7 replies to this topic

[PhaQ]

I've finally admitted it to myself. I have binge eating disorder... bad. I eat when I'm not hungry. I eat when I don't even want to eat. I eat until I feel sick. I have no control. Its just something I HAVE to do to stop thinking about eating. I can usually force myself to eat relatively sensibly for a few weeks, but even then I'm usually eating healthy amounts of clean protein and then packing in salad. I'm insanely obese, which just creates a vcious cycle of anxiety/depression and eating. I'm not going around on a scooter or anything, but I weigh about 400lbs. Anyway, I've been reading up, and it seems eating disorders are basically a kind of OCD. It makes a lot of sense to me. My binge eating disorder symptoms are practically the same as OCD symptoms. The problem is, the drugs recommended almost all cause weight gain. What kind of pharmacological/supplement interventions can I use to stop the intrusive thoughts that won't keep me fat or possibly make me gain even more weight?

[Tom_]

This isn't entirely correct.

 

Anorexia has a strong link to autistic and OCD like disorders (called neurodevelopmental disorders) and Bulimia and Binge eating are much more strongly linked with emotional regulation disorders. This picture might help you get a grasp:

http://www.google.co...rt-1%2F;804;605

 

So you are more likely to have mood disorders, cluster B personality traits (in particular Borderline personality traits) and addictive disorders. While people with anorexia are more likely to have severe anxiety disorders - OCD related, Cluster C personality traits (in particular Obessive complusive traits) and autistic spectrum disorders. ADHD tends to spread fairly evenly between to while Anorexics are more likely to show hyperactive symptoms and binge eaters are more likely to show inattentive and hendonism seeking behaviour.

Both types of disorder respond relatively poorly to only medication. Psychotherapy - CBT in particular - for binge eating is the most effective treatment, with 50% of patients being fully recovered and it also improves other psychiatric disorders significantly more than just behavioural changes.

 

SSRI's are the first line medication for both disorders (they improve obessional behaviour and emotional regulation). Some cause weight gain or weight loss but in general they tend to be realitvely weight netural drugs. Fluoxetine is the best option as it also acts as a 5HT2c antagonist and can improve self control and emotional regulation. It also tends to reduce appetite. Unfortinately in eating disorders much higher doses than those used for depression are typically needed and longer trials are a must. A minimum of 40mg is ususally needed but 60-80 is the normal successful dose range for these disorders. Rather than the normal 8 week trials for depression or non-OCD anxiety disorders to know whether the drug will be effective it can take 12 weeks before improvement in eating behaviour is seen. However as you have mentioned depression and anxiety as co-morbid you may well see significant improvement in those before then. But just because it doesn't work for the depression by week 8 doesn't mean it won't help with the eating by week 12. So in short, minimum of 40mg and give it atleast 12 weeks to work.

 

There are other drugs that can be used, Deluoxetine (but if you have high blood pressure this might not be best) is often used if Fluoxetine has failed as it tends to cause weight loss (although sometimes the reverse is seen). Topimate (an anticovulsant with mood stabilizing properties) is sometimes used as it tends to cause minor weight loss/reduction in appetite and can also improve general psychopathology. Psychostimulants can be used, in particular if ADHD is suspected as they reduce appetite and can help with the addictive side of binge eating - again because they increase blood pressure they aren't always a safe option. NRI's like Atomoextine and Reboxetine are similar but potentially safer alternatives. Bupropion is another option which is psychostimulant like and tends to reduce weight slightly but also acts as an antidepressant. L-Tryptophan is known to reduce appetite and increase satiy and so potentially this could be trialed. However if its being used along side serotonergic drugs then this should be monitiored more carefully. There are various weight loss drugs that can also be used but I would recommend first beating the eating disorder - which doesn't normally lead to any significant weight loss by itself and then if you are struggling to lose the weight trying weight loss drugs - they can have some nasty side effects and once you stop taking them weight gain ususally happens.

 

What you are likely to find is that Fluoxetine or an SNRI will help a bit, in particular with the depression and then after you have seen how it works for you the addition of a second drug will be helpful. One combination for depression I am particulaly fond of is SSRI + Bupropion. I suspect this would be a good combination for a binge eating disorder as well. While this is happening a course of CBT with a spesific focus on binge eating but also including body image, depression and any other problems you might have should happen. If you can find a therapist with a particular intrest in eating disorders, all the better.

