Esha Khoshnu, MD

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.

Miss G. also had taken an overdose of aspirin, up to 7 grams in 15 hours, and was disappointed to learn that the dose was not lethal. She admitted to using multiple drugs, including alcohol, marijuana, heroin, cocaine, cigarettes, caffeine, and amphetamines to control her moods and behavior in the past. But she had never been treated with psychotropics.

Her family history proved significant. One of her great grandfathers had committed suicide, and a maternal aunt was in treatment with several psychotropics and was on disability.

My initial diagnoses

Initially, I diagnosed this patient with eating disorder, bulimic type; eating disorder not otherwise specified; and polysubstance dependence in early remission with multiple rule-outs, including anxiety disorder NOS; psychotic disorder, NOS; bipolar disorder NOS; and bipolar disorder with psychosis. I explained to her the diagnosis and my concern about the possibility of mood swings and the risk of being on SSRIs or other antidepressants that are commonly prescribed for eating disorders, and that can worsen what I suspected was underlying bipolar disorder, and alter the course and treatment outcome – and the overall clinical outcome. She really did not care about the diagnosis or the treatment and was willing to take any medication that would not cause weight gain. She agreed to take topiramate and adamantly decided against taking anything else.

On subsequent visits, she reported worsening of concentration and anger but insisted on continuing on the topiramate because it had lowered her appetite and her bingeing and purging behavior had become less frequent.

At this point, I confirmed the diagnosis as bipolar disorder and had her agree to take lamotrigine. She continued to experience anger and mood swings, although she was taking 300 mg of lamotrigine. Risperidone had no therapeutic response. Although it proved difficult to persuade her to take sodium valproate she agreed, because she understood the consequences of her anger. Miss G. knew that continuing to behave disrespectfully toward her teachers would jeopardize her education and her future.

To elaborate on the time frames, let me point out that Miss G. started on the topiramate on the first day of her treatment. The lamotrigine was started the following month. The sodium valproate was introduced about 7 months after that with improvement, but she continued to complain of weight gain and appetite, which was not controlled – even with an H-2 blocker. So I had to stop the sodium valproate 4 months after it was introduced. Her concentration continued to either decline or not improve with mood stabilization.

This is the point at which I introduced clonidine. Although Miss G. did experience some side effects, her concentration improved. Her mood remained fairly stable on lamotrigine and clonidine after I discontinued the sodium valproate.

My last session with Miss G. occurred about 1 year and 3.5 months after the first visit. On that day, she was casually but neatly dressed. She told me that she would be graduating from high school and attending college out of state.

When I asked her about some of the behaviors tied to her eating disorder, she said "not at all" but after further exploration she said "once or twice a week; it became a lifestyle and right now, it is not a lifestyle anymore," she said. Miss G. went on to describe her current weight of 145 as "ideal," but said she still struggled to see herself in a healthy way. "By being treated for my bipolar disorder, my eating disorder did not reach such a low point," she said. "I consider myself a recovered eating disorder patient."

Her mood was good and her affect appropriate. She said she had no thoughts of harming herself.

We must get this right

Most prior patients with a diagnosis of eating disorder come to my office on SSRIs with poor functioning and symptom control. Initially, they say, "You are the doctor; whatever you say," but in the end, they either failed to accept the diagnosis of bipolar disorder or to follow my treatment recommendations and left my practice. In each of these cases, I have been concerned that these patients with eating disorder diagnoses might indeed have bipolar disorder.

As I mentioned earlier, some studies have been conducted exploring the connections between eating disorder and bipolar disorder, but more are needed. Specifically, we need to determine the extent to which eating disorder and bipolar disorder are comorbidities – or whether eating disorder is an episode that leads to bipolar disorder. In addition, we must compare the treatment outcome and clinical course of patients who are treated with SSRIs for eating disorder with the treatment outcome and clinical course of patients who are treated with mood stabilizers – even if they have started episodes of eating disorder.

Finally, organized psychiatry must establish guidelines and develop tools for the proper diagnosis of bipolar disorder, even if eating disorder episodes are already under way.

*Miss G. enthusiastically gave her permission to publish these details about her treatment and even offered to allow me to use her full name, if doing so might help others get proper diagnosis and treatment.

Dr. Khoshnu is a general adult psychiatrist who is mostly in private practice in the West Caldwell and Somerset, N.J., areas. She also is affiliated with Overlook Hospital in Summit, N.J.

