Do eating disorders co‐occur with personality disorders? Comparison groups matter

OBJECTIVE: To assess and compare lifetime rates of occurrence of eating disorders (ED) with four Axis II personality disorders (PD) and with major depressive disorder (MDD) without PD. The eating disorders met criteria outlined in the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). METHOD: Six hundred sixty-eight patients recruited for the Collaborative Longitudinal Personality Disorders Study (CLPS) were reliably assessed with the Structured Clinical Interview for DSM-IV Axis I Disorders and the Diagnostic Interview for DSM-IV Personality Disorders. The distribution of ED diagnoses was compared among four PD study groups (schizotypal, borderline, avoidant, obsessive-compulsive) and a fifth study group with MDD without any PD. RESULTS: The distribution of lifetime diagnoses of anorexia nervosa (N = 40), bulimia nervosa (N = 56), and eating disorder not otherwise specified (N = 118) did not differ significantly across the five study groups, between the MDD group versus all PD groups, and among the four PD study groups. CONCLUSIONS: ED diagnoses did not differentially co-occur significantly across common Axis I and II disorders. The pattern of ED lifetime co-occurrence rates demonstrates the powerful influence of base rates and highlights that declarations of comorbidity demand significant variations from base-rate patterns.     

Alcohol and drug-related negative consequences in college students with bulimia nervosa and binge eating disorder

OBJECTIVE: The purpose of this study was to investigate the association between disordered eating and substance use in a nonclinical sample of college students. METHOD: Participants completed the Eating Disorder Diagnostic Scale (EDDS), which includes full diagnostic criteria for bulimia nervosa (BN), binge eating disorder (BED), and anorexia nervosa (AN) as outlined in the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders, as well as assessments of both alcohol and drug use and use-related consequences. RESULTS: Individuals meeting criteria for BN reported more alcohol-related negative consequences despite the fact that they did not drink significantly more alcohol and did not drink more frequently than non-eating-disordered individuals. Similarly, individuals with BN reported more negative consequences related to illicit drug use than non-eating-disordered individuals, although no differences in lifetime and recent use of drugs were found. DISCUSSION: Results highlight the importance of distinguishing between use and consequences in evaluating eating disorders and comorbid substance use problems.     

Comorbidity of body dysmorphic disorder and eating disorders: severity of psychopathology and body image disturbance

OBJECTIVE: The current study examined comorbidity and clinical correlates of eating disorders in a large sample of individuals with body dysmorphic disorder (BDD). METHOD: Two hundred individuals with DSM-IV (4th ed. of the Diagnostic and Statistical Manual of Mental Disorders. Washington, DC: American Psychiatric Association; 1994) BDD completed reliable interviewer-administered and self-report measures, including diagnostic assessments and measures of body image, symptom severity, delusionality, psychosocial functioning, quality of life (QOL), and history of psychiatric treatment. RESULTS: A total of 32.5% of BDD subjects had a comorbid lifetime eating disorder: 9.0% had anorexia nervosa, 6.5% had bulimia nervosa, and 17.5% had an eating disorder not otherwise specified. Comparisons of subjects with a comorbid lifetime eating disorder (n = 65) and subjects without an eating disorder (n = 135) indicated that the comorbid group was more likely to be female, less likely to be African American, had more comorbidity, and had significantly greater body image disturbance and dissatisfaction. There were no significant group differences in BDD symptom severity, degree of delusionality, or suicidal ideation or attempts. Functioning and QOL were notably poor in both groups, with no significant between-group differences. However, a higher proportion of the comorbid eating disorder group had been hospitalized for psychiatric problems. This group had also received a greater number of psychotherapy sessions and psychotropic medications. CONCLUSION: Eating disorders appear relatively common in individuals with BDD. BDD subjects with a comorbid eating disorder differed on several demographic variables, had greater comorbidity and body image disturbance, and had received more mental health treatment than subjects without a comorbid eating disorder. These findings have important implications for the assessment and treatment of these comorbid body image disorders.     

