“The Food Matches the Mood”: Experiences of Eating Disorders in Bipolar Disorder

Abstract

Approximately 33% of those with bipolar disorder (BD) have a comorbid eating disorder (ED). However, the trajectory of these conditions has received little research attention. Nine participants who met criteria for BD and an ED participated in qualitative interviews exploring experiences of illness onset, the interaction of these conditions, and service provision. Almost all participants in the sample reported minimal to no screening of ED problems, despite their health professionals’ frequent discussion of obesity. Findings suggested that ED features were diverse and evolved over time. Mania and depression were connected to ED features such as overeating and restricting, but this differed between and within participants. Most participants disclosed historic trauma which they considered central to their mental health concerns. This clinical group appears to be underserviced. Clinicians and researchers should routinely screen for ED features when treating and diagnosing BD to inform their physical and mental health interventions.

Keywords

bipolar disorder eating disorder thematic analysis quality of life quality of care Australia obesity trauma qualitative

People with bipolar disorder (BD) experience disproportionately poor physical health and quality of life (Kolotkin et al., 2008; Sanchez-Moreno et al., 2009). A number of mechanisms are thought to explain why difficulties with eating, weight, appetite, body esteem, and maintaining physical health are prevalent in BD. Depression, which is more common in BD than mania (Colom et al., 2006), can induce overeating, especially when other mechanisms to alleviate stress and elevated cortisol are blunted (Singh, 2014). Furthermore, atypical depression, characterized by lethargy and increased appetite, is more common in BD than major depression, and associated with weight gain (Lojko et al., 2015). Impulsivity is high in people with BD but particularly during mania (Swann et al., 2009) and this may affect dietary intake (Amianto et al., 2011). In short, multiple aspects of BD could exert strong influences on diet, appetite, and physical activity.

The episodic nature of BD is also likely relevant to its elevated rates of obesity. Weight cycling (gaining and then losing weight) is associated with higher body fat percentage (Graci et al., 2004), and more weight gain in the long term (Mackie et al., 2017), as well as poorer inflammatory profiles (Reininghaus et al., 2015). It therefore makes sense that repeat illness episodes could induce short term weight changes that affect long-term weight management. Finally, BD management can involve treatment with multiple obesogenic medications (Outhred et al., 2016), and while this is unlikely to explain all incidents of obesity in BD (Galvez et al., 2015; Lopresti & Drummond, 2013), it undoubtedly contributes, with obesity being overrepresented in BD (Zhao et al., 2016).

The presence of comorbid eating disorders (EDs) may help explain poor physical and mental health outcomes in BD. EDs are characterized by persistently disturbed eating and related behaviors, as well as significant preoccupation with weight, shape and/or diet, which harm physical health and/or psychological wellbeing (American Psychiatric Association [APA], 2013). EDs are associated with poor physical and mental health outcomes including impaired quality of life (Mitchison et al., 2012; Mond et al., 2012; Mond & Hay, 2007; Van Zutven et al., 2015). ED behaviors such as dieting predict increased weight-gain in the longer term (Neumark-Sztainer et al., 2007).

EDs are believed to occur in as many as one in three people who meet criteria for BD (Thiebaut et al., 2019). A number of large-scale but necessarily large-grain projects have identified clinical correlates of this comorbid subgroup, such as earlier illness onset of BD, higher rates of anxiety disorders, depressive polarity, higher body mass index (BMI), higher suicide rates, and higher functional impairment (Balzafiore et al., 2017; Brietzke et al., 2011). Comorbid EDs may also contribute to physical health concerns in BD, including obesity and poor cardio-metabolic health (Wildes et al., 2006).

Despite the implications of living with two concurrent psychiatric illnesses, little is known about this population, and they are arguably often missed in clinical practice (McAulay et al., 2019). While research has found higher rates of binge eating disorder (BED) and bulimia nervosa (BN) in BD, than anorexia nervosa (AN; McElroy et al., 2016a), few studies have gathered information about historic symptoms, individual trajectories, or the onset of these features (an exception is Godart et al., 2015). None, to the authors’ knowledge, have substantially explored the experiences of this clinical subgroup.

This study was initially conceived in part due to an interest in how BD and EDs are connected, and together, how they relate to weight gain. Claire McAulay worked with research participants with BD who spontaneously reported ED features (including binge eating and excessive dietary restriction). Some also reported difficulties maintaining a healthy weight. This perceived connection between the two conditions and obesity was supported by a review of the literature. This study served as follow-up to a cross-sectional quantitative study that found that ED features were common in a sample (N = 73) of people who met criteria for BD (McAulay et al., 2019b). Only one of those (N = 23) who screened positive for an ED reported this as a formal diagnosis, suggesting that this comorbidity was underidentified and potentially undertreated (McAulay et al., 2019b).