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.

Miss G. also had taken an overdose of aspirin, up to 7 grams in 15 hours, and was disappointed to learn that the dose was not lethal. She admitted to using multiple drugs, including alcohol, marijuana, heroin, cocaine, cigarettes, caffeine, and amphetamines to control her moods and behavior in the past. But she had never been treated with psychotropics.

Her family history proved significant. One of her great grandfathers had committed suicide, and a maternal aunt was in treatment with several psychotropics and was on disability.

My initial diagnoses

Initially, I diagnosed this patient with eating disorder, bulimic type; eating disorder not otherwise specified; and polysubstance dependence in early remission with multiple rule-outs, including anxiety disorder NOS; psychotic disorder, NOS; bipolar disorder NOS; and bipolar disorder with psychosis. I explained to her the diagnosis and my concern about the possibility of mood swings and the risk of being on SSRIs or other antidepressants that are commonly prescribed for eating disorders, and that can worsen what I suspected was underlying bipolar disorder, and alter the course and treatment outcome – and the overall clinical outcome. She really did not care about the diagnosis or the treatment and was willing to take any medication that would not cause weight gain. She agreed to take topiramate and adamantly decided against taking anything else.

On subsequent visits, she reported worsening of concentration and anger but insisted on continuing on the topiramate because it had lowered her appetite and her bingeing and purging behavior had become less frequent.

At this point, I confirmed the diagnosis as bipolar disorder and had her agree to take lamotrigine. She continued to experience anger and mood swings, although she was taking 300 mg of lamotrigine. Risperidone had no therapeutic response. Although it proved difficult to persuade her to take sodium valproate she agreed, because she understood the consequences of her anger. Miss G. knew that continuing to behave disrespectfully toward her teachers would jeopardize her education and her future.

To elaborate on the time frames, let me point out that Miss G. started on the topiramate on the first day of her treatment. The lamotrigine was started the following month. The sodium valproate was introduced about 7 months after that with improvement, but she continued to complain of weight gain and appetite, which was not controlled – even with an H-2 blocker. So I had to stop the sodium valproate 4 months after it was introduced. Her concentration continued to either decline or not improve with mood stabilization.

This is the point at which I introduced clonidine. Although Miss G. did experience some side effects, her concentration improved. Her mood remained fairly stable on lamotrigine and clonidine after I discontinued the sodium valproate.

My last session with Miss G. occurred about 1 year and 3.5 months after the first visit. On that day, she was casually but neatly dressed. She told me that she would be graduating from high school and attending college out of state.

When I asked her about some of the behaviors tied to her eating disorder, she said "not at all" but after further exploration she said "once or twice a week; it became a lifestyle and right now, it is not a lifestyle anymore," she said. Miss G. went on to describe her current weight of 145 as "ideal," but said she still struggled to see herself in a healthy way. "By being treated for my bipolar disorder, my eating disorder did not reach such a low point," she said. "I consider myself a recovered eating disorder patient."

Her mood was good and her affect appropriate. She said she had no thoughts of harming herself.

We must get this right

Most prior patients with a diagnosis of eating disorder come to my office on SSRIs with poor functioning and symptom control. Initially, they say, "You are the doctor; whatever you say," but in the end, they either failed to accept the diagnosis of bipolar disorder or to follow my treatment recommendations and left my practice. In each of these cases, I have been concerned that these patients with eating disorder diagnoses might indeed have bipolar disorder.

As I mentioned earlier, some studies have been conducted exploring the connections between eating disorder and bipolar disorder, but more are needed. Specifically, we need to determine the extent to which eating disorder and bipolar disorder are comorbidities – or whether eating disorder is an episode that leads to bipolar disorder. In addition, we must compare the treatment outcome and clinical course of patients who are treated with SSRIs for eating disorder with the treatment outcome and clinical course of patients who are treated with mood stabilizers – even if they have started episodes of eating disorder.

Finally, organized psychiatry must establish guidelines and develop tools for the proper diagnosis of bipolar disorder, even if eating disorder episodes are already under way.

*Miss G. enthusiastically gave her permission to publish these details about her treatment and even offered to allow me to use her full name, if doing so might help others get proper diagnosis and treatment.

Dr. Khoshnu is a general adult psychiatrist who is mostly in private practice in the West Caldwell and Somerset, N.J., areas. She also is affiliated with Overlook Hospital in Summit, N.J.

