Episode 17 – Bipolar Disorder And Addiction
Dr. Ashish Bhatt ❘
Bipolar disorder isn’t just mood swings. Get an inside look on the disorder from an expert and someone who’s experienced it themselves.
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HAYLEY: Hello, my name is Hayley, and this is Straight Talk with the Doc. A podcast that takes a real look at addiction, mental health, and treatment. We have our medical director Dr. Bhatt with us today and our content director Jeff. How are you guys doing?
DR. BHATT: Doing well Hayley, how are you, how are you Jeff?
JEFF: I’m doing well too!
HAYLEY: Awesome. Today we’re going to be talking about eating disorders and the connection between them and addiction. Recently, I read that eating disorders are one of the most deadly mental illnesses, so I wanted to talk about why that is. But first, Dr. Bhatt, can you explain what some of the most common eating disorders are?
DR. BHATT: Sure! We have this thing in psychiatry, which is the science of treating mental health, that classifies eating disorders. Historically, there were 3 more common ones, and we’ve kind of expanded slightly in the past 5 or 6 years due to some of the symptoms of people who suffer from eating disorders not meeting certain criteria. So I’m going to start a little bit broadly with one of the more common ones that we’ve heard about, or defined, and that’s anorexia, or anorexia nervosa.
That one is basically when somebody is suffering with a significant dissatisfaction or distorted perception of their body image. They see themselves as often being overweight, and they have this pursuit to be a lot thinner, and they often restrict their food intake. This can cause pretty catastrophic body consequences and health consequences.
The next major eating disorder is bulimia nervosa. And bulimia nervosa, it differs somewhat from anorexia in the fact that with bulimia, people tend to often eat a lot of food in stead of restricting. They eat a lot in a short amount of time and then they end up often having compensatory behaviors. Mechanisms that end up trying to get rid of that food they took in either through vomiting or excess use of laxatives. Some other way to try and get rid of that food.
We have a new diagnostic mental health disorder regarding eating, and that is binge eating disorder. This is where people will often eat excessive amounts of food in a small amount of time. Often this goes along with a lot of anxiety and compulsory eating, but they don’t have that purging behavior that happens afterwords, which we often see with bulimia. So those are the 3 major ones, anorexia, bulimia, and binge eating disorder. Then we have this unspecified, or eating disorder not otherwise specified, classification, where people suffer from some sort of disordered eating, but don’t necessarily fulfill one of these – the criteria meeting one of these other disorders.
HAYLEY: So, can somebody binge eat, but not throw up? That’s just binge eating disorder? With someone with bulimia, do they always binge eat first?
DR. BHATT: Well yeah, one of the hallmark characteristics of bulimia is that they are going to eat a lot of food in a short amount of time. So that would be considered like a binging type episode. So that is a hallmark characteristic, and again part of it is with this compensatory mechanism to somehow get rid of the food they get in. With binge eating disorder, it’s more the increased amount of eating, the binge eating episode without the attempt to purge the food they took.
HAYLEY: So are there certain groups of people, like certain ages, that are more likely to suffer from an eating disorder?
DR. BHATT: You know, as the DSM 5, which is the diagnostic and statistical manual that is issued by the American Psychiatric Association which helps clinicians and practitioners classify, diagnose, and treat mental illness; you know they changed from DSM 4 to DSM 5, a more updated version, in 2013. I bring that up because there are feeding and eating type of illnesses that occur often at younger ages, but we’re not going to speak about them too much. Like pika, where people eat things of non-nutritional value. Those things fall under these feeding disorders.
As for the eating disorders, they tend to occur more in young adult, adolescence, teenage years, young adulthood. That tends to be the time when we see the onset of these disorders.
HAYLEY: Are there mental health conditions that are also seen in people with an eating disorder, like anxiety, or depression?
