The Comorbidity Between Eating Disorders and Anxiety Disorders, Many Are Plagued by Methodological Problems, Limiting the Usefulness of Findings

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JESSICA. M. SWINBOURNE BA (Psych) GD Science (Psych)

A thesis submitted in fulfillment of the requirements for the degree of DOCTOR OF CLINICAL PSYCHOLOGY / DOCTOR OF PHILOSOPHY

Department of Psychology Faculty of Science The University of Sydney

July 2008

Statement of Originality

This thesis is submitted to the University of Sydney in fulfilment of the requirements for the Degree of Doctor of Clinical Psychology / Doctor of Philosophy. The work presented in this thesis is, to the best of my knowledge and belief, original except as acknowledged in the text. I hereby declare that I have not submitted this material, either in full or in part, for a degree at this or any other institution.

______J.M. Swinbourne Date

2 ABSTRACT

Research indicates that eating disorders and anxiety disorders frequently co-occur. The prevalence of anxiety disorders amongst anorexia nervosa and bulimia nervosa samples has been reported in a number of investigations. Despite the significant number of research papers investigating the comorbidity between eating disorders and anxiety disorders, many are plagued by methodological problems, limiting the usefulness of findings. Furthermore, there is a significant lack of research examining the prevalence of eating disorders among anxiety patients, and as a result, the frequency of eating disorder pathology among patients presenting to specialty anxiety clinics is unclear. The current research investigated the prevalence of comorbid eating and anxiety disorders amongst 152 women presenting for either eating disorder treatment or anxiety disorder treatment. The prevalence of anxiety disorders was determined from a sample of 100 women presenting for inpatient and outpatient eating disorder treatment. The prevalence of eating disorders was determined from a sample of 52 women presenting for outpatient treatment of an anxiety disorder. The current study found that 65% of women with eating disorders also met criteria for at least one comorbid anxiety disorder. Furthermore, 69% reported the onset of the anxiety disorder to precede the onset of the eating disorder. Of the anxiety disorders diagnosed, Social Phobia was most frequently diagnosed (42%) followed by PTSD (26%), GAD (23%), OCD (5%), Panic/Ag (3%) and Specific Phobia (2%). We also found that 13.5% of women presenting for anxiety treatment also met criteria for a comorbid eating disorder. The results of this study suggest that the prevalence of eating and anxiety disorder comorbidity is high. It is hoped that the present research will have significant etiological and therapeutic implications and further the understanding of the development and maintenance of eating disorder pathology.

OVERVIEW

The present research endeavours to investigate the prevalence of comorbid eating disorders and anxiety disorders. Chapter 1 provides a general overview of the eating disorders, Anorexia Nervosa, Bulimia Nervosa and Eating Disorder Not Otherwise Specified, as well as the available literature investigating eating disorders, including diagnosis, assessment, comorbidity, treatment and outcome. Chapter 2 provides a general overview of the anxiety disorders including core features and a review of the literature regarding diagnosis, assessment, comorbidity, and treatment of anxiety disorders. Chapters 3 and 4 provide a detailed literature review of the research investigating comorbidity between anxiety and eating disorders. These chapters also pay special attention to the methodological limitations inherent in much of the research investigating this area to date. Chapter 5 outlines the aims and objectives for the current study. The methodology for the current study is described in Chapter 6. Chapter 7 outlines the characteristics of the samples. Chapter 8 outlines the results obtained from the current study. Chapter 9 consists of a discussion of the results obtained, as well as a discussion on the strengths and limitations of the current study and directions for future research in the area of eating disorder and anxiety disorder comorbidity.

ACKNOWLEDGEMENTS

I would sincerely like to thank all the women who were so generous with their time and were willing to participate in my research. Your courage in discussing such difficult and personal issues was incredible, and without your support this research would not have been completed. I hope that this research may in some way, help you and others who continue to struggle with an eating or anxiety disorder.

I would also like to acknowledge the ongoing support from all the health professionals who were involved in this research. In this regard, I am especially grateful to Adrienne Alexander, Natalie Crino, Olivia Patrick and Dr Margaret Sheridan.

My sincerest thanks also to my associate supervisors, Dr Caroline Hunt, Dr Maree Abbott, Professor Janice Russell and Tamsen St Clare, whose assistance throughout this research was vital. I would also like to thank Dr Margaret Charles for her statistical assistance throughout this research.

I am indebted to my supervisor, Professor Stephen Touyz, for his constant enthusiasm, encouragement, support and guidance of this research and thesis. The supervision of such a respected figure in the area of eating disorders has been instrumental in furthering my learning in clinical psychology and research. In particular, Stephen has highlighted to me the importance of continued efforts to improve treatment and outcomes for individuals suffering from eating disorders.

I would also like to thank my Mum and Dad, my brother Malcolm and sister-in-law Paula (and my new nephew Alistair) and my Uncle Pete, for their constant love and support over the years and for never losing faith that I would finally finish my studies. I also thank my parents for instilling in me a love of learning and for always encouraging me to

5 give things a go. I am also lucky to have a wonderful group of friends, who have provided welcomed distraction, as well as enormous support over many years.

It is with sadness I acknowledge my friend Jared whose life was tragically cut short in November 2007. I admired Jared’s wisdom, kindness, energy and passion for life. He is dearly missed by many.

Finally, I would not have completed this research without the incredible love and support of my husband Banjo. I am constantly amazed by your patience, enthusiasm, your unwavering belief in me and your endless encouragement. If only I could find the words.

Jessica Swinbourne July, 2008

PREFACE

The study presented in this thesis represents research undertaken by the candidate in conjunction with other professionals and researchers at the Wesley Private Hospital inpatient and outpatient eating disorder unit, Northside Clinic inpatient eating disorder unit, Westmead Hospital Anxiety Treatment and Research Unit, Westmead Hospital Eating Disorder Day Program, the University of Sydney Psychology Clinic and Psychology and Psychiatry Practices in the Sydney Metropolitan area. Ethics was granted by the University of Sydney Human Research Ethics Committee, South West Sydney Area Health Service Human Research Ethics Committee, South West Sydney Area Health Service Scientific Advisory Committee and Northside Clinic.

The candidate was involved in all aspects of the study and was responsible for coordinating the study under the supervision of Professor Stephen Touyz, Dr Caroline Hunt, Dr Maree Abbott, Professor Janice Russell and Tamsen St Clare.

The contributions of the candidate include: Study design: The candidate was responsible for designing the study, under the guidance of Professor Stephen Touyz. The candidate was also responsible for recruiting the study sample of 152 participants from Wesley Private Hospital inpatient eating disorder unit, Northside Clinic inpatient eating disorder unit, Westmead Hospital Anxiety Treatment and Research Unit, Westmead Hospital Eating Disorder Day Program, the University of Sydney Psychology Clinic and Psychology and Psychiatry Private Practices located in the Sydney Metropolitan area. The candidate was responsible for conducting assessments on participants, as well as for selecting the assessment measures, questionnaires and demographic questions utilsed in this study.

Data collection, entry and analysis: The candidate was responsible for all aspects of data collection, entry and analyses. The candidate was responsible for the hypotheses derived

7 within this thesis. All data presented in this thesis was analysed by the candidate under the guidance of Professor Stephen Touyz and Dr Margaret Charles.

Manuscripts: The candidate was responsible for the conceptualisation and the interpretation of the data and was the principle author of the manuscripts presented in this thesis, under the supervision of Professor Stephen Touyz.

CONTENTS

Abstract………………………………………………………………………………….3 Overview………………………………………………………………………………...4 Acknowledgements……………………………………………..………………………5 Preface…………………………………………………………………………………..7 List of Tables…………………………………………………………………………...16 List of Figures………………………………………………………………………….19 Publications and Presentations Arising from the Research…………………………21 List of Abbreviations…………………………………………………………………..23

Chapter 1 INTRODUCTION TO THE EATING DISORDERS 24

1. 1 Anorexia Nervosa: Core Features…………………………………………………24 1.2 Bulimia Nervosa: Core Features…………………………………………………..27 1.3 Eating Disorders Not Otherwise Specified: Core Features………………………..30 1.4 Assessment………………………………………………………………………...31 1.4.1 DSM-IV Classification…………………………………………………..31 1.4.2 Assessment Instruments………………………………………………….34 1.5 Comorbidity of Mental Disorders …………………………………………………36 1.5.1 Mood Disorders…………………………………………………………..37 1.5.2 Substance-Abuse Disorders………………………………………………37 1.5.3 Personality Disorders……………………………………………………..37 1.6 Treatment…………………………………………………………………………...39 1.6.1 Anorexia Nervosa………………………………………………………...39 1.6.2 Bulimia Nervosa………………………………………………………….41 1.6.3 Eating Disorder Not Otherwise Specified………………………………..43

9 1.7 Outcome…………………………………………………………………………….44 1.7.1 Anorexia Nervosa………………………………………………………...45 1.7.2 Bulimia Nervosa………………………………………………………….47 1.7.3 Eating Disorder Not Otherwise Specified………………………………..48 1.8 Summary……………………………………………………………………………48

Chapter 2 INTRODUCTION TO THE ANXIETY DISORDERS 50

2.1 Panic Disorder and Agoraphobia……………………………………………...……51 2.2 Specific Phobia ……………………………………………………………..…...…56 2.3 Social Phobia ………………………………………………………………………58 2.4 Obsessive Compulsive Disorder ……………………………………………...……60 2.5 Post Traumatic Stress Disorder……………………………………………………..62 2.6 Generalised Anxiety Disorder………………………………………………………67 2.7 Assessment……………………………………………………………….…………69 2.7.1 DSM-IV Classification ………………………………………..…………69 2.7.2 Assessment Instruments ………………………………………………….70 2.8 Comorbidity of Mental Disorders ………………………………………………….70 2.8.1 Mood Disorders…………………………………………………………..70 2.8.2 Substance Abuse Disorders……………………………………………….71 2.8.3 Personality Disorders……………………………………………………..71 2.9 Treatment…………………………………………………………………………...72 2.10 Summary……………………………………………………………………………75

Chapter 3 LITERATURE REVIEW: THE COMORBIDITY 77 OF EATING DISORDERS AND ANXIETY DISORDERS – A REVIEW

The comorbidity of eating disorders and anxiety disorders: a review…………………...78

Chapter 4 EATING DISORDER AND ANXIETY DISORDER 100 COMORBIDITY

4.1 Introduction to Research…………………………………………………………..100 4.1.1 Defining Comorbidity………………………………………………...…100 4.1.2 Background to the comorbidity between eating disorders and anxiety…101

4.2 Eating Disorder Comorbidity with Anxiety Disorders…………………………….111 4.2.1 Obsessive Compulsive Disorder…………………………………………111 4.2.2 Social Phobia……………………………………………………………113 4.2.3 Agoraphobia…………………………………………………………...... 115 4.2.4 Panic Disorder…………………………………………………………...115 4.2.5 Specific Phobia………………………………………………………….116 4.2.6 Post Traumatic Stress Disorder…………………………………...……..116 4.2.7 Generalised Anxiety Disorders…………………………………….....…118 4.3 Perfectionism and Obsessive Compulsive Personality Disorder………………….119 4.4 Temporal Relationship Between Eating Disorders and Anxiety Disorders……….121 4.5 Eating Disorders amongst Anxiety Disorder Populations……………...…………125 4.6 Implications for Treatment and Outcome…………………………………………127 4.7 Methodological Limitations in the Research……………...………………………128 4.7.1 Sample Sources and Selection…………………………………..………128 4.7.2 General Methodological Limitations……………………………………129 4.7.3 Diagnostic Criteria for Eating Disorders and Anxiety Disorders….……129 4.7.4 Diagnostic Instruments……………………………………………….…130 4.8 Summary and Research Implications…………………………………………...…131

Chapter 5 AIMS AND OBJECTIVES FOR THE CURRENT 132 STUDY

5.1 Background……………………………………………………………..…………132

11 5.2 Aims of the Current Study………………………………………………………..133 5.3 Objectives for the Current Study…………………………………………………134 5.3.1 Objectives regarding the Eating Disorder sample…………………...…134 5.3.2 Objectives regarding the Anxiety Disorder sample……………………135 5.3.3 Objectives regarding the Anxiety Disorder Diagnoses……………...…135

Chapter 6 METHOD 136

6.1 Study Design………………………………………………………………………136 6.2 Ethics Approval ……………………………………………………………..……136 6.3 Participants……………………………………………………………………...…137 6.3.1 Eating Disorder Inpatient Sample……………………………...………..137 6.3.2 Eating Disorder Outpatient Sample…………………………………..…138 6.3.3 Anxiety Disorder Outpatient Sample……………………………………138 6.4 Assessment Measures……………………………………………………………..138 6.4.1 Eating Disorder Assessment Measures……………………………….…138 i) Eating Disorder Examination…………………………………….…139 ii) Eating Disorder Examination – Questionnaire…………………...…139 iii) Eating Attitudes Test……………………………………………….140 iv) Eating Disorder Inventory………………………………………..…140 6.4.2 Anxiety Disorder Assessment Measures…………………………..……141 i) Anxiety Disorder Interview Schedule………………………………141 6.4.3 Depression Assessment Measure……………………….………………141 i) Depression Anxiety and Stress Scale………………………………141 6.4.4 Socio-Demographic Questionnaire…………………………………...…142 6.4.5 Height and Weight Measurements………………………………………142 6.4.6 Excluded Measures…………………………………………………...…142 i) Beck Depression Inventory – II………………………………………142 ii) Anorexia Nervosa Stages Of Change –Questionnaire………………143 iii) Eating Disorder Belief Questionnaire………………………………144

12 iv) Anxiety Questionnaires…………………………………………..…144 6.5 Procedure……………………………………………………………………….…148 6.5.1 Eating Disorder Participants………………………………………….…148 i) Inpatient Sample………………………………………………….…148 ii) Outpatient Sample………………………………………………..…149 6.5.2 Anxiety Participants…………………………………………………..…149 6.5.3 Age at Onset………………………………………………………..……150 6.6 Statistical Analysis…………………………………………………………...……150 6.6.1 Data Screening………………………………………………………..…150 6.6.2 Statistical Analyses………………………………..………………….…151

Chapter 7 SAMPLE CHARACTERISTCS 152

7.1 Recruitment of the Eating Disorder Sample………………………………………152 7.1.1 Inpatient ED Sample………………………………………………….…152 7.1.2 Outpatient ED Sample………………………………………………..…153 7.2 Recruitment of the Anxiety Disorder Sample…………………………….………153 7.3 Characteristics of the Eating Disorder Sample……………………………………154 7.3.1 Inpatient ED Sample………………………………………………….…154 7.3.2 Outpatient ED Sample……………………………………………..……155 7.4 Characteristics of the Anxiety Disorder Sample………………………………..…157 7.5 Sample Comparisons……………………………………………...………………163

Chapter 8 RESULTS 165

8.1 The Prevalence of Comorbid Anxiety and Eating Disorders……… .……………165 8.1.1 Inpatient Eating Disorder Sample…………………………………….…165 8.1.2 Outpatient Eating Disorder Sample…………………………………..…169 8.1.3 Entire Inpatient and Outpatient Eating Disorder Sample………….……172

13 8.1.4 Outpatient Anxiety Eating Disorder Sample……………………………183 8.2 The Temporal Relationship between Comorbid Anxiety and Eating Disorders ………………………………………………………………....………183 8.2.1 Inpatient Eating Disorder Sample…………………………………….…183 8.2.2 Outpatient Eating Disorder Sample…………………………………..…185 8.2.3 Entire Inpatient and Outpatient Eating Disorder Sample………….……187 8.2.4 Outpatient Anxiety Eating Disorder Sample……………………………190 8.3 Comparisons across the Comorbid and ED Only Sample ……………….………190 8.3.1 Comparison of the frequency of diagnosed anxiety disorders across the ED sample ………………………………………………….....……190 8.3.2 Comparison between AD and ED temporal onset, age of onset and illness duration…………………………………………..…………192 8.3.3 Summary of EDE scores across the entire sample………………..……195

Chapter 9 DISCUSSION 197

9.1 Research Overview…………………………………….………………………….197 9.2 Summary and Interpretation of the Results………………………...……………..199 9.3 Recruitment and assessment procedures………………………………..…………208 9.4 Strengths of the current research………………….……………………………….210 9.5 Limitations of the current research………………………………………………..212 9.6 Clinical Implications arising from the current research…………………………...215 9.7 Directions for Future Research………………………………………………...….217 9.8 Conclusion……………………………………………………...…………………219

REFERENCES 221

APPENDICES 270

A Sydney University Participant Information Sheets & Consent forms….270 B Northside Clinic Participant Information Sheets & Consent forms…….277 C SWAHS Clinic Participant Information Sheet & Consent forms………280 D University of Sydney Ethical Approval for Research……………..……291 E SWAHS Ethical Approval for Research……………………………..…305 F Northside Clinic Ethical Approval for Research……………………….312 G Assessment Measures………………………………………………..…315 H Excluded Assessment Measures……………………………………..…378 I Statistical Analyses (located on the disk on the back cover of thesis)….410

LIST OF TABLES

Table 1.1 DSM-IV-TR diagnostic criteria for Anorexia Nervosa…………….……25 Table 1.2 DSM-IV-TR diagnostic criteria for Bulimia Nervosa…………………...28 Table 1.3 DSM-IV-TR diagnostic criteria for EDNOS...... 30

Table 2.1.1 DSM-IV-TR criteria for Panic Attack…………………………………...51

Table 2.1.2 DSM-IV-TR criteria for Agoraphobia…………………………………...53

Table 2.1.3 DSM-IV-TR diagnostic criteria for Panic Disorder Without

Agoraphobia……………………………………………………………...54

Table 2.1.4 DSM-IV-TR diagnostic criteria for Panic Disorder With Agoraphobia…55

Table 2.1.5 DSM-IV-TR diagnostic criteria for Agoraphobia Without

a History of Panic Disorder…………………………………..…………..56

Table 2.2 DSM-IV-TR diagnostic criteria for Specific Phobia…………...………..57

Table 2.3 DSM-IV-TR diagnostic criteria for Social Phobia…...………………….59

Table 2.4 DSM-IV-TR diagnostic criteria for Obsessive-Compulsive Disorder…..61

Table 2.5.1 DSM-IV-TR diagnostic criteria for Post Traumatic Stress Disorder……64

Table 2.5.2 DSM-IV-TR diagnostic criteria for Acute Stress Disorder…….………..65

Table 2.6 DSM-IV-TR diagnostic criteria for Generalised Anxiety Disorder…..…68

Table 4.1. Lifetime and Current prevalence of anxiety disorders in

patients with eating disorders……………………………………….….107

Table 4.2. Summary of research papers investigating eating disorder

comorbidity with anxiety disorders…………………………………….108

Table 4.3 Summary of research papers investigating AN and AD comorbidity.....109

16 Table 4.4. Summary of research papers investigating BN and AD comorbidity…..109

Table 4.5. Summary of research papers investigating treatment

response and outcome of individuals with comorbid ED and AD…...…110

Table 7.1 Demographic profile of participants………………………………...….160

Table 7.2 Eating disorder characteristics of participants……………………...…..161

Table 7.3 Demographic and clinical characteristics of eating

disorder subtypes (Eating Disorder Unit Only)………………..……….162

Table 8.1 Current prevalence of anxiety disorders across the

inpatient ED sample…………………………………………………….167

Table 8.2 Summary of clinical characteristics of comorbid ED and

ED only group across the inpatient sample……………………………..168

Table 8.3 Current prevalence of anxiety disorders across the outpatient

ED sample………………………………...…………………………….171

Table 8.4 Summary of clinical characteristics for the comorbid ED and ED

only groups across the outpatient sample………………………………172

Table 8.5 Current prevalence of anxiety disorders across the entire ED sample…175

Table 8.6 Summary of clinical characteristics of comorbid ED and ED

only group across the entire ED sample………………………..………176

Table 8.7 Summary of eating disorder and anxiety disorder length and

onset across the comorbid inpatient ED sample………………………..184

Table 8.8 Age of onset (years) of anxiety disorders across the inpatient

ED sample……………………………………………………...……….185

17 Table 8.9 Summary of eating disorder and anxiety disorder length

and onset across the comorbid outpatient ED sample……………….…186

Table 8.10 Age of onset (years) of anxiety disorders across the

outpatient ED sample………………………………………..………….187

Table 8.11 Summary of eating disorder and anxiety disorder length and

onset across the entire comorbid ED sample……….………….…..…...188

Table 8.12 Age of onset (years) of anxiety disorders across the entire ED sample..189

Table 8.13 Summary of eating disorder and anxiety disorder length and

onset across the outpatient anxiety sample………………..…….….…..190

Table 8.14 Current prevalence of anxiety disorders across the inpatient

and outpatient ED samples………………….…………………..………191

Table 8.15 Temporal relationship of anxiety and eating disorders

across the ED sample……………………………………….…….….…192

Table 8.16 Temporal relationship of anxiety and eating disorders

across the ED subtypes…………………………………………………193

Table 8.17 Summary of eating disorder and anxiety disorder length and

onset across inpatient and outpatient comorbid samples………..….….193

Table 8.18 Onset of anxiety disorders relative to the time of onset of

eating disorders for comorbid ED and anxiety sample…………………194

Table 8.19 Summary of EDE scores across the ED sample…………………...…...195

Table 8.20 Summary of EDE scores across the Comorbid ED and ED

only groups……………………………………………………………...196

LIST OF FIGURES

Figure 4.1 Eating Disorders incorporated into a wider model of

disorders characterised by anxiety and concomitant safety behaviours..104

Figure 8.1 Prevalence of primary anxiety disorders diagnosed across the

inpatient ED comorbid sample………………………………………….167

Figure 8.2 Prevalence of primary anxiety disorders diagnosed across

the outpatient ED comorbid sample………………………..…………..171

Figure 8.3 Prevalence of primary anxiety disorders diagnosed across

the entire comorbid ED sample………………………..…….………….175

Figure 8.4 Mean BMI scores for each anxiety disorders across the entire

ED sample………………………...…………………………………….178

Figure 8.5 Mean ED onset age for each anxiety disorders across the entire

ED sample………..……………………………………………….…….179

Figure 8.6 Mean ED duration for each anxiety disorders across the entire

ED sample………………………………………..…………….……….180

Figure 8.7 Mean binge episodes for each anxiety disorder across the

entire ED sample……………………………….…………….…………181

Figure 8.8 Mean exercise episodes for each anxiety disorder across

the entire ED sample……………………………..……………….…….182

Figure 8.9 Purgative abuse across the anxiety disorders……………….…..………182

19 Figure 8.10 Temporal relationship between ED and anxiety disorder onset

across the inpatient ED comorbid sample……..……………………….184

Figure 8.11 Temporal relationship between ED and anxiety disorder onset

across the outpatient ED comorbid sample………………….…………186

Figure 8.12 Temporal relationship between ED and Anxiety Disorder Onset

across the entire comorbid ED sample………………………………….188

20 PUBLICATIONS AND PRESENTATIONS ARISING FROM THE RESEARCH

Publications Swinbourne, J.M. & Touyz, S.W. (2007). The Comorbidity of Eating Disorders and Anxiety Disorders: A Review. European Eating Disorder Review Journal, 15, 253 - 274.

Conference and Research Presentations Swinbourne, J., Touyz, S.W., Hunt, C., Abbott, M., St Clare, T. and Russell, J. (2008, May) The Comorbidity Between Eating Disorders and Anxiety Disorders. Presentation for the Rivendell Child, Adolescent & Family Mental Health Service, SSWAHS, Concord.

Swinbourne, J., Touyz, S.W., Hunt, C., Abbott, M., St Clare, T. and Russell, J. (2007, Oct) The Comorbidity Between Eating Disorders and Anxiety Disorders. Proceedings of the 13th Annual Conference of the Eating Disorders Research Society, Pittsburgh, USA.

Swinbourne, J., Touyz, S.W., Hunt, C., Abbott, M., St Clare, T. and Russell, J. (2007, July). The Comorbidity Between Eating Disorders and Anxiety Disorders. Poster presented at the World Congress of Behavioural and Cognitive Therapies Conference, Barcelona, Spain.

Swinbourne, J., Touyz, S.W., Hunt, C., Abbott, M., St Clare, T. and Russell, J. (2007, April). The prevalence of co-morbid eating disorders and anxiety disorders: Do individuals with co-morbid diagnoses display more severe symptoms? Presentation at the Congress of the Royal Australian and New Zealand College of Psychiatrists, Gold Coast, Australia.

Swinbourne, J., Touyz, S.W., Hunt, C., Abbott, M., St Clare, T. and Russell, J. (2007, March). International forum: Breaking new frontiers in research into eating disorders: Exciting new data from the Antipodes, including data from The Comorbidity Between

21 Eating Disorders and Anxiety Disorders. Presentation at the 8th London International Conference on Eating Disorders, London, UK.

Swinbourne, J., Touyz, S.W., Hunt, C., Abbott, M., St Clare, T. and Russell, J. (2006, November). The Comorbidity Between Eating Disorders and Anxiety Disorders. Presentation at the 8th Annual Postgraduate Research Conference, School of Psychology, University of Sydney.

Swinbourne, J., Touyz, S.W., Hunt, C., Abbott, M., St Clare, T. and Russell, J. (2006, October). The Prevalence of Comorbid Eating Disorders and Anxiety Disorders: Do individuals with comorbid disorders display more severe symptoms? Presentation at the 4th National Conference of Australia and New Zealand Academy of Eating Disorders, Adelaide.

22 LIST OF ABBREVIATIONS

ACT Acceptance and Commitment Therapy AD Anxiety Disorder ADIS-IV Anxiety Disorder Interview Schedule AG Agoraphobia AN Anorexia Nervosa ASD Acute Stress Disorder BN Bulimia Nervosa CBT Cognitive Behaviour Therapy DASS Depression Anxiety and Stress Scale DBT Dialectical Behaviour Therapy DSM-IV Diagnostic and Statistical Manual of Mental Disorders EAT Eating Attitudes Test ED Eating Disorder EDE Eating Disorder Examination EDE-Q Eating Disorder Examination Questionnaire EDI-3 Eating Disorder Inventory EDNOS Eating Disorder Not Otherwise Specified GAD Generalised Anxiety Disorder IPT Interpersonal Psychotherapy MBCT Manual Based Cognitive Therapy MET Motivational Enhancement Therapy OCD Obsessive Compulsive Disorder OCPD Obsessive Compulsive Personality Disorder PD Panic Disorder PST Problem Solving Therapy PTSD Post Traumatic Stress Disorder SP Social Phobia Sp Ph Specific Phobia

23 CHAPTER 1 INTRODUCTION TO THE EATING DISORDERS

An eating disorder diagnosis describes the observational pattern of clinical symptoms which, broadly defined, reflect a severe disturbance in issues concerning body weight and shape. The diagnostic criteria for an eating disorder incorporates the presence of behaviours specifically designed to influence body weight and shape (American Psychiatric Association, 2000). To date, there is a large body of research investigating the etiology, course, treatment and outcome of eating disorders. This chapter will provide an overview of the core features of eating disorders as well as the literature investigating assessment, treatment and outcome of eating disorders.

1.1 Anorexia Nervosa: Core Features

Anorexia Nervosa (AN) is characterised by severe disturbances in eating behaviour. Specifically, an individual with this disorder refuses to maintain a minimally normal body weight, is intensely fearful of gaining weight and exhibits a significant disturbance in their perception of their shape and size (American Psychiatric Association, 2000; see Table 1.1). In addition, the Diagnostic and Statistical Manual of Mental Disorders (DSM- IV, American Psychiatric Association, 2000) includes amenorrhea in post menarchal females as a diagnostic feature of this disorder.

Table 1.1

DSM-IV-TR diagnostic criteria for Anorexia Nervosa (American Psychiatric Association, 2000)

DSM-IV-TR Diagnostic Criteria for Anorexia Nervosa

A. Refusal to maintain body weight at or above a minimally normal weight for age and height (e.g., weight loss leading to maintenance of body weight less than 85% of that expected; or failure to make expected weight gain during period of growth, leading to body weight less than 85% of that expected. B. Intense fear of gaining weight or becoming fat, even though underweight. C. Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight. D. In postmenarcheal females, amenorrhea, i.e., the absence of at least three consecutive menstrual cycles. (A woman is considered to have amenorrhea if her periods occur only following hormone, e.g., estrogen administration.)

Specify Type:

Restricting Type: during the current episode of Anorexia Nervosa, the person has not regularly engaged in binge-eating or purging behaviour (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas)

Binge-Eating/Purging Type: during the current episode of Anorexia Nervosa, the person has regularly engaged in binge-eating or purging behaviour (i.e., self- induced vomiting or the misuse of laxatives, diuretics, or enemas)

The inclusion of amenorrhea as a diagnostic criterion has been criticised, as it is considered unreliable due to the frequency with which individuals with AN are prescribed contraceptive medication to regulate menses (Bulik, Reba, Siega-Riz & Reichborn-Kjennerud, 2005). Furthermore, research has found that there do not appear to be meaningful differences between those individuals with AN who have amenorrhea and those who do not (Watson & Andersen, 2003). Specifically, individuals meeting all criteria for AN except the amenorrhea condition, appear to have few statistically

25 significant differences in terms of demographics, psychiatric comorbidity, family history or early experiences (Garfinkel, Lin, Goering, Spegg, Goldbloom, Kennedy, Kaplan & Woodside, 1996), or illness history and treatment response (Watson & Andersen, 2003).

In addition to the above concerns regarding the amenorrhea criterion, researchers have also called for the inclusion of patients with eating restraint but without shape and weight concerns to be included under the diagnosis of AN (Fairburn & Bohn, 2005; Palmer, 1993, 2005; Rieger, Touyz, Swain & Beumont, 2001). This proposal has stemmed from several authors questioning the necessity of including both weight phobia and body- image disturbance in the diagnosis of AN (Casper, 1983; Habermas, 2005; van Deth & Vandereycken, 1991). The reported absence of body-weight phobia and body image disturbance in non-Western patients with low body weight adds strength to this proposal (Lee, Ho & Hsu, 1993).

The DSM-IV distinguishes between two subtypes of AN: the restricting type (ANR) and the binge eating/purging type (ANBP). The restricting type has presentations in which weight loss is achieved primarily through dieting, fasting or excessive exercise (American Psychiatric Association, 2000). During this period, the individual has not regularly engaged in binge eating or purging. In contrast, the binge eating/purging type is used to describe individuals who have regularly engaged in binge eating and or purging during the present episode.

Generally, most individuals with AN who binge eat also purge through the use of self induced vomiting, and or the misuse of laxatives, diuretics or enemas. Some individuals in this subtype do not engage in binge eating, but will regularly purge after the consumption of a small amount of food. Although it would appear that individuals with binge eating/purging type will engage in these behaviours at least weekly, the DSM-IV (American Psychiatric Association, 2000) does not apply a minimum frequency of such behaviours.

Support for the DSM-IV based subtypes of AN has been limited. The AN subtypes were originally differentiated based on observations that women with AN with binge purge

26 symptoms displayed increased comorbid psychopathology and distress than did the women with AN restricting subtype (DaCosta & Halmi, 1992; Herzog, Keller, Sachs, Yeh & Lavori, 1992). More recent research has failed to find differences between the restricting and binge/purge subtypes of AN in terms of co-morbid psychopathology, recovery, relapse or mortality rates (Herzog, Dorer, Keel, Selwyn, Ekeblad, Flores, Greenwood, Burwell & Keller, 1999; Keel, Dorer, Eddy, Franko, Charatan & Herzog, 2003; Keel, Dorer, Franko, Jackson & Herzog, 2005).

AN appears to be far more prevalent in industrialised countries, and more than 90% of cases are observed in females (American Psychiatric Association, 2000). The prevalence of AN amongst women is approximately 0.5% - 1% in Western Cultures (Hsu, 1996; Wilson & Pike, 2001). The observed course of AN appears to suggest that the disorder typically begins in mid to late adolescence, and onset is rarely observed in females over the age of 40 years (American Psychiatric Association, 2000).

1.2 Bulimia Nervosa: Core Features

The core features of Bulimia Nervosa (BN) are binge eating and inappropriate compensatory methods to prevent weight gain. Similarly to AN, the individual’s self- evaluation is excessively influenced by body shape and weight. The DSM-IV (American Psychiatric Association, 2000; see table 1.2) specifies that the binge eating and compensatory behaviour must occur on average, at least twice a week for a 3 month period.

27 Table 1.2

DSM-IV-TR diagnostic criteria for Bulimia Nervosa (American Psychiatric Association, 2000)

DSM-IV-TR Diagnostic Criteria for Bulimia Nervosa

A. Recurrent episodes of binge eating. An episode of binge eating is characterised by both of the following: (1) eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances (2) a sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating) B. Recurrent inappropriate compensatory behaviour in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise. C. The binge eating and inappropriate compensatory behaviours both occur, on average, at least twice a week for 3 months. D. Self evaluation is unduly influenced by body shape and weight. E. The disturbance does not occur exclusively during episodes of Anorexia Nervosa.

Specify Type:

Purging Type: during the current episode of Bulimia Nervosa, the person has regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas

Nonpurging Type: during the current episode of Bulimia Nervosa, the person has used other inappropriate compensatory behaviours, such as fasting or excessive exercise, but has not regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas

The DSM-IV defines a binge as eating an amount of food larger than what most individuals would eat under similar circumstances, in a discrete period of time (usually less than two hours). In terms of assessment, clinicians use their own judgement of what would be considered a normal quantity of food to determine whether this criterion is satisfied. In addition, an episode of binge eating also includes a sense of losing control over one’s eating. Specifically, individuals will report a feeling that they are unable to

28 stop eating or control how much they are consuming. Recurrent inappropriate compensatory behaviour to avoid weight gain is also a key characteristic of BN. Such behaviour may include the use of self-induced vomiting, misuse of laxatives or diuretics, fasting or excessive exercise.

Critics of the diagnostic criteria for BN have called for the twice-weekly threshold for binge eating and purging to be reduced (Herzog, Norman, Rigotti & Pepose, 1986; Wilson & Eldredge, 1991; Garfinkel, Kennedy & Kaplan, 1995; Fairburn & Bohn, 2005). This proposal has stemmed from evidence that individuals with once-weekly binge eating episodes demonstrate similar co-existing psychopathology and clinical outcome to those who binge more often (Garfinkel, Kennedy & Kaplan, 1995). Furthermore, the definition of what constitutes a binge episode has been difficult to operationalise which has also led to criticism (Pratt, Niego & Agras, 1998; Rossiter & Agras, 1990). The concept that the binge is time limited is not empirically based and there is no evidence suggesting that differentiating between the duration of binge episodes has clinical utility (Franco, Wonderlich, Little & Herzog, 2004).

The DSM-IV distinguishes between two subtypes of this disorder: the purging type and the non-purging type (American Psychiatric Association, 2000). The purging type includes those individuals who have regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics or enemas. The non-purging type refers to those individuals who have used other inappropriate behaviours such as fasting or excessive exercise, but have not regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics or enemas.

Research indicates that BN typically begins in late adolescence or early adult life (American Psychiatric Association, 2000). The binge eating typically begins during or after a period of dieting, and indeed the restrictive dietary behaviours often observed in BN are not only recognised as triggers for binge eating but also a maintaining factor associated with this disorder. As with AN, BN is most often observed in industrialised countries, and at least 90% of individuals with BN are female (American Psychiatric

29 Association, 2000). The prevalence of BN amongst women is approximately 1% - 3% in Western cultures (Wilson & Pike, 2001).

1.3 Eating Disorders Not Otherwise Specified (EDNOS): Core Features

The EDNOS category is reserved for individuals considered to have a clinically significant eating disorder, whilst not meeting the specified criteria for AN or BN (see Table 1.3). This category includes the provisional diagnostic category of binge eating disorder.

Table 1.3

DSM-IV-TR diagnostic criteria for Eating Disorder Not Otherwise Specified (American Psychiatric Association, 2000)

DSM-IV-TR Diagnostic Criteria for Eating Disorder Not Otherwise Specified

1. For females, all the criteria for AN are met except that the individual has regular menses. 2. All the criteria for AN are met except that, despite significant weight loss, the individual’s current weight is within normal limits. 3. All of the criteria for BN are met except that the binge eating and inappropriate compensatory behaviours occur at a frequency of less than twice a week or for a duration of less than 3 months. 4. The regular use of inappropriate compensatory behaviour by an individual of normal body weight after eating small amounts of food. 5. Repeatedly chewing and spitting out, but not swallowing, large amounts of food. 6. Binge-eating disorder: recurrent episodes of binge eating in the absence of the regular use of inappropriate compensatory behaviours characteristic of BN.

30 Although the EDNOS category was intended to classify individuals with disorders residual to the specific categories subsumed under AN and BN, recent studies have found that EDNOS is the most common eating disorder diagnosis made in outpatient settings (Martin, Williamson & Thaw, 2000; Ricca, Mannucci, Mezzani, Di Bernado, Zucchi, Paionni, Placidi, Rotella, & Faravello, 2001; Turner & Bryant-Waugh, 2004). This situation is concerning, given the possibility that EDNOS diagnoses may be considered less severe than a diagnosis of AN or BN. Consequently, researchers have argued for a review of the classification system. Furthermore, although EDNOS is a common eating disorder diagnosis seen by clinicians, it has often been overlooked by researchers, particularly in regard to efficacious treatment approaches (Grave & Calugi, 2007). Furthermore, little is known about the incidence and prevalence of Binge Eating Disorder (BED), which is included under the EDNOS diagnostic criteria of the DSM-IV (Hsu, 1996). It is estimated that the prevalence of BED in the general population is approximately 4% (Wilfley, Agras, Telch, Rossiter, Schneider, Cole, Sifford & Raeburn, 1993).

1.4 Assessment

1.4.1 DSM-IV Classification

The present DSM-IV classification system for the diagnosis of eating disorders has several strengths. Firstly, it enables reliable diagnosis through the use of semi-structured and clinical interviews (Peterson & Miller, 2005). Secondly, as AN and BN appear to demonstrate different longitudinal patterns with regard to recovery (Herzog, Dorer, Keel, Selwyn, Ekeblad, Flores, Greenwood, Burwell & Keller, 1999) and mortality (Keel et al., 2003), diagnostic validity can be inferred (Wonderlich, Joiner, Keel, Williamson & Crosby, 2007).

The current classification system for eating disorders also has limitations. Firstly, empirical studies of the current DSM-IV classification have raised several concerns including, the individual diagnostic criteria for the eating disorders, the validity of the

31 AN and BN subtype distinctions, and questions about the validity of the AN, BN and EDNOS diagnoses themselves (Franco et al., 2004).

There is conflicting opinions in the literature concerning the overall relationship between the AN, BN and residual EDNOS categories. It is unclear whether each category represents a distinct disorder, or whether they are merely a perceived reflection of severity. It is clear that patients may frequently move from one diagnosis to another over the course of their eating disorder (Zipfel, Lowe, Reas, Deter & Herzog, 2000; Fairburn & Harrison, 2003). Indeed it is not uncommon for chronic restrictive AN patients to develop binge eating and purging behaviours over time and eventually display symptoms consistent with a diagnosis of BN (American Psychiatric Association, 2000). The present structure of the DSM-IV effectively enables diagnosis between an AN and BN category to be distinguished by way of an individual’s weight falling below 85% of what would be expected. By definition, an individual with AN is below normal weight, individuals with BN range from normal to obese and individuals with EDNOS may range from underweight to obese. Essentially, a diagnosis of AN overrides a diagnosis of BN which in turn overrides a diagnosis of EDNOS. The DSM-IV diagnostic criteria is based on the present views regarding AN and BN, which suggest that these disorders are related conditions with similar maintenance processes.

In terms of the criteria for AN, concerns have been raised about the fear of weight gain criterion, on the grounds that it may be culturally specific (Wonderlich et al., 2007), although this has also been debated (Habermas, 1989; Katzman & Lee, 1997). The amenorrhea criterion has been questioned, due to its unreliability as an indicator of weight status and its utility for providing comorbidity or outcome information (Garfinkel et al., 1996; Anderson, Bowers & Watson, 2001; Herzog & Delinsky, 2001). Furthermore, there do not appear to be meaningful differences between individuals with AN with and without menses (Watson & Anderson, 2003).

The criteria for BN has also been criticised for a number of reasons. The definition of a binge as being a consumption of food definitely larger than what most people would consume has been extremely difficult to operationalise (Rossiter & Agras, 1990; Pratt et

32 al., 1998). Furthermore, the idea that the binge is time limited is not based on empirical testing, and the evidence is unclear on whether differentiating between longer or shorter binge episodes has any clinical utility (Franko et al., 2004). Finally the criterion that the bulimic symptoms must occur twice a week for a three month period has also failed to receive empirical support in a number of investigations (Kendler, Maclean, Neale, Kessler, Heath & Eaves, 1991; Crow, Agras, Halmi, Mitchell & Kraemer, 2002).

Another limitation of the DSM-IV classification system is the subtyping within AN (binge-purge vs. restricting) and BN (purging vs. non purging). Early research suggested differences between binge-purge and restricting anorexic women, in that the women with binge-purge symptoms displayed more co-morbid psychopathology and distress than did the restricting only group (DaCosta & Halmi, 1992; Herzog, Keller, Sacks, Yeh & Lavori., 1992). However, recent prospective and longitudinal research studies have failed to find convincing evidence for differences between the AN subtypes in terms of comorbid psychopathology, recovery, relapse or mortality rates (Herzog et al., 1999; Keel et al., 2003; Keel et al., 2005). Furthermore, it is well reported that individuals with restricting type AN are likely to report some binge – purge behaviours over time (Bulik, Sullivan, Fear & Pickering, 1997; Eddy, Keel, Dorer, Delinsky, Franco & Herzog, 2002). In terms of the subtyping of individuals with BN, there are very few studies providing any support to the validity of these subtypes (Wonderlich et al., 2007).

In terms of the overall utility of the DSM-IV classification system, recent data has suggested that approximately 60% of individuals with eating disorders do not meet criteria for either AN or BN (Fairburn & Bohn, 2005; Wade, Crosby & Martin, 2006), and instead meet criteria for EDNOS. This is problematic, as the EDNOS category is designed to capture a residual group. Furthermore, the disorders within the EDNOS group tend to be no less clinically severe than AN or BN (Fairburn & Bohn, 2005). One study has suggested that approximately 70% of EDNOS patients move to either AN or BN over a 30-month follow up period (Milos, Spindler, Schnyder & Fairburn, 2005). Wonderlich et al. (2007) point out that this variation may be better explained by fluctuating body weight and symptom severity as opposed to actual transitions from one illness to another. Of concern is the potential that individuals with clinically significant

33 eating disorders are diagnosed with EDNOS simply because they fail to meet one of the diagnostic criterion.

These issues raise the possibility that the DSM-IV classification system for eating disorders is not functioning as intended. Furthermore, the limitations with the current classification system discussed above suggest that there is a need for a more empirically based classification of eating disorders to better assist with assessment and treatment procedures.

Reliable and valid diagnostic and outcome assessment of eating disorders is essential to defining and describing the course and outcome of AN, BN and EDNOS. Therefore, it is clear that eating disorder assessments have a significant impact on clinical care, research and social policy. Consequently, standardised assessments are vital for a number of reasons including, providing consistent and comprehensive diagnosis, facilitating reliable monitoring of course and outcome and providing norms for comparison of clinical status and severity (Pike, 2005).

1.4.2 Assessment Instruments

In psychiatric research, it is generally agreed that interview assessments have the potential to provide the most accurate data (Pike, 2005). Conducting assessments by way of a structured interview enables complex constructs to be thoroughly assessed (e.g., definitions of restraint and binge eating) and constructs for which everyday usage differ from diagnostic definitions (e.g., dieting and body shape concerns) (Pike, 2005). Furthermore, it enables the application of clinical judgement to assess the accuracy and reliability of the individual’s report (Pike, 2005), which is often a criticism of self-report based questionnaires for diagnosis.

Unfortunately much of the available eating disorder research utilises self-report assessment procedures which form the basis for much of the criticism of such studies. In comparison to a self-report assessment, the main disadvantage of a structured interview is its time consuming nature and the need for expertise and training to properly conduct such an assessment (Pike, 2005).

