Alcohol use disorder comorbidity in eating disorders: a multicenter study

BACKGROUND: Eating disorders and alcohol use disorders (AUDs) commonly co-occur, although the patterns of comorbidity differ by eating disorder subtype. Our aim was to explore the nature of the co-morbid relation between AUDs and eating disorders in a large and phenotypically well-characterized group of individuals. METHOD: We compared diagnostic and personality profiles of 97 women with lifetime anorexia nervosa only, 282 women with lifetime bulimia nervosa only, and 293 women with a lifetime history of both anorexia nervosa and bulimia nervosa or anorexia nervosa with binge eating (ANBN) (DSM-IV criteria). All individuals were participants in a multicenter study of the genetics of anorexia nervosa and bulimia nervosa. We explored pattern of onset, Axis I and II comorbidity, and personality characteristics of individuals with and without AUDs by eating disorder subtype. Personality characteristics were assessed with the Multidimensional Perfectionism Scale, the Temperament and Character Inventory, and the Barratt Impulsivity Scale. RESULTS: Alcohol use disorders were significantly more prevalent in women with ANBN and bulimia nervosa than in women with anorexia nervosa (p =.0001). The majority of individuals reported primary onset of the eating disorder, with only one third reporting the onset of the AUD first. After eating disorder subtype was controlled for, AUDs were associated with the presence of major depressive disorder, a range of anxiety disorders, and cluster B personality disorder symptoms. In addition, individuals with AUDs presented with personality profiles marked by impulsivity and perfectionism. CONCLUSIONS: Individuals with eating disorders and AUDs exhibit phenotypic profiles characterized by both anxious, perfectionistic traits and impulsive, dramatic dispositions. These traits mirror the pattern of control and dyscontrol seen in individuals with this comorbid profile and suggest that anxiety modulation may be related to alcohol use in this group.     

Diagnostic crossover in anorexia nervosa and bulimia nervosa: implications for DSM-V

OBJECTIVE: The Diagnostic and Statistical Manual of Mental Disorders (DSM) is designed primarily as a clinical tool. Yet high rates of diagnostic "crossover" among the anorexia nervosa subtypes and bulimia nervosa may reflect problems with the validity of the current diagnostic schema, thereby limiting its clinical utility. This study was designed to examine diagnostic crossover longitudinally in anorexia nervosa and bulimia nervosa to inform the validity of the DSM-IV-TR eating disorders classification system. METHOD: A total of 216 women with a diagnosis of anorexia nervosa or bulimia nervosa were followed for 7 years; weekly eating disorder symptom data collected using the Eating Disorder Longitudinal Interval Follow-Up Examination allowed for diagnoses to be made throughout the follow-up period. RESULTS: Over 7 years, the majority of women with anorexia nervosa experienced diagnostic crossover: more than half crossed between the restricting and binge eating/purging anorexia nervosa subtypes over time; one-third crossed over to bulimia nervosa but were likely to relapse into anorexia nervosa. Women with bulimia nervosa were unlikely to cross over to anorexia nervosa. CONCLUSIONS: These findings support the longitudinal distinction of anorexia nervosa and bulimia nervosa but do not support the anorexia nervosa subtyping schema.     

Investigation of factors associated to crossover from anorexia nervosa restricting type (ANR) and anorexia nervosa binge-purging type (ANBP) to bulimia nervosa and comparison of bulimia nervosa patients with or without previous ANR or ANBP

Objective

To characterize factors associated to diagnostic crossover from anorexia nervosa restricting type (ANR) and anorexia nervosa binge-purging type (ANBP) to bulimia nervosa (BN) and to compare BN individuals with initial ANR or ANBP to subjects with stable BN.

Method

Two hundred thirty-eight patients with current and lifetime diagnosis of AN or BN underwent diagnostic, psychopathological, and historical examinations by means of ad hoc clinical interviews and rating scales.

