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Comparative of Women With Bulimia Nervosa and Obsessive-Compulsive Disorder

Cynthia M. Bulik, Deborah C. Beidel, Erich Duchmann, Theodore E. Weltzin, and Waiter H. Kaye

Twenty woman with bulimia nervosa (BN) and 20 indicated higher scores on somatization, interpe~onal women with obsessive-compulsive disorder (OCD) sensitivity, and psychotic&m in the BN sample. Bu- were compared on responses to the Minnesota Mul- limic women did not differ significantly from OCD tiphasic Personality Inventory (MMPI), Symptom women on either obsessive-compulsive measures or Ch~kiist-S~Revi~d (SCL-SO-R), and tha Beck Depres- other measures of . Similarities and differencas sion Inventory (6DI). ~uRivariate analyses showed no in symptom profiles between these two groups are significant differences between bulimic and OCD discussed, as well as their implications for alternative women on the MMPI, although a greater number of treatment approaches for BN. bulimic women showed significant elevations on sev- Copyright 6 1992 by W.8. Saunders Company eral of the clinical scales. Analyses of SCL-90-R profiles

LTHOUGH its precise etiology is un- state of fullness, which she then counteracts by A known, bulimia nervosa (BN) has been purging. viewed as a disorder of weight and Despite their symptomatological similarities, dysregulation influenced by factors such as socio- few studies have directly compared bulimic and cultural pressures to be thin, need for perceived OCD patients; however, several lines of evi- control, affective disturbances, and neurochem- dence suggest this may be a worthwhile area of ical abnormalities.1-3 In addition, obsessive and inquiry and one which may eventually lead to compulsive features have been noted in women enhanced treatment approaches for BN. with BN and its symptoms have been likened to It has been well established that patients with an obsessive-compulsive syndrome.4~6 In ad- anorexia and BN have increased risk for major vanced stages of the disorder, the bulimic woman affective disorder for themselves and in their can occupy several hours per day thinking about family members. ‘-9 Much less attention has food and engaging in binge-purge activities. been directed toward delineating the comorbid- Rosen and Leitenbergs highlight a parallel be- ity and family profiles of anxiety disorders in tween this cycle and behaviors commonly seen this group. In a review of 11 studies of comorbid in individuals with obsessive-compulsive disor- features of anorexia patients (both bulimic and der (OCD). They noted that the purging serves restrictor anorectics were included in many of to “undo” the effects of binging by preventing the studies), RothenberglO concluded that obses- (or the anxiety caused by overeat- sive-compulsive features were the second most ing) in much the same way that compulsive frequently reported comorbid features of handwashing, for example, undoes the effects of disorders. , as predicted, ranked first. contamination (i.e., it is a~ety-reducing). Purg- The results of this summary report were diflicult ing is therefore negatively reinforced by reduc- to interpret, as the data represented subjective ing the bulimic’s fear of weight gain. However, reappraisals of studies that employed a vast important differences do exist. Unlike the indi- range of diagnostic and evaluation procedures. vidual with OCD who avoids situations in which Individual studies of the lifetime prevalence contamination could occur, the bulimic individ- of OCD in women with eating disorders have ual appears to self-induce the aced-provoking reported 15% to 69% in women with only, 7% to 33% in women with BN only, and 15% to 44% in women with both From the Depatiment of Psychology University of Canter- disorders.8J1J2 bury, Christchurch, New Zeuland; the Western Psychiatric Z~t~ture and Clinic, ~nive~i~ of Pittsbu~h School of Medi- Studies that focused on familial psychopathol- cine, Pittsbwgh, PA; and the De~~ment of Psychology, ogy have yielded little information regarding the Louisiana State University, Baton Rouge, LA. prevalence of anxiety disorders in family mem- Address reprint requests to Cynthia M. Bulik, Ph.D., Depati- bers of bulimic women, Several investigations ment of Psychology, Private Bag, ~niv~rsi~ of Canterbury, failed to report data for the anxiety disor- Ch~tchu~h 1, New Zealand. Co~~ght 0 1992 by W B. Saunders Company ders.13-15 Those that did generally found low DolO-440X19213303-0012$03,0010 morbid risksll or low prevalence8 of anxiety

