Miss G. also had taken an overdose of aspirin, up to 7 grams in 15 hours, and was disappointed to learn that the dose was not lethal. She admitted to using multiple drugs, including alcohol, marijuana, heroin, cocaine, cigarettes, caffeine, and amphetamines to control her moods and behavior in the past. But she had never been treated with psychotropics.
Her family history proved significant. One of her great grandfathers had committed suicide, and a maternal aunt was in treatment with several psychotropics and was on disability.
My initial diagnoses
Initially, I diagnosed this patient with eating disorder, bulimic type; eating disorder not otherwise specified; and polysubstance dependence in early remission with multiple rule-outs, including anxiety disorder NOS; psychotic disorder, NOS; bipolar disorder NOS; and bipolar disorder with psychosis. I explained to her the diagnosis and my concern about the possibility of mood swings and the risk of being on SSRIs or other antidepressants that are commonly prescribed for eating disorders, and that can worsen what I suspected was underlying bipolar disorder, and alter the course and treatment outcome – and the overall clinical outcome. She really did not care about the diagnosis or the treatment and was willing to take any medication that would not cause weight gain. She agreed to take topiramate and adamantly decided against taking anything else.
On subsequent visits, she reported worsening of concentration and anger but insisted on continuing on the topiramate because it had lowered her appetite and her bingeing and purging behavior had become less frequent.
At this point, I confirmed the diagnosis as bipolar disorder and had her agree to take lamotrigine. She continued to experience anger and mood swings, although she was taking 300 mg of lamotrigine. Risperidone had no therapeutic response. Although it proved difficult to persuade her to take sodium valproate she agreed, because she understood the consequences of her anger. Miss G. knew that continuing to behave disrespectfully toward her teachers would jeopardize her education and her future.
To elaborate on the time frames, let me point out that Miss G. started on the topiramate on the first day of her treatment. The lamotrigine was started the following month. The sodium valproate was introduced about 7 months after that with improvement, but she continued to complain of weight gain and appetite, which was not controlled – even with an H-2 blocker. So I had to stop the sodium valproate 4 months after it was introduced. Her concentration continued to either decline or not improve with mood stabilization.
This is the point at which I introduced clonidine. Although Miss G. did experience some side effects, her concentration improved. Her mood remained fairly stable on lamotrigine and clonidine after I discontinued the sodium valproate.
My last session with Miss G. occurred about 1 year and 3.5 months after the first visit. On that day, she was casually but neatly dressed. She told me that she would be graduating from high school and attending college out of state.
When I asked her about some of the behaviors tied to her eating disorder, she said "not at all" but after further exploration she said "once or twice a week; it became a lifestyle and right now, it is not a lifestyle anymore," she said. Miss G. went on to describe her current weight of 145 as "ideal," but said she still struggled to see herself in a healthy way. "By being treated for my bipolar disorder, my eating disorder did not reach such a low point," she said. "I consider myself a recovered eating disorder patient."
Her mood was good and her affect appropriate. She said she had no thoughts of harming herself.
We must get this right
Most prior patients with a diagnosis of eating disorder come to my office on SSRIs with poor functioning and symptom control. Initially, they say, "You are the doctor; whatever you say," but in the end, they either failed to accept the diagnosis of bipolar disorder or to follow my treatment recommendations and left my practice. In each of these cases, I have been concerned that these patients with eating disorder diagnoses might indeed have bipolar disorder.
As I mentioned earlier, some studies have been conducted exploring the connections between eating disorder and bipolar disorder, but more are needed. Specifically, we need to determine the extent to which eating disorder and bipolar disorder are comorbidities – or whether eating disorder is an episode that leads to bipolar disorder. In addition, we must compare the treatment outcome and clinical course of patients who are treated with SSRIs for eating disorder with the treatment outcome and clinical course of patients who are treated with mood stabilizers – even if they have started episodes of eating disorder.