Characteristics of monozygotic twins discordant for bulimia nervosa

OBJECTIVE: We studied monozygotic (MZ) twins who were discordant for bulimia nervosa in order to identify environmental factors that could have contributed to the expression of bulimia nervosa in only one member of these genetically identical twin pairs. METHOD: Female twin pairs from the Virginia Twin Registry were identified. One twin met DSM-III-R criteria for bulimia nervosa (excluding the frequency and duration criterion) and the co-twin either reported some symptoms of bulimia nervosa but never met full diagnostic criteria (n = 20 pairs) or reported no symptoms of bulimia nervosa (n = 10). We compared the twins on demographic, developmental, personality, and psychiatric dimensions using self- and maternal report. RESULTS: Affected twins were more likely to report lifetime generalized anxiety disorder and were described by their mothers as more anxious and fearful as children. They also had significantly lower mastery, optimism, and self-esteem, and significantly greater obsessive and compulsive symptoms than their unaffected co-twins. Affected twins recalled greater discord in their families but viewed their parents as more warm toward them than toward their unaffected co-twin. DISCUSSION: Given that MZ twins are genetically identical and share a common family background, differences between them must be attributable to unique environmental factors. Although it is difficult to disentangle predisposing risk factors from sequelae of psychiatric illness in a retrospective co-twin control design, the affected twins were perceived to have been more anxious as children by their mothers-possibly reflecting a predisposing trait. More extensive interviews are required to determine the nature of environmental events that contribute to the expression of the observed personality, behavioral, anxious, and eating-related traits in the affected twins.     

Recognition and therapy of eating disorders in young women in primary care

Objective To evaluate the prevalence of eating disorders (ED) in a general population sample of young German women, compare those to primary care diagnoses, and investigate their medical treatments.Methods In a prospective epidemiological study, a representative sample of young women (n=1555, between 18 and 25 years of age) was questioned twice during a structured psychological interview (F-DIPS) for mental disorders according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). At the same time, personal health insurance data were recorded and primary care physicians diagnoses and payments for services rendered were analyzed.Results The lifetime prevalence of eating disorders was 3.3% (2.3% anorexia nervosa, 1.1% bulimia nervosa). The primary care physicians diagnosed eating disorders in only about 20% of the women concerned. Eating disorders were often overlooked, although physicians detected physical and mental complaints (e.g., menstrual cycle disorders, abnormal weight loss, flatulence, depression, anxiety disorders), which are closely related to eating disorders. If the primary care physicians had diagnosed eating disorders, they mostly recommended psychotherapeutic treatment as the only measure, or in combination with pharmacological therapy.Conclusion The study indicates that primary care physicians need better training, particularly in diagnostic procedures for eating disorders. Screening methods and systematic assessment might be helpful in improving the detection of eating disorders in primary care     

Anxiety and psychoactive substance use disorder comorbidity in anorexia nervosa or depression

OBJECTIVE: This study considered whether the prevalence and type of anxiety and psychoactive substance use disorder (PSUD) diagnoses differ between women with spectrum anorexia nervosa (AN) (N=40) and women with major depressive disorder (N = 58) participating in outpatient clinical trials. METHOD: Anxiety and PSUD diagnoses (according to criteria in the 3rd Rev. ed. of the Diagnostic and Statistical Manual of Mental Disorders) were assessed using structured clinical interviews. Comparisons were made between AN subtypes (restricting or binge eating/purging) and by history of depression within the AN sample. RESULTS: A high prevalence of obsessive-compulsive disorder (OCD) was found in women with AN. However, social phobia, simple phobia, and PSUD were significantly elevated in both women with depression and women with AN. Prevalences were similar for anxiety and PSUD diagnoses between AN subtypes. DISCUSSION: Women with anorexia or depression were comparable in all respects, except for the elevated OCD prevalence in AN, emphasizing the need to use clinical comparison groups to avoid inadvertently attributing elevated prevalences of comorbid conditions to specific disorders.     

Are there subgroups of bulimia nervosa based on comorbid psychiatric disorders?

