Psychiatric Comorbidities in Eating Disorders: Treatment and Medication Considerations
Feb 14, 2024
Jennifer Lander
In this episode of Landing Imperfect, Jen gives a comprehensive overview of the connection between eating disorders and psychiatric conditions. From the impact of malnutrition on serotonin levels to the challenges of prescribing medications, Jen provides valuable insights into the complex treatment necessary for those with eating disorders. She highlights the importance of an integrated approach, combining psychotherapy, medications, and nutritional rehabilitation.
00:00 Malnutrition affects mood, sleep, and mental health.
03:18 Abuse and trauma may correlate with eating disorders.
09:32 Different medications are used for various mental illnesses.
13:20 Benzos used rarely for anxiety treatment. Integrated approach essential for eating disorder.
14:36 Therapy, meds, nutrition for improved treatment outcome.
In this episode of Landing Imperfect, Jen gives a comprehensive overview of the connection between eating disorders and psychiatric conditions. From the impact of malnutrition on serotonin levels to the challenges of prescribing medications, Jen provides valuable insights into the complex treatment necessary for those with eating disorders. She highlights the importance of an integrated approach, combining psychotherapy, medications, and nutritional rehabilitation.
00:00 Malnutrition affects mood, sleep, and mental health.
03:18 Abuse and trauma may correlate with eating disorders.
09:32 Different medications are used for various mental illnesses.
13:20 Benzos used rarely for anxiety treatment. Integrated approach essential for eating disorder.
14:36 Therapy, meds, nutrition for improved treatment outcome.
Hey guys, I do want to put a trigger warning to this episode because the topic is eating disorders and there may be some material, a part of this episode that could be triggering to some people. So please just be mindful and make sure you're taking care of yourselves. So I will get into the episode. Hey guys. I hope you're having a great week. So my week and weekend has really been focused on putting together and practicing those, the work presentation that I'm giving for the Cleveland clinic. A group of primary care doctors. So I thought it would be interesting this week if I just add that portion of the presentation to the episode this week. So for anyone who's interested in eating disorders and psychiatry then take a listen. So during this portion of the presentation, we're going to be talking about. Psychotropic medication management and some common psychiatric comorbid conditions seen in eating disorders. Let's first, take a look at some conditions that we might see the most common ones are depression, anxiety, OCD, and PTSD. Depression and anxiety are two examples of psychiatric conditions that can either be the cause of an eating disorder or the consequence of the eating disorder. So what I like to do when I'm seeing my patients for the first time is if they're reporting to me that they're experiencing symptoms of anxiety or depression, Is to ask them if their eating disorder symptoms started before or after they started experiencing these symptoms. If their symptoms started before their eating disorder, we can be suspicious that their symptoms of depression and anxiety may not completely subside, or maybe even worsen as they rehearse their bodies. I want us to take a closer look at depression in the relation to these symptoms, being the consequence of the patient's eating disorder. We know that serotonin is the key neurotransmitter. Emitter responsible for mood and sleep regulation among other things. But for the sake of this example, we're going to focus on mood and sleep. When someone is restricting and they become malnourished, they are lacking enough trip to fan, which is that amino acid that's found in food tryptofan helps our bodies make melatonin and serotonin. So that restriction of food in turn creates a depletion of serotonin in their brains. And then they begin to experience depressive symptoms. We see this time and time again in this scenario that once a patient starts eating and decreases his habit of restriction, their mood and sleep, start to improve. So it's important to note while we're discussing diagnoses that you may see a patient with a symptomatic eating disorder who are meeting, or they are close to meeting criteria for OCD, borderline personality, bipolar or ADHD, but have not been previously diagnosed. We want to be sure that the patient has properly nourished before diagnosing any of these disorders so that we can have a clearer picture of what their baseline symptoms are. What may look like a comorbid condition may be symptoms such as the inability to focus and concentrate. The obsessive cognitive distortion, some impulsivity. I could be some emotional dysregulation and some mood fluctuations. That are symptoms of their eating disorder and nothing more. So trauma can be linked to the development of an eating disorder, but I want to be clear that not everyone who has experienced abuse or trauma. We'll develop an eating disorder. And not everyone who has an eating disorder has experienced abuse or trauma, but during your assessment, it can be helpful to ask these questions to have. Better understanding of the patient's presenting symptoms. Now if a patient does have a co-occurring diagnosis, we know that it can complicate the treatment process and make it more challenging to address both conditions