Eating disorder as an episode heralding in bipolar


The relationship between binge eating disorder and bipolar disorder is underappreciated in psychiatry. In fact, after many years of practice, I would submit that bipolar disorder can present as an episode of eating disorder. Failing to make this possible connection can have serious implications for our patients. If bipolar disorder is actually the diagnosis in these cases, treating them with selective serotonin reuptake inhibitors can lead to poor outcomes.

Several studies have explored the possible connection between bipolar disorder and eating disorder. One involving 717 patients with bipolar disorder who were participating in the Mayo Clinic Bipolar Biobank found that among patients with bipolar disorder, binge eating disorder and obesity are highly prevalent and correlated. The investigators went on to suggest that bipolar disorder and binge eating disorder "may represent a clinically important sub-phenotype" (J. Affect. Disord. 2013 June 3 [doi:10.1016/j.jad.2013.05.024]).

Another study of 875 outpatients with DSM-IV bipolar I or II found that more than 14% of them met the criteria for at least one comorbid lifetime eating disorder. The most common was binge eating disorder (J. Affect. Disord. 2011;128:191-8). However, these cases did not make the connection that eating disorder might be an episode heralding in bipolar disorder.

One of my own patients, whom I will call Miss G.,* fits one of those categories.

A complex presentation

I first saw Miss G. in spring 2010. She was aged 16 years and 6 months, stood at 5 feet, 8 inches tall, and was fairly built. She had acne on her face and looked more mature than her age.

The adolescent was an only child and lived with her parents. (Her father drove her to my office for almost all of her appointments.) She was in high school, and worked as a waitress and a cashier at a drugstore. She reported that she had good friends and denied any history of abuse. She had been called "chubby" and "fat," starting at the very early age of 7, but denied feeling sad or crying about being called fat – and never had to defend herself about it.

During the first visit, she described her problem this way: "I get anxious in the middle of the day (and) get hyped up at night." She said she had been diagnosed with eating disorder and had been getting treatment by a therapist for the past 4 years. She reported symptoms of excessive eating, bingeing, and then purging more than 2-10 times a day.

In fifth grade, her crash dieting had begun, which escalated into excessive eating, followed by purging, calorie counting, and excessive use of treadmills and other equipment at a gym in an effort to lose weight. At her lowest weight, she succeeded in getting down to 113 pounds. At her highest, she reached 150.

In her sophomore year, she said that the severity of her illness had led to fainting because of low potassium levels and hypotension requiring frequent visits and treatment in the emergency department to balance her electrolytes. She also reported having panic attacks, which had lessened over the last 2 years. She reported undergoing weekly blood tests for electrolytes and presently was within normal limits. She assured me that the problems leading to her fainting would never happen again. Although Miss G. had been under the treatment of a therapist, she was not under that therapist’s care when she came to see me. It seems that one day, Miss G. walked out of the therapist’s office in anger and was now feeling embarrassed about going back to her.

I continued to explore Miss G.’s symptoms further, which revealed a decreased focus and attention, with a dramatic drop in recent months in school performance, from straight As to Bs, and eventually, to Cs.

In subsequent sessions, the patient admitted to having gone days without sleeping at night and described having excessive energy, "craving for movement," stay(ing) awake, hyper, constant movement, action, happiness, cutting myself." At one point, she said, "I was giddy and buzzing on some weird high and had an impulse to throw up food."

Also during that year, Miss G. said she had "graffitied many parks, shoplifted food, eaten it, and then thrown it up, gotten caught dining and dashing at night." Then there were times when she would just "sit at home and cry – and have no motivation to go out."

In describing her symptoms after many months, she said: "I was depressed before anything started. I hated myself." She denied hearing any voices but admitted to hearing her own voice. "At times, it would start screaming," she said. The patient denied having ever made serious suicidal attempts but had constant thoughts of killing herself by hanging or cutting her wrists 4 months prior to her first visit with me.

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