As well as a lack of identification in clinical practice, there are no targeted psychological interventions that treat EDs in the context of comorbid BD (McAulay et al., 2016). Weight loss treatments for BD have been designed (e.g., Sylvia et al., 2013), but none explicitly consider treating ED features. In fact, few psychological theories about EDs are integrated into their designs. This is concerning given the high comorbidity rates of EDs in BD. Treating these conditions in isolation, without considering competing therapeutic demands, may prove hazardous or blinkered (DeSocio, 2019). For example, ED features might vary substantially during mood episodes, or stay consistent regardless of mood state. This population may benefit from specialist care, to address how these two illness processes may interact and consider unique challenges that deserve a tailored approach.

Weight gain in bipolar treatment (as is common) could also be particularly dangerous for those with vulnerabilities to EDs. This is because people with BD may seek to mitigate the obesogenic effects (whether perceived or actual) of their medications through noncompliance (Dayabandara et al., 2017), or unhealthy compensatory strategies such as excessive dietary restriction or purging. This could damage both mood and physical health in the long term. Clinical decision-making in this group must be thoughtful regarding the choice of pharmacotherapy, whether to deliver simultaneous or consecutive interventions, and balancing the priorities of outcomes such as healthy weight maintenance versus mood stability (Malhi et al., 2018). To achieve this, a specialist team that understands both illness processes may be required. However, integrated care is particularly challenging without a thorough understanding of how EDs in BD present.

It is important to amplify the voices of this group. Both BD (Crowe et al., 2012; Fisher et al., 2018) and acute EDs (Aardoom et al., 2014; Steiger et al., 2017) can be long-standing, chaotic and associated with reduced autonomy in how recipients of mental health care are able and allowed to make treatment decisions. They interfere significantly with quality of life and the pursuit of developmental milestones, especially when illness begins during adolescence (Sanchez-Moreno et al., 2009). Disempowering experiences may disrupt identity formation further and reduce belief in the utility of treatment. Indeed, it is difficult to assess the benefits of early and appropriate psychological treatment, as this does not occur for many people with BD (Jones et al., 2018) and EDs (Mitchison et al., 2017).

This study adopted a qualitative approach to flexibly explore the nuances of this clinical group’s experience over time and with regards to health care provision. The first domain of interest was the presentation and evolution of these illness processes in tandem. We sought to investigate when eating difficulties emerge in people with BD; what types; whether they interact with aspects of BD and its treatment; and whether participants linked these with changes in weight. Furthermore, what, if any, function do ED features seem to serve? The second domain concerned experiences of service provision.

The goal of this study was ultimately to better understand this group, but also better inform health professionals charged with their care.

Method

Methodology

Qualitative methods were used to explore the complexities of the experiences of people with BD and EDs with the aim of capturing rich and nuanced data. Semi-structured individual interviews were used to explore the history of BD and ED symptoms, the relationship between them and the “function” of ED behaviors. Interviews also explored the experiences of treatment. Interviews were conducted by Claire McAulay and the Standards for Reporting Qualitative Research (SRQR) were followed (O’Brien et al., 2014) as per Enhancing the QUAlity and Transparency Of health Research (EQUATOR) network guidelines (Collins et al., 2019). Claire was a doctoral candidate completing their research in the overlap between BD and EDs, who has previously worked in research in both these areas including the below-mentioned clinical trial. The remaining authors work predominantly in the fields of psychology, psychiatry, sociology, public health, and medicine across research and clinical settings.

Data were subjected to an applied thematic approach (Braun & Clarke, 2006), which allowed for identifying, analyzing, and reporting patterns (themes) within the data. We adopted an interpretivist paradigm, emphasizing personal processes and subjective experience of participants in the data collection/analysis (McChesney & Aldridge, 2019). We considered this approach more collaborative and in line with exploration of the lived experience of people with BD and EDs.

Participants

The majority of participants were initially sourced from a large public hospital in Sydney. All participants were above 18 years old and self-reported a formal diagnosis of BD by a health care professional. A probable ED diagnosis was considered if participants had endorsed severe weight or shape overvaluation alongside the regular occurrence of one or more ED behaviors on the Eating Disorder Examination Self-Report Questionnaire (EDE-Q; Fairburn & Beglin, 1994): extreme dietary restriction, objective binge eating episodes, purging (vomiting and/or laxative use), and/or excessive exercise. All types of EDs were included. The University of Sydney Human Research Ethics Committee approved the study (Project # 2017/745). All participants had consented to be contacted for follow-up studies. They were recruited between 2018 and 2019 and received an AUD$30 gift voucher for taking part.

Participants were emailed or telephoned regarding an unspecified follow-up study and asked for permission to speak further via telephone. They were subsequently screened to confirm whether they endorsed the observed ED features. They were then informed that due to their responses, they appeared to be experiencing symptoms of an ED and were therefore eligible for the follow-up study. If they were still amenable to research participation, they were invited to read the information/consent form and consider participating at a later date. All were offered guidance regarding accessing support for their ED features, regardless of their treatment history or participation in the study.