simultaneously. Psychiatric conditions can influence the person's ability to really engage in their treatment and to follow treatment recommendations and to maintain that recovery that they worked so hard for. It can also increase the severity of the eating disorder symptoms. This bi-directional relationship between eating disorders and mental health. It means that on one hand, the eating disorder can negatively affect mental health. And on the other hand, Mental health conditions can play a role in developing, developing an eating disorder as a way to cope with the emotional distress that they're experiencing. The eating disorder can serve as a maladaptive coping mechanism and a way to exert control when they're being faced with an overwhelming amount of emotions. It's crucial to address both the eating disorder and that underlying mental health condition for the best possible outcome and recovery. Now as we step into the pharmacological treatment options for those who have an eating disorder, I want to mention how different this can look from someone who's experiencing treatment for anxiety and depression in the absence of an eating disorder. In these situations, we begin treatment for anxiety and depression with that combination of psychotherapy and psychotropics. But medications really fall behind psychotherapy and nutritional rehabilitation in the treatment of an eating disorder that proceeds anxiety and depression. An appropriate time to start medications while someone is seeking treatment for an eating disorder is if their anxiety and depression are becoming a significant barrier to their participation in treatment. As mentioned before, it's also appropriate and crucial to start medications for known comorbid psychiatric conditions that they have been previously diagnosed with such as mood disorders, psychosis, anxiety, and depression. If they've been off their medications for some time. Medications commonly used for bulemia are selective serotonin re-uptake inhibitors, which is unlike medications used for severe anorexia. And we're going to get into that a little bit more in a few minutes, but first I want to address some of the challenges that we can see. While trying to manage and prescribe medications in this population of people. There are two primary issues that we, that may surface when recommending a medication to patients with an eating disorder. And those are resistance to medications. And also that interplay between medication side effects and eating disorder symptoms. The resistance to medications can be seen in patients who have a difficult time recognizing or admitting that they have a problem, or they may feel like they don't need treatment. A significant concern for most people in this population is that fear of weight gain on medications. And because I know that this is a concern for people in this population before they even tell me that this is a fear of theirs, I will address the side effects, including the possibility of weight gain, if there is one and I will reassure them that. If there is any concern about weight gain due to this medication. That I will bring this to their attention and we will address any of their concerns and all of their concerns related to side effects. And then they may feel. As if they are losing control. And because patients with eating disorders often feel that their eating disorder behaviors have there a way to have control over their lives, accepting medications can feel that they're relinquishing that control. There are some psychotropic medications that cause GI distress that's that nausea, vomiting, constipation, diarrhea, stomach cramping. And as we know, our patients with eating disorders may already have a sensitive GI system. The medications that also. Increase or decrease appetite can be triggering to this population and may interfere with their treatment and recovery. And then we have some medications that may be beneficial to someone's anxiety and depression, but because of the concern. Or because of the certain eating disorder behaviors that the patient may be engaging in, these medications can lead to dangerous electrolyte, imbalances, and other medical complications as well. We can manage these challenges by making sure that we're fully understanding or making sure that the patient is fully understanding the risks and benefits of taking these medications that we're recommending. This really helps reduce their fears around taking meds, and then making sure that we're closely monitoring for potential side effects. And we want them to feel included in the decision-making process. This can help them feel more in control and invested in their treatment. Treatment and offering supportive therapy around these reasons why they may feel. Resistant or fearful to try and medications. There continues to be a stigma around mental health. And even though we've come a far away, they're still a little ways to go. And I have patients who feel ashamed or they feel that it's a weakness. If they were to try a psychotropic medication. This really is about reframing this idea so that they feel empowered by using tools to improve their mental health and medication certainly are a tool that they can utilize to reach their treatment goals. And knowing that a slow and steady approach can really make a huge difference. So building that rapport and taking time to educate them on their medications and start in at lower doses to reduce the risk of side effects can help reduce their fears as well. I