262 Co~p~e~e~sive Psychiaity, Vol. 33, No. 4 (Jul~/August~, 1992: pp 262-268 BULIMIA AND OCD 263 disorders in relatives of patients with eating R’* criteria for OCD. These women were consecutive cases disorders. Methodological complications in- seen by the Anxiety Disorders Clinic at WPIC. Initial IEF diagnoses were confirmed using the Anxiety Disorders cluded failure to assess the relatives directly and Interview Schedule-Revised (ADPY~-R)~~and a variety of utilization of instruments that may have been self-report inventories. Six OCD patients were hospitalized insufficient to provide reliable anxiety disorders and 14 were treated with intensive outpatient intervention. diagnoses. Subjects above the age of 50 were excluded from the study. A second relevant area of inquiry includes No OCD patient had been given a concurrent diagnosis of any . psychometric analyses. Studies of bulimic women generally have revealed a depressed, anxious, Procedure and obsessional symptom profile. Bulimic Both BN and OCD subjects completed the psychological women often produce Minnesota Multiphasic battery before initiation of their respective treatment pro- Personality Inventory (MMPI) profiles with ele- grams. All subjects completed the MMPI,z5 the Symptom vated depression (D); psychopathic deviate (Pd), Checklist-90-R (SCL-90-R),26 and the Beck Depression psychasthenia (Pt), and (SC) Inventory (BDI).*’ The battery was chosen to measure scales.16-l* Similarly, OCD patients commonly general psychopathology, depression, anxiety. and obsession- ality. exhibit elevations on the D, Pt, and SCscales.19*20 The only study to our knowledge that has RESULTS directly compared BN and OCD samples showed that the eating disorder patients (a combined Data Analysis anorexia and BN group) scored more similarly Age and BDI scores were compared using to obsessionals than to individuals with other univariate t tests. Two multivariate analyses of anxiety disorders.6 Unfortunately, the eating covariance (MANCOVAs) were performed disorders data were collected an average of 12 comparing differences between BN and OCD years after the anxiety disorders data, introduc- women on the MMPI and SCL-90-R scales. ing multiple potential sources of error. Univariate ANCOVAs were then performed on This study was designed to assess similarities the significant MANCOVA. To determine and differences in female patients with BN and whether the scale scores could discriminate OCD on measures of general psychopathology, between the BN and OCD groups, a stepwise depression, anxiety, and obsessionality. discriminant analysis was performed followed by a classification analysis. All analyses were

