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Lifetime Anxiety Disorders in Women with Bulimia Nervosa

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Lifetime Anxiety Disorders in Women with Bulimia Nervosa Lifetime Anxiety Disorders in Women With Bulimia Nervosa Cynthia M. Bulik, Patrick F. Sullivan, Frances A. Carter, and Peter R, Joyce We examined the prevalence and ages at onset of ence of a mood or anxiety disorder revealed no differ- additional childhood and adult psychiatric disorders in ences in the core bulimic symptoms across groups. women with bulimia nervosa and evaluated the differ- The presence of a mood disorder was associated with ential impact of a mood or anxiety disorder on the greater body dissatisfaction, lower Global Assessment presentation of bulimia nervosa. One hundred four- of Functioning Scales (GAFS) score, more externaliz- teen women participating in a clinical trial of cognitive- ing disorders of childhood, and, as expected, higher behavioral therapy for bulimia nervosa were assessed Hamilton Depression Rating Scale (HDRS) scores. The at pretreatment with structured diagnostic methodol- presence of an anxiety disorder was related to a ogy. Although mood disorders were the most fre- history of anorexia nervosa and earlier age at onset of quently occurring additional psychiatric disorder (75%), drug or alcohol dependence. Early-onset anxiety disor- 64% experienced an additional anxiety disorder. Age ders are prevalent and may represent one potential at onset of the anxiety disorders was markedly earlier pathway to bulimia nervosa. than age at onset of bulimia nervosa or other comorbid Copyright © 1996by W.B. Saunders Company conditions. Stratification of the sample on the pres- A SUBSTANTIAL NUMBER of investiga- entire sample had a lifetime anxiety disorder. tions have examined patterns of concur- Brewerton et al. 11 also found a 36% prevalence rent and lifetime comorbidity in women with of anxiety disorder in bulimic women, with 71% bulimia nervosa. 1-9 Most of these studies have showing the onset of anxiety disorders before focused on the high prevalence of lifetime the onset of bulimia. In a related study, Deep et affective disorders in bulimic women. Fewer al. 12 found that 75% of 25 long-term weight- have addressed prevalence of anxiety disorders. recovered anorectics had a lifetime diagnosis of In studies that have examined ages at onset of one or more anxiety disorders and that 58% had additional psychiatric disorders, a consistent the onset of one or more childhood anxiety finding has emerged--anxiety disorders tend to disorders before age 18. Seventy-nine percent occur substantially earlier than the onset of of these women had the onset of the anxiety bulimia nervosa. disorder before the onset of anorexia nervosa. Schwalberg et al. 1° found that 75% of women There was no difference in the prevalence of with bulimia nervosa had an additional lifetime anxiety disorders between restrictor and bu- diagnosis of an anxiety disorder, and 59% of limic anorectics. Taken together, these four these women reported that the age at onset of studies suggest that early-onset anxiety disor- the anxiety disorder preceded the onset of ders may be of etiological significance, or may in bulimia. Braun et al. 6 compared the prevalence some way predispose individuals to the develop- of anxiety disorder across subtypes of women ment of bulimia nervosa. with eating disorders and found that more The present study was designed to replicate women with concurrent anorexia and bulimia and extend these findings in a sizeable sample nervosa tended to have an anxiety disorder as of women with bulimia nervosa. All subjects their first psychiatric diagnosis, and 37% of the were studied with structured diagnostic method- ology. We hypothesized that the majority would report lifetime affective and anxiety disorders From the Department of Psychology, University of Canter- and that early-onset anxiety disorders--but not bury, Christchurch; and the University Department of Psycho- early-onset affective disorders--would be preva- logical Medicine, Christchurch School of Medicine, lent in women with bulimia nervosa. Christchurch, New Zealand. P.F.S. was supported by a research training fellowship from METHOD the Health Research Council of New Zealand. This project was supported by grants from the Health Research Council and the The subjects for this study were 114 women aged 17 to 45 Lottery Grants Board. years who participated in an outpatient trial of three Address reprint requests to Cynthia M. Bulik, Ph.D., Depart- psychological treatments for bulimia nervosa. 1315 All of ment of Psychology, University of Canterbury, Private Bag these women met DSM-III-R 16 criteria for bulimia nervosa 4800, Christchurch, New Zealand. with clearly "objective" binges. 