Results

One hundred twenty-three individuals had a stable BN. Seventy patients had a diagnosis of ANR and 45 of ANBP at the time of disease onset; 24 ANR patients and 23 ANBP subjects developed BN, whereas 46 ANR patients and 22 ANBP subjects did not crossover. Although the rate of diagnostic crossover was higher in the ANBP group than in the ANR one, the difference was not statistically significant. Longer illness duration, higher maximum past body mass index (BMI), higher novelty seeking, and lower self-directedness resulted significantly associated to crossover from ANR to BN, whereas higher maximum past BMI, higher desired body weight, higher novelty seeking, and lower harm avoidance were significantly associated to crossover from ANBP to BN. As compared to stable BN subjects, BN patients with initial ANR exhibited lower minimum past BMI, lower desired body weight, higher drive for thinness, ascetism, and social insecurity scores; BN patients with initial ANBP exhibited lower minimum past BMI and decreased enteroceptive awareness scores.

Conclusions

Different clinical and personality factors seem to be associated to crossover from ANR and ANBP to BN. Moreover, BN with initial ANR seems to differ clinically from stable BN. These findings may have therapeutic and prognostic implications.     

The prevalence of personality disorders in 210 women with eating disorders.

BACKGROUND: The purpose of this study was to assess the prevalence, reliability, and predictive value of comorbid personality disorders in a large sample of 210 women seeking treatment for anorexia nervosa (N = 31), bulimia nervosa (N = 91), or mixed disorder (N = 88). METHOD: All subjects were interviewed using the Structured Interview for DSM-III Personality Disorders as part of a longitudinal outcome study of eating disorders currently underway at Massachusetts General Hospital. RESULTS: Of the 210 subjects, 27% had at least one personality disorder; the most commonly observed was borderline personality disorder in 18 subjects (9%). The highest prevalence of personality disorders was found in the anorexia nervosa/bulimia nervosa group at 39%, followed by 22% in the anorexics and 21% in the bulimic sample. We found statistically significant differences regarding the distribution of personality disorders across eating disorder groups. The dramatic personality disorder cluster was differentially distributed across groups; this finding was accounted for by higher rates of borderline personality disorder in the bulimia nervosa and anorexia nervosa/bulimia nervosa groups than in the anorexia nervosa group. The anxious personality disorder cluster was differentially distributed across groups with higher rates in the anorexia nervosa and anorexia nervosa/bulimia nervosa samples. Those subjects with a comorbid personality disorder had a significantly slower recovery rate than those without a comorbid personality disorder. CONCLUSION: The prevalence of personality disorders is not high in treatment-seeking women with eating disorders compared with previously studied samples. The greatest frequency of comorbid personality disorders is in the anorexia nervosa/bulimia nervosa group; this subset also had longer duration of eating disorder illness and much greater comorbid Axis I psychopathology compared with the rest of the sample. Future studies should address whether personality disorders have predictive value in the long-term course and outcome of eating disorders.     

Temperament, character and suicide attempts in anorexia nervosa, bulimia nervosa and major depression.

OBJECTIVE: We examined the relation between personality traits as measured by the Temperament and Character Inventory (TCI) and a reported history of suicide attempts in women with anorexia nervosa, bulimia nervosa and major depression. METHOD: We compared the prevalence and severity of suicide attempts in women with anorexia nervosa (n = 68), bulimia nervosa (n = 152) and major depression with no history of an eating disorder (n = 59), and we examined the relation between the TCI scales and suicide attempts. RESULTS: Comparable numbers of women across the three groups had attempted suicide. The temperament dimension of high persistence and the character dimensions of low self-directedness and high self-transcendence were associated with a reported history of suicide attempts. CONCLUSION: Suicide attempts are equally common in women with eating disorders and women with depression. Whether the observed association between temperament and suicide attempts reflects correlates, causal factors or sequelae of suicide attempts is unknown.     

