Treating Comorbidities in Eating Disorders

@iaedp
#iaedp2021
By Heba Essawy MD., CEDS.,
Prof of Psychiatry
International Chapter chair –Egypt Iaedps
Head of Egyptian Association of Eating Disorders
Head of Eating Disorders Clinics
Okasha Institute -Medical school
Ain Shams University.Cairo- Egypt

@iaedp
#iaedp2021
 Eating disorders is one of the devastating
disorder
 Psychiatric comorbidities with Eds have recently
emerged as significant clinical, public health and
research issues
 Diagnosing and treating these comorbidities
improves outcomes for the eating disorders and
on other hand treating an Eating Disorders will
significantly improve other mental conditions
Blinder et., al., 2006

@iaedp
#iaedp2021
To clarify this relationship between Eds
and psychiatric comorbidity
it is important to understand :
 The timelines and sequencing of the onset
of psychiatric comorbidities.
 To consider the potential impact of
comorbidities on either diagnosis ,
treatment and prognosis of the Eds
Bernstein et., al., 2014

@iaedp
#iaedp2021
 1-Identification of the most common forms of
comorbidity with Eds that might present to the
clinicians
 2-Recognition of the confounding effects on
either diagnosis , adverse effects and response to
treatment of the comorbidity
 3-Discuss the different pharmacological
approaches for treatment of comorbid mental
disorders with Eds

@iaedp
#iaedp2021
 Individuals with EDs very often have
comorbid medical and or psychiatric
condition.
 Almost 97% of female inpatients with Eds were
found to have one or more Comorbid diagnosis
 55% - 98% of individuals with AN met the
criteria for another psychiatric disorder
 88% of Individuals with BN met the criteria
for another psychiatric disorder
 65.5% BED self report a life prevalence of MDD
Hughes et., al., 2013

@iaedp
#iaedp2021
The most frequent comorbid psychiatric disorders
are :
- Depression
- Suicidality
- Borderline personality Disorder
- Anxiety
- Substance abuse disorder
- OCD
 - Post traumatic stress disorder ( PTSD)

@iaedp
#iaedp2021
 MDD is the most frequent comorbid psychiatric
disorders
 Life time prevalence of comorbid depression in Eds
is 94%
 In AN, mortality is 18 times higher when
depression is present
 Elise in 2021, concluded that AN patients, had
greater clinical severity when they had comorbid
disorder as MDD,GAD, SP over their lifetime
Elise et.,al., 2021

@iaedp
#iaedp2021
 It is difficult to make an accurate diagnosis of
depression in AN or BN due to the confounding
effects of starvation , as starvation may
contribute to depressive symptoms
 AN clients identify their mood as abnormal , flat
or empty mood or extreme labiality of mood
 The vegetative symptoms as energy, libido and
sleep are all disrupted on account of starvation
 Cognitively, the patient experience helplessness
or hopelessness, but this often due to the chronic
nature of their condition

@iaedp
#iaedp2021
 Onset : Studies of the onset of Eds and depression
suggest that Eds tend to precede the development of
depression
 Prognosis :
-Comorbid depression may predict a longer course
of illness
- Depressed mood improves with weight
restoration
 Hughes, et., al., 2013

@iaedp
#iaedp2021
 Suicidality refers to a wide range of thoughts and
behaviors either ;
- Passive ideation (passive thoughts about not
wanting to live anymore) to lethal attempts.
- Non Suicidal self – injuries behavior :
- self-harm such as cutting, burning, scratching,
or harming the skin.
 Individuals with any type of Eds history were more
likely to have a greater number of suicide attempts
compared to those without an eating disorder history

@iaedp
#iaedp2021
 lifetime history of an Eating Disorders are at
increased risk of having a suicide attempt history.
 The prevalence of suicide attempts In 36,000 clients
with Eds history was 24.9% among those with a
history of anorexia.
 The prevalence of suicide attempts with the
binge/purge subtype was much higher than the
restricting subtype (44.1% and 15.7% respectively).
 The prevalence of suicide attempts with history of
Bulimia is 31.4% .
 22.9% of those with a history of BED had attempted
suicide .