Other imporant things you can do are listed:

Go to your G.P and have a health check. Being as obese as you are high blood pressure, diabeties and high cholestrol may need to be controlled. Its very rare in eating disorders but occational 'physical' disorders can be the cause worsen symptoms. A standard blood test and blood pressure is all thats needed.

Keep a food diary. Note binges and any possible events and emotions that trigger them - this can be both useful for you to recognise 'at risk' times and do something about it (I'll come on to that in a min) and to show to your doctors/therapists so they can get a better grasp of what's going on. http://www.cci.healt...ocs/ACF4530.pdf shows you an example and gives instructions on how to do it.
Treat your binge eating a bit like self harm (the same technequies can work for both and they have similar causes). Learn about and use DBT skills - they are the most effective way to manage impusive behaviour (better than meds or any other type of therapy). http://www.dbtselfhe...ctiveness1.html is one good site. Most of the stuff you read about DBT will be focused on borderline personality disorder and self harm/suicide. You can ignore that, I'm not trying to insuiate you have the disorder, but the skills are equally applicable.
Hold yourself accountable. If you eat to much, it is your problem. Don't blame it on anyone else. At the same time, respect that you have a real illness and you aren't going to get better over night. Expect to relapse and when you do, accept it, move on and deal with the now.

Get some good quality sleep. Don't stay up all night on the internet etc..(also you are more likely to eat when you are bored). Your metabolism and mood are best with 7-9 hours of sleep a night, at a reasonable time, without taking naps in the day. Researching sleep hygieine will tell you all about how to change your sleep patterns if this is a problem.

Try to get some exercise. Whether its two or twenty mins a day (don't over do it). Try to leave the house every day.

Create a meal plan and stick to it as best you can. Rather than having three meals a day have 6 smaller ones. This will both increase your metabolism and decrease your hunger/desire to snack. It is the best way to lose weight. Each meal should contain some lean protein (grilled chicken is great, that kinda thing), some complex carbs and some veg. Portions of each should be about the size of your fist. Don't go on crazy crash diets, you should eat every day and while reducing your overall calorific intake is vital to losing weight don't cut it down to stupid amounts. Look at roughly how many calaories you eat now and steadily reduce it over a number of weeks or months.

 

If you have to snack, try to snack on something healthy, fruit or complex carb biscuits are good. Even better, if you snack try to make a rule where you must prepare something if you are going to snack. Try not to have junk food in the house and if you must have it make sure you have to travel to get it (walk if possible).

 

 

 

 

 

[Tom_]

Generally I'm not an advocate for unevidence based supplements but a medical grade multivitamin (in particular if you aren't getting enough vits) every couple of days alongside omega 3 oils might be slightly benefial. Low levels of vitamins can lead to weight gain and worsen or cause depression and the like. I very much doubt its playing any significant part but its worth the addition. Omega 3 may improve (conflicting evidence, some for, some showing no effect) impulse control and help depression and its also good for the cardiovascular system and yours has likely taken a bit of a beating.

 

Additionally try to stay away from drugs - in particular booze and cannabis (although of couse staying away from illegal drugs is always a good idea). Don't start up smoking to lose weight. In the long run it can do more harm than good.

[PhaQ]

Thanks for your input, Tom_. You seem to be more correct than I am. Your first link doesn't work for me, however. I really really really want to stay away from SSRI's. I watched them blow up my mom like a baloon.

 

I tried Topiramate once. It was amazing. I couldn't eat if I wanted to. I was on it during my birthday. I had half of a small piece of cake and a few bites of ice cream. That was about all I had that day. It also gave me horrible palpitations, so I had to discontinue it.

 

I'm considering asking my doctor about naltrexone and bupropion, though I'd rather try naltrexone with reboxetine and selegiline.

[Tom_]

Do not fall into the trap of thinking all SSRI's are alike. Many of them have very significant other effects to. Fluoxetine is well known for causing people to lose weight and one of the most commonly reported side effects is loss of appetite. I don't know how much you know about SSRI's but if she put on that much weight there is a good chance she wasn't taking an SSRI and it was a similar drug like Mirtazapine.