Eating Disorder and Schizophrenia

Abstract: Five cases with eating disorders (one case with anorexia nervosa alone, 4 cases with anorexia nervosa and bulimia nervosa) complicated with schizophrenia and 3 cases of bulimia nervosa complicated with schizophrenia were reported. The eating disorders and schizophrenia were diagnosed according to the diagnostic criteria of DSM-III-R. As to the type of schizophrenia, 4 patients were of an undifferentiated type and 4 cases were of a disorganized type. Regarding the prepsychotic personality, 6 of the 8 cases showed schizothyme personality traits. All the patients showed depressive symptoms which are relatively common in eating disorders. In all the patients, significant social or school life difflculties persisted and a resumption of premorbid functioning was not seen. The possibility of an afflnity between anorexia nervosa and schizophrenia was discussed.     

Longitudinal relationships between childhood, adolescent, and adult eating disorders.

OBJECTIVE: This study investigates the longitudinal course of eating problems from childhood though adulthood.The following questions are answered: (1) How stable are eating disorder symptoms and diagnoses over a 17-year interval from childhood to adulthood? (2) Do early childhood eating problems predict the occurrence of eating disorders in adulthood? METHOD: An epidemiologically selected sample of approximately 800 children and their mothers received DSM-based structured psychiatric assessments in 1975, 1983, 1985, and 1992. The stability of full DSM diagnostic criteria for anorexia nervosa and bulimia nervosa, symptom scales derived from DSM criteria, and individual symptoms such as binge eating or dieting between early adolescence, late adolescence, and young adulthood was examined. RESULTS: Early adolescent bulimia nervosa is associated with a 9-fold increase in risk for late adolescent bulimia nervosa and a 20-fold increase in risk for adult bulimia nervosa. Late adolescent bulimia nervosa is associated with a 35-fold increase in risk for adult bulimia nervosa. Symptom scale scores for anorexia nervosa and bulimia nervosa correlate in the 0.3 to 0.5 range from early to late adolescence and young adulthood. For both anorexia nervosa and bulimia nervosa, gender, as well as eating symptoms at early and late adolescence, all predict young-adult eating disorder symptoms. Risk factors for the later development of eating disorders comprise eating conflicts, struggles with food, and unpleasant meals in early childhood. CONCLUSION: The presence of eating problems in early childhood or an eating disorder in adolescence confers a strong risk for an eating disorder in young adulthood.     

Stability of personality traits in patients who received intensive treatment for a severe eating disorder

A longitudinal prospective design with four assessments was used to examine the stability of personality traits and their relation to recovery in patients with restrictive anorexia nervosa (N=35), bingeing/purging anorexia nervosa (N=37), bulimia nervosa (N=47), and eating disorder not otherwise specified (N=27). Recovery is associated with changes in personality traits in the direction of healthy control women. Recovered patients still show higher harm avoidance and higher persistence than healthy control women. These temperament factors seem to be a vulnerability factor for developing an eating disorder. Novelty seeking seems to define the type of eating disorder one is prone to develop. The character dimensions contribute the most to recovery. High self-directedness contributes to a favorable prognosis of bulimic symptomatology, whereas high cooperativeness contributes to an unfavorable prognosis in patients with anorexia nervosa.     

