The Role of Psychotropic Medications in Treating Eating Disorders

Tune into this episode of Landing Imperfect's for an insightful talk with Jen Lander as she explores the role of psychotropic medications in treating eating disorders alongside other mental health conditions. Addressing the critical links between conditions like depression, anxiety, OCD, and PTSD with eating disorders, Jen emphasizes the need for a tailored therapeutic approach. She discusses the impact of malnutrition on brain function and the judicious use of SSRIs and atypical antipsychotics. Acknowledging patient concerns about medication, such as fears of weight gain and side effects, Jen capably balances the use of drugs with empathy and caution. The episode also tackles the challenges of stigma and dependency, providing a nuanced perspective on managing eating disorders pharmacologically. Join us for a thoughtful dive into mental health treatment complexities at Landing Imperfect.

00:00 Common mental health disorders in relation to eating disorders include depression, anxiety, OCD, and PTSD. These conditions can be either the cause or consequence of an eating disorder. It is important to assess the timing of symptoms in relation to the eating disorder. Malnourishment can affect serotonin levels, impacting mood and sleep.

03:36 Psychiatric conditions can affect eating disorder treatment.

07:40 Consider over and under reporting in diagnoses.

12:22 Monitor medical complications, educate, empower, reduce stigma.

18:13 Increase SSRI doses for binging and purging.

21:17 Vyvanse can help reduce binge behavior impulsivity.

22:47 ADHD treatment challenges and impact on metabolism.

Resources:
Landing Imperfect Website
https://landingimperfect.godaddysites.com/

Follow Jen:
Instagram: https://www.instagram.com/jen.lander/
Facebook: https://www.facebook.com/jennifer.butram/

