Psychosis in eating disorders: warning signs

The appearance of psychosis during an eating disorder constitutes a negative prognostic factor and a risk factor for future episodes, so it is necessary to establish specific treatment as soon as possible.

There are three key risk factors for the development of psychosis in eating disorders:

• The premorbid personality (propensity to dissociation).
• Sensory-perceptual distortion.
• The degree of malnutrition (although a psychotic episode can occur in normal weight – Body Mass Index (BMI) individuals).

Psychosis is a mental disorder in which, essentially, the way of perceiving and interpreting reality is disrupted. That is, it basically consists of an alteration in perception, such as the appearance of hallucinations, and in thought, with the appearance of delusional ideas. Both can cause alterations in emotions or behavior.

These symptoms may appear in combination or only one of them.

In any case, a break with reality occurs that can have serious consequences: harmful behaviors (self-harm or harm to others) or suicide attempts, social isolation, abandonment of usual academic or work activities, deterioration in family and social relationships, etc. Therefore, we must be vigilant if these symptoms appear.

When perception and thought become distorted, behavior is also altered, in addition to any abnormalities that may already exist due to the eating disorder itself.

Introduction to self-harm in adolescents

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The main psychotic (endogenous) disorders in adolescents are schizophrenia and schizoaffective disorder, although other disorders, such as depression, bipolar disorder, or obsessive-compulsive disorder, can also present with psychotic symptoms. Some psychotic (exogenous) disorders are induced by the use of substances or medications, or are due to an identified medical condition (endocrinological, tumorous, etc.). The main diagnostic task is to differentiate between endogenous and exogenous psychosis, induced by the aforementioned conditions.

Both delusions and hallucinations can present with a wide range of clinical manifestations. In eating disorders, they are primarily related to physical appearance, food intake, and feelings of rejection, whether internalized or externalized.

Psychosis in an eating disorder is rare but potentially serious.

Distortion, dissociation, and psychosis

Strictly speaking, the perceptual distortion that most people with anorexia and bulimia exhibit (seeing or feeling their own body differently from what their actual measurements indicate, usually more voluminous, in any case highly unpleasant) is itself a perception not congruent with reality as interpreted by most people.

Body image distortion in eating disorders is usually selective rather than global, but because it often goes unnoticed by an outside observer, it is not explored. Typically, the individual experiences their own body with intense dislike, if not outright disgust, concentrated especially in certain areas (primarily the stomach and thighs). However, there are other forms of distortion that involve seeing or feeling that the body is deformed in specific areas.

Here, too, one must consider the influence of social stereotypes, the androgynous and slim silhouette that has been valued since the sixties; as well as the racial biotype (for genetic reasons, the height, wingspan or measurements of someone from Scandinavia are not the same as those of someone born in South America or China, to give an example).

The perceptual distortion characteristic of eating disorders does not necessarily indicate a full-blown psychotic episode. This distortion would be an initial and partial symptom of mental disorder and a disconnection from reality.

Both distortion and psychosis appear more easily (and are intensified) when there is a pre-existing personality type with a propensity for dissociation. That is, with a tendency to separate feelings from thoughts and actions (behavior), attempting to sever their intimate connection and transfer the resulting anxiety to another area: food and physical appearance, in this case, instead of seeking a connection between them.

This usually occurs due to the intense feelings of inadequacy and low self-esteem underlying all eating disorders.

In fact, this restriction can be a way of "numbing" these feelings that one cannot recognize or express adequately (alexithymia). And this trait, like cognitive rigidity and difficulties grasping certain aspects of social interaction, is shared with other mental health disorders.

In dissociation, as a result of mental suffering, logical thought and feelings become separated. In certain circumstances, dissociation acts as a defense mechanism to cope with pain. But if this internal division persists, it is potentially dangerous.

Dissociation itself can function as a coping mechanism. In practice, it can manifest as feelings of estrangement from one's own body and mind (depersonalization) or from the environment (derealization). These symptoms are not exclusive to psychosis and can occur in states of intense anxiety, drug use, and other conditions.

But let's focus. Let's leave the neuropsychological profile and the distortion itself for future discussions and concentrate on psychotic episodes that involve delusions and/or hallucinations. When it occurs, psychosis constitutes a negative prognostic factor in eating disorders.

The prevalence of comorbidity between psychosis and eating disorders is 10-15%.

In eating disorders, the prevalence of psychotic episodes is estimated at 10-15% of cases. Most are transient episodes, but in 1-3% a diagnosis of long-term psychosis (mainly schizophrenia) is established.

It appears primarily, but not exclusively, in anorexia nervosa , because the state of malnutrition and underweight fosters a loss of contact with reality. When this contact is maintained, the low weight inclines individuals toward depression. In fact, the neuropsychological profile and even the cerebral blood flow in anorexia (especially restrictive anorexia) share characteristics with schizophrenia. And the biochemical and hormonal imbalance caused by sustained restriction or purging leads to a dopaminergic predominance over serotonin, which can induce a psychotic episode. This is one of the reasons why we sometimes prescribe antipsychotics for eating disorders (and why they work). But an episode can also occur even when the individual's weight and BMI are within the normal range.