Procedure

The interview script constituted general prompting questions that progressed into more specific probes if required (see Supplemental File 1). For example, Domain 1: “Do you feel like your bipolar disorder and eating health interact? How so?” and Domain 2: “Do you feel as if you receive sufficient support for your mental health?” These questions were not rigidly followed, but utilized as a guide for the interviewer to cover all areas of interest. Interviews were recorded on a mobile voice recorder device and securely stored on the University server. NVivo v.2 was used to facilitate thematic coding of transcribed interviews (“NVivo Qualitative Data Analysis Software,” 2018).

Analysis

Memos were taken following each interview to increase familiarization with the data and allow for reflection upon unexpected information. This process was also used to identify potential themes and emerging similarities in participant narratives; and to increase the rigor of the study, as per Phase 1 of thematic analysis (Braun & Clarke, 2006). Memos were used to inform any new interview questions, as per the iterative interview design process. Interviews were then transcribed and entered into NVivo, and information was preliminarily coded (Phase 2). After reflecting on data clusters and initial interpretations of the data, themes and subthemes were provisionally generated and collaboratively reviewed after every 2–3 interviews (Phases 3–4). Theme names were initially allocated and refined after review, and to amalgamate smaller subthemes into broader units (Phase 5). The final thematic structure and a selection of coded data were reviewed after producing the first draft of the report (Phase 6). Thematic saturation (Glaser & Strauss, 1999) was utilized to avoid superfluity in the data and expedite meaning-making. Thematic saturation was considered met once three consecutive interviews presented no novel codes within themes or subthemes (judged both subjectively and quantitatively in the coding process); and once no novel data (for the purposes of the aims of the study) had presented itself. In this way, it employed a hybrid of the “inductive thematic saturation” and “data saturation” concepts (Saunders et al., 2018).

Results

Nineteen of 23 participants deemed to meet criteria for a current ED were successfully contacted, and 13 consented to take part in the study. A total of nine interviews were completed after four participants’ availability changed or contact was lost. Interviews typically lasted 50–70 minutes. Thematic saturation was achieved at nine participants (see Supplemental Figure 1).

Sample Characteristics

Demographic information and ED diagnostic classifications can be seen in Supplemental Table 1.

Qualitative Findings

Our analysis is organized around two main research questions:

Research Question 1 (RQ1): Illness processes: What is the relationship between BD and EDs?

Research Question 2 (RQ2): Service provision: How is health care service provision experienced by people with BD and EDs?

Overall, data suggested that these two illnesses interact but in highly heterogeneous ways. Results have significant implications for the delivery of health care, which currently appears to not meet the needs of this clinical subgroup. Themes and subthemes are as follows and follow the structure of the two areas of interest above. In the first area of interest, the trajectory of BD symptoms alongside ED symptoms and their interplay were explored.

Illness processes

Variable onset and trajectory, and trauma as a precipitant

Body esteem difficulties were common and described as long-standing, rather than emerging in response to BD illness or treatment, for almost all participants (see Supplemental Table 1). A number of participants described being overweight as children and experiencing high levels of shame. Most participants clarified that overt ED behaviors (e.g., binge eating) emerged later in life (see Supplemental Table 1). Interestingly, ED features appeared to vary in terms of when they emerged. Most participants, however, experienced their first BD symptoms in adolescence, often depression, with mood features worsening in their 20s or 30s (see Supplemental Table 2). BD diagnosis typically occurred around 10 or 20 years after symptoms began.

A number of participants formulated trauma or major, stressful life events as the core root of their mood and eating difficulties, even if minor symptoms or traits existed before such events. The process of understanding this was gradual, requiring self-reflection:

My eating behaviors do stem a lot from my trauma . . . I can be like, “oh I just have issues eating, I just feel like I need to be skinny”—but that’s to do with what’s happened to me and how that makes me feel about myself, and my place in the world. That’s why I have those behaviors. You can’t compartmentalize things because we’re human! That’s not how we work, even though we want to! (Participant)

Hence, this theme revealed that ED and BD experiences were diverse but connected.

Nature of ED features—Beyond binge eating

A number of participants reported ED features beyond binge eating, such as restricting, excessive exercise, grazing, laxative use, and use of substances that suppress appetite such as caffeine and nicotine (Supplemental Table 1), which could change over time.

Interplay of ED features, BD symptoms, and weight

Most participants (N = 8) endorsed the idea that ED features and food intake, and sometimes weight, changed according to bipolar illness episodes. Experiences varied significantly between different participants.