34 In terms of useful structured interviews for the diagnosis of eating disorders, the Structured Clinical Interview for DSM-IV (SCID; First, Spitzer, Gibbon & Williams, 1997) is commonly utilised for diagnosis. However, as the SCID does not provide continuous assessment of severity of eating disorder pathology, it should be used in conjunction with other instruments to achieve a more thorough assessment (Pike, 2005). A more comprehensive interview assessment for the eating disorders is the Eating Disorder Examination (EDE; Fairburn & Cooper, 1993). The EDE provides both descriptive and continuous data of eating pathology and provides operationally defined DSM-IV eating disorder diagnoses (Pike, 2005). Although not as widely utilised, the Interview for Diagnosis of Eating Disorders (IDED; Williamson, 1990) and the Structured Interview for Anorexic and Bulimic Disorders (SIAB; Fichter, Eleton, Engel, Meyer, Mall & Poustka, 1991) also provide categorical and continuous data for the assessment of eating disorders (Pike, 2005).

There are a number of self-report measures with acceptable psychometric properties that may be utilised to complement an interview based assessment. Self-report instruments are particularly useful in generating continuous data on eating pathology, including binge eating, purging and dietary restriction, and attitudinal dimensions such as body shape and weight concerns (Pike, 2005). They are also beneficial in assessing clinical status over time, and capturing meaningful changes that may not be reflected by clinical diagnosis (Pike, 2005). In terms of self-report instruments useful for providing a diagnosis of general eating pathology, the Eating Disorder Diagnostic Scale (EDDS; Stice, Telch & Rizvi, 2000) is recognized as a good measure as it provides DSM eating disorder diagnoses based on self-report data and demonstrates good internal consistency and construct validity. The Eating Disorder Examination Questionnaire (EDE-Q; Fairburn & Beglin, 1994), is a self-report version of the Eating Disorder Examination (EDE; Fairburn & Cooper, 1993) and is recognised as another good measure for identifying general eating pathology. The EDE-Q assesses the same attitudinal and behavioural aspects of eating disorders as the EDE, over a 28 day time period.

35 The Eating Attitudes Test (EAT-40; Garner & Garfinkel, 1979) and the EDI-3 (Garner, 2004) are also good measures of eating disorder psychopathology. In terms of self-report instruments for measuring dietary restraint, the Dutch Eating Behaviour Questionnaire (DEBQ; van Strien, Frijters, Bergers & Defares, 1986) and the Three Factor Eating Questionnaire (TFEQ-R; Stunkard & Messick, 1985) are recognized as reasonably sound instruments in terms of their psychometric properties.

Self-report instruments for measuring body dissatisfaction and body image disturbance include the Body Shape Questionnaire (BSQ; Cooper, Taylor, Cooper & Fairburn, 1987) and the Body Image Avoidance Questionnaire (BIAQ; Rosen, Srebnik, Salzberg & Wendt, 1991). Finally, in terms of specific self-report measures for binge eating, the Binge Eating Scale (BES; Gormally, Black, Daston & Rardin, 1982) demonstrates reasonable test-retest reliability and validity.

The use of assessment measures is of particular importance when addressing issues relating to comorbidity.

1.5 Comorbidity of Mental Disorders Psychiatric comorbidity amongst individuals suffering from eating disorders is extremely common. In the last few decades there has been increased research investigating the prevalence of comorbidity amongst the eating disorders. The findings from this research indicated that identifying comorbid psychiatric illnesses is extremely important in terms of the etiological perspectives of eating disorders and also in driving evidenced based treatment approaches. Of the common comorbid psychiatric illnesses, mood disorders, anxiety disorders and personality disorders are most frequently implicated (Carroll, Touyz & Beumont, 1996; Råstam, Gillberg & Gillberg, 1995). As the comorbidity between eating and anxiety disorders is discussed extensively in chapters 3 and 4, the comorbidity with mood, substance abuse and personality disorders is discussed below.

36 1.5.1 Mood Disorders Research into comorbidity amongst the eating disorders has found that mood disorders are frequently diagnosed. The lifetime prevalence of affective disorders in patients with eating disorders has been estimated to be approximately 70% (Råstam et al., 1995; Halmi et al, 1991). Furthermore, it has been suggested that major depression is the most common comorbid psychiatric condition in both AN and BN (O’Brien & Vincent, 2003). In an AN sample, Råstam (1992) reported that 40% met criteria for a current diagnosis of major depressive disorder, and this figure went up to 90% for a lifetime mood disorder. In BN samples, clinical depression has been identified in between 20 – 40% of subjects (Brewerton et al., 1995; Garfinkel, Lin, Goering, Spegg, Goldbloom, Kennedy, Kaplan & Woodside, 1995).

1.5.2 Substance-Abuse Disorders Studies consistently report that individuals with eating disorders frequently report comorbid substance abuse disorders. This is particularly evident amongst the binge/ purge subtypes of AN and BN (Holderness, Brooks-Gunn, & Warren, 1994; O’Brien & Vincent, 2003). One study found that 61 – 67% of their BN sample reported hazardous levels of alcohol consumption, compared with approximately 36% of the control group (Kozyk, Touyz & Beumont, 1998). Interestingly, eating disorder symptoms have also been reported to be higher than expected in females with substance abuse disorders (Schukit, Tipp, Anthenelli, Bucholz, Hesselbrock, & Nurnberger, 1996).

1.5.3 Personality Disorders Axis II comorbidity amongst eating disorder patients is reported to be high, with one study reporting Axis II comorbidity in over 30% of a BN sample compared with less than 7% of controls (Carroll et al., 1996). A meta-analysis of 28 studies (Rosenvinge, Martinussen, & Ostensen, 2000) found that 58% of eating-disordered women met criteria for a personality disorder compared with 28% of comparison women. Furthermore, they reported that BN patients demonstrated higher proportions of Cluster-B personality traits (44% overall) compared with AN patients or controls (Rosenvinge et al., 2000). Cluster A personality disorders were equivalent in both AN and BN groups.

37 Gartner, Marcus, Halmi & Loranger (1989) reported that 25.7% of their AN sample met diagnostic criteria for OCPD. Interestingly, none of their BN sample met criteria for OCPD leading to the speculation that this personality feature is more consistent with individuals with AN (Gartner et al., 1989). However, Rossiter, Agras, Telch & Schneider (1993) reported that 10% of their BN sample met criteria for OCPD. Thornton and Russell (1997) reported that 19% met criteria for comorbid OCPD, and this was almost exclusively found in the AN sample. Lilenfeld, Kaye, Greeno, Merikangas, Plotnicov, Pollice, Rao, Strober, Bulik & Nagy (1998) reported that AN probands had higher rates of OCPD lending support to reports of perfectionism and inflexibility among individuals with restricting type AN. Lilenfeld et al. (1998) also found that 31% of AN probands met criteria for OCPD and OCD, leading to the suggestion that individuals with OCPD may be more vulnerable to the development of OCD than those without this personality pattern.

Given the well documented adverse effects of malnutrition upon personality functioning (Keys, Brozek, Henschel, Mickelson, & Taylor, 1950), it is extremely important for studies to distinguish between symptoms that are secondary to the eating disorder and those that reflect stable trait patterns. Several studies investigating recovered eating disorder patients for comorbid personality disorders found that personality disorders were still prevalent even after recovery and weight restoration (Nilsson, Gillberg, Gillberg, & Råstam, 1999; Matsaunaga, Kaye, McConaha, Plotnicov, Pollice, & Rao, 2000).

The literature investigating comorbidity amongst eating disorders suggests that existing treatment approaches may fail to adequately address comorbid diagnoses, targeting only the eating disorder symptoms. This is particularly problematic when considering that comorbid diagnoses may have preceded the onset of the eating disorder and furthermore, may play a role in the maintenance of eating pathology. Although this will be addressed in proceeding chapters, it is necessary to first provide a brief overview of the current evidenced-based approaches for the treatment of eating disorders.

38 1.6 Treatment

1.6.1 Anorexia Nervosa

The available research investigating the effective treatments for AN is weak (Berkman, Bulik, Brownley & Lohr, 2006). Over the last two decades, as few as 15 comparative trials have been completed and published. The paucity of controlled treatment research in AN is attributable to several factors associated with the disorder, including its rarity, the presence of medical complications sometimes requiring management in an inpatient setting and the protracted treatment period often necessary for full remission of symptoms (Wilson, Grilo & Vitousek, 2007). Motivational factors also play a role in the difficulty researching this population (Agras, Brandt, Bulik, Dolan-Sewell, Fairburn, Halmi, Herzog, Jimerson, Kaplan, Kaye, le Grange, Lock, Mitchell, Rudorfer, Street, Striegel-Moore, Vitousek, Walsh & Wilfley, 2004).

To date, family therapy is the most extensively researched treatment for AN, and the results have generally been encouraging. The best studied approach is a specific form of family therapy known as the Maudsley model (Dare & Eisler, 1997; Lock & Le Grange, 2005). The Maudsley model was first tested as a means of preventing weight loss post hospitalisation in subgroups of AN patients (Russell, Szmukler, Dare & Eisler, 1987). The findings indicated that younger patients with more recent onset responded well to conjoint family therapy, with 90% symptom free at 5 years. Furthermore, this approach was far more effective than a dynamically oriented approach (Russell et al., 1987; Eisler, Dare, Hodes, Russell, Dodge & le Grange, 2000). For patients with a longer history of illness and older age at onset, neither approach appeared beneficial (Wilson et al., 2007). Despite the encouraging research results supporting a family therapy based approach for AN, several researchers suggest that these results have been widely misunderstood (Fairburn, 2005; Vitousek & Gray, 2005). One criticism stems from the possibility that the favourable results may simply reflect the characteristics of the samples to which this approach has been delivered (Fairburn, 2005; Vitousek & Gray, 2005). Furthermore, in both the controlled and naturalistic studies, outcomes for young adolescents have been much more promising than the aggregate 50% recovery rate cited for all patients with AN

39 (Steinhausen, 2002; Nilsson & Hagglof, 2005). Much of the research has also suggested that symptom duration is a strong predictor of response to family therapy, where patients with a 16 month or longer history respond more poorly than those with an 8 month history (Eisler et al., 2000).

The final criticism comes from the evidence of two randomised controlled trials comparing the conjoint format with a separated version, in which the anorexic child and parents attend different sessions (le Grange, Eisler, Dare & Russell, 1992; Eisler et al., 2000). Despite both trials finding a favourable trend towards the theoretically less preferred separated format, the treatment manual strongly recommends the conjoint model for treatment (Wilson et al., 2007).

Cognitive behaviour therapy (CBT) is the most frequently investigated individual treatment for AN, however, results are difficult to interpret due to the methodological limitations of these studies (Wilson et al., 2007). A cognitive behavioural framework for conceptualising and treating AN was initially described by Garner & Bemis (1982 & 1985) and Garner, Vitousek & Pike (1997). Since the original postulation of this framework, there have been many variations of this approach (Kleifield, Wagner & Halmi, 1996; Wolff & Serpell, 1998; Fairburn, Shafran & Cooper, 1999; Fairburn, Cooper & Shafran, 2003), however they all broadly overlap with respect of their theoretical framework and strategies. Generally, all CBT approaches stress the importance of motivational issues, the problems associated with starvation and the need for weight gain (Garner et al., 1997).

Three studies have compared CBT with one or more alternative psychotherapies (Channon, de Silva, Hemsley & Perkins, 1989; Ball & Mitchell, 2004; McIntosh, Jordan, Carter, Luty, McKenzie, Bulik, Frampton & Joyce, 2005). In each of these studies, no clear differences were found between CBT and comparison conditions (Wilson et al., 2007). It is noted that the methodological limitations of these studies limit the general application of the results. Unfortunately, another three randomised controlled trials also had methodological limitations, specifically the use of a non psychological comparative condition, which limits the ability to assess the efficacy of the CBT condition (Wilson et

40 al., 2007). Two of these studies compared CBT to nutritional counselling (Serfaty, Turkington, Heap, Ledsham & Jolley, 1999; Pike, Walsh, Vitousek, Wilson & Bauer, 2003) whilst the other compared CBT with fluoxetine and a combined treatment group (Halmi, Agras, Crow, Mitchell, Wilson, Bryson & Kraemer, 2005).

Finally, as research and clinical practice suggests, AN can be a notoriously difficult population to treat. Due to their resistance to treatment, AN patients have been likened to patients with substance abuse problems (Vitousek, Watson & Wilson, 1998). Consequently, research has focussed on the inclusion of motivational approaches used in the field of addictions to treat eating disorders. Specifically, Motivational Enhancement Therapy (MET) is derived from integrating the transtheoretical model of change (Prochaska & DiClemente, 1992) with the skills of motivational interviewing (Miller & Rollnick, 1991). There is increasing support for the use of interventions designed to enhance readiness to change amongst individuals with eating disorders (Garner & Bemis, 1982; Vitousek, 1995; Pike, Loeb & Vitousek, 1996; Garner et al., 1997; Killick & Allen, 1997; Levy, 1997; Strober, 1997; Treasure & Ward, 1997; Vitousek et al., 1998). Nevertheless, there remains a lack of well controlled research to review the use of MET in this treatment population. One pilot study found that motivational enhancement may improve engagement and result in behaviour change and early weight gain in adolescents with AN (Gowers & Smyth, 2004).

1.6.2 Bulimia Nervosa

Antidepressant medications and CBT have become well established as effective treatments for BN (Shafran, Keel, Haedt & Fairburn, in press). Manual based cognitive therapy (MBCT) is the most researched evidence-based treatment for BN and interpersonal psychotherapy has also received some empirical support (Wilson et al., 2007). Most of the research in BN involves outpatient populations, as generally the vast majority of patients can be treated in this setting, unless these are contraindications such as suicidality or self harm (Wilson et al., 2007).

41 MBCT is based on the cognitive model for BN, implicating over-concern with body shape and weight as the core pathology leading to eating disorder behaviours (Fairburn, Marcus & Wilson, 1993). Typically treatment involves enhancing motivation for change, replacing dysfunctional dieting with a regular and flexible pattern of eating, decrease in the concern with body shape and weight and relapse prevention (Wilson et al., 2007). Treatment usually consists of between 16 to 20 individual sessions, however group therapy has also been successful (Chen, Touyz, Beumont, Fairburn, Griffiths, Butow, Russell, Schotte, Gertler & Basten, 2003; Nevonen & Broberg, 2006). MBCT for adults has been shown to be superior to other psychological treatments, at least in the short term (Wilson & Fairburn, 2002).

Other approaches to the treatment of BN include interpersonal psychotherapy (IPT), which was originally developed for the treatment of depression (Klerman, Weissman, Rounsaville & Chevron, 1984). The rationale for the use of this therapeutic approach stems from the observation that an eating disorder often develops during late adolescence and early adulthood, during which time, interpersonal difficulties are prevalent (Crafti, 2002). Subsequently, it has been hypothesised that binge eating is not only triggered by, but becomes a coping strategy for the negative affect elicited by interpersonal problems (Klerman et al., 1984). Fairburn, Jones, Peveler, Hope & O’Connor (1993), adapted this treatment approach for BN, the emphasis of which is on identifying and modifying the interpersonal problems that are hypothesised to be maintaining the eating disorder. This treatment tends to be both non-directive and non-interpretive and does not directly focus on the eating disorder symptoms (Wilson et al., 2007).

One study has reported that interpersonal psychotherapy was inferior to CBT at post treatment but equally effective at one and six year follow-ups (Fairburn, Jones, Peveler, Hope & O’Connor, 1993). Similar results have been reported by Agras, Walsh, Fairburn, Wilson & Kraemer (2000), where manual based CBT was found to be significantly superior to interpersonal psychotherapy at post-treatment, however at one year follow up there was no statistical difference. Crafti (2002) combined CBT with interpersonal components in a group setting and found significant improvements in binge eating and purging symptoms compared with a wait list control group.

42 Finally, given the evidence that links bulimic symptoms with negative emotions (Polivy & Herman, 1993; Telch & Agras, 1996; Agras & Telch, 1998), there has been increased interest in treatment specifically developed to target these difficulties with affect regulation strategies in BN (Esplen, Garfinkel, Olmsted, Gallop & Kennedy, 1998) and binge eating disorder (Telch, Agras & Linehan, 2000). Dialectical behaviour therapy (DBT; Linehan, 1993a & 1993b), was developed as a treatment for borderline personality disorder and is currently regarded as the most comprehensive and empirically validated affect regulation treatment (Safer, Telch & Agras, 2001). Generally the research investigating the use of DBT for BN has returned positive results, and specific strategies of DBT have been incorporated within CBT for BN (Wilson et al., 2007). In particular, training in mindfulness, distress tolerance and emotional regulation appear to be useful for addressing the high levels of negative affect that are frequently observed in BN (Stice & Agras, 1999; Fairburn, Stice, Cooper, Doll, Norman & O’Connor 2003). Safer et al. (2001) found that the use of DBT was associated with a decrease in bingeing and purging behaviours. Although this study was limited by the small number of participants, the results are nevertheless promising, and suggest that further research is necessary to determine the effectiveness of DBT for the treatment of BN.

1.6.3 Eating Disorders Not Otherwise Specified

As previously discussed, the EDNOS category consists of variations of BN, AN and binge eating disorder, for which the provisional criteria are available (American Psychiatric Association, 2000). Despite the prevalence and clinical severity of EDNOS, there is a paucity of published controlled treatment trials, with the exception of the binge eating disorder category (Wilson et al., 2007). It would appear however, that the existing evidence based treatment approaches may also be useful for the full range of eating disorders (Wilson et al., 2007).

Fairburn, Cooper & Shafran (2003) developed an enhanced manual for the treatment of the full range of eating disorders, expanding on their previous body of work which identified the mechanisms involved in the maintenance of BN, on which the original CBT (Fairburn, Marcus & Wilson, 1993) was based. Furthermore, Ghaderi (2006) has

43 suggested that a broader, more individualised CBT approach is superior to a more focussed, standardised CBT treatment for BN.

In contrast to BN, there have been very few well controlled studies on the treatment of binge eating disorder. Research interventions have more recently stemmed from the approaches used to treat BN, such as CBT and interpersonal psychotherapy (Wilson et al., 2007). CBT for binge eating disorder (Fairburn, Marcus & Wilson, 1993) uses an adapted version of the cognitive model of BN, however there is increasing evidence to suggest that the eating pattern observed in binge eating disorder is much less restrictive than in BN (Masheb & Grilo, 2000). Overall the controlled trials for binge eating disorder support the use of CBT, as reductions in binge eating and other associated problems (except weight loss) have been reported to be significantly superior to those of controls (Wilfley et al., 1993). Furthermore, studies have also indicated that gains are maintained at 12 month follow up (Agras, Telch, Arnow, Eldredge & Marnell, 1997; Wilfley, Welch, Stein, Spurrell, Cohen, Saelens, Dounchis, Frank, Wiseman & Matt, 2002).

In terms of alternative psychological approaches, interpersonal therapy has also proven effective, as studies have reported outcomes identical to those for CBT (Wilfley et al., 1993 & 2002). DBT has also demonstrated efficacy (relative to wait list controls) and impressive outcome results, with 56% remission rates observed at 6 month follow up (Telch, Agras & Linehan, 2001).

The literature investigating the treatment of eating disorders gives rise to the importance of considering outcome studies in eating disorder populations. This is briefly addressed below.

1.7 Outcome

Follow up studies of the eating disorders suggest varied outcomes ranging from recovery to death (Berkman, Lohr & Bulik, 2007; Keel, Mitchell, Davis, Fieselman & Crow, 2000). Relapse rates range from 22% to 51% across outcome studies of AN and BN (Keel et al., 2005). A recent study found that at 10 years follow up, 11% of AN and 10% of BN patients met recovery criteria, and at 15 years this increased to 16% for AN and

44 25% for BN (von Holle, Poyastro Pinheiro, Thornton, Klump, Berrettini, Brandt, Crawford, Crow, Fichter, Halmi, Johnson, Kaplan, Keel, LaVia, Mitchell, Strober, Woodside, Kaye & Bulik, 2008). Interestingly, this study also found that the BN group had three times the rate of recovery at 10 – 14 years than the AN group (von Holle et al., 2008). There have been a number of studies investigating outcome in the eating disorders. However, differences in approach and method across these studies have made it difficult to compare and draw inferences from them. Methodological differences across studies include the duration and method of follow up, assessment procedures used, sample size and attrition rate of the participants (Herzog, Nussbaum & Marmor, 1996).

Importantly, many studies have utilised different definitions of outcome, or recovery presumably at least partly due to a lack of consensus in the eating disorders field on what constitutes recovery (Walsh, 2008). More recently, studies have tended to utilise consistent criteria to measure outcome, such as those of Morgan & Russell (1975). Across the eating disorders, there appear to be several predictors of poor outcome that are consistently supported by research. Among these predictors are very low body weight, long duration of illness, premorbid developmental or clinical abnormalities, bulimic symptoms (including the use of purgatives) and disturbed family relationships (Herzog, Nussbaum & Marmor, 1996). Furthermore, Baran, Weltzin & Kaye (1995) found that low weight at discharge was a significant indicator of poor outcome.

1.7.1 Anorexia Nervosa

The course and outcome of AN is highly variable. The research appears to suggest that some individuals will obtain a complete recovery, some display a fluctuating pattern of weight gain and relapse and others will exhibit a chronically deteriorating course of illness over many years (American Psychiatric Association, 2000). Remission rates for AN range from 31% to 76% (Strober, Freeman & Morrell, 1997; Herzog et al., 1999; Carter, Blackmore, Sutandar-Pinnock & Woodside, 2004; Clausen, 2004; Keel et al., 2005; Couturier & Lock, 2006; Fichter, Quadflieg & Helund, 2006). Although research outcomes are varied, it is clear that once symptoms of AN have persisted for several years, the course of the illness appears to be relatively unremitting (Steinhausen, 2002).

45 In terms of research studies investigating longer term outcome in eating disorders, a prospective cohort study found at 5 year follow up that 59% of patients with AN were considered recovered (Gillberg, Råstam & Gillberg, 1994a; Gillberg, Råstam & Gillberg, 1994b; Råstam, Gillberg & Gillberg, 1995). However the AN group were significantly less likely than controls to have been at normal body weight during the previous 6 months. Furthermore, they also displayed significantly higher scores on measures of eating disorder symptomatology. At 10 years follow up, 27% still met criteria for an eating disorder and they continued to display more eating disorder symptomatolgy than the control group (Nilsson et al., 1999; Wentz, Gillberg, Gillberg & Råstam, 2001; Råstam, Gillberg & Wentz, 2003). Another study reported 30% recovery rate of AN patients at 12 year follow up, and similarly they reported that regardless of eating disorder status, all AN groups continued to display worse eating related outcomes than controls (Sullivan, Bulik, Fear & Pickering, 1998; Bulik, Sullivan, Fear & Pickering, 2000). A US study found similar results after 10 year follow up, with approximately 27% of their AN group no longer meeting diagnostic criteria for an eating disorder (Halmi et al., 1991).

Several studies have identified risk factors for poor outcome in AN which include, an extreme compulsive drive to exercise and a history of poor social relationships prior to onset of illness (Strober et al., 1997). Conversely, predictors of a more favourable outcome include less purging behaviour (Deter, Schellberg, Kopp, Friederich & Herzog, 2005) and fewer social disturbances (Deter & Herzog, 1994). Furthermore, recovered patients were less likely to have major affective disorder or anxiety disorders (Eckert, Halmi, Marchi, Grove & Crosby, 1995). Not surprisingly, a shorter duration of the AN episode significantly predicted recovery after 4 years (Herzog, Field, Keler, West, Robbins, Staley & Colditz, 1996) and 8 years (Herzog et al., 1999). In terms of psychological risk factors, one study reported that the absence of a mood disorder was significantly associated with resolution of the eating disorder (Gillberg et al., 1994b).

In terms of psychological outcomes, one study found at 5 year follow up that the AN group were significantly more likely to have personality disorders (in particular avoidant, dependent & obsessive-compulsive) and greater rates of OCD, Asperger’s syndrome and

46 any autistic like condition, compared with the comparison group (Gillberg, Råstam & Gillberg, 1995). Similar findings have been reported after 10 years follow up (Wentz, Gillberg, Gillberg & Råstam 2000; Wentz et al., 2001; Råstam et al., 2003). AN has also been associated with a lifetime prevalence of depression (Ivarsson, Råstam, Wentz, Gillberg & Gillberg, 2000).

1.7.2 Bulimia Nervosa

The course and outcome of BN appears to be more favourable than that of AN with many individuals displaying a decrease in symptoms at long term follow up. Periods of remission of longer than 1 year are generally associated with a better long term prognosis (American Psychiatric Association, 2000). The course of BN may be chronic or intermittent, with periods of remission alternating with recurrences of binge eating (American Psychiatric Association, 2000). Estimates of remission for BN range between 21% and 75% (Field, Herzog, Keller, West, Nussbaum & Colditz, 1997; Herzog et al., 1999; Keel, Mitchell, Miller, Davis & Crow, 1999; Clausen, 2004; Fichter & Quadflieg, 2004; Keel et al., 2005; Olmsted, Kaplan & Rockert, 2005). Generally, individuals with BN appear to derive benefit from antidepressant medication and psychotherapy, and continue to recover from their illness over time (Keel & Mitchell, 1997; Fairburn, Cooper, Doll, Norman & O’Connor, 2000).

One study comparing individuals with BN with a no illness control group found at 12 year follow up that the BN group (including those who had recovered) were significantly more symptomatic than the comparison group (Fichter & Quadflieg, 2004). Nevertheless, at follow up, 67% of the BN group did not meet criteria for an eating disorder. Studies with no comparison groups have yielded mixed results. At 5 year follow up BN patients had improved on a variety of measures including a reduction in objective binge episodes and purging behaviours (Fairburn, Norman, Welch, O’Connor, Doll & Peveler, 1995; Fairburn, Cooper, Doll, Norman & O’Connor, 2000; Fairburn, Stice, Cooper, Doll, Norman & O’Connor, 2003; Stice & Fairburn, 2003). In a US study, at 7 years follow up, 73% had remained symptom free for a period of 8 consecutive weeks (Herzog et al., 1999). The US study also reported that after testing predictors of outcome, such as

47 duration of illness, age at onset, weight, binge/purge frequency and co-morbid psychiatric conditions) none were significant. Fichter & Quadflieg (2004) found that lifetime psychiatric comorbidity predicted a significantly higher probability of having any eating disorder at 2 and 6 years, but not 12 years. Fichter & Quadflieg (1997 & 2004) also reported that psychiatric comorbidities were only associated with the BN group and not the comparison group. Furthermore, this study found that at 12 years, 41% had a psychiatric disorder in the month prior to assessment, with 50% of those suffering from major depression and 36% meeting criteria for an anxiety or substance use disorder (Fichter & Quadflieg, 2004).

1.7.3 Eating Disorder Not Otherwise Specified

In terms of outcome studies investigating binge eating disorder, there are several case series studies, one involving a comparison group, from which outcome results may be inferred. In a German study, at 6 year follow up, 78% had no eating disorder diagnosis, 6% continued to meet criteria for binge eating disorder and a minority had developed BN over the follow up interval (Fichter, Quadflieg & Gnutzmann, 1998). This study also reported an improvement in depression, anxiety and obsessionality measures. Another study reported a poorer outcome at 1 year follow up, in terms of a greater number of reported binge days, for individuals with cluster B personality disorders (Wilfley, Friedman, Dounchis, Stein, Welch & Ball, 2000).

1.8 Summary

Future models of eating disorder classification and assessment will have enormous implications on the empirical research and treatment development available for this serious psychopathology. It is clear that the present system for eating disorder classification, the DSM-IV, whilst significantly better than its predecessors, has inherent problems limiting its effectiveness and subsequently clinical utility. Ultimately the development of more effective eating disorder treatments will depend not only on improved classification and assessment systems, but also a better understanding of the mechanisms by which psychological treatments produce therapeutic change (Kraemer,

48 Wilson, Fairburn & Agras, 2002). In terms of the assessment instruments used to diagnose eating disorders both in clinical practice and research, it is clear from the literature, that the use of a structured clinical interview is vital for obtaining reliable diagnoses. Although self-report questionnaires are favoured due to their ease of administration and less time consuming nature, they should not be relied upon for diagnostic purposes and should only be used in conjunction with a clinical interview.

It is clear from the literature, that comorbid psychiatric illnesses are prevalent amongst the eating disorders. In particular, mood and anxiety disorders, substance abuse disorders and personality disorders, feature prominently. Subsequently, assessment procedures must also take into account the possibility of comorbid psychiatric illnesses, and in particular the temporal and functional relationships between comorbid disorders. The issue of comorbidity will be addressed in greater detail in the following chapters.

In terms of evidence based treatment approaches, whilst the research for efficacious treatments for AN is variable, generally family therapy and cognitive therapy obtain more favourable outcomes. For BN and binge eating disorder, the research tends to favour the use of CBT, IPT and DBT. It is clear across all eating disorder groups that the use of motivational therapy is vital regardless of the therapeutic approach. In terms of outcome, there are difficulties associated with drawing inferences from the available literature due to the varied methodological approaches utilised. Nevertheless, the outcomes of individuals with BN tend to be more consistently favourable than those for AN. It is clear that further research is essential in this area.

As outlined in this chapter, the issue of psychiatric comorbidity amongst the eating disorders has received a great deal of interest to date. The purpose of the current study is to explore this area in greater depth. The following chapter provides a summary of the current literature concerning assessment and treatment of anxiety disorders, as well as providing an outline of the core features of anxiety disorders and psychiatric comorbidity associated with each disorder. Chapter 2 is important in providing background to the following chapters discussing the comorbidity between eating disorders and anxiety disorders.

49 CHAPTER 2

INTRODUCTION TO THE ANXIETY DISORDERS

As discussed in the previous chapter, the comorbidity between eating disorders and other Axis I disorders has been well established. In particular, anxiety disorders have more recently been implicated. Prior to discussing comorbidity between eating and anxiety disorders, a review of the current anxiety disorder literature, including a brief review of the DSM-IV diagnostic criteria for each of the anxiety disorders, is presented in this chapter.

Anxiety is a universal phenomenon experienced by most human beings within the course of their lifetime (Di Tomasso & Gosch, 2002). Barlow & Cerny (1988) define anxiety as an unpleasant affective experience marked by a significant degree of apprehensiveness about the potential of future aversive or harmful events. It has been estimated that approximately 15% of the population are affected by an anxiety disorder at some point throughout their lifetime (Brown & Barlow, 1992). It is important to distinguish between the experience of anxiety in one’s life, and what characterises an anxiety disorder, and furthermore, to clearly delineate between primary anxiety symptomatology and those symptoms secondary to other Axis I disorders.

Essentially an anxiety disorder diagnosis necessitates a frequency, intensity, severity, breadth and mix of symptoms, which are significant enough to adversely impact on social, occupational or other areas of functioning of an individual’s life (American Psychiatric Association, 2000). The DSM IV classification system for anxiety disorders is comprised of panic disorder, panic disorder with agoraphobia, specific phobia, social phobia, generalized anxiety disorder, post traumatic stress disorder, acute stress disorder and anxiety disorder not otherwise specified. Each of these disorders are discussed below.

2.1 Panic Disorder and Agoraphobia: Core Features The essential feature of panic disorder is the presence of recurrent, unexpected panic attacks followed by at least one month of persistent concern about having another panic attack (American Psychiatric Association, 2000; see Table 2.1.1). Individuals with this disorder will also report concerns about the possible implications or consequences of the panic attacks (such as death, collapse or madness), and or display significant behavioural change as a result of these attacks. It is important to note that the DSM-IV specifies that for panic disorder to be present, the panic attacks must be unexpected, that is, the individual does not immediately associate it with a situational trigger, and it is perceived as occurring “out of the blue” (American Psychiatric Association, 2000, p434). Nevertheless, as a result of the experience of anxiety, people may begin to associate the experience with a particular situation or context, such as driving a car, or attending a shopping centre.

Table 2.1.1

DSM-IV-TR criteria for Panic Attack (American Psychiatric Association, 2000)

DSM-IV-TR Criteria for Panic Attack

A discrete period of intense fear or discomfort, in which four (or more) of the following symptoms developed abruptly and reached a peak within 10 minutes:

(1) palpitations, pounding heart, or accelerate heart rate

(2) sweating

(3) trembling or shaking

(4) sensations of shortness of breath or smothering

(5) feeling of choking

(6) chest pain or discomfort

(7) nausea or abdominal distress

(8) feeling dizzy, unsteady, lightheaded, or faint

51 Table 2.1.1 (continued)

(9) derealisation (feelings of unreality) or depersonalisation (being detached from oneself)

(10) fear of losing control or going crazy

(11) Fear of dying

(12) Paresthesias (numbness or tingling sensations)

(13) Chills or hot flushes

Additional features associated with the diagnosis of Panic Disorder include assessment for the presence of Agoraphobia (see Table 2.1.2). The essential feature of Agoraphobia is anxiety about being in public places or situations, from where escape or receiving assistance may be unavailable in the event of an individual having a panic attack. Subsequently, this anxiety leads to pervasive avoidance of a variety of situations and places. Some individuals, who do expose themselves to these situations, do so with intense dread and discomfort. The DSM-IV allows for the coding of Panic Disorder with or without agoraphobia (American Psychiatric Association, 2000; see Table 2.1.3 and Table 2.1.4). Agoraphobia may also be associated with a more limited form of panic called limited symptom attacks, which does not meet the diagnostic criteria for panic disorder (Di Tomasso & Gosch, 2002). Furthermore, The DSM-IV provides diagnostic criteria for agoraphobia without a history of panic disorder (see Table 2.1.5).

The age of onset for Panic Disorder varies considerably, but onset is typically between late adolescence and the mid-30’s (American Psychiatric Association, 2000). Furthermore, the DSM-IV notes that there may be a bimodal distribution, with one peak in late adolescence and a second peak in the mid-30’s. Although rare, a small number of cases may begin in childhood or onset after age 45 years (American Psychiatric Association, 2000).

52 According to the DSM-IV, lifetime prevalence rates of Panic Disorder (with or without Agoraphobia) in community samples have been reported to be between 1 – 3.5%. One year prevalence rates are between 0.5 – 1.5%. The prevalence rates in clinical samples are considerably higher, and may be around 10% in mental health settings (American Psychiatric Association, 2000). In an Australian study surveying the rates of DSM-IV disorders in a large mixed gender sample, Panic Disorder with and without Agoraphobia had a 12 month prevalence rate of 1.1%, whilst Agoraphobia without Panic Disorder had a 12 month prevalence rate of 0.5% (Andrews, Henderson & Hall, 2001).

Table 2.1.2

DSM-IV-TR criteria for Agoraphobia (American Psychiatric Association, 2000)

DSM-IV-TR Criteria for Agoraphobia

A. Anxiety about being in places or situations from which escape might be difficult (or embarrassing) or in which help may not be available in the event of having an unexpected or situationally predisposed Panic Attack or panic-like symptoms. Agoraphobic fears typically involve characteristic clusters of situations that include being outside the home alone; being in a crowd or standing in a line; being on a bridge; and travelling in a bus, train or automobile. B. The situations are avoided (e.g., travel is restricted) or else are endured with marked distress or with anxiety about having a Panic Attack or panic-like symptoms, or require the presence of a companion. C. The anxiety or phobic avoidance is not better accounted for by another mental disorder, such as Social Phobia, Specific Phobia, Obsessive-Compulsive Disorder, Posttraumatic Stress Disorder, or separation Anxiety Disorder.

53 Table 2.1.3

DSM-IV-TR diagnostic criteria for Panic Disorder Without Agoraphobia (American Psychiatric Association, 2000)

DSM-IV-TR Diagnostic Criteria for Panic Disorder Without Agoraphobia

A. Both (1) and (2):

(1) recurrent unexpected Panic Attacks (2) at least one of the attacks has been followed by 1 month (or more) of one (or more) of the following:

(a) persistent concern about having additional attacks

(b) worry about the implications of the attack or its consequences (e.g., losing control, having a heart attack, and “going crazy”)

B. Absence of Agoraphobia

C. The panic Attacks are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism).

D. The Panic Attacks are not better accounted for by another mental disorder such as Social Phobia, Specific Phobia, Obsessive-Compulsive Disorder, Posttraumatic Stress Disorder, or separation Anxiety Disorder.

Table 2.1.4

DSM-IV-TR diagnostic criteria for Panic Disorder With Agoraphobia (American Psychiatric Association, 2000)

DSM-IV-TR Diagnostic Criteria for Panic Disorder With Agoraphobia

A. Both (1) and (2):

(1) recurrent unexpected Panic Attacks (2) at least one of the attacks has been followed by 1 month (or more) of one (or more) of the following:

(a) persistent concern about having additional attacks

(b) worry about the implications of the attack or its consequences (e.g., losing control, having a heart attack, and “going crazy”)

B. The presence of Agoraphobia

C. The panic Attacks are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism).

Table 2.1.5

DSM-IV-TR diagnostic criteria for Agoraphobia Without a History of Panic Disorder (American Psychiatric Association, 2000)

DSM-IV-TR Diagnostic Criteria for Agoraphobia Without a History of Panic Disorder

A. The presence of Agoraphobia related to a fear of developing panic–like symptoms (e.g., dizziness or diarrhoea). B. Criteria have never been met for Panic Disorder C. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition D. If an associated general medical condition is present, the fear described in Criterion A is clearly in excess of that usually associated with the condition.

2.2 Specific Phobia: Core Features The essential feature of Specific Phobia is marked and persistent fear of certain objects or situations (American Psychiatric Association, 2000; see Table 2.2.). These situations or objects may include (but are not limited to): animals, heights, storms, water, blood/injection/injury, air travel, enclosed spaces, driving or dental/medical procedures. Exposure to the phobic stimulus almost always invokes an immediate anxiety response (which may include a situational bound panic attack). The diagnosis of this disorder is only appropriate if the avoidance, fear or anxious anticipation of encountering the phobic stimulus interferes with the individual’s functioning (daily routine, occupational functioning or social life). The DSM-IV further codes specific phobias into five distinct subtypes including animal type, natural environment type, blood-injection-injury type, situational type or other type. The DSM-IV highlights that although phobias are common in the general population, they rarely result in sufficient impairment or distress to warrant a diagnosis of specific phobia. In community samples, current prevalence rates range from 4 – 8.8% and lifetime rates range from 7.2 – 11.3% (American Psychiatric Association, 2000). In terms of age of onset, the first symptoms of a specific phobia tend

56 to occur in childhood or early adolescence and may occur at a younger age for women than men (American Psychiatric Association, 2000). The age at onset tends to vary depending on the type of phobia, with situational type phobias tending to be bimodally distributed with a peak in childhood and a second peak in the mid-20’s. Natural environment type phobias tend to begin primarily in childhood, although the development of height phobia in early adulthood is not uncommon (American Psychiatric Association, 2000). The age of onset for animal and blood- injection-injury type phobias tend to be in childhood.

Table 2.2

DSM-IV-TR diagnostic criteria for Specific Phobia (American Psychiatric Association, 2000)

DSM-IV-TR Diagnostic Criteria for Specific Phobia

A. Marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood).

B. Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response, which may take the form of a situationally bound or situationally predisposed Panic Attack.

C. The person recognises that the fear is excessive or unreasonable

D. The phobic situation(s) is avoided or else endured with intense anxiety or distress

E. The avoidance, anxiety anticipation, or distress in the feared situation(s) interferes significantly with the person’s normal routine, occupational (or academic) functioning, or social activities or relationships, or there is marked distress about having the phobia.

F. In individuals under age 18 years, the duration is at least 6 months.

G. The anxiety, Panic Attacks or phobic avoidance associated with the specific object or situation are not better accounted for by another mental disorder such as Obsessive- Compulsive Disorder, Posttraumatic Stress Disorder, Separation Anxiety Disorder, Social Phobia, Panic Disorder with Agoraphobia, or Agoraphobia Without a history of Panic Disorder.

Table 2.2 (continued)

Specify Type:

Animal Type

Natural Environment Type (e.g., heights, storms, water)

Blood-Injection-Injury type

Situational Type (e.g., airplanes, elevators, enclosed places)

Other Type (e.g., fear of choking, vomiting or contracting an illness)

2.3 Social Phobia: Core Features An individual is diagnosed with Social Phobia when they display a marked and persistent fear of social or performance situations in which embarrassment may occur. Exposure to such situations invariably provokes an immediate anxiety response (American Psychiatric Association, 2000; see Table 2.3). Usually, the social or performance based situation is avoided, however at times an individual will confront the situation and endure it with dread. Epidemiological and community based studies have reported a lifetime prevalence of social phobia ranging from 3% to 13% (American Psychiatric Association, 2000). In an Australian study social phobia had a 12 month prevalence rate of 1.3% (Andrews et al., 2001). Social phobia typically has an onset in the mid-teens, however some individuals report an onset early childhood.

58 Table 2.3

DSM-IV-TR diagnostic criteria for Social Phobia (American Psychiatric Association, 2000)

DSM-IV-TR Diagnostic Criteria for Social Phobia

A. Marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing.

B. Exposure to the feared social situation almost invariably provokes anxiety, which may take the form of a situationally bound or situationally predisposed Panic Attack.

C. The person recognises that the fear is excessive or unreasonable.

D. The feared social or performance situations are avoided or else are endured with intense anxiety or distress.

E. The avoidance, anxious anticipation, or distress in the feared social or performance situation(s) interferes significantly with the person’s normal routine, occupational (or academic) functioning, or social activities or relationships, or there is marked distress about having the phobia.

F. In individuals under age 18 years, the duration is at least 6 months.

G. The fear or avoidance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition and is not better accounted for by another mental disorder (e.g., Panic Disorder With or Without Agoraphobia

Obsessive-Compulsive Disorder, Separation Anxiety Disorder, Body Dysmorphic Disorder, a Pervasive developmental Disorder, or Schizoid Personality Disorder)

H. If a general medical condition or another mental disorder is present, the fear in Criterion A is unrelated to it, e.g., the fear is not of stuttering, trembling in Parkinson’s disease, or exhibiting abnormal eating behaviour in Anorexia Nervosa or Bulimia Nervosa.

Specify if:

Generalised: if the fears include most social situations (also consider the additional diagnosis of Avoidant Personality Disorder)

59 2.4 Obsessive Compulsive Disorder (OCD): Core Features The essential features of OCD include recurrent obsessions or compulsions. Obsessions relate to persistent ideas, thoughts, impulses or images that are experienced as intrusive or inappropriate and cause marked distress or anxiety (American Psychiatric Association, 2000; see Table 2.4). Importantly, these obsessions are often referred to as ego-dystonic, meaning that the individual regards the content of the obsession as “alien, not within his or her own control, and not the kind of thought that he or she would expect to have” (American Psychiatric Association, 2000, p457). Common obsessions include thoughts about contamination, repeated doubts, a need to have things in a particular order, aggressive or horrific impulses and sexual imagery. As a result of the obsessions, the individual usually feels compelled to ignore, suppress or neutralize them in order to reduce the anxiety and distress.

Compulsions refer to the repetitive behaviours or mental acts the individual engages in to prevent or reduce anxiety or distress. It is important to note that the performance of these acts are not completed to provide pleasure or gratification (American Psychiatric Association, 2000).

OCD typically begins in adolescence or early adulthood, however it may begin in childhood. Modal age of onset tends to be lower in males (6 – 15 years) than females (20 – 29 years) (American Psychiatric Association, 2000).

In terms of prevalence rates, the DSM-IV cites community studies estimating a lifetime prevalence of 2.5% and a 1 year prevalence of between 0.5 – 2.1% in adults. It is noted that methodological problems with assessment tools raise the possibility that true prevalence rates may be much lower (American Psychiatric Association, 2000). The 12 month prevalence rate for OCD across an Australian sample was found to be 0.7% (Andrews et al., 2001).

Table 2.4

DSM-IV-TR diagnostic criteria for Obsessive-Compulsive Disorder (American Psychiatric Association, 2000)

DSM-IV-TR Diagnostic Criteria for Obsessive-Compulsive Disorder

A. Either obsessions or compulsions:

Obsessions as defined by (1), (2), (3), and (4):

(1) Recurrent and persistent thoughts, impulses or images that are experienced, at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress

(2) The thoughts, impulses, or images are not simply excessive worries about real life problems

(3) The person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralise them with some other thought or action

(4) The person recognises that the obsessional thoughts, impulses, or images are a product of his or her own mind (not imposed from without as in thought insertion)

Compulsions as defined by (1) and (2):

(1) Repetitive behaviours (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly

(2) The behaviours or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviours or mental acts either are not connected in a realistic way with what they are designed to neutralise or prevent or are clearly excessive

B. At some point during the course of the disorder, the person has recognised that the obsessions or compulsions are excessive or unreasonable.