Transcript

0:00

Hey guys. So I just wanted to share with you, um, a presentation that I gave a week or two ago for some of my coworkers, the topic is eating disorders, medications, diagnoses, things like that. So just be mindful with the episode. Um, And if you are someone who is on any of these medications and we're talking about side effects and things like that, I just want to make sure that you guys are. Deferring to your specific providers on any questions that you may have, um, because they have a fuller picture on your complete story and your history and your recovery and your treatment and all the things. So just make sure that you're reaching out to them. If you have any questions, and of course you can reach out to me too, but, um, as far as like your treatment plan goes, just make sure your. You're covering things with your provider. All right. Let's get started. All right. So what we're going to be talking about. Some of the common. Psychotropic meds. That you guys may see us prescribing to some of our patients. And then we're going to touch on some of the psych co-morbidities. So I'm going to leave space at the end. Also, if anyone has any questions related to eating disorder, diagnoses. But, um, I'm not just gonna go through like the DSM-V cause I'm pretty sure that we're all very familiar with. Diagnosing those, but I know some of the cases can be kind of complicated. So if you guys have any questions about that, And feel free to ask that whenever really. So let's see. I want us to first take a look at, um, mental health disorders that we may see in combination with eating disorders. So the most common ones are depression, anxiety, OCD, PTSD. So depression and anxiety are two examples. Those are conditions that can either be the cause of the eating disorder and the consequences of. The eating disorder. So I like to do when I'm seeing someone for the first time and they're reporting to me that they're experiencing symptoms of anxiety and or depression is to ask them if their eating disorder symptoms started before. Um, After they started experiencing symptoms of their eating disorder. And the symptoms started before. The eating disorder. And then we can be suspicious that there are symptoms of depression and anxiety may not completely subside, or they may even worse. After they renourished their bodies. So. Um, Taking a closer look at depression in relation to these symptoms. The consequence of the patient's eating. Eating disorder. We know that serotonin is the key. Neuro transmitter that's responsible for mood and sleep regulation. So when someone's restricting. They. Become malnourished. And they become owners. They're lacking enough term. Mino acid found in food. The fan helps our brains make melatonin and serotonin. So that restriction of food create the depletion of serotonin in our brains, and then they become to experience some symptoms. Um, depression and anxiety. So we see it time and time again in situations like this, that once a patient starts eating and decrease in that habit of restriction and their mood and sleep start. To improve. I do have trauma listed on here. Um, linked to the development of eating disorders, but we all know that not everyone who's experienced trauma is going to develop an eating disorder. Um, even though we don't provide trauma treatment here in higher levels of care, it can be helpful to ask assessment question that way we can have a better understanding of the patients. Um, presenting symptoms, which is something that we include in our psych assessments, too. No. If a patient does have co-occurring diagnoses. It can complicate the treatment process and make it more challenging to address both conditions simultaneously. So psychiatric conditions can influence a person's ability. We see all the time. I'm engaging in their therapy or following the treatment recommendations that we're giving to them and then maintaining them in recovery too. So, It can also mean to the severity of the eating disorders. Um, we've seen this in every one of our programs, but I will say DBT gets a lot of experience in treating patients who are struggling with that co-occurring diagnosis or diagnoses. So it can be challenging at times to decide. What the most appropriate treatment modality. As for the patient. And then the patient's eating disorder that's causing that exacerbation of the co-occurring psychiatric symptoms or vice versa. But regardless if someone is struggling with eating disorder behaviors, we want to make sure that we've exhausted all of those resources while they're here to help reduce both eating disorder behaviors and their declining mood symptoms. So when Moda. Um, is interfering with the patient's ability to show up to program or their participate. Their participation and treatment. We might say them with a rapid cycling of mania where they're dealing with moderate to severe psychosis. It is likely very appropriate to address that in a primary mood. Uh, program. Or some other facility and then returned to eating disorder treatment if needed. So that bi-directional relationship between, um, eating disorders and mental health means that on one hand, the eating disorder can negatively affect their mental health. And then on the other hand, it's the mental health condition that could be playing a role in developing eating disorder. As a way for them to cope with that emotional distress that they're under. So the eating disorder can serve as that. Maladaptive coping mechanism. And it's a way for them to exert control when they're faced with a lot of those overwhelming emotions. It's uh, it's crucial to address, obviously. We know both of those eating disorders and that underlining mental health condition. So while we're talking about. Uh, the diagnoses that we may see. Um, Patients with symptomatic eating disorders who are needing, or they're close to meeting criteria for OCD, borderline personality. Bipolar. Or ADHD. Um, We may Steven with. The presenting