Bipolar Disorder & Eating Disorders

Bipolar Disorder is one of the most commonly known mental disorders as well as one of the most commonly misunderstood. When individuals switch emotion-states quickly, people casually refer to them as “bipolar,” creating a societal lack of understanding for what it means to truly struggle with bipolar disorder.

Bipolar disorder is an incredibly challenging mental illness to overcome and often leads to impulsive and maladaptive behaviors such as substance use, overspending, and, the focus of this article, eating disorders.

What is Bipolar Disorder?

To begin, it is important to dispel the popular understanding of bipolar disorder and consider what this mental illness actually presents as. The Diagnostic & Statistical Manual of Mental Illness (DSM-5) specifies bipolar disorders in their own category, specifying that these disorders are placed in the book “between the chapters on schizophrenia spectrum and other psychotic disorders and depressive disorders in recognition of their place as a bridge between the two diagnostic classes in terms of symptomatology, family history, and genetics [1].” Essentially, bipolar disorders lie somewhere in between depression and psychotic disorders because it shares symptoms of both.

Few even know that bipolar disorder is actually separated into two types, Bipolar I Disorder and Bipolar II Disorder. Bipolar I is the most commonly understood manifestation of the disorder and was once referred to as “manic depressive disorder.” Bipolar I involves an individual experiencing a combination of manic episodes that last all day for at least one week as well as possible a depressive episode lasting at least two weeks [1]. Bipolar II differs in that individuals with bipolar II do not experience mania at all, instead experiencing similar depressive episodes with periods of “hypomania,” which involves manic symptoms but for a shorter period of time of 4 days or so.

A bipolar I diagnosis requires symptoms of mania to occur for at least a week but does not require that depression is present. A bipolar II diagnosis requires that an individual experience a depressive episode as well as hypomania but not full-blown mania [1].

People with bipolar disorder cycle between mania and depression. The three kinds of bipolar disorder are:

Bipolar I

Manic episodes that last at least seven days or are so severe the person has to be hospitalized
Depressive episodes that last about two weeks

Bipolar II

Hypomanic (episodes that are less severe than mania seen in bipolar I and don’t require hospitalization)
Depressive episodes
Can have episodes with hypomanic and depressive symptoms happening at the same time

Cyclothymia

Cycles of hypomania and depression that last for at least two years (one year in people under 18)
These symptoms don’t meet the requirements for bipolar I or II [2]

Signs of Bipolar Disorder

To understand Bipolar disorders, it is important to know what the above symptoms of “mania,” “depression,” and “hypomania” are.

Mania

Mania is “a distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally persistently increased goal-directed activity or energy [1].” According to the DSM-5, mania often involves behaviors such as:

Inflated self-esteem or grandiosity.
Decreased need for sleep
More talkative than usual or pressure to keep talking.
Flight of ideas or subjective experience that thoughts are racing
Distractibility
Increase in goal-directed activity
Excessive involvement in activities that have a high potential for painful consequences such as spending sprees, sexual indiscretions, foolish business investments, substance use, etc [1].

Hypomania

Hypomania involves the same behaviors above, however, the difference between the two is related to the severity and impact of these behaviors. Individuals struggling with mania experience these symptoms with such intensity that it causes “marked impairment in social or occupational functioning” or “necessitate(s) hospitalization to prevent harm to self or others [1].” Hypomania is not severe enough to cause these repercussions yet does lead to an “unequivocal change in functioning [1].”

Depression

According to the DSM-5, a Major Depressive Episode is characterized by at least 5 of the symptoms below occurring for at least 2 weeks:

Feeling sad, empty, or hopeless.
Markedly diminished interest or pleasure in activities that once brought joy or interest.
Significant weight loss when not dieting or weight gain.
Sleeping too much or too little
Psychomotor agitation or retardation
Fatigue or low energy
Feelings of worthlessness or excessive, inappropriate guilt
Diminished ability to think of concentrate or indecisiveness
Recurrent thoughts of death, suicidal ideation without a specific plan, a sucidie attempts, or a plan for committing suicide [1].

