As psychiatric-mental health nurse practitioners (PMHNPs), we confront a myriad of complex issues surrounding both mental health and addictive behaviors. One area of particular interest is Binge Eating Disorder (BED), characterized by recurrent episodes of eating an excessive amount of food within a relatively short period while experiencing a loss of control overeating behaviors. This blog post aims to delve into the diagnostic criteria, substance use issues, symptoms related to Binge Eating Disorder, and how medications like Lisdexamfetamine can play a crucial role in treatment.
Binge Eating Disorder: DSM-5 Diagnostic Criteria
According to the American Psychiatric Association (2013) in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.), the diagnostic criteria for Binge Eating Disorder include:
· Recurrent binge eating episodes, characterized by: Consuming a substantial amount of food within a specified timeframe, typically within two hours.
· Experiencing a loss of control overeating during these episodes.
Eating an amount of food during these discrete time periods (for example, within any two-hour period) that is significantly larger than what most individuals would eat under similar circumstances.
A profound sense of lack of control overeating during these episodes, often accompanied by feelings of being unable to stop eating or to manage what and how much is being consumed (Berkman et al., 2015).
- Binge eating episodes are associated with three (or more) of the following:
- Eating much more rapidly than normal.
- Eating until feeling uncomfortably full.
- Eating large amounts of food when not physically hungry.
- Eating alone due to feelings of embarrassment over the quantity consumed.
- Feeling disgusted with oneself, depressed, or very guilty afterward.
- Binging eating occurs, on average, at least once a week for three months.
- The binge eating is not associated with the recurrent use of inappropriate compensatory behaviors (e.g., purging) and does not occur exclusively during the course of bulimia nervosa or anorexia nervosa.
Substance Use and Street Names
Although Binge Eating Disorder (BED) is not classified as a substance use disorder, its behavioral and psychological dimensions can occasionally drive individuals to misuse substances, including food, as a means of managing emotional distress. One medication prescribed for BED, Lisdexamfetamine (commonly known as “Vyvanse”), addresses the underlying impulsivity and compulsivity frequently associated with the disorder.
According to Weyandt et al. (2016), the misuse of prescription stimulants has sharply increased among college students without the disorder due to Lisdexamfetamine being classified as a Schedule II controlled substance. Many students buy stimulants to stay awake for studying, which can be harmful and addictive. Furthermore, purchasing stimulants off the street may lead to serious health concerns, as individuals may not be aware of the potential side effects, which can be life-threatening.
Lisdexamfetamine, commonly known by its brand name “Vyvanse,” is a stimulant medication. Misuse can happen when people take larger doses than what is prescribed, leading to unwanted effects and a risk of addiction. Some common street names for the misuse of such stimulants are “speed,” “uppers,” “glass,” and “pep pills.”
Symptoms of Use and Withdrawal
Individuals using Lisdexamfetamine may demonstrate several symptoms, including:
- Increased energy or concentration problems
- Decreased appetite and potential weight loss
- Increased heart rate or blood pressure
- Restlessness or agitation
- Anxiety or irritability
Symptoms of Withdrawal
Withdrawal from Lisdexamfetamine may lead to a range of uncomfortable symptoms, such as:
- extreme fatigue, depression if lisdexamfetamine is abruptly stopped; taper the dosage off slowly under medical advice.
- Dizziness, impair judgment
- Fatigue
- Mood swings
- Shaking, irritability, and sweating
- (Drug.com, 2023).
First-Line Treatment Options
- Psychotherapy: Cognitive-behavioral therapy (CBT) has shown efficacy in treating BED, targeting the cognitive distortions and behaviors associated with eating patterns.
- Medications: Lisdexamfetamine is one of the few FDA-approved medications for treating BED and can effectively reduce binge eating episodes (Schneider et al., 2022).
FDA-Approved Medication
Lisdexamfetamine (Vyvanse): This medication is specifically approved for BED by the FDA (Stahl, 2017).