have patients who have needed more than several appointments to finally feel ready and comfortable enough to start a medication. So time and patients is truly key here. So when we're working with patients who have different types of mental health disorders, such as anxiety, depression, mood disorders, and psychosis. There are a few differences in the medications that we recommend to patients with eating disorders. So if we skip down here on the slide to. Um, The last portion here, we may see someone who has anorexia was psychosis. At which times I prexa or Seroquel would make sense. However, When someone with anorexia presents with anxiety and depression, many providers will initiate antidepressants. Like I mentioned before patients with symptomatic anorexia have depleted serotonin levels due to restrict of nutritional intake. And because of this SSRI is that Sarah. That selective serotonin re-uptake inhibitors really don't work in low weight anorexia. It's important to know that olanzapine is indicated for anorexia above any other psychotropic medications. For, uh, for adults who I will prescribe olanzapine for, it's really starting at low, low doses at bedtime just to reduce that anxiety and over sedation and then slowly titrating up. And I will only increase the medication after the patient is completely free of any side effects. For medication so that I'm not over sedating them. Now let's jump back up to the antidepressants. And take a look at a patient who has an R or I'm sorry, who has anxiety and depression with purging behaviors. So the FDA has approved Prozac for those struggling, with purging behaviors and. For patients who have bulemia the most effective dosages to help decrease eating disorder behaviors are that 60 milligram dose a day, once a day dosing. So providers typically will start someone on Prozac at 10 to 20 milligrams a day. Then start. And then they'll stay at that 20 milligram dose for four to six weeks before considering an increase. But for someone who has bingeing and purging, we really want to increase the dose much quicker. So increasing every one to two weeks until we hit that 60 milligram dose, as long as the patient is tolerating the increase. Really SSRI. Uh, a higher dose can be effective for reducing these behaviors. So if your patient can't tolerate Prozac, then try and select the 40 milligrams. They'll have 200 milligrams. Those are also reasonable options. Now I would be admiss. If I did not mention Welbutrin. While we're talking about purging behaviors. We really want to stay away from this medication for someone who's engaging in this type of behavior, because it really increases the patient's risk for seizures. We can't say the exact cause of this, but we believe that it's due to electrolyte imbalances that occur when someone is actively engaging in, in a purging behavior on this medication. I don't have this listed on the slide, but I think it's worth mentioning that. The FDA has approved for moderate to severe binge eating disorders. Vyvanse Vyvanse at 50 to 70 milligram. Dosages can significantly decrease if not completely stopped the binge eating behavior. Even, so there. Is something to be cautious over. And that is the patients who are in a significant binge restrict cycle. So. It's that restriction that can be really concerning. And these patients when initiating a stimulant due to the potential side effect on appetite when starting and titrating doses. So let's talk about benzodiazepines quickly. It isn't out of the question to start this temporarily for someone who's an anxiety is interfering with their treatment, but it's in rare cases that I will lean into this type of medication to help treat anxiety. The most obvious is that dependency component. But the other is when patients are in a higher level of care, such as partial hospitalization, even IOP at times, residential, of course, The patient has an opportunity for a sudden, a significant amount of exposures during meals and snacks to challenge their eating disorder. Behaviors. So benzos can numb this experience and exposure, which the exposures are really what we want here. If we're giving them benzos during this crucial time, then they may be missing an opportunity to truly face their fears and anxiety around these exposures. And once they come off of the benzo, their anxiety will likely resurface. So we do our best to try to avoid these types of medications. But like I said, sometimes they are necessary. So. I know. Have I know we talked about this a little bit earlier, but having that integrated approach to treatment for people who are struggling with, with eating disorders is really essential. This combination of psychotherapy, medications and nutritional rehabilitation can make a positive difference in a patient's treatment and outcome. Thank you so much for joining me on this episode of landing imperfect. I truly appreciate you being a part of this community and sharing this journey with me. If you do want to connect further, then don't hesitate to follow me on Instagram at Jen dot Lander. I would love to hear your thoughts, any questions or any stories that you want to share. So, DME there, I also have a website. It's a landing and perfect website where I share a blog post about my podcast, and then you can join my email list. I have a PDF that provides anxiety and stress management tools that you can. And use as well when you join my email list. So check it out. My website will be linked in my show notes. So don't hesitate to reach