OBJECTIVE: The current study sought to determine whether there are subtypes of bulimia nervosa (BN) differentiated by comorbid psychiatric disorders. METHOD: Data on comorbid psychiatric diagnoses in female relatives of probands and controls in the Collaborative Study of the Genetics of Alcoholism (COGA) who met criteria for BN (as outlined in the 3rd Rev. ed. of the Diagnostic and Statistical Manual of Mental Disorders) were analyzed using latent class analysis. Resulting latent classes were compared on a variety of variables related to impulsive behaviors and psychological functioning. RESULTS: The best-fitting solution, a two-class model, yielded one class (72%) characterized by substance dependence, depression, antisocial personality disorder (ASPD), and anxiety disorders, and another characterized by depression. The highly comorbid class had more suicidality, more daily smokers, sought help for emotional problems, and had lower Global Assessment of Functioning (GAF) scores compared with those in the comorbid depression only class. DISCUSSION: Latent class findings suggest the existence of two classes of BN differentiated by substance dependence, impulsive behaviors, and poorer psychological functioning.     

辽宁省居民情感、焦虑和酒精使用障碍共病影响因素分析

目的分析辽宁省居民情感障碍、焦虑障碍及酒精使用障碍的共病率及主要危险因素。方法辽宁省居民精神疾病调查以DSM-Ⅲ-R为诊断标准,共诊断1 214例精神障碍患者,以单纯情感障碍、单纯焦虑障碍和单纯酒精使用障碍患者为对照,采用Logistic回归模型分析情感与焦虑共病、焦虑与情感共病、酒精与情感或焦虑共病的各主要危险因素的OR值及95%CI。结果情感与焦虑障碍是最常见的共病,离异者情感共病焦虑、焦虑共病情感、酒精共病情感或焦虑的危险度增加3～5倍,女性酒精使用障碍共病情感或焦虑障碍的危险性明显高于男性(OR=5.28,95%CI=1.84～15.15),农村居民焦虑共病情感障碍的危险性明显低于城市居民(OR=0.57,95%CI=0.36～0.92)。结论辽宁省居民精神障碍患者中情感障碍、焦虑障碍和酒精使用障碍共病普遍存在,精神疾病共病的预防、诊断和治疗水平亟待提高。     

Risk of psychiatric disorders among individuals reporting same-sex sexual partners in the National Comorbidity Survey

OBJECTIVES: This study examined the risk of psychiatric disorders among individuals with same-sex sexual partners. METHODS: Data are from the National Comorbidity Survey, a nationally representative household survey. Respondents were asked the number of women and men with whom they had sexual intercourse in the past 5 years. Psychiatric disorders according to Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition (DSM-III-R) criteria were assessed with a modified version of the Composite International Diagnostic Interview. RESULTS: A total of 2.1% of men and 1.5% of women reported 1 or more same-sex sexual partners in the past 5 years. These respondents had higher 12-month prevalences of anxiety, mood, and substance use disorders and of suicidal thoughts and plans than did respondents with opposite-sex partners only. Decomposition showed that the elevated same-sex 12-month prevalences were largely due to higher lifetime prevalences. Ages at onset and persistence of disorders did not differ between the same-sex and opposite-sex subsamples. CONCLUSIONS: Homosexual orientation, defined as having same-sex sexual partners, is associated with a general elevation of risk for anxiety, mood, and substance use disorders and for suicidal thoughts and plans. Further research is needed to replicate and explore the causal mechanisms underlying this association.     

Epidemiology and risk factors of eating disorders: a two-stage epidemiologic study in a Spanish population aged 12-18 years

