicit snack. But when she got home, her dad was waiting up for her with an empty cereal box that she had binge-eaten and purged earlier that week. He asked her to get help—and this time, she agreed. “I was tired,” she says. “I was ready.”

At the time, Lindsey, now 27 and a client service partner at a PR firm in Denver, was among the many college-aged students combining alcohol consumption with food restriction, excessive exercise, and/or bingeing and purging. Some drink on empty stomachs to get drunk faster, while others compensate for their intake of alcohol calories by not eating or by throwing up their food. Either way, these behaviors—known by the term “drunkorexia”—can lead to scary outcomes, say experts. Lindsey has dealt with anorexic (restricting how much she ate) and bulimic (bingeing and purging) behaviors over the years, and alcohol fueled these.

“Drunkorexia is not a formal diagnosis, but it’s being looked at as a precursor to problem drinking or disordered eating,” says Dipali Venkataraman Rinker, Ph.D., an assistant professor at the University of Texas who studies disordered drinking. “It goes beyond the frequency and amount. It’s the manner in which college students drink.”

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Rinker recently published a preliminary study of 1,184 college students in Texas, which found that among those who imbibed excessively (more than four drinks in a sitting for women and five for men) at least once in the past 30 days, as many as eight in 10 also engaged in at least one “drunkorexic” behavior within the same month. 

For Lindsey, drunkorexia became dangerous. She used to down a couple of glasses of wine before running, and when she went into rehab she had stress fractures in her legs. But the worst of her health issues were from purging: nine cavities, an esophageal tear, and low electrolyte levels.

“They told me I had the bones of an 82-year-old when I first went in,” says Lindsey. “I didn’t believe them. Because I wasn’t seriously underweight, I didn’t think I had a problem.”

Drunkorexia isn’t just about getting drunk. Tom Hildebrandt, Ph.D., an associate professor of psychiatry at Mt. Sinai Hospital who studies eating and alcohol disorders in women, says that body image concerns also encourage these types of behaviors. And in Rinker’s study, women and men were equally as likely to engage in almost every type of drunkorexic behavior. “Guys are becoming more concerned about their appearance [and] more weight conscious,” says Rinker.

Lindsey says that college life made a preexisting eating disorder worse and that drunkorexia was about doing “whatever it took” not to gain weight. “I’ve never drunk to be completely hammered,” she says. “I’d work out, and I didn’t want to eat and ‘lose’ all those calories I’d just burned. So I’d have a glass of wine. My motive for drinking was just to be tipsy enough to not think about food.” 

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At Lindsey’s sorority at the University of Arkansas, she says that restricting calories before drinking even seemed to be the norm. “We’d always joke about it light-heartedly: ‘I guess we’re going to have a liquid dinner tonight,’” she says. “I just didn’t think about it. If you wanted to stay thin, you wouldn’t eat. We gave up food because it was easier than giving up alcohol.”

Rinker says that it’s exactly this type of environment that puts people at greatest risk. “In our work, the biggest predictor for drunkorexia was having the perception that everyone is doing it,” she says.

So how do you know if you have a problem? While occasional experimentation with calorie restriction or bingeing and purging is relatively common, says Hildebrandt, some people get stuck in a pattern. “If it happens one weekend, you learn from your mistakes and don’t revert back to it…it’s not part of a disorder,” he says. But it’s time to seek help if a behavior causes dangerous impairment, like blackouts, or if it becomes a persistent pattern—i.e., it happens several times a week over several months.

Hildebrant adds that it’s easy for your body to become conditioned to the ritual. “You may get relief and have the best night of your life, but you threw up,” he says. “Even if it’s the first time, you can’t unlearn this association. The more times you do it, more likely it is to become a habit. And habits are hard to change.”

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If you do think drunkorexia is a pattern in your life, Lindsey stresses the importance of talking to someone you trust. “My best friends and family have full permission to call me out if they see me doing it,” she says. She recalls a buffet at a friend’s house before she went into rehab when she had one of the worst binges of her life. “I threw up blood, I was on the ground, I thought I was going to die,” says Lindsey. “I had binged on like 5,000 calories and drank so much because I was so nervous and fidgety.” So this past year, she told her mom and dad to keep an eye on her at their Fourth of July buffet. “They kept me in check,” she says. “My family and friends keep me in check.”

Since Lindsey came out about her eating disorder and got treatment, her experience inspired two of her friends to admit they had eating disorders, too. “I think talking about my story has allowed all of us to admit we all did it,” she says.

Lindsey says that although she’s in remission and her therapist would rather she not drink at all, she does. But she tries to do so smartly—with food in her stomach. “I’m still 27,” she says. “I go out on dates, I have wine. I try to just manage it as I go.”

Ultimately, Lindsey shares a warning for all women: “I missed a lot of years being tipsy and being obsessed with my eating disorder,” she says. “You don’t get those moments back.”

This article originally appeared on WomensHealthmag.com.