Mechanism of Action (How it works)
Lisdexamfetamine is a prodrug of dextroamphetamine, meaning it is inactive until it is absorbed by the intestinal tract and converted into its active form, dextroamphetamine, along with l-lysine. Once transformed into dextroamphetamine, it enhances norepinephrine and, in particular, dopamine activity by inhibiting their reuptake and promoting their release. This increase in dopamine and norepinephrine levels in specific brain regions, such as the dorsolateral prefrontal cortex, can lead to improvements in attention, concentration, executive functioning, and wakefulness (Stahl, 2017).
Class: Neuroscience-based Nomenclature
dopamine and norepinephrine reuptake
inhibitor and releaser (DN-RIRe)
• Stimulant (Stahl, 2017).
Schedule II Controlled Substance
How Drug Causes Side Effects
Increases in norepinephrine, especially peripherally, can cause autonomic side effects, including tremor, tachycardia, hypertension, and cardiac arrhythmias
Increases in norepinephrine and dopamine centrally can cause CNS side effects such as insomnia, agitation, psychosis, and substance abuse (Stahl, 2017).
Notable Side Effects
Insomnia, headache, exacerbation of tics,
nervousness, irritability, overstimulation,
tremor, dizziness
Anorexia, nausea, dry mouth,
constipation, diarrhea, weight loss (Stahl, 2017).
These side effects can often be managed by dose adjustments, patient education, and close monitoring.
Life-threatening or dangerous side effects may include psychotic episodes, seizures, palpitations, tachycardia, hypertension, rare activation of hypomania, mania, or suicidal ideation (though controversial), as well as cardiovascular adverse effects that can lead to sudden death in patients with preexisting cardiac structural abnormalities (Stahl, 2017).
Medication Administration
Dose and Use
Binge eating disorder: 50–70 mg/day
Dosage Forms:
Capsule 10 mg, 20 mg, 30 mg, 40 mg,
50 mg, 60 mg, 70 mg
How to Dose:
Binge eating disorder: initial 30 mg/day in
The morning; can increase by 20 mg each
week; maximum dose generally 70 mg/day
How Long Until It Works
Some immediate effects can be seen with first dosing
Can take several weeks to attain maximum therapeutic benefit
Dosing Tips
The medication has a clinical action duration of 10 to 12 hours and is available in capsule form. It can be taken whole or opened and dissolved in water; however, if mixed with water, the entire solution should be consumed immediately, and the contents of a single capsule should not be divided. The once-daily dosing regimen is a significant benefit, as it simplifies stimulant use by eliminating complications related to lunchtime dosing at school, such as storage issues, the risk of diversion, and the need for medical supervision outside the home. It is advisable to avoid dosing after the morning to reduce the risk of insomnia, and the medication can be taken with or without food (Stahl, 2017).
Baseline and Ongoing Assessments
Before initiating treatment with Lisdexamfetamine, baseline assessments should include:
- Comprehensive mental health and substance use evaluation
- Vital signs, particularly heart rate and blood pressure due to stimulant effects, monitor blood pressure regularly (Stahl, 2017).
- Assessment of any potential cardiac conditions that may contraindicate stimulant use
Ongoing assessments may include regular monitoring of blood pressure, heart rate, weight, and any emerging psychiatric symptoms. Establishing a follow-up schedule, typically biweekly initially, can help monitor side effects or complications (Stahl, 2017).
Non-Pharmacologic Interventions
In addition to pharmacotherapy, non-pharmacologic interventions are key in treating BED. These may include:
- Cognitive-Behavioral Therapy (CBT): A structured approach that targets maladaptive thinking patterns, enabling individuals to respond to emotional triggers without resorting to binge eating (Nakao et al., 2021).
- Nutritional Counseling: Working with dietitians can help patients develop healthier eating patterns and understand hunger cues.
- Mindfulness and Stress Management Techniques: Integrating mindfulness practices can enhance emotional regulation and reduce impulsivity.
- Support Groups: Participation in group therapy can foster a sense of community, reduce isolation, and provide an environment for shared experiences and strategies.
