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.     

Psychiatric comorbidity in treatment-seeking anorexics and bulimics.

Current and lifetime psychiatric diagnoses were compared in 229 female patients seeking treatment for current episodes of anorexia nervosa (N = 41), bulimia nervosa (N = 98) and mixed anorexia nervosa and Schizophrenia-Lifetime Version, which was modified to include a section for DSM-III-R eating disorders, the Longitudinal Interval Follow-up Evaluation, and the Structured Interview for DSM-III Personality Disorders. Seventy-three percent of the anorexia nervosa subjects, 60% of the bulimia nervosa subjects, and 82% of the mixed anorexia nervosa and bulimia nervosa subjects had a current comorbid Axis I diagnosis. Major depression was the most commonly diagnosed comorbid disorder. Low rates of alcohol and substances abuse disorder were diagnosed, and personality disorder occurred in a minority of the sample. The subjects with mixed disorder manifested a higher lifetime prevalence of kleptomania than either the anorexics or the bulimics. High levels of comorbidity were noted across the eating disorder samples. Mixed disorder subjects manifested the most comorbid psychopathology and especially warrant further study.     

Core beliefs in anorexic and bulimic women

There is research evidence to suggest the presence of dysfunctional cognitions in anorexia nervosa and bulimia nervosa that are not related to food, weight, or shape. These maladaptive cognitions have not been addressed by the conventional cognitive behavioral models of etiology or therapy. This study aimed to assess the impact of unhealthy core beliefs on eating disorders and their symptoms. Twenty restricting anorexics, 10 bulimic anorexics, 27 bulimics, and 23 normal controls completed Young's Schema Questionnaire. Eating behaviors and attitudes were also measured. The results indicate that both anorexic and bulimic women had significantly higher levels of unhealthy core beliefs than comparison women, but the clinical groups only differed on one individual core belief (entitlement). However, there were different patterns of association between core beliefs and eating psychopathology in anorexic and bulimic women. It is suggested that future clinical practice should incorporate core beliefs as a potential element in the assessment and treatment of eating disorders.     

Eating disorders and insulin-dependent diabetes mellitus (IDDM): relationships with glycaemic control and somatic complications

This study was designed to assess (by means of a diagnostic interview based on DSM-III-R criteria) the prevalence of eating disorders in 69 insulin-dependent diabetic (IDDM) out-patients, and the relationship with somatic risks. We found no cases of anorexia nervosa or bulimia nervosa, current or lifetime, in male patients with IDDM. No female patients with IDDM had anorexia, and 4.8% had current and lifetime bulimia. Eating disorders not otherwise specified (bulimic type) were significantly more frequent in women than in men (lifetime incidence 43% vs. 21%; current incidence 33% vs. 5%), and generally occurred after the onset of IDDM. Self-reports of bulimic behaviours according to the Bulimic Investigatory Test of Edinburgh (BITE) were associated with high levels of glycosylated haemoglobin. There was no association between eating disorders (current or lifetime), with somatic complications being more likely to be explained by a long duration of illness and impaired glycaemic control.     

A four-year prospective follow-up study of 49 eating-disordered adolescents: differences in course of illness

In a 4-year prospective follow-up study of 25 anorectic and 24 bulimic adolescents (DSM-III-R criteria), we studied fluctuations and differences in the course of illness, using repeated measurement. Morgan & Russell general outcome categories on the Outcome Schedule were more favourable than in adult studies. Of all patients, 47% had good, 43% intermediate and 10% poor outcome scores after 4 years. The groups differed significantly as to the kind and severity of disturbed eating behaviour and its consequences, but were rather similar in mental, psychosocial and psychosexual symptoms during the course of the illness. Eight percent of the anorectic patients became bulimic. We conclude that anorexia nervosa and bulimia nervosa can be considered as different symptom patterns of one basic eating disorder, in which preoccupation with food and a disturbed body image are core symptoms.     

Substance dependence and eating disorders: impact of sequence on comorbidity.

There is a high comorbidity between eating disorders and substance dependence. The sequence of illness may indicate differences in the underlying pathology and could reflect different etiologies and treatment. The present study subjects were 218 inpatients and outpatients with diagnoses of anorexia nervosa binge-purge type (AN-BP), bulimia nervosa (BN), and eating disorder NOS (ED-NOS). Of these 218 patients, 38 had substance dependence predating the eating disorder (SDED), 71 had an eating disorder predating the substance dependence (EDSD), and 109 had only an eating disorder (ED-only). All subjects were administered the Structured Clinical Interview for DSM-III-R, Patient Edition With Psychotic Screen (SCID-P). EDSD patients had an earlier onset of the eating disorder than SDED patients and had the greatest prevalence of comorbid pathology. SDED patients were dependent on more substances. We conclude that the sequence of development of the eating disorder and substance dependence in eating disorder patients influences the amount of comorbid psychopathology. Clinical implications and future research are discussed.     