C. The obsessions or compulsions cause marked distress, are time consuming (take more than 1 hour a day), or significantly interfere with the person’s normal routine, occupational (or academic) functioning, or usual social activities or relationships.

Table 2.4 (continued)

D. If another Axis I disorder is present, the content of the obsessions or compulsions is not restricted to it (e.g., preoccupation with food in the presence of an Eating Disorder; hair pulling in the presence of Trichotillomania; concern with the appearance in the presence of Body Dysmorphic Disorder; preoccupation with drugs in the presence of

Substance Use Disorder; preoccupation with sexual urges or fantasies in the presence of Hypochondriasis; preoccupation with sexual urges or fantasies in the presence of a Paraphilia; or guilty ruminations in the presence of Major Depressive Disorder).

E. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition

Specify if:

With Poor insight: if, for most of the time during the current episode, the person does not recognise that the obsessions and compulsions are excessive or unreasonable.

2.5 Post Traumatic Stress Disorder (PTSD) and Acute Stress Disorder (ASD): Core Features PTSD refers to the development of characteristic symptoms following exposure to an extreme traumatic stressor involving direct personal experience of an event that involves actual or threatened death or injury; or witnessing an event involving actual or threatened death or injury; or learning about the unexpected violent death, serious harm, or threat of death or injury experienced by a family member or close associate (American Psychiatric Association, 2000; see Table 2.5.1). An individual’s response to such an event involves intense fear, helplessness or horror.

The characteristic symptoms resulting from exposure to a trauma as described above include persistent re-experiencing of the event, persistent avoidance of stimuli associated with the event and numbing of general responsiveness, and persistent symptoms of increased arousal.

Although the perception of what constitutes a traumatic event may differ from person to person, such events may include: military combat, violent personal assault (mugging, sexual assault), kidnapping, hostage situations, terrorist attack, torture, incarceration, natural or manmade disasters, car accidents, or being diagnosed with a life threatening illness (American Psychiatric Association, 2000). The DSM-IV notes that the disorder is likely to be especially severe or long lasting when the trauma is of human design, such as torture or sexual assault (American Psychiatric Association, 2000).

The defining characteristic of PTSD and ASD is the experiencing or witnessing of a traumatic or life threatening event during which the individual has experienced a sense of helplessness or horror. What distinguishes ASD from PTSD is the duration of the problem. Specifically, a diagnosis of ASD is assigned when the individual experiences the disturbance outlined above for a minimum of two days and a maximum of four weeks, and occurs within four weeks of the traumatic event (American Psychiatric Association, 2000; see Table 2.5.2).

In terms of prevalence rates for PTSD, community-based studies reveal a lifetime prevalence of approximately 8% of the US adult population (American Psychiatric Association, 2000). The prevalence of ASD in the general population is unknown, however in the few available studies, rates ranging from 14 – 33% have been reported in individuals exposed to severe trauma (American Psychiatric Association, 2000). The 12 month prevalence rate for PTSD across an Australian sample was found to be 1.3% (Andrews et al., 2001). Onset for PTSD can occur at any age, including childhood (American Psychiatric Association, 2000).

63 Table 2.5.1

DSM-IV-TR diagnostic criteria for Post traumatic Stress Disorder (American Psychiatric Association, 2000)

DSM-IV-TR Diagnostic Criteria for Post Traumatic Stress Disorder

A. The person has been exposed to a traumatic event in which both of the following were present:

(1) The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others (2) The person’s response involved intense fear, helplessness, or horror.

B. The traumatic event is persistently reexperienced in one (or more) of the following ways: (1) recurrent and intrusive distressing recollection of the event, including images, thoughts, or perceptions (2) recurrent distressing dreams of the event (3) Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated). (4) Intense psychological distress at exposure to internal or external cues that symbolise or resemble an aspect of the traumatic event (5) Physiological reactivity on exposure to internal or external cues that symbolise or resemble an aspect of the traumatic event C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following: (1) efforts to avoid thoughts, feelings, or conversations associated with the trauma (2) efforts to avoid activities, places, or people that arouse recollections of the trauma (3) inability to recall an important aspect of the trauma (4) markedly diminished interest or participation in significant activities (5) feeling of detachment or estrangement from others (6) restricted range of affect (e.g., unable to have loving feelings) (7) sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)

Table 2.5 (continued)

D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following: (1) difficulty falling asleep or staying asleep (2) irritability or outbursts of anger (3) difficulty concentrating (4) hypervigilance (5) exaggerated startle response E. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than 1 month. F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning

Specify if:

Acute: if duration of symptoms is less than 3 months

Chronic: if duration of symptoms is 3 months or more

Specify if:

With Delayed Onset: if onset of symptoms is at least 6 months after the stressor

Table 2.5.2

DSM-IV-TR diagnostic criteria for Acute Stress Disorder (American Psychiatric Association, 2000)

DSM-IV-TR Diagnostic Criteria for Acute Stress Disorder

A. The person has been exposed to a traumatic event in which both of the following were present:

Table 2.5.2 (continued)

B. either while experiencing or after experiencing the distressing event, the individual has three (or more) of the following dissociative symptoms: (1) a subjective sense of numbing, detachment, or absence of emotional responsiveness (2) a reduction in awareness of his or her surroundings (e.g., “being in a daze”) (3) derealisation (4) depersonalisation (5) dissociative amnesia (i.e., inability to recall an important aspect of the trauma) C. The traumatic event is persistently reexperienced in one (or more) of the following ways: recurrent images, thoughts, dreams, illusions, flashback episodes, or a sense of reliving the experience; or distress on exposure to reminders of the traumatic event D. Marked avoidance of stimuli that arouse recollections of the trauma (e.g., thoughts, feelings, conversations, activities, places, and people). E. Marked symptoms of anxiety or increased arousal (e.g., difficulty sleeping, irritability, poor concentration, hypervigilance, exaggerated startle response, motor restlessness). F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or impairs the individual’s ability to pursue some necessary task, such as obtaining necessary assistance or mobilising personal resources by telling family members about the traumatic experience. G. The disturbance lasts for a minimum of 2 days and a maximum of 4 weeks and occurs within 4 weeks of the traumatic event. H. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition, is not better accounted for by Brief Psychotic Disorder, and is not merely an exacerbation of a pre-existing Axis I or Axis II disorder.

66 2.6 Generalised Anxiety Disorder (GAD): Core Features The essential feature of GAD is excessive anxiety and worry occurring on more days than not for a period of at least 6 months. The anxiety and worry relates to a number of events or activities in the individual’s life, and the worry is perceived as uncontrollable. In addition, the anxiety and worry are accompanied by at least three additional symptoms including restlessness, being easily fatigued, concentration impairment, irritability, muscle tension, and disturbed sleep (American Psychiatric Association, 2000; see Table 2.6). Although individuals may not always regard the worry as excessive, they will report subjective distress resulting from the constant worry, have difficulty controlling the worry, or experience related impairment in social, occupational or daily functioning. It is important to note that the DSM-IV specifies that the intensity, duration or frequency of the worry is significantly out of proportion with the actual likelihood or impact of the feared event. Typical areas of worry include minor matters, work or educational commitments, family, finances, social/interpersonal, health (self or others) or community or world affairs. It is typical for worries to shift focus from one concern to another over the course of this disorder (American Psychiatric Association, 2000).

In terms of prevalence rates, in a community sample, the 1-year prevalence rate was approximately 3% and the lifetime rate was 5% (American Psychiatric Association, 2000). The 12 month prevalence rate for GAD across an Australian sample was found to be 2.6% (Andrews et al., 2001).

Table 2.6 DSM-IV-TR diagnostic criteria for Generalised Anxiety Disorder (American Psychiatric Association, 2000)

DSM-IV-TR Diagnostic Criteria for Generalised Anxiety Disorder

A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance). B. The person finds it difficult to control the worry C. The anxiety or worry are associated with three (or more) of the following six symptoms (with at least some symptoms present for more days than not for the past 6 months):

(1) Restlessness or feeling keyed up or on edge (2) Being easily fatigued (3) Difficulty concentrating or mind going blank (4) Irritability (5) Muscle tension (6) Sleep disturbance (difficulty falling asleep or staying asleep, or restless, unsatisfying sleep)

D. The focus of the anxiety and worry is not confined to features of an Axis I disorder, e.g., the anxiety or worry is not due to Panic Disorder, Social Phobia, Obsessive- Compulsive Disorder, Separation Anxiety disorder, Anorexia Nervosa, Somatization Disorder, Hypochondriasis, or Posttraumatic Stress Disorder. E. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. F. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g. hyperthyroidism) and does not occur exclusively during a Mood Disorder, a Psychotic Disorder, or a Pervasive Developmental Disorder.

68 2.7 Assessment The interest in assessment procedures is of particular relevance in the comorbidity literature, and unfortunately has been a source of recurrent criticism. Although this will discussed in greater detail later, the differentiation between a comorbid anxiety disorder and symptoms secondary to other Axis I disorders is crucial, and relies on the assessment measures and procedures used to draw this distinction. A brief overview of current measures and procedures recommended for the assessment of anxiety disorders is provided below.

Assessment of anxiety disorders for clinical and research purposes, utilise a number of different methods including interviews, questionnaire measurements, observational techniques and self- monitoring (Wells, 1997). The interview is recognized as the most frequently utilized assessment method, and may be conducted as either a standardized diagnostic interview or a clinical assessment interview (Wells, 1997). Essentially, the assessment serves to identify the problem(s), elicit information for case formulation, determine the level of past and present functioning and monitor treatment outcome (Wells, 1997). The aim of the initial assessment is also to provide a diagnostic understanding of the presenting problem, which may assist with evidenced based treatment planning.

2.7.1 DSM-IV Classification The current DSM-IV diagnostic system for anxiety disorders represents a significant improvement in the process of diagnosis, compared with its previous versions. It is clear that the introduction of diagnostic systems, such as the DSM and the International Classification of Diseases (ICD) has been extremely important in assisting the development of evidence based treatment approaches. Nevertheless, inherent problems remain, such as the error variance within the classification system, limited reliability in cross diagnosis, and difficulties when presented with individuals meeting criteria for more than one disorder (Kendall & Clarkin, 1992). Furthermore, this is particularly salient when considering the prevalence of comorbidity amongst Axis I disorders, and the possibility that our present diagnostic system and assessment procedures may contribute

69 to false comorbidity rates. Subsequently, the issue of comorbidity is inextricably tied to the diagnostic classification system used to diagnose the disorders.

2.7.2 Assessment Instruments Structured diagnostic instruments have been designed to improve the reliability of the clinical judgment in regards to whether a patient meets the diagnostic criteria (Andrews, Creamer, Crino, Hunt, Lampe & Page, 2003) and to allow accurate distinction between different diagnoses. These interviews are useful due to the standardisation of questioning leading to greater validity. However as Andrews et al., (2003) note, validity will be limited to the validity of the diagnostic criteria upon which the interview was based, and how efficiently the interview can elicit the cognitions, emotions and behaviours contained within the diagnostic criteria. There are a number of assessment instruments specific to anxiety symptomatology, including structured and semi-structured interviews as well as questionnaire based assessment tools. Some of these will be discussed in greater detail in chapter 6.

The current literature concerning anxiety disorder comorbidity with mood, substance abuse and personality disorders is detailed below. The comorbidity between anxiety and eating disorders is discussed in detail in proceeding chapters.

2.8 Comorbidity of Mental Disorders Assessment of comorbid disorders amongst individuals presenting with an anxiety disorder is extremely important given the reported high rates of comorbid psychiatric illness, including additional anxiety disorders, mood disorders, substance abuse disorders and personality disorders. These will be discussed briefly below.

2.8.1 Mood Disorders Previous research has found that individuals presenting with anxiety disorders often display symptoms consistent with an additional anxiety disorder or mood disorder diagnosis. One study reported that as many as 50% of participants with a principal anxiety disorder had at least one clinically significant additional anxiety or mood disorder

70 (Moras, DiNardo, Brown & Barlow, 1991). Furthermore, GAD and social phobia at clinically significant levels were found to be the most commonly diagnosed comorbid anxiety disorder (Moras et al., 1991).

2.8.2 Substance Abuse Disorders A number of previous research studies have reported high comorbidity rates between anxiety and substance abuse disorder. Most of these studies have examined the rates of anxiety disorders amongst substance abuse samples, finding lifetime prevalence rates of anxiety disorders to range between 25 – 45% (Bowen, Cipywnyk, D’Arcy & Keegan, 1984; Hesselbrock, Meyer & Keener, 1985; Chambless, Cherney, Caputo & Rheinstein, 1987). Studies examining rates of alcohol use disorders amongst anxiety disorder outpatient samples have found that approximately 15% – 25% meet criteria for a current or past diagnosis of alcohol abuse or dependence (Bibb & Chambless, 1986; Thyer, Parrish, Himle, Cameron, Curtis & Nesse, 1986). Another study reported that substance abuse was the most common comorbid diagnosis in a male sample of Vietnam veterans with PTSD (Kulka, Schlenger, Fairbank, Hough, Jordan, Marmar & Weiss, 1990).

2.8.3 Personality Disorders Comorbidity between anxiety disorders and personality disorders has been investigated in a number of studies. Much of the literature focuses on the prevalence of personality disorders amongst individuals with Panic Disorder, suggesting that between 27% - 65% of patients demonstrate evidence of a comorbid personality disorder (Koenigsberg, Kaplan, Gilmore & Cooper, 1985; Mavissakalian & Hamann, 1986; Friedman, Shear & Frances, 1987; Reich, Noyes & Troughton, 1987; Green & Curtis, 1988). Two studies examining the rates of comorbid personality disorders in GAD (Sanderson & Wetzler, 1991) and OCD (Steketee, 1990) both reported that 50% met criteria for a personality disorder.

Finally, the comorbidity between Axis I and II disorders is particularly problematic when considering evidenced based treatment approaches available for people with multiple diagnoses. Unfortunately, there are a number of problems associated with the use of

71 diagnosis to drive treatment approaches. Although clearly the use of a diagnostic system such as the DSM-IV is useful for determining the selection of evidenced based treatments, limitations stem from the fact that many people present with multiple diagnoses (Brown, Campbell, Lehman, Grisham & Mancill, 2001) or their anxiety features do not meet full symptom criteria for a particular anxiety disorder (Antony & Rowa, 2005). Subsequently, evidenced based treatment guidelines say little about how best to treat such individuals (Antony & Rowa, 2005). As will be discussed later, treatment of multiple diagnoses may involve modification of current approaches, to ensure that all symptoms are addressed, particularly where there is a relationship between the disorders. A brief overview of current treatment approaches for the anxiety disorders is discussed below.

2.9 Treatment Treatment for anxiety disorders have been influenced by Mowrer’s (1939) two-factor theory, which combines classical and operant conditioning, and forms the basis for much of behaviour therapy (Meadows & Phipps, 2002). Subsequent cognitive–behavioural models of anxiety disorders and their treatments have incorporated the idea that avoidance learning is central to the maintenance of anxiety disorders and therefore reducing avoidance behaviour is crucial in disrupting the anxiety cycle.

Although initially, behaviour therapists did not focus on the role of cognitions in maintaining anxiety disorders, the work of Ellis and Beck throughout the 1960’s emphasized the importance of cognitions impacting upon emotional states and behaviours (Meadows & Phipps, 2002). Beck’s cognitive theory (1967) stated that humans do not respond to events directly, but to our interpretation of these events. Subsequently it was postulated that by challenging our interpretations and erroneous beliefs, we could replace them with more rational or adaptive ones, leading to more adaptive emotions and behaviours (Meadows & Phipps, 2002).

Cognitive explanations have also been used to explain the underlying mechanisms involved in exposure based treatment programs (Meadows & Phipps, 2002). Foa &

72 Kozak (1986) postulated that exposure involves the introduction of corrective information which leads to a decrease in fear, rather than simply the disruption of associations between a situation and the ensuing anxious state.

More recently new combinations of CBT treatments have begun to emerge, which attempt to integrate elements of other therapeutic approaches into standard CBT interventions (Bates, 2007). Some examples of these ‘enhanced’ treatment packages include incorporating mindfulness techniques (Linehan, 1993a) and psychodynamic methods (Ryle, 2004).

Within the cognitive behavioural treatment paradigm, problem–solving therapy (PST) has emerged as an empirically supported treatment approach for anxiety disorders (Felgoise, Nezu & Nezu (2002). PST focuses on the emotional, cognitive and behavioural processes that interfere with an individual’s ability to cope with problems in daily living (Felgoise et al, 2002). The main focus of PST is on the social and interpersonal context in which problems and problem solving often occur. Furthermore, this approach states that maladaptive psychological and physical responses are the result of an individual’s inability to cope with negative mood states and stressful life events (Felgoise et al, 2002). A number of research studies have suggested that effective problem solving may moderate the effects of the stress-distress relationship, specifically with regard to anxious and depressive states (Nezu & Ronan, 1985 & 1988; Nezu, Nezu, Saraydarian, Kalman & Ronan, 1986; Kant, D’Zurilla & Maydeau-Olivares, 1997). PST has been reported to be effective for the treatment of social phobia (DiGiuseppe, Simon, McGowan & Gardner, 1990).

Another treatment approach gaining support in the treatment of anxiety disorders is Acceptance and Commitment Therapy (ACT). ACT is a contextual behavioural psychotherapy (Hayes, Strosahl & Wilson, 1999) sharing its philosophical roots with constructivism, narrative psychology, dramaturgy, social constructionism, feminist psychology, Marxist psychology, and other contextulistic approaches (Hayes, Luoma, Bond, Masuda & Lillis, 2006). Essentially, ACT views psychopathology as a relatively

73 frequent and normal side effect of human language processes (Hayes, Pankey & Gregg, 2002). Verbal processes are seen as driving suffering, in so much as individuals, through language are able to think, reason and problem solve, and similarly able to amplify suffering (Hayes et al, 2002). ACT therefore focuses on reducing experiential avoidance, deconstructing language representations, teaching acceptance and willingness towards unwanted private events, assisting in maintaining contact with a transcendent sense of self, clarifying life values and directions, assisting with directing behaviour in line with chosen life values (Hayes et al, 2002). An increasing body of literature supports the empirical value of ACT (Hayes et al., 1999; Hayes et al., 2006). In a randomized controlled study investigating the treatment of workplace anxiety and stress, ACT was found to be useful (Bond & Bunce, 2000). ACT was also found to be effective in the treatment of GAD (Roemer & Orsillo, 2002).

Interpersonal Psychotherapy (IPT) is another therapeutic approach which has been receiving greater attention as a treatment for anxiety disorders. IPT, originally developed for the treatment of depression, is a focused, time-limited treatment approach, concentrating on interpersonal as opposed to the cognitive-behavioural aspects of an individual’s life (Goldstein & Gruenberg, 2002). The IPT model proposes to address anxious and depressive symptoms, by specifically focusing on an individual’s current stressors in interpersonal relationships in combination with the stress response associated with those relationships (Goldstein & Gruenberg, 2002). Interpersonal therapy (IPT) has proven efficacious for major depression (Elkin, Shea, Watkins, Imber, Sotsky, Glass, Pilkonis, Leber & Docherty, 1989; Weissman, Markowitz, & Klerman, 2000) and for bulimia (Fairburn et al.,1995). Although there is some research indicating that IPT may be an effective treatment for Social Phobia (Lipsitz, Markowitz & Cherry, 1999; Borge, Hoffart, Sexton, Clark, Markowitz & McManus, 2007), there is a need for further research in this area, particularly with regard to specific phobia and GAD (Goldstein & Gruenberg, 2002).

Pharmacological approaches have also been implicated in the treatment of anxiety disorders, namely benzodiazepines and antidepressant medications. Over the last few

74 decades there have been a number of studies confirming the efficacy of benzodiazepines in the treatment of GAD (Leonard, 1998). Unfortunately, tolerance and dependence may occur with prolonged use of benzodiazepine medication, and Consequently, there have been criticisms surrounding its use as a frontline treatment for anxiety disorders. Furthermore, as previously indicated, a key component of many of the psychotherapeutic approaches is a reduction in avoidance based coping strategies, which does not necessarily fit with the prescription of medication designed to reduce anxiety symptoms without cognitive or behavioural change. The use of benzodiazepines may also interfere with the generalization of skills learnt during therapy (Andrews et al., 2003).

Antidepressant medication, however, appears to be different, and has been effectively been used in the treatment of anxiety and comorbid anxiety and depression (Feighner, 1999). To date, the research has supported the efficacy of SSRI’s and tricyclic antidepressants in the treatment of anxiety disorders. Although they do not contain the same reinforcing properties and subsequent dependence issues identified with benzodiazepine class medications, there may still be the risk that treatment gains or improvements are attributed to the antidepressant and not changes made by the individual.

2.10 Summary This chapter has provided a brief summary of issues relating to the assessment and treatment of Anxiety Disorders. The core features of each of the anxiety disorders have been discussed, and whilst each has its own specific diagnostic criteria, it is clear that a key characteristic across all of the disorders is the experience of anxious apprehension (Barlow & Cerney, 1988). Other commonalities across all of the disorders are the marked, persistent and excessive nature of symptoms experienced and their subsequent impact on an individual’s ability to function.

Although the current DSM-IV diagnostic system for anxiety disorders represents a significant improvement in the process of diagnosis, compared with its previous versions, nevertheless, inherent problems remain. These limitations prove problematic for

75 clinicians and researchers, in regards to diagnostic and treatment issues. Comorbidity is an area that has frequently been complicated by the present diagnostic system. Given the clear evidence that comorbid psychiatric disorders feature prominently in anxiety disorder samples, this is of particular concern.

Psychiatric comorbidity amongst Axis I and II disorders is common, and in particular, anxiety disorders are frequently associated with eating disorders. Despite the fact that anxiety disorders are frequently implicated in eating disorder populations, there is little research regarding the prevalence of eating disorders amongst anxiety populations. Such research is needed to improve the understanding of the relationship between eating and anxiety disorders. The following two chapters provide a detailed summary of the literature concerning the comorbidity of eating disorders and anxiety disorders, as well as a critical analysis of the research to date. That analysis is the background to the development of the current research project.

76 CHAPTER 3

LITERATURE REVIEW: THE COMORBIDITY BETWEEN EATING DISORDERS AND ANXIETY DISORDERS – A REVIEW

77 European Eating Disorders Review Eur. Eat. Disorders Rev. 15, 253–274 (2007) The Co-Morbidity of Eating Disorders and Anxiety Disorders: A Review

Jessica M. Swinbourne* and Stephen W. Touyzy School of Psychology, University of Sydney, Australia

Objective: To critically review the literature examining the co-morbidity between eating disorders and anxiety disorders. Method: A review of the literature on the co-morbidity between anorexia nervosa, bulimia nervosa and eating disorders not otherwise specified and the anxiety disorders of OCD, PTSD, social anxiety, GAD, panic and agoraphobia. Results: Of the empirical studies undertaken, it is clear that anxiety disorders are significantly more frequent in subjects with eating disorders than the general community. Researchers have shown that often anxiety disorders pre-date eating disorders, leading to a suggestion that early onset anxiety may predispose individuals to developing an eating disorder. To date however, the research presents strikingly inconsistent findings, thus complicat- ing our understanding of eating disorder and anxiety co-morbidity. Furthermore, despite indications that eating disorder prevalence amongst individuals presenting for anxiety treatment may be high, there is a distinct lack of research in this area. Discussion: This review critically examines the available research to date on the co-morbidity of eating disorders and anxiety disorders. Some of the methodological limitations of previous research are presented, in order to highlight the issues which warrant further scientific investigation in this area. Copyright # 2007 John Wiley & Sons, Ltd and Eating Disorders Association.

Keywords: anorexia nervosa; bulimia nervosa; eating disorder not otherwise speciﬁed; OCD; social phobia; PTSD; panic disorder

INTRODUCTION (BN) experience one or more anxiety disorders (Kaye et al., 2004). The prevalence of anxiety Research indicates that eating disorders and anxiety disorders amongst BN samples has been reported disorders frequently co-occur. Studies have con- in a number of investigations (Bulik et al., 2000; sistently shown that a signiﬁcant number of patients Brewerton et al., 1995; Hudson et al., 1983, 1987; with anorexia nervosa (AN) or bulimia nervosa Laessle et al., 1989; Piran et al., 1985; Powers et al., 1988; Schwalberg et al., 1992; Walsh et al., 1985). Similarly, prevalence amongst AN samples has also * Correspondence to: Jessica M. Swinbourne, Clinical Psychol- been investigated (Deep et al., 1995; Halmi et al., ogy Unit (F12), School of Psychology, University of Sydney NSW 2006, Australia. Tel: þ61 2 93515952. Fax: þ61 2 93512984 1991; Herpertz-Dahlmann et al., 1996; Laessle et al., E-mail: [email protected] 1987) (see Table 1). Lifetime prevalence rates of at yCo-Director Peter Beumont Centre for Eating Disorders. least one anxiety disorder varies from 25% (Keck

Copyright # 2007 John Wiley & Sons, Ltd and Eating Disorders Association. Published online 12 February 2007 in Wiley InterScience (www.interscience.wiley.com) DOI: 10.1002/erv.784 254 Copyright Table 1. Lifetime and Current prevalence of anxiety disorders in patients with eating disorders

Reference & country Subjects N Diagnostic criteria Summary of results Limitations of research

# & instruments 07Jh ie os t n aigDsresAssociation. Disorders Eating and Ltd Sons, & Wiley John 2007 Brewerton et al. (1995) BN 59 DSM-III-R; SCID 36% reported at least 1 AD No speciﬁc ED diagnostic instrument; USA 71% anxiety preceded BN No control group

Bulik et al. (1996) BN 114 DSM-III-R; SCID; 64% reported at least 1 AD. No specific ED diagnostic instrument; New Zealand SCID II; SADS; AD had a mean onset of 8 year Sample not representative (exclusion HDRS; GAFS and BN mean age of onset 20 year criteria); No control group; Comorbid lifetime alcohol dependence in 48% of sample; No Ax PTSD Bulik et al. (2000) BN Monozyg 20 pairs DSM-III-R; SCID BN twin more likely to report Small sample size; No specific ED USA twins lifetime GAD & mother report diagnostic instrument; No control more anxious as child group Deep et al. (1995) AN 24 DSM-III-R; SADS-L 75% prevalence of 1 AD Small sample size; Sample not USA L/T recovered 79% AD preceded ED representative (exclusion criteria); No control group; No specific ED diagnostic instrument

Fornari et al. (1992) AN 42 DSM-III-R; SADS-L 45.8%of AN had at least PTSD and SP not assessed; Small USA BN 21 1 lifetime AD sample size; No speciﬁc ED diagnostic instrument; No control group; Males and females included

Godart et al. (2000) ANR 29 DSM-IV; DSM-III-R 72% AN-R at least 1 AD Small sample size; No control group; France BN 34 for AD; CIDI 65% BN at least 1 AD No speciﬁc ED diagnostic instrument; .M wnoreadS .Touyz W. S. and Swinbourne M. J. u.Et iodr Rev. Disorders Eat. Eur. Retrospective diagnosis; Males and females included

Godart et al. (2003) AN 166 DSM-IV; MINI 71% prevalence AD in ED Sample may not be representative France BN 105 41.8–53.3% AD preceded ED (more severe ED) NC 271 Retrospective diagnosis; Small numbers in BN-NP group 15 O:10.1002/erv DOI: 5–7 (2007) 253–274 , Halmi et al. (1991) AN 62 DSM-III-R; DIS; 62.9% at least 1 lifetime AD in No speciﬁc ED diagnostic instrument; USA NC 62 RDC-FH AN 1 year prevalence in AN: No Ax PTSD OCD:11.3%; PD: 4.8%; Ph:24.2%

(Continues) Table 1. (Continued)

Reference & country Subjects N Diagnostic criteria Summary of results Limitations of research & instruments Copyright Review A Disorders: Anxiety and Disorders Eating of Co-Morbidity The Herpertz-Dahlmann AN adolescents 34 DSM-III-R; Morgan 6 month prevalence: 41% at Standardised measures not used at et al. (1996) Germany Russell least 1 AD each time period; Small sample size SIAB-P; CIDI; BDI; 53% reported AD preceding ED and varying ages of sample; No # ANIS; SCL-90 R control group; Males and females 07Jh ie os t n aigDsresAssociation. Disorders Eating and Ltd Sons, & Wiley John 2007 included Hudson et al. (1983) AN 16 DSM-III; DIS; EDS 54% ED group at least 1 AD No speciﬁc ED diagnostic instrument; USA BN 49 Inclusion of an AN þ BN group; Small AN þ BN 25 sample size and groups unequal

Hudson et al. (1987) BN 51 DSM-III; DIS; ADDS; 43% BN sample at least 1 AD No speciﬁc ED diagnostic instrument; USA Hx BN 19 EDS for ED No Ax PTSD, SP and phobias; Apart Depression 24 from BN group, small sample; Males NC 28 and females included

Iwasaki et al. (2000) AN 98 DSM-IV; SCID-P 41% ED group at least 1 AD Exclusion of EDNOS; No control Japan BN 73 group; No speciﬁc ED diagnostic instrument; Hospital sample more severe

Kaye et al. (2004) AN 97 DSM-IV; SCID; YBOCS; 63.5% ED group at least 1 AD Modiﬁed ED criteria; AD diagnosed USA BN 282 STAI; FMPS; TCI when subthreshold AN þ BN 293 EDNOS excluded; No control group; No speciﬁc ED diagnostic instrument; Query representativeness of sample

Keck et al. (1990) BN 69 DSM-III-R; DSM-III; SCID 25% Prevalence of at least Sample not representative (exclusion u.Et iodr Rev. Disorders Eat. Eur. USA Bulimia 50 1 AD in BN higher than criteria); No Ax of PTSD; No speciﬁc DC 24 NC though non sig ED diagnostic instrument; Small NC 28 control group

Laessle et al. (1989) AN R 21 DSM-III; CIDI 33.3% At least 1 AD in AN-R No Ax GAD & PTSD; No speciﬁc ED Germany ANBP 20 55% At least 1 AD in AN-BP diagnostic instrument; Small sample BN 27 70.4% At least 1 AD BN size; No control group BN–Hx AN 23 65.2% At least 1 AD BN-Hx AN 15 O:10.1002/erv DOI: 5–7 (2007) 253–274 , Laessle et al. (1987) AN 13 DSM-III; CIDI; EDI; EAT 23% prevalence of 1 AD in AN Small sample size; No speciﬁc ED Germany AN þ Bulimia 26 diagnostic instrument BN 13 No Ax for PTSD & GAD; Males and

DC 47 females included 255

(Continues) 256 J. M. Swinbourne and S. W. Touyz

et al., 1990) to 75% (Schwalberg et al., 1992) in BN and from 23% (Laessle et al., 1987) to 75% (Deep et al., 1995) in AN. Several studies have shown that, in most cases, the onset of an anxiety disorder precedes the onset of an eating disorder (Brewerton et al., 1995; Bulik, 2003; Deep et al., 1995; Godart et al., 2003; Schwalberg et al., 1992) (see Table 1 for summary). These findings have led some researchers to speculate that early onset anxiety disorders may represent a potential genetically mediated pathway toward the development of an eating disorder (Kaye et al., 2004), and at the very least it suggests that No specific ED diagnostic instrument Small sample size; NoNo control specific group; ED diagnostic instrument early onset anxiety disorders may in some way predispose individuals to the development of an eating disorder (Bulik et al., 1996). Of the anxiety disorders, obsessive-compulsive disorder and social phobia have been found to have the highest co-morbidity with eating disorders. Table 2 provides a summary of the research findings investigating comorbid eating disorders and anxiety disorders. The prevalence rates of anxiety disorders also differs amongst the eating disorder subtypes a summary of which can be seen in Table 3 and Table 4 for AN and BN, respectively. Summary of results Limitations of research 59.3% AD preceded ED Whilst most studies have focused on the prevalence of anxiety disorders in eating disorder populations, significantly less research has examined the prevalence of eating disorders among anxiety patients (Bulik, 1995). As a result, there is a general lack of information as to frequency of eating disorder pathology among patients presenting to specialty anxiety clinics, and it is unclear whether eating disorders are more commonly associated with some anxiety disorders as compared to others Diagnostic criteria & instruments (Black Becker et al., 2004). This raises the possibility that eating disorders may go unidentified and

N untreated, particularly given that eating disorder assessment and treatment is often viewed as a clinical specialty and subsequently many clinicians in anxiety clinics may not be adept at detecting eating disorder symptomatology (Black Becker et al., 2004). The only study we have found which investigates eating disorder rates amongst women BN 30 DSM-III-R; SCID 53% At least 1 AD No Ax PTSD; Small sample size; BN 20 DSM-III-R; ADIS-R 75% prevalence of 1 AD presenting to an anxiety clinic is that by Black Becker et al. (2004). They found that 12% of 257 women presenting to an anxiety clinic met criteria for a possible eating disorder. Other studies have investigated eating disorder rates amongst speciﬁc anxiety disorders (Brewerton et al., 1993; Lipschitz et al., 1999) or amongst individuals with sexual abuse trauma (Pribor and Dinwiddie, 1992; Far- avelli et al., 2004) and war veterans (Striegel-Moore Powers et al. (1988) USA Table 1. (Continued) Reference & country Subjects Schwalberg et al. (1992) USA et al., 1999).

Copyright # 2007 John Wiley & Sons, Ltd and Eating Disorders Association. Eur. Eat. Disorders Rev. 15, 253–274 (2007) DOI: 10.1002/erv Copyright Review A Disorders: Anxiety and Disorders Eating of Co-Morbidity The Table 2. Summary of research papers investigating eating disorder comorbidity with anxiety disorders

Reference & country Subject N Diagnostic criteria Summary of results Limitations of research

# & instruments 07Jh ie os t n aigDsresAssociation. Disorders Eating and Ltd Sons, & Wiley John 2007 Fornari et al. (1992) ANR 24 DSM-III-R; SADS-L Lifetime OCD ANR (25%) and No Ax PTSD and SP; Small USA ANBP 18 ANBP (66%) (sig difference). sample size; No speciﬁc ED BN 21 BN OCD (42.9%) diagnostic instrument; No control group; Males and females included

Gleaves et al. (1998) AN 121 DSM-III-R; BULIT-R; AN: 47% PTSD/BN: 62% PTSD No control group; Type of USA BN 103 EAT; DES; TSC-40; EDNOS: 74% reported traumatic trauma identiﬁed in less than EDNOS 70 TSC-40-ANX; PSS event; 52% met criteria for PTSD 10% of sample Use of self report measure to diagnose PTSD

Godart et al. (2000) ANR 29 DSM-IV; DSM-III-R for AN-R: SP55%; Ph34%; GAD24%; Small sample size; No control France BN 34 AD CIDI OCD21%; PD7%; AG3% group; No speciﬁc ED BN: SP59%; OCD0%; GAD23%; diagnostic instrument AG6%; PD15%; Ph21% Retrospective diagnostic procedure; Males and females included

Godart et al. (2003) AN 166 DSM-IV; MINI AN GAD 45.6%; ANR: OCD 17.5%; Sample may not be France BN 105 ANBP OCD 21.8 representative (severe ED); NC 271 BN GAD 31.4% Retrospective diagnosis of past disorders; Small u.Et iodr Rev. Disorders Eat. Eur. numbers in BNNP group

Hinrichson et al. (2003) ANR 21 DSM-IV; BITE; DES-II; ANR: SP 71.4% No speciﬁc ED and AD UK ANBP 34 FNE ANBP: SP 88.2% diagnostic instrument BN 59 BN: SP 67.8% NC 50 NC: SP 30% 15

O:10.1002/erv DOI: (Continues) 5–7 (2007) 253–274 , 257 258 Copyright Table 2. (Continued)

Reference & country Subject N Diagnostic criteria Summary of results Limitations of research & instruments #

07Jh ie os t n aigDsresAssociation. Disorders Eating and Ltd Sons, & Wiley John 2007 Hudson et al. (1983) AN 16 DSM-III; DIS; EDS AN: OCD69%; PD38%; AG13%; No speciﬁc ED diagnostic USA BN 49 Ph25%; instrument; Inclusion of an AN þ BN 25 BN: PD39%; OCD24%; phobia12%; AN þ BN group AG10% Small sample size and groups AN þ BN: PD44%; OCD44%; unequal; No Ax for SP AG24%; Ph4%;

Iwasaki et al. (2000) ANR 62 DSM-IV; SCID-P In all subjects, OCD was most prev Exclusion of EDNOS; No Japan ANBP 36 (19%); followed by SP (18%), PD control group; No speciﬁc ED BNP 57 (16%) and GAD (13%); 43% of sample diagnostic instrument; Hospital BNNP 16 met criteria for AD and lifetime prev sample may be more severe GAD more prev amongst ANBP and BNP than ANR

Kaye et al. (2004) AN 97 DSM-IV; SCID; YBOCS; Prevalence of OCD, PD, SP, AG Modified ED criteria; AD USA BN 282 STAI; FMPS; TCI and GAD did not differ diagnosed when subthreshold; AN þ BN 293 significantly across EDNOS excluded ED subtypes No control group; No specific ED OCD (35–44%); SP (16–23%); diagnostic instrument; Sample Ph (12–18%); GAD (8–13%); may not be not representative PD (9–11%); AG (2–4%); PTSD x3 more frequent in BN (13%) than AN (5%)

Laessle et al. (1987) AN 13 DSM-III; CIDI; EDI; EAT AN: SP 23%; Ph: 15%; OCD 15%; Small sample size; No speciﬁc .M wnoreadS .Touyz W. S. and Swinbourne M. J. u.Et iodr Rev. Disorders Eat. Eur. Germany AN þ BN 26 AG 0% ED diagnostic instrument; No BN 13 AN þ BN: SP 50%; Ph: 19%; Ax for PTSD, GAD and PD DC 47 OCD 15% AG 15% BN: Ph: 46%; SP 31%; OCD 8% Ag 8%

Laessle et al. (1989) ANR 21 DSM-III; CIDI; EAT ANR: SP 23.8%; Ph14.3%;OCD 9.5%; No Ax for GAD & PTSD; Germany ANBP 20 PD 4.8%; AG 0% No speciﬁc ED diagnostic 15 O:10.1002/erv DOI: BN 27 ANBP: SP 40%; AG 20%; Ph 15%; instrument; Small sample size; 5–7 (2007) 253–274 , BN (Hx AN) 23 OCD 10%; PD 5% No control group BN: SP 48%; phob 37%; OCD 18.5%; AG 14.8%; PD 11% BN (Hx AN): SP 56.5%; AG 17.4%; OCD 13%; Ph 8.7%; PD 4.3%

(Continues) Table 2. (Continued)

Copyright Reference & country Subject N Diagnostic criteria Summary of results Limitations of research Review A Disorders: Anxiety and Disorders Eating of Co-Morbidity The & instruments

# Lilenfeld et al. (1998) ANR 26 DSM-III-R; SADS; KSADS ANR: OCD 62%; SP 31%; GAD 31%; No Ax for AG; Small AN sample;

07Jh ie os t n aigDsresAssociation. Disorders Eating and Ltd Sons, & Wiley John 2007 USA BN 47 Eating Disorder Family Ph 27%; PTSD 7%; PD 4% Unbalanced sample sizes CW 44 History Interview BN: PTSD 30%; OCD 21%; Ph 19%; SP15%; GAD 13%; PD 4% CW: Ph 7%; PTSD 7%; SP 5%; OCD 5%; GAD 2%; PD 0% SP more frequent in ANR vs controls

Milos et al. (2002) AN 84 DSM-IV; SCID-I 29% OCD in ED; no diff between Self-report retrospective data Switzerland BN 153 AN and BN; Comorbid OCD assoc on ED course; No speciﬁc ED with longer hx of ED & earlier onset diagnostic instrument; No control group

Piran et al. (1985) AN 14 DSM-III; SADS; DST; Lifetime: No Ax PTSD; No speciﬁc ED Canada BN 33 BDI; MMPI; HSCL; AN: SP 53.8%; PD 42.8%; OCD 14%; diagnostic instrument; No HDS; HAS AG 0%; Ph 0% control group BN: PD 52.7%; SP 48.7%; AG 3%; Ph 3%; OCD 0%

Speranza et al. (2001) AN 58 DSM-IV; MINI; YBOCS Current and lifetime prev of OCD Small sample size of ED France BN 31 sig higher ED (15.7% and 19%) than subtypes; AN inpatients CW 89 in general population (0% and 1.1%) vs BN outpatients may differ AN current (19%) and lifetime (22.4%) in severity of illness BN current (9.7%) and lifetime (12.9%) ANBP higher prev than ANR and BN Anxiety preceded ED in 65% of cases u.Et iodr Rev. Disorders Eat. Eur.

Stiger & Zanko (1990) ANR 16 DSM-III-R; EAT; DSQ 30% of ED women report CSA. CSA Modiﬁed ED criteria; NC group Canada ANBP 12 more prevalent among BP group than may have been comprised of BN 45 ANR. Only 8% of NC reported trauma well functioning individuals NC 24 (hospital staff etc) and therefore PC 21 not representative of the normal population; small sample size; 15

O:10.1002/erv DOI: No speciﬁc ED diagnostic 5–7 (2007) 253–274 , instrument

(Continues) 259 260 Copyright Table 2. (Continued)

Reference & country Subject N Diagnostic criteria Summary of results Limitations of research & instruments #

07Jh ie os t n aigDsresAssociation. Disorders Eating and Ltd Sons, & Wiley John 2007 Thornton and Russell AN 35 DSM-III-R; CIDI; AN: 37% OCD Inpatients only, therefore maybe (1997) Australia BN 33 Personality Disorders BN: 3% OCD more severe and not representative Inventory 21% of ED reported OCD; OCD of population; No speciﬁc ED usually predated ED diagnostic instrument; No 19% had premorbid OCPD control group

Turnbull et al. AN 90 ICD-10; DSM-III-R; SCID No differences between AN, BN The onset of PTSD in relation to (1997) UK BN 54 Childhood adversity and EDNOS groups: Lifetime and ED not assessed; No speciﬁc ED EDNOS 20 and trauma interview current rates of PTSD were 18% diagnostic instrument and 11% respectively. Comorbid No control group PTSD was not associated with greater severity of illness.

