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Eating Disorders and Psychosis
By Mary V. Seeman, MD
April 29, 2016

While treating women with psychotic illness, I noticed that many of my patients, in addition to their psychosis, had eating disorders (anorexia and binge eating) and I wondered whether my prescription of antipsychotic drugs was responsible. I knew that these drugs led to increased appetite and weight gain, which could provoke a counter reaction, ie, a drive to be thin.

The neuroscientist and author Erin Hawkes?who was treated for schizophrenia with olanzapine?writes about how her bulimia subsequently intensified:

I was put on olanzapine. Terrible mistake: I was, within two months, 137 pounds of (in my opinion) fat. My purging went wild. . . . Olanzapine gave me a ravenous appetite. . . . Thus, purging became all-important.1

She is not the only person to have made the connection between antipsychotic medication and increased eating disorder symptoms. Olanzapine and clozapine in particular have been implicated in medication- induced bingeing secondary to antipsychotic drug intake.2,3

On the other hand, a 2013 meta-analysis of 8 randomized trials involving olanzapine, risperidone, or amisulpride in eating disorders concluded that, when compared with placebo, these agents did not cause significant body dissatisfaction, nor did they curtail eating.4 Note, however, that the participants in these trials had an eating disorder and were not being treated primarily for psychosis. The doses in the 8 trials were relatively low (eg, 4.2 to 10 mg of olanzapine)?substantially lower than they would have been had the target been psychotic symptoms. Moreover, only 2 of the 8 trials controlled for medication adherence?a particularly significant issue for patients with an eating disorder, who would be strongly tempted to stop treatment if it made them gain weight.

Antipsychotics are sometimes used off label for eating disorders. The reason is because clinicians find it difficult to distinguish the firm belief that one is fat (when that is clearly not the case) from a delusion. The body image disturbance at the heart of anorexia nervosa is a false perception akin to the perceptual disorders found in schizophrenia. Additional psychotic features associated with eating disorders?usually transient?have been attributed to the effects of starvation and electrolyte imbalance.

Mavrogiorgou and colleagues5 report the case of a 37-year-old woman with anorexia who, for 4 years, had acute paranoid-hallucinatory psychosis at the tail end of fasting episodes (when she was most starved). Psychotic symptoms were not in evidence either before or after the fasting periods; this suggests a cause-and-effect relationship between starvation and psychotic decompensation. The authors hypothesize that starvation led to acute hyperactivity of the dopaminergic system, giving rise to a subsequent transient psychosis.

However, despite several potential explanations for the co-occurrence of the conditions, it is possible that eating disorders and psychotic disorders are different phenotypic expressions of a similar genetic predisposition (Figure).

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