Youth With Bipolar Disorder at High Risk of Eating Disorders

Batya Swift Yasgur, MA, LSW

June 06, 2022

Youth with bipolar disorder (BD) have a high risk of eating disorders (EDs), new research shows.

Investigators studied close to 200 youth with BD and found that more than 25% had a lifetime ED, which included anorexia nervosa (AN), bulimia nervosa (BN), and an ED not otherwise specified (NOS).

Those with comorbid EDs were more likely to be female and to have BD-II subtype. Their presentations were also more complicated and included a history of suicidality, additional psychiatric conditions, smoking, and a history of sexual abuse, as well as more severe depression and emotional instability.

"We think the take-home message is that in addition to other more recognized psychiatric comorbidities, youth with BD are also vulnerable to developing EDs. Thus, clinicians should be routinely monitoring for eating, appetite, and body image disturbances when working with this population," lead author Diana Khoubaeva, BSc, Hons, research analyst, Centre for Youth Bipolar Disorder, Centre for Addiction and Mental Health, Toronto, Ontario, Canada, and senior author Benjamin Goldstein, MD, PhD, director, Centre for Youth Bipolar Disorder, told Medscape Medical News in an e-mail.

"Given the more complicated clinical picture of youth with co-occurring BD and EDs, this combination warrants careful attention," the investigators note.

The study was published online May 11 in The Journal of Clinical Psychiatry.

Lack of Research

"From the existing literature, we learned that EDs are not uncommon in individuals with BD, and that they are often associated with a more severe clinical profile," say the researchers. "However, the majority of these studies have been limited to adult samples, and there was a real scarcity of studies that examined this co-occurrence in youth."

This is "surprising" because EDs often have their onset in adolescence, so the researchers decided to explore the issue in their "fairly large sample of youth with BD."

To investigate the issue, the researchers studied 197 youth (aged 13 – 20 years) with a diagnosis of BD (BD-I, BD-II, or BD-NOS) who were recruited between 2009 and 2017 (mean [SD] age, 16.69 [1.50] years; 67.5% female).

ED diagnoses included both current and lifetime AN, BN, and ED-NOS. The researchers used the Kiddie Schedule for Affective Disorders and Schizophrenia for School Age Children, Present and Lifetime Version (K-SADS-PL) to determine the diagnosis of BD.

They also collected information about comorbid psychiatric disorders, as well as substance use disorders and cigarette smoking. The Life Problems Inventory (LPI) was used to identify dimensional borderline personality traits.

Information about physical and sexual abuse, suicidal ideation, nonsuicidal self-injury (NSSI), and affect regulation were obtained from other measurement tools. Participants' height and weight were measured to calculate body mass index.

Neurobiological and Environmental Factors

Of the total sample, 24.84% had received a diagnosis of ED in their lifetime.

AN 3.6%
BN 8.1%
ED-NOS 16.8%


Moreover, 28.9% had a lifetime history of binge eating. Of these, 17.7% also had been diagnosed with an ED.

Participants with BD-II were significantly more likely than those with BD-I to report both current and lifetime BN. There were no significant differences by BD subtype in AN, ED-NOS, or binge eating.

Higher correlates of clinical characteristics, psychiatric morbidity, treatment history, and dimensional traits in those with vs those without an ED are detailed in the table below.

BD-II χ2 = 4.6 Uncorrected P = .03
Lifetime "most severe" depression scores t = 4.9 P < .001
Lifetime history of NSSI χ2 = 17.1 P < .001
Suicidal ideation χ2 = 9.6 P = .006
Suicide attempts χ2 = 10.5 P = .004
History of sexual abuse χ2 = 7.2 P = .02
History of cigarette smoking χ2 = 13.8 P = .001
Comorbid anxiety disorder χ2 = 10.4 P = .004
Posttraumatic stress disorder χ2 = 10.4 P = .004
Substance use disorder χ2 = 9.6 P = .006
Family history of anxiety disorders χ2 = 9.8 P = .01
History of individual therapy χ2 = 8.4 P = .01
Self-reported lability scores t = 4.6 P < .001
Self-reported life problem scores t = 5.3 P < .001


The ED group scored significantly higher on all LPI scores, including impulsivity, emotional dysregulation, identity confusion, and interpersonal problems, compared to those without an ED. They also were less likely to report lifetime lithium use (χ2 = 7.9, P = .01).