Treatment implications of Axis-II comorbidity in eating disorders

In this article, we review the clinical research on the implications of comorbid personality disorders (PDs), pathological personality traits, and the expression and response to treatment of those with eating disorders (EDs) (i.e., anorexia and bulimia nervosa, and binge eating disorder). Obsessive-compulsive PDs and related traits, such as perfectionism and rigidity, appear to be clear-cut risk and maintenance factors for anorexia nervosa. In bulimia nervosa, trait impulsivity seems to be related to early termination from therapy and, according to at least some indices, poorer responses to treatment. Dramatic-Erratic PD features, generally more characteristic of binge-purge ED variants, clearly predict a protracted course for general psychiatric symptoms, but may have less prognostic value for eating symptoms. Recent guidelines from two influential bodies--the American Psychiatric Association (APA, 2000) and the United Kingdom's National Institute for Clinical Excellence (NICE, 2004)--both include the concept that "trait-oriented" interventions, targeting personality-linked components like perfectionism, affective instability, impulsivity, and interpersonal disturbances, may optimize treatment effects. In general, the literature supports the recommendation that clinicians should apply well-validated, symptom-focused therapies for the EDs; in addition, clinicians may wish to incorporate trait-focused interventions in patients in whom personality pathology contributes to suboptimal response.     

Recent research of relationships among eating disorders and personality disorders

This review focuses on recent research examining the relationships among eating disorders (ED) and personality disorders (PD). Studies that have examined rates of PD in patients with ED and rates of ED in patients with PD have generally reported high rates of diagnostic co-occurrence, although the marked inconsistency and variability in rates across studies is striking. Methodologic limitations and conceptual problems make interpretation of the existing literature ambiguous. Overall, circumspect review suggests that anorexia nervosa may be associated with obsessional and perfectionistic forms of personality disturbances, bulimia nervosa with impulsive and unstable personality disturbances, and binge eating disorder with avoidant and anxious forms of personality disturbances. In terms of longitudinal associations, PD may be more closely associated with the course of general psychiatric or psychosocial functioning than with fluctuations in the course of ED. The significance (and more precise nature) of these associations, however, is unclear and will require sophisticated longitudinal studies to arrive at more definitive answers.     

Treatment Implications of Axis-II Comorbidity in Eating Disorders

In this article, we review the clinical research on the implications of comorbid personality disorders (PDs), pathological personality traits, and the expression and response to treatment of those with eating disorders (EDs) (i.e., anorexia and bulimia nervosa, and binge eating disorder). Obsessive-compulsive PDs and related traits, such as perfectionism and rigidity, appear to be clear-cut risk and maintenance factors for anorexia nervosa. In bulimia nervosa, trait impulsivity seems to be related to early termination from therapy and, according to at least some indices, poorer responses to treatment. Dramatic-Erratic PD features, generally more characteristic of binge-purge ED variants, clearly predict a protracted course for general psychiatric symptoms, but may have less prognostic value for eating symptoms. Recent guidelines from two influential bodies—the American Psychiatric Association (APA, 2000) and the United Kingdom's National Institute for Clinical Excellence (NICE, 2004)—both include the concept that “trait-oriented” interventions, targeting personality-linked components like perfectionism, affective instability, impulsivity, and interpersonal disturbances, may optimize treatment effects. In general, the literature supports the recommendation that clinicians should apply well-validated, symptom-focused therapies for the EDs; in addition, clinicians may wish to incorporate trait-focused interventions in patients in whom personality pathology contributes to suboptimal response.     

Anger and personality in eating disorders

Objective: This study was designed to examine how anger, temperament and character profiles differ across subtypes of eating disorders (EDs) in comparison to healthy controls and to analyze the relationship between anger expression, eating attitudes and personality dimensions. Method: One hundred and thirty-five outpatients (50 of whom suffered from anorexia nervosa restrictor type [AN-R], 40 from anorexia nervosa binge/purging [AN-BP] and 45 from bulimia nervosa [BN]) and 50 control subjects were recruited and administered State-Trait Anger Expression Inventory (STAXI), Temperament and Character Inventory (TCI) and Eating Disorder Inventory II (EDI-II). Results: STAXI showed greater levels of anger in patients with BN than in those with AN. TCI showed different personality profiles, in accordance with previous studies. Correlations were found between the management of anger feelings and psychological and personality traits typical of patients with EDs. Conclusions: Clinically, impulsivity seems to be the psychopathologic element most strongly correlated to anger. Moreover, it appears clear that anger is better managed by individuals with greater character strength.     

