Prevalence of eating disorders in female and male adolescents (14-15 years)

OBJECTIVE: The main aim of the present study is to establish the prevalence of eating disorders (ED) in adolescents of both genders. To our knowledge, such data have not previously been published using both DSM-IV and DSM-III-R criteria. METHOD: The study sample consisted of 1960 adolescents (1026 girls and 934 boys), 14-15 years of age. The participants completed the Survey for Eating Disorders (SEDs), including DSM-III-R and DSM-IV diagnoses for all subcategories of ED. RESULTS: Lifetime prevalence of any ED among girls was 17.9% anorexia nervosa (AN) 0.7%, bulimia nervosa (BN) 1.2%, binge eating disorder (BED) 1.5%, and EDs not otherwise specified (EDNOS) 14.6%. Corresponding numbers for boys for any ED is 6.5%, AN 0.2%, BN 0.4%, BED 0.9%, and EDNOS 5.0%. DISCUSSION: Our prevalence rates on AN, BN, and BED largely support previous school/community-based studies, while our figures on EDNOS were rather high. Generally, we found high numbers for boys with ED.     

Comparison of DSM-IV versus proposed DSM-5 diagnostic criteria for eating disorders: reduction of eating disorder not otherwise specified and validity

Objective:

Revised Eating Disorder (ED) diagnostic criteria have been proposed for the Diagnostic and Statistical Manual (DSM)‐5 to reduce the preponderance of eating disorder not otherwise specified (EDNOS) and increase the validity of diagnostic groups. This article compares DSM‐IV and proposed DSM‐5 diagnostic criteria on number of EDNOS cases and validity.

Method:

Participants (N = 397; 91% female) completed structured clinical interviews in a two‐stage epidemiological study of EDs. Interviewers did not follow standard skip rules, making it possible to evaluate alternative ED diagnostic criteria.

Results:

Using DSM‐IV versus DSM‐5 criteria, 34 (14%) versus 48 (20%) had anorexia nervosa, 43 (18%) versus 44 (18%) had bulimia nervosa, and 163 (68%) had EDNOS versus 20 (8%) had binge eating disorder (BED), and 128 (53%) had EDNOS, respectively, reflecting a significant decrease in EDNOS. Validation analyses supported significant differences among groups with some improvement associated with delineation of BED.

Discussion:

Proposed revisions to EDs in the DSM‐5 significantly reduced reliance on EDNOS without loss of information. © 2011 by Wiley Periodicals, Inc.     

Gender Differences in Treatment Outcomes for Eating Disorders: A Case-Matched,Retrospective Pre–Post Comparison

Eating disorders (EDs) are increasingly emerging as a health risk in men, yet men remain underrepresented in ED research, including interventional trials. This underrepresentation of men may have facilitated the development of women-centered ED treatments that result in suboptimal outcomes for men. The present study retrospectively compared pre- vs. post-treatment outcomes between age-, diagnosis-, and length-of-treatment-matched samples of n = 200 men and n = 200 women with Anorexia Nervosa (AN), Bulimia Nervosa (BN), Binge Eating Disorder (BED), or Eating Disorder Not Otherwise Specified (EDNOS), treated in the same setting during the same period, and using the same measurements. Compared to women, men with AN showed marked improvements in weight gains during treatment as well as in ED-specific cognitions and general psychopathology. Likewise, men with BED showed marked weight loss during treatment compared to women with BED; ED-specific cognitions and general psychopathology outcomes were comparable in this case. For BN and EDNOS, weight, ED-specific cognitions, and general psychopathology outcomes remained largely comparable between men and women. Implications for treatments are discussed.     