17 Exclusion criteria were Copyright © 1996 by W.B. Saunders Company current anorexia nervosa, a body mass index < 17 or _> 30 0010-440X/96/3705-0008503.00/0 kg/m z, and the current use of psychoactive medication (e.g., 368 ComprehensivePsychiatry, Vol. 37, No. 5 (September/October), 1996: pp 368-374 LIFETIME ANXIETY IN BULIMIA 369 antidepressants). Three of the subjects presented here were Table 1. Lifetime Psychiatric Disorders in a Cohort of 114 not entered into the treatment study because it was judged Women with Bulimia Nervosa clinically that bulimia nervosa was not the principal current Lifetime diagnosis (one because of current severe major depression Prevalence Age at Onset and two because of current severe alcohol dependence). Disorder % No. (mean-+ SD) The clinical trial was publicized widely in the media and in publications for local eating disorders support groups. Bulimia nervosa 100 114 20 -+ 5 Patients were either self-referred or referred from general Anorexia nervosa* 25 28 19 -+ 4 practitioners and mental health workers. The study had Mood disorder1" 75 85 18 -+ 6 received prior ethical approval and all subjects provided Major depression 54 62 19 -+ 6 written informed consent. Bipolar II mood disorder 18 20 16 -+ 4 All subjects underwent a 2- to 4-hour assessment con- Anxiety disorder¢ 64 73 8 -+ 7 ducted by one of the authors. This assessment consisted of Social phobia 30 34 11 -+ 5 the Structured Clinical Interview for DSM-III-R (SCID) 18 Simple phobia 30 34 9 -+ 6 which we modified to obtain more information about Overanxious disorder 27 31 7 + 4 lifetime history of eating disorders and related behaviors. Separation anxiety disorder 10 11 7 -+ 4 Age at onset of each of the disorders was established in the Panic disorder 10 11 21 -+ 8 "chronology" section of each diagnostic module, which Drug or alcohol dependence 48 55 19 -+ 5 determines the age at onset of each individual disorder. In Alcohol dependence 47 54 20 --+ 5 addition, we assessed the presence of four childhood Any drug dependence§ 22 25 19 -+ 4 psychiatric disorders (overanxious disorder, separation anxi- Childhood externalizing disorder 26 30 NA ety disorder, attention deficit-hyperactivity disorder, and Conduct disorder 23 26 NA oppositional-defiant disorder). 16 The presence of these Oppositional defiant disorder 10 11 9 -+ 3 disorders before age 18 was assessed with supplementary Attention deficit-hyperactivity dis- modules of the Schedule for Affective Disorders and Schizo- order 7 8 5 -+ 2 phrenia-Lifetime Version19 written by Kathleen R. Merikan- Abbreviation: NA, not available. gas, Ph.D., and colleagues at Yale University. Only behav- *An additional 9% had subthreshold anorexia nervosa. iors or symptoms present frequently or constantly, and tLow rates of dysthymia (4%, n = 4) were found. The dysthy- which clustered in the same time period, were considered to mia section in the SCID is skipped for subjects with major satisfy diagnostic criteria. The interviewing clinician also depression for more than half of the prior 2 years, for those who completed the Structured Clinical Interview for DSM-III- have ever experienced a manic or hypomanic episode, or those R--Personality Disorders (SCID-II) ~° to assess the pres- with a chronic psychotic disorder. ence of the 11 DSM-III-R personality disorders.16 Conduct ~tLow endorsement rates were found for obsessive-compul- disorder was assessed as part of the SCID-II. Finally, the sive disorder (4%, n = 4), agoraphobia without panic disorder interviewing clinician completed the 17-item Hamilton De- (2%, n = 2), and generalized anxiety disorder (2%, n = 2). As pression Rating Scale (HDRS), 21 Global Assessment of the section on generalized anxiety disorder (GAD) in the SCID is Functioning Scale (GAFS), 16 and a structured interview skipped for subjects with a current mood disorder, the rate of that assessed bulimic symptomatology in the prior fortnight GAD may be spuriously low. including the number of objective binges, the total episodes §There was considerable overlap across drug categories. The of purging via vomiting and via laxatives, and the degree of most prevalent were cannabis dependence (16%, n = 18) and food restriction and body dissatisfaction. All statistical stimulant dependence (10%, n = 11). analyses were performed with the JMP statistics package. 22 RESULTS interest, the prevalence of lifetime alcohol or The majority of the present sample of bulimic drug abuse was quite low suggesting an "all or women met diagnostic criteria for at least one nothing" approach to substance use in these additional lifetime psychiatric disorder besides women. Externalizing disorders of childhood bulimia nervosa (89% or 102 of 114). Mood (especially conduct disorder) had been present disorders (75 %) were the most prevalent comor- in 26% of our sample. Finally, 25% of these 114 bid condition (Table 1). Of note, the bipolar II bulimic women had met criteria for anorexia pattern of full depressive and hypomanic epi- nervosa. sodes was relatively common. Lifetime anxiety The age-at-onset data in Table 1 clearly disorders (particularly social phobia, simple suggest that anxiety disorders had the earliest phobia, and childhood overanxious disorder) mean age at onset (8 years). Panic disorder is a were an additional diagnosis in 64% of these conspicuous exception since its mean age at bulimic women. Forty-eight percent of our onset tended to be considerably later (21 years). sample also met criteria for alcohol or drug The mean age at onset of bulimia nervosa (20 dependence at some point in their lives.
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