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Anxiety is common in people living with eating disorders. Anti-anxiety medications aren't the complete answer for this additional challenge of these conditions, but they can be very helpful. Here are three things you need to know about these medications.

Anxiety in various guises almost always accompanies eating disorders. Sometimes it manifests itself as a social anxiety disorder. It may appear as a phobia or set of phobias that interfere with day to day living. Or anxiety may be free-floating, as generalized anxiety disorder. Medication is never the whole answer for treating anxiety for people who live with eating disorders, but it is often helpful.

Here are three things you need to know.

Doctors have guidelines for treating anxiety with medication

Anxiety is considered serious enough to merit treatment when:

1. There has been excessive worry about any issue more days than not for six months or longer.

2. The individual makes an effort to control worry, but can't.

3. This excessive worry has been associated with three or more of the following:

  • Mind going blank, or attention deficits
  • Muscle tension.
  • Feeling keyed up or on edge or restless.
  • Getting a fatigued feeling after little or no exertion or effort.
  • Difficulty falling asleep or staying asleep, or sleeping all the time.
  • Irritability.

In children, just one of these symptoms is sufficient for a diagnosis of anxiety.

4. The worry, anxiety, and/or physical symptoms interfere with social interaction, work, school, or other activities of daily living.

5. This disturbance isn't due to a medication or drug abuse.

6. The disturbance isn't better explained by a different diagnosis. For instance, if someone were anxious primarily about having panic attacks, a more appropriate diagnosis might be panic disorder. If the anxiety was repeatedly set off by reminders of past events, the more appropriate diagnosis might be post-traumatic stress disorder.

Most people recognize anxiety in themselves or people close to them by predictable symptoms. Maybe the problem is sleep. Or someone breaks out in cold sweats or farts a lot. They may have clammy hands or heart palpitations or queasy stomach. We all know anxiety when we see it. But it's not a condition that needs to be medically treated unless it happens basically all the time. In most eating disorders, anxiety happens basically all the time.

Tranquilizers aren't really the first line of treatment for anxiety in eating disorders.

Sometimes medications are prescribed to deal with the problem directly. This older approach to treatment is a group of drugs commonly called tranquilizers. The most commonly prescribed tranquilizers are benzodiazepines, which include:

  • Alprazolam (Xanax)
  • Clonazepam (Klonipin)
  • Diazepam (Valium)
  • Lorazepam (Ativan)

Benzodiazepine tranquilizers work by slowing down the central nervous system. The problem is that sometimes they slow down the central nervous system too much. They can cause daytime drowsiness. It may not be safe to drive when you are on benzodiazepine tranquilizers. The combination of a tranquilizer and alcohol can provide a knock-out or worse. Benzodiazepine overdose is a common method in attempted suicide.

But there is one form of eating disorder for which tranquilizers provide primary relief: sleep-related eating disorder. The primary symptom in sleep-related eating disorder is overeating after waking up from sound sleep. It's a kind of sleep eating that is a lot like sleep walking. Weight gain results from eating large amounts of high-calorie foods, but that's not the only potential problem. Sometimes sleep eaters consume toxic substances. 

In other eating disorders, benzodiazepine tranquilizers may be helpful. They interrupt a circuit in the brain from the hypothalamus to the forebrain that triggers eating when there is a sense of risk. They keep the brain from sending out signals to deal with insecurity by eating food.

Antidepressants are better at treating anxiety in eating disorders than tranquilizers, although doctors don't know why

The traditional treatments for anxiety aren't the first line of treatment for anxiety in eating disorders any more. Nowadays, a person living with an eating disorder and anxiety will be offered an antidepressant first.

Why would an antidepressant relieve anxiety?

At this time, researchers don't know the answer to that question. There is a reliable scientific understanding of how tranquilizers treat anxiety, but researchers don't really know how or why selective serotonin reuptake inhibitor (SSRI) antidepressants relieve anxiety. These are medications like fluoxetine (Prozac), fluvoxamine (Luvox), and citalopram (Celexa). They just know that SSRI antidepressants work in many but not all cases of anxiety in people who live with eating disorders.

But there are also some limitations to these medications:

  • SSRIs don't usually help people who have anorexia nervosa while they are suffering severe weight loss. Calorie- and nutrient-deprivation affect the production of neurochemicals in the brain. A reuptake inhibitor can't conserve a brain chemical that the brain doesn't have the raw materials to produce. But by the time someone who has anorexia nervosa has regained to 85 percent of normal weight, SSRIs help keep recovery on track.
  • SSRIs tend to be more helpful for people living with bulimia nervosa. They reduce both anxiety and depression, and make binge eating episodes less frequent. In the United States, the Food and Drug Administration has approved Prozac (fluoxetine) for treating anxiety, depression, and the symptoms of bulimia nervosa. 
  • SSRIs are usually helpful for people who have binge eating disorder.They relieve the obsessions and compulsions that underlie anxiety in this condition. A different kind of drug, topiramate (Topamax), also helps control obsessive thoughts and impulsivity that feed anxiety in this eating disorder.
But the bottom line for treating anxiety in eating disorders is that the whole answer is never taking a pill. Psychotherapy and family support are much more helpful in quelling the anxiety that comes with the condition.

  • Cassidy RM, Lu Y, Jere M, Tian JB, Xu Y, Mangieri LR, Felix-Okoroji B, Selever J, Xu Y, Arenkiel BR, Tong Q. A lateral hypothalamus to basal forebrain neurocircuit promotes feeding by suppressing responses to anxiogenic environmental cues.Sci Adv. 2019 Mar. 5(3):eaav1640. doi: 10.1126/sciadv.aav1640. eCollection 2019 Mar. PMID: 30854429.
  • Chiaro G, Caletti MT, Provini F. Treatment of Sleep-Related Eating Disorder Curr Treat Options Neurol. 2015 Aug
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  • Locke AB, Kirst N, Shultz CG. Diagnosis and management of generalized anxiety disorder and panic disorder in adults. Am Fam Physician. 2015 May.91(9):617-24. Review. PMID: 25955736.
  • Photo courtesy of SteadyHealth

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