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Divergent responses to fluoxetine from two compulsive, food-related conditions: Bulimia nervosa and compulsive water drinking
CASE REPORT
Divergent Responses to Fluoxetine from Two Compulsive, Food-Related Conditions: Bulimia Nervosa and Compulsive Water Drinking Charles Kornreich, Bernard Dan, Paul Verbanck, Eric Fontaine, and Isidore Pelc Background: The association of compulsive water drinking with bulimia nervosa is rarely encountered. Nevertheless similar behavior patterns could involve a common pathophysiological mechanism. Methods: A case report with the association of those two disorders is described. Treatment with fluoxetine was introduced to alleviate the compulsive aspects of those disorders.
ResuLts: Fluoxetine had a positive effect on bulimia nervosa but none on compulsive water drinking. Conclusions: The different response to pharmacologic treatment could mean that bulimia nervosa and compulsive water drinking are based on different physiological mechanisms. Biol Psychiatry 1998;43:5110-311 © 1998 Society of Biological Psychiatry Key Words: Bulimia nervosa, compulsive water drinking, fluoxetine
Introduction eports of bulimia nervosa associated with compulsive water drinking are scarce (Barlow and De Wardener 1959; Bremner and Regan 1991). The clinical resemblance in behavior between these two disorders may reflect a common basic pathophysiology (Jenike 1990). We report the case of a young woman in which the association of the two conditions was present, and disc ass the possible implications resulting from response to lreatment.
R
Case Report A 22-year-old woman was referred to our clinic for a compulsive water drinking problem. She had no previous psychiatric history. Her father was overweight, and went occasionally on a diet, alone or with other members of the family. Chih:lhood and adolescence were uneventful.
From the Department of Psychiatry, Brugmann University Hospital, Universit6 Libre de Bruxelles, Brussels, Belgium. Address reprint requests to Dr. Charles Kornreich, Department of Psychiatry, Brugmann University Hospital, Universit6 Libre de Bruxelles, PI A. Van Gehuchten. 4- t020 Brussels, Belgium. Received July 2'4, 1996; revised January 27, 1997; accepled April 21, 1997.
© t998 Society of Biological Psychiatry
Shortly after her marriage 4 years before referral, she went on a diet to please her husband. Having heard that drinking large amounts of water could help her lose weight, she started to drink more and more, finally reaching an average consumption of 8-12 L of water per day. No weight loss occurred. On the contrary, newly developed binge eating increased her weight from 75 kg to 100 kg. Moreover, she complained of disrupted sleep because of secondary polyuria. Excessive eating and drinking was mostly hidden from her family. Distressed by the weight gain, she began to engage into compensatory behavior, using diuretics and laxatives, which resulted in a weight drop of 20 kg. These medications were discontinued as she wanted to become pregnant. Shortly thereafter, following a minor stress, she started forcing herself to vomit preferably savory meals that she particularly craved. In contrast to the polydipsia, this self-induced vomiting seemed to be related to periods of greater stress and fluctuated around four times a week. Psychiatric assessment was unremarkable. In particular, no depressive, psychotic, or other obsessive-compulsive elements were detected. Diabetes insipidus was excluded. She was admitted to our Addictive Disorders Unit to achieve a better control of the compulsive water drinking. She then drank half a liter of water per hour at daytime, as well as 20 cL of milk in the morning, 25 cL of a soft drink at lunch time, 2 cups of tea in the afternoon, and 33 cL of apple juice in the evening, totaling a fluid intake of up to 12 L per day. During the day, she urinated every hour and a half. At night, she woke up every 2 h to urinate and drink half a liter of water at a time. She stayed 3 weeks, during which the water intake was progressively reduced from 10.5 to 3 L per day, provided in sealed bottles. Sleep problems improved with the reduction of water intake. Binge eating and vomiting were fluctuating, and increased by the end of the hospitalization up to one episode of vomiting per day. One week after discharge, she had resumed her earlier water consumption. We then prescribed fluoxetine, which was progressively increased from 20 mg per day during a week to 40 mg for the next 2 weeks, and finally to 60 mg. Fluoxetine seemed to have a very rapid effect on the binge eating and the vomiting, suppressing both completely with as little as 20 mg per 0006-3223/98/$19.00 PII S0006-3223(97)00244-8
Case Report
day, but with no effect at all on water consumption. After 1 month, while she was on 60 mg per day, the patient decided to stop the medication because of a renewed desire of pregnancy, and the poor effect on compulsive water drinking. Shortly after discontinuation, both binge eating and vomiting recurred as earlier.