OBJECTIVE: The authors studied the prevalence rates of eating disorders (ED) and their risk factors in a Spanish population aged 12-18 years. METHOD: A two-stage epidemiologic study was conducted in the province of Valencia. Educational centers, classrooms, and individuals were selected randomly. The initial sample comprised 544 subjects. During Stage 1, subjects were screened with the 40-item Eating Attitude Test and a sociodemographic questionnaire that evaluates risk factors. During Stage 2, a semistandardized clinical interview was conducted with each participant. A random control group was paired by class, age, and sex. Comorbid psychiatric disorders and partial and subclinical forms were detected using criteria in the 4th ed. of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). RESULTS: Using DSM-IV criteria, the morbidity rate was 2.91%, women comprised 5.17% of the sample, men comprised 0.77% of the sample, and the sex ratio was 6.71. Using DSM-IV criteria, including subclinical forms, the morbidity rate was 5.56%, women comprised 10.3% of the sample, men comprised 1.07% of the sample, and the sex ratio was 9.63. Six risk factors were isolated: psychiatric comorbidity, friend on a diet in the last year, desire to lose weight, desire to be less corpulent, sentimental problems, and diet in the last year. DISCUSSION: This is the first Spanish two-stage epidemiologic study to include a control group and to investigate risk factors.     

Comorbidity between eating disorders and anxiety disorders: a review

OBJECTIVE: We conducted a critical literature review on studies assessing the prevalence of anxiety disorders (AD) in subjects with eating disorders (ED) (anorexia nervosa and bulimia nervosa). In the first part, we discuss methodological issues relevant to comorbidity studies between ED and AD. In the second part, taking into account these methodological considerations raised, we summarize the findings of these studies. METHOD: We performed a manual and computerized search (Medline) for all published studies on comorbidity between ED and AD, limiting our search from 1985-2001 to get sufficiently homogeneous diagnostic criteria for both categories of disorders. RESULTS: Too few studies include control groups and few studies have compared diagnostic subgroups of ED subjects, with scarce or conflicting results. DISCUSSION: We discuss the results taking into account the methodological problems observed. We give guidelines for reviewing the results of published studies and planing future research.     

Night eating syndrome in young adult women: prevalence and correlates

OBJECTIVE: The current study examined the prevalence and clinical significance of night eating syndrome (NES) in a community cohort of Black and White women. METHOD: We assessed 682 Black and 659 White women for NES, eating disorders, and psychiatric symptomatology. RESULTS: The prevalence was 1.6% (22 of 1,341; Blacks [n = 20]; Whites [n = 2]). Comparisons between identified Black women and the remaining Black participants revealed no significant differences in obesity, psychiatric comorbidity, or self-reported psychiatric distress. Comorbidity with eating disorders as outlined in the 4th ed. of the Diagnostic and Statistical Manual of Mental Disorders (Washington, DC: American Psychiatric Association) was low (n = 1 [4.5%]). Black NES women were significantly less likely than Black non-NES women to be overweight and significantly more likely to have two or more children. DISCUSSION: NES was rare in this sample of young women. Low comorbidity of NES with other eating disorders suggests that NES may be distinct from the DSM-IV recognized eating disorders. Longitudinal data are needed to determine the long-term health implications of this behavioral pattern.     

Characteristics of monozygotic male and female twins discordant for overweight: a descriptive study

OBJECTIVES: BMI is highly heritable. Yet, trends in obesity highlight environmental influences on body weight. Monozygotic (MZ) twins discordant for overweight offer a unique opportunity to examine these factors. METHODS: MZ male (n=8 pairs) and female twins (n=10 pairs) discordant for overweight (defined as the BMI of one twin being at least 24.5, and the BMI of his/her co-twin being below 24.5 and at least three points lower) were identified from the Mid-Atlantic Twin Registry. Variables were assessed via self-report questionnaires. RESULTS: One overweight and two non-overweight females met criteria for bulimia nervosa. Rates of dieting and binge eating were high among all males and females. Hunger scores were higher among non-overweight females; disinhibition scores were higher among overweight males. Only one non-overweight and three overweight males smoked; 90% of non-overweight and 40% of overweight females smoked. CONCLUSIONS: Assessing tobacco use and eating disorders may be important when sampling on the basis of family members who are discordant for BMI. Finally, results suggest possibilities for interventions in individuals at-risk for overweight.     