Vize and Cooper AN 40 DSM-III-R; interview Sexual abuse of any form was Groups not equal in numbers; (1995) UK BN 60 based on EDE; SADS; identiﬁed in 52.5% of AN group, Results may underestimate sexual NC 40 PDQ-R; BDI; CECA 35% of BN group and 12% of abuse given participants were DC 40 control group only given one opportunity to disclose abuse .M wnoreadS .Touyz W. S. and Swinbourne M. J. u.Et iodr Rev. Disorders Eat. Eur. 15 O:10.1002/erv DOI: 5–7 (2007) 253–274 , Copyright Review A Disorders: Anxiety and Disorders Eating of Co-Morbidity The # 07Jh ie os t n aigDsresAssociation. Disorders Eating and Ltd Sons, & Wiley John 2007 Table 3. Summary of research papers investigating AN and AD comorbidity

Reference & country Subject N Diagnostic criteria Summary of results Limitations of research & instruments Halmi et al. (1991) AN 62 DSM-III-R; DIS; AN:SP33.9%; OCD25.8%; AG14.5%; No speciﬁc ED diagnostic instrument; USA NC 62 RDC-FH Ph12.9%;PD8.1% No Ax PTSD NC:Ph14.5%; PD8.1%; OCD6.5%; AG3.2%; SP3.2% Higher lifetime AG in AN vs NC

Halmi et al. (2003) ANR 147 DSM-IV; SIAB; YBOCS AN-R: 68% lifetime OCD Modiﬁed criteria for AN; Sample may USA ANBP 177 AN-BP: 79.1% lifetime OCD not be representative (family cases) OCD 116

Herpertz-Dahlmann AN 34 DSM-III-R; Morgan SP21%; Ph17.6%; PD11.8%; AG5.9%; Standardised measures not used at et al. (1996) Germany adolescents Russell; SIAB-P; CIDI; OCD0% each time period; Small sample size BDI; ANIS; SCL-90 12% of sample had obsessive compulsive and varying ages of sample; No control behaviour without meeting DSM-III group; Males and females included criteria for OCD

Matsunaga et al. ANR 53 DSM-III-R; DSM-IV; 40% met criteria for OCD after excluding Small sample size; No speciﬁc ED (1999) Japan OCD 23 MAS for AD; SDS; OC symptoms typical of ED; Comorbid diagnostic instrument SCID-II; SCID-P OCD assoc with more severe ED symptoms

Pollice et al. (1997) AN 48 DSM-III-R; HRSD; BDI; Anxiety and obsessionality most severe in Small sample; Mixed longitudinal and

u.Et iodr Rev. Disorders Eat. Eur. USA NC 18 HARS; STAI; YBOCS; underweight state, symptoms reduced after cross sectional design; No speciﬁc ED YBOCS-ED short term and long term weight restoration diagnostic instrument

Ra˚stam et al. (1995) AN 51 DSM-III-R; SCID-II Sig more AN subjects (31%) met criteria for PTSD not assessed; No speciﬁc ED Sweden NC 51 lifetime OCD compared with NC (8%). 20% diagnostic instrument of the AN group continued to meet OCD diagnosis at follow up compared with 6% of NC. Other than OCD there was No sig diff b/w AN and NC in AD prevalence 15 O:10.1002/erv DOI: 5–7 (2007) 253–274 , 261 262 Copyright Table 4. Summary of research papers investigating BN and AD comorbidity

Reference & country Subject N Diagnostic criteria Summary of results Limitations of research

# & instruments

07Jh ie os t n aigDsresAssociation. Disorders Eating and Ltd Sons, & Wiley John 2007 Brewerton et al. (1995) BN 59 DSM-III-R; SCID SP17%; GAD12%; PD10%; No speciﬁc ED diagnostic instrument USA PTSD 3%; OCD3% No control group No Ax for AG

Bulik et al. (1996) BN 114 DSM-III-R; SCID; Lifetime prevalence: SP: 30%; No speciﬁc ED diagnostic instrument; New Zealand SCID II; SADS; Ph: 30%; PD: 10%; OCD: 4%; Sample not representative (exclusion HDRS; GAFS AG without PD: 2%; GAD: 2% criteria); No control group; Comorbid lifetime alcohol dependence in 48% of sample; No Ax PTSD

Bulik et al. (2000) BN Monozy 20 pairs DSM-III-R; SCID 75% reported GAD prior to ED Small sample size; No speciﬁc ED USA twins diagnostic instrument; No control group

Dansky et al. (1997) BN 72 DSM-IV BN Current PTSD 21.4% Telephone screening; No diagnostic USA CW 2929 BN Lifetime PTSD 36.9% instruments used for ED or AD CW Current PTSD 4.2% CW Lifetime PTSD 11.8% Sig difference b/w BN and CW

Hudson et al. (1987) BN 51 DSM-III; DIS; ADDS; BN: OCD33%; PD/AG14% No speciﬁc ED diagnostic instrument; USA Hx BN 19 EDS for ED Hx BN: OCD32%; PD/AG26% No Ax for PTSD, SP and phobias; Apart from BN group, small sample; Males and females included

Powers et al. (1988) BN 30 DSM-III-R; SCID-P Ph: 20%; SP: 17%; AG: 13%; No Ax for PTSD and PD; Small USA GAD: 10%; OCD: 3% sample size; No speciﬁc ED diagnostic instrument .M wnoreadS .Touyz W. S. and Swinbourne M. J. u.Et iodr Rev. Disorders Eat. Eur. Rorty et al. (1994) BN 40 DSM-III-R; Proposed No sig diff between BN group Sample may not be representative USA BN Hx 40 DSM-IV; SCID-P; and NC in reported sexual due to recruitment through NC 40 SCID-II; EAT-SADS-L; abuse–BN (28.8%) v NC (20%) advertisement; Problem associated EDQ; SAEQ; AEIII; PSY Non sexual abuse more with retrospective study–reliance prevalent in BN group vs NC on recollection

Schwalberg et al. BN 20 DSM-III-R; ADIS-R GAD: 55%; SP: 45%; OCD: 15%; Small sample size; No control group; (1992) USA Ph: 10%; PTSD: 10%; AG: 0%; No speciﬁc ED diagnostic instrument 15 O:10.1002/erv DOI:

5–7 (2007) 253–274 , PD: 0%;

Welch and Fairburn BN 100 DSM-III-R; EDE; Sexual abuse reports were similar Retrospective design; Interviewers (1994) UK NC 100 SCID in BN groups vs control groups not blind to the case status of subjects PC 50 The Co-Morbidity of Eating Disorders and Anxiety Disorders: A Review 263

A final point of interest in the area of eating elements. Early descriptive studies suggested that disorder and anxiety comorbidity is whether a 50%–100% of patients with AN showed obsessional comorbid anxiety disorder has implications for the or compulsive features. More recent studies have treatment and outcome of an eating disorder. It is found a lower but still significant level of obsessions clear that individuals with comorbid conditions often and compulsions among patients with AN (Halmi displaymoreseveresymptomsandsubsequently et al., 1991, 2003; Matsunaga et al., 1999; Pollice may be at greater risk for a poorer treatment outcome. et al., 1997; Ra˚stam et al., 1995) (see Table 3 for a Research findings however, are inconsistent. Some summary of AN and OCD comorbidity findings). studies have suggested that comorbid anxiety may be Fornari et al. (1992) and Speranza et al. (2001) one indicator for poor outcome (Fichter and Quad- found a significant difference in the OCD flieg, 2004; Gleaves and Eberenz, 1994; Goodwin and lifetime prevalence between purging AN and Fitzgibbon, 2002; Halmi et al., 1973; Herpertz- restrictive AN, where purging AN patients exhib- Dahlmann et al., 1996; Procopio, Holm-Denoma, ited higher prevalence of OCD than the restricting Gordon, & Joiner, 2006; Thompson–Brenner and AN patients. Westen, 2005; von Ranson et al., 1999), however other There is some argument that the pattern of studies have not found this to be the case (Bulik et al., obsessions and compulsions most commonly pre- 1996; Halmi et al., 1991 and Thiel et al., 1998) sent in AN is different from that found in OCD. (A summary of these studies and their findings can be Therefore, it is important to distinguish those seen in Table 5). behaviours that are not directly related to food, Despite the significant number of research papers weight and shape. The lack of clear evidence investigating the comorbidity between eating dis- regarding these mechanisms means that it is orders and anxiety disorders, many are plagued by difficult to draw clear causal conclusions. However methodological problems, limiting the usefulness of at a functional level, an important issue is that findings (the limitations have been summarised in compulsive behaviours reduce anxiety levels. It can Tables 1–5). This paper aims to critically review the be hypothesized that the same function is served in available literature examining the co-morbidity the eating disorders, given the affect regulation between eating disorders and anxiety disorders. function of restriction and bulimic behaviours (Lockwood et al., 2004). This however, does not explain the difference between the ego-dystonic OBSESSIVE COMPULSIVE nature of OCD and the ego-syntonic nature of eating DISORDER (OCD) disorders. This important distinction does need to be addressed. A relationship between AN, BN and OCD has been Holden (1990) noted that the obsessions and suggested by clinical observation and, increasingly, compulsions of OCD patients are ego-dystonic by empirical investigation. A number of studies whereas the preoccupations and rituals of AN have reported significant comorbidity between patients are largely ego-syntonic. Mazure et al. individuals with eating disorders and OCD (Fornari (1994) suggested that phobic thoughts of food and et al., 1992; Godart et al., 2000; Halmi et al., 1991; weight repeatedly enter the mind of AN patients, Hudson et al., 1983, 1987; Iwasaki et al., 2000; but not necessarily against their will. Although Kaye et al., 2004; Laessle et al., 1989; Lilenfeld et al., these thoughts or preoccupations may be distres- 1998; Matsunaga et al., 1999; Milos et al., 2002; sing, they are not regarded as senseless. This is in Ra˚stam et al., 1995; Speranza et al., 2001; Thornton contrast to typical obsessions and compulsions and Russell, 1997) (see Table 2 for summary). unrelated to eating, which also may occur in AN Thornton and Russell (1997) showed that OCD patients (Bastiani et al., 1996). usually predated the onset of an eating disorder, One of the most common concerns raised in the suggesting that OCD may be a risk factor for current debate is whether people with AN display developing an eating disorder. Milos et al. (2002) ‘typical’ or ‘true’ OCD symptoms as seen in patients reported that individuals with OCD co-morbidity diagnosed with primary OCD, or whether their have a longer history of an eating disorder and are symptoms are secondary to weight loss and likely to have developed the eating disorder at an malnutrition, or a combination of these. These earlier age. concerns arise due to evidence that in conditions of AN has a considerable overlap with obsessive– semistarvation, psychologically ‘normal’ adults can compulsive disorder (OCD) and this may reflect develop a range of obsessional features. Keys et al. common neurobiological, genetic, or psychological (1950) illustrated how obsessions and compulsions,

Copyright # 2007 John Wiley & Sons, Ltd and Eating Disorders Association. Eur. Eat. Disorders Rev. 15, 253–274 (2007) DOI: 10.1002/erv 264 Copyright Table 5. Summary of research papers investigating treatment response and outcome of individuals with comorbid ED and AD

Reference & country Subjects N Diagnostic criteria Summary of results Limitations of research

# & instruments 07Jh ie os t n aigDsresAssociation. Disorders Eating and Ltd Sons, & Wiley John 2007 Bulik et al. (1996) BN 114 DSM-III-R; SCID; Comorbid AD not associated No speciﬁc ED diagnostic New Zealand SADS-L; HRDS with differences in BN instrument; Sample not symptoms. However, an AD representative (exclusion was associated with a Hx AN criteria); No control group; and earlier age of onset of Comorbid lifetime alcohol drug and alcohol dependence dependence in 48% of sample; No Ax PTSD

Fichter and Quadﬂieg BN (Ax pre and 196 DSM-III; DSM-III-R; Lifetime anxiety found in 36% Telephone interviews; Inpatients (2004) Germany post Tx and 2yr, DSM-IV; SIAB-S; EDI; & comorbidity was the only therefore may be more 6yr and 12 yr F/U) HSCL strongest predictor of severe; Retrospective unfavourable outcome assessment–bias; No control group

Gleaves and Eberenz BN 464 DSM-III-R; self report 71% reporting a Hx of sexual Insufﬁcient assessment of sexual (1994) USA questionnaire based abuse also had indicators of abuse; possible underestimate on DSED-R poor prognosis of sexual abuse due to non disclosure; No control group

Goodwin and Fitzgibbon AN or BN 28 EDI; BORI for SP Individuals who did not enter Small sample size; The (2002) USA treatment had signiﬁcantly diagnostic criteria for ED and higher levels of social anxiety AD unclear; No speciﬁc ED than those who engaged with or AD diagnostic instruments; treatment No control group

Halmi et al. (1973) AN 42 Feighner et al. More severe non ED OC The diagnostic criteria for AD USA behaviours assoc with poor unclear; No speciﬁc ED or AD .M wnoreadS .Touyz W. S. and Swinbourne M. J. u.Et iodr Rev. Disorders Eat. Eur. outcome. moderate to severe diagnostic instruments; No anxiety symptoms were control group frequent in those who did and did not recover

Halmi et al. (1991) AN (10 yr F/U) 62 DSM-III-R; DIS; RDC-FH Recovered patients had the No speciﬁc ED diagnostic USA NC 62 same prevalence of lifetime instrument; No Ax PTSD psychiatric dx as those with 15 O:10.1002/erv DOI: persisting ED symptoms 5–7 (2007) 253–274 ,

(Continues) Table 5. (Continued)

Copyright Reference & country Subjects N Diagnostic criteria Summary of results Limitations of research Review A Disorders: Anxiety and Disorders Eating of Co-Morbidity The & instruments Herpertz-Dahlmann AN 34 DSM-III-R; Morgan 41% at initial assessment met Standardised measures not et al. (1996) Germany Outcome study Russell; SIAB-P; CIDI; criteria for AD. At 7 years used at each time period; # Adolescents BDI; ANIS; SCL-90 R follow up 38% met criteria Small sample size and varying; 07Jh ie os t n aigDsresAssociation. Disorders Eating and Ltd Sons, & Wiley John 2007 for AD ages of sample; No control Patients with poor outcome group; Males and females show higher levels of included psychopathology

Pollice et al. (1997) AN (underweight 22 DSM-III-R; HRSD; BDI; Anxiety and obsessionality Small sample; Mixed USA and at S/Trecovery) 26 HARS; STAI; YBOCS; most severe in underweight longitudinal and cross sectional AN (at L/Trecovery) 18 YBOCS-ED state, symptoms reduced after design; No speciﬁc ED NC short term and long term diagnostic instrument weight restoration

Procopio et al. Bulimic symptom 150 EDI; RSE; BDI; BAI The level of anxiety symptoms No specific ED or AD diagnostic (2006) USA Two Ax over 2.5 years significantly predicted the level instruments; Sample not of bulimic symptoms 2.5 years classified as per DSM-IV BN later criteria; No control group

Ra˚stam et al. (1995) AN 51 DSM-III-R; SCID-II; 20% of the An group continued No Ax PTSD; No speciﬁc ED Sweden NC 51 Morgan-Russell; EAT to meet OCD diagnosis at diagnostic instrument follow up compared with 6% of NC

Srinivasagam et al. Recovered AN 20 EDI; FMPS AN sample had higher Small sample size; Inclusion (1995) USA NC 16 perfectionism scores and of women in recovery at least greater symmetry and 1 year, therefore unclear exactness scores than controls whether some had longer u.Et iodr Rev. Disorders Eat. Eur. recovery times which may impact on results

Thompson–Brenner and Bulimic Symptoms 145 DSM-IV; SWAP 200 Comorbidity was systematically Patients with and without Westen (2005) USA related to treatment length and DSM-IV BN included; outcome, such that the comorbid Retrospective clinician reports; patients tended to have longer Different therapeutic and less successful treatments approaches; Selective response 15

O:10.1002/erv DOI: by clinician report. rate–bias; No speciﬁc ED and 5–7 (2007) 253–274 , AD diagnostic instruments; No control group

(Continues) 265 266 Copyright Table 5. (Continued)

Reference & country Subjects N Diagnostic criteria Summary of results Limitations of research & instruments #

07Jh ie os t n aigDsresAssociation. Disorders Eating and Ltd Sons, & Wiley John 2007 Thiel et al. (1998) AN 27 DSM-IV; YBOCS; EDI; At assessment 37% met criteria Signiﬁcant drop out rate (19%); Germany BN 48 Hamburg OCI for OCD; no sig diff between Small sample size; No speciﬁc (Ax pre Tx and at ED diagnosis and OCD status; ED diagnostic instruments; 30 month F/U) Dropout was not related to No control group OCD status; Poorer prognosis for BN and comorbid OCD; patients with most improved ED showed highest reduction in obsessions and compulsions

Toner et al. (1988) AN (14 year F/U) 47 Feigner et al. DSM III; DIS Symptomatic and improved AN No Ax PTSD and GAD; Canada CW 26 group were sig higher in AD Retrospective recall in than CW assessment of anxiety and Symptomatic group had sig depression higher incidence of AD prior to onset of AN relative to asymptomatic group (83% vs 55% respectively)

Von Ranson et al. BN 31 DSM-III-R; SADS-L; YBOCS; YBOCS scores for BN and OCD not diagnosed in BN (1999) USA Recovered BN 29 HDRS; HARS; EDI recovered BN groups were group; Cross sectional NC 19 similar and were signiﬁcantly design; Small sample size; higher than NC group No speciﬁc ED diagnostic instruments

Note: ED: Eating Disorder; AN: Anorexia Nervosa; ANR: Anorexia Nervosa Restricting type; ANBP: Anorexia Nervosa Binge Purge type; BN: Bulimia Nervosa; BNP: Bulimia .M wnoreadS .Touyz W. S. and Swinbourne M. J. u.Et iodr Rev. Disorders Eat. Eur. Nervosa Purging type; BNNP: Bulimia Nervosa Non Purging type; EDNOS: Eating disorder not otherwise specified; AD: Anxiety Disorder; CW: Control Women; NC: Normal Controls; DC: Depressed Controls; PC: Psychiatric controls; SP: Social Phobia; GAD: Generalised Anxiety Disorder; OCD: Obsessive Compulsive Disorder; PTSD: Post Traumatic Stress Disorder; AG: Agoraphobia; Ph: phobia; PD: Panic Disorder; Hx: History of; Ax: Assessment; CSA: Child Sexual Assault; L/T: long term; S/T: short term; Tx: treatment; F/U: Follow up; b/w: between. 15 O:10.1002/erv DOI: 5–7 (2007) 253–274 , The Co-Morbidity of Eating Disorders and Anxiety Disorders: A Review 267 particularly those concerned with the preparation structured investigations into Axis II diagnosis and consumption of food, develop under conditions amongst eating disorder patients. of food restriction. This study also provides Gartner, Marcus, Halmi, and Loranger (1989) evidence for the possibility that the obsessive and used the PDE to assess inpatient ED subjects and compulsive symptoms observed in people with AN reported that 25.7% met diagnostic criteria for may at least partly be the result of their malnour- OCPD. None of the BN sample met criteria for ished state, and not evidence of a true OCD. Some OCPD leading to the speculation that this person- evidence for this comes from the discrepancy ality feature is more consistent with individuals between inpatient and outpatient AN OCD rates, with AN. However, Rossiter, Agras, Telch, and whereby lower rates have been reported in the latter Schneider (1993) reported that 10% of their BN group (Serpell et al., 2002). sample met criteria for OCPD. Thornton and Russell Studies that have compared rates of OCD in AN (1997) reported that 19% met criteria for comorbid and BN have usually found higher co-morbidity in OCPD, and this was almost exclusively found in the AN. However, two Japanese studies found a AN sample. Lilenfeld et al. (1998) reported that AN significant number of BN participants met criteria probands had higher rates of OCPD lending for OCD (Iwasaki et al., 2000; Matsunaga et al., support to reports of perfectionism and inflexibility 1999), even after excluding the OCD-like symptoms among individuals with restricting type AN. typical of eating disorders. Matsunaga et al. (1999) Lilenfeld et al. (1998) also found that 31% of AN also reported that BN subjects with concurrent OCD probands met criteria for OCPD and OCD, leading were more likely than subjects without OCD to have to the suggestion that individuals with OCPD may more severe mood and core eating disorder be more vulnerable to the development of OCD psychopathology. Among BN subjects with con- than those without this personality pattern. current OCD, symptoms related to symmetry and order were most frequently identified, followed by contamination and aggressive obsessions, and checking and cleaning/washing compulsions (Mat- Social Phobia sunaga et al., 1999). Whilst the link between eating problems and obsessive-compulsive pathology has been clearly established (O’Brien and Vincent, 2003), other Perfectionism and Obsessive Compulsive manifestations of fear, such as social phobia, Personality Disorder (OCPD) agoraphobia and panic, have received less research As discussed above, the research into OCD and attention (Hinrichson et al., 2004). eating disorders reveals a significant relationship, A number of studies show that social phobia is and several researchers have reported that non food common in patients with eating disorders (Brewer- related obsessions and compulsions, including ton et al., 1995; Godart et al., 2000; Halmi et al., 1991; significantly more cleanliness, orderliness, perfec- Hinrichson, Wright, Waller, & Meyer, 2003; Iwasaki tionism, rigidity, miserliness, scrupulosity have et al., 2000; Kaye et al., 2004; Laessle et al., 1987, been identified in patients with eating disorders 1989; Lilenfeld et al., 1998; Piran et al., 1985; Powers (Brumberg, 1988; Kasvikis et al., 1986; Rothenberg, et al., 1988; Schwalberg et al., 1992) (see Tables 2–4 1986; Solyom et al., 1982). This has fuelled sugges- for a summary of findings). Several studies suggest, tions that distinct personality traits may be that social anxiety may be a more common important in the development and maintenance co-morbid condition with eating disorders than of an eating disorder. The literature also suggests OCD, and some researchers have speculated that that perfectionism and dichotomous thinking may social anxiety may play a role in the aetiology of mediate the relationship between extreme concerns eating disorders (Black Becker et al., 2004). about shape and weight and rigid and intense Hinrichson et al. (2003) demonstrated that levels of dieting (Fairburn, 1997). Furthermore, Fairburn social phobia in patients with AN and BN are (1997) suggests that perfectionism and dichotomous significantly elevated compared to control women, thinking may mediate the relationship between and that social phobia is associated with higher levels intense, rigid dieting and binge eating. This has lead of eating psychopathology in bulimic individuals. to significant interest in investigating the prevalence The prevalence rate of social phobia and eating of personality disorders in the eating disorders and disorders has differed across studies. In AN, subsequently, there have been a number of prevalence rates of between 16% (Kaye et al.,

Copyright # 2007 John Wiley & Sons, Ltd and Eating Disorders Association. Eur. Eat. Disorders Rev. 15, 253–274 (2007) DOI: 10.1002/erv 268 J. M. Swinbourne and S. W. Touyz

2004) and 88.2% (Hinrichson et al., 2003) have been Specific Phobia reported and between 17% (Brewerton et al., 1995; The reported lifetime prevalence of specific phobias Powers et al., 1988) and 67.8% (Hinrichson et al., amongst individuals with eating disorders varies 2003) in BN. Lilenfeld et al. (1998) also reported that considerably, ranging from 0% (Piran et al., 1985) to social phobia is significantly more frequent in AN 34% (Godart et al., 2000) in AN and from 10% than in controls. Two controlled follow-up studies (Schwalberg et al., 1992) to 46% (Laessle et al., 1987) of AN found differing results, one found a in BN. Follow up studies have reported that there is significantly higher rate of social phobia in AN no difference between AN and controls (Lilenfeld than normal controls (Halmi et al., 1991), whilst the et al., 1998) however, in a community study, the risk second found no difference (Ra˚stam et al., 1995). for phobia is increased by 2 to 4 in AN subjects (Kendler et al., 1991; Walters and Kendler, 1995) and by 2.37 in BN subjects (Kendler et al., 1991). Agoraphobia Studies investigating ED and agoraphobia have found varying results. In AN, lifetime prevalence of Post Traumatic Stress Disorder (PTSD) agoraphobia ranges from 0% (Laessle et al., 1989) to Although a history of trauma, particularly child- 3% (Godart et al., 2000) in restricting subgroups, hood sexual abuse, is considered to be a non-specific wheras a study of binge/purge AN found a 20% risk factor for the development of an eating rate (Laessle et al., 1989). In follow up studies of AN, disorder, surprisingly few studies have examined significantly higher lifetime prevalence rates of co-morbidity of PTSD with eating disorders (Black agoraphobia have been reported in the AN group Becker et al., 2004). Studies investigating PTSD compared to controls (Halmi et al., 1991), however a co-morbidity among eating disordered individuals study by Ra˚stam et al. (1995) reported no difference. have reported rates ranging from 11% to 52% The lifetime prevalence of agoraphobia in BN (Gleaves et al., 1998; Turnbull et al., 1997). Faravelli varies from 0% (Schwalberg et al., 1992) to 17.4% et al. (2004) found that women who had been (Laessle et al., 1989). In the community, lifetime sexually assaulted were significantly more likely to prevalence of agoraphobia in BN varies from 27% report an eating disorder compared with women (Bushnell et al., 1994) to 34.5% (Garfinkel et al., who had not been assaulted. This is supported by 1995). the literature reporting the most frequently reported psychiatric consequences of sexual abuse in women are PTSD, mood disorders, substance abuse disorders, eating disorders and sexual disorders Panic Disorder (Putnam & Trickett, 1997; Dahl, 1989; Thompson The findings of panic disorder co-morbidity et al., 2003). amongst eating disorder samples is also varied A number of studies have demonstrated a with one study reporting between 9% and 11% positive association between child sexual assault prevalence (Kaye et al., 2004) and another finding (CSA) and clinical eating disorders (Johnson et al., between 42% and 52% preavlence (Piran et al., 2002; Steiger & Zanko, 1990; Vize & Cooper, 1995; 1985). Bulimic samples have been varied, ranging Welch & Fairburn, 1994). A meta-analysis by from 0% (Schwalberg et al., 1992) to 39% (Hudson Smolak & Murnen (2002) found a relationship et al., 1983). Several studies have found the lifetime between CSA and eating disorders, such that CSA is prevalence rates of panic disorder ranges from 4% associated with an increased likelihood of eating (Lilenfeld et al., 1998) to 7% (Godart et al., 2000) in disorder symptomatology. Furthermore, Jacobi AN–R and is estimated to 15% in AN- B/P (Laessle et al. (2004) reported that there was a high likelihood et al., 1989). Two AN controlled outcome studies that sexual abuse preceded the eating disorder. have estimated that the lifetime prevalence of panic However, there have also been a number of studies disorder is 8.1%, and 6 month prevalence between that have not found a relationship between CSA and 2% and 11.8% (Halmi et al., 1991; Ra˚stam et al., eating disorders (Pribor & Dinwiddie, 1992; Rorty 1995). Walters and Kendler (1995) reported that et al., 1994). in a community study, individuals with ‘possible When considering the eating disorder subtypes, anorexia’ have the risk of panic disorder increased Dansky et al. (1997) reported current and lifetime by 3.4. rates of PTSD in women with BN to be high and

Mantero and Crippa (2002) reported that PTSD of eating disorders concurrent with one particular subjects were considered to be at 3.36 times the risk anxiety disorder, usually OCD (Bulik, 1995). of developing BN. Tozzi et al. (2003) report that Among female OCD patients, eating disorder several studies have shown that psychological co-morbidity estimates have ranged from 11% to stress or stressful life events can trigger the onset 42% depending on the type of eating disorder and of AN. However, the nature and identity of these the method of assessment (Bulik, 1995). Brewerton stressors remain poorly defined (Beumont et al., et al. (1993) reported that 20% of women with social 1978; Casper & Jabine, 1986; Pyle, Mitchell, & phobia met the criteria for an eating disorder. Eckert, 1981; Strober, 1984). Kaye et al. (2004) Lipschitz et al. (1999) reported that 25% of an observed that PTSD was approximately three times adolescent mixed-gender PTSD inpatients met the more frequent in individuals with BN as opposed to criteria for an eating disorder. Black Becker et al. those with AN. (2004) indicates that although the number of studies is limited, estimates of the prevalence of eating disorders amongst anxiety disorder patients is high. Generalised Anxiety Disorders (GAD) Reported rates are markedly higher than the Considerably less research has considered the estimated prevalence of AN or BN among young relationship between eating disorders and GAD, females. however Godart et al. (2000) and Lilenfeld et al. (1998) estimate the lifetime prevalence of GAD in AN to be 31% and 24%, respectively. Studies reviewing the relationship between GAD and BN LIMITATIONS IN THE RESEARCH have found that lifetime prevalence varies between 10% (Powers et al., 1988) and 55% (Schwalberg et al., Many studies investigating the co-morbidity 1992). Kaye et al. (2004) identified GAD in their AN between eating and anxiety disorder suffer from and BN sample of 13% and 7%, respectively, which general methodological limitations (Mitchell et al., is significantly lower than the 45.6% and 31.4%, 1991; Schwalberg et al., 1992; Godart et al., 2002; respectively, reported by Godart et al. (2003). Micali and Heyman, 2006; Godart et al., 2006). The Iwasaki et al. (2000) reported that 13% of their variability between estimated co-morbidity of AN and BN subjects met the criteria for GAD, and anxiety disorders and eating disorders amongst interestingly, their findings indicate that GAD was the available research is a significant limitation more prevalent amongst the purging subtypes of when considering the prevalence of co-morbid both AN and BN subjects, although this difference disorders. A number of factors may contribute to did not reach significance. this variability. Bulik et al. (2000) reported that the maternal perception of greater childhood anxiety was supported by the twin self report, with the affected Sample Sources and Selection twin being at a greater risk for lifetime GAD. They suggested that because the age of onset for GAD Research into ED and AD often include samples was reported to be prior to or concurrent with the from various sources including inpatients, out- onset of BN in 75% of the cases, it is possible that the patients and community samples. Unfortunately anxiety may be a predisposing factor rather than a this may bias the sample, as one could expect that sequelae of BN. These results support a growing an inpatient sample may be more likely to have body of literature that has reported elevated rates of multiple diagnoses and may not be representative premorbid anxiety disorders in women with BN of all patients with the disorder (Godart et al., 2002). (Bulik et al., 1997; Deep et al., 1995). Furthermore, some researchers have used exclusion criteria that may limit the frequency of comorbid AD. Keck et al. (1990) excluded all subjects with comorbid substance abuse, despite patients with Eating Disorders Amongst Individuals AD often reporting comorbid substance abuse With Anxiety Disorders (Bulik et al., 1996). Several studies excluded subjects There is less research available examining the taking psychoactive medication (Bulik et al., 1996; prevalence of eating disorders amongst individuals Bulik et al., 1997; Deep et al., 1995; Keck et al., 1990) with anxiety disorders. Of the studies that have and subsequently may have diminished the rates of considered this, they have generally examined rates AD identified.

Copyright # 2007 John Wiley & Sons, Ltd and Eating Disorders Association. Eur. Eat. Disorders Rev. 15, 253–274 (2007) DOI: 10.1002/erv 270 J. M. Swinbourne and S. W. Touyz

General Methodological Limitations research to exclude PTSD from the anxiety assessment, and this presents a limitation when consider- General methodological limitations included: (1) In ing the suggestion that a history of trauma, many of the studies reviewed in this paper, the particularly CSA is a non-specific risk factor for sample sizes were small, often including at least one the development of an eating disorder (Black Becker group of less than 30 subjects; (2) Some studies et al., 2004). include both males and females, while it is recognised that women have more lifetime AD Diagnostic Instruments than men (Wittchen and Essau, 1993) and that ED are rare in men (Godart et al., 2002); (3) Few studies Diagnostic instruments used to assess both eating are controlled, and often those that are controlled disorders and anxiety disorders have also varied have larger control groups than ED groups and are across studies and present a significant limitation not matched for age or other characteristics; (4) The when drawing conclusions about ED and AD definition of current prevalence varies across comorbidity (Micali and Heyman, 2006; Godart studies, referring to either 6-month (Herpertz- et al., 2006). Unfortunately, many of the studies Dahlmann et al., 1996; Ra˚stam et al., 1995) or 1-year presented in this paper have failed to use well- prevalence (Halmi et al., 1991). standardised, internationally accepted diagnostic instruments to identify eating disorders, limiting the usefulness of their findings. Similarly, some of Diagnostic Criteria for Eating Disorders and the research has used inadequate diagnostic instru- Anxiety Disorders ments or criteria to identify anxiety disorders. This is particularly important to enable one to dis- Changes in diagnostic criteria for ED and AD over tinguish between eating disorder and anxiety the past 15 years [e.g. Feighner criteria (1972), symptomatology. For example considering the high Research Diagnostic Criteria (RDC) (1977), DSM-III but also variable rates of reported OCD in eating (APA, 1980), DSM-III-R (APA, 1987), DSM-IV (APA, disorder populations, one may conclude that some 1994)] have clearly had an impact on the prevalence research has insufficiently distinguished between findings. Even in more recent studies, it is some- obsessive compulsive symptoms that are secondary times unclear whether they have utilised the to malnutrition and the ED and those which may DSM-IV or ICD-10 criteria to diagnose ED (e.g. reflect a true OCD. Furthermore, as mentioned by Goodwin and Fitzgibbon, 2002). Changes in AD Bulik et al. (1996), GAD in the SCID (with DSM-III-R diagnostic criteria may also have impacted on the criteria) is skipped for subjects with a current mood findings of studies over time. For example In the disorder. A number of the studies reported in this RDC (1977) and the DSM-III (1980) it was not paper have used the SCID (e.g. Brewerton et al., possible to diagnose a depressive disorder and AD 1995; Bulik et al., 1997; Powers et al., 1988; Ra˚stam simultaneously, which may have influenced the et al., 1995; Walters and Kendler, 1995) and prevalence of AD reported in some studies (Godart therefore the rates of GAD may be an underestimate et al., 2002). It is possible that certain anxiety in these studies. disorders may have been over reported due to the changes in diagnostic criteria between the DSM-III and the DSM-III-R. Specifically OCD and Social SUMMARY AND RESEARCH phobia DSM-III-R criteria stipulates both disorders IMPLICATIONS cannot be diagnosed if the obsessions and compulsions or the social anxiety are exclusive to food It is clear from the research that anxiety disorders related concerns. Whilst some researchers already are significantly more frequent in subjects with incorporated this in addition to DSM-III criteria it eating disorders than the general community. The may provide an explanation as to higher rates of available research investigating the prevalence of both of these disorders in earlier studies. Finally, the anxiety disorders amongst eating disordered indi- number of anxiety disorders assessed often differs viduals presents strikingly inconsistent findings. between the studies and will obviously affect the Whilst there are a large number of studies research- prevalence rates. A number of the studies reported ing this area, the inconsistencies complicate the in this paper excluded certain AD from the understanding of eating disorder and anxiety co- assessment, which is a significant limitation when morbidity. This presents the need for researchers to drawing conclusions about prevalence rates of AD use well-standardised, internationally accepted instru- and ED. Significantly, it is not uncommon in the ments to identify and investigate both eating disorders

Copyright # 2007 John Wiley & Sons, Ltd and Eating Disorders Association. Eur. Eat. Disorders Rev. 15, 253–274 (2007) DOI: 10.1002/erv The Co-Morbidity of Eating Disorders and Anxiety Disorders: A Review 271 and anxiety disorders. Furthermore, the lack of research trolled study. Acta Psychiatrica Scandinavica, 96, into the prevalence of eating disorders amongst 101–107. individuals presenting for anxiety treatment, Bulik, C., Wade, T., & Kendler, K. (2000). Characteristics of despite indications that prevalence may be high, monozygotic twins discordant for bulimia nervosa. International Journal of Eating Disorders, 29, 1–10. suggests the need for greater research in this area. Bulik, C. M. (2003). Anxiety, depression and eating dis- A study currently being undertaken by the orders. In J. Treasure, U. Schmidt, & E. van Furth authors endeavours to examine the comorbidity (Eds.), Handbook of eating disorders (pp. 193–198). between eating disorders and anxiety disorders Chichester, UK: Wiley. using well standardised, internationally accepted Bushnell, J. A., Wells, J. E., McKenzie, J. M., Hornblow, diagnostic instruments and questionnaires. The A. R., Oakley, M. A., & Joyce, P. R. (1994). Bulimia co-morbidity in the general population and in the current literature would suggest that further clinic. Psychological Medicine, 24, 605–611. investigation into the co-morbidity between anxiety Casper, R. C., & Jabine, L. N. (1986). Psychological func- and eating disorders may have significant aetiolo- tioning in anorexia nervosa: A comparison between gical and therapeutic implications. anorexia nervosa patients on follow-up and their sisters. In J. H. Lacey & D. A. Sturgeon (Eds.). Proceedings of the 15th European Conference on Psychosomatic Research. Libbey, London. Dahl, S. (1989). Acute response to rape: A PTSD variant. REFERENCES Acta Psychiatr Scand, 335, 56–62. American Psychiatric Association. (1980). Diagnostic Dansky, B. S., Brewerton, T. D., Kilpatrick, D. G., & O’Neil, and statistical manual of mental disorder (3rd ed.). P. M. (1997). The national women’s study: Relationship Washington, DC: American Psychiatric Association. of victimization and posttraumatic stress disorder to American Psychiatric Association. (1987). Diagnostic bulimia nervosa. International Journal of Eating Dis- and statistical manual of mental disorder (3rd ed., rev.). orders, 21, 213–228. Washington, DC: American Psychiatric Association. Deep, A. L., Nagy, L. M., Weltzin, T. E., Rao, R., & Kaye, American Psychiatric Association. (1994). Diagnostic W. H. (1995). Premorbid onset of psychopathology in and statistical manual of mental disorder (4th ed.). long term recovered anorexia nervosa. International Washington, DC: American Psychiatric Association. Journal of Eating Disorders, 17, 291–297. Bastiani, A. M., Altemus, M., Pigott, T., Rubenstein, C., Fairburn, C. G. (1997). Eating disorders. In D. M. Clark, & Weltzin, T. E., & Kaye, W. H. (1996). Comparison of C. G. Fairburn (Eds.), Science and practice of cognitive obsession and compulsion in patients with anorexia behaviour therapy. UK: Oxford University Press. nervosa and obsessive-compulsive disorder. Biological Faravelli, C., Giugni, A., Salvatori, S., & Ricca, V. (2004). Psychiatry, 39, 966–969. Psychopathology after rape. American Journal of Psy- Beumont, P. J., Abraham, S. F., Argall, W. J., George, C. W., chiatry, 161, 1483–1485. & Glaun, D. E. (1978). The onset of anorexia nervosa. Fichter, M., & Quadflieg, N. (2004). Twelve-year course Australian and New Zealand Journal of Psychiatry, 12, and outcome of bulimia nervosa. Psychological Medi- 145–149. cine, 34, 1395–1406. Black Becker, C., DeViva, J., & Zayfert, C. (2004). Eating Fornari, V., Kaplan, M., Sandberg, D. E., Matthews, M., disorder symptoms among female anxiety disorder Skolnick, N., & Katz, J. (1992). Depressive and anxiety patients in clinical practice: The importance of disorders in anorexia nervosa and bulimia nervosa. co-morbidity assessment. Journal of Anxiety Disorders, International Journal of Eating Disorders, 12, 21–29. 18, 255–275. Garfinkel, P. E., Lin, E., Goering, P., Spegg, C., Goldbloom, Brewerton, T. D., Lydiard, R. B., Ballenger, J. C., & Herzog, D. S., Kennedy, S., Kaplan, A. S., & Woodside, D. B. D. B. (1993). Eating disorders and social phobia (letter (1995). Bulimia Nervosa in a Canadian community comment). Archives of General Psychiatry, 50, 70. sample: Prevalence and comparison of subgroups. Brewerton, T. D., Lydiard, R. B., Herzog, D. B., Brotman, American Journal of Psychiatry, 152, 1052–1058. A., O’neil, P., & Ballenger, J. C. (1995). Comorbidity of Gartner, A. F., Marcus, R. N., Halmi, K., & Loranger, A. W. axis I psychiatric disorders in bulimia nervosa. Journal (1998). DSM-III-R personality disorders in patients of Clinical Psychiatry, 56, 77–80. with eating disorders. American Journal of Psychiatry, Brumberg, J. J. (1988). Fasting girls: The emergence of anor- 146, 1585–1591. exia nervosa as a modern disease. Cambridge: Harvard Gleaves, D. H., & Eberenz, K. P. (1994). Sexual abuse University Press. histories among treatment resistant bulimia nervosa Bulik, C. M. (1995). Anxiety disorders and eating dis- patients. International Journal of Eating Disorders, 15, orders: A review of their relationship. New Zealand 227–231. Journal of Psychology, 24, 51–62. Gleaves, D. H., Eberenz, K. P., & May, M. C. (1998). Scope Bulik, C., Sullivan, P., Carter, A., & Joyce, P. (1996). Life- and significance of posttraumatic symptomatology time anxiety disorders in women with bulimia ner- among women hospitalized for an eating disorder. vosa. Comprehensive Psychiatry, 37, 368–374. International Journal of Eating Disorders, 24, 147–156. Bulik, C., Sullivan, P., Fear, J. L., & Joyce, P. (1997). Eating Godart, N., Flament, M., Lecrubier, Y., & Jeammet, P. disorders and antecedent anxiety disorders: A con- (2000). Anxiety Disorders in AN and bulimia nervosa:

Copyright # 2007 John Wiley & Sons, Ltd and Eating Disorders Association. Eur. Eat. Disorders Rev. 15, 253–274 (2007) DOI: 10.1002/erv 272 J. M. Swinbourne and S. W. Touyz

Co-morbidity and chronology of appearance. European and suggestions for a general taxonomy. Psychological Psychiatry, 15, 38–45. Bulletin, 130, 19–65. Godart, N., Flament, M., Perereau, F., & Jeammet, P. Johnson, J. G., Cohen, P., Kasen, S., & Brook, J. S. (2002). (2002). Co-morbidity between eating disorders and Childhood adversities associated with risk for eating anxiety disorders: A review. International Journal of disorders or weight problems during adolescence or Eating Disorders, 32, 253–270. early adulthood. American Journal of Psychiatry, 159, Godart, N. T., Flament, M. F., Curt, F., Perdereau, F., Lang, 394–400. F., Venisse, J. L., Halfon, O., Bizouard, P., Loas, G., Kasvikis, Y. G., Tsakiris, F., Marks, I. M., Basaglu, M., & Corcos, M., Jeammet, P., & Fermanian, J. (2003). Noshirvani, H. F. (1986). Past history of anorexia ner- Anxiety disorders in subjects seeking treatment for vosa in women with obsessive compulsive disorder. eating disorders: A DSM-IV controlled study. Psychia- International Journal of Eating Disorders, 5, 1069–1075. try Res, 117, 245–258. Kaye, W., Bulik, C., Thornton, L., Barbarich, N., Masters, Godart, N., Berthoz, S., Perereau, F., & Jeammet, P. (2006). K., & the Price Foundation Collaborative Group. Co-morbidity of anxiety disorders with eating dis- (2004). Co-morbidity of anxiety disorders with Anor- orders and OCD (Letter to the Editor). American Journal exia and Bulimia Nervosa. The American Journal of of Psychiatry, 163, 326. Psychiatry, 161, 2215–2221. Goodwin, R., & Fitzgibbon, M. (2002). Social phobia as a Keck, P., Pope, H., Hudson, J., McElroy, S., Yurgelun- barrier to treatment for eating disorders. International Todd, D., & Hundert, E. (1990). A controlled study of Journal of Eating Disorders, 32, 103–106. phenomenology and family history in outpatients with Halmi, K., Eckert, E., Marchi, P., Sampugnaro, V., Apple, bulimia nervosa. Comprehensive Psychiatry, 31, 275–283. R., & Cohen, J. (1991). Co-morbidity of psyciatric Kendler, K. S., MacLean, C., Neale, M., Kessler, R., Heath, diagnoses in anorexia nervosa. Archives of General Psy- A., & Eaves, L. (1991). The genetic epidemiology of bulimia chiatry, 48, 712–718. nervosa. American Journal of Psychiatry, 148, 1627–1637. Halmi, K. A., Brodland, G., & Loney, J. (1973). Prognosis in Keys, A., Brozek, J., Henschel, A., Mickelson, O., & Taylor, anorexia nervosa. Annals of Internal Medicine, 78, H. L. (1950). The biology of human starvation (Vol. 1). 907–909. Minneapolis: University of Minnesota Press. Halmi, K., Sunday, S., Klump, K., Strober, M., Leckman, J., Laessle, R., Kittl, S., Fichter, M., Wittchen, H., & Pirke, K. Fichter, M., Kaplan, A., Woodside, B., Treasure, J., (1987). Major affective disorder in anorexia nervosa Berrettini, W., Al Shabboat, M., Bulik, C., & Kaye, and bulimia. A descriptive diagnostic study. British W. (2003). Obsessions and compulsions in anorexia Journal of Psychiatry, 151, 785–789. nervosa subtypes. International Journal of Eating Dis- Laessle, R., Wittchen, H., Fichter, M., & Pirke, K. (1989). orders, 33, 308–319. The signiﬁcance of subgroup of bulimia and anorexia Herpertz-Dahlmann, B., Wewetzer, C., Schulz, E., & nervosa: Lifetime frequency of psychiatric disorders. Remschmidt, H. (1996). Course and Outcome in ado- International Journal of Eating Disorders, 8, 569–574. lescent anorexia nervosa. International Journal of Eating Lilenfeld, L., Kaye, W., Greeno, C., Merikangas, K., Plot- Disorders, 19, 335–345. nicov, K., Pollice, C., Rao, R., Strober, M., Bulik, C., & Hinrichson, H., Waller, G., & Gerko, K. (2004). Social Nagy, L. (1998). A controlled family study of anorexia phobia and agoraphobia in the eating disorder: Associ- nervosa and bulimia nervosa: Psychiatric disorders in ations with eating attitudes and behaviours. Eating ﬁrst-degree relatives and effects of proband Behaviours, 5, 285–290. co-morbidity. Archives of General Psychiatry, 55, Hinrichson, H., Wright, F., Waller, G., & Meyer, C. (2003). 603–610. Social anxiety and coping strategies in the eating dis- Lipschitz, D. S., Winegar, R. K., Hartnick, E., Foote, B., & orders. Eating Behaviors, 4, 117–126. Southwick, S. M. (1999). Posttraumatic stress disorder Holden, M. (1990). Is anorexia nervosa an obsessive- in hospitalised adolescents: Psychiatric co-morbidity compulsive disorder? British Journal of Psychiatry, and clinical correlates. Journal of the American Academy 157, 1–5. of Child and Adolescent Psychiatry, 38, 385–392. Hudson, J. I., Pope, H. G., Jonas, J. M., & Yurgelun-Todd, Lockwood, R., Lawson, R., & Waller, G. (2004). Compul- D. (1983). Phenomenologic relationship of eating dis- sive features in the eating disorders: A role for trauma? orders to major affective disorder. Psychiatry Research, The Journal of Nervous and Mental Diseases, 192, 247–249. 9, 345–354. Mantero, M., & Crippa, L. (2002). Eating disorders and Hudson, J. I., Pope, H. G., Yurgelun-Todd, D., Jonas, J. M., chronic post traumatic stress disorder: Issues of psy- & Frankenburg, F. R. (1987). A controlled study of chopathology and co-morbidity. European Eating Dis- lifetime prevalence of affective and other psychiatric orders Review, 10, 1–16. disorders in bulimic outpatients. American Journal of Matsunaga, H., Miyaga, A., Iwasaki, H., Matsui, T., Fuji- Psychiatry, 144, 1283–1287. moto, K., & Kiriike, N. (1999). A comparison of clinical Iwasaki, Y., Matsunaga, H., Kiriike, N., Tanaka, H., & features among Japanese eating disordered women Matsui, T. (2000). Comorbidity of axis I disorders with obsessive compulsive disorder. Comparative Psy- among eating-disordered subjects in Japan. Compre- chiatry, 40, 337–342. hensive Psychiatry, 41, 454–460. Mazure, C. N., Halmi, K. A., Sunday, S. R., Romano, S., & Jacobi, C., Hayward, C., deZwaan, M., Kraemer, H. C., & Einhorn, A. (1994). The Yale brown Cornell Eating Agras, W. S. (2004). Coming to terms with risk factors Disorder Scale: Development, use, reliability and for eating disorders: Application of risk terminology validity. Journal of Psychiatric Research, 28, 425–445.