Naltrexone is a bad idea. There is very little evidence for it for binge eating and its not a very friendly drug. And no doctor worth his degree is going to prescribe it without having tried more evidence based methods and at least one good course of psychotherapy first.

 

Reboxetine again has a lack of evidence although Atomoxetine is a reasonable second line agent.

Everyone on this board is obsessed with selegiline. At a proper antidepressant dose it could be effective (although loss of appetite is a relatively rare side effect) but this is no different to taking an MAOI. Moclobremide would be a better choice but again other antidepressants should be tried first. Combining Selegiline and Reboxetine could be potentially very dangerous and such combinations should only be used in extremely resistant depression.

 

The reason I'm so hell bent on Fluoxetine is because it is the only antidepressant that has been shown in lots of studies to be effective. Other than Topiramate its the only psychotropic drug that should be considered a first line treatment. Studies show it significantly reduces obsessive thoughts around food, improves emotional regulation and leads to weight loss.

 

If Topiramate worked it could be worth trying it again at a lower dose and either building it up slowly (to see if the palpitations go) or just keeping it at a low dose.

 

This is how I would approach the situation pharm wise. Be aware that no doctor is going to start you on more than 1 psychotropic drug at a time (and rightly so).

 

Start Fluoxetine 20mg. Increase to 30mg the next week and the following week increase to 40mg. If side effects are bad wait two weeks for them to reduce (the worst of side effects tend to disappear by week 4 as 5ht1a receptors down regulate), otherwise increase to 60mg the next week. Leave it for 8 weeks (reduce the dose if side effects are bad). If it hasn't helped, stop it. If its helped a bit consider adding in Bupropion or Atomoxetine or increasing the dose to 80mg. If it hasn't helped, consider low dose Topiramate, Atomoxetine, Bupropion, Lamotragine or a psychostimulant. If the FLoxetine and Bupropion/Atomoxetine aren't helping enough Trial Fluoxetine + psychostimulant/Topiramate/Lamotragine/switch to Imipramine/Desprimaine

 

After you have tried Fluoxetine, Bupropion, Atomoxetine and Despriamine and at least one psychostimulant and Moclobremide if you can get it in your area, some of the more wacky ideas like Naltrexone might be worth a shot (even in the few studies there are of it, it wasn't any more effective than Fluoxetine).

[Boopy!]

Tom -- you are truly my hero (don't blush,  take the compliment like a man.)   I had an eating disorder that began as anorexia and then I actively changed to bulimia because I knew I would die otherwise.  I was the typical anorexic in that I was never close to overweight,   had perfectionist negative parents,  did ballet,  etc.   At times I felt that I binge ate because once you have ever gone hungry your brain actually changes.   This is a fact.    Dieters cannot lose weight and keep it off because not only the body goes into starvation mode,  the brain does too. 

 

Why are you my hero?  Because in just a few simple paragraphs you stated everything more clearly and more helpfully than ANY SHRINK I have ever paid for (now over 20 thousand dollars,  decades of crappy help and pills that don't work.)   I stopped throwing up because of me,  not because any shrink I paid helped me.  I stopped years ago but I still have some of the hallmarks of an eating disordered patient,  like obsessive thinking and negative self-talk.   I'm like a dry drunk.   Why is it someone online is so much more clear and helpful than my crappy shrinks?   ARGH!!   I really,  really am angry at the state of healthcare here in America.   Basically you either cure yourself or die --  that is it.   I have been on so many SSRIs and SNRIs because my shrink is an idiot.   I am going to go online,   get me some Prozac (fluoxetine,  is that right?)  and NEVER PAY THAT JERK ANOTHER CENT.   He's been prescribing me things like Pristiq which is not a generic,  costs me tons,  and does not work.  All I do is lie in bed miserable and unable to move.   I asked him about welbutrin and he refused.  I have to inform HIM of studies that have been done in the last ten years.  I did it the "legal'  and "right"  way and guess what?   It doesn't work and I AM FED UP.