The natural course of bulimia nervosa and eating disorder not otherwise specified is not influenced by personality disorders

OBJECTIVE: To examine prospectively the natural course of bulimia nervosa (BN) and eating disorder not otherwise specified (EDNOS) and to test the effects of personality disorder (PD) comorbidity on the outcomes. METHOD: Ninety-two female patients with current BN (N=23) or EDNOS (N=69) were evaluated at baseline enrollment in the Collaborative Longitudinal Personality Disorders Study (CLPS). Eating disorders (EDs) were assessed with the Structured Clinical Interview for DSM-IV Axis I Disorders. Personality disorders (PDs) were assessed with the Diagnostic Interview for DSM-IV PD (DIPD-IV). The course of BN and EDNOS was assessed with the Longitudinal Interval Follow-up Evaluation and the course of PDs was evaluated with the Follow-Along version of the DIPD-IV at 6, 12, and 24 months. RESULTS: Probability of remission at 24 months was 40% for BN and 59% for EDNOS. To test the effects of PD comorbidity on course, ED patients were divided into groups with no, one, and two or more PDs. Cox proportional regression analyses revealed that BN had a longer time to remission than EDNOS (p<.05). The number of PDs was not a significant predictor of time to remission, nor was the presence of Axis I psychiatric comorbidity or Global Assessment of Functioning scores. Analyses using proportional hazards regression with time-varying covariates revealed that PD instability was unrelated to changes in ED. CONCLUSIONS: BN has a worse 24-month course (longer time to remission) than EDNOS. The natural course of BN and EDNOS is not influenced significantly by the presence, severity, or time-varying changes of co-occurring PDs, co-occurring Axis I disorders, or by global functioning.     

The body as a simulacrum of identity: the subjective experience in the eating disorders

This study aims at better understanding the subjective experience, the so-called Erlebnis, in individuals diagnosed with Eating Disorders (ED). We shall highlight the particular way in which people with such disorders perceive their own bodies and specifically how they perceive their bodies in the presence of other people. To this end we shall analyze the subjective experience by means of two concepts as described by French philosopher Jean-Paul Sartre: "body-self" and "body-forothers". Our hypothesis is that some people suffering from eating disorders, especially those with a diagnosis of Eating Disorders Not Otherwise Specified (EDNOS), experience their body mainly as body-for-others. Rather than a diagnostic category, EDNOS could be conceived as an anthropological configuration vulnerable to ED. Eating disorders appear as an "identity disorder" characterized by a suspension of the experiential polarity between self and other-than-self.     

The clinical features of EDNOS: Relationship to mood,health status and general functioning

Study purposeEating disorder not otherwise specified (EDNOS) remains poorly evaluated in terms of eating disorder features and relationship to mood, health status and general functioning. This study investigated the clinical profiles of a sample of EDNOS patients, and how they compared to patients with anorexia nervosa (AN) and bulimia nervosa (BN).MethodThe sample consisted of 178 patients. All completed the Eating Disorder Examination, Beck Depression Inventory, Work and Social Adjustment Scale and Sf-36. ANOVAs were conducted to explore group differences.ResultsNo differences were found for depression. No differences were found between BN and EDNOS on measures of health status and general functioning. AN patients reported greater role limitations due to physical health and experienced greater physical pain compared with BN or EDNOS patients, and reported poorer social functioning, lower vitality and higher functional impairment compared with EDNOS patients.ConclusionEDNOS patients are generally no less clinically impaired than those with BN. However AN patients may be more impaired in some aspects of general functioning compared with BN or EDNOS patients.     

The prevalence of eating disorders not otherwise specified

OBJECTIVE: Eating Disorders Not Otherwise Specified (EDNOS) represent the most common eating disorder diagnosed in specialized treatment settings. The purpose of the current study is to assess the prevalence of EDNOS in a nationwide community sample. METHOD: Participants were 2,028 female students, aged 12-23, attending public schools in the 9th to 12th grades in Portugal. Participants completed the Eating Disorder Examination Questionnaire in Stage 1 of the study. In Stage 2, we selected all the participants who met any of these criteria: (1) BMI < or =17.5, (2) scores > or =4 on any of the four EDE-Q Subscales, (3) a total EDE-Q score > or =4, or (4) the presence of dysfunctional eating behaviors. In Stage 2, eating disorder experts interviewed 901 participants using the Eating Disorder Examination. RESULTS: The prevalence of all eating disorders was 3.06% among young females. Prevalence for anorexia nervosa was 0.39%, for bulimia nervosa 0.30%, EDNOS 2.37%. CONCLUSION: EDNOS is a very common eating disorder and accounts for three-quarters of all community cases with eating disorders.     