Micali, N., & Heyman, I. (2006). Comorbidity of anxiety Smolak, L., & Murnen, S. K. (2002). A meta-analytic exam- with eating disorders and OCD (Letter to the Editor). ination of the relationship between child sexual abuse American Journal of Psychiatry, 163, 326–327. and eating disorders. International Journal of Eating Milos, G., Spindler, A., Ruggiero, G., Klaghofer, R., & Disorders, 31, 136–150. Schnyder, U. (2002). Co-morbidity of obsessive- Solyom, L., Freeman, R. J., & Miles, J. E. (1982). compulsive disorders and duration of eating dis- A comparative psychometric study of anorexia ner- orders. International Journal of Eating Disorders, 31, vosa and obsessive neurosis. Canadian Journal of Psy- 284–289. chiatry, 27, 282–286. Mitchell, M. J., Speckert, S. M., & de Zwaan, M. (1991). Speranza, M., Corcos, M., Godart, N., Loas, G., Guilbaud, Co-morbidity and medical complication of bulimia O., Jeammet, P., & Flament, M. (2001). Obsessive com- nervosa. Journal of Clinical Psychiatry, 52, 13–20. pulsive disorders in eating disorders. Eating Beha- O’Brien, K. M., & Vincent, N. K. (2003). Psychiatric viours, 2, 193–207. co-morbidity in anorexia and bulimia nervosa: Nature, Srinivasagam, N. M., Kaye, W. H., Plotnicov, K. H., prevalence and causal relationships. Clinical Psychology Greeno, C., Weltzin, T. E., & Radhika, R. (1995). Per- Review, 23, 57–74. sistent perfectionism, symmetry and exactness after Piran, N., Kennedy, S., Garfinkel, P., & Owens, M. (1985). long term recovery from anorexia nervosa. American Affective disturbance eating disorders. Journal of Ner- Journal of Psychiatry, 152, 1630–1634. vous and Mental Disease, 173, 395–400. Steiger, H., & Zanko, M. (1990). Sexual traumata among Pollice, C., Kaye, W. H., Greeno, C., & Weltzin, T. E. (1997). eating disordered, psychiatric, and normal female Relationship of depression, anxiety, and obsessionality groups. Journal of Interpersonal Violence, 5, 74–86. to state of illness in anorexia nervosa. International Striegel-Moore, R. H., Garvin, V., Dohm, F. A., & Rosen- Journal of Eating Disorders, 21, 367–376. heck, R. (1999). Eating disorders in a national sample of Powers, P., Coovert, D., Brightwell, D., & Stevens, B. hospitalized female and male veterans: Detection rates (1988). Other psychiatric disorders among bulimic and psychiatric comorbidity. International Journal of patients. Comprehensive Psychiatry, 29, 503–508. Eating Disorders, 25, 405–414. Pribor, E. F., & Dinwiddie, S. H. (1992). Psychiatric corre- Strober, M. (1984). Stressful life events associated with lates of incest in childhood. American Journal of Psy- bulimia in anorexia nervosa. Empirical findings and chiatry, 149, 52–56. theoretical speculations. International Journal of Eating Procopio, C. A., Holm-Denoma, J. M., Gardon, K. H., & Disorders, 3, 3–16. Joiner, T. E. (2006). Two–three year stability and inter- Thiel, A. T., Zu¨ ger, M., Jacoby, G., & Schu¨ ßler, G. (1998). relations of bulimiotypic indicators and depressive Thirty month outcome in patients with anorexia or and anxious symptoms in middle-aged women. Inter- bulimia nervosa and concomitant obsessive- national Journal of Eating Disorders, 39, 312–319. compulsive disorder. American Journal of Psychiatry, Putnam, F., & Trickett, P. (1997). Psychobiological effects 155, 244–249. of sexual abuse: A longitudinal study. Annals of the New Thompson, K., Crosby, R., Wonderlich, S., Mitchell, J., York Academy of Sciences, 821, 150–159. Redlin, J., Demuth, G., Smyth, J., & Haseltine, B. (2003). Pyle, R. L., Mitchell, J. E., & Eckert, E. D. (1981). Bulimia: A Psychopathology and sexual trauma in childhood and report of 34 cases. Journal of Clinical Psychiatry, 42, 60–64. adulthood. Journal of Trauma Stress, 16, 35–38. Ra˚stam, M., Gillberg, C., & Gillberg, C. (1995). Anorexia Thompson–Brenner, H., & Westen, D. (2005). nervosa 6 years after onset: Part II. Co-morbid A naturalistic study of psychotherapy for bulimia psychiatric problems. Comprehensive Psychiatry, 36, nervosa, part 1: Comorbidity and therapeutic outcome. 70–76. The Journal of Nervous and Mental Diseases, 193, 573–584. Rorty, M., Yager, J., & Rossotto, E. (1994). Childhood Thornton, C., & Russell, J. (1997). Obsessive compulsive sexual, physical and psychological abuse in bulimia co-morbidity in the dieting disorders. International nervosa. American Journal of Psychiatry, 151,1122– Journal of Eating Disorders, 21, 83–87. 1126. Toner, B. B., Garfinkel, P. E., & Garner, D. M. (1988). Rossiter, E. M., Agras, W. S., Telch, C. F., & Schneider, J. A. Affective and anxiety disorders in the long-term fol- (1993). Cluster B personality disorder characteristics low-up of anorexia nervosa. International Journal of predict outcome in the treatment of bulimia nervosa. Psychiatry in Medicine 18, 357–364. International Journal of Eating Disorders, 13, 349– Tozzi, F., Sullivan, P., Fear, J., McKenzie, J., & Bulik, C. 357. (2003). Causes and recovery in anorexia nervosa: The Rothenberg, A. (1986). Eating disorder as a modern obses- patient’s perspective. International Journal of Eating sive compulsive syndrome. Psychiatry, 49, 45–53. Disorders, 33, 143–154. Serpell, L., Livingstone, A., Neiderman, M., & Lask, B. Turnbull, S. J., Troop, N. A., & Treasure, J. L. (1997). The (2002). Anorexia nervosa: Obsessive–compulsive dis- prevalence of posttraumatic stress disorder and its order, obsessive–compulsive personality disorder, or relation to childhood adversity in subjects with eating neither? Clinical Psychology Review, 22, 647–669. disorders. European Eating Disorders Review, 5, 270– Schwalberg, M., Barlow, D., Alger, S., & Howard, L. 277. (1992). Comparison of bulimics, obese binge eaters, Vize, C. M., & Cooper, P. J. (1995). Sexual abuse in patients social phobics and individuals with panic disorder on with eating disorders, patients with depression and co-morbidity across DSM-III-R anxiety disorders. Jour- normal controls: A comparative study. British Journal of nal of Abnormal Psychology, 101, 4675–4681. Psychiatry, 167, 80–85.

Copyright # 2007 John Wiley & Sons, Ltd and Eating Disorders Association. Eur. Eat. Disorders Rev. 15, 253–274 (2007) DOI: 10.1002/erv 274 J. M. Swinbourne and S. W. Touyz

VonRanson,K.M.,Kaye,W.H.,Weltzin,T.E.,Rao,R.,& female twin sample. American Journal of Psychiatry, Matsunaga, H. (1999). Obsessive-compulsive disorder 152, 64–71. symptoms before and after recovery from bulimia ner- Welch, S. L., & Fairburn, C. G. (1994). Sexual abuse and vosa. The American Journal of Psychiatry, 156, 1703–1708. bulimia nervosa: Three integrated case control Walsh, B. T., Roose, S. P., Glassman, A. H., Gladis, M., & comparisons. American Journal of Psychiatry, 151, 402– Sadik, C. (1985). Bulimia and depression. Psychosomatic 407. Medicine, 47, 123–131. Wittchen, H. U., & Essau, C. A. (1993). Epidemiology of Walters, E. E., & Kendler, K. S. (1995). Anorexia Nervosa anxiety disorders. In H. U. Wittchen, & C. A. Essau and anorexic-like syndromes in a population-based (Eds.), Psychiatry. Philadelphia: J.B Lippincott.

Copyright # 2007 John Wiley & Sons, Ltd and Eating Disorders Association. Eur. Eat. Disorders Rev. 15, 253–274 (2007) DOI: 10.1002/erv

CHAPTER 4

EATING DISORDER AND ANXIETY DISORDER COMORBIDITY

This chapter is an extended version of the preceding chapter, providing a comprehensive and critical review of the literature to date, concerning the comorbidity between eating disorders and anxiety disorders.

4.1 Introduction to Research

4.1.1 Defining Comorbidity Comorbidity has been defined as the simultaneous occurrence of two separate disorders within the same person at a given point in time or all of the diagnoses for which an individual has ever met diagnostic criteria over a given period of time (Brown & Barlow, 1992). Widiger, Frances, Harris, Jacobsberg, Fryer & Manning (1991) suggested that comorbidity can involve the co-occurrence of two independent disorders, with a common underlying etiology or two disorders having a causal relation between them. Comorbidity may be examined cross-sectionally, where one records the co-occurrence of disorders at a given point in time, or longitudinally, where all diagnoses are assessed over a specified time frame, such as over a lifetime (Brown & Barlow, 1992).

Klerman (1990) proposed three definitions for establishing comorbidity and identifying primary versus secondary diagnoses. The first is chronological, to identify the temporal relationship between the two disorders, where the disorder that appeared first would be classified as the primary disorder. A second approach is to establish a causal link between the disorders, to determine whether one disorder promoted the development of the other. The final approach is symptomatic, to consider the severity and level of impairment generated by both disorders, and defining the primary disorder as the one causing the greatest level of impairment (Klerman, 1990). It is clear that all three approaches may be

100 useful in providing a greater understanding of the etiological basis of identified disorders, as well as providing an impetus for the selection of treatment approaches.

4.1.2 Background to the comorbidity between eating disorders and anxiety

Research considering the etiological aspects of eating disorders often refers to the developmental, social and biological processes which are thought to influence the development of eating pathology (Garner, 1993; Treasure & Campbell, 1994). Cultural attitudes toward body weight and shape are critical, yet insufficient to account for pathogenesis (Kaye, Devlin, Barbarich, Bulik, Thornton, Bacanu, Fichter, Halmi, Kaplan, Strober, Woodside, Bergen, Crow, Mitchell, Rotondo, Mauri, Cassano, Keel, Plotnicov, Pollice, Klump, Lilenfelf, Ganjei, Quadflieg and Berrettini, 2004). Research has sought to investigate the possible genetic factors influencing the development of eating pathology, and subsequent family and twin studies have provided support for the hypothesis of heritability in eating disorders (Bulik, Sullivan & Kendler, 1998). It is not surprising therefore, that research into psychiatric comorbidity amongst the eating disorders has also increased over the last decade.

Research to date has consistently demonstrated that anxiety disorders and eating pathology often co-occur. However, limitations in the research in this area has impaired the utility of the results. Briefly, those limitations include: 1) the problems establishing the accurate prevalence rates for eating and anxiety disorder comorbidity, due to much of the previous research focusing on AN and BN, despite the indication that the residual category of EDNOS is at least as common in clinical practice (Fairburn & Walsh, 2002; Fairburn & Harrison, 2003); 2) The focus of much of the research on only a few of the anxiety diagnoses, often excluding PTSD despite the suggestion that trauma is a non specific risk factor for the development of eating pathology; and 3) the tendency of research to utlise insufficient diagnostic instruments, such as self-report questionnaires, possibly affecting rates of diagnosis.

101 Notwithstanding these methodological limitations, the role of anxiety in the eating disorders has been clearly described by a number of authors. Furthermore, eating disorder patients have reported that eating binges are more likely to be triggered by anxiety and anger states, than depression (Arnow, Kennedy & Agras, 1992).

Several conceptual models have been proposed to account for the observed comorbidity between eating pathology and anxiety. A number of authors have suggested that AN could represent a variant of OCD, based on clinical (Hollander & Wong, 1995) and biological (Kennedy & Garfinkel, 1992) observations. However, this theory has largely been discredited (Holden, 1990; Hsu, Kaye & Weltzin, 1993). Another theory has suggested that the eating pathology may be secondary to the anxiety symptoms and serve to reduce it (Godart et al., 2000). This theory suggests that many of the behaviours that characterise the eating disorders (e.g. restriction, bingeing, purging and body checking) may be considered safety behaviours, reducing the immediate level of anxiety through the blocking of awareness of that emotional state (Pallister & Waller, 2008). In particular, research in this area has reported that anxiety has been associated with vomiting (Carter & Duncan, 1984), laxative abuse (Weltzin, Bulik, McConaha & Kaye, 1995) and restriction (Chesler, 1995). In exactly the same way that safety behaviours are viewed in the anxiety disorder literature, the eating disorder behaviours, whilst initially reducing the level of arousal, serve to maintain and even increase anxiety levels in the long term (Waller, 2008). This theory has been investigated in a number of BN samples.

In one study, researchers found that the frequency of bingeing and purging behaviours was correlated to the severity of anxiety, as rated by a clinician (Piran, Kennedy, Garfinkel & Owens, 1985). Another study hypothesised that the frequency of GAD and social phobia reported in BN could be accounted for by individuals attempting to reduce anxiety through focus on shape and weight, followed by strict dieting and subsequent bulimic behaviours (Mitchell, Speckert & de Zwaan, 1991). Researchers have also suggested a link between PTSD and the development of an eating disorder. One theory has suggested that as PTSD tends to increase anxiety and vigilance overall, this may exacerbate or trigger a pre-existing diathesis to develop an eating disorder (Black Becker, DeViva & Zayfert, 2004). Other theories have implicated the role of eating disordered

102 behaviours such as restriction, bingeing and purging, in a reduction of anxiety and distress as a result of PTSD symptoms.

Biological theories implicate the common functional abnormalities observed in the anxiety and eating disorder, namely the pattern serotonergic dysfunction inherent in both disorders (Brewerton, 1995). Abnormalities with the serotonin system have not only been implicated in the anxiety disorders, but also depression and personality disorders which are also frequently associated with the eating disorders (Godart et al., 2000). The obvious difficulty with this theory is in terms of providing a causal account for the development of comorbid eating and anxiety disorders, as serotonin is also likely to be affected as a result of these disorders. Strober, Freeman, Lampert & Diamond (2007) recently suggested that individuals with AN inherit neural circuitry that is predisposed towards anxiety and fear reactions. Consequently, such individuals will regard novel situations and experiences as threatening and will use compulsive behaviours to ensure predictability. These observations have led several authors to propose that eating disorders be subsumed into the anxiety disorder diagnostic category (Strober et al., 2007; Waller, 2008). In his recent article, Waller (2008) incorporates this idea into a schematic model (see figure 4.1), using only a few of the anxiety disorder diagnoses to demonstrate where the eating disorders could sit if they were categorised with the anxiety disorders.

103

Figure 4.1 Eating Disorders incorporated into a wider model of disorders characterised by anxiety and concomitant safety behaviours (Waller, 2008)

Disorders characterized by non-specific anxiety and vulnerability cognitions

Anxiety and safety Anxiety and safety behaviours focused behaviours focused on danger on danger of of overarousal and physical negative evaluation injury / death by others

Anxiety and safety behaviours focused Anxiety and safety on food, eating, behaviours focused weight and shape on personal responsibility for negative outcomes

No Anxiety Disorder

Amongst the Axis I disorders, research indicates that eating disorders and anxiety disorders frequently co-occur (Herzog, Keller, Sachs, Yeh & Lavori, 1992; Milos, Spindler & Schnyder, 2004). Studies have consistently shown that a significant number of patients with AN or BN experience one or more anxiety disorders (Kaye, Bulik, Thornton, Barbarich, Masters & the Price Foundation Collaborative Group, 2004). Herzog, Keller, Sachs, Yeh & Lavori, (1992) reported that 73% patients with AN restricting type (ANR), 82% with AN binge/purge type (ANBP) and 60% with BN had one or more concurrent Axis I comorbidities.

104 The prevalence of anxiety disorders amongst BN samples has been reported in a number of investigations (Hudson, Pope, Jonas & Yurgelun-Todd, 1983; Piran et al., 1985; Walsh, Roose, Glassman, Gladis & Sadik, 1985; Hudson, Pope, Yurgelun-Todd, Jonas & Frankenburg, 1987; Powers, Coovert, Brightwell & Stevens 1988; Laessle, Wittchen, Fichter & Pirke, 1989; Schwalberg, Barlow, Alger & Howard, 1992; Brewerton, Lydiard, Herzog, Brotman, O’Neil & Ballenger, 1995; Bulik, Wade & Kendler, 2000). Similarly, prevalence amongst AN samples has also been investigated (Laessle, Kittl, Fichter, Wittchen & Pirke, 1987; Halmi, Eckert, Marchi, Sampugnaro, Apple & Cohen, 1991; Deep, Nagy, Weltzin, Rao & Kaye, 1995; Herpertz-Dahlmann, Wewetzer, Schulz & Remschmidt, 1996) (see Table 4.1). Lifetime prevalence rates of at least one anxiety disorder varies from 25% (Keck at al., 1990) to 75% (Schwalberg et al., 1992) in BN and from 23% (Laessle et al., 1987) to 83% (Godart et al., 2000) in AN.

Several studies have shown that, in most cases, the onset of an anxiety disorder precedes the onset of an eating disorder (Schwalberg et al., 1992; Brewerton et al., 1995; Bulik, 2003; Deep et al., 1995; Godart, Flament, Curt, Perdereau, Lang, Venisse, Halfon, Bizouard, Loas, Corcos, Jeammet & Fermanian, 2003) (see Table 4.1 for summary). These findings have led some researchers to speculate that early onset anxiety disorders may represent a potential genetically mediated pathway toward the development of an eating disorder (Kaye, Bulik, Thornton, Barbarich, Masters & the Price Foundation Collaborative Group, 2004), and at the very least it suggests that early onset anxiety disorders may in some way predispose individuals to the development of an eating disorder (Bulik, Sullivan, Carter & Joyce, 1996).

Unfortunately methodological limitations evident in many of the studies investigating anxiety and eating comorbidity may account for the striking variability amongst prevalence rates reported. Despite these discrepancies, it is clear that anxiety and eating disorders consistently demonstrate a high comorbidity, generally two to three times higher than those reported in the community (Laessle et al., 1989; Mitchell et al., 1991 & Fornari et al., 1992).

105 Of the anxiety disorders, obsessive-compulsive disorder and social phobia have been found to have the highest comorbidity with eating disorders. Table 4.2 summarises the findings of research investigating comorbid eating disorders and anxiety disorders. The prevalence rates of anxiety disorders also differs amongst the eating disorder subtypes, a summary of which can be seen in Table 4.3 and Table 4.4 for AN and BN respectively.

Finally, it is impossible to discuss the comorbidity between eating and anxiety disorders without further addressing the familial relationship that has been discussed in the literature. In terms of the consideration of an etiological relationship between these disorders, research has included twin studies and family design studies to further test this relationship. To date well designed research in this area is limited, however Lilenfeld et al., (1998) reported that relatives of AN and BN probands had significantly increased rates of GAD and panic disorder, compared with normal controls. Similarly, Wade, Bulik, Prescott & Kendler (2004) reported a shared familial risk factor between GAD and BN. Furthermore, a multivariate twin study found evidence for a shared genetic vulnerability between BN and anxiety disorders (panic disorder and phobias) (Kendler, Walters, Neale, Kessler, Heath & Eaves, 1995). Similarly, Keel et al., (2005) utilising a discordant monozygotic twin design, found support for a shared transmission between anxiety and eating disorders. Nevertheless, they did not elaborate on the nature of this shared diathesis. Thus, it is clear that further research in this area is crucial.

106 Table 4.1.

Lifetime and Current prevalence of anxiety disorders in patients with eating disorders Reference & Subjects N Diagnostic Summary of Limitations of Research Country Criteria & Results Instruments Brewerton et al. BN 59 DSM-III-R; SCID 36% reported at least 1 AD No specific ED diagnostic instrument; No control (1995) 71% anxiety preceded BN group USA Bulik et al. (1996) BN 114 DSM-III-R; SCID; SCID 64% reported at least 1 No specific ED diagnostic instrument; Sample not New Zealand II; SADS; HDRS; GAFS AD. AD had a mean onset representative (exclusion criteria); No control group; of 8 yr and BN mean age Comorbid lifetime alcohol dependence in 48% of of onset 20yr sample; No Ax PTSD Bulik, Wade & BN Monozyg 20 DSM-III-R; SCID BN twin more likely to Small sample size; No specific ED diagnostic Kendler (2000) twins pairs report lifetime GAD & instrument; No control group USA mother report more anxious as child Deep et al. (1995) AN 24 DSM-III-R; SADS-L 75% prevalence of 1 AD Small sample size; Sample not representative USA L/T recovered 79% AD preceded ED (exclusion criteria); No control group; No specific ED diagnostic instrument Fornari et al. (1992) AN 42 DSM-III-R; SADS-L 45.8%of AN had at least 1 PTSD and SP not assessed; Small sample size; No USA BN 21 lifetime AD specific ED diagnostic instrument; No control group; Males and females included Godart et al. (2000) ANR 29 DSM-IV; DSM-III-R for 71% AN-R at least 1 AD Small sample size; No control group; No specific ED France BN 34 AD; CIDI 65% BN at least 1 AD diagnostic instrument; Retrospective diagnosis; Males and females included Godart et al. (2003) AN 166 DSM-IV; MINI 71% prevalence AD in ED Sample may not be representative (more severe ED) France BN 105 41.8–53.3% AD preceded Retrospective diagnosis; Small numbers in BN-NP NC 271 ED group Halmi et al.(1991) AN 62 DSM-III-R; DIS; RDC-FH 62.9% at least 1 lifetime No specific ED diagnostic instrument; No Ax PTSD USA NC 62 AD in AN 1 year prevalence in AN: OCD:11.3% ; PD: 4.8% ; Ph:24.2% Herpertz-Dahlmann AN 34 DSM-III-R; Morgan 6 month prevalence: Standardised measures not used at each time period; et al. (1996) Adolescents Russell 41% at least 1 AD Small sample size and varying ages of sample; No Germany SIAB-P; CIDI; BDI; ANIS; 53% reported AD control group; Males and females included SCL-90 R preceding ED Hudson et al. AN 16 DSM-III ; DIS; EDS 54% ED group at least 1 No specific ED diagnostic instrument; Inclusion of an (1983) BN 49 AD AN + BN group; Small sample size and groups USA AN+BN 25 unequal Hudson et al.(1987) BN 51 DSM-III ; DIS; ADDS ; 43% BN sample at least 1 No specific ED diagnostic instrument; No Ax PTSD, USA Hx BN 19 EDS for ED AD SP and phobias; Apart from BN group, small sample; Depression 24 Males and females included NC 28 Iwasaki et al.(2000) AN 98 DSM-IV; SCID-P 41% ED group at least 1 Exclusion of EDNOS; No control group; No specific Japan BN 73 AD ED diagnostic instrument; Hospital sample more severe Kaye, Bulik, AN 97 DSM-IV; SCID; YBOCS; 63.5% ED group at least 1 Modified ED criteria; AD diagnosed when Thornton, BN 282 STAI; FMPS; TCI AD subthreshold Barbarich, Masters AN+BN 293 EDNOS excluded; No control group; No specific ED & the PFCG, 2004) diagnostic instrument; Query representativeness of USA sample Keck et al. (1990) BN 69 DSM-III-R; DSM-III ; 25% Prevalence of at least Sample not representative (exclusion criteria); No Ax USA Bulimia 50 SCID 1 AD in BN of PTSD; No specific ED diagnostic instrument; Small DC 24 higher than NC though non control group NC 28 sig Laessle et al.(1989) AN R 21 DSM-III ; CIDI 33.3% At least 1 AD in AN- No Ax GAD & PTSD; No specific ED diagnostic Germany ANBP 20 R instrument; Small sample size; No control group BN 27 55% At least 1 AD in AN- BN – Hx AN 23 BP 70.4% At least 1 AD BN 65.2% At least 1 AD BN- Hx AN Laessle et al.(1987) AN 13 DSM-III ; CIDI; EDI ; EAT 23% prevalence of 1 AD Small sample size; No specific ED diagnostic Germany AN+Bulimia 26 in AN instrument BN 13 No Ax for PTSD; GAD; Males and females included DC 47 Powers et al. (1988) BN 30 DSM-III-R; SCID 53% At least 1 AD No Ax PTSD; Small sample size; No specific ED USA diagnostic instrument Schwalberg et al. BN 20 DSM-III-R ; ADIS-R 75% prevalence of 1 AD Small sample size; No control group; No specific ED (1992) USA 59.3% AD precededED diagnostic instrument

107 Table 4.2 Summary of research papers investigating eating disorder comorbidity with anxiety disorders Reference & Subject N Diagnostic Criteria Summary of Results Limitations of Research Country & Instruments Fornari et al. (1992) ANR 24 DSM-III-R; SADS-L Lifetime OCD ANR (25%) and ANBP (66%) (sig difference). BN OCD No Ax PTSD and SP; Small sample size; No specific ED USA ANBP 18 (42.9%). diagnostic instrument; No control group; Males and females BN 21 included Gleaves et al. AN 121 DSM-III-R; BULIT- AN: 47% PTSD / BN: 62% PTSD No control group; Type of trauma identified in less than 10% of (1998) BN 103 R; EAT; DES; TSC- EDNOS: 74% reported traumatic event; 52% met criteria for PTSD sample USA EDNOS 70 40 ; Use of self-reportmeasure to diagnose PTSD TSC-40-ANX; PSS Godart et al. (2000) ANR 29 DSM-IV; DSM-II-R AN-R: SP55%; Ph34%; GAD24%; OCD21%; PD7%; AG3% Small sample size; No control group; No specific ED diagnostic France BN 34 for AD CIDI BN: SP59%; OCD0%; GAD23%; AG6%; PD15%; Ph21% instrument Retrospective diagnostic procedure; Males and females included Godart et al. (2003) AN 166 DSM-IV; MINI AN GAD 45.6%; ANR: OCD 17.5%; ANBP OCD 21.8 Sample may not be representative (severe ED); Retrospective France BN 105 BN GAD 31.4% diagnosis of past disorders; Small numbers in BNNP group NC 271 Hinrichson et al. ANR 21 DSM-IV ; BITE ; ANR: SP 71.4% No specific ED and AD diagnostic instrument (2003) ANBP 34 DES-II ; FNE ANBP: SP 88.2% UK BN 59 BN: SP 67.8% NC 50 NC: SP 30% Hudson et al. (1983) AN 16 DSM-III ; DIS; EDS AN: OCD69%; PD38%; AG13%; Ph25%; No specific ED diagnostic instrument; Inclusion of an AN + BN USA BN 49 BN: PD39%; OCD24%; phobia12%; AG10% group AN+BN 25 AN + BN: PD44%; OCD44%; AG24%; Ph4%; Small sample size and groups unequal; No Ax for SP Iwasaki et al.(2000) ANR 62 DSM-IV; SCID-P In all subjects, OCD was most prev (19%); followed by SP (18%), PD Exclusion of EDNOS; No control group; No specific ED diagnostic Japan ANBP 36 (16%) and GAD (13%); 43% of sample met criteria for AD and lifetime instrument; Hospital sample may be more severe BNP 57 prev GAD more prev amongst ANBP and BNP than ANR BNNP 16 Kaye, Bulik, AN 97 DSM-IV ; SCID; Prevalence of OCD, PD, SP, AG and GAD did not differ significantly Modified ED criteria; AD diagnosed when subthreshold; EDNOS Thornton, BN 282 YBOCS; STAI; across ED subtypes excluded Barbarich, AN+BN 293 FMPS; TCI OCD (35 – 44%) ; SP (16 – 23%) ; Ph (12 – 18%); GAD (8 – 13%) ; PD No control group; No specific ED diagnostic instrument; Sample Masters & the (9-11%) ; AG (2 – 4%) ; PTSD x3 more frequent in BN (13%) than AN may not be not representative PFCG, 2004) (5%) USA Laessle et al. (1987) AN 13 DSM-III ; CIDI; EDI ; AN: SP 23%; Ph: 15%; OCD 15%; AG 0% Small sample size; No specific ED diagnostic instrument; No Ax Germany AN+BN 26 EAT AN + BN: SP 50%; Ph: 19%; OCD 15% AG 15% for PTSD, GAD and PD BN 13 BN: Ph: 46%; SP 31%; OCD 8% Ag 8% DC 47 Laessle et al. (1989) ANR 21 DSM-III ; CIDI; EAT ANR: SP 23.8%; Ph14.3%;OCD 9.5%;PD 4.8%;AG 0% No Ax for GAD & PTSD; No specific ED diagnostic instrument; Germany ANBP 20 ANBP: SP 40%; AG 20%; Ph 15%; OCD 10%; PD 5% Small sample size; No control group BN 27 BN: SP 48%; phob 37%; OCD 18.5%; AG 14.8%; PD 11% BN (Hx AN) 23 BN (Hx AN): SP 56.5%; AG 17.4%; OCD 13%; Ph 8.7%; PD 4.3% Lilenfeld et al. ANR 26 DSM-III-R; SADS; ANR: OCD 62%; SP 31%; GAD 31%; Ph 27%; PTSD 7%; PD 4% No Ax for AG; Small AN sample; Unbalanced sample sizes (1998) BN 47 KSADS BN: PTSD 30%; OCD 21%; Ph 19%; SP15%; GAD 13%; PD 4% USA CW 44 Eating Disorder CW: Ph 7%; PTSD 7%; SP 5%; OCD 5%; GAD 2%; PD 0% Family History SP more frequent in ANR vs controls Interview. Milos et al. (2002) AN 84 DSM-IV ; SCID-I 29% OCD in ED; no diff between AN and BN; Comorbid OCD assoc with Self-report retrospective data on ED course; No specific ED Switzerland BN 153 longer hx of ED & earlier onset diagnostic instrument; No control group Piran et al. (1985) AN 14 DSM-III ; SADS; Lifetime: No Ax PTSD; No specific ED diagnostic instrument; No control Canada BN 33 DST; BDI; MMPI; AN: SP 53.8%; PD 42.8%; OCD 14%; AG 0%; Ph 0% group HSCL; HDS; HAS BN: PD 52.7%; SP 48.7%; AG 3%; Ph 3%; OCD 0% Speranza et al. AN 58 DSM-IV ; MINI ; Current and lifetime prev of OCD sig higher ED (15.7% and 19%) than in Small sample size of ED subtypes; AN inpatients vs BN (2001) BN 31 YBOCS general population (0% and 1.1%). outpatients may differ in severity of illness France CW 89 AN current (19%) and lifetime (22.4%) BN current (9.7%) and lifetime (12.9%) ANBP higher prev than ANR and BN Anxiety preceded ED in 65% of cases

Stiger & Zanko ANR 16 DSM-III-R ; EAT; 30% of ED women report CSA. CSA more prevalent among BP group Modified ED criteria; NC group may have been comprised of well (1990) ANBP 12 DSQ than ANR. Only 8% of NC reported trauma functioning individuals (hospital staff etc) and therefore not Canada BN 45 representative of the normal population; small sample size; No NC 24 specific ED diagnostic instrument PC 21 Thornton & Russell AN 35 DSM-III-R; CIDI ; AN: 37% OCD Inpatients only, therefore maybe more severe and not (1997) BN 33 Personality BN: 3% OCD representative of population; No specific ED diagnostic instrument; Australia Disorders Inventory 21% of ED reported OCD; OCD usually predated ED No control group 19% had premorbid OCPD Turnbull et al. AN 90 ICD-10; DSM-III-R ; No differences between AN, BN and EDNOS groups: Lifetime and The onset of PTSD in relation to ED not assessed; No specific ED (1997) BN 54 SCID current rates of PTSD were 18% and 11% respectively. Comorbid PTSD diagnostic instrument UK EDNOS 20 Childhood adversity was not associated with greater severity of illness. No control group and trauma interview Vize & Cooper AN 40 DSM-III-R ; Sexual abuse of any form was identified in 52.5% of AN group, 35% of Groups not equal in numbers; Results may underestimate sexual (1995) BN 60 interview based on BN group and 12% of control group abuse given participants were only given one opportunity to UK NC 40 EDE; SADS; PDQ- disclose abuse. DC 40 R; BDI; CECA

108

Table 4.3

Summary of research papers investigating AN and AD comorbidity Reference & Subjec N Diagnostic Summary of Results Limitations of Research Country t Criteria & Instruments Halmi et AN 62 DSM-III-R; DIS; AN:SP33.9%; OCD25.8%; AG14.5%; Ph12.9%;PD8.1% No specific ED diagnostic instrument; No Ax PTSD al.(1991) NC 62 RDC-FH NC:Ph14.5%; PD8.1%; OCD6.5%; AG3.2%; SP3.2% USA Higher lifetime AG in AN vs NC Halmi et al. ANR 147 DSM-IV ; SIAB ; AN-R: 68% lifetime OCD Modified criteria for AN; Sample may not be representative (family cases) (2003) ANBP 177 YBOCS AN-BP: 79.1% lifetime OCD USA OCD 116 Herpertz- AN 34 DSM-III-R; SP21%; Ph17.6%; PD11.8%; AG5.9%; OCD0% Standardised measures not used at each time period; Small sample size and Dahlmann et Adolesc Morgan Russell ; 12% of sample had obsessive compulsive behaviour varying ages of sample; No control group; Males and females included al. (1996) ents SIAB-P; CIDI; without meeting DSM-III criteria for OCD Germany BDI; ANIS; SCL- 90 Matsunaga et ANR 53 DSM-III-R; DSM- 40% met criteria for OCD after excluding OC symptoms Small sample size; No specific ED diagnostic instrument al. (1999) OCD 23 IV ; MAS for AD; typical of ED; Comorbid OCD assoc with more severe ED Japan SDS; SCID-II; symptoms SCID-P Pollice et al. AN 48 DSM-III-R; HRSD; Anxiety and obsessionality most severe in underweight Small sample; Mixed longitudinal and cross sectional design; No specific ED (1997) NC 18 BDI; HARS; STAI; state, symptoms reduced after short term and long term diagnostic instrument USA YBOCS; YBOCS- weight restoration. ED Rastam et al. AN 51 DSM-III-R ; SCID- Sig more AN subjects (31%) met criteria for lifetime OCD PTSD not assessed ; No specific ED diagnostic instrument (1995) NC 51 II compared with NC (8%). 20% of the AN group continued Sweden to meet OCD diagnosis at follow up compared with 6% of NC. Other than OCD there was No sig diff b/w AN and NC in AD prevalence

Table 4.4

Summary of research papers investigating BN and AD comorbidity Reference Subject N Diagnostic Criteria & Summary of Results Limitations of Research & Country Instruments Brewerton et BN 59 DSM-III-R; SCID SP17%; GAD12%; PD10%; PTSD 3%; OCD3% No specific ED diagnostic instrument al.(1995) No control group USA No Ax for AG Bulik et BN 114 DSM-III-R; SCID; SCID Lifetime prevalence: SP: 30%; Ph: 30%; PD: 10%; No specific ED diagnostic instrument; Sample not representative (exclusion al.(1996) II; SADS; HDRS; GAFS OCD: 4%; AG without PD: 2%; GAD: 2% criteria); No control group; Comorbid lifetime alcohol dependence in 48% of New sample; No Ax PTSD Zealand Bulik, Wade BN 20 DSM-III-R; SCID 75% reported GAD prior to ED Small sample size; No specific ED diagnostic instrument; No control group & Kendler Monozy pairs (2000) USA twins Dansky et BN 72 DSM-IV BN Current PTSD 21.4% Telephone screening ; No diagnostic instruments used for ED or AD al. (1997) BN Lifetime PTSD 36.9% USA CW 2929 CW Current PTSD 4.2% CW Lifetime PTSD 11.8% Sig difference b/w BN and CW Hudson et BN 51 DSM-III; DIS; ADDS ; BN: OCD33%; PD/AG14% No specific ED diagnostic instrument; No Ax for PTSD, SP and phobias ; Apart al. (1987) Hx BN 19 EDS for ED Hx BN: OCD32%; PD/AG26% from BN group, small sample; Males and females included USA Powers et BN 30 DSM-III-R ; SCID-P Ph: 20%; SP: 17%; AG: 13%; GAD: 10%; OCD: 3% No Ax for PTSD and PD; Small sample size; No specific ED diagnostic al.(1988) instrument USA Rorty et al. BN 40 DSM-III-R; Proposed No sig diff between BN group and NC in reported Sample may not be representative due to recruitment through advertisement; (1994) BN Hx 40 DSM-IV; SCID-P; sexual abuse – BN (28.8%) v NC (20%) Problem associated with retrospective study – reliance on recollection USA NC 40 SCID-II; EAT-SADS-L ; Non sexual abuse more prevalent in BN group vs EDQ ; SAEQ; AEIII; NC. PSY Schwalberg BN 20 DSM-III-R ; ADIS-R GAD: 55%; SP: 45%; OCD: 15%; Ph: 10%; PTSD: Small sample size; No control group; No specific ED diagnostic instrument et al.(1992) 10%; AG: 0%; PD: 0%; USA Welch & BN 100 DSM-III-R ; EDE; SCID Sexual abuse reports were similar in BN groups vs Retrospective design; Interviewers not blind to the case status of subjects Fairburn NC 100 control groups. (1994) PC 50 UK

109 Table 4.5

Summary of research papers investigating treatment response and outcome of individuals with comorbid ED and AD Reference & Subjects N Diagnostic Criteria Summary of Results Limitations of Research Country & Instruments Bulik et al. (1996) BN 11 DSM-III-R; SCID; Comorbid AD not associated with differences in No specific ED diagnostic instrument; Sample not representative (exclusion New Zealand 4 SADS-L; HRDS BN symptoms. However, an AD was associated criteria); No control group; Comorbid lifetime alcohol dependence in 48% of with a Hx AN and earlier age of onset of drug sample; No Ax PTSD and alcohol dependence Fichter & Quadflieg BN (Ax pre 19 DSM-III; DSM-III-R; Lifetime anxiety found in 36% & comorbidity Telephone interviews; Inpatients only therefore may be more severe; (2004) Germany and post Tx 6 DSM-IV; SIAB-S; was the strongest predictor of unfavourable Retrospective assessment – bias; No control group and 2yr, 6yr EDI; HSCL outcome and 12 yr F/U) Gleaves & Eberenz BN 46 DSM-III-R; self- 71% reporting a Hx of sexual abuse also had Insufficient assessment of sexual abuse; possible underestimate of sexual (1994) USA 4 reportquestionnaire indicators of poor prognosis abuse due to non disclosure; No control group based on DSED-R Goodwin & AN or BN 28 EDI; BORI for SP Individuals who did not enter treatment had Small sample size; The diagnostic criteria for ED and AD unclear; No specific Fitzgibbon (2002) significantly higher levels of social anxiety than ED or AD diagnostic instruments; No control group USA those who engaged with treatment Halmi et al. (1973) AN 42 Feighner et al More severe non ED OC behaviours assoc with The diagnostic criteria for AD unclear; No specific ED or AD diagnostic USA poor outcome. moderate to severe anxiety instruments; No control group symptoms were frequent in those who did and did not recover Halmi et al. (1991) AN (10 yr 62 DSM-III-R; DIS; Recovered patients had the same prevalence of No specific ED diagnostic instrument; No Ax PTSD USA F/U) 62 RDC-FH lifetime psychiatric dx as those with persisting NC ED symptoms Herpertz- AN 34 DSM-III-R; Morgan 41% at initial assessment met criteria for AD. At Standardised measures not used at each time period; Small sample size and Dahlmann et al. Outcome Russell; SIAB-P; 7 years follow up 38% met criteria for AD. varying; ages of sample; No control group; Males and females included (1996) study CIDI; BDI; ANIS; Patients with poor outcome show higher levels Germany Adolescents SCL-90 R of psychopathology. Pollice et al. (1997) AN 22 DSM-III-R; HRSD; Anxiety and obsessionality most severe in Small sample; Mixed longitudinal and cross sectional design; No specific ED USA (underweight BDI; HARS; STAI; underweight state, symptoms reduced after diagnostic instrument and at 26 YBOCS; YBOCS-ED short term and long term weight restoration. S/Trecovery) 18 AN (at L/Trecovery) NC Procopio et al. Bulimic 15 EDI; RSE; BDI; BAI The level of anxiety symptoms significantly No specific ED or AD diagnostic instruments; Sample not classified as per DSM- (2006) symptom 0 predicted the level of bulimic symptoms 2.5 IV BN criteria; No control group USA years later Two Ax over 2.5 years Rastam et al. AN 51 DSM-III-R; SCID-II; 20% of the An group continued to meet OCD No Ax PTSD; No specific ED diagnostic instrument (1995) NC 51 Morgan-Russell; diagnosis at follow up compared with 6% of NC. Sweden EAT Srinivasagam et al. Recovered 20 EDI; FMPS AN sample had higher perfectionism scores Small sample size; Inclusion of women in recovery at least 1 year, therefore (1995) AN 16 and greater symmetry and exactness scores unclear whether some had longer recovery times which may impact on results USA NC than controls Thompson Brenner Bulimic 14 DSM-IV; SWAP 200 Comorbidity was systematically related to Patients with and without DSM-IV BN included; Retrospective clinician reports; & Westen (2005) Symptoms 5 treatment length and outcome, such that the Different therapeutic approaches; Selective response rate – bias; No specific ED USA comorbid patients tended to have longer and and AD diagnostic instruments; No control group less successful treatments by clinician report. Thiel et al. (1988) AN 27 DSM-IV; YBOCS; At assessment 37% met criteria for OCD; no sig Significant drop out rate (19%); Small sample size; No specific ED diagnostic Germany BN 48 EDI; Hamburg OCI diff between ED diagnosis and OCD status; instruments; No control group (Ax pre Tx Dropout was not related to OCD status; Poorer and at 30 prognosis for BN and comorbid OCD; patients month F/U) with most improved ED showed highest reduction in obsessions and compulsions Toner, Garfinkel & AN (14 year 47 Feigner et al ; DSM Symptomatic and improved AN group were sig No Ax PTSD and GAD; Retrospective recall in assessment of anxiety and Garner (1988) F/U) III ; DIS higher in AD than CW. Symptomatic group had depression Canada sig higher incidence of AD prior to onset of AN CW 26 relative to asymptomatic group (83% vs 55% respectively) von Ranson et al. BN 31 DSM-III-R; SADS-L; YBOCS scores for BN and recovered BN OCD not diagnosed in BN group; Cross sectional design; Small sample size; No (1999) Recovered 29 YBOCS; HDRS; groups were similar and were significantly specific ED diagnostic instruments USA BN 19 HARS; EDI higher than NC group NC

Note. ED: Eating Disorder; AN: Anorexia Nervosa; ANR: Anorexia Nervosa Restricting type; ANBP: Anorexia Nervosa Binge Purge type; BN: Bulimia Nervosa; BNP: Bulimia Nervosa Purging type; BNNP: Bulimia Nervosa Non Purging type; EDNOS: Eating disorder not otherwise specified; AD: Anxiety Disorder; CW: Control Women; NC: Normal Controls; DC: Depressed Controls; PC: Psychiatric controls; SP: Social Phobia; GAD: Generalised Anxiety Disorder; OCD: Obsessive Compulsive Disorder; PTSD: Post Traumatic Stress Disorder; AG: Agoraphobia; Ph: phobia; PD: Panic Disorder; Hx: History of; Ax: Assessment; CSA: Child Sexual Assault; L/T: long term; S/T: short term; Tx: treatment; follow up: F/U

110

4.2 Eating Disorder Comorbidity with Anxiety Disorders 4.2.1 Obsessive Compulsive Disorder (OCD)

A relationship between AN, BN and OCD has been suggested by clinical observation and, increasingly, by empirical investigation. A number of studies have reported significant comorbidity between individuals with eating disorders and OCD (Hudson et al., 1983; Hudson et al., 1987; Laessle et al., 1989; Halmi et al., 1991; Fornari et al., 1992; Råstam et al., 1995; Thornton and Russell, 1997; Lilenfeld et al., 1998; Matsunaga et al., 1999; Godart et al., 2000; Iwasaki et al., 2000; Speranza et al., 2001; Milos et al., 2002; Godart et al., 2003; Kaye, Bulik, Thornton, Barbarich, Masters & the Price Foundation Collaborative Group, 2004) (see Table 4.2 for summary). Thornton and Russell (1997) showed that OCD usually predated the onset of an eating disorder, suggesting that OCD may be a risk factor for developing an eating disorder. Milos et al. (2002) reported that individuals with OCD comorbidity have a longer history of an eating disorder and are likely to have developed the eating disorder at an earlier age.