 

Well perhaps one thing I disagree with is that there is a distinct "anorexic"  personality and a distinct "bulimic"  personality because they both cross over too much and stem too much from the same branch.  One cannot simply say,  anorexic is more autistic and OCD and bulimia is more borderline personality disorder,  etc.,  because -- fyi -- most people who start out as anorexic then become bulimic because otherwise they die,  plain and simple.  I have know hundreds of women with eating disorders and I believe only one or two of them (except the ones that died while in hospital) ever were simply anorexic.   So would this mean that they switch from autistic type behaviors to a very different behavior of pleasure-seeking hedonism  or borderline personality disorder?   I was straight up bulimic towards the end of my active disorder but I really never came close to the borderline personality disorder type.   I did notice I was way more "insane"  seeming when anorexic (I would freak out if I kissed someone who had eaten bacon,   convinced I would gain weight from THEIR breath!)   But both types of eating disorders,   as well as simple binge eating,  are ADAPTIVE behaviors --  they are all done to avoid pain,  I would say.   Anorexia is to feel more powerful over circumstances,  bulimia to not die from anorexia and fit into society, because you can't live at too low a weight,   and binge eating to numb oneself.   So this is why CBT would work,  more than any drug, since you find healthier ways to cope.   

 

I no longer have a life-threatening eating disorder (unless you count eating disgustingly healthy as an eating disorder.)   If I binge or eat when I am bored it's on veggies dipped in mustard,  my fave go-to snack.    PHAQ I didn't do it the right way,  but if I could stop throwing up after fifteen years,  on my own,  no meds,  no decent shrink,   then you can start that long journey of health (I know,  it seems like an eternity but it snowballs and becomes almost fun at a certain point.)   For example,  I know it sounds harsh,  but if you live alone,  never,  ever have certain foods around (I never have cereal or bread at my house.   People hate me for this since there is only things like salads to eat chez moi,  or sugar free popsicles,  but it's better than dealing with temptation.)   I remember Judge Judy only had dogfood in her pantry -- no joke.   When you have to leave each and every time,  at least you put that much more time between unhealthy actions.  Or figure out your own way to fight your own mind,  if you know what i mean.  Jekyl and Hyde -- there's a reason literature about the duality in ourselves has never gotten stale.    In order to get better you have to accept feeling incredibly,  horribly awful and i don't mean the average person's idea of awful.  I mean lie in bed and want to die awful,  but it's worth it because the alternative (death or severe health problems)   is worse.  And those times make you feel proud of yourself since it takes such enormous strength and focus.

 

Sorry if this sounds rambling as I haven't had therapy in so long and this is what's been screaming in the back of my mind for eons.  So  thanks to both of you for bringing up a painful topic as it helped more than just one person.   Truly.

[PhaQ]

Yes it was SSRI's that made my mom put on weight. Also, most of the studies I've seen show that weight loss on fluoxetine is only temporary, then weight gain sets in. However, my father has been on fluoxetine for years and years and hasn't had any weight gain problems. I still really want to try to avoid SSRI's. If I do, I'd like to try something like phen-pro, which is prozac and phentermine. I do develop tolerance to stimulants very quickly though. After using phentermine, modafinil, or ephedrine for a single day, the next morning they are almost worthless.

 

I was going to get some tianeptine to experiment with after I get paid on Friday. Do you think that may be any help?

 

As far as my reasoning with naltrexone goes, I thought it might work not only because some studies show it to, but because the bupropion/naltrexone combo was in trials to be approved as a weight loss drug, but the FDA said there needed to be more studies of cardiac risk, which is total bill, IMHO. The weight loss drugs that have caused heart problems have been because of excessive 5ht2b agonism.

 

I welcome continued input on the matter.

 

Oh one more thing. I'm certain the issue with topiramate was its carbonic anhydrase inhibition. A glass of baking soda and water would knock the palpitations out after a few minutes. I couldn't fall asleep if I didn't take bicarb.

[kurdishfella]

I like to convince myself when I eat too much sugar that I am doing it for my family's sake preventing them from consuming it so they can be healthy and I take the damage. So remove what causes you to binge eat. So we stopped buying unhealthy food.

Edited by kurdishfella, 08 June 2022 - 11:39 PM.