DR. BHATT: Yea, definitely! The statistics show that there’s a high correlation with co-occurring anxiety disorders, depressive disorders, often trauma, personality disorders, or character pathology that happens. Often, they go hand in hand with part of the symptoms and dynamics that occur when you have an eating disorder is that you often feel guilty, you often feel ashamed, you often feel anxiety, you often feel depressed. Either before or after the behaviors that you are acting upon. So, it becomes almost like this vicious cycle.
If there is this co-occurring or additional mental health issue going on, a primary anxiety, or depression, or bipolar, or trauma. It just exacerbates, one exacerbates the other. That’s why it’s really important to get treated for whatever co-occurring issues exist with the eating disorder.
HAYLEY: I want to talk about what’s going on in the brain of someone with an eating disorder. Do they feel satisfaction or accomplishment after words?
DR. BHATT: It depends what stage we’re talking about, or what stage in the behavior we’re talking about. Eating disorders, they’re not understood that well. We’ve made attempts to talk about people who suffer from eating disorders. Often they do have this distorted image of themselves. There’s this attempt to gain some sort of control. There’s a psychological aspect of maybe seeking perfectionism. This is often attempted to be attained through the eating cycle.
When somebody is maybe binging or binge eating at that moment, they might feel significant amount relief from some anxiety that was built up. Then, that eating behavior ends up making them feel less anxious. That is this compensation for that anxiety build up. Or often the other, sometimes when you eat too much, eat in excess, and they feel this excessive fullness, they start to feel embarrassed or guilty or shameful and that’s the trigger to purge or use the laxatives. It depends on what stage or disorder we’re talking about, but often there is some psychological pursuit or escape that is occurring to drive the motivation for that behavior.
HAYLEY: I want to talk about the stages a little bit. When does dieting or restricting food become a danger and when is it just “I’m trying to lose a little bit of weight”? Where is that line?
DR. BHATT: I think when somebody’s underlying health and psychological and physical health is affected, that’s where clinical attention needs to be sought. And when we talk about, for example, with anorexia, it’s not just people trying to restrict their food intake to the point where they want to lose a few pounds. These people have a very big incongruency between the way they look at themselves and the way I think a science or medical person would assess them. They really think, if they fit into a certain criterion of being a proper or ideal body weight, they might see themselves as being overweight or fat.
The extent of restricting themselves often is going from someone who doesn’t need to restrict calories to someone who is restricting calories and that creates nutritional deficiencies. This type of stuff becomes very dangerous because then we’re absent from not only caloric intake, but we can create electrolyte and mineral deficiencies which can cause a plethora of different illnesses and worse outcomes.
HAYLEY: That kind of brings me to the danger of eating disorders. What is happening to the body and what can happen in somebody who has a very severe eating disorder?
DR. BHATT: It depends on what symptoms we’re talking about, but if we’re talking about anorexia, we have restricting, we can have purging and binging. All of this can occur within the scope – there is a little bit of overlap. But in general, if you’re restricting like I said before, you’re depriving your body of the proper nutrients and this can cause significant issues.
You can have problems anywhere from — if you have a lack of electrolytes you can have cardiac arrythmias. If you are vomiting on purpose you can cause erosion in your throat and change the way your oral cavity, mouth, and health of your teeth. Significant tearing inside your esophagus from the purging and the strainging that occurs with it to having a heart attack and sudden cardiac death. The breadth of symptoms that can occur are pretty wide and pretty significant.
HAYLEY: I also want to talk about the link with addiction. Is someone with an eating disorder, are they more likely to suffer from a substance use disorder?
DR. BHATT: Yea, I think the statistic is somewhere around of people who suffer with an eating disorder, around 50% have a substance use disorder. Trying to find a link in the brain is somewhat controversial. There are some ways we can say it’s related to addiction. I don’t want people to misconstrue the fact that there’s a higher prevalence meaning they have the same causation. That’s not always the case. There are some aspects of it that have similar causation in the brain, but that doesn’t necessarily mean all of it together is the same. Just looking at it from a statistical perspective, there’s a much higher prevalence of substance use disorders in those who suffer with eating disorders than in the general population.
