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The Interplay of Mood Disorders and Eating Disorders: Page 2 of 4

The Interplay of Mood Disorders and Eating Disorders: Page 2 of 4

Lifetime prevalence of mood disorders in patients with eating disordersTABLE. Lifetime prevalence of mood disorders in patients with eating d...
SIGNIFICANCE FOR THE PRACTICING PSYCHIATRISTSignificance for the Practicing Psychiatrist


Diagnostic challenges

Axis I diagnosis of comorbid mood and eating disorders, and determination of which clinical problem is more “primary,” can present a challenge. For example, several neurovegetative symptoms of depression, including fatigue, insomnia, poor concentration, and dysphoria, may be the sequelae of malnutrition. Therefore, a diagnosis of a coexisting depressive disorder may be delayed or deferred if the clinical history suggests that the restrictive behavior predated the mood symptoms. As discussed by Israel and Steiger,3 the question of identifying “depression as a symptom” of an eating disorder, rather than an independent syndrome, is significant in terms of guiding treatment and expected clinical response. For example, mood symptoms secondary to malnutrition tend to improve with weight restoration.

Although patients with bulimia nervosa and binge eating disorder do not suffer from acute starvation, other features may serve to amplify and/or create mood symptoms. For example, some or even most symptoms in patients with comorbid MDD and bulimia nervosa or binge eating disorder may stem from dissatisfaction with shape and weight. Disruptions in energy, concentration, and sleep cycle, as well as the “increased or decreased appetite” typically observed in MDD, may result from the effects of food restriction, binge eating, and/or vomiting. Moreover, these behaviors can lead to medical problems (eg, anemia, electrolyte disturbance).

Recovered or long-term weight-restored individuals with anorexia nervosa experience significantly elevated rates of depression, anxiety, and obsessive behavior compared with healthy controls.4,5 Therefore, careful evaluation for the possibility of a past eating disorder is important in any general psychiatric consultation. Eliciting a history of an eating disorder might heighten the clinician’s sensitivity to the potential presence of current mood symptoms. Conversely, given that fewer than half of individuals with bulimia nervosa or binge eating disorder have ever sought treatment specifically for their eating disorder but have at some point received care for an emotional problem, a thorough psychiatric review of symptoms may elicit a history of an eating disorder in a patient who presents with a different complaint.

Careful assessment of suicidality is critical in patients with eating disorders because suicide is a major cause of death in this population. Suicide has consistently been identified as the second most common cause of death after medical complications in patients with anorexia nervosa. Rates of suicide attempts range from 3.0% to 29.7% in patients with anorexia nervosa and from 10% to 40% in those with bulimia nervosa.6-8 Research on suicidality in binge eating disorder is limited. One study found that 12.5% of individuals with binge eating disorder who presented for outpatient treatment had a lifetime history of attempted suicide.9 Notably, completed suicide is more common in individuals with anorexia nervosa. The rates (standardized mortality ratio) for completed suicide in persons with anorexia nervosa have been reported to be up to 5.2 to 30 times higher than those of the general population.8,10


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