Co-Occurring Eating Disorders

Manic, hypomanic, and depressive symptoms often co-occur with disordered eating behaviors for differing reasons. In mania and hypomania, individuals are more likely to engage in impulsive and harmful behaviors which can lead to binge eating or purging behaviors. Depression often co-occurs with eating disorder behaviors due to restricting or over-consuming food becoming a maladaptive coping skill.

Bipolar Disorder and Anorexia

Bipolar disorder and anorexia nervosa can co-occur for a few reasons. An individual in a manic, hypomanic, or depressive state might experience a loss of appetite, leading to irregularities in their diet that might become more consistent eating behaviors.

Additionally, individuals that engage in restrictive eating behaviors often report feeling motivated by a need for control, whether over their bodies or the situation. Individuals struggling with bipolar I or II disorders often report feeling out of control and might begin restrictive behaviors as a way to cope.

Further, individuals that experience depressive episodes experience similar eating disorder pathology of low self-worth, which can lead to issues with self-view and body image. Eating disorder behaviors might result as an attempt to make oneself feel worthy.

Binge Eating Disorder and Bipolar

The most common overlapping symptoms of bipolar disorders and binge eating disorder involve impulsivity. Individuals are often impulsive when experiencing mania or hypomania and binge episodes often occur when an individual is in an impulsive state or struggling with self-control and listening to body cues.

Additionally, individuals struggling with a depressive episode might utilize food consumption as a means of coping. Food creates a bodily response that can feel euphoric at times, therefore, individuals struggling with depression might continue engaging with food to prolong this physical and emotional response even past the point of fullness.

It is likely these connections that lead to BED and bipolar disorders co-occuring, as “approximately one in three people with bipolar disorder also meet criteria for binge eating disorder, bulimia nervosa, or variants of these disorders [3].”

Bipolar Disorder and Bulimia

As mentioned above, individuals with bipolar disorder are also more likely to experience bulimia nervosa behaviors. Purging is an impulsive behavior, therefore, those with bipolar disorder might engage in both bingeing and purging behaviors when in a manic or hypomanic state.

Individuals experiencing mania or hypomania also tend to be hyper-focused and goal-directed on certain activities which can include exercise. These individuals might exercise past the point of exhaustion or injury due to the manic energy they experience.

Related Reading

Bipolar Disorder Statistics

Bipolar disorders have been extensively studied and the following information garnered about its prevalence and impact:

Approximately 5.7 million, or 2.6%, of US adults experience bipolar disorder [4].
The median age of onset for bipolar disorders is 25 years old [4].
“Past year prevalence of bipolar disorder among adults was similar for males (2.9%) and females (2.8%) [5].”
Approximately 4.4 million adults in the US will experience bipolar symptoms at some point in their lives [5].
“82.9% of people with bipolar disorder had serious impairment, the highest percent serious impairment among mood disorders [5].”
2.9% of individuals ages 13 -18 have bipolar disorder [5].
“Prevalence of bipolar disorder among adolescents was higher for females (3.3%) than for males (2.6%) [5].”
17.1% of individuals with bipolar disorders report moderate impairment [5].
8.6% of individuals with hypomania, 8.6% of those with major depressive disorder, and 7.9% of those with mania had an eating disorder [6].

Treating Co-Occurring Bipolar and Eating Disorders

It is an unfortunate truth that bipolar disorders and eating disorders often go undiagnosed or misdiagnosed. One study found that “consumers with bipolar disorder face up to ten years of coping with symptoms before getting an accurate diagnosis, with only one in four receiving an accurate diagnosis in less than three years [4].”

Early diagnosis is important in treating both eating disorders and bipolar disorders, as the longer the symptoms are experienced, the more impacted an individual’s life becomes.

Medication

There is no current FDA-approved medication therapy for eating disorders, however, most individuals with an eating disorder have a co-occuring disorder that is part of their eating disorder psychopathology. Treating these disorders with medication can also help in treating the eating disorder.