@iaedp
#iaedp2021
• Depression
• Previous suicide attempts
• Preoccupation with death
• Statements like, "You would be better off without me"
or "I wish I were dead"
• Talking openly about wanting to kill oneself
• Inappropriately saying goodbye
• Making ambiguous statements like, "You won't have to
worry about me anymore," "I wish I could go to sleep
and never wake up," or "I just can't take it anymore"

@iaedp
#iaedp2021
are :
- Depression
- Suicidality
- Borderline personality Disorder
- - Substance abuse disorder
- OCD
 - - Post traumatic stress disorder ( PTSD)

@iaedp
#iaedp2021
 People with borderline personality disorder have a
greater prevalence of eating disorders than people in
the general population.
 53.8% of patients with BPD also met criteria for an
eating disorder (compared to 24.6% of patients with
other personality disorders).
 21.7% of patients with BPD met criteria for anorexia
nervosa and 24.1% for bulimia nervosa.


@iaedp
#iaedp2021
are :
- Depression
- Suicidality
- Anxiety
- OCD
 - Borderline personality Disorder

@iaedp
#iaedp2021
 Anxiety disorders co-occur in more than half (56%)of Ed
cases
 Life time prevalence of OCD are around 40% in patients
with Eds
- OCD rituals, affecting 56% of individuals with AN
cases
 Social phobia was prevalent as in 20% of AN cases
 Panic Disorder affect 11% of Eds cases
 Generalized Anxiety Disorder is prevalent in 10% of Eds
patients
Kaye et., al., 2004. Bulik et.,al.,
2002

@iaedp
#iaedp2021
 OCD diagnosis represents a complex challenge, in AN
1- Ritualistic activities ( excessive exercise and
repetitive weighting) should not be counted when
diagnosing OCD as these are part of Eds
2- Perfectionist is a major trait for AN patients , a
character trait that persists even after weight restoration
3- Patients with OCPD ( preoccupied with rules,
orderliness, and control) and Eds may be mistaking as
OCD

@iaedp
#iaedp2021
 Anxiety Disorders commonly had their onset in
childhood before the onset of Eds , raising the
possibility they are vulnerability factor for
developing AN or BN
 The emergence of Eds as a coping mechanism
against the Childhood Anxiety disorders arise will
support that Anxiety disorder will predate Eds
 Early onset anxiety disorders may represent a
genetically – based pathway toward the
development of an Eds

@iaedp
#iaedp2021
are :
- Depression
- Anxiety
- OCD
 - Borderline personality Disorder

@iaedp
#iaedp2021
 PTSD is a commom comorbidity with Eds
 PTSD occur in 13% in Eds patients
 PTSD is present in 50% for the restricting forms
of AN
 PTSD is over 80%for the binge-purging AN
 Severity of PTSD tend to increase with severity
of Eds

@iaedp
#iaedp2021
 SUD is associated with 25% of clients with Eds
 Lifetime prevalence of alcohol abuse ranges from 17%
in the restricting AN to 46% in BN
 SUD is used as suppressor of Appetite in Anorexics (
Drunkorexia)
 Substance abuse may serve as a self- medicating
function as an attempt to alleviate the anxiety that
often underlies disordered eating
Kay et.,al., 1996

@iaedp
#iaedp2021
 1-Identification of the most common forms of
comorbidity with Eds that might present to the
clinicians
 2-Recognition of the confounding effects of
starvation and unstable eating on either
diagnosis , adverse effects and response to
treatment of the comorbidity
 3-Discuss the different pharmacological
approaches for treatment of comorbid mental
disorders with Eds

@iaedp
#iaedp2021
 There is little evidence on which treatment work
best for people with Eds and comorbidity
 In treating ,AN and BN with comorbid depression
any Antidepressant is acceptable except of
Brupropion which can be associated with seizures
with Binge Eating and or purging
 The benefit of older Antidepressants such as Tcas
and MAOIs need to be carefully weighted against
their less adverse effect profiles
Blake Woodside 2006

@iaedp
#iaedp2021
 Dosages used should be those for depression in
other setting
 Fluoxetine,paroxitine and citalopram should be
started at 20mg/day, Sertraline at
100mg/day,Venlafaxine at 75mg/day
 It is not necessary to reduce the dosage of the
antidepressant on the basis of patient s weight
 Patients of very low weight may need to given lower
dosages than normal if they experience significant
adverse effects
 It is very important to provide an adequate dosage of
the drug in question

@iaedp
#iaedp2021
 The antidepressant is not having much effect on
underlying anorexic symptomatology
 Patients with AN will not fully respond to AD
until they are weight-restored

