The most important anorexia comorbidities

These are the psychological disorders that often occur at the same time as anorexia nervosa.

Anorexia has become a very common disorder in the last fifty years, especially due to the imposition of the female canon of beauty, 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 not only manifests this disorder, but also suffers from some kind of additional psychiatric problem.

The following are the main comorbidities of the main co-morbidities of anorexiaThe following are the main comorbidities of anorexia, together with the treatment routes that are usually used for this type of combined disorders.

Comorbidities of anorexia.

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

Comorbidity is understood as the presence of two or more psychiatric disorders or medical conditions, not necessarily related, occurring in the same patient. Knowing the comorbidity of two disorders, in this case anorexia and another disorder, be it an anxiety, mood or personality disorder, makes it possible to explain the appearance of both in the same patient, as well as to provide the necessary information to professionals and to proceed to carry out evaluations and therapeutic decisions.

1. Bipolar disorder

The comorbidity between eating disorders and bipolar disorder has been investigated. The reason that psychiatric research is increasingly focusing on this line of study is that EDs are more prevalent in the bipolar population, necessitating the design of specific treatment for patients with both diagnoses. requires designing a specific treatment for patients with both diagnoses..

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

The emotional lability of anorexic patients may be mistaken for symptoms of bipolar disorder. It should be noted that the main problem in patients who meet criteria for diagnosis with both disorders is the patient's concern about 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 who are new to treatment. newly initiated in the treatment.

2. Depression

One of the main problems in treating depression in patients with eating disorders, and especially with cases of anorexia nervosa, is making an accurate diagnosis. Given that patients with anorexia often present with malnutrition and lack of energy, depression may be camouflaged among the symptoms of starvation.It may be the case that depression is camouflaged among the symptoms of starvation. Many patients will recognize that their moods are not normal and describe them as 'depressed', but this does not necessarily have to be the case.

This is why the patient's progress should be closely monitored once she is undergoing 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, which is why, once the person is no longer malnourished, if these symptoms are still observed, it is possible to make a diagnosis of depression.

Once a person with anorexia nervosa has been identified with a diagnosis of depression, psychotherapeutic and pharmacological treatment is usually undertaken. In these cases any Antidepressant is acceptable, with the exception of bupropion.. The reason for this is that it can provoke epileptic seizures in those who binge and subsequently purge. Although these symptoms are typical of bulimia nervosa, it should be noted that progression from one ED to another is relatively common.

The dosage of antidepressants in patients with anorexia nervosa is something that should be monitored, given that, as they are not at normal weight, there is a risk that, by prescribing a normal dose, a case of overdosage may occur.. Fluoxetine, citalopram and paroxetine are usually started at 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 he or she does not increase his or her weight, 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 drugs implies about a 25% improvement in mood. In any case, professionals, to ensure that it is not a false positive of depression, make sure that 6 weeks of improvement in eating habits pass before addressing depression pharmacologically.

Psychological therapy, especially cognitive-behavioral therapies, should not be forgotten.Most of the treatments for EDs, especially anorexia and bulimia, involve working on the cognitive component behind the body distortions present in these disorders. However, it is necessary to point out that patients with very low weight are too malnourished for their participation in this type of therapy to be beneficial in the short term.

3. Obsessive-compulsive disorder (OCD)

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

First, food-related ritualswhich may hinder the diagnosis and may be seen as more related to anorexia than to OCD per se. In addition, the person may engage in excessive exercise or obsessive behaviors such as repetitive weighing.

The second factor is the personality type common to patients with both disorders, with perfectionistic traits, personality aspects that persist in both disorders.The second factor is the personality type common to patients with both disorders, with perfectionist traits, aspects of personality that persist even after normal weight has been achieved. It should be noted that having rigid and persistent personality characteristics that persist beyond the end of therapy is not a clear indication of OCD.

Pharmacological treatment is usually initiated with antidepressants such as fluoxetine, paroxetine or citalopram. An additional strategy is to incorporate small doses of antipsychotics, as some experts 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 as problematic in an ACT patient as in any other.

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

5. Specific phobias

Specific phobias are not a common occurrence in patients with ED, apart from fears related to the disorder itself, such as phobia of gaining weight or of specific foods, especially those rich in fats and carbohydrates.. These types of fears are treated together with the anorexia, since they are symptoms of it. It does not make sense to treat the patient's body distortion or aversion to dishes such as pizza or ice cream 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 aside body and food phobias, specific phobias are equally common in the anorexic population as in the general population.

6. Post Traumatic Stress Disorder (PTSD)

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

However, there is much controversy between having been a victim of traumatic events and its effect on other comorbid diagnoses. Individuals who have suffered prolonged sexual abuse tend to present mood disturbances, unstable love/sexual relationships and self-injurious behaviors, all of which are symptoms associated with borderline personality disorder (BPD). It is here that the possibility of a triple comorbidity presents itself: BDD, PTSD and BPD.

The pharmacological pathway is complex for this type of comorbidity. It is common for the patient to present severe mood swings, elevated intensity and phobic behaviors, which would suggest the use of a medication for this type of comorbidity.which would suggest the use of an antidepressant and benzodiazepine. The problem is that this has been found not to be a good option because, although the patient will see his anxiety reduced, there is a risk of overdosing, especially if the patient has obtained the drugs from multiple professionals. This can have the adverse effect of a seizure.

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

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 anorexics report lifetime alcohol abuse or dependence.. It should be noted that, although there is considerable data on alcoholism and ED, the rates of drug abuse, especially benzodiazepine abuse, in the anorexic population are less clear.

Cases of anorexia combined with substance abuse are particularly sensitive. When one of these is detected, it is necessary, before applying any pharmacological treatment, to place them in rehabilitation to try to overcome their addiction. Alcohol consumption in anorexic individuals with a very low BMI complicates any pharmacological treatment.

Bibliographic references:

• Godoy-Sánchez, L. E.; Albrecht-Roman, W. R. and Mesquita-Ramírez, M. N. (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