For treating bipolar disorder, there are many medications that can be helpful. Lithium is a common medication for treating bipolar symptoms, as “The antimanic, antidepressant, and long-term prophylactic mood-stabilizing effects of lithium in bipolar disorder, including suicide prevention, have been well documented [6].”

What is interesting is that studies on lithium’s impact on anorexia, bulimia, and binge eating symptoms have shown promising results. One study found that, of 8 patients with anorexia nervosa receiving lithium, all 8 showed greater weight gain in a 3 to 4 week span than those that did not receive lithium [6]. Further, in a study using lithium to treat bulimia nervosa, “patients (that received lithium) showed a 75% or greater reduction in binge–purge episodes in combination with cognitive behavior therapy [6].” All of this is promising in that lithium might help treat both disorders.

Other medications approved to treat bipolar disorders include Abilify, Saphris, Clozaril, Fanapt, Latuda, Zyprexa, Symbyax, Invega, Seroquel, Risperdal, and Geodon [7].

Therapy

Both bipolar disorders and eating disorders are best treated with a combination of medication as well as therapy. For both, cognitive behavioral therapies have proven to be effective. These therapies support an individual in identifying the core beliefs that lead to their thoughts and then connect these with their behaviors.

Dialectical Behavior Therapy (DBT) is a type of cognitive therapy that is particularly helpful for those struggling with eating disorders and bipolar disorders due to the emphasis DBT skills have on learning to regulate emotion-states and tolerate distressing emotions.

Therapy, regardless of theoretical orientation, also allows individuals to increase awareness of their triggers, experiences, and behaviors in a way that can support mindfulness and intentionality of their decisions as well as increase self-accountability.

Relapse Prevention and Aftercare Support

Due to the unpredictable nature of bipolar disorders, relapse is a risk that many with eating disorders and co-occurring bipolar disorders experience.

An important part of relapse prevention for individuals struggling with both disorders is maintaining an effective and helpful treatment team. This might mean while one is in treatment, however, it should continue through to one’s outpatient team. An individual struggling with these disorders should always have an awareness of their resources and support so that, should they struggle with lapses or urges, they can receive help.

Another important piece to relapse prevention for those with bipolar disorder and eating disorders involves consistency of medication. It may not be ideal to take medication every day, however, it is shown to be a positive behavior in allowing those with bipolar disorders to live fulfilling lives not impacted by their symptoms.

It is difficult to experience one debilitating mental illness and having two can be challenging and overwhelming. Individuals struggling with both a bipolar disorder and eating disorder diagnosis should do their best to practice acceptance of their disorders. This acceptance will allow room for them to deal with what this means for their daily lives. It is possible to receive effective treatment for both disorders and live fulfilling lives, however, maintaining proactivity and involvement in treatments are key.

Citations

[1] American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).

[2] National Institute of Mental Health. (2020). Bipolar disorder. https://www.nimh.nih.gov/health/topics/bipolar-disorder/

[3] McAulay, C. et al (2019). Eating disorders, bipolar disorders and other mood disorders: complex and under-researched relationships. Journal of Eating Disorders, 7:19.

[4] Unknown (2021). Bipolar disorder statistics. Depression and Bipolar Support Alliance. Retrieved from https://www.dbsalliance.org/education/bipolar-disorder/bipolar-disorder-statistics/.

[5] Unknown (2021). Bipolar disorder. National Institute of Mental Health. Retrieved from https://www.nimh.nih.gov/health/statistics/bipolar-disorder.

[6] McElroy, S. L. et al (2005). Comorbidity of bipolar and eating distinct or related disorders with shared dysregulations? Journal of Affective Disorders, 86:2-3.

[7] Unknown (2016). Atypical antipsychotic drugs information. U.S. Food and Drug Administration. Retrieved from https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/atypical-antipsychotic-drugs-information.

Author: Margot Rittenhouse, MS, LPC, NCC

Last Reviewed & Approved By: Jacquelyn Ekern, MS, LPC 2.8.22