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.

Miss G. also had taken an overdose of aspirin, up to 7 grams in 15 hours, and was disappointed to learn that the dose was not lethal. She admitted to using multiple drugs, including alcohol, marijuana, heroin, cocaine, cigarettes, caffeine, and amphetamines to control her moods and behavior in the past. But she had never been treated with psychotropics.

Her family history proved significant. One of her great grandfathers had committed suicide, and a maternal aunt was in treatment with several psychotropics and was on disability.

My initial diagnoses

Initially, I diagnosed this patient with eating disorder, bulimic type; eating disorder not otherwise specified; and polysubstance dependence in early remission with multiple rule-outs, including anxiety disorder NOS; psychotic disorder, NOS; bipolar disorder NOS; and bipolar disorder with psychosis. I explained to her the diagnosis and my concern about the possibility of mood swings and the risk of being on SSRIs or other antidepressants that are commonly prescribed for eating disorders, and that can worsen what I suspected was underlying bipolar disorder, and alter the course and treatment outcome – and the overall clinical outcome. She really did not care about the diagnosis or the treatment and was willing to take any medication that would not cause weight gain. She agreed to take topiramate and adamantly decided against taking anything else.

On subsequent visits, she reported worsening of concentration and anger but insisted on continuing on the topiramate because it had lowered her appetite and her bingeing and purging behavior had become less frequent.

At this point, I confirmed the diagnosis as bipolar disorder and had her agree to take lamotrigine. She continued to experience anger and mood swings, although she was taking 300 mg of lamotrigine. Risperidone had no therapeutic response. Although it proved difficult to persuade her to take sodium valproate she agreed, because she understood the consequences of her anger. Miss G. knew that continuing to behave disrespectfully toward her teachers would jeopardize her education and her future.

To elaborate on the time frames, let me point out that Miss G. started on the topiramate on the first day of her treatment. The lamotrigine was started the following month. The sodium valproate was introduced about 7 months after that with improvement, but she continued to complain of weight gain and appetite, which was not controlled – even with an H-2 blocker. So I had to stop the sodium valproate 4 months after it was introduced. Her concentration continued to either decline or not improve with mood stabilization.

This is the point at which I introduced clonidine. Although Miss G. did experience some side effects, her concentration improved. Her mood remained fairly stable on lamotrigine and clonidine after I discontinued the sodium valproate.

My last session with Miss G. occurred about 1 year and 3.5 months after the first visit. On that day, she was casually but neatly dressed. She told me that she would be graduating from high school and attending college out of state.

When I asked her about some of the behaviors tied to her eating disorder, she said "not at all" but after further exploration she said "once or twice a week; it became a lifestyle and right now, it is not a lifestyle anymore," she said. Miss G. went on to describe her current weight of 145 as "ideal," but said she still struggled to see herself in a healthy way. "By being treated for my bipolar disorder, my eating disorder did not reach such a low point," she said. "I consider myself a recovered eating disorder patient."

Her mood was good and her affect appropriate. She said she had no thoughts of harming herself.

We must get this right

Most prior patients with a diagnosis of eating disorder come to my office on SSRIs with poor functioning and symptom control. Initially, they say, "You are the doctor; whatever you say," but in the end, they either failed to accept the diagnosis of bipolar disorder or to follow my treatment recommendations and left my practice. In each of these cases, I have been concerned that these patients with eating disorder diagnoses might indeed have bipolar disorder.

As I mentioned earlier, some studies have been conducted exploring the connections between eating disorder and bipolar disorder, but more are needed. Specifically, we need to determine the extent to which eating disorder and bipolar disorder are comorbidities – or whether eating disorder is an episode that leads to bipolar disorder. In addition, we must compare the treatment outcome and clinical course of patients who are treated with SSRIs for eating disorder with the treatment outcome and clinical course of patients who are treated with mood stabilizers – even if they have started episodes of eating disorder.

Finally, organized psychiatry must establish guidelines and develop tools for the proper diagnosis of bipolar disorder, even if eating disorder episodes are already under way.

*Miss G. enthusiastically gave her permission to publish these details about her treatment and even offered to allow me to use her full name, if doing so might help others get proper diagnosis and treatment.

Dr. Khoshnu is a general adult psychiatrist who is mostly in private practice in the West Caldwell and Somerset, N.J., areas. She also is affiliated with Overlook Hospital in Summit, N.J.