METHOD performed using the Statistical Analysis Sys- tem.“s Subjects All subjects were initially screened using the Initial Evaluation Form (IEF), a semistructured interview rou- The bulimic women were significantly younger tinely used at Western Psychiatric Institute and Clinic (WPIC).z’ Following this interview, patients were referred than the OCD women (23.4 + 5.0 1’ 30.6 + 7.9 to either specialized eating or anxiety disorders clinics for years; t = 3.5, df = 38, P < .OOOl). further evaluation and treatment. The BN group consisted of 20 women who met DSM-III- BDI R’? criteria for BN. The 20 subjects were randomly selected from a patient list of all inpatient admissions in 1989. The BN group scored significantly higher on Subjects younger than 17 or older than 50 were excluded the BDI than the OCD group (BN, 30.2 2 10.4; from the study. The IEF diagnoses were confirmed by OCD, 21.1 + 12.6; t = 2.5, df= 38, P = .02). consensus of the two treating psychiatrists (W.H.K. and The mean BDI score indicates severe depres- T.E.W.) and using self-report ratings from the Diagnostic sion for the BN group and moderate-severe Schedule for Eating Disorders-Revised (DSED-R).23 No bulimic patient had been given a concurrent diagnosis of depression for the OCD group. OCD at the time of admission. Subjects with the diagnosis of eating disorder not otherwise specified were excluded. Of Mh4PI the 20 bulimic women, five were at low body weight (defined MANCOVA was conducted comparing the as <85% of ideal body weight [IBW]), four reported a history of low body weight, and 11 had never been signifi- BN and OCD samples on the MMPI. All t cantly . scores for scales 1 to 10 were entered into the The OCD group included 20 women who met DSM-III- analysis. Age was entered as a covariate. The 264 BULIK ET AL overall MANCOVA was not significant (Wilk’s Table 1. Chi-Square of Elevations on MMPI Clinical Scales A = 0.6, F = 2.0, df= [10,28], P = .07). Fur- No. of No. of ther univariate analyses were therefore not MMPI Scale BN (%I oco (%) x* P performed. 10 (50) 2 (10) 5.8 .02 To explore further the nature of similarities Depression 19 (95) 15 (75) .78* Hysteria 11 (65) 2.6 .ll and differences in response patterns between 5 (25) Psychopathic deviate I5 (75) 7 (35) 4.9 .03 BN and OCD women, we plotted the mean Masculinity-femininityt 1 (5) 1 (5) 1 .o* MMPI profiles for the two groups (Fig 1). 11 (55) 5 (25) 2.6 .ll Interestingly, the pattern of response was simi- Psychasthenia 17 (85) 16 (80) 1.0’ lar between groups, but the BN mean profile Schizophrenia I? (85) 11 (55) 3.0 .08 Hypomania 1 .o* indicated greater overall psychopatholo~. The 1 15) 1 (6) Social introversion 11 (55) 7 (35) 0.9 .34 mean MMPI profile for the BN group was a *Denotes Fisher’s exact test probability. 2-4-7-8 profile, and the mean OCD profile was a tT.scores < 30. 2-7 high point pair. As profiles based on group means can occa- sionally be misleading, we examined profile (Wilk’s A = 0.40, F = 4.1, df = [10,28], patterns for individual subjects and the number P = .OOl). Table 2 presents results of the univari- of subjects in each group who had t scores ate ANCOVAs and posthoc analyses for the greater than 70 on each of the clinical scales. scale scores. The fact that more BN than OCD For the BN group, one subject had a 2-4-7-8 women were hospitalized was reflected in their profile, and five had a 2-7-8 profile. Ninety-five higher Global Symptom Index (GSI) scores. percent of the bulimic women had an elevated scale 2, 75% an elevated scale 4, 85% an Comparison of UnderweightVersus elevated scale 7, and 85% an elevated scale 8. Normal-Weight Eating Disorder Samples For the OCD group, two subjects displayed We then attempted to determine whether the the 2-7 high point pair, and seven had a 2-7-8 high obsessionali~ evidenced in the BN group profile. Seventy-five percent of the OCD women was due primarily to those individuals who had an elevated scale 2, 80% an elevated scale either were at the time of the study or had a 7, and 55% an elevated scale 8. history of low body weight ( < 85% IBW). To do Chi-square analyses indicated that signifi- so, we subdivided the BN sample into low- cantly more bulimic women than OCD women weight (n = 9) and normal-weight (n = 11) had elevations on MMPI scales Hs (hypochon- groups and performed t tests on the 10 MMPI driasis) and Pd (Table 1). and 10 SCL-90-R scale scores. The low-weight and normal-weight groups did not differ signifi- SCL-90-R cantly on any of the MMPI clinical scales. A second MANCOVA was then performed Likewise, there were no significant differences comparing SCL-90-R t scores between BN and between the two groups on the obsessive- OCD samples. Age was entered as the covari- compulsive, anxiety, or phobic anxiety scales of ate. The overall MANCOVA was significant the SCL-90-R. The low-weight bulimics did score significantly higher on interpersonal sensi- tivity (81.7 Z!Z7.4 v 74.3 + 7.3, t[18] = -2.2, P = 0.03), depression (76.2 2 5.8 v 68.5 2 7.8, t[18] = -2.4, P = .03), hostility (66.3 + 8.4 v 57.5 2 5.6, t[18] = -2.5, P = .02), psychoticism (81 2 10.6 v 71.5 + 9.5, t[18] = -2.1, P = .05), and the GSI (77.8 + 8.8 v 69.3 + 7.8, t[18] = -2.3, P = .003)

DISCUSSION The results of this study show marked similar- Fig 1. Mean MMPI profiles of BN and OCD women. ities between women with BN and OCD on trait BULIMIA AND OCD 265

Table 2. Mancova for SCL-90-R Scales and Univariate ANCOVAs

BN OCD

Observed Observed Mean 2 SD Corrected Mean k SD Corrected F SCL-90-R Scale h = 201 Mean t SE In = 20) Mean k SE w 12,371) P