Postremission predictors of relapse in women with eating disorders

OBJECTIVE: The authors sought to evaluate patterns and predictors of relapse among women with eating disorders. METHOD: Interviews were conducted biannually to annually to assess symptoms of eating disorders, axis I disorders, treatment, and psychosocial function on a weekly basis for women diagnosed with anorexia nervosa (N=136) or bulimia nervosa (N=110) and prospectively followed for 9 years. At the last follow-up, 229 (93%) of the subjects had been retained in the study group. RESULTS: Relapse occurred in 36% of the women with anorexia nervosa and 35% of the women with bulimia nervosa. Women with intake diagnoses of anorexia nervosa, restricting subtype, tended to develop bulimic symptoms during relapse, whereas women with intake diagnoses of anorexia nervosa, binge-purge subtype, or bulimia nervosa tended to return to bulimic patterns during relapse. Greater body image disturbance contributed to a risk of relapse in both eating disorders, and worse psychosocial function increased the risk of relapse in bulimia nervosa. CONCLUSIONS: These results may explain the long-term efficacy of interpersonal therapy for bulimia nervosa and suggest that focused body image work during relapse prevention may enhance long-term recovery from eating disorders.     

Is major depressive episode related to anxiety disorders in anorexics and bulimics?

OBJECTIVE: To determine whether the presence of anxiety disorders is related to depressive comorbidity in subjects with eating disorders (ED), while taking into account certain variables that may be related to depression (subjects' age, ED duration, prior incidents of anorexia nervosa in bulimic subjects, inpatient or outpatient status, nutritional state [as measured by body mass index]). METHOD: We evaluated the frequency of depressive disorders in 271 subjects presenting with a diagnosis of either anorexia nervosa or bulimia, using the Mini International Neuropsychiatric Interview, DSM-IV version. RESULTS: A multivariate analysis reveals that anxiety disorders do not all have the same influence in terms of risk of onset of major depressive episode in anorexics and bulimics when adjusted on variables related to depression. CONCLUSION: Depression in subjects with ED can be explained in part by comorbidity with obsessive-compulsive disorder, generalized anxiety, social phobia, and panic disorder.     

Anorexia nervosa patients with a prior history of bulimia nervosa

OBJECTIVES: To investigate clinical and psychological features of patients with anorexia nervosa (AN) with a previous history of bulimia nervosa. METHOD: Three hundred thirty-three patients with a full diagnosis of AN were assessed by the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, the Eating Disorders Inventory, and the Hopkins Symptom Checklist. RESULTS: Twenty-four patients (7%) reported a previous diagnosis of bulimia nervosa and were compared with a control group of 48 patients without a history of bulimia, matched for diagnostic subtype. Among the patients with a history of bulimia nervosa, 11 were of the restricting type and 13 of the binge eating/purging type. Among restricting anorexic patients, those with a history of bulimia reported greater age of onset, more psychiatric symptoms, more family psychiatric morbidity, and a higher rate of sexual abuse. On the contrary, among patients with the AN bingeing-purging subtype, the presence of a previous bulimia nervosa was not associated with any of the investigated variables. CONCLUSIONS: Patients with restricting AN who report a history of previous bulimia nervosa are not frequent among those referring to an outpatient eating disorders unit. However, our findings in this small group of subjects confirm that a lifetime history of bingeing and purging in patients with eating disorder, irrespective of when it occurs, is always associated with more psychopathology compared with those restricting patients with AN who have never had a period of bingeing and purging.     

Abnormal caloric requirements for weight maintenance in patients with anorexia and bulimia nervosa

OBJECTIVE: This study tested previous findings that patients with eating disorders who attain normal weight have abnormal caloric requirements for maintaining weight. METHOD: Fifty-three female patients meeting the DSM-III-R criteria for anorexia nervosa and/or bulimia nervosa were divided into four subgroups, and their daily caloric intake was measured over a weight-stable period. Patients with anorexia nervosa (restricting and bulimic subtypes) were studied 4 weeks after refeeding and weight gain, when they had attained 95% of average body weight. Patients with normal-weight bulimia (previously anorexic or never previously anorexic) were studied 1-4 weeks after admission to an inpatient unit. RESULTS: After weight restoration, restricting anorexic patients required significantly more calories per day to maintain weight than did bulimic anorexic patients, as measured with corrections for weight, body surface area, and fat-free mass. Previously anorexic normal-weight bulimic patients required significantly more calories per day to maintain weight than never-anorexic normal-weight bulimic patients, as measured with correction for weight but not with the other factors used to correct caloric intake. CONCLUSIONS: To maintain stable weight after weight restoration, restricting anorexic patients require a significantly higher caloric intake than do bulimic anorexic patients. Differences in caloric needs between normal-weight bulimic patients with and without histories of anorexia may depend on the methods used to correct caloric requirements. Body surface area may be the most precise correction factor across different subgroups of eating disorder patients. Elevated caloric requirements, when coupled with reduced food intake, may particularly contribute to relapse in anorexic patients.     