Discussion The coexistence of compulsive water drinking and bulimia nervosa is rarely observed (Barlow and De Wardener 1959; Bremner and Regan 1991); however, these two disorders could be related in the sense that they are both characterized by loss of control on either food or water intake. Compulsive water drinking has been found in association with several conditions, mainly schizophrenia and mental retardation, with a higher prevalence than usually expected (Bremner and Regan 1991). Compulsive drinking has also been reported in association with affective disorders, neurotic disorders, and alcoholism (Zubenko et al 1984). On the other hand, bulimia nervosa has mostly been associated with mood disorders% some authors even postulating that bulimic behavior may have a moodregulating function (Wallin and Rissaner 1994). On the basis of this hypothesis, antidepres:dve medications including fluoxetine have been tested in bulimia nervosa, usually with good results (Fluoxetine Bulimia Nervosa Collaborative Study Group 1993). The tentative assignment, on a clinical basis, of bulimia nervosa to the obsessive-compulsive disorders group has been proposed (Thiel et al 1995) and strengthened by the observation that both these disorders tended to respond well to selective serotonin reuptake, inhibitors. Various dosages of fluoxetine have been used in bulimia nervosa, with a positive effect using only 20 nag per day; however, 60 mg per day seems to be the optimal dosage for producing an important effect on both the frequency of vomiting and of binge eating (Fluoxel:ine Bulimia Nervosa Collaborative Study Group 1993). The maximum effect seems to occur during the first 2 weeks of treatment (Fluoxetine Bulimia Nervosa Collaborative Study Group 1993). In our patient, both vomiting and binge eating disappeared within 1 week of treatment with 20 mg of fluoxetine, per day. We were expecting a possible effect of fluoxetine on polydipsia also, based on a similarity between compulsive water drinking and other obsessive-
BIOL PSYCHIATRY 1998;43:310-311
31 1
compulsive disorders (Goldman and Janecek 1991). Even at a dosage of 60 mg per day during 1 month, no visible effect occurred on the daily amount of water ingested. Although delayed effect on compulsive water drinking cannot be totally excluded, our results are in accordance with similar findings described elsewhere (Goldman and Janecek 1991). In addition to the differential pharmacologic response of the two disorders, the effect of environmental changes was different. First, stress clearly increased bulimia, whereas it did not alter spontaneous polydipsia. Second, when water supply and consequently intake was reduced, thereby achieving a reduction in polydipsia, bulimia also tended to increase; the latter occurred most possibly either because of stress induced by the water intake reduction program or the prospect of nearing discharge. This report suggests that bulimia nervosa and compulsive water drinking may constitute two different conditions possibly resting on distinct pathophysiological processes, as suggested by the different responses of the two disorders to fluoxetine and environmental factors. Further clinical and experimental research is needed to confirm this discrepancy and perhaps offer some insight into the underlying mechanisms.
References Barlow ED, De Wardener HE (1959): Compulsive water drinking. Q J Med 110:235-238. Bremner AJ, Regan A (1991): Intoxicated by water. Polydipsia and water intoxication in a mental handicap hospital. Br J Psychiatry, 158:244-250. Fluoxetine Bulimia Nervosa Collaborative Study Group (1993): Fluoxetine in the treatment of bulimia nervosa. Arch Gen Psychiatry 49:139-147. Goldman MB, Janecek H (1991): Is compulsive drinking a compulsive behavior? A pilot study. Biol Psychiatry 29:503505. Jenike MA (1990): Trichotillomania. N Engl J Med 322:472. Thiel A, Broocks A, Ohlmeier M, et al (1995): Obsessivecompulsive disorder among patients with anorexia nervosa and bulimia nervosa. Am J Psychiatry 152:72-75. Wallin MS, Rissanen AM (1994): Food and mood: Relationship between food, serotonin and affective disorders. Acta Psychiatr Scand Suppl 377:36-40. Zubenko GS, Altesman RI, Cassidy JW, et al (1984): Disturbances of thirst and water homeostasis in patients with affective illness. Am J Psychiatry 141:436-437.