Effects of multiple forms of childhood abuse and adult sexual assault on current eating disorder symptoms

The objective of this study is to examine the effect of recent adult sexual assault on current eating disorder symptoms when controlling for the effects of multiple forms of childhood abuse. A total of 489 undergraduate women completed the Eating Disorder Examination-Questionnaire, and surveys regarding childhood abuse and sexual assault that had occurred in the previous three months. Approximately 30% of the sample indicated recent unwanted sexual experiences. Childhood emotional abuse contributed unique variance to the prediction of current ED symptoms, but sexual and physical abuse did not. Recent sexual assault contributed additional unique variance to current ED symptoms when controlling for childhood abuse, thus both emotional abuse in childhood and sexual assault in adulthood contributed unique variance to ED symptoms.     

Evaluating the treatment of eating disorders from the patient's perspective

OBJECTIVE: This study investigated the evaluation of treatment of eating disorders (EDs) from the patient's perspective in a large community based sample in the Netherlands. It investigated perceived helpfulness of different types of treatment. Furthermore it investigated which patient and treatment characteristics contribute to the evaluation of treatment. METHOD: The Eating Disorder Examination questionnaire was administered to 44 anorexia nervosa (AN), 43 bulimia nervosa (BN), 69 EDNOS (ED not otherwise specified), and 148 former ED patients. A questionnaire specifically designed for the purpose of this study addressing treatment history and patient's evaluation of their treatment was administered. RESULTS: There is a substantial patient and doctor delay in seeking and finding treatment. Treatment in specialized ED centers, self-help groups, and treatment with a partner were reported to be most helpful. Beneficial components of treatment reported in specialized ED centers refer to the communication skills of professionals, the therapist-patient working alliance, the contact with peers, and the focus of treatment on both ED symptoms as well as underlying issues. CONCLUSION: The patient's perspective on treatment of EDs does provide recommendations for the improvement of treatment of EDs that will facilitate clinical decision making and treatment planning.     

Eating disorders and alcohol use: group differences in consumption rates and drinking motives

Alcohol use and drinking motives were investigated among college women divided into four probable eating disorder groups: Bulimia Nervosa, purging subtype (BN n=16) Binge Eating Disorder (BED n=30) Eating Disorder, Not Otherwise Specified (EDNOS n=85) and Non-Eating Disordered Controls (NEDC n=252). Participants completed questionnaires that assessed eating behaviors and attitudes, motives for drinking alcohol, quantity and frequency of alcohol use, and binge drinking. The BED group reported greater weekend alcohol consumption and binge drinking than the EDNOS and NEDC groups. The BN and BED groups were significantly more likely to endorse Coping as a drinking motive than the EDNOS and NEDC groups. The NEDC group was more likely to endorse Mood Enhancement than the EDNOS group. These results offer one explanation for the relationship between eating and alcohol use disorders. Women with eating disorders may use alcohol to cope with negative affect, analogous to findings that women with eating disorders report binge eating to regulate negative affect [Mizes, J. S. (1985). Bulimia: A review of its symptomatology and treatment. Advances in Behavior Research and Therapy, 7, 91-142].     

“Diagnostic shift” from eating disorder not otherwise specified to bulimia nervosa using DSM-5 criteria: A clinical comparison with DSM-IV bulimia

In the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the diagnostic threshold for binging and compensation in bulimia nervosa (BN) decreased from twice to once weekly for 3 months. This study investigates the validity of this change by examining whether BN patients and those whose diagnoses “shift” to BN with DSM-5 are similar in their psychological functioning. EDNOS patients whose symptoms met DSM-5 BN criteria (n = 25) were compared to DSM-IV BN patients (n = 146) on clinically relevant variables. No differences were found on: BMI; weight-based self-evaluation; perfectionism; depression and anxiety symptoms; or readiness for change. Differences were found on one Eating Disorder Inventory subscale (i.e., bulimia), with the BN group reporting higher scores, consistent with group definitions. These findings support the modified criteria, suggesting that psychopathology both directly and indirectly related to eating disorders is comparable between those with once weekly versus more frequent bulimic episodes.     

