Co-Morbidities

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Co-Morbidities

Mood Disorders

It is not uncommon that clients presenting with an eating disorder also have additional diagnosis concurrently. Depression is often seen accompanying a diagnosis of an eating disorder. Grubb, Sellers, & Waligroski (1993) reported a high percentage of depressive disorders among eating-disordered women and contend that often the depressive symptoms decrease after treatment of the eating disorder. Depression has been described as a prominent, though not the exclusive form of psychopathology in these disorders (Wexler & Cicchetti, 1992). Additionally, measures of depression are often influenced by the subject's current state or illness. It is not uncommon that depression, rather than eating disturbances, is the symptom for which women seek psychological counseling (Grubb, Sellers, & Waligroski, 1993; Schwartz & Cohn, 1996; Zerbe, 1995).

Deborah J. Kuehnel, LCSW, © 1998

Bi-polar Disorder

Kruger, Shugar, & Cooke (1996) addressed the comorbidity of binge eating disorder, partial binge eating syndrome, and bipolar disorder. The work of Kruger, Shugar, & Cooke (1996) was the first to describe and link the consistent occurrence of night binging syndrome between 2:00 and 4:00 a.m. This behavior was thought this to be of significance in the bipolar population because the early morning hours are also the time in which mood switches are reported to occur in subjects with bipolar disorder. Kruger, Shugarr, & Cooke (1996) encouraged along with others that there is a definite need for developing useful diagnostic categories by redefining the eating disorders not otherwise specified (de Zwaan, Nutzinger, & Schoenbeck, 1993; Devlin, Walsh, Spitzer, & Hasin, 1992; Fichter, Quadflieg, & Brandl, 1993).

Eating is more than just food intake; eating plays an important role in our social interactions, and it can also be used to alter emotional states, and even to influence brain function. Serotonin, or 5-hydroxytryptamine (5-HT ), is a neurotransmitter that plays an important role in the regulation of circadian and seasonal rhythms, the control of food intake, sexual behavior, pain, aggression, and the mediation of mood (Wallin & Rissanen, 1994). Dysfunction of the serotoninergic system has been found in a wide array of psychiatric disorders: Depression, anxiety, disorders of the sleep-wake cycle, obsessive-compulsive disorder, panic disorder, phobias, personality disorders, alcoholism, anorexia nervosa, bulimia nervosa, obesity, seasonal affective disorder, premenstrual syndrome, and even schizophrenia (van Praag, Asnis, & Kahn, 1990).

While the background of eating disorders is complex, the disorders probably involve dysregulation of several neurotransmitter systems. The involvement of impaired hypothalamic serotonin function in these disorders is well documented (Leibowitz, 1990; Kaye & Weltzin, 1991). There is good evidence from experimental and clinical studies to suggest that serotoninergic dysfunction creates vulnerability to recurrent episodes of large binge meals in bulimic patients (Walsh, 1991). There is also evidence that bulimic behavior has a mood-regulating function, (e.g., binging and purging are used by the patients to relieve psychic tension). However, bulimic behavior seems to have different functions for different subgroups (Steinberg, Tobin, & Johnson, 1990). Binging may be used to relieve anxiety, but it may result in an increase in guilt, shame, and depression (Elmore, De Castro, 1990).

Deborah J. Kuehnel, LCSW, © 1998

Obsessive-Compulsive Disorder

Obsessional personality traits and symptoms have been reported in between 3% to 83% of eating-disordered cases depending on the criteria used. Up to 30% of anorexia nervosa patients have been reported to have significant obsessional personality features at first presentation. Clinical similarities between obsessional personality and the dieting disorders have led to the contention that obsessional personality traits might predate the onset of the eating disorder (Fahy, 1991; Thornton & Russell, 1997).
Thornton & Russell (1997) discovered that 21% of the eating disorder patients were found to have comorbid Obsessive-Compulsive Disorder (OCD) but even more significant was that 37% of anorexia nervosa patients had comorbid OCD. By contrast, individuals with bulimia nervosa had much lower rates of comorbidity for OCD (3%). Thornton & Russell (1997) stressed the likelihood that the impact of starvation exaggerates an already (premorbid) obsessional personality in those with eating disorders. When individuals with a premorbid obsessional personality and symptoms focus on food, weight, and shape issues, these may become enmeshed into their series of obsessions and compulsions. These obsessions and compulsions may result in feelings of guilt, shame, and a sense of "loss of control" for the individual (Fahy, 1991; Thornton et al, 1997).

Within these obsessions and compulsions, Andrews (1997) found one explanation for the concurrent occurrence of bodily shame with bulimic and anoretic symptomatology may be that the shame itself taps directly into a central component of the disorders - undue preoccupation with body shape and dread of getting too fat. Bodily shame was shown to have a significant association with disordered eating patterns but it was unclear whether shame was an antecedent concomitant or consequence of the eating disorder (Andrews, 1997; Thornton et al, 1997).

Deborah J. Kuehnel, LCSW, © 1998

Self-Mutilation

Yaryura-Tobias, Neziroglu, & Kaplan (1995) presented the relationship between OCD and self harm and explored this connection with respect to anorexia. Four observations were found:

First, there was a disturbance of the limbic system resulting in both self-mutilation and menstrual changes. Second, pain stimulation releases endogenous endorphins which produce a pleasant feeling, control dysphoria, and actively maintain the analgesia-pain-pleasure circuit. Third, 70% of their patients studied reported a history of sexual or physical abuse. Finally, the administration of fluoxetine, a selective serotonin reuptake blocker, has been successful in treating self-injurious behavior. (p. 36).

With these observations, Yaryura-Tobias, Neziroglu, & Kaplan (1995) encouraged clinicians treating OCD and eating disorders to be aware of the possibility of self-mutilation among their patients. Conversely, those treating self-mutilation may look for symptoms of OCD and eating disorders (Chu & Dill, 1990; Favazza & Conterio, 1989).

Deborah J. Kuehnel, LCSW, © 1998