1. Disparate experiences with EDs while manic

ED features manifested in a range of ways when participants were experiencing mania. Some participants reported increased appetite and food intake, and being less bothered by body esteem concerns. Those who overate or binged while manic referred to increased hunger, disorganization, not planning meals, and impulsivity playing a role. Others experienced reduced appetite and intake due to high energy and distractibility:

When I am hypomanic I am always bouncing off the walls. So when I am like that, I am just like too excited to eat, I have too much to do, can’t do it. Can’t stop to eat! (Participant)

2. Disparate experiences with EDs while depressed

Depression was similarly associated with changes in appetite and diet. Reduced appetite, sometimes even food aversion and nausea, was regularly experienced by some participants while depressed:

So obviously with the depression, naturally you just don’t want to eat; can’t be bothered eating as much. You might initially start overeating. And then you get to the point where nothing will make you happy. I do lose weight in the depressive stage. (Participant)

Conversely, a few participants tended to experience increased appetite and carbohydrate cravings, changes in weight/shape concerns, and increased food intake. This may reflect different types of depression (e.g., atypical versus melancholic; Simmons et al., 2020). Interestingly, one participant described a seasonal pattern to both her moods and eating patterns, such that she would become depressed and lethargic and overeat in Autumn/Winter, but experienced improved mood and lost weight during Spring/Summer.

3. Weight changes occur during bipolar episodes

Most participants reported weight changes during mood episodes. Some participants who lost their appetite while unwell appreciated not having to worry about eating food:

When I was hypomanic, I realized that I didn’t have to eat as much, as I wasn’t very hungry or anything . . . I was pleased that I didn’t have to eat and that yeah it wouldn’t cause me a big bother not to eat? Or it’s, like, more convenient. (Participant)

Others felt that the excessive energy and accompanying excessive exercise associated with manic gave them permission to eat in a carefree manner, with euphoria or distractibility also reducing eating concern. Participants could feel heartened by this weight loss and would sometimes capitalize on low appetite to deliberately reduce their intake. Others characterized any weight loss while manic as unintentional. One participant connected significant fluctuations in weight across her lifespan to historically poorly managed depression which impaired her ability to notice weight changes:

After I had my third child, I stayed a 12 for years . . . It wasn’t a perfect body but I fit into size 12 clothing. And ‘round about <year>, I started putting on weight. I went up to 14, then 16, a couple of years later 18, and then a size 22. When you are depressed, you don’t look at yourself—you can’t see yourself getting fatter and fatter and fatter, but you are. You are eating so much just to get through the depression. (Participant)

A number of participants linked weight gain to BD medication side effects. One, however, connected significant weight loss to starting appropriate medications for bipolar depression, and felt that it supported her making better choices around diet.

Overall, this theme highlighted how most participants experienced their EDs and BD as connected parts of a greater whole, and were conscious of how these two illnesses interrelated, despite significant variation between participants. The influence of mania or depression on ED features seems diverse. Weight changes appear common in BD, especially in relation to mood episodes. However, while some people deliberately change eating behaviors while manic or depressed to influence their weight, this does not seem to be universal. Sometimes, ED features such as dietary restraint or binge eating may also shift in response to mood episodes. In other cases, weight may change due to the mood episode’s direct impacts on sleep, activity, and food intake.

Different functions of ED behaviors

Participants perceived ED behaviors to have a variety of functions. Nonhungry eating was reportedly employed to manage loneliness and provide comfort, improve sense of control, deal with stress or depressive symptoms, and cope with boredom. For others, ED behaviors were more a smokescreen for severe psychological distress, for example, stemming from abuse,

Food is something you can control, whereas so much else . . . when you are depressed and having the mood swings, you feel like you have no control, it is just all happening, but you can control what you shove in your mouth. (Participant)

Some participants labeled restricting as a type of a self-harm or neglect:

When I get depressed I don’t feel like eating at all, sort of thing, and I usually have two or three beers a night and then I cut back on that. I just can’t do anything, I lose interest in the whole survival thing. (Participant)

One participant, however, felt that not eating when she didn’t have an appetite negated the punitive aspect of restricting. This implied that restricting only “counted” if painful, suggesting that self-harm and punishment was its function rather than weight reduction:

It might have been a throwaway comment, but you said something about; “if it doesn’t hurt, you’re not doing it right?” Was that about bingeing? (Claire)

Uh no, I meant restricting; sometimes I think, if shit’s too easy-, cos after a while, if you stop eating, then you don’t get hungry?—it makes me feel like I don’t really have an issue or something? Not that I would want to have an issue? But it’s sort of an intrusive thought to me; “well, you’re not actually . . . punishing yourself or anything.” (Participant)

BD diagnosis and treatment as somewhat protective

Having a comorbidity appeared to be somewhat protective, in some cases. For example, a participant described ensuring that she ate and drank enough to avoid serious medication side-effects, such as kidney failure, despite her desire to restrict. Others expressed knowledge about the importance of healthy diet and avoiding excess caffeine. Hence, having a comorbid complex mental illness may motivate people to deliberately or inadvertently adapt their ED features to protect their health (and vice-versa).

Service provision

The second area of interest was service provision experiences for this clinical population.

Underdiagnosed EDs

One participant previously hospitalized for AN in early adolescence reported a formal ED diagnosis. Two participants had been assessed to some extent, but neither had received formal diagnoses, and only one had received structured treatment. The remainder denied ever being asked about body esteem, significant weight gain, or ED behaviors.