Divergent Responses to Fluoxetine from Two Compulsive, Food-Related Conditions: Bulimia Nervosa and Compulsive Water Drinking Charles Kornreich, Bernard Dan, Paul Verbanck, Eric Fontaine, and Isidore Pelc Background: The association of compulsive water drinking with bulimia nervosa is rarely encountered. Nevertheless similar behavior patterns could involve a common pathophysiological mechanism. Methods: A case report with the association of those two disorders is described. Treatment with fluoxetine was introduced to alleviate the compulsive aspects of those disorders.
ResuLts: Fluoxetine had a positive effect on bulimia nervosa but none on compulsive water drinking. Conclusions: The different response to pharmacologic treatment could mean that bulimia nervosa and compulsive water drinking are based on different physiological mechanisms. Biol Psychiatry 1998;43:5110-311 © 1998 Society of Biological Psychiatry Key Words: Bulimia nervosa, compulsive water drinking, fluoxetine
Introduction eports of bulimia nervosa associated with compulsive water drinking are scarce (Barlow and De Wardener 1959; Bremner and Regan 1991). The clinical resemblance in behavior between these two disorders may reflect a common basic pathophysiology (Jenike 1990). We report the case of a young woman in which the association of the two conditions was present, and disc ass the possible implications resulting from response to lreatment.
R
Case Report A 22-year-old woman was referred to our clinic for a compulsive water drinking problem. She had no previous psychiatric history. Her father was overweight, and went occasionally on a diet, alone or with other members of the family. Chih:lhood and adolescence were uneventful.
From the Department of Psychiatry, Brugmann University Hospital, Universit6 Libre de Bruxelles, Brussels, Belgium. Address reprint requests to Dr. Charles Kornreich, Department of Psychiatry, Brugmann University Hospital, Universit6 Libre de Bruxelles, PI A. Van Gehuchten. 4- t020 Brussels, Belgium. Received July 2'4, 1996; revised January 27, 1997; accepled April 21, 1997.
© t998 Society of Biological Psychiatry
Shortly after her marriage 4 years before referral, she went on a diet to please her husband. Having heard that drinking large amounts of water could help her lose weight, she started to drink more and more, finally reaching an average consumption of 8-12 L of water per day. No weight loss occurred. On the contrary, newly developed binge eating increased her weight from 75 kg to 100 kg. Moreover, she complained of disrupted sleep because of secondary polyuria. Excessive eating and drinking was mostly hidden from her family. Distressed by the weight gain, she began to engage into compensatory behavior, using diuretics and laxatives, which resulted in a weight drop of 20 kg. These medications were discontinued as she wanted to become pregnant. Shortly thereafter, following a minor stress, she started forcing herself to vomit preferably savory meals that she particularly craved. In contrast to the polydipsia, this self-induced vomiting seemed to be related to periods of greater stress and fluctuated around four times a week. Psychiatric assessment was unremarkable. In particular, no depressive, psychotic, or other obsessive-compulsive elements were detected. Diabetes insipidus was excluded. She was admitted to our Addictive Disorders Unit to achieve a better control of the compulsive water drinking. She then drank half a liter of water per hour at daytime, as well as 20 cL of milk in the morning, 25 cL of a soft drink at lunch time, 2 cups of tea in the afternoon, and 33 cL of apple juice in the evening, totaling a fluid intake of up to 12 L per day. During the day, she urinated every hour and a half. At night, she woke up every 2 h to urinate and drink half a liter of water at a time. She stayed 3 weeks, during which the water intake was progressively reduced from 10.5 to 3 L per day, provided in sealed bottles. Sleep problems improved with the reduction of water intake. Binge eating and vomiting were fluctuating, and increased by the end of the hospitalization up to one episode of vomiting per day. One week after discharge, she had resumed her earlier water consumption. We then prescribed fluoxetine, which was progressively increased from 20 mg per day during a week to 40 mg for the next 2 weeks, and finally to 60 mg. Fluoxetine seemed to have a very rapid effect on the binge eating and the vomiting, suppressing both completely with as little as 20 mg per 0006-3223/98/$19.00 PII S0006-3223(97)00244-8
Case Report
day, but with no effect at all on water consumption. After 1 month, while she was on 60 mg per day, the patient decided to stop the medication because of a renewed desire of pregnancy, and the poor effect on compulsive water drinking. Shortly after discontinuation, both binge eating and vomiting recurred as earlier.