Somatization 66.1 2 9.7 65.8 + 2.0 52.7 + 6.4 53.0 -+ 2.0 12.9 Obsessive-compulsive 73.8 + a.8 72.5 I 2.7 68.5 -t 13.6 69.7 -c 2.1 1.8 .7a Interpersonal sensitivity 77.6 + a.1 78.9 + 2.4 65.0 + 11.8 63.7 + 2.4 9.0 ,001 Depression 72.0 f 7.9 72.5 + 2.5 64.0 + 12.1 63.5 + 2.5 3.2 .05 Anxiety 66.2 + 9.8 66.1 + 2.6 65.3 + 11.3 65.3 + 2.6 0.04 .96 Hostility 61.5 t 8.8 62.1 + 1.9 56.3 + 6.4 55.6 ‘- 1.9 2.7 .08 Phobic anxiety 62.9 -r 9.2 63.1 f. 2.2 59.3 + 9.1 59.0 + 2.2 0.8 .46 Paranoia 68.6 2 10.4 68.9 I 2.6 60.5 2 11.2 60.1 k 2.6 2.8 .07 Psychoticism 75.8 + 10.8 75.8 + 2.9 65.7 ? 13.2 65.7 +- 2.9 3.4 .04 GSI 73.1 t 9.1 73.3 + 2.4 63.8 -+ 11.9 63.6 k 2.4 4.2 .02