Personality traits after recovery from eating disorders: Do subtypes differ?

OBJECTIVE: We compared individuals recovered from anorexia (AN) and bulimia nervosa (BN) to determine characteristics that are shared by or distinguish eating disorder (ED) subtypes. METHOD: Sixty women recovered for > or = 1 year from AN or BN were compared with 47 control women (CW). Assessments included the Yale-Brown-Cornell Eating Disorder Scale, the Spielberger State-Trait Anxiety Inventory, the Beck Depression Inventory, the Yale-Brown Obsessive Compulsive Scale, the Temperament and Character Inventory, and Structured Clinical Interviews for DSM-IV. RESULTS: Individuals recovered from an ED had similar scores for mood and personality variables that were significantly higher than the scores for CW. Few recovered subjects had Cluster B personality disorder. Most individuals recovered within 6 years of their ED onset. A latent profile analysis identified an "inhibited" and "disinhibited" cluster based on personality traits. CONCLUSION: A wide range of symptoms persist after recovery and do not differ between subtypes of ED. These findings may aid in identifying traits that create vulnerabilities for developing an ED.     

Quality of life and eating disorders

Objective: Eating disorders (EDs) can have a serious impact on various life domains and may lead to physical, mental and social impairment and consequently to poor quality of life (QOL). This study compared the QOL of ED patients and former ED patients in a large community based sample to the QOL of a normal reference group and to the QOL of patients with mood disorders. Differences between ED diagnostic groups were examined. The study investigated what factors contribute to QOL.Methods: A generic health-related quality of life questionnaire, the Short Form-36 (SF-36), and the Eating Disorder Examination-Questionnaire were administered to 156 ED patients – 44 anorexia nervosa patients, 43 bulimia nervosa patients, 69 eating disorder not otherwise specified patients – and 148 former ED patients.Results: ED patients reported significantly poorer QOL than a normal reference group. No differences were found between the diagnostic groups. Former ED patients still had poorer QOL than a normal reference group. ED patients reported significantly poorer QOL than patients with mood disorders. Self esteem contributed most to QOL.Conclusion: EDs have a severe impact on many domains of QOL. Therefore QOL needs to be addressed in effectiveness research and clinical practice.     

Body attitudes in patients with eating disorders at presentation and completion of intensive outpatient day treatment

Due to the importance of the distorted body experience in eating disorder diagnosis and treatment, we wanted to explore body attitudes of patients with eating disorders before and after 5 months of intensive specialized outpatient day treatment. We assessed 193 patients diagnosed with Anorexia Nervosa (AN), Bulimia Nervosa (BN) and Eating Disorder Not Otherwise Specified (EDNOS) using the Body Attitude Test (BAT), Body Mass Index (BMI), Eating Disorder Evaluation Scale (EDES) and Symptom Checklist 90 (SCL-90). Eating disorder subtypes differed in BMI, total body attitudes and negative appreciation of body size at intake, but not at termination of treatment. Following treatment, all patient groups reported large improvements in eating disorder pathology and all but the AN-Restrictive (AN-R) group, reported large improvements in overall psychological functioning. The AN patients demonstrated significant improvement in BMI, however the Anorexia Nervosa purging (AN-P) and Anorexia Nervosa restrictive (AN-R) subtypes differed in their changes in body attitudes. AN-R patients indicated no significant improvement in body attitudes. AN-P patients improved in total body attitudes, except one subscale. Patients with Bulimia Nervosa non-purging (BN-NP) subtype, Bulimia Nervosa purging (BN-P) subtype and EDNOS demonstrated similar improvements in total body attitudes (BAT). Body attitudes provide important insights into differences between eating disorder diagnostic categories and their treatment responsiveness.     