AN has a considerable overlap with obsessive–compulsive disorder (OCD) and this may reflect common neurobiological, genetic, or psychological elements. Early descriptive studies suggested that 50% to 100% of patients with AN showed obsessional or compulsive features. More recent studies have found a lower but still significant level of obsessions and compulsions among patients with AN (Halmi et al., 1991; Råstam et al., 1995; Pollice et al., 1997; Matsunaga et al., 1999; Halmi et al., 2003) (see Table 4.3 for a summary of AN and OCD comorbidity findings). Fornari et al. (1992) and Speranza et al. (2001) found a significant difference in the OCD lifetime prevalence between purging AN and restrictive AN, where purging AN patients exhibited higher prevalence of OCD than the restricting AN patients. Godart et al. (2003) found significantly higher lifetime rates of OCD in women with AN compared with controls (24.3% for ANR and 23.6% for ANBP), however this difference was not found in their BN sample. A similar pattern of results was also reported by Bulik, Sulivan, Fear & Joyce (1997).

111 Arguably, the pattern of obsessions and compulsions most commonly present in AN is different from that found in OCD. Therefore, it is important to distinguish those behaviours that are not directly related to food, weight and shape. The lack of clear evidence regarding these mechanisms means that it is difficult to draw clear causal conclusions. However at a functional level, an important issue is that compulsive behaviours reduce anxiety levels. It can be hypothesized that the same function is served in the eating disorders, given that restriction and bulimic behaviours act to regulate affect (Lockwood et al., 2004). This however, does not explain the difference between the ego- dystonic nature of OCD and the ego-syntonic nature of eating disorders. This important distinction needs to be addressed.

Holden (1990) noted that the obsessions and compulsions of OCD patients are ego- dystonic whereas the preoccupations and rituals of AN patients are largely ego-syntonic. Mazure et al. (1994) suggested that phobic thoughts of food and weight repeatedly enter the mind of AN patients, but not necessarily against their will. Although these thoughts or preoccupations may be distressing, they are not regarded as senseless. This is in contrast to typical obsessions and compulsions unrelated to eating, which also may occur in AN patients (Bastiani et al., 1996).

One of the most common concerns raised in the current debate is whether people with AN display ‘typical’ or ‘true’ OCD symptoms as seen in patients diagnosed with primary OCD, or whether their symptoms are secondary to weight loss and malnutrition, or a combination of these. These concerns arise due to evidence that in conditions of semi-starvation, psychologically ‘normal’ adults can develop a range of obsessional features. Keys et al. (1950) illustrated how obsessions and compulsions, particularly those concerned with the preparation and consumption of food, develop under conditions of food restriction. This study also provides evidence for the possibility that the obsessive and compulsive symptoms observed in people with AN may at least partly be the result of their malnourished state, and not evidence of a true OCD. Some evidence for this comes from the discrepancy between inpatient and outpatient AN OCD rates, whereby

112 lower rates have been reported in the latter group (Serpell Livingstone, Neiderman & Lask, 2002).

Studies that have compared rates of OCD in AN and BN have usually found higher comorbidity in AN, for example, Blinder, Cumella & Sanathara (2006) found that their ANR and ANBP sample was twice as likely to have OCD compared with BN and EDNOS patients. However, two Japanese studies found a significant number of BN participants met criteria for OCD (Matsunaga et al., 1999; Iwasaki et al., 2000), even after excluding the OCD-like symptoms typical of eating disorders. Matsunaga et al. (1999) also reported that BN subjects with concurrent OCD were more likely than subjects without OCD to have more severe mood and core eating disorder psychopathology. Among BN subjects with concurrent OCD, symptoms related to symmetry and order were most frequently identified, followed by contamination and aggressive obsessions, and checking and cleaning/washing compulsions (Matsunaga et al., 1999).

4.2.2 Social Phobia

Whilst the link between eating problems and obsessive-compulsive pathology has been clearly established (O’Brien & Vincent, 2003), other manifestations of fear, such as social phobia, agoraphobia and panic, have received less research attention (Hinrichson et al., 2004).

A number of studies show that social phobia is common in patients with eating disorders (Piran et al., 1985; Laessle et al., 1987; Laessle et al., 1989; Halmi et al., 1991; Schwalberg et al., 1992; Garfinkel, Lin, Goering, Spegg, Goldbloom, Kennedy, Kaplan & Woodside, 1995; Brewerton et al., 1995; Lilenfeld et al., 1998; Powers et al., 1998; Godart et al., 2000; Iwasaki et al., 2000; Godart et al., 2003; Hinrichson et al., 2003; Kaye, Bulik, Thornton, Barbarich, Masters & the Price Foundation Collaborative Group, 2004) (see Table 4.2, 4.3 and 4.4 for a summary of findings). Several studies suggest that social anxiety may be a more common co-morbid condition with eating disorders than

113 OCD, and some researchers have speculated that social anxiety may play a role in the etiology of eating disorders (Black Becker et al., 2004).

The prevalence rate of social phobia and eating disorders has differed across studies. Halmi et al. (1991) reported significantly higher lifetime rates of social phobia in their eating disorder group (33.9%) compared with controls (3.2%). Furthermore, Godart et al. (2003) found similarly high rates of social phobia in their eating disorder sample. In AN, prevalence rates of between 16% (Kaye, Bulik, Thornton, Barbarich, Masters & the Price Foundation Collaborative Group, 2004) and 88.2% (Hinrichson et al., 2003) have been reported and between 17% (Powers et al., 1988; Brewerton et al., 1995) and 67.8% (Hinrichson et al., 2003) in BN. Lilenfeld, et al. (1998) reported that social phobia is significantly more frequent in AN than in controls. However Bulik, Sulivan, Fear & Joyce (1997) did not find a significant difference between their AN sample and controls. Two controlled follow-up studies of AN found differing results, one finding a significantly higher rate of social phobia in AN than normal controls (Halmi et al., 1991), whilst the second found no difference (Råstam et al., 1995).

Hinrichson et al. (2003) demonstrated that levels of social phobia in female patients with AN and BN are significantly elevated compared to control women, and that social phobia is associated with higher levels of eating psychopathology in bulimic individuals.

Garfinkel, Lin, Goering, Spegg, Goldbloom, Kennedy, Kaplan & Woodside (1995) observed significantly higher prevalence rates of social phobia amongst women with clinical and subthreshold BN compared with controls. Bulik, Sulivan, Fear & Joyce (1997) supported this finding with a significantly higher rate of social phobia reported amongst their BN sample (30.2%) compared with normal controls (6.1%). Furthermore, Godart et al. (2003) found that of the anxiety disorders, social phobia was the most prevalent amongst their BN sample.

It must be noted that prevalence rates for social phobia amongst the eating disorders may be inconsistent due to the observation that many women with eating pathology avoid social situations and consequently the lower rates of social anxiety may reflect a lack of

114 social interactions as opposed to a lack of social anxiety per se (Bulik, Sulivan, Fear & Joyce, 1997).

4.2.3 Agoraphobia

Studies investigating ED and agoraphobia have found varying results. Godart et al. (2002) report that comorbidity rates for agoraphobia vary from 0% to 34.5% and findings in this area are limited and contradictory. In AN, lifetime prevalence of agoraphobia ranges from 0% (Laessle et al., 1989) to 3% (Godart et al., 2000) in restricting subgroups, whereas a study of binge/purge AN found a 20% rate (Laessle et al., 1989). A later study by Godart et al. (2003), reported significantly higher lifetime rates of agoraphobia in women with AN (19.8% for ANR and 27.3% for ANBP) compared with matched controls (7.3%). In follow up studies of AN, significantly higher lifetime prevalence rates of agoraphobia have been reported in the AN group compared to controls (Halmi et al., 1991), however a study by Råstam et al. (1995) reported no difference.

The lifetime prevalence of agoraphobia in BN varies from 0% (Schwalberg et al., 1992) to 17.4% (Laessle et al, 1989). In the community, lifetime prevalence of agoraphobia in BN varies from 27% (Bushnell et al., 1994) to 34.5% (Garfinkel, Lin, Goering, Spegg, Goldbloom, Kennedy, Kaplan & Woodside, 1995). Furthermore, Garfinkel, Lin, Goering, Spegg, Goldbloom, Kennedy, Kaplan & Woodside (1995) and Godart et al. (2003), found significantly higher lifetime rates of agoraphobia in their BN samples compared to their control groups (7.5% and 17.4%).

4.2.4 Panic Disorder

The findings of panic disorder comorbidity amongst eating disorder samples is also varied with one study reporting between 9 - 11% prevalence (Kaye, Bulik, Thornton, Barbarich, Masters & the Price Foundation Collaborative Group, 2004) and another finding between 42 – 52% prevalence (Piran et al., 1985). Bulimic samples have been varied, ranging from 0% (Schwalberg et al., 1992) to 39% (Hudson et al., 1983). Several studies have found the lifetime prevalence rates of panic disorder ranges from 4% (Lilenfeld et al., 1998) to 7% (Godart et al., 2000) in ANR and is estimated to be around

115 15% in ANBP (Laessle et al., 1989). Two AN controlled outcome studies have estimated that the lifetime prevalence of panic disorder is 8.1%, and 6 month prevalence between 2% and 11.8% (Halmi et al., 1991; Råstam et al., 1995). Walters & Kendler (1995) reported that in a community study, individuals with “possible anorexia” have the risk of panic disorder increased by 3.4.

4.2.5 Specific Phobia

The reported lifetime prevalence of specific phobias amongst individuals with eating disorders varies considerably, ranging from 0% (Piran et al., 1985) to 34% (Godart et al,. 2000) in AN and from 10% (Schwalberg et al.,1992) to 46% (Laessle et al., 1987) in BN. Bulik at al. (1996) reported that 30% of their BN sample met a lifetime diagnosis of specific phobia. Lilenfeld et al. (1998) found that whilst 19% of their BN sample met criteria for specific phobia, this was not significantly different to their controls (7%). Conversely, Lilenfeld et al. (1998) found a significant difference between prevalence rates between their AN sample (27%) and controls. Furthermore, a community study reported that the risk for phobia is increased by 2 to 4 in AN subjects (Kendler et al., 1991; Walters & Kendler, 1995) and by 2.37 in BN subjects (Kendler et al., 1991).

In terms of follow up studies, Halmi et al. (1991) found no significant difference in lifetime prevalence of specific phobia in women with a history of AN compared to controls. Garfinkel, Lin, Goering, Spegg, Goldbloom, Kennedy, Kaplan & Woodside (1995) found significantly higher lifetime rates of specific phobia in women with clinical and subthreshold BN (40 – 40.9% respectively) compared to controls (11.4%).

4.2.6 Post Traumatic Stress Disorder (PTSD)

There has been considerable interest in the relationship between eating disorders and trauma (Vanderlinden & Vandereycken, 1997). Although a history of trauma, particularly childhood sexual abuse, is considered to be a non-specific risk factor for the development of an eating disorder, surprisingly few studies have examined comorbidity of PTSD with eating disorders (Black Becker et al., 2004). A study conducted by Godart et al. (2000) indicated that one of their objectives was to assess the comorbidity of all anxiety

116 disorders amongst their eating disorder sample. However, they did not include PTSD in the assessment. Studies investigating PTSD comorbidity among eating disordered individuals have reported rates ranging from 11% to 52% (Turnbull et al., 1997; Gleaves et al., 1998). Faravelli et al. (2004) found that women who had been sexually assaulted were significantly more likely to report an eating disorder compared with women who had not been assaulted. This is supported by the literature reporting the most frequently reported psychiatric consequences of sexual abuse in women are PTSD, mood disorders, substance abuse disorders, eating disorders and sexual disorders (Dahl, 1989; Putnam & Trickett, 1997; Thompson et al., 2003). Striegel-Moore, Garvin, Dohm & Rosenheck (1999) reported that 25% of their eating disorder sample met criteria for PTSD. Black Becker et al. (2004) also found support for a link between PTSD and eating disorders in their clinical population.

A number of studies have demonstrated a positive association between child sexual assault (CSA) and clinical eating disorders (Root & Fallon, 1989; Steiger & Zanko, 1990; Welch & Fairburn, 1994; Vize & Cooper, 1995; Fallon & Wonderlich, 1997; Johnson et al., 2002). Links have also been proposed between a history of child sexual assault and specific eating disorder symptoms, specifically, bingeing, vomiting and negative body image (Waller, 1992; Waller, Hamilton, Rose, Sumra & Baldwin, 1993). It has also been suggested that abuse may act as a moderator between a range of causal factors and eating disorder pathology (van Gerko, Hughes, Hamill & Waller, 2005).

A meta-analysis by Smolak & Murnen (2002) found a relationship between CSA and eating disorders, such that CSA is associated with an increased likelihood of eating disorder symptomatology. Furthermore, Jacobi, Hayward, de Zwaan, Kraemer & Agras, (2004) reported that there was a high likelihood that sexual abuse preceded the eating disorder. However, there have also been a number of studies that have not found a relationship between CSA and eating disorders (Pribor & Dinwiddie, 1992; Rorty et al., 1994). Furthermore, the prevalence of childhood sexual abuse varies considerably across the studies, due to differences in definitions, methodologies and measures used (Welch & Fairburn, 1994).

117 When considering the eating disorder subtypes, Dansky et al. (1997) reported current and lifetime rates of PTSD in women with BN to be high and Mantero and Crippa (2002) reported that PTSD subjects were considered to be at 3.36 times the risk of developing BN. Tozzi et al. (2003) report that several studies have shown that psychological stress or stressful life events can trigger the onset of AN. However, the nature and identity of these stressors remain poorly defined (Beumont et al., 1978; Pyle, Mitchell, & Eckert, 1981; Strober, 1984; Casper & Jabine, 1986). Kaye, Bulik, Thornton, Barbarich, Masters & the Price Foundation Collaborative Group (2004) observed that PTSD was approximately three times more frequent in individuals with BN as opposed to those with AN. Blinder et al. (2006) reported that ANBP patients were twice as likely to have PSTD compared with ANR, BN and EDNOS. When considering child sexual abuse, the prevalence of this type of trauma is consistently low in ANR, but high in women with binge/purge symptomatology (Steiger & Zanko, 1990; Waller, Halek & Crisp, 1993). One reason for this observation is that bingeing and purging behaviours may assist with regulating disturbing cognitions and emotions that may arise from a history of abuse (Root & Fallon, 1989). It is interesting to note that the literature does not appear to implicate restrictive and non-purgative compensatory behaviour such as exercise, to a history of abuse (van Gerko et al., 2005).

4.2.7 Generalised Anxiety Disorder (GAD)

Considerably less research has considered the relationship between eating disorders and GAD, and there are wide variations in the estimated prevalence of GAD across eating disorder studies (Godart, Flament, Perereau, Jeammet, 2002). Lilenfeld et al. (1998) and Godart et al. (2000) estimated the lifetime prevalence of GAD in AN to be 31% and 24% respectively. Studies reviewing the relationship between GAD and BN have found that lifetime prevalence varies between 10% (Powers et al., 1988) and 55% (Schwalberg et al., 1992). Kaye, Bulik, Thornton, Barbarich, Masters & the Price Foundation Collaborative Group (2004) identified GAD in their AN and BN sample of 13% and 7% respectively, which is significantly lower than the 45.6% and 31.4% respectively, reported by Godart et al. (2003). Furthermore, Lilenfeld et al. (1998) found that 13% of

118 their BN patients had a lifetime prevalence of GAD, which was not significantly different to the prevalence amongst controls (2%). Iwasaki et al. (2000) reported that 13% of their AN and BN subjects met the criteria for GAD, and interestingly, their findings indicate that GAD was more prevalent amongst the purging subtypes of both AN and BN subjects, although this difference did not reach significance. Garfinkel, Lin, Goering, Spegg, Goldbloom, Kennedy, Kaplan & Woodside (1995) found that the lifetime rate of GAD amongst a community sample of women with BN (10.9%) was significantly higher than that of their comparison sample (2.5%).

Bulik, Wade & Kendler (2000) reported that the maternal perception of greater childhood anxiety was supported by the twin self report, with the affected twin being at a greater risk for lifetime GAD. They suggested that because the age of onset for GAD was reported to be prior to or concurrent with the onset of BN in 75% of the cases, it is possible that the anxiety may be a predisposing factor rather than a sequelae of BN. These results support a growing body of literature that has reported elevated rates of premorbid anxiety disorders in women with BN (Deep et al., 1995; Bulik, Sulivan, Fear & Joyce, 1997).

4.3 Perfectionism and Obsessive Compulsive Personality Disorder (OCPD)

As discussed above, the research into OCD and eating disorders reveals a significant relationship, and several researchers have reported that non food related obsessions and compulsions, including significantly more cleanliness, orderliness, perfectionism, rigidity, miserliness, scrupulosity have been identified in patients with eating disorders (Solyom, 1982; Kasvikis et al., 1986; Rothenberg, 1986; Brumberg, 1988; Bastiani, Rao, Weltzin & Kaye, 1995; Halmi, Sunday, Strober, Kaplan, Woodside, Fichter, Treasure, Berrettini & Kaye 2000; Lilenfeld, Stein, Bulik, Strober, Plotnicov, Pollice, Rao, Merikangas, Nagy & Kaye, 2000; Bulik, Tozzi, Anderson, Mazzeo, Aggen & Sullivan, 2003; Sutandar-Pinnock, Blake, Carter, Olmsted & Kaplan, 2003). Furthermore, perfectionism has been identified as a risk factor for the development of an eating disorder, as supported by Fairburn, Cooper, Doll & Welch (1999) who found that

119 perfectionistic tendencies tended to predate the onset of an eating disorder. There is also evidence that perfectionistic traits may persist following recovery from an eating disorder (Bastiani et al., 1995; Srinivasagam, Kaye, Plotnicov, Greeno, Weltzin & Radhika, 1995; Kaye, Greeno, Moss, Fernstrom, Fernstrom, Lilenfeld, Weltzin & Mann, 1998; Sutandar- Pinnock et al., 2003). This has fuelled suggestions that distinct personality traits may be important in the development and maintenance of an eating disorder.

The literature also suggests that perfectionism and dichotomous thinking may mediate the relationship between extreme concerns about shape and weight and rigid and intense dieting (Fairburn, 1997). Furthermore, Fairburn (1997) suggests that perfectionism and dichotomous thinking may mediate the relationship between intense, rigid dieting and binge eating. This has led to significant interest in investigating the prevalence of personality disorders in the eating disorders and subsequently, there have been a number of structured investigations into Axis II diagnosis amongst eating disorder patients.

The prevalence rates of OCPD amongst individuals with eating disorders has varied significantly amongst the studies, ranging from 3% - 60% (Piran, Lerner, Garfinkel, Kennedy & Brouilette, 1988; Gartner et al., 1989; Wonderlich, Swift, Slotnick & Goodman, 1990; Herzog, Keller, Lavori, Kenny & Sacks, 1992; Rossiter et al., 1993; Thornton & Russell, 1997; Lilenfeld et al., 1998).

Gartner et al. (1989) used the PDE to assess inpatient ED subjects and reported that 25.7% met diagnostic criteria for OCPD. None of the BN sample met criteria for OCPD leading to the speculation that this personality feature is more consistent with individuals with AN. However, Rossiter et al. (1993) reported that 10% of their BN sample met criteria for OCPD. Thornton and Russell (1997) reported that 19% met criteria for comorbid OCPD, and this was almost exclusively found in the AN sample. Lilenfeld et al. (1998) reported that AN probands had higher rates of OCPD lending support to reports of perfectionism and inflexibility among individuals with restricting type AN. Lilenfeld et al. (1998) also found that 31% of AN probands met criteria for OCPD and OCD, leading to the suggestion that individuals with OCPD may be more vulnerable to the development of OCD than those without this personality pattern.

120 4.4 Temporal Relationship Between Eating Disorders and Anxiety Disorders

The research to date clearly indicates that individuals with eating disorders frequently exhibit anxiety symptoms. Furthermore, there is the suggestion that eating pathology may occur in response to a pre-existing anxiety disorder (Johnson & Larson, 1982). Although the specific nature of the relationship between eating disorders and anxiety is still unclear, some researchers have suggested that anxiety disorders may contribute to the onset and maintenance of eating disorders (Fornari et al., 1992). Godart et al. (2003) implicate three possible explanations for the observed comorbidity between eating and anxiety pathology. Firstly, that anxiety may be a risk factor for the development of an eating disorder. Secondly, that anxiety may be secondary to eating pathology and thirdly that both disorders may share common vulnerability factors.

This area has been notoriously difficult to investigate due to the inherent problems associated with prospective studies of at risk populations (Serpell et al., 2002). A number of studies have considered the temporal relationship between eating disorders and anxiety disorders (Toner et al., 1988; Schwalberg et al., 1992; Brewerton et al., 1995; Bulik et al., 1996; Thornton & Russell, 1997; Godart et al., 2000; Milos et al. (2002); Godart et al., 2003 and Sanci, Coffey, Olsson, Reid, Carin & Patton, 2008). Of these studies, all but one (Sanci et al., 2008) were retrospective. The retrospective research has focused reporting the temporal relationship between the onset of both disorders and drawing inferences about etiological links (Pallister & Waller, 2008). The methodological limitations associated with assessing the age of onset of psychiatric diagnoses by retrospective recall have been raised by a number of authors (Toner et al., 1988; Godart et al., 2000; Godart et al., 2003). The limitations associated with retrospective studies include memorization or reconstruction biases that may affect the ability for someone to recognise the symptoms of a disorder and recall the time of onset and difficulties associated with interpreting the appearance chronology of anxiety and eating pathology (Godart et al., 2000). Furthermore, there are often inconsistencies in the determination of the age of onset, which sometimes refers to the age when the first symptom occurred and sometimes to the age when all criteria for the disorder were met (Wittchen & Essau,

121 1993). Certainly prospective studies have the benefit of fewer potential sources of bias and confounding than retrospective studies, however there are few available prospective studies investigating the comorbidity between anxiety and the onset of eating pathology. Whilst retrospective data must be interpreted with caution, the results may nevertheless provide extremely useful information about the vulnerability factors that may be associated with the development of an eating disorder.

Notwithstanding the limitations associated with researching the temporal pattern of onset between eating and anxiety pathology, some research has interestingly suggested that there may be a relationship between early onset (childhood) anxiety disorders and the later development of an eating disorder. Whilst this pattern of onset may simply reflect the natural course of the two disorders (Silberg & Bulik, 2005), some researchers have speculated that early onset anxiety disorders may represent a potential genetically mediated pathway toward the development of an eating disorder (Kaye, Bulik, Thornton, Barbarich, Masters & the Price Foundation Collaborative Group, 2004), or, at the very least suggests that early onset anxiety disorders may in some way predispose individuals to the development of an eating disorder (Bulik et al., 1996).

Whilst clinical studies investigating the comorbidity between eating disorders and anxiety may identify associations that do not exist in the community because of differential referral (Berkson, 1946), epidemiological studies provide estimates of comorbidity that are not confounded by treatment seeking (Silberg & Bulik, 2005). Walters & Kendler (1995) reported from a retrospective population-based sample of over 2000 twins, that the presence of AN significantly increased the risk of suffering from a comorbid anxiety disorder, in particular, GAD, phobias and panic disorder. Similar findings have been reported in a BN sample, suggesting that early onset anxiety disorders may represent an etiological risk factor for BN (Schwalberg et al., 1992; Bulik et al., 1996; Kaye, Bulik, Thornton, Barbarich, Masters & the Price Foundation Collaborative Group, 2004). Multivariate twin models exploring the structure of the genetic relationship between anxiety disorders, mood disorders and substance abuse, have identified shared genetic factors among BN, phobias and panic disorder (Kendler, Walters, Neale, Kessler, Heath

122 & Eaves, 1995). Furthermore, Silberg & Bulik (2005) reported results from a large juvenile twin study, indicating that a common genetic factor influenced vulnerability towards anxiety, depression and eating disorder pathology.

A number of research papers considering the temporal relationship between eating disorders and anxiety have shown that, in most cases, the onset of anxiety disorders precedes the onset of an eating disorder (Bulik, 2003). Godart et al. (2003) reported that between 41.8 and 53.3% of co-morbid cases had an anxiety disorder preceding the onset of the eating disorder. In particular Godart et al. (2003) reported that social phobia commonly occurred first. Kaye, Bulik, Thornton, Barbarich, Masters & the Price Foundation Collaborative Group (2004) found that a number of anxiety disorders (OCD, social phobia, specific phobia and GAD) typically began in childhood, their onset typically preceding that of the eating disorder. Bulik, Wade & Kendler (2000) set out to address this further by investigating monozygotic twins discordant for BN. They found that mothers retrospectively recalled the affected twin as having been more shy and fearful as children and this was supported by the twin self report. Subsequently, they hypothesised that this could suggest that early anxiety could play a role in the development of BN. They also reported markedly higher obsessive-compulsive scores in affected twins, which supports the literature suggesting a shared diathesis between BN and obsessive-compulsive disorder.

Similar findings have been reported in retrospective studies in BN populations. Schwalberg et al. (1992) found that in 59% of women with a lifetime diagnosis of an anxiety disorder, the anxiety preceded the eating disorder. Brewerton et al. (1995) found that 71% of their sample reported the onset of anxiety prior to the development of BN. Godart et al. (2000) reported that 88% of their BN sample had at least one anxiety disorder prior to the onset of the eating disorder. These results support a growing body of literature that has reported elevated rates of premorbid anxiety disorders in women with BN (Deep et al., 1995; Bulik, Sulivan, Fear & Joyce, 1997).

123 In AN, the findings are similar, with one retrospective study reporting that 79% of their female sample had the onset of anxiety before the onset of AN (Deep et al., 1995). Godart et al. (2000) reported that 75% of their AN sample had at least one anxiety disorder prior to the onset of the eating disorder.

Studies investigating the onset of specific comorbid anxiety disorders with eating pathology have reported a similar pattern. In two small studies, Brewerton et al. (1993) reported that social phobia preceded the eating disorder in all of their BN participants, whilst Braun, Sunday & Halmi (1994) found that the anxiety disorder predated the eating disorder in 79% of their AN and BN participants. In another small sample investigating the prevalence of OCD and AN, Kasvikis et al. (1986) reported that 40% reported the onset of the OCD to predate the onset of the AN. In a large casenote study investigating the prevalence of eating pathology amongst OCD patients, patients with comorbid eating and anxiety pathology reported the onset of both disorders at the same time and the age of onset was lower than for those without comorbid AN (Fahy, Osacar & Marks, 1993).

A prospective Australian study investigating the link between child sexual assault before the age of 16 years and later onset of bulimia and anorexia nervosa symptoms in females found that childhood sexual abuse seems to be a risk factor for the development of bulimic syndromes, not necessarily mediated by psychiatric morbidity or severe dieting (Sanci, Coffey, Olsson, Reid, Carin & Patton, 2008).

It is important to note that anxiety disorders do not always precede the onset of eating pathology. Godart et al. (2003) found that OCD, GAD and panic disorder typically occurred simultaneously or following the onset of the eating disorder. Kaye, Bulik, Thornton, Barbarich, Masters & the Price Foundation Collaborative Group (2004) also reported from their sample that PTSD, panic disorder and agoraphobia tended to have an onset simultaneous or later than the eating disorder. These findings lead to speculation that eating disorders may lead to or exacerbate anxiety symptomatology (Pallister & Waller, 2008). Once again, this gives rise to the possibility that anxiety symptomatology may be secondary to eating disorder pathology, such as malnutrition, rather than a

124 distinct anxiety disorder diagnosis. This hypothesis was demonstrated in the Keys et al. (1950) study and has since been discussed by several authors since (Pollice et al., 1997; Serpell et al., 2002). Consequently, research in this area must be careful to clearly delineate between the anxiety symptoms related to eating pathology and those that represent a distinct anxiety disorder.

Understanding the relationship between eating disorders and anxiety pathology becomes more complicated when one considers the possibility that both may result from common vulnerability factors (Wonderlich & Mitchell, 1997; Godart et al., 2003). This theory proposes that early negative experiences may give rise to risk factors for the development of both disorders. Pallister & Waller (2008) describe this model in detail, suggesting that underlying vulnerability cognitions lead to harm avoidance cognitions which result in the implementation of safety behaviours comprising disordered eating and anxiety behaviours.

The suggestion that childhood anxiety may play an etiological role in the development of eating disorders has stemmed from the possibility that excessive fear about certain events or situations may lead into excessive concerns about eating, shape and weight and subsequently lead to the development of eating pathology (Pallister & Waller, 2008). It is clear that further research needs to be conducted into the interaction between anxiety and specific prodromal symptoms of eating disorders (Jacobi et al., 2004).

4.5 Eating Disorders amongst Anxiety Disorder Populations In order to clearly understand the pattern of comorbidity between eating and anxiety disorders, it is important to not only consider the prevalence of anxiety amongst individuals with eating pathology, but also the prevalence of eating disorders amongst people with anxiety disorders (Pallister & Waller, 2008). However, whilst most studies have focused on the prevalence of anxiety disorders in eating disorder populations, significantly less research has examined the prevalence of eating disorders among anxiety patients (Bulik, 1995). As a result, there is a general lack of information as to frequency of eating disorder pathology among patients presenting to specialty anxiety clinics, and it

125 is unclear whether eating disorders are more commonly associated with some anxiety disorders as compared to others (Black Becker et al., 2004). This raises the possibility that eating disorders may go unidentified and untreated, particularly given that eating disorder assessment and treatment is often viewed as a clinical specialty and subsequently many clinicians in anxiety clinics may not be adept at detecting eating disorder symptomatology (Black Becker et al., 2004). The absence of formal eating disorder assessment in anxiety treatment settings is also indicated by the lack of eating disorder assessment items in assessment instruments for the anxiety disorders. The best example of this is the ADIS-IV, arguably one of the best structured interviews available for the assessment of anxiety disorders, which does not include an assessment of eating pathology in the sections that screen for all other Axis I disorders.

The only study the author found which investigates eating disorder rates amongst women presenting to an anxiety clinic is that by Black Becker et al. (2004). They found that 12% of 257 women presenting to an anxiety clinic met criteria for a possible eating disorder. Furthermore, although the rates of probable eating disorders across the anxiety diagnoses did not differ significantly, social phobia had unique variance in the regression analysis (Black Becker et al., 2004). Interestingly, despite the research implicating a link between eating disorders and OCD, Black Becker et al. (2004) did not find that OCD contributed to the unique variance in their regression analysis. They suggested that apparent relationships between OCD and eating pathology may be due to other comorbid anxiety disorders. Other studies have investigated eating disorder rates amongst specific anxiety disorders (Brewerton et al., 1993; Lipschitz et al., 1999) or amongst individuals with sexual abuse trauma (Pribor and Dinwiddie, 1992; Faravelli et al., 2004) and war veterans (Striegel-Moore et al., 1999).

Of the studies that have investigated eating disorders amongst anxiety patients, they have generally examined rates of eating disorders concurrent with one particular anxiety disorder, usually OCD (Bulik, 1995). Among female OCD patients, eating disorder comorbidity estimates have ranged from 11 to 42% depending on the type of eating disorder and the method of assessment (Bulik, 1995). Fahy et al. (1993) found that 11%

126 of their OCD patients also had co-morbid AN. Brewerton et al. (1993) reported that 20% of women with social phobia met the criteria for an eating disorder. Lipschitz et al. (1999) reported that 25% of adolescent mixed-gender PTSD inpatients met the criteria for an eating disorder. Wittchen, Stein & Kessler (1999) investigated rates of social phobia and related comorbidities amongst a large mixed gender sample. They reported significantly higher rates of eating disorders (generally EDNOS) amongst individuals with social phobia (15%) compared to those without (2.6%).

Black Becker et al. (2004) indicates that although the number of studies is limited, estimates of the prevalence of eating disorders amongst anxiety disorder patients is high. Reported rates are markedly higher than the estimated prevalence of AN or BN among young females.

4.6 Implications for Treatment and Outcome A further point of interest in the area of eating disorder and anxiety comorbidity is whether a comorbid anxiety disorder has implications for the treatment and outcome of an eating disorder. A number of authors have discussed the importance of considering comorbidity in the formulation and treatment of eating pathology (Braun et al., 1994; Serpell et al., 2002; O’Brien & Vincent, 2003). Unfortunately, despite the increasing body of literature discussing the prevalence of anxiety in the eating disorders, few studies to date have investigated the impact of comorbid anxiety on treatment.

It is clear that generally individuals with comorbid conditions often display more severe symptoms and subsequently may be at greater risk for a poorer treatment outcome. Similarly, psychiatric comorbidity may increase eating disorder severity, chronicity and treatment resistance (Blinder, Chaitlin & Goldstein, 1988; Bulik, 2002). Eating disorder patients with psychiatric comorbidity may require specialised treatment protocols (Herzog, Field, Keler, West, Robbins, Staley & Colditz, 1996; Saccomani, Savoini, Cirrincione, Vercellino & Ravera, 1998; Woolsey, 2002). For example, in the case of comorbid obsessive compulsive disorder, they may require an exposure and response prevention component (Boutelle, 1998). Research findings however, are inconsistent.

127 Some studies have suggested that co-morbid anxiety may be one indicator for poor outcome (Halmi et al., 1973; Gleaves and Eberenz., 1994; Weltzin et al., 1995; Herpertz Dahlmann et al., 1996; von Ranson et al., 1999; Goodwin and Fitzgibbon., 2002; Fichter and Quadfleig., 2004; Thompson-Brenner and Westen, 2005; Procopio et al., 2006), however other studies have not found this to be the case (Halmi et al., 1991; Bulik et al., 1996; Thiel et al., 1998) (A summary of these studies and their findings can be seen in Table 4.5).

Torem and Curdue (1988) presented a series of case reports of 4 women with eating disorder symptomatology and a previously undiagnosed PTSD diagnosis. They reported that following treatment focusing on the resolution of the trauma symptoms, each of the women showed an overall improvement in their general wellbeing as well as their eating disorder symptoms. Furthermore, Torem and Curdue (1988) noted that for each of their patients, vomiting was regarded as important not only for regaining a sense of self- control, but also as a means of cleansing themselves.

4.7 Methodological Limitations in the Research Despite the significant number of research papers investigating the comorbidity between eating disorders and anxiety disorders, many of these studies suffer from general methodological limitations (Mitchell et al., 1991; Schwalberg et al., 1992, Godart et al., 2002; Godart, Berthoz, Perereau & Jeammet, 2006; Godart, Berthoz, Rein, Perereau, Lang, Venisse, Halfon, Bizouard, Loas, Corcos, Jeammet, Flament & Curt, 2006; Micali and Heyman, 2006). These limitations have been summarised in Tables 4.1 – 4.5. The variability between estimated comorbidity of anxiety disorders and eating disorders amongst the available research is a significant limitation when considering the prevalence of co-morbid disorders. A number of factors may contribute to this variability and are discussed below.

4.7.1 Sample Sources and Selection Research into ED and AD often include samples from various sources including inpatients, outpatients and community samples. Unfortunately this may bias the sample,

128 as one could expect that an inpatient sample may be more likely to have multiple diagnoses and may not be representative of all patients with the disorder (Godart et al., 2002). Furthermore, some researchers have used exclusion criteria that may limit the frequency of comorbid AD. Keck et al. (1990) excluded all subjects with comorbid substance abuse, despite patients with AD often reporting comorbid substance abuse (Bulik et al., 1996). Several studies excluded subjects taking psychoactive medication (Keck et al., 1990; Deep et al., 1995; Bulik et al., 1996; Bulik, Sulivan, Fear & Joyce, 1997) which may have diminished the rates of AD identified.

4.7.2 General Methodological Limitations General methodological limitations included: 1) In many of the studies reviewed in this paper, the sample sizes were small, often including at least one group of less than 30 subjects; 2) Some studies include both males and females, while it is recognised that women have more lifetime AD than men (Wittchen and Essau, 1993) and that ED are rare in men (Godart et al., 2002); 3) Few studies are controlled, and often those that are controlled have larger control groups than ED groups and are not matched for age or other characteristics; 4) The definition of current prevalence varies across studies, referring to either 6-month (Herpertz- Dahlmann et al., 1996; Råstam et al., 1995) or 1-year prevalence (Halmi et al., 1991).

4.7.3 Diagnostic Criteria for Eating Disorders and Anxiety Disorders Changes in diagnostic criteria for ED and AD over the past 15 years [e.g. Feighner criteria (1972), Research Diagnostic Criteria (RDC) (1977), DSM-III (American Psychiatric Association, 1980), DSM-III-R (American Psychiatric Association, 1987), DSM-IV-TR (American Psychiatric Association, 2000) have clearly had an impact on the prevalence findings. Even in more recent studies, it is sometimes unclear whether they have utilised the DSM-IV or ICD-10 criteria to diagnose ED (e.g. Goodwin and Fitzgibbon, 2002). Changes in AD diagnostic criteria may also have impacted on the findings of studies over time. For example, In the RDC (1977) and the DSM-III (1980) it

129 was not possible to diagnose a depressive disorder and AD simultaneously which may have influenced the prevalence of AD reported in some studies (Godart et al., 2002). It is possible that certain anxiety disorders may have been over reported due to the changes in diagnostic criteria between the DSM-III and the DSM-III-R. Specifically OCD and Social phobia DSM-III-R criteria stipulates both disorders cannot be diagnosed if the obsessions and compulsions or the social anxiety are exclusive to food related concerns. Whilst some researchers already incorporated this in addition to DSM-III criteria, it may provide an explanation as to higher rates of both of these disorders in earlier studies. Finally, the number of anxiety disorders assessed often differs between the studies and will obviously affect the prevalence rates. A number of the studies previously reported excluded certain AD from the assessment, which is a significant limitation when drawing conclusions about prevalence rates of AD and ED. Significantly, it is not uncommon in the research to exclude PTSD from the anxiety assessment, and this presents a limitation when considering the suggestion that a history of trauma, particularly CSA, is a non-specific risk factor for the development of an eating disorder (Black Becker et al., 2004).

4.7.4 Diagnostic Instruments Diagnostic instruments used to assess both eating disorders and anxiety disorders have also varied across studies and present a significant limitation when drawing conclusions about ED and AD comorbidity (Godart, Berthoz, Perereau & Jeammet, 2006; Godart, Berthoz, Rein, Perereau, Lang, Venisse, Halfon, Bizouard, Loas, Corcos, Jeammet, Flament & Curt, 2006; Micali and Heyman, 2006). Unfortunately, many of the studies previously presented have failed to use well standardised, internationally accepted diagnostic instruments to identify eating disorders, limiting the usefulness of their findings. Similarly, some of the research has used inadequate diagnostic instruments or criteria to identify anxiety disorders. This is particularly important to enable one to distinguish between eating disorder and anxiety symptomatology. For example, considering the high but also variable rates of reported OCD in eating disorder populations, one may conclude that some research has insufficiently distinguished between obsessive compulsive symptoms that are secondary to malnutrition and the ED and those which may reflect a true OCD. Furthermore, as mentioned by Bulik et al.

130 (1996), GAD in the SCID (with DSM-III-R criteria) is skipped for subjects with a current mood disorder. A number of the studies previously reported have used the SCID (e.g. Powers et al., 1988; Brewerton et al., 1995; Råstam et al., 1995; Walters and Kendler, 1995; Bulik, Sulivan, Fear & Joyce, 1997) and therefore the rates of GAD may be an underestimate in these studies.

4.8 Summary and Research Implications

It is clear from the research that anxiety disorders are significantly more frequent in subjects with eating disorders than the general community. However, the available research investigating the prevalence of anxiety disorders amongst eating disordered individuals presents strikingly inconsistent findings. Whilst there are a large number of studies researching this area, the inconsistencies complicate the understanding of eating disorder and anxiety comorbidity. It should be noted that many of the studies presented in this thesis involve clinical samples, and as such, comorbidity may be overrepresented. Du Fort, Newman and Bland (1993) cited the phenomenon of Berkson’s Bias, whereby individuals with comorbid diagnoses are more likely to seek treatment than those with a single diagnosis. Nevertheless, there is a clear need for researchers to use well standardised, internationally accepted instruments to identify and investigate eating anxiety disorder comorbidity. Furthermore, the lack of research into the prevalence of eating disorders amongst individuals presenting for anxiety treatment, despite indications that prevalence may be high, suggests the need for greater research in this area. It is this clear need for further research in this area that provided the impetus for the development of the current research. The next chapter provides a detailed overview of the aims and objectives for the current study.

131 CHAPTER 5 AIMS AND OBJECTIVES FOR THE CURRENT STUDY

5.1 Background Eating disorders are amongst the most debilitating of psychiatric illnesses (Klein & Walsh, 2003) and responsible for the highest mortality rate of any of the psychiatric conditions. As earlier discussed, there are significant limitations in a number of the studies investigating comorbidity between eating disorders and anxiety disorders. These limitations affect the conclusions that can be extrapolated from those studies. A number of authors have highlighted the general methodological limitations found in research investigating eating and anxiety comorbidity including Mitchell et al., 1991; Schwalberg et al., 1992, Godart et al., 2002; Micali & Heyman, 2006; Godart, Berthoz, Perereau & Jeammet, 2006 and Godart, Berthoz, Rein, Perereau, Lang, Venisse, Halfon, Bizouard, Loas, Corcos, Jeammet, Flament & Curt, 2006. A number of factors arguably contributing to the limitations in the research resulting from the variability of its findings was discussed earlier at Chapter 4.7.

It is both the lack of research on prevalence of eating disorders in anxiety populations and the inherent methodological limitations in comorbidity research generally, that has led to the development of the present study. There are several key studies which have led to the development of the aims and objectives for the current study, including Godart et al. (2000), Godart et al. (2003), Black-Becker et al. (2004) and Kaye, Bulik, Thornton, Barbarich, Masters & the Price Foundation Collaborative Group (2004).

The current literature would suggest that further investigation into the comorbidity between anxiety and eating disorders may have significant etiological and therapeutic implications. To date, there continues to be limitations involved in the successful treatment of eating disorder pathology (particularly in respect of AN), and outcome research is varied. It is clear that research identifying etiological factors associated with eating disorders may assist in the provision of effective evidenced based treatment for

132 eating pathology. These factors have also provided impetus for the aims and hypotheses tested in the present research.

5.2 Aims of the Current Study A key objective of the present study was to investigate the prevalence of comorbid eating disorders and anxiety disorders using well standardised, internationally accepted measures in order to accurately determine diagnoses, assess various hypotheses commensurate with the current literature, and avoid replicating methodological errors observed in previous research.

The present study was designed to investigate the prevalence of anxiety disorders amongst an eating disorder population, comparing prevalence rates amongst an inpatient sample and an outpatient sample. In order to investigate whether eating disorders were also prevalent amongst individuals presenting for anxiety disorder treatment, an area previously lacking in research, this study also completed eating disorder assessments with individuals seeking treatment from an anxiety disorder outpatient unit. To this end, the researchers were also interested in comparing the eating disorder group with anxiety disorders and anxiety group with eating disorders, specifically with regards to the severity of eating disorder and anxiety symptomatology. This comparison was considered clinical relevant in furthering our understanding of why individuals with comorbid disorders present for specific treatment.