Discussion The coexistence of compulsive water drinking and bulimia nervosa is rarely observed (Barlow and De Wardener 1959; Bremner and Regan 1991); however, these two disorders could be related in the sense that they are both characterized by loss of control on either food or water intake. Compulsive water drinking has been found in association with several conditions, mainly schizophrenia and mental retardation, with a higher prevalence than usually expected (Bremner and Regan 1991). Compulsive drinking has also been reported in association with affective disorders, neurotic disorders, and alcoholism (Zubenko et al 1984). On the other hand, bulimia nervosa has mostly been associated with mood disorders% some authors even postulating that bulimic behavior may have a moodregulating function (Wallin and Rissaner 1994). On the basis of this hypothesis, antidepres:dve medications including fluoxetine have been tested in bulimia nervosa, usually with good results (Fluoxetine Bulimia Nervosa Collaborative Study Group 1993). The tentative assignment, on a clinical basis, of bulimia nervosa to the obsessive-compulsive disorders group has been proposed (Thiel et al 1995) and strengthened by the observation that both these disorders tended to respond well to selective serotonin reuptake, inhibitors. Various dosages of fluoxetine have been used in bulimia nervosa, with a positive effect using only 20 nag per day; however, 60 mg per day seems to be the optimal dosage for producing an important effect on both the frequency of vomiting and of binge eating (Fluoxel:ine Bulimia Nervosa Collaborative Study Group 1993). The maximum effect seems to occur during the first 2 weeks of treatment (Fluoxetine Bulimia Nervosa Collaborative Study Group 1993). In our patient, both vomiting and binge eating disappeared within 1 week of treatment with 20 mg of fluoxetine, per day. We were expecting a possible effect of fluoxetine on polydipsia also, based on a similarity between compulsive water drinking and other obsessive-
BIOL PSYCHIATRY 1998;43:310-311
31 1
compulsive disorders (Goldman and Janecek 1991). Even at a dosage of 60 mg per day during 1 month, no visible effect occurred on the daily amount of water ingested. Although delayed effect on compulsive water drinking cannot be totally excluded, our results are in accordance with similar findings described elsewhere (Goldman and Janecek 1991). In addition to the differential pharmacologic response of the two disorders, the effect of environmental changes was different. First, stress clearly increased bulimia, whereas it did not alter spontaneous polydipsia. Second, when water supply and consequently intake was reduced, thereby achieving a reduction in polydipsia, bulimia also tended to increase; the latter occurred most possibly either because of stress induced by the water intake reduction program or the prospect of nearing discharge. This report suggests that bulimia nervosa and compulsive water drinking may constitute two different conditions possibly resting on distinct pathophysiological processes, as suggested by the different responses of the two disorders to fluoxetine and environmental factors. Further clinical and experimental research is needed to confirm this discrepancy and perhaps offer some insight into the underlying mechanisms.
References Barlow ED, De Wardener HE (1959): Compulsive water drinking. Q J Med 110:235-238. Bremner AJ, Regan A (1991): Intoxicated by water. Polydipsia and water intoxication in a mental handicap hospital. Br J Psychiatry, 158:244-250. Fluoxetine Bulimia Nervosa Collaborative Study Group (1993): Fluoxetine in the treatment of bulimia nervosa. Arch Gen Psychiatry 49:139-147. Goldman MB, Janecek H (1991): Is compulsive drinking a compulsive behavior? A pilot study. Biol Psychiatry 29:503505. Jenike MA (1990): Trichotillomania. N Engl J Med 322:472. Thiel A, Broocks A, Ohlmeier M, et al (1995): Obsessivecompulsive disorder among patients with anorexia nervosa and bulimia nervosa. Am J Psychiatry 152:72-75. Wallin MS, Rissanen AM (1994): Food and mood: Relationship between food, serotonin and affective disorders. Acta Psychiatr Scand Suppl 377:36-40. Zubenko GS, Altesman RI, Cassidy JW, et al (1984): Disturbances of thirst and water homeostasis in patients with affective illness. Am J Psychiatry 141:436-437.