The interaction of personality disorders and eating disorders: a two-year prospective study of patients with longstanding eating disorders

OBJECTIVE: The current study aimed to investigate the relation between personality disorders and symptoms of both eating disorders and general psychopathology over time. METHOD: Seventy-four patients, with a mean age of 30 years and admitted to a hospital for treatment of a chronic eating disorder, were assessed using the Eating Disorder Inventory (EDI), the Eating Disorder Examination (EDE), the Symptom Check List-90-Revised (SCL-90-R), and the Structured Clinical Interview for DSM-IV Axis II disorders (SCID-II) at admission, and after 1 and 2 years. RESULTS: At the 2-year follow-up, there was considerable reduction in both personality and symptoms (effect size = 0.83-0.94). Panel modeling using structural equation modeling techniques indicated that symptomatic changes generally preceded changes in the personality disorder. DISCUSSION: Eating disorder symptoms and general symptomatology had direct effects on a dimensional personality disorder index. Thus, personality disorders may be at least partially a consequence of general symptomatology in chronic eating disorders. Symptom improvement appears to precede changes in personality in this sample of patients with chronic eating disorders.     

The EDE-Q, BULIT-R, and BEDT as self-report measures of binge eating disorder

Binge eating disorder, currently classified as an eating disorder not otherwise specified, is a valid and clinically useful psychiatric diagnosis. Given its probable inclusion in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), identification of self-report measures with high levels of diagnostic utility should improve the likelihood and accuracy of screening. The aim of the current study was to assess the diagnostic utility of two widely used measures of eating disorder symptoms, namely the Eating Disorder Examination-Questionnaire (EDEQ) and the Bulimia Test-Revised (BULIT-R), as well as a factor of the BULIT-R (coined the Binge Eating Disorder Test or BEDT), newly created specifically for the assessment of BED. Participants included 15 individuals with BED and 26 non-BED controls, as determined via the diagnostic section of the Eating Disorder Examination, who met criteria for being overweight or obese. Results showed that the BEDT achieved 100% sensitivity, specificity, positive and negative predictive values. The BULIT-R and Eating Concern subscale of the EDE-Q evidenced strong sensitivity (100 vs 87), specificity (96 vs 100), positive predictive values (94 vs 100), and negative predictive values (100 vs 93), respectively. Results suggest that the BEDT is an excellent overall measure of BED in obese populations. The BULIT-R affords the advantage of ruling out compensatory behaviors, particularly of the non-purging variety (e.g., severe restriction outside of binges), while the brevity of the Eating Concern subscale of the EDE-Q makes it optimal for use in brief screening situations.     

Characteristics of eating disorder patients without a drive for thinness

OBJECTIVE: The aim of this study was to investigate two samples of patients affected by anorexia nervosa (AN) or bulimia nervosa (BN), respectively, with and without the diagnostic feature of drive for thinness (DT). METHOD: The samples comprised 70 consecutive eating disorder (ED) outpatients at the Department of Psychiatry (University of Pisa) and 106 AN patients admitted to a day hospital in Toronto, Canada. Subjects were assessed on clinical and psychometric parameters. RESULTS: In both countries, 17% of the subjects had low DT as measured by the Eating Disorder Inventory (EDI). They comprised the atypical group and appeared to have less severe psychopathology. DISCUSSION: Weight phobia should not be viewed as critical to the diagnosis of ED and DT could be a culture-bound dimension. Considering the differences between the two groups, the characterization of patients as typical and atypical may be clinically useful.     