The present study had several aims 1. To examine the prevalence of anxiety disorders in an eating disorder population and to examine the prevalence of eating disorders in an anxiety disorder population. The present study drew from several key studies in this area (including Kaye, Bulik, Thornton, Barbarich, Masters & the Price Foundation Collaborative Group, 2004 and Godart et al., 2003) finding a high prevalence of anxiety disorders amongst women with eating disorders. Subsequently the present study aimed to further explore the question of whether anxiety disorders are prevalent amongst eating disorder populations. The interest in investigating the prevalence of eating disorders amongst an anxiety population

133 stemmed from the fact that there is a distinct lack of research studies in this area. Research conducted by Black Becker et al. (2004) found that 12% of their anxiety sample also met criteria for an eating disorder, suggesting that this was an area in need of greater research. 2. To examine the temporal relationship between comorbid eating disorders and anxiety disorders. This aim was derived from research by Godart et al. (2003) who also found that the anxiety pathology commonly preceded the onset of the eating disorder. The present research aimed to investigate whether individuals with co-morbid eating disorders and anxiety disorders would retrospectively report the onset of the anxiety disorder to be prior to the onset of the eating disorder. 3. To make an overall comparison between eating disorder group with anxiety disorders and anxiety group with eating disorders. Consider the severity of eating disorder symptomatology and anxiety symptomatology in both groups. This aim was contingent upon finding enough people in the anxiety group with a co-morbid eating disorder to draw comparisons. To this end, the researchers were also interested in comparing the eating disorder group with anxiety disorders and anxiety group with eating disorders, specifically with regards to the severity of eating disorder and anxiety symptomatology. This comparison was considered clinical relevant in furthering our understanding of why individuals with comorbid disorders present for specific treatment.

4. To make an overall comparison between the inpatient eating disorder group and outpatient eating disorder group in terms of the prevalence rates of co-morbid anxiety disorders. This research aim stemmed from the Godart et al. (2002) paper highlighting the limitations with previous research investigating comorbidity amongst inpatient samples only, and therefore this led to the aim to investigate whether anxiety disorders would be more prevalent amongst the inpatient eating disorder sample than the outpatient sample.

5.3 Objectives for the Current Study 5.3.1 Objectives regarding the Eating Disorder sample The present study drew from several key studies in this area (including Kaye, Bulik, Thornton, Barbarich, Masters & the Price Foundation Collaborative Group, 2004 and

134 Godart et al., 2003) finding a high prevalence of anxiety disorders amongst women with eating disorders. Subsequently the present was an extension of previous research aiming to further explore the question of whether anxiety disorders are prevalent amongst eating disorder populations, and which of the anxiety disorders were most prevalent. The present research also aimed to investigate whether individuals with co-morbid eating disorders and anxiety disorders would retrospectively report the onset of the anxiety disorder to be prior to the onset of the eating disorder, replicating the work of Godart et al. (2003). Finally, Godart et al. (2002) highlighted the limitations with previous research investigating comorbidity amongst inpatient samples only, and therefore to explore this issue, the present research aimed to investigate whether anxiety disorders would be more prevalent amongst the inpatient eating disorder sample than the outpatient sample.

5.3.2 Objectives regarding the Anxiety Disorder sample The research of Black Becker et al. (2004) highlighted the need to further investigate the prevalence of eating disorders amongst anxiety populations. Due to the paucity of research in this area, the present study aimed to replicate the study undertaken by Black Becker et al. (2004), by exploring the prevalence of eating disorders amongst anxiety disorder populations. Furthermore, in line with previous research on the temporal relationship between eating and anxiety disorders, this research hypothesized that individuals with co-morbid eating disorders and anxiety disorders would retrospectively report the onset of the anxiety disorder to be prior to the onset of the eating disorder.

5.3.3 Objectives regarding the Anxiety Disorder Diagnoses Previous research has found that of the anxiety disorders OCD and social phobia tend to be the most prevalent amongst eating disorder populations. Subsequently, in participants meeting criteria for both an eating disorder and anxiety disorder, the present study hypothesized that of the anxiety disorders, OCD and social phobia would be the most prevalent. Nevertheless, we were interested in extending on previous research in this area which often excluded certain anxiety disorders from the assessment.

135 CHAPTER 6 METHOD

This chapter outlines the methodology for the current study, including the study design, ethics approval, participants, recruitment and assessment procedure. Details of all assessment instruments utilised is also described in detail.

6.1 Study Design Eating disorder and anxiety disorder pathology was assessed in two samples, an eating disorder sample and an anxiety disorder sample. The method of assessment included structured interviews and the completion of several self-report questionnaires. The findings from these assessments then enabled calculation of prevalence of comorbid anxiety and eating disorder symptomatology in both samples.

In order to obtain an eating disorder sample reflecting a range of severity and character of eating disorder psychopathology, participants were recruited from both inpatient eating disorder treatment units and outpatient eating disorder treatment services (see 6.3.1 and 6.3.2 for details of the treatment sites).

6.2 Ethics Approval This study was approved by the University of Sydney Human Research Ethics Committee (see Appendix D), the Sydney West Area Health Service Human Research Ethics Committee (see Appendix E), the Westmead Health Scientific Advisory Committee (see Appendix E), the Northside Clinic Ethics Committee (see Appendix F) and by the executive committee of Wesley Private Hospital, Ashfield. As several amendments were made over the course of this study, each of the corresponding ethics approval letters are also included in Appendices D, E and F. All participants gave written consent and were provided with an information sheet outlining the background and procedures involved in the study. Copies of the information sheets and consent forms used are provided in Appendices A, B and C.

136

6.3 Participants A total of 198 women presenting for treatment of an eating disorder or an anxiety disorder, who met study criteria, were approached to participate in the current study. A total of 152 women were recruited for this study. The subsequent sample represents 76.8% of patients who were approached to participate. Reasons given for not consenting for participation in the current study included an unwillingness to participate in research (n=40), an inability to find the time due to work or other commitments (n=3). 1 participant was excluded for completing questionnaires incorrectly, and 2 eating disorder participants following assessment, met criteria for BED, and were subsequently excluded from the study. A further 41 patients were deemed unsuitable for participation in this study due to being under 18 years of age (n=27), acute suicidality (n=8), absconding from the treating unit (n=1) and not meeting a DSM-IV diagnosis for an eating disorder or an anxiety disorder (n=5).

Inclusion criteria for participants with eating disorders were a current DSM-IV diagnosis of AN, BN or EDNOS, aged 18 years or over and not subject to serious medical complications resulting from their eating disorder.

Inclusion criteria for participants with anxiety disorders were a current DSM-IV diagnosis of an anxiety disorder and aged 18 years or over. Details of each sample are described below.

The present study did not assess for additional comorbid disorders, such as depressive disorders, substance abuse or personality disorders and subsequently, did not exclude individuals who may have met criteria for these disorders.

6.3.1 Eating Disorder Inpatient Sample Consecutive female patients entering the inpatient unit of the Peter Beumont Centre for Eating Disorders (PBCED) at Wesley Private Hospital, and the Eating Disorder Unit at

137 Northside Clinic (NSC), who met the noted inclusion criteria, were approached to participate in the current study. A total of 50 inpatients were recruited for this study.

6.3.2 Eating Disorder Outpatient Sample Patients entering the outpatient unit of the PBCED at Wesley Private Hospital, the SWAHS Eating Disorder Day Treatment program, the University of Sydney Psychology Clinic or accessing private psychiatry or psychology treatment services in the Sydney Metropolitan area who met the noted inclusion criteria, were approached to participate in the current study. A total of 50 outpatients were recruited for this study.

6.3.3 Anxiety Disorder Outpatient Sample Consecutive patients entering the Westmead Anxiety Disorder Treatment and Research Unit and the University of Sydney Psychology Clinic who met the noted inclusion criteria, were approached to participate in the current study. A total of 52 anxiety disorder outpatients were recruited for this study.

6.4 Assessment Measures Copies of all assessment measures used in this study are contained in Appendix G. 6.4.1 Eating Disorder Assessment Measures The eating disorder measures utilised in this study had several purposes. Firstly, two self report measures were used to screen for eating disorder symptomatology amongst individuals presenting for treatment of an anxiety disorder. The rationale for utilizing two self report measures was to ensure that eating disorder symptomatolgy was sufficiently screened, to minimize the possibility of missing cases. Both self-report measures are brief, and can be easily administered, therefore minimising participant burden. A diagnostic interview was used to confirm eating disorder diagnoses amongst individuals presenting for treatment of an eating disorder, and to confirm diagnoses amongst women presenting for anxiety treatment whose self-reports measures were indicative of an eating disorder. Each of these measures will be discussed below.

138 i) Eating Disorder Examination (EDE; Cooper & Fairburn, 1987; Fairburn & Cooper, 1993) The EDE was used to evaluate the eating disorder specific psychopathology and to elicit the clinical DSM-IV eating disorder diagnoses. All EDE interviews were completed by a 3rd year Doctoral level student (the present author, JMS), who had been trained in the administration of the EDE by Christopher Fairburn. The EDE is a standardised, investigator based interview, considered to be the “gold standard” in the assessment of eating disorders (Garner, 1995). The EDE assesses the frequency of key behavioural and attitudinal aspects of eating disorders during the preceding 28 days. The EDE evaluates the major areas of eating disorder psychopathology on four subscales: Restraint, Eating Concern, Shape Concern and Weight Concerns. Interrater reliability for the Global EDE score has been estimated to be 0.97 – 0.99 (Wilson & Smith, 1989). Furthermore, the four subscales have good discriminant validity in distinguishing between individuals with eating disorders and controls (Cooper, Cooper & Fairburn, 1989; Fairburn & Cooper, 1993). The Weight and Shape Concern subscales also have good discriminant validity in distinguishing between individuals with eating disorders and restrained eaters (Wilson & Smith, 1989).

ii) Eating Disorder Examination – Questionnaire (EDE-Q; Fairburn & Beglin, 1994) Eating disorder symptomology was screened using the EDE-Q, which is a self-report version of the EDE (Fairburn & Cooper, 1993). The EDE-Q assesses the same attitudinal and behavioural aspects of eating disorders as the EDE, over a 28 day time period. The EDE-Q consists of the same four subscales utilised in the EDE, including shape concern, weight concern, dietary restraint and eating concern. The EDE-Q yields scores on each of these subscales as well as a Total Scale score. These subscales have demonstrated excellent test-retest reliability over a two week period with co-efficients ranging from 0.81 to 0.94 (Luce & Crowther, 1999). It also contains items enabling the assessment of binge eating and compensatory behaviours in terms of the number of days each behaviour occurred and the number of distinct episodes on each day. The EDE-Q appears to be useful as a screening measure for eating disorder pathology, and its generally good

139 convergent validity with the EDE, suggests that it may be used as a substitute for the EDE (Fairburn & Beglin, 1994). Nevertheless, given that it may indicate a higher frequency of problematic eating disorder symptoms, it was decided that this measure alone would not be utilised to identify eating disorder diagnoses. Subsequently, this measure was purely used to identify any eating disorder pathology, and where indicated, the EDE was then utilised to confirm diagnoses.

iii) Eating Attitudes Test (EAT-40; Garner & Garfinkel, 1979) The EAT-40 was originally developed to assess attitude and behaviour characteristics of individuals with AN. It not only discriminates AN samples from controls, it also discriminates BN samples from control groups (Gross, Rosen, Leitenberg & Willmuth, 1986). The EAT-40 may be most appropriately used as an assessment of the severity of concerns typically observed amongst individuals with eating disorders, namely drive for thinness, fear of weight gain and restrictive eating patterns (Williamson, 1990). The EAT- 40 has three subscales: dieting, bulimia/food preoccupation, and oral control, which are highly correlated with each other (Garner, Olmsted, Bohr & Garfinkel, 1982). The EAT-40 also demonstrates good psychometric properties. The EAT-40 was administered with the EDE-Q to screen for possible eating disorder pathology.

iv) Eating Disorder Inventory -3 (EDI-3; Garner, 2004) The EDI-3 is a revised version of a widely utlised self-report measure of psychological traits and constructs demonstrated to be clinically relevant in individuals with eating disorders (Garner, 2004). This measure consists of 91 items organized into 12 primary scales, with higher scores reflecting greater levels of pathology. The subscales include drive for thinness, bulimia, body dissatisfaction, low self esteem, personal alienation, interpersonal insecurity, interpersonal alienation, interoceptive deficits, emotional dysregulation, perfectionism, asceticism and maturity fears.

Items are presented in a 6-point Likert scale, in which respondents rate whether the item applies to them always, usually, often, sometimes, rarely, or never. The reliability (internal consistency [α = 0.83-0.93] and test-retest reliability [α = 0.67 – 0.85]) and

140 validity (content, construct, concurrent validity and discriminant validity) of the EDI and its revisions have been demonstrated (Garner, Olmsted & Polivy,1983).

This measure was included in the current study to further assess a wide range of eating disorder pathology. It was anticipated that this measure could be used to investigate any possible differences between eating pathology and severity amongst the comorbid and non-comorbid groups.

6.4.2 Anxiety Disorder Assessment Measures i) Anxiety Disorder Interview Schedule - IV (ADIS-IV; Brown et al., 1994) The ADIS-IV was used to assess for current anxiety symptoms and to determine whether a DSM-IV anxiety disorder diagnosis was met. The ADIS-IV is designed to identify the following anxiety disorders: panic disorder, agoraphobia, social phobia, OCD, GAD, PTSDr, ASD and specific phobia. The ADIS-IV, is a semi-structured clinician administered interview that yields DSM-IV diagnoses. Although this interview is extremely thorough, and provides a detailed and reliable assessment, its time consuming administration means that it is better suited to small scale clinical research projects (Andrews et al., 2003). The ADIS-IV has demonstrated favourable levels of diagnostic reliability (Grishham, Brown & Campbell, 2004), making it a popular measure for diagnosing anxiety disorders in research settings.

6.4.3 Depression Assessment Measure i) Depression Anxiety and Stress Scale (DASS-21; Lovibond & Lovibond, 1995) The DASS-21 is a short form of Lovibond and Lovibond’s (1995) 42-item measure of depression, anxiety and stress. It consists of three 7-item self-report scales taken from the full version of the DASS. There is evidence the DASS scales do constitute valid measures of the constructs they were intended to represent (Lovibond & Lovibond, 1995; Crawford & Henry, 2003; Henry & Crawford, 2005). The DASS-21 has a number of advantages over the full length DASS. As it is shorter than its full length counterpart, it is more acceptable for clients, whilst still demonstrating adequate reliability and omits items from the full DASS that have been identified as problematic (Henry & Crawford, 2005).

141 The DASS-21 was used to identify depression, anxiety and stress symptoms experienced in the preceding 7 days.

6.4.4 Socio-Demographic Questionnaire A socio demographic questionnaire including date of birth, ethnic origin, marital status, number of children (if any), occupational history, highest level of education obtained and medications of each participant was completed on assessment.

6.4.5 Height and Weight Measurements Anxiety participants provided their height and current weight measurements, in order for the researchers to calculate body mass index (BMI) scores. Although self-report height and weight measurements are not considered optimal, as reported by Black Becker et al. (2004), research has shown that self report weights are reasonably accurate (Stunkard & Albaum, 1981). For eating disorder participants, height and weight measurements were taken from clinical records upon entry into treatment.

6.4.6 Excluded Measures A number of additional measures were initially included in the first phase of this study, however it was found that the time pressures on participants to complete these was too great, and therefore they were excluded from the study. A number of the measures were discontinued after the first 30 participants were assessed, with the response rate at less than 60% for completing all questionnaires. Subsequently, the ANSOCQ, EDBQ & Anxiety self –report measures were excluded from the study. These are described briefly below and copies are contained in Appendix H.

i) Beck Depression Inventory II (BDI-II; Beck, Steer & Brown, 1996) The BDI-II is a 21-item self-report instrument intended to assess the existence and severity of symptoms of depression as listed in the DSM-IV (American Psychiatric Association, 2000). This new revised edition replaces the BDI and the BDI-1A, and includes items intending to index symptoms of severe depression, which would require hospitalization. In the BDI-II items have been revised to indicate increases or decreases

142 in sleep and appetite, items labeled body image, work difficulty, weight loss, and somatic preoccupation were replaced with items labeled agitation, concentration difficulty and loss of energy, and many statements were reworded resulting in a substantial revision of the original BDI and BDI-1A. When presented with the BDI-II, a patient is asked to consider each statement as it relates to the way they have felt for the past two weeks, to more accurately correspond to the DSM-IV criteria. The BDI has been reported to be highly reliable regardless of the population. It was decided that instead of using the BDI- II, this study would utilise the DASS-21 (Lovibond and Lovibond, 1995). The main reason for making this change was so that the researchers would also be able to examine the differences between samples on general levels of anxiety, as well as screening for depression.

ii) Anorexia Nervosa Stages Of Change Questionnaire (ANSOCQ; Rieger, Touyz, Schotte, Beumont, Russell, Clarke, Kohn & Griffiths, 2000) The ANSOCQ is a 20-item self-report measure assessing symptomatology relevant to AN, specifically in terms of eating behaviours, body shape and weight concerns and weight control strategies, problematic personality characteristics and interpersonal difficulties. It was designed to measure readiness to change, based on the stages of change model proposed by DiClimente and Prochaska (1998). Furthermore, the ANSOCQ has demonstrated good internal consistency in adult (Rieger et al., 2000) and adolescent AN samples (Serrano, Castro, Ametller, Martinez & Toro, 2004). Initially this questionnaire was included, as the authors thought that it might be interesting to consider any differences between readiness to change for individuals with and without an anxiety disorder. As this questionnaire was developed for use in an AN population, it was not suitable for the BN & EDNOS participants who were included in the study. Furthermore, due to the lengthy nature of the assessment procedure, it was decided that this questionnaire was too time consuming to include in addition to the other self-report items.

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iii) Eating Disorder Belief Questionnaire (EDBQ; Cooper, Cohen-Tovee, Todd, Wells & Tovee, 1997) The EDBQ is a 32 item self-report questionnaire designed to assess assumptions and beliefs associated with eating disorders. This measure assesses core beliefs rating to four dimensions, including, negative self-beliefs, weight and shape as a means to acceptance by others, weight & shape as a means to self-acceptance and control over eating. Participants indicate the strength with which they hold a particular belief, using a scale ranging from 0 to 100, with responses being analysed under each of the four dimensions (Cooper et al, 1997). In the development phases for the current research, it was initially thought that an interesting aspect would be to explore any differences between core beliefs for individuals with and without comorbid anxiety disorders. Although in the early stages of this research, this questionnaire was included in the self-report battery given to participants, a number of participants did not complete this measure. It was determined that due to the time intensive nature of the initial assessment, the expectation for participants to also complete this questionnaire was too great. Subsequently, this questionnaire was removed from the assessment battery.

iv) Anxiety Questionnaires A number of anxiety specific self-report questionnaires were also included in the initial design of this research. The purpose of including these questionnaires was so that comparisons could be drawn between participants with comorbid anxiety and eating disorders presenting for anxiety treatment versus eating disorder treatment. Specifically, the authors were interested in whether there was an observable difference between the specific anxiety disorder symptoms experienced (as measured by the self-report questionnaires) between these groups. This analysis in the research was always dependent on identifying sufficient numbers of comorbid cases in each group. As will be detailed in the following chapter, only a small number of participants presenting for anxiety treatment also met diagnosis for a current eating disorder, and subsequently, there were insufficient numbers to draw comparisons. As previously highlighted, the time consuming nature of the initial assessment meant that participants were reluctant to

144 complete further questionnaires. The completion rate for the anxiety specific self-report questionnaires was very low. The following anxiety self-report measures were initially incorporated in the assessment procedure:

Generalised Anxiety Disorder • Metacognitions questionnaire (MCQ; Cartwright-Hatton & Wells, 1997) • Penn State Worry questionnaire (PSWQ; Meyer, Miller, Metzger and Borkovec, 1990) The MCQ is 65-item measure of beliefs about worrying thoughts, attitudes and processes associated with cognition. The scale consists of 5 factor-derived subscales including positive beliefs; beliefs about uncontrollability and danger of thoughts; cognitive confidence; need for control, responsibility and punishment and cognitive self- consciousness (Wells, 1997). The subscales demonstrate adequate to good internal consistencies and adequate to very good test-retest reliabilities (Roemer, 2001).

The PSWQ is a 16-item self-report measure of worry. Each item is rated on a 5-point scale (1 = "not at all typical" to 5 = "very typical"). Several studies indicate that the PSWQ provides a reliable and valid measure of general worry in patient and nonpatient samples (Brown, Antony & Barlow, 1992; Ladouceur, Freeston, Dumont, Letarte, Rheaume, Gagnon & Thibodeau, 1992; Brown, Moras, Zinbarg & Barlow, 1993; Davey, 1993).

Social phobia • Social interaction anxiety scale (SIAS; Mattick & Clark, 1989) • Social phobia scale (SPS; Mattick & Clark, 1989) • Fear of negative evaluation scale (FNE; Watson & Friend, 1969)

The SIAS and SPS are 20 item scales designed to assess social anxiety in situations involving social interaction (SIAS) and situations involving observation by others (SPS). Both the SPS and SIAS have demonstrated good reliability and discriminative validity (McNeil, Ries & Turk, 1995).

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The FNE scale measures the cognitive and affective/behavioural aspects of social anxiety (Watson & Friend, 1969). Although this scale has been used extensively in clinical and research settings, some limitations exist. These limitations including having reversed items, which may cause confusion in responses and the ‘True/False’ format which impairs the potential sensitivity of the scale (Wells, 1997). Generally however, the FNE scale is considered to be valuable in the assessment and treatment of social phobia, and a number of studies support its validity (McNeil et al., 1995).

Panic Agoraphobia • Agoraphobic cognitions questionnaire (ACQ; Chambless, Caputo, Bright & Gallagher, 1984) • Body sensations questionnaire (BCQ; Chambless, Caputo, Bright & Gallagher, 1984) The ACQ and the BSQ are twin scales based on the fear of fear model proposed by Goldstein & Chambless (1978). The ACQ is a 14 item measure of thoughts about negative consequences of anxiety. The BSQ is a 17 item measure of an individual’s fear of bodily sensations associated with high arousal and panic states. The ACQ and BSQ are recognized as extremely important tools in the assessment and treatment of panic disorder and agoraphobia (Wells, 1997).

Obsessive Compulsive Disorder • Yale – Brown obsessive compulsive scale (Y-BOCS; Goodman, Price, Rasmussen, Mazure, Fleishmann, Hill, Heninger & Charney, 1989 & Goodman, Price, Rasmussen, Mazure, Fleishmann, Hill, Heninger & Charney, 1989) • Padua Inventory - Washington State University Revision (PI-WSUR; Burns, Keortge, Formea & Sternberger, 1996) • Maudsley Obsessional Compulsive inventory (MOCI; Hodgson & Rachman, 1977) The Y-BOCS is a semi-structured interview designed to assess the presence and severity of symptoms found in patients with OCD. Initially a symptom checklist for both

146 obsessions and compulsions is generated for both current and lifetime symptoms. Following this, the clinician assesses the severity and clinical significance of the symptoms. The Y-BOCS reliability and validity has been well established (Goodman, Price, Rasmussen, Mazure, Fleishmann, Hill, Heninger & Charney, 1989; Goodman, Price, Rasmussen, Mazure, Fleishmann, Hill, Heninger & Charney, 1989). Initially this measure was going to be used in addition to the ADIS-IV to further assess for obsessive and compulsive symptomatology. However, it was subsequently decided by the authors that the ADIS-IV OCD assessment section was sufficient, and as previously mentioned, the already time consuming nature of the initial assessment meant that the authors needed to be cognisant of the time pressures placed on participants.

The PI-WSUR is a 39-item self-report measure of obsessions and compulsions. Each item is rated on a 5-point scale according to the degree of disturbance caused by the thought or behavior. This measure is separated into five subscales: (1) contamination, obsessions and washing compulsions, (2) dressing/grooming compulsions, (3) checking compulsions, (4) obsessional thoughts of harm to self/others, and (5) obsessional impulses to harm self/others. The PI-WSUR has good reliability and good test-retest reliability (Burns et al., 1996). The revised version was designed to limit the overlap between worry and obsessions observed in the original PI (Sanavio, 1988). Despite this overlap having been reduced, significant overlap still remains (Wells & Papageorgiou, 1998).

The MOCI is a 30-item self-report questionnaire with four subscales consisting of checking, cleaning, slowness and doubting. The measure has been shown to be valid in identifying obsessions and compulsions in both clinical and non-clinical samples (Sternberger & Burns, 1990). The MOCI also has good reliability and validity (Myers & Wells, 2005).

Post Traumatic Stress Disorder • Post Traumatic Diagnostic Scale (PDS; Foa, Cashman, Jaycox & Perry, 1997) • Impact of Events Scale Revised (IES-R; (Weiss & Marmar, 1997)

147 The PDS assessment is designed to aid in the diagnosis of PTSD (PTSD) and with the quantification of the severity of symptoms. The PDS is a 49-item self-report questionnaire designed to parallel the DSM-IV diagnostic criteria for PTSD. The PDS has demonstrated excellent internal consistency overall and very good internal consistency for the symptom subscales. The validity of this scale has also been demonstrated to be sound (Orsillo, 2001).

The Impact of Events Scale (IES; Horowitz, Wilner & Alvarez, 1979; Zilberg, Weiss & Horowitz, 1982; Weiss & Marmar, 1997) is a 15-item scale designed to assess subjective distress for any specific life event. As the original IES was developed prior to the inclusion of PTSD in the DSM, the IES-R was designed to parallel the DSM-IV criteria for PTSD. Thus, while the IES only assesses intrusion and avoidance symptoms, the IES- R includes questions assessing hyperarousal symptoms. Generally the psychometric properties of the IES-R appear sound and Weiss and Marmar (1997) reported that the internal consistency of the 3 subscales was very high.

6.5 Procedure 6.5.1 Eating Disorder Participants i) Inpatient Sample Consecutive referrals of patients attending the inpatient units for eating disorder treatment were invited to participate in the current study (see Section 6.3.1 for details of the inpatient treatment units involved). Of the 50 participants assessed, the author (JMS), completed all of these assessments. The assessment consisted of conducting the EDE, in order to confirm an eating disorder diagnosis, and then completion of the ADIS-IV (Anxiety Disorders Section Only) to identify comorbid anxiety disorder diagnoses. Participants were also given a socio-demographic questionnaire, the DASS-21 and the EDI-3 to complete. As discussed in Section 6.4.6, initially some additional eating disorder and anxiety self-report questionnaires were also given to participants, however these were subsequently discontinued.

All eating disorder participants received detailed information about the procedures and aims of the study, and gave written consent.

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ii) Outpatient Sample Attending patients referred to outpatient services for eating disorder treatment were invited to participate in the current study (see Section 6.3.2 for details of the outpatient treatment services involved). Of the 50 participants assessed, the author (JMS), completed all of these assessments. The assessment consisted of conducting the EDE, in order to confirm an eating disorder diagnosis, and then completion of the ADIS-IV (Anxiety Disorders Section Only) to identify comorbid anxiety disorder diagnoses. Participants were also given a socio-demographic questionnaire, the DASS-21 and the EDI-3 to complete. As discussed in Section 6.4.6, initially some additional eating disorder and anxiety self-report questionnaires were also given to participants, however these were subsequently discontinued.

All eating disorder participants received detailed information about the procedures and aims of the study, and gave written consent.

6.5.2 Anxiety Participants Patients attending the generalist or specialist units for anxiety treatment were invited to participant in the current study (see Section 6.3.3 for details of the outpatient treatment services involved). All participants who agreed to participate were assessed for current anxiety disorder diagnoses using the ADIS-IV (complete). The ADIS-IV assessments were all completed by the author (JMS) and by Doctoral Students in their 2nd or 3rd year of clinical training, who had been trained by Clinical Psychologists in the use of the ADIS-IV. Participants were also given two eating disorder self-report questionnaires to complete (the EDE-Q and the EAT-40) as well as the DASS-21 and a socio-demographic questionnaire. As discussed in Section 6.4.6, initially some additional eating disorder and anxiety self-report questionnaires were also given to participants, however these were subsequently discontinued.

Participant responses on the EDE-Q and the EAT-40, enabled the researchers to determine the presence of a possible eating disorder. Based on the eating disorder self-

149 report measures, participants obtaining scores indicative of eating disorder pathology were invited back for a more comprehensive eating disorder assessment using the EDE (the EDE assessments were all completed by the author, JMS). This further assessment enabled an eating disorder diagnosis to be confirmed. Participants with confirmed eating disorder diagnoses were also given the EDI-3 to complete.

All anxiety participants received detailed information about the procedures and aims of the study, and gave written consent.

6.5.3 Age at Onset For participants reporting that the anxiety disorder was present during childhood “for as long as I could remember”, the age of onset was set at 5 years of age based on the assumption that childhood recollections may be limited prior to this age, in line with previous research in this area (Kaye, Bulik, Thornton, Barbarich, Masters & the Price Foundation Collaborative Group, 2004). For each eating disorder and anxiety disorder diagnosed, the researchers determined the age of onset as defined by the age at which all the symptoms necessary to make an eating or anxiety disorder diagnosis were present concurrently. This was based on the recollection of the participant only, and no additional measures were used to determine this. From this information the researchers were able to determine the temporal relationship between the onset of comorbid diagnoses, specifically whether the onset of one disorder was prior to, concurrent or following the onset of the comorbid disorder.

6.6 Statistical Analysis 6.6.1 Data Screening All statistical analyses were performed using Statistical Package for the Social Sciences (SPSS, 2006) for Windows (Version 15.0). The data set was thoroughly screened prior to commencing analyses, and the accuracy of the data file was ensured by double-checking all entries and screening for the presence of missing data.

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6.6.2 Statistical Analyses The data analysis was performed using SPSS (v15.0, 2006). In order to investigate the prevalence of comorbid anxiety and eating disorders much of the information collected in the current study was summarised with percentages. The information regarding the temporal relationship between disorders was also summarised with percentages. Comparisons across the sample were made using chi-square analyses, t-tests, ANOVA and logistic regression. Specifically, significant mean group differences for parametric variables were analysed using t-tests and one-way analysis of variance (ANOVA) statistical procedures. In place of t-tests, Mann-Whitney tests were conducted in cases where the t test normality assumption was violated (determined by skewness and kurtosis) and sample sizes were small. Chi-Square (χ²) tests were used for categorical independent variables. Furthermore, Fisher’s exact test was used when the minimum expected cell size was 5 or less and Craméres V was used when independent variables had more than 2 categories (Hills, 2008). A logistical regression analysis was also conducted for the comparison of EDE scores across the sample. For all statistical analyses reported, the alpha was set at p<.05, unless otherwise indicated. All tests performed were two-tailed. For all SPSS output files refer to Appendix I.

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CHAPTER 7 SAMPLE CHARACTERISTICS

This chapter is an overview of the participant recruitment and sample characteristics at assessment for the current study. Demographic characteristics are reported, as well as participants’ scores on self-report measures. The demographic characteristics for the eating disorder sample were similar to those reported in similar studies (Godart et al., 2003, Kaye, Bulik, Thornton, Barbarich, Masters & the Price Foundation Collaborative Group, 2004, Blinder et al., 2006) as were the demographic characteristics for the anxiety sample (Black Becker et al., 2004). The depressive symptoms as measured by the DASS in the present study appear similar to Mood Disorder rates reported by Blinder et al., (2006) across their eating disorder sample.

7.1 Recruitment of the Eating Disorder Sample A total of 100 eating disorder participants were recruited for the current study. This included 50 participants from inpatient eating disorder units and 50 patients from outpatient treatment services.

7.1.1 Inpatient ED Sample A total of 78 eating disorder inpatients who appeared to meet inclusionary criteria were invited to participate in the study. The aim was to see all participants as soon after admission as possible (within the first week). All eating disorder assessments investigated the 28 day period prior to admission into treatment. The subsequent inpatient sample represents 64% of patients who were approached to participate. Most participation refusals were encountered at one of the treatment sites (NSC), where only 3 (16%) of the 18 patients approached consented. The main reason for refusal appeared to be that patients were already involved in a number of research projects being undertaken in the unit. Subsequently, it was decided to cease recruitment at NSC and continue recruitment through the PBCED at Wesley Hospital.

152 Of the patients who were deemed unsuitable for participation, 26 were unsuitable due to being under 18 years of age, 4 were unsuitable due to acute suicidality and self harm attempts (three were reported to have a comorbid PTSD diagnosis), and 1 had absconded from the hospital just after admission.

7.1.2 Outpatient ED Sample A total of 58 eating disorder outpatients who appeared to meet inclusionary criteria were invited to participate in the study. The subsequent outpatient sample represents 86.2% of patients who were approached to participate. Reasons given for not consenting for participation in the current study included an unwillingness to participate in research (n=5) and an inability to find the time due to work commitments (n=1). Two patients (n=2) were also excluded as they met criteria for EDNOS (Binge Eating Disorder), as this study was investigating anxiety amongst patients with AN, BN and subthreshold diagnoses of these disorders.

Of the patients who were deemed unsuitable for participation (n=8), 1 was unsuitable due to being under 18 years of age, 4 were unsuitable due to acute suicidality and the remaining 3 did not meet DSM-IV criteria for an eating disorder on assessment.

7.2 Recruitment of the Anxiety Disorder Sample A total of 52 anxiety disorder participants were recruited for the current study. All participants were recruited through outpatient treatment units. A total of 62 anxiety disorder outpatients who appeared to meet inclusionary criteria were invited to participate in the study. The subsequent outpatient sample represents 83.9% of patients who were approached to participate. Reasons given for not consenting for participation in the current study included unwillingness to participate in research (n=7) and an inability to find the time due to work or other commitments (n=2).

One participant was excluded from the study due to completing the questionnaires incorrectly.

153 Of the patients who were deemed unsuitable for participation (n=2), both were unsuitable due to not meeting criteria for a DSM-IV anxiety disorder.

Of the 23% (n=12) of women identified as having a potential eating disorder (as indicated by the self-report questionnaires) only 3 participants were unable to complete a further eating disorder assessment to confirm diagnosis. Two of these participants were unable to be contacted, and the other declined to participate in a further interview.

7.3 Characteristics of the Eating Disorder Sample 7.3.1 Inpatient Sample All 50 female participants met DSM-IV (American Psychiatric Association, 2000) criteria for an eating disorder, including 66% (n=33) for AN (38% (n=19) for restricting subtype and 28% (n=14) for binge purging subtype); 12% (n=6) for BN; and 22% (n=11) for EDNOS. Of the participants diagnosed with EDNOS, 54.5% (n=6) presented with subthreshold BN and 45.5% (n=5) presented with subthreshold AN.

All diagnoses were made by the author (JMS) following an assessment using the EDE. The mean (± sd) estimated duration for eating disorder pathology was 88 months (± 78.5 months). The range was from a minimum of 3 months to a maximum of 276 months. The mean age of onset of eating disorder pathology was 17.9 years (± 6.3), with onset ranging from age 11 through to age 43 years.

Regarding bingeing and purging behaviours in the preceding 28 days, 38% (n= 19) reported at least one objective binge episode; 50% (n=25) reported to have engaged in self induced vomiting on at least one occasion and 24% (n=12) reported laxative abuse in the preceding month. 44% (n=22) reported having engaged in excessive exercise in the preceding 28 days. See Table 7.2 for a summary of eating disorder characteristics of participants and Table 7.3 for a summary of demographic and clinical characteristics by ED subtype.

154 At assessment, the mean (± sd) body mass index (BMI in kg/m²) for all participants was 17.3 kg/m² (± 3.2) with the mean for AN (n=33) being 15.4 (±1.0), for BN (n=6) the mean was 20.7 (±2.7) and for EDNOS (n=11) the mean was 20.95 (±3.2). Across the entire sample, the minimum BMI was 12.5 kg/m² and the maximum was 25.5 kg/m².

The mean age for participants was 25 years (± 8.3), with an age range of 18-56 years of age. The mean level of education for the sample was 14.2 years (± 2) with the minimum level of education being 11 years and the maximum 20 years. In respect of employment status, at the time of the assessment, 46% (n=23) of the sample were employed, 30% (n=15) were unemployed and 24% (n=12) were involved in full time study. In terms of marital status, at the time of the assessment, 72% (n=36) of the sample were single, 10% were married (n=5), 12% (n=6) had a partner and 6% (n=3) were separated or divorced. Furthermore, 92% (n=46) reported not having any children, whilst the remaining 8% (n=4) reported having 1 or more children. In antidepressant medications, 74% (n=37) reported currently taking antidepressant medications, whilst the remaining 26% (n=13) denied taking current medications.

Regarding depression levels, as measured by the DASS scores, 48% (n=24) obtained scores in the severe to extremely severe range, 28% (n=14) were in the mild to moderate range, and 12% (n=6) obtained scores in the normal range. The remaining 12% (n=6) did not return the questionnaire, and therefore their depression scores were unable to be calculated. See Table 7.1 for a summary of the demographic profile of participants.

7.3.2 Outpatient Sample All 50 female participants met DSM-IV (American Psychiatric Association, 2000) criteria for an eating disorder, including 58% (n=29) for EDNOS; 30% (n=15) for BN; and 12% (n=6) for AN (10% (n=5) for restricting subtype and 2% (n=1) for binge purging subtype). Of the participants diagnosed with EDNOS, 58.6% (n=17) presented with subthreshold AN and 41.4% (n=12) presented with subthreshold BN.

All diagnoses were made by the author (JMS) following an assessment using the EDE.

155 The mean (± sd) estimated duration for eating disorder pathology was 99.1 months (± 76.8 months). The range was from a minimum of 6 months to a maximum of 336 months. The mean age of onset of eating disorder pathology was 16.8 years (± 4.7), with onset ranging from age 9 through to age 34 years. In terms of bingeing and purging behaviours in the preceding 28 days, 54% (n= 27) reported at least one objective binge episode; 52% (n=26) reported to have engaged in self-induced vomiting on at least one occasion and 4% (n=2) reported laxative abuse in the preceding month. 38% (n=19) reported having engaged in excessive exercise in the preceding 28 days. See Table 7.2 for a summary of eating disorder characteristics of participants and Table 7.3 for a summary of demographic and clinical characteristics by ED subtype.

At assessment, the mean (± sd) body mass index (BMI in kg/m²) for all participants was 20.4 kg/m² (± 3.2) with the mean for AN (n=6) being 16.58 (±0.5), for BN (n=15) the mean was 21.7 (±2.9) and for EDNOS (n=29) the mean was 20.6 (±3.1). Across the entire sample, the minimum BMI was 15.4 kg/m² and the maximum was 28.9 kg/m².

The mean age for participants was 25.0 years (± 6.4), with an age range of 18-45 years of age. The mean level of education for the sample was 13.6 years (± 2.1) with the minimum level of education being 10 years and the maximum 19 years. In respect of employment status, at the time of the assessment, 36% (n=18) of the sample were employed, 22% (n=11) were unemployed and 42% (n=21) were involved in full time study. Regarding marital status, at the time of the assessment, 60% (n=30) of the sample were single, 22% (n=11) had a partner, 14% were married (n=7) and 4% (n=2) were separated or divorced. Furthermore, 80% (n=40) reported not having any children, whilst the remaining 20% (n=10) reported having 1 or more children. In terms of antidepressant medications, 60% (n=30) denied taking current medications, whilst the remaining 40% (n=20) reported currently taking antidepressant medications.

In respect of depression levels, as measured by the DASS scores, 46% (n=23) obtained scores in the severe to extremely severe range, 32% (n=16) were in the mild to moderate range, and 20% (n=10) obtained scores in the normal range. A further 2% (n=1) did not

156 return the questionnaire, and therefore their depression scores were unable to be calculated. See Table 7.1 for a summary of the demographic profile of participants.

7.4 Characteristics of the Anxiety Disorder Sample All 52 female participants met DSM-IV (American Psychiatric Association, 2000) criteria for an anxiety disorder: 28.8% (n=15) for social phobia, 23.1% (n=12) for OCD, 17.3% (N=9) for GAD, 17.3% (N=9) for Panic with Agoraphobia, 5.8% (N=3) for specific phobia, 5.8% (N=3) for PTSD and 1.9% (n=1) for ASD. Secondary anxiety disorder diagnoses were also diagnosed in 25% (n=13), 2 of these participants met diagnosis for 2 secondary anxiety disorders and one met criteria for 3 secondary anxiety disorder diagnoses.

A total of 23% (n=12) of participants obtained scores on the EAT-40 and EDE-Q indicative of the presence of eating disorder pathology. Of these 12 cases, 9 participants completed a further assessment interview to establish the presence or absence of an eating disorder diagnosis. Of the 3 who did not complete a further assessment, 1 declined and 2 were unable to be contacted by the researcher. Following a further eating disorder assessment, 7 participants (13.5% of the whole anxiety disorder sample) were diagnosed as meeting DSM-IV (American Psychiatric Association, 2000) criteria for an eating disorder (EDNOS). Of the participants diagnosed with EDNOS, 3 presented with subthreshold BN, n=2 with subthreshold AN and 2 with Binge Eating Disorder. All confirmed eating disorder diagnoses were made by the author (JMS) following an assessment using the EDE.

In terms of individuals meeting criteria for both an anxiety disorder and an eating disorder (n=7), the mean (± sd) age was 31.3 (± 12.8) and mean (± sd) level of education was 13 years (± 1.2). Regarding marital status, 57.1% (n=4) reported being single, whilst 42.9% (n=3) reported being either married or having a partner. In terms of children, 57.1% (n=4) reported having no children, whilst the remaining 42.9% (n=3) reported having between 1 and 3 children. Of this sample, 57.1% (n=4) were employed, 28.6% (n=2) were full time students and the remaining 14.3% (n=1) were unemployed. The

157 mean (± sd) estimated duration for anxiety disorder pathology was 197.1 months (± 161.1 months). The range was from a minimum of 24 months to a maximum of 504 months. The mean (± sd) age of onset for anxiety disorders was 14 years (±9.2), ranging from onset at age 5 to age 32 years. The mean (± sd) estimated duration for eating disorder pathology was 147.4 months (± 105.9 months). The range was from a minimum of 72 months to a maximum of 348 months. In relation to the age of onset for eating disorder pathology, the mean (± sd) was 19 years (± 9.9), with onset ranging from age 9 years to age 40 years. Regarding bingeing and purging behaviours in the preceding 28 days, 71.4% (n= 5) reported engaging in at least one objective binge episode; 14.3% (n=1) reported engaging in self induced vomiting on at least one occasion and 100% (n=7) denied laxative abuse in the preceding month. A further 42.9% (n=3) reported having engaged in excessive exercise in the preceding 28 days. See Table 7.2 for a summary of eating disorder characteristics of participants.

At assessment, the mean (± sd) body mass index (BMI in kg/m²) for participants with an eating disorder diagnosis was 27.7 kg/m² (±12.4), with the minimum BMI being 17.6 kg/m² and the maximum 51.2 kg/m². In terms of antidepressant medication, 71.4% (n=5) reported not currently taking an antidepressant, whilst the remaining 28.6% (n=2) reported that they were. Finally, of this sample, 42.9% (n=3) reported severe to extremely severe levels of depression, 28.6% (n=2) reported moderate levels of depression and 28.6% (n=2) obtained scores in the normal range for depression.

For the entire sample, the mean age for participants was 34.9 (± 12.3), with an age range of 18 – 70 Years of age. The mean level of education for the sample was 13.45 years (± 2.4) with the minimum level of education being 7 years and the maximum 21 years. However, 15.4% (n=8) participants failed to record their level of education and therefore this calculation is based on the information from 84.6% (n=44) participants who recorded this information. In terms of employment status, at the time of the assessment, 48.1% (n=25) of the sample were employed, 32.7% were unemployed (n=17), 13.5% (n=7) were involved in full time study and 1.9% (n=1) reported being retired. Regarding marital status, at the time of the assessment, 50% (n=26) of the sample were single, 21.2% were

158 married (n=11), 21.2% (n=11) had a partner, 5.7% (n=3) were separated or divorced and 1.9% (n=1) reported being widowed. Furthermore, 57.7% (n=30) reported not having any children, whilst the remaining 42.3% (n=22) reported having 1 or more children. In respect of antidepressant medications, 69.2% (n=36) denied taking current medications, whilst the remaining 30.8% (n=16) reported currently taking antidepressant medications. In terms of depression levels, as measured by the DASS scores, 34.6% (n=18) obtained scores in the severe to extremely severe range, 25% (n=13) were in the mild to moderate range, and 40.4% (n=21) obtained scores in the normal range. See Table 7.1 for a summary of the demographic profile of participants.