Multivariate analysis revealed that lifetime EDs were significantly associated with female sex, history of cigarette smoking, history of individual therapy, family history of anxiety, and LPI total score and were negatively associated with BD-I subtype.

Characteristic OR (95% CI) P value
Female sex 4.61 (1.63 – 13.01) .004
History of cigarette smoking 2.78 (1.22 – 6.35) .02
History of individual therapy 3.92 (1.17 – 13.14) .03
Family history of anxiety disorders 2.86 (1.15 – 7.08) .02
LPI total score 1.01 (1.00 – 1.02) .009
BD-I subtype .21 (.04 - .83) .03


"The comorbidity [between EDs and BD] could be driven by both neurobiological and environmental factors," Khoubaeva and Goldstein noted. EDs and BD "are both illnesses that are fundamentally linked with dysfunction in reward systems— that is, there are imbalances in terms of too much or too little reward seeking."

They added that individuals affected by these conditions have "ongoing challenges with instability of emotions and ability to manage emotions; and eating too much or too little can be a manifestation of coping with emotions."

In addition, medications commonly used to treat BD "are known to have side effects such as weight/appetite/metabolic changes, which may make it harder to regulate eating, and which may exacerbate pre-existing body image challenges."

The researchers recommend implementing trauma-informed care, assessing and addressing suicidality and self-injury, and prioritizing therapies that target emotional dysregulation, such as dialectical behavioral therapy.

"Clarion Call"

Commenting for Medscape Medical News, Roger McIntyre, MD, professor of psychiatry and pharmacology, University of Toronto, Canada, and head of the Mood Disorders Psychopharmacology Unit, said the study is "the first of its kind to comprehensively characterize the prevalence of ED in youth living with BD.

"It could be hypothesized that EDs have overlapping domain disturbances of cognitive dysfunction, such as executive function and impulse control, as well as cognitive reward processes," said McIntyre, who is the chairman and executive director of the Brain and Cognitive Discover Foundation, Toronto, and was not involved with the study.

"The data are a clarion call for clinicians to routinely screen for EDs in youth with BD and, when present, to be aware of the greater complexity, severity, and risk in this patient subpopulation. The higher prevalence of ED in youth with BD-II is an additional reminder of the severity, morbidity, and complexity of BD-II," McIntyre said.

The study received no direct funding. It was supported by philanthropic donations to the Centre for Youth Bipolar Disorder and the CAMH Discovery Fund. Goldstein reports grant support from Brain Canada, Canadian Institutes of Health Research, Heart and Stroke Foundation, National Institute of Mental Health, and the Departments of Psychiatry at the University of Toronto and Sunnybrook Health Sciences Centre. He also acknowledges his position as RBC investments chair in Children's Mental Health and Developmental Psychopathology at CAMH, a joint Hospital-University chair between the University of Toronto, CAMH, and the CAMH Foundation. Khoubaeva reports no relevant financial relationships. The other authors' disclosures are listed in the original article. McIntyre has received research grant support from CIHR/GACD/National Natural Science Foundation of China (NSFC); speaker/consultation fees from Lundbeck, Janssen, Alkermes, Neumora Therapeutics, Mitsubishi Tanabe, Purdue, Pfizer, Otsuka, Takeda, Neurocrine, Sunovion, Bausch Health, Axsome, Novo Nordisk, Kris, Sanofi, Eisai, Intra-Cellular, NewBridge Pharmaceuticals, Abbvie, and Atai Life Sciences. Roger McIntyre is a CEO of Braxia Scientific Corp.

J Clin Psychiatry. Published online May 11, 2022. Full text

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