Exercise and eating disorders: a 3-year inpatient hospital record analysis

The purpose of this study was to describe the exercise behavior across the DSM-IV eating disorder diagnosis (anorexia nervosa (AN), bulimia nervosa (BN), and eating disorder not otherwise specified (EDNOS)) and determine if differences exist among exercise category (high level and low level), type of exercise (aerobic, strength, and total), Eating Attitudes Test (EAT), Eating Disorders Inventory (EDI-2), and the length of inpatient hospitalization. This study was a retrospective analysis of 199 inpatient hospital records of female patients (age M=20.6, S.D.=7.03) in the following diagnostic categories: AN (n=115, 58%), BN (n=38, 19%), and EDNOS (n=46, 23%). Patients were also grouped by a median split into low- and high-level exercise categories based on their total amount of weekly exercise. No significant relationship was found between diagnosis and exercise category (high and low) or diagnosis and exercise type (total, aerobic, and strength exercise). This is valuable because exercise specialist may be a worthwhile addition to treatment teams working with all eating disorder diagnostic groups. The high-level exercisers showed significantly greater scores on the EAT [F(2,1,110)=5.117, P<.05] and weight preoccupation [F(1,1010)=4.861, P<.05] than the low-level exercise groups. There were significant relationships between total exercise and EAT (r=.354, P<.01), drive for thinness (r=.262, P<.01), and body dissatisfaction (r=.312, P<.001). Total aerobic exercise was significantly related to EAT (r=.352, P<.001), drive for thinness (r=.272, P<.01), and body dissatisfaction (r=.268, P<.01). Finally, total strength exercise was related to body dissatisfaction (r=.249, P<.05). A significant difference was found among exercise group and length of hospitalization [F(1,155)=14.384, P<.000]. The high-level exercisers were in treatment for 3 weeks longer than their low-level exercisers. A forced stepwise multiple linear regression was calculated to predict the length of hospitalization. At Step 1, diagnosis and Body Mass Index (BMI) on admission explained 27% of the variance in length of inpatient hospitalization [F(4,154)=18.08, P<.004, r(2)=.273]. When two exercise variables were included, aerobic activity explained an additional 5% of variance, whereas strength activity explained an additional 0.3% of the variance. Three-fourths of the predictors explained significant components of the total 32% variance. The present study demonstrates that patients with greater total exercise and a greater total aerobic exercise show a significantly greater drive for thinness and require a longer length of hospitalization. This association was not present with total strength exercise levels. Effective clinical methods to modify total aerobic exercise levels need to be determined with inpatient populations.     

Assessment of binge eating in overweight youth using a questionnaire version of the Child Eating Disorder Examination with Instructions

OBJECTIVE: Existing self-report methods for assessing eating disorder (ED) symptoms in youth do not adequately measure binge eating and lack sufficient psychometric support. The Youth Eating Disorder Examination-Questionnaire (YEDE-Q), a self-report version of the Child Eating Disorder Examination (ChEDE), was designed to assess the spectrum of ED psychopathology in youth. METHOD: The YEDE-Q was compared to the ChEDE and the Questionnaire for Eating and Weight Patterns-Adolescent version (QEWP-A) in a sample of 35 overweight adolescents aged 12-17. RESULTS: The YEDE-Q showed significant agreement (ps < .001) with the ChEDE on all four subscale scores, the global score, and measurement of objective bulimic episodes. The YEDE-Q and the QEWP-A showed significant agreement (ps < .001) on the measurement of shape and weight concerns. CONCLUSION: The YEDE-Q appears promising in the assessment of eating-related pathology in overweight adolescents, but remains in need of validation in children and ED populations.     

A comparison of the frequency of familial suicide attempts across eating disorder diagnoses

This study examined the prevalence of reported suicide attempts among family members of individuals with an eating disorder (ED). 1870 individuals presenting for ED treatment reported whether their family members ever made a suicide attempt using the Eating Disorders Questionnaire. A lifetime suicide attempt by any family member was reported by 10.8% (n = 202) of the sample and ranged from 7.0% of those with eating disorder not otherwise specified to 16.1% of those with purging disorder. Controlling for age and gender, individuals with bulimia nervosa had a higher prevalence of any familial suicide attempt and mother suicide attempt than individuals with EDNOS; no other differences were observed across ED diagnoses. There were no differences in prevalence of reported suicide attempts made by fathers, brothers, sisters, uncles, or aunts by ED diagnosis. Findings support a growing literature indicating a familial association between EDs and suicide risk.