Personality pathology and its influence on eating disorders

Personality disorders appear to be present in a significant minority of individuals with eating disorders. For example, in contrast to reported rates in the general population of eight percent, obsessive compulsive personality is present in approximately 22 percent of individuals with anorexia, restricting type. Likewise, in contrast to rates in the general population of six percent, borderline personality is present in approximately 25 percent of individuals with anorexia nervosa, binge-eating purging type, and in 28 percent of individuals with bulimia nervosa. Could these high rates of comorbidity indicate a partially causal relationship? At the very least, these specific personality disorders may be shaping corresponding styles of eating pathology, with obsessive compulsive personality disorder partially accounting for restrictive eating pathology and borderline personality disorder partially accounting for impulsive eating pathology. These potential associations are explored.     

Predictive validity of bulimia nervosa as a diagnostic category

OBJECTIVE: The authors sought to investigate the predictive validity of bulimia nervosa as a diagnostic category. METHOD: More than 10 years after they appeared as patients with bulimia nervosa, 177 women (participation rate=79.7%) completed follow-up assessments. RESULTS: Among the women with a current eating pathology, most engaged in recurrent binge eating and purging. Anorexia nervosa and binge eating disorder were relatively uncommon. Eating disorder outcome was significantly related to the presence of mood, substance use, and impulse control disorders but not to the presence of anxiety disorders. CONCLUSIONS: These results support the validity of bulimia nervosa as a diagnostic category that is distinct from anorexia nervosa. Furthermore, these results suggest that bulimic symptoms are associated with disorders involving distress and disinhibition.     

Incidence, prevalence and mortality of anorexia nervosa and other eating disorders

PURPOSE OF REVIEW: The purpose of this review is to evaluate the recent literature on the incidence and prevalence of and mortality associated with eating disorders. RECENT FINDINGS: General-practice studies show that the overall incidence rates of anorexia nervosa remained stable during the 1990s, compared with the 1980s. Some evidence suggests that the occurrence of bulimia nervosa is decreasing. Anorexia nervosa is a common disorder among young white females, but is extremely rare among black females. Recent studies confirm previous findings of the high mortality rate within the anorexia nervosa population. SUMMARY: The incidence of anorexia nervosa is around eight per 100,000 persons per year. An upward trend has been observed in the incidence of anorexia nervosa in the past century till the 1970s. The most substantial increase was among females aged 15-24 years, for whom a significant increase was observed from 1935 to 1999. The average prevalence rates for anorexia nervosa and bulimia nervosa among young females are 0.3 and 1%, respectively. Only a minority of people with eating disorders, especially with bulimia nervosa, are treated in mental healthcare.     

Childhood obsessive-compulsive personality traits in adult women with eating disorders: defining a broader eating disorder phenotype

OBJECTIVE: The authors retrospectively examined a spectrum of childhood traits that reflect obsessive-compulsive personality in adult women with eating disorders and assessed the predictive value of the traits for the development of eating disorders. METHOD: In a case-control design, 44 women with anorexia nervosa, 28 women with bulimia nervosa, and 28 healthy female comparison subjects were assessed with an interview instrument that asked them to recall whether they had experienced various types of childhood behavior suggesting traits associated with obsessive-compulsive personality. The subjects also completed a self-report inventory of obsessive-compulsive disorder (OCD) symptoms. RESULTS: Childhood obsessive-compulsive personality traits showed a high predictive value for development of eating disorders, with the estimated odds ratio for eating disorders increasing by a factor of 6.9 for every additional trait present. Subjects with eating disorders who reported perfectionism and rigidity in childhood had significantly higher rates of obsessive-compulsive personality disorder and OCD comorbidity later in life, compared with eating disorder subjects who did not report those traits. CONCLUSIONS: Childhood traits reflecting obsessive-compulsive personality appear to be important risk factors for the development of eating disorders and may represent markers of a broader phenotype for a specific subgroup of patients with anorexia nervosa.     