EDs are equated with being severely underweight by many clinicians/participants

The group’s knowledge about the different types of EDs seemed limited. One participant who experienced extreme restriction alongside subjective and objective binge eating, but was not underweight, dismissively laughed when stating that she knew she didn’t have AN, when in fact her symptoms were quite pronounced and distressing, and consistent with atypical AN or other specified feeding and eating disorder (OSFED),

It definitely sounds like you would meet criteria for that <OSFED>. Do you know much about eating disorder diagnoses? Have you heard of the different types? (Claire)

Nup. I know a little bit about, um, like anorexia and stuff? I definitely know I am not anorexic <laughs>! (Participant)

The idea that one must be severely underweight to have an ED was pervasive, both in participants and reportedly in clinicians. One participant reported recently not being diagnosed with AN due to her BMI being 18—despite reporting severe ED features including excessive restriction. This experience, described by the participant as quite frustrating and invalidating, continued to interfere with her treatment-seeking. This stereotype impacted treatment adherence and the therapeutic alliance. One participant described intense fear that she would no longer receive support once she became weight-recovered, with her GP reassuring her that this would not be the case,

I had an awesome GP though, and I used to go to her all the time. I used to be like, “it’s not fair, like, you know, you try to make me fat and then, like, I won’t be your problem anymore!” and she was like, “no, that’s . . . I know you’ll still have an eating disorder,” and even when I was like at a healthy weight she would still say “oh yes, referral—whatever—um, you know—patient has anorexia” and I’m just like, it was kind of like that relief of that <sighs> I’m still that, and that’s retarded, that, like, . . . (Participant)

Is it because you feel like getting the label makes you sound like you’re underweight, even if you’re not? (Claire)

No, it’s that kind of, like, that reassurance of like, okay, so “I’ll <the GP will> take it seriously; and I’ll still take it seriously,” even though I’ve “fattened up,” that I’m still, I still struggle with it. (Participant)

Misunderstanding of EDs may partly explain underdiagnosis and treatment of these conditions in people with BD, especially those who are overweight. It suggests insufficient psychoeducation in health care providers as well as more broadly within the community.

Not enough support for managing weight

Both participants who underwent elective gastric surgery were initially told that they were not overweight enough to justify “extreme” weight loss options; however, no other structured support for weight loss was forthcoming. One participant described motivation to change after observing the experiences of her fellow patients with BD:

I think that the tablets get blamed so much, and they want you to be so regular on your tablets, but when they see you blowing up and getting bigger and bigger, they just don’t seem to address it? . . . with the people in the hospital on my clinic days . . . there’s so many getting the gastric band, but they were, like hundred kilos plus kind of thing, and I just kept thinking to myself, “this is going to be me, if I don’t do something about it!” So, it was more to do with the patients then it was to do with anybody trying to tell me in the hospital. (Participant)

Minimization of participants’ being overweight was juxtaposed with passive commentary about this issue from health professionals. A number of participants mentioned that while their GPs or other clinicians would tell them they needed to lose weight, they did not receive sufficient support, direction or specialist referrals to achieve this goal. Only one participant who underwent gastric surgery reported being previously referred to additional support (a dietician and group psychologist) for managing excess weight. However, a few did benefit from a gentle style of intervention:

I have never had a lot of support from my medical practitioners. I’ve asked, I have asked my doctor “can I get some help,” and he just sort of pushes it under the rug. (Participant)

Does he say, “you are doing fine, you are not overweight?” (Claire)

Oh no, he tells me I am overweight, that I need to do something . . . (Participant)

Participants expressed frustration that their health care team did not appear to acknowledge or address weight issues, such as by considering changes to medications:

But unfortunately, I’ve had the opposite thing said when I’ve asked, invariably every time—“does it put on weight?,” “uh, no; well it’s too bad, you just have to be on it anyway.” And see, the gastric banding is a result of exactly those comments . . . (Participant)

When you went on those things, and if you did gain weight, did they respond by changing the dose, or giving you different medications at all? (Claire)

No. And if anything, even higher doses, you know, per time . . . I’m very angry about that, needless to say. You know? . . . maybe I wouldn’t have needed this gastric banding. (Participant)

In addition to less-than-assertive care, participants identified a range of barriers to getting help, including cost, knowledge, motivation, criticism, stigma, and shame. While this population wish to be healthier and feel better about their bodies, they are shown no clear path to achieve this, despite current recommendations (Malhi et al., 2018).