NOTE, MANCOVA (Wilk’s A = 0.40, F = 4.1, df [10,28],P = .OOl). measures of personality and psychopatholo~. size and shape may extend to a vigilance over However, differences did emerge when compar- other somatic s~ptoms. We wiil discuss this ing current symptom profiles of both groups. hypothesis in greater detail below. On the MMPI, the vast majority of both BN A second difference noted in MMPI profiles and OCD women exhibited clinically significant was that significantly more bulimic than OCD elevations on scales 2 (depression) and 7 (psy- patients showed elevations on scale 4 (psycho- chasthenia). Elevations on scale 2 suggest de- pathic deviate), which may reflect impaired pression, social withdrawal, low self-confidence, impulse control commonly thought to be part of and physical symptoms commonly associated the bulimic disturbance~9-31; however, higher with depression. Scale 7 elevations in this range scores on Pd would also be expected in a are suggestive of anxiety and tension, as well as younger sample.3” a fearful and apprehensive state. Obsessions, The greater (although nonsignificant) eleva- compulsions, and ruminations are common in tion in the BN group on the MMPI profile and individuals with high scores on this scale. They the significantly higher scores on the BDI and also tend to be perfectionistic, self-critical, and XL-90-R GSI may well be an artifact of sam- plagued by doubt. pling. As 100% of the BN subjects required The 2-7-8 profile was common in both groups. inpatient treatment, onIy the most severe of BN Traditionally, this profile reflects depression, patients are represented here. In contrast, only anxiety, and nervousness, and strong obses- 30% of OCD women were hospitalized and sional characteristics. In addition, the 2-7-8 hence the sample includes a wider range of tends to set high standards and feel guilty when psychopathology. they are not met. Feelings of inadequacy and The greatest difference between the two inferiority are common as is a schizoid personal- groups emerged in the SCL-90-R subscales. ity style. Confirming the MMPI results, BN women scored Differences in MMPI profiles included the significantly higher than the OCD women on more frequent elevation on scale 1 (hypochon- the somatization scale, which measures distress driasis) in the bulimic women. This elevation arising from perceptions of bodily dysfunction could be due to several factors. One possibility by assessing an array of physical complaints. is that the bulimic women did indeed suffer Although the BN group scored significantly from a variety of physical disturbances second- higher than the OCD women, their mean score ary to binge-eating, , poor nutrition, was not elevated above the clinically significant abuse, and disturbances, range (t > 70). Again, the higher scores in the which emerges as a preoccupation with physical BN women could reflect actual disease pro- complaints or symptoms. Alternatively, the close cesses or physical problems secondary to the scrutiny with which bulimics monitor their body eating disorder. It is also possible that they, in 266 BULIK ET AL contrast to the OCD patients, focus a great to inclusion by bulimic women of obsessional amount of attention to the physical workings of thoughts and beiiefs about , weight, their body and may be hypervigilant to minor and food. Although worthy of further inquiry, a physica changes or symptoms. On the other recent study by Kaye et a1.35 on anorectic hand, a greater number of OCD patients may women indicated that they scored comparably have a more externalized focus and spend a to OCD patients reported in the literature on greater amount of time scanning the environ- the Yale-Brown Obsessive-Compulsive Scale36*37 ment for threatening stimuli. after exclusion of all body- and food-related Bulimic women also scored higher on the items suggesting that obsessionali~ is not just depression, interpersonal sensitivity, and psy- limited to symptoms of the eating disorder. choticism scales. While the D scores confirm the It is clear that a fear of weight gain is central BDI findings, high scores on interpersonal sensi- to BN; however, our findings indicate that their tivity suggest feelings of personal inadequacy, fears may be as pervasive and complex as those inferiority, and extreme social discomfort. This seen in OCD patients. For example, the stimuli scale includes items that could reflect the bulim- that produce anxiety for the bulimic are most ic’s discomfort about eating and physical appear- likely more than just weight gain. Other specific ance such as “feeling uncomfortable about eat- adieu-producing stimuli may include stomach ing or drinking in public” or “feeling uneasy fullness, fit of clothes, decreased activity, seeing where people are watching or talking about other thin or obese individuals, sight, taste, and you”; however, it may also reflect a more smell of high-risk foods, mirrors, etc. As in generalized fear of negative evaluation and OCD, random exposure to these stimuli occurs discomfort in social situations. Indeed, we have throughout the day, which leads to heightened recently shown that both bulimic and anorexic vigilance, anxiety, and dysphoria common to women score ~mparably high to women with both disorders. social on the Social Phobia and Anxiety Given the similarities in symptom profiles Inventory33 and that these elevations are not between BN and OCD women and the seem- due solely to fears of eating in public, but rather ingly viable conceptualization of BN as similar reflect a more prototypic social phobic stance.34 to OCD with patients displaying pervasive obses- Finally, the clinically elevated psychoticism sional thinking about food and body weight, scale may less reflect frank psychotic experi- food-related rituals, and possibly compulsive ences and more tap the socially withdraw and binging and purging, it is relevant to examine schizoid life-style that often develops during the feasibility of applying treatments known to extreme phases of the bulimic disorder. be effective in OCD to intervention in bulimic It is of particular interest that the BN women women. scored comparably to the OCD women on the The efficacy of for BN, which has three SCL-90-R anxiety scales (obsessive-com- been shown to be effective for 0CD,38,39 has pulsive, phobic anxiety, and anxiety). Although shown initial positive resuits.40,41 In terms of one would expect to find a high degree of behavioral interventions, exposure with re- anxiety and depression in both of the disorders, sponse prevention is considered the treatment the fact that the BN group displayed compara- of choice for patients with 0CD,39,42with approx- ble and numerically higher levels than the OCD imately 70% to 90% of patients showing moder- patients may be important in the further concep- ate to significant symptomatic improvement and tualization of the disorder. Also, it is of particu- gains being maintained in follow-up periods lar interest that the high obsessionality and ranging from several months to several years. A anxiety scores were not limited to those individ- debate continues in the literature on BN as to uals with current or past-low body weight and whether the addition of exposure with response that these symptoms also occur in the normal- prevention techniques to baseline cognitive- weight bulimia population. behavioral treatment enhances43a44 or detracts One possible interpretation of these findings from treatment outcome.45 Williamson et a1.46 is that elevated scores on the OCD scale are due concluded that ERP (exposure with response BULIMIA AND OCD 267 prevention) is an effective treatment for some ing following exposure to high-risk cues would bulimics, but that a significant number of pa- produce more lasting results. tients are not symptom-free at the end of In summary, this study found marked similar- treatment and that relapse prior to follow-up ities in trait-related personality and psycho- often occurs. Each of the aforementioned stud- pathological features between women with BN ies used exposure to eating with prevention of and those with OCD. Given the relatively small vomiting. One could question whether the trials sample size used here, future studies examining were adequate, as all cues were not incorpo- larger numbers of women should continue to rated, and whether response prevention was explore the nature of anxiety in women with BN correctly applied. Perhaps prevention of bing- and related eating disturbances.

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