@iaedp
#iaedp2021
 Psychotherapy
- CBT
- Interpersonal therapies
 Psychopharmacological treatment for BED :
- For binging and weight : Topiramate and or
Naltroxane
- For appetide regulation :sibutramine
- For obssesive thought : Lisdexamfetamine
- For Anxiety and Depression : SSRIs , SNRIs,
vortioxitine
Sanchez ,et.,al., 2015 Gonda ,et.,al., 2019

@iaedp
#iaedp2021
 Psychiatric hospitalization because it provides
increased security for the patient.
 Short-term management of crises include increased
monitoring and social support, removal of lethal
methods, and treatment of acute psychiatric symptoms.
 Dialectical behavior therapy(DBT) is targeted to
behaviors according to a hierarchy. Suicidal behaviors
are considered the highest priority for treatment.

@iaedp
#iaedp2021
 Little responses on OCD either using
pharmacotherapy or psychotherapy until
changes have begun to occur in the core
symptoms of the Eds
 Once changes have started , treatment with AD is
the first line of attack
 Start with typtical dosage ofAD either Fluxetine
, paroxitine, citalopram 20mg/ day ( not
necessary to reduce the dose on account of the
patients )

@iaedp
#iaedp2021
 If a decision is made to increase the dosage of
AD, it should be raised to the highest dosage
that can be tolerated by the patients
• Addition of very small dose of Antipsychotic as
an augmentation agent as this will be more
intense and rapid response than AD alone ( as
Resperidone in 0.5-2mg/day)
• Clinicians should resist the urge to increase the
dosage of the AD in patients whose eating is not
improving

@iaedp
#iaedp2021
 DBT was originally created to treat borderline
personality, but is sometimes used in eating disorder
treatment because of how effective it can be. DBT
focuses on the following core skills:
• Mindfulness
• Relational skills
• Distress tolerance
• Emotional regulation.

@iaedp
#iaedp2021
Antidepresant
• (Effexor (venlafaxine)
• Prozac (fluoxetine)
• Brintillix (Vortioxitine)
• Zoloft (sertraline) Spravato ( Esketamine)
Antipsychotics
• Abilify (aripiprazole)
• Risperdal (risperidone)
• Seroquel (quetiapine) / Lurasidone
• Zyprexa (olanzapine)/ Neopression ( Brixpeprazol)
Mood stabilizers valproate Lamotrigine – Topiramate

@iaedp
#iaedp2021
 It is not recommended to provide the usual lines of
treatment both an AD and Benzodiazepines as this a
wrong choice because the patient will report a dramatic
but transient in anxiety and immediately begin the
escalate the dosage
 Low dosage of Atypical antipsychotic is preferably
used instead of Bz ( Quetiapine 12.5mg three times a
day, resperidone 0,5 mg)
 Some patients may require higher dosages, up to 150-
200mg of quetiapine per day
 Clinicians should always try to use the lowest possible
dosages

@iaedp
#iaedp2021
 In SUD comorbidity with Eds, it demands
treatment as an urgent priority
 It is advisable to try to “dry out” the patient
before attempting any significant treatment for
Eds , 30 –day residential treatment where the
clinicians are much aware of the patient s ED
 Pharmacological treatments for SUD are not
recommended

@iaedp
#iaedp2021
 Failure to recognize and treat comorbidities
-Place an individual who has recovered from an
Eating disorder at greater risk of relapse when
faced with acute stressor trauma
- Integrative therapy provides the best option
for long- term physical and mental health for Eds

@iaedp
#iaedp2021
• Management of Eds Clients should include :
 - Comprehensive screening for a range of
mental disorders
- Therapeutic plan addressing multiple
diagnosis
this will ensure an efficient , long lasting
recovery for clients with Eds

@iaedp
#iaedp2021
Thank you
Heba Essawy MD., CEDS.,
Email: essawi_h@yahoo.com
Website: www.heba essawy.com

Treating Comorbidities in Eating Disorders

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to Treating Comorbidities in Eating Disorders

Similar to Treating Comorbidities in Eating Disorders (20)

More from Heba Essawy, MD

More from Heba Essawy, MD (20)

Recently uploaded

Recently uploaded (20)

Treating Comorbidities in Eating Disorders

Editor's Notes