Double-edged sword of health literacy and being one’s own advocate

Participants receiving more targeted care had made significant efforts to secure this—extensive online research, finding the right clinician, making major lifestyle changes or using the private health care system. This autonomy could be quite pronounced, and sometimes dangerous with some participants independently tailoring medication doses to ameliorate obesogenic side effects. Some described subsequently experiencing mood relapses or experiencing subthreshold mood symptoms:

They’re like, “unless you put on 10 kilos, we’re not gonna worry about that.” That’s just not good enough! . . . I did play around with it a bit, and dropped it too quickly, and so they said, “DO NOT drop it too quickly, because you’ll relapse” and I’m like “no no no, it’s fine, ‘s’fine,” and of course I went manic again . . . (Participant)

I put on stacks of weight being on Lithium . . . and I was told it wouldn’t. All those meds put on weight incredibly . . . But I’m sure it’s maybe dose-related. So I’ve gotta say, even though maybe I need a higher dose, I don’t want to have one. (Participant)

Some participants described other major lifestyle or life changes they had made to make it possible to take better care of themselves and/or lose weight, especially given financial barriers. These could also be quite drastic, such as involving significant housing or career changes. One participant reported somewhat impulsively moving to a new community and changing her job with the aim of sparking personal transformation:

When my psychiatrist wrote his first report about me he said he saw a very obese tattooed woman (because I was size 22). And I thought to myself, “now that is how people are looking at me. I am obese.” And I didn’t do anything about it at that stage, but I thought “that’s terrible.” And it still took me another year, and then . . . I looked at myself and I just was so fat and so big, and something happened. Last year, something snapped inside of me and said “no. No. You can’t look like this for the rest of your life, you are just going to get bigger and bigger and bigger.” And I don’t know whether it is because I was over depressed or under depressed or not depressed, I don’t know, I just said to myself “no, you can’t go on like this—you have got to do something about it.” After my husband and I moved away from our kids, we got a one-bedroom unit in an over-55 complex. (Participant)

The tendency to make dramatic life changes arguably poses a risk for those with BD, given that instability associated with major life events (even positive ones) can increase the risk of mood episodes (Aldinger & Schulze, 2017).

Some participants with high autonomy chose elective gastric surgery for weight loss. They described the decision-making process as difficult, oftentimes feeling unsupported by family and medical practitioners, despite their agreement that their weight was problematic. Beyond management of ED features or weight, some participants described having to provide psychoeducation on depression and BD to their doctors, including about common contraindications with their medications. So, when people with comorbid BD and ED do make some progress toward better mental and physical health, they appear to encounter structural and psychosocial barriers and may be putting themselves at higher risk of mood episodes (Aldinger & Schulze, 2017).

Variability in expertise of clinicians, and its impact on rapport and outcomes

Many participants distinguished between positive and negative treatment experiences, with some describing a lack of trust toward health care providers. Some participants trusted the expertise of those with lived experience over clinicians,

Have you met people in your mental health journey who’ve really supported you? (Claire)

No, no one at all. I have never really connected with a counsellor or a medical professional or anyone. Like, I have sort of dealt with it myself . . . I do quite a lot of reading on the internet and researching stuff about bipolar and how other people have dealt with it. (Participant)

Alongside negative reports, participants readily heaped praise on those they considered experts—the “right” clinician, who were allies and gave them hope. Clinician attributes mentioned included honesty, frankness, humor, skillfulness, thoroughness, insight, a collaborative approach with clear goals, offering validation, pushing for change, and a gentle manner. These sessions appeared to be more productive and solution-focused:

I probably had signs of BD in my early 20s, late teens . . . But you just put it down to <being> a teenager, starting things, trying to rebel. But I didn’t ever think about that until I started going to Dr <Name>. He went back and did a full history. (Participant)

I went to the hospital last Thursday and Friday, and the doctor who treated me there, she had bipolar. A really lovely girl . . . The thing is, you run into those sort of people and you talk about it and they understand your ups and downs, and ins and outs of everything? It’s not a sympathy vote, sort of thing, it’s a . . . (Participant)

It’s an actual understanding? (Claire)

An actual understanding. (Participant)

Certain treatments that felt appropriate and effective were described with great enthusiasm, and differentiated from previous treatments that did not fit. Key important elements mentioned included structured, short-term strategies to manage distress (as found in Dialectical Behavior Therapy [DBT]); flexibility and patience with clients less able to tolerate distress and discomfort (DBT was seen as incompatible and reportedly “failed” another participant in this regard); consideration of the client’s own expertise; and shared understanding of the client’s experience:

With the DBT, are you getting one-on-one support as well? (Claire)

It’s individual and group, so yeah—it’s good, so far. And—in case it’s useful at all . . . I do want to mention that CBT really didn’t do much for me at all, and, on my first session with DBT, it was completely different and really great—my individual <sessions> are very structured . . . I’ve only done it for two weeks now, but, <it> is so much more productive, and it feels like I’m making more progress there. With <previous> CBT, I was with the same psychologist for quite a considerable time last year, and it was useful to talk to someone, and it’s good to be able to express that, but I felt like I wasn’t really moving anywhere, and making any steps. (Participant)

CBT doesn’t work for me. I don’t like it. It annoys me, having to check kind of everything. It just isn’t my kind of thing. Even keeping the food diaries and stuff, because it almost makes me focus more on what I’m eating! Or maybe—the control thing, or constantly throughout the day having to think of something? . . . Whereas this counsellor I see, I guess it’s more talking therapy? None of the clichés, like “oh how do you feel”; “oh that must be hard for you,” or, “I’m just wondering about this . . . ” you know? I just want a normal conversation, and she just knows how to do that. She’s a straight-talker, in a normal way. (Participant)

This theme highlighted the importance of three key aspects of treatment which often seem overlooked: perceived rapport, expertise, and suitability of the treatment modality.