symptoms, but they haven't been previously diagnosed with any of these disorders. So we want to be sure that the patient is properly nourished before diagnosing any of these disorders. So that we can have a clear picture of what. With our baseline symptoms truly are. So what may look like a co-morbid condition because they're experiencing. And these are some of those symptoms that, you know, we're seeing it's. Um, trouble focusing or concentrating on what we're directing them to obsessive cognitive distortions. They can be. Have that emotional dysregulation in the mood fluctuations. These are those common symptoms that could be related to the eating disorder and not a true. Co-occurring psychiatric disorder. So I'll speak for myself as a psych provider. And if you're new to working with me since I'm in this. Um, you'll learn a little bit about my professional styles, so I will always be careful and cautious when it comes to diagnosing a patient with any of these disorders listed on this side. I'm not going to jump into diagnosing any of these disorders off of the first. Appointments that I knew someone. And the reason for this is because I've learned along the way, the importance of getting to know a patient's full story and their history, because there's things that are said. And not said in the first few appointments that could be too. Misdiagnosing a patient. And I worked with many patients. Who've come to me with a laundry list of diagnoses and. It's it's been given to them throughout their treatment. And their treatment and a lot of times. Well, I shouldn't say a lot of times, but sometimes these diagnoses are given to them off. Their first appointment ever. Mediator per rider. And working. With them. For weeks to months, I've seen the symptoms. To some of the diagnoses subsiding after they burst their bodies. So we also want to consider that over and under reporting that we don't know. Is happening until we've spent more time with the patients. We've been able to gather more information. So I've also had patients who did one treatment round with us and then swore up and down that they weren't engaging in certain behaviors. And then. And return months, two years later. And they admit to that dishonesty. So that could be things like not only eating disorder. They're engaging in, but it could be, you. You know, substance abuse. So alcohol drugs, things like that, that they weren't disclosing. Um, the first time around. And even though. We have come a long way in the mental health world. There's still some level of mental health stigma. And I just want to be absolutely sure that. I'm giving a diagnosis that I have no doubt about the diagnosis. Because unfortunately, Certain diagnoses that follow the patients around can have a negative impact on their treatment, the treatment that they received. So I believe that it's fair to patients to absolutely provide an initial diagnosis, to help them receive the treatment that they deserve. But I also want to make sure I'm being fair. By not providing the diagnosis when. I've only met them a few times and I haven't been able to gather enough information to support any of these diagnoses. So we're going to jump into the pharmacological treatment options for those. Come have eating disorders. And I want to mention how different this can look from someone who is being treated with anxiety and depression in the absence of an eating disorder. So in these situations, We begin treatment for anxiety and depression, with the combination of psychotherapy and psychotropics. The medications really do. Do full behind psychotherapy and nutritional rehabilitation. And treatment of eating disorders that proceedings. And depression so inappropriate time for us to start medications. Well, someone who's seeking treatment for their eating disorders. If their anxiety and depression are becoming a significant barrier to their participation in treatment. It's also appropriate. To start medications for comorbid psychiatric conditions that have been previously diagnosed because we'll see patients come in and they have mood disorders. Bipolar. Psychosis anxiety, depression. And the patients. With their medications for awhile. So we want to make sure that we're restarting those medications for them and helping them. And I'll have some consistency. And before we do get into some specific medications. I do want us to address. Um, some challenges that, that we see when trying to manage. Prescribed some of these medications. Um, there's two primary issues. That do service when we're recommending medications to patients. Disorders and that's resistance to medications. And then also it's. This interplay between the medication side effects and eating disorder symptoms. The resistance to medications can be. And patients who maybe they have a difficult time recognizing or admitting that they do have a problem and they don't feel like they need the treatment with a medication. And then another significant concern is. Most of the patients that we see are a lot of them have this fear of gaining weight on these medications. Because I know that that's a concern for these patients. And in our population. Before they even tell me that this was a fear oldest. I discussed the side effects, including the possibility of weight gain. Um, if they take one of these medications, So I'll reassure them that if there is any concerns about weight gain, due to the medication that. I will bring this to their attention and we'll address it. If they have any concerns or any side effects related to the medicine. Um, Asian. It's also may feel like they're losing control. And because the patients that we see often with eating disorders, They feel like their eating disorder behaviors are a way to control or have control over their lives. Accepting meds can feel like they're relinquishing that control. So then secretary pick medications can also cause some side effects, the GI distress. So that nausea and vomiting, constipation, diarrhea. Which