Subgroups of anorexia nervosa and bulimia: validity and utility

Sociodemographic and psychodynamic similarities and differences among four subgroups of eating disordered females seeking outpatient consultations for anorexia nervosa and bulimia are presented. Supporting the spectrum concept of eating disorders, the four diagnostic subgroups are: anorexia nervosa, restricting; anorexia nervosa with bulimic complications; normal weight bulimia with a history of anorexia nervosa; and normal weight bulimia without a history of anorexia nervosa. Overall, the 165 patients are white, middle to upper-middle class females in their early twenties. The highest levels of psychopathology, as measured by the Eating Disorder Inventory, was manifested by patients afflicted with both anorexic and bulimic symptomatology, either in the past or at time of consultation. Implications for diagnostic classification and clinical intervention are discussed.     

A controlled family study of anorexia nervosa

A family study of eating disorders in first and second-degree relatives of anorexia nervosa and nonanorexic psychiatrically ill control probands found increased rates of anorexia-nervosa, bulimia nervosa, and subclinical anorexia nervosa in relatives of anorexic probands. The pattern of familial clustering suggests that these disorders may represent variable expressions of a common underlying psychopathology, although restricter and bulimic subforms of eating disorder may segregate within families. Implications of these findings for understanding factors important to the pathogenesis and subclassification of eating disorders are discussed.     

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.     

Depression modulates non-eating-disordered psychopathology in eating-disordered patients

The general psychopathology in subgroups of inpatients with eating disorders was investigated with the MMPI. One hundred and sixty-three females were diagnosed according to both DSM-III-R and DSM-IV into four subgroups: 1a) DSM-III-R anorexia nervosa-restricting subtype (AN-R), 1b) DSM-IV anorexia nervosa-restricting subtype (AN-R), 2a) DSM-III-R anorexia nervosa and bulimia nervosa (AN-B), and 2b) DSM-IV anorexia nervosa binge/purge type (AN-BP), 3) bulimia nervosa with no history of anorexia nervosa (BN), and 4) bulimia nervosa with a history of anorexia nervosa (BN hx AN). Subjects also completed the Beck Depression Inventory (BDI). Results indicated a common core disturbance, and significant group differences in overall profiles and severity of psychopathology. The results differed slightly between DSM-III-R and DSM-IV. The dual-diagnosis groups (AN-B and BN-hx-AN) displayed the most psychopathology, and AN-R displayed the least. With the former nosological system, there were slightly more differences between the diagnostic subgroups. When level of depressive symptoms (BDI score) was coearied, most of the direrences between the diagnostic subgroups were no longer present. Only the Psychopathic Deviate scale remained significantly diferent between groups, with .4N-R displaying lower levels than the other three groups.     

Pre-menarchal bulimia nervosa.

Although pre-pubertal anorexia nervosa has been well described, pre-pubertal bulimic behaviour in the context of this disorder appears to be uncommon. There have been no published reports of pre-pubertal bulimia nervosa occurring independently. Of 323 patients with bulimia nervosa attending an eating disorders research clinic between 1980 and 1989, the authors identified six patients who described pre-menarchal binge eating in the absence of a concurrent history of anorexia nervosa or massive obesity. Three (0.93%) of these patients described a pre-menarchal onset of bulimia nervosa, but there was no evidence that they were pre-pubertal. The implications of these findings are discussed.     

Les troubles des conduites alimentaires : évaluation des troubles obsessionnels compulsifs et leur influence sur l’expression clinique des troubles

To estimate the prevalence of obsessive-compulsive disorder (OCD) in patients with eating disorders, the difference of prevalence of OCD and the distribution of autogenous and reactive obsessions according to the subtype of eating disorder (ED) and the degree of intensity of ED according the presence or not of OCD, 10 patients with restricting anorexia nervosa, 19 with bulimia nervosa and 14 with obsessive-compulsive disorder were assessed. The results showed that the prevalence was higher in bulimic patients than in anorexic patients, which is in accordance with most international studies. On the other hand, this research revealed a different distribution of autogenous and reactive obsessions in these patients, and a particular correlation between the presence of OCD and the intensity of the eating disorders.     

