The most important comorbidities of anorexia

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

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

We'll see now the main comorbidities of anorexia, together with the treatment routes that are usually used for this type of combined disorders.

• Related article: "Anorexia nervosa: symptoms, causes and treatment"

Comorbidities of anorexia

Anorexia nervosa is an eating disorder. In this disorder, the patient has a body mass index (BMI) significantly lower than that 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 behaviors that reject food..

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

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 with both diagnoses.

It is important to adjust the treatment in such a way that the mistake is not made of trying to improve the prognosis of, for example, a case of bipolar disorder, as a side effect the course of the TCA.

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 the criteria to be diagnosed with both disorders is the patient's concern from one of the side effects of 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 depression can be confused with the lack of energy and lack of libido typical of anorexic patients just started treatment.

• You may be interested in: "Main comorbidities of bipolar disorder"

2. Depression

One of the main problems when treating the depression in patients with eating disorders, and especially with cases of anorexia nervosa, is to carry out an accurate diagnosis. Given the patients with anorexia often present with 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 this does not necessarily have to be the case.

That is why it is necessary to rigorously follow 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 is no longer 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, they usually proceed to psychotherapeutic and pharmacological treatment. In these cases, any antidepressant is acceptable, except bupropion. The reason for this is that it can cause epileptic seizures in those who binge and then purge. Although these symptoms are typical of bulimia nervosa, it should be noted that evolving from one eating disorder 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, a case of overdose is taking place.. In the case of fluoxetine, citalopram and paroxetine, it is usual to start with 20 mg/day, while venlafaxine at 75 mg/day and sertraline at 100 mg/day.

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

It should not be forgotten psychological therapy, especially cognitive-behavioral therapies, since most of the treatments for eating disorders, especially anorexia and bulimia, involve to work on the cognitive component behind the bodily distortions present in these disorders. However, it is necessary to highlight that in patients with very low weight they are too malnourished for their participation in this type of therapy to be somewhat beneficial in the short term term.

3. Obsessive-compulsive disorder (OCD)

There are two main factors to consider regarding obsessive-compulsive disorder (OCD) combined with EDs.

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

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

Pharmacological treatment usually begins 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 the production of a greater and faster therapeutic response than if they were administered alone antidepressants.

4. panic disorder

The symptoms of panic disorder, with or without agoraphobia, are as troublesome in a patient with an eating disorder as in any other.

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

5. specific phobias

Specific phobias are not common in patients with ED, leaving aside the fears related to the disorder itself, such as the phobia of gaining weight or specific foods, especially rich in fats and carbohydrates. These types of fears are treated together 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 creams without taking into account her nutritional status or working on anorexia as a whole.

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

• You may be interested in: "Types of Phobias: Exploring Fear Disorders"

6. Post Traumatic Stress Disorder (PTSD)

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

In any case, there is much controversy between having been a victim of traumatic events and its effect on other comorbid diagnoses. Individuals who have suffered sexual abuse, prolonged in time, tend to present alterations in their mood, relationships unstable love/sexual relationships and autolytic behaviors, behaviors which are symptoms associated with borderline personality disorder (TLP). This is where the possibility of a triple comorbidity arises: ED, PTSD and BPD.

The pharmacological pathway is complex for this type of comorbidity. It is common for the patient to present severe mood swings, high intensity and phobic behaviors, 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 her anxiety reduced, runs the risk of overdosing, especially if the patient has obtained the drugs from multiple professionals. This can give as an adverse effect crisis.

In this type of case, it is necessary to explain to the patient that it is difficult to treat anxiety completely through the pharmacological route, which allows a symptomatic but not total reduction of the PTSD. It should be noted that some authors consider the use of low-dose atypical antipsychotics more appropriate instead of benzodiazepines, since patients do not tend to escalate their dose.

• You may be interested in: "Post Traumatic Stress Disorder: Causes and Symptoms"

7. Substance abuse

Substance abuse is a difficult area to 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 is plenty of data regarding alcoholism and eating disorders, there is no so clear what are the rates of drug abuse, especially benzodiazepines, in the population anorexic.

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

Bibliographic references:

• Godoy-Sanchez, L. AND.; Albrecht-Roman, W. R. and Mesquita-Ramirez, M. no. (2019) Psychiatric comorbidities of anorexia and bulimia nervosa in pediatrics. Rev. nac. 11(1), pp.17-26. ISSN 2072-8174. http://dx.doi.org/10.18004/rdn2019.0011.01.017-026.
• Woodside, B.D. & Staab, R. (2006) Management of Psychiatric Comorbidity in Anorexia Nervosa and Bulimia Nervosa CNS Drugs 20: 655. https://doi.org/10.2165/00023210-200620080-00004