Predictors of treatment utilization among women with anorexia and bulimia nervosa.

OBJECTIVE: The authors sought predictors of treatment utilization among women with eating disorders. METHOD: Women diagnosed with either anorexia or bulimia nervosa (N=246) completed prospective evaluations of eating disorder status, comorbid disorders, global assessment of functioning, and treatment utilization. RESULTS: Women with anorexia nervosa received significantly more inpatient treatment than did women with bulimia nervosa. Predictors of treatment utilization included lower global assessment of functioning scores and presence of personality disorders. CONCLUSIONS: Women with more severe pathology have higher treatment utilization rates. This pattern may explain the seeming lack of treatment efficacy for eating disorders outside of randomized controlled studies.     

Comorbidity of anxiety disorders with anorexia and bulimia nervosa

OBJECTIVE: A large and well-characterized sample of individuals with anorexia nervosa and bulimia nervosa from the Price Foundation collaborative genetics study was used to determine the frequency of anxiety disorders and to understand how anxiety disorders are related to state of eating disorder illness and age at onset. METHOD: Ninety-seven individuals with anorexia nervosa, 282 with bulimia nervosa, and 293 with anorexia nervosa and bulimia were given the Structured Clinical Interview for DSM-IV Axis I Disorders and standardized measures of anxiety, perfectionism, and obsessionality. Their ratings on these measures were compared with those of a nonclinical group of women in the community. RESULTS: The rates of most anxiety disorders were similar in all three subtypes of eating disorders. About two-thirds of the individuals with eating disorders had one or more lifetime anxiety disorder; the most common were obsessive-compulsive disorder (OCD) (N=277 [41%]) and social phobia (N=134 [20%]). A majority of the participants reported the onset of OCD, social phobia, specific phobia, and generalized anxiety disorder in childhood, before they developed an eating disorder. People with a history of an eating disorder who were not currently ill and never had a lifetime anxiety disorder diagnosis still tended to be anxious, perfectionistic, and harm avoidant. The presence of either an anxiety disorder or an eating disorder tended to exacerbate these symptoms. CONCLUSIONS: The prevalence of anxiety disorders in general and OCD in particular was much higher in people with anorexia nervosa and bulimia nervosa than in a nonclinical group of women in the community. Anxiety disorders commonly had their onset in childhood before the onset of an eating disorder, supporting the possibility they are a vulnerability factor for developing anorexia nervosa or bulimia nervosa.     

Risk factors for anorexia nervosa: three integrated case-control comparisons

BACKGROUND: Many risk factors have been implicated in the development of anorexia nervosa. Little is known about their relative contributions, nor in most cases is it clear whether they are specific to anorexia nervosa or risk factors for all eating disorders or for psychiatric disorder in general. METHODS: We used a case-control design involving the comparison of 67 female subjects with a history of anorexia nervosa with 204 healthy control subjects, 102 subjects with other psychiatric disorders, and 102 subjects with bulimia nervosa. A broad range of risk factors was assessed by interview. RESULTS: The subjects with anorexia nervosa and the healthy controls differed in their exposure to most of the putative risk factors. There was no greater exposure to factors that increased the likelihood of dieting, once the influence of other classes of risk factors had been taken into account. Premorbid perfectionism and negative self-evaluation were especially common and more so than among the general psychiatric controls. Parental obesity and an early menarche, together with parental psychiatric disorder, distinguished those with bulimia nervosa from those with anorexia nervosa. CONCLUSIONS: There appears to be a broad range of risk factors for anorexia nervosa and bulimia nervosa, some of which are shared with other psychiatric disorders. Factors that increase the likelihood of dieting seem to have more important influence as risk factors for bulimia nervosa than anorexia nervosa. Perfectionism and negative self-evaluation appear to be particularly common and characteristic antecedents of both eating disorders.