On the flip side, people who suffer with substance use disorders also have a higher proportion of eating disorders within that category compared to the general population. We see that co-occurrence happen more with the two.
JEFF: I would also like to point out in some circumstances people actively use substances and abuse substances to further their eating disorder and gain further control over their weight. “Drunkorexia” is a term for when people use alcohol to do that, and I know many people with eating disorders use cocaine because it suppresses appetites.
DR. BHATT: If you dig further into the dynamics of it and go beyond “there’s more – a higher occurrence of….” Yea for sure, people who want to lose weight can start to abuse substances that help control appetite. Cocaine suppresses appetite, nicotine, caffeine, stimulants. You’ll see people suffering with eating disorders look for ways to help control their appetite or lose weight quickly. And if there are drugs and illicit substances out there that assist with that definitely. You’re going to be more attracted to that and that can increase your risk of developing addiction – already when you’re dealing with control issues in itself, you see that increase risk dramatically. Yes, it goes hand in hand.
HAYLEY: I was going to ask that actually, I’m glad you brought that up Jeff about certain substances that are more likely to be abuse by people with an eating disorder. I guess it depends on the eating disorder and the goals, maybe?
DR. BHATT: We see substance use disorders tend to be higher in people that have more of the binging/purging type behaviors that go along with their eating disorders vs. the restricting type. Again, there’s not much to discuss right now in terms of the why it is there, that we do see more substance use issues with those who have those binging/purging behaviors.
And again, when we see things – people who’ve had gastric bypass and who might have suffered with obesity beforehand, we do see – maybe if they have some unresolved binge eating issues in the first place, or disordered eating often they can’t eat that much. They might try to achieve that reward or satisfaction that they did from food through some other mechanism. And that’s what often might lead to pursuing illicit substances or alcohol for example.
That’s a big one that we see with people who have a gastric bypass and have the propensity for addiction. We do see them abusing alcohol. And that takes us back to, is there a relationship between the reward mechanism? Food is something that creates pleasure for us. I know most of us are not eating just to stay alive, we eat because we like certain foods and we like the way it tastes. We get happy when we eat.
There is some conflict in terms of the deprivation of food causing someone to pursue addiction more. Some animal models have shown that when you actually restrict someone from food, there is an increased pursual of illicit substances. That doesn’t play out though when it comes to human beings where we see restriction, we don’t see the increase, we see the opposite. When you binge and purge, you see people using substances more. There’s that little bit of discrepancy in the scientific models we have.
At the end of the day, we do often see when someone’s treated for substances use issues, the eating disorder that might have been controlled or not been acted upon often will start up again. Or vise versa. When we see the eating disorder controlled, the substance use starts to act out. So, when it’s cooccurring, you have to treat both because one often can exacerbate the other.
HAYLEY: That’s what I wanted to ask as well. Can someone get treatment who has an eating disorder and substance use disorder? Can they receive treatment for both of those issues at the same time, or is one typically focused on?
DR. BHATT: With the right provider, with the right treatment centers that specialize in these things, you can get treated for both at the same time. Especially where someone who suffers from an eating disorder has become nutritionally compromised and their health is so weak. Obviously, we need to address those things first. So we need to get them healthy and we want to make sure any underlying medical illnesses that have occurred as a consequence of their eating disorder is addressed.
That being said, if they are stable and they can get both addressed in a facility that can treat both sides. Yea definitely, it would be ideal to treat both. But they have to be stable enough to focus on that.
HAYLEY: And do you mean stable physically?
DR. BHATT: Yea, physically stable. Again, we talked about how eating disorders can wreck your body so much. We have to ensure that their body is not in a life-threatened state. We actually have to make sure they’re stable enough to go through alternative types of talk therapies. So if they need IV and nutritional replacement urgently, well we don’t want them going into a group. We want them to make sure that their medical needs are addressed first. Ultimately, if one is not addressed the risk of relapse is very high.
