The most important comorbidities of anorexia

Anorexia has become a very common disorder in the last fifty years, especially due to the imposition of the canon of feminine beauty, characterized by the model of extreme thinness in women.

As this disorder of eating behavior increases, there have been more and more cases in which the patient not only manifests this disorder, but also suffers from some type of added psychiatric problem.

Next we will see the main comorbidities of anorexia , together with the treatment routes that are usually used for this type of combined disorders.

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Comorbidities of anorexia

Anorexia nervosa is a disorder of eating behavior. In this disorder, the patient has a significantly lower body mass index (BMI) than expected in a person of the same height and age, usually less than 85% of the expected weight. This low body size is due to the intense fear of gaining weight, which is accompanied by food rejection behaviors .

Comorbidity is understood as the presence of two or more psychiatric disorders or medical ailments, not necessarily related, that occurred in the same patient. Knowing the comorbidity of two disorders, in this case anorexia and another one, whether this anxiety disorder, mood or personality, allows to explain the appearance of both in the same patient, in addition to providing appropriate information to professionals and proceed to carry out evaluations and therapeutic decisions.

1. Bipolar disorder

Comorbidity between eating disorders and bipolar disorder has been investigated. The reason why psychiatric research is increasingly focusing on this line of study is that eating disorders are more frequent in the bipolar population, which requires designing a specific treatment for patients who have both diagnoses .

It is important to adjust the treatment in such a way that the error of is not committed, when trying to improve the prognosis of, for example, a case of bipolar disorder, as a side effect the course of the ACT is impaired.

The emotional lability of anorexic patients can be confused with symptoms of bipolar disorder. It should be noted that the main problem in patients who meet criteria to be diagnosed with both disorders is the patient’s concern about one of the side effects of the medication for bipolar disorder, usually lithium and atypical antipsychotics, which can cause weight gain.

This comorbidity is especially striking in the case of patients who are in a state of malnutrition and the depressive episode of bipolar disorder. The symptoms of a depression can be confused with the lack of energy and absence of libido typical of anorexic patients newly initiated in treatment.

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2. Depression

One of the main problems when treating depression in patients with eating disorders, and especially with cases of anorexia nervosa, is to carry out an accurate diagnosis. Since patients with anorexia usually have malnutrition and lack of energy , it may be the case that depression is camouflaged among the symptoms of starvation. Many patients will recognize that their mood is not normal and will describe them as ‘depressed’, but it does not necessarily have to be that way.

That is why it is necessary to follow rigorously how the patient evolves once she is under treatment to increase weight and have normal blood nutrient levels. Malnutrition and depression share very striking symptoms such as loss of libido and sleep disturbances, it is for this reason that, once the person stops being malnourished, if these symptoms are still observed, it is possible to make the diagnosis of depression.

Once the person with anorexia nervosa has been identified with a diagnosis of depression, psychotherapeutic and pharmacological treatment is usually carried out. In these cases, any antidepressant is acceptable, except for bupropion . The reason for this is that it can cause seizures in those who binge and subsequent purges. Although these symptoms are typical of bulimia nervosa, it should be noted that evolving from one TCA to another is relatively common.

The dosage of antidepressants in patients with anorexia nervosa is something that should be monitored, since, since they are not in normal weight, there is a risk that, when prescribing a normal dose, there is a case of overdosing . In the case of fluoxetine, citalopram and paroxetine are usually started with 20 mg / day, while venlafaxine at 75 mg / day and sertraline at 100 mg / day.

Whatever the type of antidepressant prescribed, professionals ensure that the patient understands that, if he does not increase his weight, the benefit of the antidepressants will be limited. In people who have reached a healthy weight, it is expected that the consumption of this type of drugs implies about a 25% improvement in mood. In any case, professionals, to ensure that it is not a false positive of depression, ensure that they spend 6 weeks of improvement in eating habits before pharmacologically addressing depression.

It is important not to forget psychological therapy, especially cognitive behavioral therapies , since most treatments for eating disorders, especially anorexia and bulimia, imply that the cognitive component is worked behind the body distortions present in these disorders. However, it is necessary to highlight that in patients with very low weight they are too malnourished so that their participation in these types of therapies will be beneficial in the short term.