we know that a lot of our patients already have sensitive GI systems. So that can be a barrier to. Um, the medications that we. Prescribed. It can cause an increase or decrease in appetite. Um, Can be triggering too. So that may interfere with their treatment and recovery. And then we have medication that may be beneficial for someone who has anxiety and depression, but because of the certain eating disorder behaviors that the patients engaging in, then. Medications could be to some dangerous side effects. So it could be electrolyte imbalances, or some other medical complications that we have to keep an eye on. Um, So we can manage some of these challenges by making sure that the patient is fully aware of the risks and benefits of taking the medicine that we're recommending. This does help reduce some of the fears that they have around taking the meds. Um, and making sure that we're closely monitoring some of those potential side effects too. So we want them to feel included in the decision making process. So. So does can help them feel more in control and invested in their treatment. And then offering supportive therapy around the reasons why. They may feel resistant. If you're full to try and use medications. And I know a lot of the therapists. But there are those that I work with. Um, They do such a great job. So thank you guys. And helping support that. We're talking about their fears around medications. And then they're like I was mentioning before there, there continues to be those stigma around mental health. And I have patients who will feel ashamed or weak. If they take a psychotropic medication. That really is about reframing this idea so that they feel empowered to use tools, to help improve their mental health and medications. I mean, they really are tools that can. That they can utilize. When you're trying to reach their treatment goals. So I always take a full and steady approach when it comes to. Um, working with patients who have some of these barriers in place. So it's building. And taking the time to educate them on their medicine and then starting at lower doses to, to reduce any side effects. Or the potential for side effects can help reduce their fears. So I've had patients who, I mean, they've needed several appointments to finally feel like they're ready and comfortable enough to start medication. So it really is time and patience. That's the key. Okay. So when we're working with patients who have different types of mental health disorders, such as anxiety, depression, mood disorders, and psychosis, There's a few different. The medications that we do recommend to patients with. So typically when someone has. Moderate or severe anxiety and or depression. We'll start then with an antidepressant like Prozac. Lexapro. Or as a loft, which those are all SSRI is. Like I mentioned before patients with symptomatic anorexia. Depleted serotonin levels due to that restrictive nutritional intake. And because. This SSRI is really don't work in low weight anorexia. So. Serotonin communicates between nerves. Exiting one. And I think through with the snaps, which is that space between the neurons and into the next neuron. So when someone's taking an SSRI, the antidepressant. And our brain and binds to the neuron. At the serotonin that is exiting, which prevents the serotonin from going back into that original, um, neuron. It helps push the serotonin into the next. Well, the problem with this and that the medicine is blocking this action. Um, And there's very little serotonin to begin with. So that's the major thing. We need to focus on the patient. Eating and renourishing their bodies so that they can create enough serotonin for the antidepressant to do its job. So once the patient is nourished, then we can read. Well, not re if they haven't even tried it, we can introduce the anti antidepressant target some of the anxiety and depressive symptoms that are present. And the store doesn't mean that we don't have any options in circumstances like this. Um, Olanzapine also known as I practice. Is indicated for anorexia, but about any other psychotropic medication. So for adults. Uh, you guys might see me start a dose of 1.2, five milligrams at bedtime to reduce. Over sedation. And then slowly titrate up because 2.5 is usually that starting dose for most people, but we weren't, we really want to start slower. I'm sure. Some of us have already seen that where patients are kind of just sweeping. All throughout the day, if they started a new medication. So starting even lower than, um, starting doses can be helpful. And I'll only increase that when the patient is completely free of any side effects from the medication, just to avoid that. And side effects. Um, If somebody is refusing to take five. Perfect. Cause that does happen. Quite often or they can't take the medication, then offer something like Seroquel. And to touch on the weight gain. Side effects. Research does show that when it comes to gaining weight, for someone who has anorexia on this medication, we typically. We see not a significant amount of waking and we're talking a few pounds. In a month time. So there's a lot of research out there that shows a significant amount of weight gain on this medication. Um, by proxy and it's important to be aware that the majority of these studies are done on patients with bipolar or psychosis. So the dosages of these medications are at a much higher dose. So there are 10 milligrams or higher. And patients with mood disorders, their brain chemistry is much different from a patient who has anorexia. So. So, this is also something that I discussed with the patients who have this fear around waking when it comes to taking the medication. Medications used to treat. Bulemia or the selective serotonin re-uptake inhibitors. The Prozac. Um, Lexapro things like that. The FDA. Has approached Prozacs. Or those who are struggling with purging behaviors and. And bulemia the most effective dosages to help. Decrease, the