We must bear in mind that, in certain personalities, the therapeutic process can trigger an identity crisis that may lead to a psychotic episode. This is especially true in cases with a history of serious trauma (childhood abuse, etc.) or if the patient is pressured to confront their underlying fears related to eating disorder too soon.

Regarding the presentation, the most frequent symptom in a psychotic episode of an eating disorder is derogatory auditory hallucinations: voices that criticize one's body shape and eating behavior, typically appearing before or after eating, accompanied by intense guilt. Sometimes these voices become even more externalized, appearing as those of the opposite sex, while maintaining their derogatory or threatening nature. The affected person may even hear the floorboards creak when walking or the chair scrape when sitting down. Other types of perceptual distortions may also occur, such as cenesthetic hallucinations (strange and unpleasant sensations related to the body, such as "feeling fat accumulating"), or other types of hallucinations.

Delusional ideas are usually related to the body or are self-referential and persecutory, focused on family members and professional caregivers, who are the ones who pressure the affected person to eat.

Depressive symptoms will emerge to the extent that obsessiveness allows for the appreciation of one's own reality and the repercussions of the disorder, and alexithymia enables or prevents its expression.

Eating disorders as an emotional refuge

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Another issue arises when a decompensated eating disorder may reveal an underlying endogenous psychosis . This rarely occurs, and in such cases, the clinical presentation is more similar to that of schizophrenia and less to the types of delusions and hallucinations we have just described.

We must perform a differential diagnosis (ruling out other causes) with the use of drugs, laxatives, or other substances, with any other intercurrent illness (endocrinological or neurological, electrolyte imbalances, etc.), and we must not fail to consider possible side effects or interactions of the pharmacological treatment, before diagnosing a primary psychosis. For example, if fever is present.

Differential diagnosis of psychotic symptoms in eating disorders:

• Major depression with psychotic symptoms
• Obsessive-compulsive disorder
• Schizophrenia and delusional disorder
• Borderline personality disorder
• Histrionic personality disorder
• Psychotic disorders induced by substances or by a medical condition.
• Schizoaffective disorder
• Bipolar disorder
• Conversion disorder
• Factitious disorder
• Iatrogenesis

Prevalence in men with eating disorders

What about men ? Can a psychotic episode also occur in male patients with eating disorders? Yes, and although the prevalence of eating disorders in men is much lower than in women (between 5 and 20% of people with eating disorders are men), they are in fact at greater risk of the episode developing into endogenous psychosis, 3.6% more than women (Bou et al., 2011). In men, eating disorders sometimes have their own characteristics (psychosis does not; it usually follows a common pattern). Consider the mutually reinforcing association of muscle dysmorphia, restriction, and psychosis (and I would add depression). Recall that during the famous Minnesota experiment, at least one case of possible psychosis occurred (Sarró, 2018).

The treatment of anorexia nervosa with psychosis

Treatment will be the same as for any psychotic episode, but special care should be taken in cases of underweight, particularly regarding increased sensitivity to side effects due to a smaller volume of distribution for medications, and also in individuals with a predisposition to dissociation as a habitual coping mechanism. Hospitalization may be necessary.

When a person with an eating disorder presents with psychotic symptoms, it is important to take extra precautions to prevent potential self-harm/harm-aggression: provide a safe environment to prevent risks and monitor the person's access to medication to avoid misuse; provide a calm, trusting, and empathetic environment, avoiding direct confrontation with the beliefs they express; individualize the pharmacological approach and provide adequate nutritional care.

Treatment of psychotic episodes in eating disorders

• Assess and treat nutritional status.
  Environmental control.
  Restraint (hospitalize if necessary, assess risk of injury or self-harm).
  Information and guidelines for the person being cared for and their family regarding psychosis and eating disorders, promoting hope and active collaboration versus helplessness.
• Psychotropic drugs (from among the following, as appropriate):
  Antipsychotics
  Antidepressants
  Anxiolytics
  Mood stabilizers
• Individual or group psychotherapy when the clinical condition allows.
• Identifying triggers and preventing relapses. "Making sense of it" to the episode.

The prognosis is usually good in most cases if nutritional status normalizes, unless the characteristics of the case suggest the onset of an endogenous process. 70-80% of cases correspond to transient psychotic episodes that resolve satisfactorily as long as nutritional status is maintained. Otherwise, as with panic attacks, if the level of stress that triggers them persists, they may recur. It is important to make the patient and their family aware of this. A diagnosis of endogenous psychosis should only be considered definitive once weight recovery has been achieved.

A final reflection

The unique role of psychosis in eating disorders, as a link connecting the apparent discontinuity between neurosis and psychosis, allows for a better understanding of both, adding a continuum dimension to the psychopathological spectrum. It also sheds light on the eating disorder itself as a complex, profound, and multidimensional condition.

Perhaps the best way to prevent psychotic episodes in eating disorders, aside from nutritional status, is to achieve the behavioral, cognitive, and emotional integration of the person being treated, enabling them to modify their internal value system to make it more adaptive.