HAYLEY: I also want to look at it in another angle. Hypothetically say, if I had anorexia and I also was an alcoholic, and I wanted to get treatment for anorexia, but didn’t want to stop drinking, could I still do that?
DR. BHATT: I don’t know that many places that are just going to say yes, go ahead and continue your disordered—your alcoholic type of drinking. And yes, were going to go ahead and treat your anorexia. Unfortunately, because there’s so much damage being done by that heavy alcohol use, how are we going to be able to properly treat the anorexia. Especially because if you’re not in the right state of mind psychologically, because alcohol for example, or whatever drug or substance you’re using, you need to be cognitively there to participate in the treatments. Both physically and mentally.
Concurrently using a substance which renders you incapable of thinking and behaving and responding adequately probably is not going to go very well. You’re not going to have a successful outcome if one continues to use while trying to treat an underlying eating disorder.
HAYLEY: Can you break down a little bit about the standard treatment for eating disorders? I understand a lot of the treatment practices for someone with a substance use disorder, but I actually don’t know. How do you help somebody with an eating disorder?
DR. BHATT: With an eating disorder – a lot of it has to do with behavioral training and underlying psychological therapy. At the end of the day, someone’s going to need to look into themselves as to what’s going on and why they’re pursuing or behaving – treating their body like they are.
Number 1: we would probably have to do a proper nutritional assessment and ensure that they are physically stable. Again, there is so much damage done from disordered eating that we have to ensure these people are safe. That could entail first getting hospitalized or being in a medical center that could help them get physically back in shape.
Second, obviously, the cognitive behavioral therapies that address the underlying thought processes and cognitions that are distorted leading to somebody eating and behaving the way they do. That’s a hallmark treatment that does occur for people with eating disorders. For those cooccurring anxieties and depressions and other psychiatric conditions, we do treat that through either medications, medications and CBT, also DBT is often used. Just a various amount of psychotherapies are included when we talk about eating disorder treatment
HAYLEY: And is there a pretty high success rate for somebody who undergoes treatment?
DR. BHATT: We see that as, as people get older, there is – the majority of people have improvement. There are probably above 50% of the people you will see go into remission. There’s a quarter to a third of the population that probably – it will go on later into their life and there’s a smaller percentage who will be chronically ill for their entire lifespan. Like with any disease there’s a variance in terms of how people respond. But for the most part with the right intervention and the right support, you can live and successfully control this.
HAYLEY: Is there anything else on this topic that you think is important for people to know?
DR. BHATT: That it is so dangerous. I think people tend to see eating disorders and they think it’s just very behaviorally oriented. I think in our western culture we do have so much influence on how people should look based on what we see in media and on television. But the fact is that it starts at a time when people are growing. They’re growing psychologically and they’re growing physically. It’s something that needs to be taken very seriously. The right screenings among the proper individuals, from our pediatricians to our physicians to our own family members recognizing this in our children and adolescents. Just to make sure they get the proper treatment as early as possible. Because again, as you mentioned at the beginning of this, this is going to be deadly. There is help out there and there are treatment centers out there that can properly address this.
HAYLEY: Yeah, absolutely. And that’s why it’s so important for someone with one of these disorders to get treatment when needed because it could actually save their life. You can check out a ton of great resources at Addictioncenter.com and you can also submit a question to Dr. Bhatt on our website. Not only on this topic, but on anything you have questions on. Once again, it was great talking with you guys, and thank you to our listeners for checking out another episode of Straight Talk with the Doc.
Dr. Ashish Bhatt
Dr. Ashish Bhatt, MD, MRO is an accomplished physician, addiction medicine specialist, and psychiatrist with over 20 years of medical and administrative leadership.