Q:  Bulimia & Bipolar Disorder

I am 40 and have been diagnosed with bipolar disorder 8 years ago. I also suffer from bulimia and wonder if there is any relationship with the outburst of my crazy eating sessions and the start of a manic state. For example during the last 2 weeks I have been eating and vomitting crazily. I try to stop myself and eat little but can't. I eat, vomit and eat again. Currently I am on Effexor XR and I have been waking up at nights with by body itching all over. During the past month I have spent more than usual but have succeded not to get into trouble. I was able to control my bulimia since 2-3 months but now I can't stop myself and think about eating nearly 24 hours. I just wonder if this the start of a severe manic state or a depressive one.

Thanks for your help
 

Dear Ms. S' -- 
There is definitely some sort of relationship between the two conditions, probably a closer one than the simple, obvious one, namely that the increased thought intensity of the manic-side which alone could make the intense interest in food worse.  They tend to co-occur more than you would expect based on the frequency of each condition alone.  

A research group at the University of Cincinnati has been studying binge eating, after one of their bipolar researchers (Susan McElroy) got interested in this cross-over between the conditions.  That group has published reports that make topiramate look pretty good as a treatment option that might have benefits for both conditions, or somehow treat what's common between them.  Here's her latest review of medication approaches to binge eating. 

Could the eating mark a manic phase? or a depressive one?  I think that's quite possible.  Some might even say the goal of treatment for the combined conditions of bipolar disorder and bulimia would be to control the bipolar first (including considering tapering the antidepressant, in favor of one or several mood stabilizers) and then treat whatever eating symptoms remain.  In my experience, there have been people who had minimal eating disorder symptoms (still there, but manageable) after their mood symptoms were controlled.  This "treat the bipolar first" idea is the general consensus on how to treat other conditions where use of antidepressants could make bipolar worse (e.g. obsessive compulsive disorder, social phobia, panic disorder).  

If you really have bipolar disorder, then adding topiramate to Effexor would leave you on two agents, neither of which is clearly capable of controlling cycling and both of which can make cycling worse.  Talk with your doctor about the list of mood stabilizers (look for the ones not associated with weight gain? -- carbamazepine and lamotrigine are such candidates, and possibly fish oil even), and how to get one of those going, with a plan to later look at topiramate or even sibutramine, as Dr. McElroy's review notes, if an additional medication was still required.  

Good luck with all that. 

Dr. Phelps

Published November, 2004