Bipolar Disease and Eating Disorders

Like a cruel pendulum, bipolar disorders cause patients to swing back and forth between periods of depression and manic energy. It may take as long as 10 years to diagnosis bipolar disorder and when these patients also have an eating disorder, treatment can become much more difficult. According to a group of Brazilian physicians, the presence of an eating disorder can impose seriously negative outcomes in patients with bipolar disease (Rev Bras Psiquiatr 2012; 34:1516).

Dr. Camila Seixas and physicians at the Center for the Study of Mood and Anxiety Disorders at the Federal University of Bahia, Salvador, Brazil, investigated all patients diagnosed with bipolar disorder who had undergone treatment over a 4-year period at two university hospitals. Out of a final group of 356 patients, 5.3%, or 19, had an eating disorder. Eleven had bulimia nervosa (BN) and 8 had anorexia nervosa; the sole male patient in the study was diagnosed with BN. The investigators used a number of measures, including a clinical and sociodemographic questionnaire, and the Structured Clinical Interview of DSM-IV Axis I (SCID-1), the Young Mania Rating Scale (YMRS), the Hamilton Depression Rating and Anxiety Rating scales (HAM-D-17 and HAM-A), the Global Assessment of Functioning (GAF), and the Clinical Global Impression scale (CGI). In addition, they administered the WHO Rating scale for quality of life evaluation (WHOQoL-BREF) to a subset of 180 participants.

More negative clinical outcomes seen

HAM-A and HAM-D scores were the only significantly different measurements reported between subjects with and without eating disorders, Patients with eating disorders tended to have higher HAN-A scores, and HAM-D scores were higher in those with eating disorders compared to those without eating disorders. Patients with bipolar disorder and eating disorders had more severe illness than did bipolar disorder patients without eating disorders. These patients had more negative clinical outcomes, mainly higher scores for depressive symptoms, lower scores on quality of life, and significantly more psychiatric comorbidities. The authors noted that some have suggested that eating disorders occur more often in the depressive phase (Acta Psychiatr Scand 2008; 18:4). They also added that mood stabilizers, which are first-line treatments for bipolar patients, lead to weight gain and this effect alone could negatively impact prognosis because it reduces adherence to treatment in persons who already have an eating disorder.

Dr. Seixas pointed out several limitations of their study, including the cross-sectional design that precluded the chance to examine any temporal relationship between the bipolar disorder and eating disorder. Participants were patients from specialized services and thus the results may not apply to other clinical settings. The researchers also did not measure body mass index, and binge eating disorder was not included in the study because it was not a diagnostic category in the DSM-IV.

The researchers hope further research will delve deeper into the genetic and neurological bases of bipolar disease and eating disorders, and urge all clinicians who work with patients with bipolar disease to test patients for possible coexisting eating disorders.

Results from a larger study

In a study of 875 outpatients with bipolar disease seen at the Craig and Frances Lindner Centre of HOPE, Mason, OH, 125 (14.3%) met DSM-IV criteria for at least one comorbid lifetime Axis 1 eating disorder. BED was more common than BN (77 patients and 27 patients, respectively). There were no significant eating disorder comorbidity differences between bipolar I and bipolar II patients (J Affect Disord 2011; 228:191).

The study also found that presence of lifetime comorbid eating disorder was associated with female gender, younger age, earlier age of onset of mood symptoms and of bipolar disease, presentation in a mixed episode, greater number of prior mood episodes, and history of rapid cycling and suicide attempts. These patients also had a greater mean body mass index (BMI, kg/m,² obesity and severe obesity and a family history of depression, bipolar disorder, alcoholism, and drug abuse.

The authors concluded that patients with bipolar disorder, especially women, not infrequently have comorbid eating disorders, and this comorbidity is associated with earlier and of onset and more severe bipolar illness.

An ongoing study to improve diagnostic criteria

According to Dr. Rodolfo N. Campos and colleagues at the University of Sao Paulo School of Medicine, the bipolar spectrum is under-recognized and its definition is not well established in current diagnostic guidelines. Dr. Campos reported on ESPECTRA (Occurrence of Bipolar Spectrum Disorders in Eating Disorders Patients), a single-site cross-sectional study involving a comparison group, which is designed to evaluate the prevalence of bipolar spectrum in an eating disorder sample (BMC Psychiatry 2011;11:59). Dr. Campos and his group will evaluate women 18 to 45 years of age, using a series of questionnaires including the HAM-D and WHOQoL.