- Lifestyle Modifications: Encouraging physical activity and establishing healthy sleep habits can have a positive impact on both physical and mental well-being.
***Helpful information ****
To discontinue use safely, it is essential to taper the medication to avoid withdrawal effects. Stopping abruptly after prolonged therapeutic use can reveal symptoms of the underlying disorder, which may necessitate follow-up and potentially resuming treatment.
Drug to Drug Interactions
Amphetamines can affect blood pressure, so they must be used cautiously alongside medications aimed at controlling it.
Gastrointestinal acidifying agents such as guanethidine, reserpine, glutamic acid, ascorbic acid, and various fruit juices as well as urinary acidifying agents like ammonium chloride and sodium phosphate, may lower amphetamine plasma levels; while these agents can be useful in overdose management, they might also reduce the effectiveness of amphetamines in therapy.
In contrast, gastrointestinal alkalinizing agents, such as sodium bicarbonate, and urinary alkalinizing agents like acetazolamide and certain thiazides, can elevate amphetamine plasma levels and amplify its effects.
Drugs like desipramine and protryptiline can cause marked and sustained increases in brain concentrations of d-amphetamine, possibly intensifying its cardiovascular effects. Theoretically, other agents with norepinephrine reuptake blocking properties such as venlafaxine, duloxetine, atomoxetine, milnacipran, and reboxetine could further enhance amphetamine’s CNS and cardiovascular effects (Stahl, 2017).
Amphetamines may counteract the sedative effects of antihistamines, while medications like haloperidol, chlorpromazine, and lithium may inhibit the stimulatory effects of amphetamines (Stahl, 2017).
Do Not Use
· In patients with extreme anxiety or agitation.
· In patients with motor tics or Tourette’s syndrome
Concurrently with an MAOI, or within 14 days of MAOI use, except in exceptional circumstances and under the supervision of an expert (Stahl, 2017).
Conclusion
As PMHNPs, we emphasize holistic treatment approaches that address both the physiological and psychological factors contributing to Binge Eating Disorder. Lisdexamfetamine is a notable FDA-approved treatment option, but it is essential to combine pharmacological solutions with psychotherapy and lifestyle interventions for a comprehensive approach.
References
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
Berkman, N. D., Brownley, K. A., Peat, C. M., Lohr, K. N., Cullen, K. E., Morgan, L. C., Bann, C. M., Wallace, I. F., & Bulik, C. M. (2015). Table A, DSM-IV and DSM-5 Diagnostic Criteria for Binge Eeating Disorder. Nih.gov; Agency for Healthcare Research and Quality (US). https://www.ncbi.nlm.nih.gov/sites/books/NBK338305/table/fm.t1/
Drug.com (2023). Lisdexamfetamine Retrieved from https://www.drugs.com/
Nakao, M., Shirotsuki, K., & Sugaya, N. (2021). Cognitive-behavioral therapy for management of mental health and stress-related disorders: Recent advances in techniques and technologies. BioPsychoSocial medicine, 15(1), 16. https://doi.org/10.1186/s13030-021-00219-w
Schneider, E., Martin, E., Rotshtein, P., Qureshi, K. L., Chamberlain, S. R., Spetter, M. S., Dourish, C. T., & Higgs, S. (2022). The effects of lisdexamfetamine dimesylate on eating behaviour and homeostatic, reward and cognitive processes in women with binge-eating symptoms: an experimental medicine study. Translational Psychiatry, 12(1), 9. https://doi.org/10.1038/s41398-021-01770-4
Stahl, S. M. (2017). Essential Psychopharmacology: The Prescriber’s Guide (Sixth Edition). Cambridge University Press
Weyandt, L. L., Oster, D. R., Marraccini, M. E., Gudmundsdottir, B. G., Munro, B. A., Rathkey, E. S., & McCallum, A. (2016). Prescription stimulant medication misuse: Where are we and where do we go from here?. Experimental and clinical psychopharmacology, 24(5), 400–414. https://doi.org/10.1037/pha0000093