BD, ED, and other mental health experiences tend to form a unified whole

One participant reported using different clinicians for different things due to concerns of trust and whether clinicians are able to handle sensitive matters. However, a number of participants endorsed the idea of physical health and mental health being linked, and different mental health syndromes being related, though it is difficult to determine the direction of causation. Due to this, integrated care may be the most appropriate:

With the gastric banding—because I didn’t run so much to food, right?—I have been able to address more things . . . I guess it’s like, unless the alcoholic stops drinking or drugs, then you’re continuing to mask the pain and just keeping it in a worse cycle. I was, kind of; a little bit—I said it blanketly that it’s putting a bandaid on a weeping wound if you just try the eating programs first. But I’ve kind of contradicted myself really. Because it’s only since I’ve had the gastric banding really that I’ve started—cos I’m not running to food the way I used to—I’ve started to look at the deeper issues. And also, I guess—not that I think it’s that, but—the bipolar’s more under control. But that’s more getting that medication working. (Participant)

Discussion

Summary of Key Findings

This study found that ED features in a sample with comorbid BD were diverse, not limited to binge eating, and changed both in response to mood episodes but also over time. Participants felt that ED features were related to weight management, and were connected (rather than adjacent) to BD, as well as to historic trauma. Most participants reported that their EDs were insufficiently screened for, and seemed less visible if they were not overtly underweight. A number were unclear regarding where to get support, and those who had received it reported high variability in service provision.

Clinical Implications

Our research has important implications for clinical care. Client needs regarding ED features in BD are arguably not being met. A key recommendation is that clinical care becomes more personalized and involves routine periodic screening for EDs to identify both formal and subthreshold features, as both are relevant to physical health and mental health management and subsequent quality of life. Clinical practice guidelines (CPGs) should reflect the importance of universal screening for EDs in BD. Furthermore, BD should also be screened for in those with EDs, given the high frequency of mood disorders in this group. This is particularly important as BD is regularly misdiagnosed as unipolar depression, making correct diagnosis with BD and hence appropriate treatment routinely delayed for around 10 years (Lish et al., 1994).

ED features were diverse and not limited to binge eating, despite this being characterized as the most relevant ED feature in people with BD (McElroy et al., 2013). In a clinical setting, it would be also important to consider how ED features interact with mood. ED behaviors can function as self-harm or ineffective emotion regulation techniques, which also characterizes those with EDs alone (Dingemans et al., 2017). This was particularly evident when considering one participant’s characterization of restriction as highly punitive. This conceptualization resembles the “Punitive Critic” Mode concept of schema therapy (Arntz & Jacob, 2012), and the malevolent “Eating Disorder Voice” (Pugh et al., 2018). It seems to imply that those with BD who are experiencing certain ED features such as extreme dietary restriction may see their behaviors as a form of self-harm rather than merely connected to weight or shape control. Impulsivity when manic, however, may reflect an underlying insufficient self-control/discipline schema (Hawke et al., 2011), and involve “surrendering” control over eating.

Trauma emerged as central to this subgroup and deserves screening and clinical attention. A unified formulation for clients, tying together trauma alongside ED features and BD, may support treatment (DeSocio, 2019). Clinicians without all specialties may find themselves outside their comfort zones, but this could be discussed with the client, who may elect to change practitioners, or request a multidisciplinary team approach, with specialized clinicians designated for each condition but consulting together.

Participants were motivated to receive support for both EDs and weight but were unclear about how to access such treatments, which limited disclosure and self-referral. Clinicians should be proactive in screening, not wait for clients to initiate conversations about these issues. While this is acknowledged as highly challenging for clinicians, novel research may offer ideas for delivering patient-centered care, such as emphasizing a self-compassionate stance during clinical consultations (Luig et al., 2020).

Implications for Future Research

This study challenges a number of assumptions regarding the nature of ED features in BD, and how these may relate to weight gain. First, binge eating was not the only or even dominant ED feature reported. Participants described significant dietary restriction and compensatory practices, with three having previously met criteria for typical AN. This is consistent with research suggesting a greater overlap between BD and AN than previously believed (Thiebaut et al., 2019; Valentin et al., 2019), and the presence of restrictive ED features in obesity (da Luz et al., 2017). Second, most participants experienced ED features before BD diagnosis and treatment. Weight gain, binge eating and overeating may relate to specific obesogenic medications, but obesity and ED features often predate BD diagnosis and pharmacological treatments (Lopresti & Drummond, 2013).

Our findings also offer greater depth of information about how ED features and BD mood symptoms can interact. Most participants strongly endorsed the idea of ED features changing according to their mood state, sometimes along with appetite and subsequently their weight. Importantly, changes noted differed between participants; while some reported increased food intake during mania, others definitively described the opposite.