eating disorder behaviors are 60 milligrams a day and sometimes even slightly higher than that. So. Providers typically will start a patient on Prozac at 10 to 20 milligrams a day. And then they'll stay at that 20 milligram dose for about four to six weeks before considering an increase. But for someone who's bingeing and purging, we want to try to increase that dose at a quicker rate. So increasing every one to two weeks until we hit that 60 milligram dose, as long as the patient's tolerating, the increases. Um, Really any assets. At a higher dose can be effective at reducing these behaviors. So if someone can't tolerate prose, Then you might see us try and Lexapro or. At higher doses to help target that. I want to make sure that we're talking about Welbutrin. Um, if someone is purging, we really want to be cautious with this medication and try to stay away from it because someone who's engaging in this type of behavior. Um, is that an increased risk of having seizures? So we can't say for sure, the exact cause of this or reason, but we do believe that it. Is due to electrolyte imbalances. When someone is actively purging on this medicine. And I haven't been good. The pain's listed here, but it really could have been listed on any of these slides. Out of the question. To start this medication temporary. Someone who's. Um, anxiety is really interfering with treatment, but it. It is a rare that I will lean into these types of medications to treat anxiety. So the most common. And the most obvious reason is the dependency co. Uh, component, but the other is in a higher level of care, such as PHP. The patient has an opportunity for a significant amount of exposures during meals and snacks to challenge their eating disorder. And benzos willing to numb that experience and exposure, which the exposure. Those are really what we want here. So, We weren't giving them guns. I was during this crucial time and they may be missing opportunities to truly face their fears and anxiety around those exposures. And once they come off the benzos. Their anxiety will. Very likely already started. When you surface. So I do my best to try to avoid using these medications. But what complicates us? I feel this very often in DBT, more than any other program. Patients will come to me and they're already on benzos and they have been for months, two years or so. If someone's already been on this medication for longer than two months. Their bodies are very likely addicted to the medication. So it's going to be challenging to try to reduce the medicine. If the dose is very high. And this seems to be a slow week off of the medication. It's rare that I'm going to get someone off of this medication. And a higher level of care. Um, Especially if they've been on it and dependent on it for a long time, but the goal is to try. But that's not always successful. So if they are taking something like Xanax or added band, and I'll try to switch them over to Klonapin, if they can tolerate that because it has a longer half-life. So it tends to be easier. And I'm going to use that term loosely. In there to wean off of the medicine. So we'll try that. Alright, so, um, medications for binge-eating disorders. The FDA has approved. Bye. It's to treat moderate to severe binge-eating disorder. The standard treatment for this disorder is CBT or DBT. One of those things. So I really try to lean into that, especially for someone who is seeking treatment in a higher level of care. When patients. Um, have been in treatment for some time and they are able to reduce that binge behavior. So something that can be considered to help decrease the impulsivity that's related to the binge. A behavior. So I'm more likely to consider this for someone who's been bingeing daily, multiple times a day has been in multiple. Treatment stays. And they're just really struggling through those for years at a time, not for someone who this is their first round in treatment. Um, And we can try to target that with some Gabriel therapy. So. Um, So at 50 to 70 milligram, dosages can significantly decrease on. If not completely stop the binge and behavior for a lot of people. So. Um, even though there is. Something to be cautious. And that's patients who are struggling with the binge restrict cycle. And it's the restriction here that can be really concerning. And this disorder. Initiating a stimulant because of that potential side effect on the appetite. So when starting and titrating those doses, they may notice that side effect. Um, Okay. So since we're already talking about stimulant medications, I think we can talk about too. Um, patients who already come to us on Adderall concerned or by Dan stimulants to help target. I am an advocate for treating ADHD. So untreated ADHD. I really can make treatment challenging for patients it's participating in their treatment, especially in a higher level of care. It requires a lot of focus and attention for them. Um, so if someone that comes to me on a stimulant, I will try my best to allow them to stay on the medication. But if someone is very low weight, Or they're engaging in eating disorder behaviors and is really struggling to reach their goal weight range. And this was a different conversation. We'll have a discussion about needing to put this medication on hold until they've gained some stability in their treatment. Um, So the new ones, don't only decrease appetite. Which is typically a theme when they're starting the medication, or if the dose is increased too quickly, or maybe it's too high of a dose for the patient. Don't really notice that. Um, changing their appetite. So not only that, but it can also speed up the patient's metabolism. So even if they're, even if they aren't engaging in eating disorder behaviors, but they aren't gaining weight when. Expected to based off their meal plan. Then it very well may be. Related to the medicine and increasing their function. But their metabolism. 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