Gonadotropin response to LH-RH in anorexia nervosa and bulimia

Serum LH and FSH levels before and after stimulation with LH-RH were measured in 9 patients with bulimia, 7 with a restricting subtype and 6 with a bulimic subtype of anorexia nervosa. All patients with anorexia nervosa and 5 (56%) patients with bulimia showed amenorrhea for at least 5 months, while 4 (44%) of the bulimic patients showed oligomenorrhea. Mean basal levels of LH and FSH were low in patients with restricting and bulimic anorexia nervosa, but were normal in patients with bulimia. The response of LH and FSH to LH-RH was impaired in approximately half of the patients with the two subtypes of anorexia nervosa, whereas it was normal in all but one patient with bulimia. These results suggest that bulimic patients with amenorrhea or oligomenorrhea have hypothalamic dysfunctions, which do not appear to be due solely to low weight or to metabolic changes resulting from binge eating, vomiting or purgative use.     

The intermediate-term outcome of Chinese patients with anorexia nervosa in Hong Kong

OBJECTIVE: The authors determined the intermediate-term outcome of anorexia nervosa for Chinese patients in Hong Kong. METHOD: A consecutive series of 88 patients who fulfilled DSM-III-R criteria for typical (i.e., fat phobic [N=63]) and atypical (i.e., no fat phobia [N=25]) anorexia nervosa were contacted at least 4 years after onset of their illness for semistructured and self-rated assessments of outcome. RESULTS: Three patients (3.4%) died; the mortality ratio for this group against the expected standard for subjects of similar age and gender was 10.5 to 1. Eighty (94.1%) of the remaining 85 patients were successfully traced 9.0 years after onset of their illness. Good, intermediate, and poor outcomes were seen in 61.8%, 32.9%, and 5.3% of the subjects, respectively. Anorexia nervosa, bulimia nervosa, or eating disorder not otherwise specified was exhibited by 55.0% of the subjects (N=44). Lifetime depressive (81.6%) and anxiety (27.6%) disorders were common. Older age at onset and the presence of fat phobia independently predicted poor outcome. Patients with atypical anorexia nervosa were symptomatically stable, less likely to demonstrate bulimia, and had a better eating disorder outcome than patients with typical anorexia nervosa. CONCLUSIONS: The outcome profile of Chinese patients supported the cross-cultural disease validity of anorexia nervosa. The cultural fear of fatness not only shaped the manifest content but also added to the chronicity of the illness.     

A comparison of clinical features among Japanese eating-disordered women with obsessive-compulsive disorder.

Clinical features, such as obsessive-compulsive disorder (OCD) symptoms, were investigated in Japanese women with DSM-III-R eating disorders (EDs) and concurrent OCD in comparison to age-matched women with OCD. Sixteen women with restricting anorexia nervosa (AN), 16 with bulimia nervosa (BN), and 16 with both AN and BN (BAN) showed commonality in a more elevated prevalence of OCD symptoms of symmetry and order compared with 18 OCD women. Among the personality disorders (PDs), likewise, obsessive-compulsive PD (OCPD) was more prevalent in each ED group compared with the OCD group. However, aggressive obsessions were more common in both BN and BAN subjects compared with AN subjects. Subjects with bulimic symptoms were also distinguished from AN subjects by impulsive features in behavior and personality. Thus, an elevated prevalence of aggressive obsessions along with an admixture of impulsive and compulsive features specifically characterized the clinical features of bulimic subjects with OCD.     

Seasonal mood patterns in eating disorders

There has been an increasing body of research literature suggesting a seasonal pattern of mood fluctuations and eating behavior in bulimic patients. Fornari et al. [5] reported worsening of bulimic symptoms during winter. There is a logical connection between Seasonal Affective Disorder (SAD) and bulimia nervosa as both show increased appetite and carbohydrate craving and probably share a common neurobiologic abnormality such as serotonergic dysfunction. The aim of this study was to determine the prevalence of SAD in a sample of 259 consecutively evaluated outpatients admitted to an eating disorders clinic (254 women and 5 men). Eating disorder diagnosis was established on the basis of DSM-III-R criteria, and a modified version of the Seasonal Pattern Assessment Questionnaire was used to determine seasonality among patients. The sample was comprised of the following: 53.7% bulimics, 27.4% anorexics, 15.1% were classified as having an eating disorder not otherwise specified, and 3.9% had a diagnosis other than an eating disorder. The results indicated that 27.0% of the eating disorder patients met criteria for SAD. Of this group, 86 (71.4%) were bulimic, 35 (18.6%) were anorexic, and 20 (10.0%) were nonspecified. Details and additional findings are discussed.