3. Obsessive-compulsive disorder (OCD)

There are two main factors to consider with regard to obsessive-compulsive disorder (OCD) combined with eating disorders.

First, food-related rituals , which can hinder the diagnosis and can be seen as more related to anorexia than to OCD itself. In addition, the person can carry out excessive exercise or obsessive behaviors such as repetitive weighing.

The second factor is the common personality type in patients of both disorders, with perfectionist traits , personality aspects that persist even after normal weight has been reached. It should be noted that having rigid and persistent personality characteristics, which remain beyond advanced therapy, are not a clear indication that this is a case of a person with OCD.

Pharmacological treatment usually starts with antidepressants, such as fluoxetine, paroxetine or citalopram. As an additional strategy, there is the incorporation of small doses of antipsychotics, since there are experts who believe that this contributes to a greater and faster therapeutic response than if only antidepressants are administered.

4. Panic Disorder

The symptoms of panic disorder, with or without agoraphobia, are problematic in both a patient with an eating disorder and in any other.

The most common treatment of choice is a combination of antidepressants along with the traditional cognitive therapy. Once the treatment is started, the first symptoms of improvement are observed after six weeks.

5. Specific phobias

Specific phobias are not common in patients with eating disorders, leaving aside the fears related to the disorder itself, such as the phobia to gain weight or specific foods, especially rich in fats and carbohydrates . These types of fears are treated along with anorexia, since they are symptoms of it. It makes no sense to treat the patient’s body distortion or aversion to dishes such as pizzas or ice cream without taking into account their nutritional status or working on anorexia as a whole.

It is for this reason that it is considered that, leaving aside body and food phobias, specific phobias are equally common in anorexic population than in the general population.

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6. Post-traumatic Stress Disorder (PTSD)

PTSD has been seen as a highly comorbid anxiety disorder with altered eating behavior. It has been seen that, the more severe the ACT, the more likely it is that the PTSD will occur and be more serious , seeing a link between both psychiatric conditions. In developed countries, where they have been living in peace for decades, most cases of PTSD are associated with physical and sexual abuse. It has been seen that about 50% of people with anorexia nervosa would meet criteria for the diagnosis of PTSD, being the cause, mostly, childhood abuse.

However, there is a lot of controversy between being a victim of traumatic events and their effect on other comorbid diagnoses. Individuals who have suffered sexual abuse, prolonged over time, tend to have mood disorders, unstable love / sexual relationships and autolytic behaviors, behaviors which are symptoms associated with borderline personality disorder (BPD). This is where the possibility of a triple comorbidity is presented: TCA, PTSD and BPD.

The pharmacological route is complex for this type of comorbidity. It is common for the patient to have severe mood swings, high intensity and phobic behavior , which would suggest the use of an antidepressant and benzodiazepine. The problem is that it has been seen that this is not a good option because, despite the fact that the patient will see his anxiety reduced, there is a risk of overdosing, especially if the patient has obtained drugs from multiple professionals. This can result in adverse crisis effect.

Given this type of case, it is necessary to explain to the patient that anxiety can hardly be treated completely through the pharmacological route, which allows a symptomatic but not total reduction of PTSD. It should be noted that some authors consider the use of atypical antipsychotics at low doses rather than benzodiazepines more appropriate, since patients do not tend to scale their dose.

7. Substance Abuse

Substance abuse is an area of ​​difficult study in terms of its comorbidity with other disorders, since symptoms can be intermingled. It is estimated that about 17% of anorexic people manifest alcohol abuse or dependence throughout their lives . It should be noted that, although there are enough data regarding alcoholism and eating disorders, the rates of drug abuse, especially benzodiazepines, in an anorexic population are not as clear.

The cases of anorexia combined with substance abuse are especially delicate. When one of these is detected, it is necessary, before applying any pharmacological treatment, to put them into rehabilitation to try to overcome their addiction. Alcohol consumption in anorexic people with a very low BMI complicates any drug treatment.


by Abdullah Sam
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