These results shed light on why people with BD may be at higher risk of weight cycling—a syndrome which may worsen weight gain in the long term (Graci et al., 2004). As ED features can change with different mood states and are associated with changes in appetite and food intake, it is unsurprising that these may predict difficulties with weight management in the longer term. Furthermore, ED features can change over time (e.g., restricting to binge eating), and may not be consistently associated with weight gain, hence why this relationship is not necessarily unilateral. In this way, ED features may not be necessary or sufficient for obesity but may still demarcate a subgroup at increased risk.

This study furthermore suggests that ED features can escalate and remit within individuals. This may also help explain why underdiagnosis is so prominent, as clients may not disclose difficulties with eating when these are in remission.

Our study has a number of implications for clinical research. As previously suggested (McElroy et al., 2016b), research on EDs in people with BD should endeavor to include a lifetime assessment. This could capture changes in ED features over time, such as a history of AN symptoms. Ideally, more longitudinal research will also consider including measures of comorbid EDs or their features, and measure their relationship with weight, medications, mood features, and psychosocial functioning.

We strongly argue that any interventions aimed at weight loss in this population do not neglect to screen for ED features. These may not need to serve as an exclusion criteria for lifestyle interventions (as in Gillhoff et al., 2010), but should at least be monitored or treated prior to intensive diet and physical activity behavior change, to ensure unhealthy ED features are not inadvertently being triggered (e.g., through promoting rigid meal planning in someone with a history of extreme dietary restriction).

Limitations

As our study investigated novel directions of exploration, there are natural limitations to its scope. The study did not clarify why some people with BD and an ED get screened and treated, while others do not. It suggested that clinicians only consider a comorbid ED in BD when faced with salient cues like low body weight, and may not screen for this comorbidity proactively. If underweight status leads to early intervention and diagnosis with an ED, emergent mood difficulties may subsequently be identified by the client’s treating team. However, more investigation is needed. Our research also primarily included women, due to sampling limitations, which is a common challenge in the field (Thiebaut et al., 2019).

Our research may have benefited from including participants with subthreshold or standalone ED features such as body dissatisfaction or less frequent binge eating; those with a history of significant weight cycling; and those without ED features at all, to compare illness trajectories and experiences of service provision. Future studies should consider employing broader inclusion criteria for ED features in BD, to see whether subthreshold features are connected similarly to the experience of BD, as for those with more marked ED features. Furthermore, the study only included nine people due to the recruitment process. Including a larger sample to aim for theoretical rather than data saturation may facilitate an even richer understanding of this group’s experiences and needs (Hennink et al., 2017). Future studies may also consider employing an interviewer with no previous contact with participants as it is possible this may artificially affect response patterns. However, previous experience with participants or their subject matter is not necessarily a weakness, even if neutrality is somewhat compromised. Such connection can enhance rapport and generate higher quality research where participants feel understood and supported (Watson et al., 1991).

Our study’s focus on a narrow clinical group and use of the “comorbid” label may also have functioned to reduce these participants to their psychiatric diagnoses. Although our employment of an interpretivist paradigm was intended to facilitate collaborative meaning-making, the aim of the study was relatively narrow in wishing to explore the overlap between BD and EDs. Indeed, many participants voiced broader difficulties in their experiences, such as managing physical health, inequities and poor experiences in the provision of mental health services including exposure to stigma, and the burden of mood disorders. While these existed somewhat outside the scope of this publication and may be considered further down the track, they have implications beyond this group alone and identify particular shortcomings of our health services. It could be argued that these domains are more urgent than the research interests of the authors and deserve additional consideration in future research.

Conclusion

Our study has arguably started a conversation rather than settled a debate. Nonetheless, this study offers insight into the lifetime experiences of a subgroup who have received insufficient research and clinical attention.

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Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Claire McAulay

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Author Biographies

Claire McAulay is a clinical psychologist currently working full time in clinical practice with a focus on eating disorders, mood disorders, trauma and schema therapy. Her PhD investigated the overlap and interplay between bipolar disorder and eating disorders with a focus on physical health and trauma.

Lisa Dawson is a clinical psychologist and the Senior Research Co-ordinator at the Centre for Family-Based Mental Health Care at St. Vincent’s Private Hospital Sydney. Her PhD investigated the definitions, theories, and narratives regarding recovery from anorexia nervosa using qualitative approaches.

Jonathan Mond is a senior research fellow in the Centre for Rural Health at the University of Tasmania. He is a research psychologist with an interest in sociological approaches to mental health problems and health promotion programs.

Tim Outhred is a postdoctoral research fellow at the University of Sydney. He researches the role of neurocognition in psychiatric disorder and its treatment.

Stephen Touyz is a professor of Clinical Psychology in the School of Psychology at the University of Sydney and Honorary Associate in the Discipline of Psychiatry at the University of Sydney. He is the Chair of the advisory council and a Lead Researcher for the InsideOut Institute – Australia’s first institute for research and clinical excellence in eating disorders.

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