Disordered (pathologic or problem) gambling and axis I psychiatric disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions

The authors' objective in this study was to examine the role of disordered gambling as a risk factor for the subsequent occurrence of specific Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Axis I psychiatric disorders after adjusting for medical conditions, health-related quality of life, and stressful life events. Community-dwelling respondents from nationally representative US samples (n = 33,231) were interviewed in 2000-2001 and 2004-2005. Past-year disordered gambling at baseline was associated with the subsequent occurrence of any Axis I psychiatric disorder, any mood disorder, bipolar disorder, generalized anxiety disorder, posttraumatic stress disorder, any substance use disorder, alcohol use disorders, and alcohol dependence disorder after adjustment for sociodemographic variables. After simultaneous adjustment for medical conditions, health-related quality of life, and recent stressful life events, disordered gambling remained significantly related to any mood disorder, generalized anxiety disorder, posttraumatic stress disorder, alcohol use disorders, and alcohol dependence. The clinical implications of these findings are that treatment providers need to screen gambling patients for mood, anxiety, and substance use problems and monitor the possible development of later comorbid conditions.     

Revised Diagnostic Subgroupings for Anorexia Nervosa

For purposes of classification, diagnosis, and treatment, future revisions of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) will subdivide anorexia nervosa into two subgroups: binge eating and severe food restriction. More appropriate treatment modalities may now be developed, based on the differences in personality characteristics and behaviors of each subgroup.     

Comorbidity between social phobia and premature ejaculation: study on 242 males affected by sexual disorders

Several studies have reported high comorbidity between psychiatric and sexual disorders, particularly between anxiety and mood disorders and sexual dysfunction. The goal of the present study is to examine the comorbidity between premature ejaculation and Axis I psychiatric disorders. Of 242 males referred to an outpatient clinic of sexology between November 2000 and July 2003, 52 were diagnosed with premature ejaculation (PE). These patients were also administered the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID; First, Spitzer, Gibbon, & Williams, 1995) for the evaluation of Axis I psychiatric disorders and a modified SCID based on Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 2000) criteria for the evaluation of sexual disorders. We also determined the age of onset of the disorders. We found that 21.5% of the overall clinical population was affected by PE, and 64.4% of PE patients were affected by at least one Axis I psychiatric disorder. PE was highly associated (p=0.015) with social phobia (SP), with an odds ratio of 2.55. The debut of SP preceded the onset of PE. Social phobia may represent risk factor for the development of PE, and adrenergic hyperactivity may represent a pathophysiology common to both disorders.     

Topiramate in the treatment of severe bulimia nervosa with comorbid mood disorders: a case series

OBJECTIVE: To report observations on the efficacy and tolerability of topiramate in a sample of five patients with severe symptoms of bulimia nervosa and comorbid mood and/or anxiety disorders. METHOD: Topiramate was added to other psychotropic medication under open-label conditions up to the maximum tolerated dose or until remission of the eating disorder was achieved. RESULTS: Topiramate almost completely eliminated binging and purging behavior in three of the five patients. Improvement was maintained throughout the period of follow-up for up to 18 months. One patient showed a partial, temporary response, and the fifth was intolerant of the drug and unable to complete an adequate trial. DISCUSSION: These results suggest strongly that the efficacy of topiramate in patients with bulimia nervosa with and without comorbid mood and anxiety disorders should be investigated more fully.     

Comorbidity of obsessive-compulsive disorders and duration of eating disorders

OBJECTIVE: This study explored the comorbidity of obsessive-compulsive disorder (OCD) and eating disorders (ED) and examined the relationship between OCD comorbidity and the duration of ED. Subjects with OCD were expected to show a longer history of ED. METHOD: ED females (N = 237; 84 with anorexia nervosa and 153 with bulimia nervosa) were assessed using the Structured Clinical Interview for DSM-IV Axis I disorders (SCID-1). Data were analyzed by logistic regression to determine whether OCD comorbidity is associated with duration of ED. RESULTS: The total sample showed a prevalence rate for OCD of 29.5%. OCD prevalence did not differ between anorexic and bulimic subjects. OCD comorbidity was significantly associated with a longer history of ED. CONCLUSION: The findings of the study support previous research indicating a high comorbidity of ED with OCD. The results also suggest that OCD may play a role in the course of ED. Prospective studies are necessary to examine this hypothesis further.