159 Table 7.1 Demographic profile of participants Eating Disorder Unit Anxiety Disorder Unit Characteristic Inpatient Outpatient Entire Sample ED Only (n=50) (n=50) (n=52) (n=7) Age (Years) Mean (± sd) 25.4 (± 8.3) 25 (± 6.4) 34.9 (± 12.3) 31.3 (± 12.8) Education (Years) Mean (± sd) 14.2 (±2) 13.6 (± 2.1) 13.45 (± 2.4) 13 (± 1.2) Employment Status % (n) Employed 46 (23) 36 (18) 48.1 (25) 57.1 (4) Unemployed 30 (15) 22 (11) 32.7 (17) 14.3 (1) F/T Student 24 (12) 42 (21) 13.5 (7) 28.6 (2) Retired 0 (0) 0 (0) 1.9 (1) 0 (0) Marital Status % (n) Married / Partner 22 (11) 36 (18) 42.4 (22) 49.9 (3) Single 72 (36) 60 (30) 50 (26) 57.1 (4) Separated/Divorced 6 (3) 4 (2) 5.7 (3) 0 (0) Widowed 0 (0) 0 (0) 1.9 (1) 0 (0) Children ( 1 or more) % (n) 8 (4) 20 (10) 42.3 (22) 42.9 (3) Antidepressant Medication % (n) 74 (37)* 40 (20) 30.8 (16) 28.6 (2) Depression Level % (n) Normal 12 (6) 20 (10) 40.4 (21) 28.6 (2) Mild – Moderate 28 (14) 32 (16) 25 (13) 28.6 (2) Severe – Ex Severe 48 (24) 46 (23) 34.6 (18) 42.9 (3) *P<0.05 v Outpatient ED (χ² test)

160

Table 7.2 Eating disorder characteristics of participants Eating Disorder Unit Anxiety Disorder Unit Characteristic Inpatient Outpatient ED Only (n=50) (n=50) (n=7) AN % (n) 66 (33) 12 (6) 0 (0) BN % (n) 12 (6) 30 (15) 0 (0) EDNOS % (n) 22 (11) 58 (29) 100 (7) Duration of ED (Months) Mean (± sd) 88.3 (± 78.5) 99.1 (±76.8) 147.4 (± 105.9) Onset of ED (Years) Mean (± sd) 17.9 (± 6.3) 16.8 (± 4.7) 19 (±9.9) BMI (kg/m²) Mean (± sd) 17.3 (± 3.2) * 20.4 (± 3.2) 27.7 (± 12.4) Objective Bingeing % (n) 38 (19) 54 (27) 71.5 (5) Self Induced Vomiting % (n) 50 (25) 52 (26) 14.3 (1) Laxative Abuse ª % (n) 24 (12) † 4 (2) 0 (0) Excessive Exercise % (n) 44 (22) 38 (19) 42.9 (3) * P<0.01 v outpatient ED † P<0.01 v outpatient ED ª Some cells had an expected count less than 5, in these cases a Fisher’s exact significance test was selected

161 Table 7.3 Demographic and clinical characteristics of eating disorder subtypes (Eating Disorder Units Only) Characteristic AN BN EDNOS Whole Sample (n=39) (n=21) (n=40) (n=100) Age (Years) ** Mean (± sd) 26.3 (± 9.1) 23.7 (±4.4) 25 (±6.72) 25.2 (±7.3) Education (Years) Mean (± sd) 14.1 (±2.0) 13.9 (±1.8) 13.7 (±2.2) 25.2 (±7.3) Employment Status % (n) ª Employed 43.6 (17) 47.6 (10) 35 (14) 41 (41) Unemployed 33.3 (13) 19 (4) 22.5 (9) 26 (26) F/T Student 23.1 (9) 33.3 (7) 42.5 (17) 33 (33) Retired 0 (0) 0 (0) 0 (0) 0 (0) Marital Status % (n) Married / Partner 25.6 (10) 23.8 (5) 35 (14) 29 (29) Single 64.1 (25) 71.4 (15) 65 (26) 66 (66) Separated/Divorced 10.2 (4) 4.8 (1) 0 (0) 5 (5) Widowed 0 (0) 0 (0) 0 (0) 0 (0) Children ( 1 or more) % (n) 15.4 (6) 0 (0) 20 (8) 14 (14) Depression Level % (n) a Normal 12.8 (5) 14.3 (3) 20 (8) 16 (16) Mild – Moderate 28.2 (11) 33.4 (7) 30 (12) 30 (30) Severe – Ex Severe 48.7 (19) 52.4 (11) 42.5 (17) 47 (47) Duration of ED (Months) Mean (± sd) 89.1(±6.9) 87.33 (±54.8) 101.8 (±84.9) 93.7 (±77.4) Onset of ED (Years) Mean (± sd) 18.8 (±6.9) 16.4 (±2.9) 16.4 (±4.9) 17.4 (±5.6) BMI (kg/m²) ** Mean (± sd) 15.6 (±1.1)† 21.4 (±2.8) 20.7 (±3.1) 18.8 (±3.6) Objective Bingeing % (n) 20.5 (8) 100 (21) 42.5 (17) 46 (46) Self Induced Vomiting % (n) 38.5 (15) 85.7 (18) 45 (18) 51 (51) Laxative Abuse % (n) ª 15.4 (6) 14.3 (3) 12.5 (5) 14 (14) Excessive Exercise % (n) 38.5 (15) 23.8 (5) § 52.5 (21) 41 (41) ** Levene’s test for equality of variances was significant, so equal variances were not assumed † P<0.01 v BN & EDNOS § P<0.05 vAN & EDNOS ª Some cells had an expected count less than 5, in these cases a Fisher’s exact significance test was selected

162 7.5 Sample Comparisons Pearson’s Chi-square tests and independent t-tests were conducted to examine any differences between the inpatient and outpatient ED samples. The data presented in tables 7.1 and 7.2 indicates that there were no significant differences between the samples N=100 (p<0.05), for age, education and N=99 (p<0.05) for illness duration and illness age of onset. A chi-square analysis revealed no significant differences between employment status, marital status (married or single), number of children, depression scores, the presence of bingeing, vomiting and excessive exercise between inpatient and outpatient ED samples. Significantly more inpatients reported taking antidepressant medications than the outpatient ED sample (χ² (1, N=57) = 5.1, p<0.05). Furthermore, significantly more of the inpatient ED sample reported laxative abuse than the outpatient sample (χ² (1, N=14) = 7.1, p<0.01). The inpatient ED sample also had significantly lower BMI scores than those in the outpatient ED sample (t(98)= -4.91, p=0.00).

Pearson’s Chi-square tests and one way Analysis of Variance (ANOVA) analyses were also conducted to examine any differences between the AN, BN and EDNOS samples across the entire inpatient and outpatient ED sample. Due to small participant numbers, the subgroups within each of the ED diagnoses were not analysed separately. The data presented in table 7.3 indicates that there were no significant differences between the samples N=100 (p<0.05), for age and education and N=99 (p<0.05) for illness duration and illness age of onset. There was a significant difference between BMI scores across

the samples (F(2,97)= 58.8, p=0.00, η²= 0.55) and a Games-Howell post Hoc comparison revealed the AN sample had significantly lower BMI scores than those in the BN or EDNOS samples. There was no significant difference found between BMI scores in the BN sample and EDNOS sample.

A chi-square analysis revealed no significant differences between employment status, marital status (married or single), number of children, depression scores, the presence of bingeing, vomiting and laxative abuse between the AN, BN and EDNOS samples. There was a statistically significant difference in the use of excessive exercise between samples (χ² (2, N=41) = 9.6, p<0.01), with the EDNOS sample reporting the most use of excessive

163 exercise (21, 52.5%), while the least use was reported by the BN sample (5, 23.8%). Excessive exercise amongst the AN sample was reported by 15 (38.5%) of the participants. A further chi square analysis revealed no statistically significant difference between the use of excessive exercise amongst the EDNOS and AN sample.

For the purpose of statistical analysis and to ensure adequate power, martial status was recorded as a dichotomous variable, single or partnered. Individuals who reported having been previously divorced or separated but were currently in a relationship were coded as partnered and those who reported not currently being in a relationship were coded as single.

164

CHAPTER 8 RESULTS

This chapter presents the analyses conducted to address the aims, objectives and hypotheses of the current study, and the results obtained from these analyses. All statistical analyses were performed using SPSS for Windows (Version 15.0).

8.1 The Prevalence of Comorbid Anxiety and Eating Disorders One of the primary aims of this study was to investigate the prevalence of comorbid eating and anxiety disorders amongst an eating disorder sample and anxiety disorder sample. This aim also included establishing which of the anxiety disorders were most prevalent. The results have been summarised and presented for the inpatient & outpatient eating disorder samples, the entire eating disorder sample and the anxiety disorder sample.

8.1.1 Inpatient Eating Disorder Sample In relation to anxiety disorder diagnoses, 74% (n= 37) of the inpatient ED sample (n=50) met DSM-IV criteria for a current primary DSM-IV anxiety disorder diagnosis, whilst the remaining 26% (n=13) did not. Secondary anxiety disorders were also identified in 42% (n=21) of the inpatient sample. Of the secondary anxiety disorders diagnosed, social phobia was the most frequent (48%, n=10), followed by GAD (33%, n=7), OCD (9.5%, n=2), PTSD (4.8%, n=1) and panic disorder with agoraphobia (4.8%, n=1). Furthermore, subthreshold anxiety disorders were also identified in 12% (n=6) of the sample, with subthreshold OCD identified in 3 participants, subthreshold specific phobia in 2 participants and subthreshold GAD in 1 of the participants.

Table 8.1 shows the current prevalence of at least one primary anxiety disorder in each of the eating disorder subgroups across the entire inpatient ED sample.

165 Figure 8.1 shows the frequencies of primary anxiety disorder diagnoses in the comorbid anxiety and eating disorder sample.

Of the inpatient sample (n=50), 32% (n=16) reported having experienced at least one trauma in their lifetime. Furthermore, of the women who disclosed having experienced a trauma, 25% (n=4) were unable to continue the PTSD assessment, due to their distress, and therefore the presence of PTSD as a diagnosis was not confirmed. 6% (n=3) of the inpatient sample met DSM-IV criteria for a possible diagnosis of OCPD.

An independent sample t-test analysis was also conducted to examine any differences between the clinical characteristics of the comorbid eating disorder and anxiety group and the eating disorder only group across the inpatient sample. Due to small participant numbers, the subgroups within each of the ED diagnoses were not analysed separately. The data presented in Table 8.2 indicates that there were no significant differences between the samples N=50 (p<0.05), for illness duration and illness age of onset, BMI, bingeing and purging episodes per month or use of excessive exercise. For the purpose of obtaining sufficient statistical power, a total purgative abuse score was calculated comprising the number of people who reported engaging in self-induced vomiting as well as laxative abuse for both the comorbid eating disorder and anxiety sample and the eating disorder only sample. Significantly more of the comorbid eating disorder and anxiety sample reported purgative abuse than the eating disorder only sample (χ² (1, N=37) = 22.7, p<0.001).

Due to small participant numbers, no statistical analyses were undertaken to consider the differences between anxiety diagnoses amongst the AN, BN and EDNOS diagnostic categories.

166 Table 8.1 Current prevalence of anxiety disorders across the inpatient ED sample Disorder AN BN EDNOS Whole (n=33) (n=6) (n=11) Sample (n=50) Any Anxiety Disorder 69.7 (23) 100 (6) 72.7 (8) 74 (37) Social Phobia 27.3 (9) 33.3 (2) 27.3 (3) 28 (14) PTSD 18.2 (6) 16.7 (1) 27.3 (3) 20 (10) GAD 12.1 (4) 50 (3) 9.1 (1) 16 (8) OCD 6.1 (2) 0 (0) 0 (0) 4 (2) Specific Phobia 3 (1) 0 (0) 0 (0) 2 (1) Panic with 3 (1) 0 (0) 0 (0) 2 (1) Agoraphobia Panic without 0 (0) 0 (0) 9.1 (1) 2 (1) Agoraphobia ASD 0 (0) 0 (0) 0 (0) 0 (0) Note: Values are expressed as the percentage %(n)

Figure 8.1 Prevalence of primary anxiety disorders diagnosed across the inpatient ED comorbid sample (N=37)

40% 38% 35% Social Phobia 30% 27% PTSD 25% 22% GAD 20% OCD 15% Panic /Ag Percentage(%) 10% 5% 5% Specific Phobia 5% 3% 0% Anxiety Disorder Diagnosis

Note: All values are the Mean ± sd (Range)

167 Table 8.2 Summary of clinical characteristics of comorbid ED and ED only group across the inpatient sample (N=50) Characteristic Comorbid ED and AD ED Only (n=37) (n=13) AN % (n) 62.2 (23) 76.9 (10) BN % (n) 16.2 (6) 0 (0) EDNOS % (n) 21.6 (8) 23.1 (3) Duration of ED (Months) Mean (± sd) 92.5 (±77.7) 75.3 (±82.9) Onset of ED (Years) Mean (± sd) 17.95 (±6.5) 18 (±6.1) BMI (kg/m²) Mean (± sd) 17.6 (±3.3) 16.4 (±3.1) Objective binge episodes / month Mean (± sd) 14.4 (±31.8) 10.7 (±19.4) Self Induced Vomiting episodes /month 39.5 (±81.4) 27.2 (±45.9) Mean (± sd) Laxative Abuse % (n) 32.4 (12) 0 (0) Purgative Abuse Total % (n) ª 89.2 (33)* 30.8 (4) Excessive Exercise Minutes / day Mean (± sd) 61.4 (±93.3) 25.4 (±42.2) ª Some cells had an expected count less than 5, in these cases a Fisher’s exact significance test was selected * P<0.001 v ED only group

168 8.1.2 Outpatient Eating Disorder Sample In terms of anxiety disorder diagnoses, 56% (n= 28) of the outpatient ED sample (n=50) met DSM-IV criteria for a current primary DSM-IV anxiety disorder diagnosis, whilst the remaining 44% (n=22) did not. Secondary anxiety disorders were also identified in 26% (n=13) of the outpatient sample. Of the secondary anxiety disorders diagnosed, social phobia was the most frequent (61.5%, n=8), followed by GAD (23.1%, n=3), OCD (7.7%, n=1) and panic disorder without agoraphobia (7.7%, n=1). Subthreshold anxiety disorders were also identified in 18% (n=9) of the sample, with subthreshold GAD identified in 3 participants, subthreshold social phobia, panic disorder with agoraphobia and OCD were each identified in 2 participants.

Table 8.3 shows the current prevalence of at least one primary anxiety disorder in each of the eating disorder subgroups across the entire outpatient sample. Figure 8.2 shows the frequencies of primary anxiety disorder diagnoses in the comorbid anxiety and eating disorder sample.

Of the outpatient sample (n=50), 32% (n=16) reported having experienced at least one trauma in their lifetime. Furthermore, of the women who disclosed having experienced a trauma, 12.5% (n=2) were unable continue the PTSD assessment, due to their distress, and therefore the presence of PTSD as a diagnosis was not confirmed. In relation to OCPD, 6% (n=3) of the outpatient sample met DSM-IV criteria for a possible diagnosis of OCPD.

An independent sample t-test and Mann-Whitney test was also conducted to examine any differences between the clinical characteristics of the comorbid eating disorder and anxiety group and the eating disorder only group across the outpatient sample. Due to small participant numbers, the subgroups within each of the ED diagnoses were not analysed separately. The data presented in Table 8.4 indicates that there were no significant differences between the samples where N=50 (p<0.05) for illness duration and illness age of onset, BMI, purging episodes per month or use of excessive exercise. There was a significant difference between these samples on reported episodes of objective

169 bingeing per month z(N=50) = 2.4, p=0.15, r²=0.1. The mean number of reported episodes of bingeing was lower in the comorbid eating disorder and anxiety sample (M=9.8, SD=18.4) than in the ED only sample (M=21.9, SD=24.3). For the purpose of obtaining sufficient statistical power, a total purgative abuse score was calculated comprising the number of people who reported engaging in self induced vomiting as well as laxative abuse for both the comorbid eating disorder and anxiety sample and the eating disorder only sample. There was no significant difference found between reported purgative abuse for both samples.

Due to small participant numbers, no statistical analyses were undertaken to consider the differences between anxiety diagnoses amongst the AN, BN and EDNOS diagnostic categories.

170 Table 8.3 Current prevalence of anxiety disorders across the outpatient ED sample Disorder AN BN EDNOS Whole (n=6) (n=15) (n=29) Sample (n=50) Any Anxiety Disorder 66.6 (4) 60 (9) 51.7 (15) 56 (28) Social Phobia 16.6 (1) 33.3 (5) 24.1 (7) 26 (13) PTSD 16.6 (1) 13.3 (2) 13.8 (4) 14 (7) GAD 33.3 (2) 13.3 (2) 10.3 (3) 14(7) OCD 0 (0) 0 (0) 3.4 (1) 2 (1) Specific Phobia 0 (0) 0 (0) 0 (0) 0 (0) Panic with 0 (0) 0 (0) 0 (0) 0 (0) Agoraphobia Panic without 0 (0) 0 (0) 0 (0) 0 (0) Agoraphobia ASD 0 (0) 0 (0) 0 (0) 0 (0) Note: Values are expressed as the percentage %(n)

Figure 8.2 Prevalence of primary anxiety disorders diagnosed across the outpatient ED comorbid sample (N=28)

50% 46%

40% Social Phobia 30% 25% 25% PTSD 20% GAD OCD Percentage(%) 10% 4% 0% Anxiety Disorder Diagnosis

171 Table 8.4 Summary of clinical characteristics for the comorbid ED and ED only groups across the outpatient sample (N=50) Characteristic Comorbid ED and AD ED Only (n=28) (n=22) AN % (n) 14.3 (4) 9 (2) BN % (n) 32.1 (9) 27.3 (6) EDNOS % (n) 53.6 (15) 63.6 (14) Duration of ED (Months) Mean (± sd) 116 (±86.9) 77.5 (±56.4) Onset of ED (Years) Mean (± sd) 16.6 (±4.7) 16.95 (±4.8) BMI (kg/m²) Mean (± sd) 20.4 (±2.7) 20.4 (±3.7) Objective binge episodes / month Mean (± sd) 9.8 (±18.4)* 21.9 (±24.3) Self Induced Vomiting episodes /month Mean (± sd) 16.3 (±25.5) 30.6 (±62.5) Laxative Abuse % (n) 7.1 (2) 0 (0) Purgative Abuse Total % (n) 57.1 (16) 54.5 (12) Excessive Exercise Minutes / day Mean (± sd) 32.1 (±50.9) 22.5 (±29.9) * P<0.05 v ED only group

8.1.3 Entire Inpatient and Outpatient Eating Disorder Sample Regarding anxiety disorder diagnoses, 65% (n= 65) of the entire ED sample (N=100) met DSM-IV criteria for a current primary DSM-IV anxiety disorder diagnosis, whilst the remaining 35% (n=35) did not. Secondary anxiety disorders were also identified in 34% (n=34) of the entire ED sample. Of the secondary anxiety disorders diagnosed, social phobia was the most frequent (52.9%, n=18), followed by GAD (29.4%, n=10), OCD (8.8%, n=3), panic disorder with and without agoraphobia (5.9%, n=2) and PTSD (2.9%,

172 n=1). Furthermore, subthreshold anxiety disorders were also identified in 15% (n=15) of the sample, with subthreshold OCD identified in 5 participants, subthreshold GAD in 4 of the participants, subthreshold social phobia, specific phobia and panic disorder with agoraphobia were each identified in 2 participants. Table 8.5 shows the current prevalence of anxiety disorders in each of the eating disorder subgroups of at least one primary anxiety disorder and across the entire inpatient and outpatient sample. Figure 8.3 shows the frequencies of primary anxiety disorder diagnoses in the comorbid anxiety and eating disorder sample.

Of the entire sample (N=100), 32% (n=32) reported having experienced at least one trauma in their lifetime. Furthermore, of the women who disclosed having experienced a trauma, 18.8% (n=6) were unable continue the PTSD assessment, due to their distress, and therefore the presence of PTSD as a diagnosis was not confirmed. In terms of the experience of trauma across the eating disorder subtypes, 30.8% (n=12) of AN, 23.8% (n=5) of BN and 37.5% (n=15) of the EDNOS participants reported having experienced at least one trauma. There were no significant differences found between the reported experience of trauma across the ED subtypes. Regarding OCPD, 6% (n=6) of the entire sample met DSM-IV criteria for a possible diagnosis of OCPD, and across the eating disorder subtypes this included 7.7% (n=3) of the AN sample and 7.5% (n=3) of the EDNOS sample.

An independent sample t-test and chi-square analysis was also conducted to examine any differences between the clinical characteristics of the comorbid eating disorder and anxiety group and the eating disorder only group across the entire inpatient and outpatient sample. Due to small participant numbers, the subgroups within each of the ED diagnoses were not analysed separately. The data presented in Table 8.6 indicates that there were no significant differences between the groups where N=100 (p<0.05) for illness duration and illness age of onset, BMI, depression scores, bingeing and purging episodes per month. Using the t-test for unequal variance because of violation of the assumption of homogeneity of variance, a statistically significant difference between these groups on reported episodes of excessive exercise was found (t(98) = 2.22, p<0.05). The mean

173 number of reported episodes excessive exercise was higher in the comorbid eating disorder and anxiety group (M=48.8, SD=78.8) than in the ED only group (M=23.6, SD=34.4). For the purpose of obtaining sufficient statistical power, a total purgative abuse score was calculated comprising the number of people who reported engaging in self induced vomiting as well as laxative abuse for both the comorbid eating disorder and anxiety group and the eating disorder only group. Significantly more of the comorbid eating disorder and anxiety group reported purgative abuse than the eating disorder only group (χ² (1, N=65) = 16.8, p<0.001).

174

Table 8.5 Current prevalence of anxiety disorders across the entire ED sample Disorder AN BN EDNOS Whole (n=39) (n=21) (n=40) Sample (N=100) Any Anxiety Disorder 69 (27) 71 (15) 57.5 (23) 65 (65) Social Phobia 26 (10) 33 (7) 25 (10) 27 (27) PTSD 18 (7) 14 (3) 17.5 (7) 17 (17) GAD 15 (6) 24 (5) 10 (4) 15 (15) OCD 5 (2) 0 (0) 2.5 (1) 3 (3) Specific Phobia 3 (1) 0 (0) 0 (0) 1 (1) Panic with 3 (1) 0 (0) 0 (0) 1 (1) Agoraphobia Panic without 0 (0) 0 (0) 1 (1) 1 (1) Agoraphobia ASD 0 (0) 0 (0) 0 (0) 0 (0) Note: Values are expressed as the percentage %(n)

Figure 8.3 Prevalence of primary anxiety disorders diagnosed across the entire comorbid ED sample (N=65)

45% 42% 40% 35% Social Phobia 30% 26% PTSD 25% 23% GAD 20% OCD 15% Panic/Ag Percentage(%) 10% Specific Phobia 5% 3% 5% 2% 0% Anxiety Disorder Diagnosis

175 Table 8.6 Summary of clinical characteristics of comorbid ED and ED only group across the entire ED sample (N=100) Characteristic Comorbid ED and AD ED Only (n=65) (n=35) AN % (n) 41.5 (27) 34.3 (12) BN % (n) 23.1 (15) 17.1 (6) EDNOS % (n) 35.4 (23) 48.6 (17) Duration of ED (Months) Mean (± sd) 102.6 (±81.96) 76.7 (±65.7) Onset of ED (Years) Mean (± sd) 17.4 (±5.8) 17.3 (±5.2) BMI (kg/m²) Mean (± sd) 18.8 (±3.4) 18.9 (±3.96) Objective binge episodes / month Mean (± sd) 12.4 (±26.7) 17.74 (±22.98) Self Induced Vomiting episodes /month Mean (± sd) 29.5 (±64.2) 29.31 (±56.2) Laxative Abuse % (n) 21.5 (14) 0 (0) Purgative Abuse Total % (n) 75.4 (49)** 45.7 (16) Excessive Exercise Minutes / day Mean (± sd) 48.8 (±78.8)* 23.6 (±34.4) Depression Level % (n) Normal 10.8 (7) 25.7 (9) Mild – Moderate 26 (17) 37 (13) Severe – Ex Severe 53.8 (35) 34.3 (12) * P<0.05 v ED only group ** P<0.001 v ED only group

176

An ANOVA was conducted comparing eating disorder symptom levels (BMI, duration of illness, onset of eating disorder, number of episodes of bingeing and vomiting an excessive exercise use) across participants with different anxiety disorder diagnoses. Unfortunately the low subject numbers (n<5) for some of the anxiety disorders (namely OCD, specific phobia and panic disorder) means that interpretation of those results is problematic due to insufficient statistical power. In any case, the results of these analyses were not significant.

Figures 8.4 to Figure 8.8 demonstrate the differences between the anxiety disorders across the entire eating disorder sample. For the purpose of obtaining sufficient statistical power, a total purgative abuse score was calculated for eating disorder participants with comorbid anxiety. This score comprised the number of people who reported engaging in self induced vomiting as well as laxative abuse across the entire ED sample (Figure 8.9 shows the frequency of purgative abuse across the anxiety disorders). A chi-square analysis was performed to establish whether there were differences between purgative abuse across each of the anxiety disorder diagnoses. Due to insufficient statistical power, analyses were not conducted where the purgative total score was 1 or less, and this was the case for Panic Disorder, OCD and Specific Phobia. Results of this analysis revealed that there was no significant difference in purgative abuse between individuals with social phobia, PTSD and GAD.

177 Figure 8.4 Mean BMI scores for each anxiety disorder across entire ED sample

20.00

18.00

16.00 Mean BMI 14.00

12.00

10.00 Panic with Panic w/o Social GAD OCD Specific PTSD Ag Ag Phobia Phobia Anxiety Disorder Diagnosis

178 Figure 8.5 Mean ED onset age for each anxiety disorder across entire ED sample

14 Mean Onset ED (Years) Age 12

10 Panic with Panic w/o Social GAD OCD Specific PTSD Ag Ag Phobia Phobia Anxiety Disorder Diagnosis

179 Figure 8.6 Mean ED duration for each anxiety disorder across entire ED sample

300

200

100 Mean ED Length (Months) Mean Length ED

0 Panic with Panic w/o Social GAD OCD Specific PTSD Ag Ag Phobia Phobia Anxiety Disorder Diagnosis

180 Figure 8.7 Mean binge episodes for each anxiety disorder across entire ED sample

15 Binging Binging per Month

5 Mean No of Episodes of Mean No

0 Panic with Panic w/o Social GAD OCD Specific PTSD Ag Ag Phobia Phobia Anxiety Disorder Diagnosis

181

Figure 8.8 Mean exercise episodes for each anxiety disorder across entire ED sample

120

100

40 Mean Exercise Per Day (Minutes) Per Day Mean Exercise 20

0 Panic with Panic w/o Social GAD OCD Specific PTSD Ag Ag Phobia Phobia Anxiety Disorder Diagnosis

Figure 8.9 Purgative abuse across the anxiety disorders

25 21 20 Social Phobia 16 15 PTSD 10 GAD

Score Score 10 OCD 5 Panic Disorder Purgative Abuse Abuse Purgative 1 1 0 0 Specific Phobia Anxiety Disorder

182

8.1.4 Outpatient Anxiety Eating Disorder Sample In terms of eating disorder diagnoses, 13.5% (n=7) were diagnosed as meeting DSM-IV criteria for an eating disorder (EDNOS). Of the participants diagnosed with EDNOS, 42.8% (n=3) presented with subthreshold BN, 28.6% (n=2) with subthreshold AN and 28.6% (n=2) with Binge Eating Disorder. The primary anxiety disorders for which participants sought treatment included OCD (n=3), social phobia (n=1), GAD (n=1), Specific Phobia (n=1) and PTSD (n=1). Regarding secondary diagnoses, there was only 1 participant who was diagnosed with a secondary anxiety disorder (social phobia). There were no cases of subthreshold anxiety disorders identified in the comorbid anxiety and eating disorder group. The experience of at least 1 trauma was reported by 3 of the participants, however in only 1 of these cases was a diagnosis of PTSD met.

Due to the small number of participants with eating disorders, further statistical analyses and comparisons were not conducted on this group.

8.2 The Temporal Relationship between comorbid Anxiety and Eating Disorders Another aim of this study was to investigate the temporal relationship between the onset eating and anxiety disorders amongst individuals with comorbid diagnoses. The results for this aim have been summarised and presented for the inpatient & outpatient eating disorder samples, the entire eating disorder sample and the anxiety disorder sample.

8.2.1 Inpatient Sample The majority (64.9%, n=24) of the comorbid anxiety and eating disorder sample reported the onset of the anxiety disorder to precede the onset of the eating disorder (see Figure 8.10 for a summary of percentages for the reported onset of anxiety and eating disorder pathology and Table 8.7 for a summary of mean (± sd) length and age of onset for eating and anxiety disorders). Table 8.8 displays the mean (± sd) age of onset and range for all of the anxiety disorders across each of the eating disorder subtypes.

183 Figure 8.10 Temporal relationship between ED and anxiety disorder onset across the inpatient ED comorbid sample (N=37)

70% 65% 60% 50% Anx before ED 40% Same Time 30% 19% Anx after ED 16%

Percentage(%) 20% 10% 0% Temporal Relationship

Table 8.7 Summary of eating disorder and anxiety disorder length and onset across the comorbid inpatient ED sample (N=37) Parameter Eating Disorder Anxiety Disorder Length of Disorder (Months) Mean (± sd) 92.5 (±77.7) 126.6 (±80.5) Age of Onset (Years) Mean (± sd) 17.95 (±6.5) 15.2 (±9.0)

184 Table 8.8 Age of onset (years) of anxiety disorders across the inpatient ED sample AN BN EDNOS Whole Sample Disorder (n=23) (n=6) (n=8) (n=37) Any Anxiety 15.3 ± 10.1 11± 3.6 18 ± 8.1 15.19 ± 9.0 Disorder (5 – 43) (6 – 15) (5 – 30) (5 – 43) 10.89 ± 4.6 10 ± 5.7 20 ± 9.5 12.71 ±6.7 Social Phobia (5 – 16) (6 - 14) (11 – 30) (5 – 30) 18.17 ± 8.7 10.0 ± 20 ± 6.2 17.9 ±7.7 PTSD (10 – 34) (10 – 10) (15 – 27) (10 – 34) 20.5 ± 16.1 12 ± 3.6 5.0 ± 0 15.38 ±12.3 GAD (5 – 43) (8 – 15) (5 – 5) (5 – 43) 11.5 ± 7.8 11.5 ±7.8 OCD (6 – 17) - - (6 – 17) 5.0 ± 0 5.0 ± 0 Specific Phobia - - (5 – 5) (5 – 5) Panic with 35.0 ± 0 35.0 ± 0

Agoraphobia (35 – 35) - - (35 – 35) Panic without 19.0 ± 0 19.0 ± 0 Agoraphobia - - (19 – 19) (19 – 19)

ASD - - - -

8.2.2 Outpatient Sample

The majority (75%, n=21) of the comorbid anxiety and eating disorder sample reported the onset of the anxiety disorder to precede the onset of the eating disorder (see Figure 8.11 for a summary of percentages for the reported onset of anxiety and eating disorder pathology and Table 8.9 for a summary of mean (± sd) length and age of onset for eating and anxiety disorders). Table 8.10 displays the mean (± sd) age of onset and range for all of the anxiety disorders across each of the eating disorder subtypes.

185 Figure 8.11 Temporal relationship between ED and anxiety disorder onset across the outpatient ED comorbid sample (N=28)

80% 75% 70% 60% 50% Anx before ED 40% Same Time 30% Anx after ED

Percentage(%) 14% 20% 11% 10% 0% Temporal Relationship

Table 8.9 Summary of eating disorder and anxiety disorder length and onset across the comorbid outpatient ED sample (N=28) Parameter Eating Disorder Anxiety Disorder Length of Disorder (Months) Mean (± sd) 116.04 (±86.9) 169.7 (±90.2) Age of Onset (Years) Mean (± sd) 16.6 (±4.7) 12.3 (±7.2)

186 Table 8.10 Age of onset (years) of anxiety disorders across the outpatient ED sample AN BN EDNOS Whole Sample Disorder (n=4) (n=9) (n=15) (n=28) Any Anxiety 19.5 ± 15.5 12.7 ± 4.7 10.1 ± 4.1 12.3 ± 7.3 Disorder (6 – 40) (5 – 17) (5 – 18) (5 – 40) 6.0 ± 0 12.6 ± 4.4 11.9 ± 5.1 11.7 ± 4.7 Social Phobia (6 – 6) (6 – 17) (5 – 18) (5 – 18) 9.0 ± 0 17.0 ± 0.0 10.0 ± 1.6 11.86 ± 3.7 PTSD (9 – 9) (17) (8 – 12) (8 – 17) 31.5 ± 12.0 8.5 ± 4.95 7.3 ± 2.5 14.6 ± 12.8 GAD (23 – 40) (5 – 12) (5 – 10) (5 – 40)

6.0 ± 0 6.0 ± 0 OCD - - (6 – 6) ( 6 – 6 )

Specific Phobia - - - -

Panic with Agoraphobia - - - - Panic without Agoraphobia - - - -

ASD - - - - Note: All values are the Mean ± sd (Range)

8.2.3 Entire Inpatient and Outpatient Eating Disorder Sample The majority (69.2%, n=45) of the comorbid anxiety and eating disorder sample reported the onset of the anxiety disorder to precede the onset of the eating disorder (see Figure 8.12 for a summary of percentages for the reported onset of anxiety and eating disorder pathology and Table 8.11 for a summary of mean (± sd) length and age of onset for eating and anxiety disorders). Table 8.12 displays the mean (± sd) age of onset and range for all of the anxiety disorders across each of the eating disorder subtypes.

187

Figure 8.12 Temporal relationship between ED and Anxiety Disorder Onset across the entire comorbid ED sample (N=65)

80% 69% 70% 60% 50% Anx before ED 40% Same Time 30% Anx after ED

Percentage(%) 20% 15% 15% 10% 0% Temporal Relationship

Table 8.11 Summary of eating disorder and anxiety disorder length and onset across the entire comorbid ED sample (N=65) Parameter Eating Disorder Anxiety Disorder

Length of Disorder (Months) 102.6 (±81.96) 145.2 (±86.8) Mean (± sd)

Age of Onset (Years) 17.4 (±5.8) 13.9 (±8.4) Mean (± sd)

188 Table 8.12 Age of onset (years) of anxiety disorders across the entire ED sample AN BN EDNOS Whole Sample Disorder (n=27) (n=15) (n=23) (n=65) Any Anxiety 15.9 ± 10.8 12.0 ± 4.2 16.4 ± 4.9 13.9 ± 8.4 Disorder (5 – 43) (5 – 17) (9 – 34) (5 – 43) 10.4 ± 4.6 11.9 ± 4.5 18.5 ± 5.5 12.2 ± 5.8 Social Phobia (5 – 16) (6 – 17) (12 – 33) (5 – 30) 16.9 ± 8.6 14.7 ± 4.0 12.9 ± 1.9 15.4 ± 6.9 PTSD (9 – 34) (10 – 17) (10 – 15) (8 – 34) 24.2 ± 14.7 10.6 ± 4.0 15.0 ± 2.8 15.0 ± 12.1 GAD (5 – 43) (5 – 15) (11 – 17) (5 – 43) 11.5 ± 7.8 15.0 ± 0 9.7 ± 6.4 OCD (6 – 17) - (15 – 15) (6 – 17) 5.0± 0 5.0 ± 0 Specific Phobia - (5 – 5) - (5 – 5) Panic with 35.0± 0 35.0 ± 0 Agoraphobia (35 – 35) - - (35 – 35) Panic without 19.0 ± 0 19.0 ± 0 Agoraphobia - - (19 – 19) (19 – 19)

ASD - - - - Note: All values are the Mean ± sd (Range)

189 8.2.4 Outpatient Anxiety Eating Disorder Sample In terms of the temporal relationship between the onset of the anxiety and eating disorder pathology, 5 participants reported the onset of the anxiety to precede the onset of the eating disorder, whilst the remaining 2 participants reported the onset of the anxiety to have occurred after the onset of the eating disorder. A summary of eating disorder and anxiety disorder mean (± sd) length and age of onset can be seen in Table 8.13.

Table 8.13 Summary of eating disorder and anxiety disorder length and onset across the outpatient anxiety sample (n=7) Parameter Eating Disorder Anxiety Disorder Length of Disorder (Months) 147.4 (±105.9) 197.1 (±161.1) Mean (± sd) Age of Onset (Years) 19 (±9.9) 14.9 (±9.2) Mean (± sd)

8.3 Comparisons Across the Comorbid and ED Only Sample The final aim of this study was to undertake comparisons across the comorbid sample with respect to the frequency of diagnosed anxiety disorders, the temporal onset, age of onset, illness duration and EDE scores. We were also interested in exploring potential differences on EDE scores across the entire ED sample (comorbid and ED only). Although the initial aim also included comparisons between comorbid groups in the eating disorder and anxiety sample, the small sample size in the anxiety sample was prohibitive in terms of meaningful analyses. Subsequently most of the analyses have only included comparison between the inpatient and outpatient samples, except for the EDE scores.

8.3.1 Comparison of the frequency of diagnosed anxiety disorders across the ED sample Chi-square analyses revealed that there was no statistically significant difference in diagnosed anxiety disorders between the inpatient and outpatient eating disorder sample, χ²(1, N=65)=1.25, p=0.26. Furthermore, analyses were conducted on differences between

190 frequencies of each of the anxiety disorders diagnosed between inpatient and outpatient samples, and no statistically significant differences were found. Due to small participant numbers, analyses were not conducted on differences between specific phobia, and panic disorder with and without agoraphobia. Table 8.14 shows the frequencies of diagnosed anxiety disorders between inpatient and outpatient eating disorder groups.

Table 8.14 Current prevalence of anxiety disorders across the inpatient and outpatient ED samples (N=100) Disorder Inpatient ED Outpatient ED (n=50) (n=50) Any Anxiety Disorder 74 (37) 56 (28) Social Phobia 28 (14) 26 (13) PTSD 20 (10) 14 (7) GAD 16 (8) 14(7) OCD 4 (2) 2 (1) Specific Phobia 2 (1) 0 (0) Panic with Agoraphobia 2 (1) 0 (0) Panic without Agoraphobia 2 (1) 0 (0) ASD 0 (0) 0 (0) Note: Values are expressed as the percentage %(n)

191 8.3.2 Comparison between anxiety and eating disorders temporal onset, age of onset and illness duration across the Inpatient and Outpatient ED sample With alpha set at 0.05, a two way chi-square analysis revealed that there was no statistical difference between the temporal relationship of anxiety disorder onset versus eating disorder onset between the inpatient and outpatient eating disorder sample, χ²(2, N=65)=0.96, p>0.05, Cramer’s V=0.12. Table 8.15 displays the frequencies of reported temporal relationship between eating and anxiety disorder across the eating disorder sample. Furthermore, a chi-square analysis revealed that there was no statistical difference between the temporal relationship between anxiety and eating disorder onset across eating disorder subtypes. Table 8.16 displays the frequencies of the reported temporal relationships between eating and anxiety disorders across the eating disorder subtypes. An independent sample t-test found no significant differences between comorbid inpatient and outpatient groups on eating disorder length and age of onset and anxiety disorder age of onset. However, a significant difference was found between these groups on anxiety disorder length (t(63)=-2.03, p<0.05), with the mean anxiety disorder duration in the outpatient group being greater than that of the inpatient sample. Table 8.17 displays the mean (± sd) of anxiety and eating disorder length and age of onset across the inpatient and outpatient comorbid groups. A further chi-square analysis comparing the temporal onset of anxiety disorders compared with eating disorders across the ED subtypes did not find any statistically significant results (see Table 8.18 for a summary of frequencies for temporal onset across the ED sample).

Table 8.15 Temporal relationship of anxiety and eating disorders across the ED sample (N=65) Temporal Relationship Inpatient Outpatient Anxiety before ED 64.9 (24) 75 (21)

Anxiety same time as ED ª 18.9 (7) 10.7 (3)

Anxiety after ED ª 16.2 (6) 14.3 (4) Note: Values are expressed as the percentage %(n) ª Some cells had an expected count less than 5, in these cases a Fisher’s exact significance test was selected

192 Table 8.16 Temporal relationship of anxiety and eating disorders across the ED subtypes (N=65) Temporal AN BN EDNOS Relationship (n=27) (n=15) (n=23) Anxiety before ED 77.7 (21) 60 (9) 65.2 (15) Anxiety same time as 11.1 (3) 26.6 (4) 13 (3)

ED ª

Anxiety after ED ª 11.1 (3) 13.3 (2) 21.7 (5) Note: Values are expressed as the percentage %(n) ª Some cells had an expected count less than 5, in these cases a Fisher’s exact significance test was selected

Table 8.17 Summary of eating disorder and anxiety disorder length and onset across inpatient and outpatient comorbid samples (N=65) Parameter Inpatient Outpatient (n=37) (n=28) Length of Eating Disorder (Months) 92.5 (± 77.7) 116.04 (±86.9) Mean (± sd) Age of Onset Eating Disorder (Years) 17.95 (± 6.5) 16.6 (±4.7) Mean (± sd) Length of Anxiety Disorder (Months) 126.6 (± 80.5)* 169.7 (±90.2) Mean (± sd) Age of Onset Anxiety Disorder (Years) 15.2 (± 9.0) 12.3 (±7.2) Mean (± sd)

* P<0.05 v Outpatient group

193 Table 8.18 Onset of anxiety disorders relative to the time of onset of eating disorders for comorbid ED and anxiety sample (N=65)

Inpatient n=37 Outpatient n=28 Entire Sample N=65 Anxiety Temp AN BN EDNOS AN BN EDNOS AN BN EDNOS Diagnosis Onset n=23 n= 6 n= 8 n= 4 n=9 n= 15 n=27 n=15 n=23 Any Prior 78(18) 67 (4) 25 (2) 75 (3) 56 (5) 87 (13) 78 (21) 60 (9) 65 (15) anxiety Same 13 (3) 33 (2) 25 (2) - 22 (2) 7 (1) 11 (3) 27 (4) 13 (3) disorder After 9 (2) - 50 (4) 25(1) 22 (2) 7 (1) 11 (3) 13 (2) 22(5) Prior 35 (8) 17 (1) 13 (1) 25(1) 33 (3) 40 (6) 33 (9) 27 (4) 30 (7) Social Same 4 (1) 17 (1) 13 (1) - 22 (2) 7 (1) 4 (1) 20 (3) 9 (2) Phobia After - - 13 (1) - - - - - 4 (1) Prior 22 (5) 17 (1) - 25(1) - 20 (3) 22 (6) 7 (1) 13 (3) PTSD Same - - 13 (1) - - - - - 4 (1) After 4 (1) - 25 (2) - 22 (2) 7 (1) 4 (1) 13(2) 13 (3) Prior 9 (2) 33 (2) 13 (1) 25(1) 22 (2) 20 (3) 11 (3) 27 (4) 17 (4) GAD Same 9 (2) 17 (1) - - - - 7 (2) 7 (1) - After - - - 25(1) - - 4 (1) - - Prior 9 (2) - - - - 7 (1) 7 (2) - 4 (1) OCD Same ------After ------Prior ------Panic with Same ------AG After 4 (1) - - - - - 4 (1) - - Prior ------Panic w/o Same ------AG After - - 13 (1) - - - - - 4 (1) Prior 4 (1) - - - - - 4 (1) - - Specific Same ------Phobia After ------Prior ------ASD Same ------After ------Note: all values are expressed as the whole percentage % (n) ª Some cells had an expected count less than 5, in these cases a Fisher’s exact significance test was selected

194 8.3.3 Summary and comparison of EDE scores across the entire sample Scores for the EDE subscales (including restraint concern, eating concern, shape concern, weight concern and a global score) were computed for all eating disorder participants across inpatient ED, outpatient ED and anxiety outpatient samples. The mean (± sd) scores are presented at Table 8.19. An ANOVA was conducted to compare differences between each of the groups on EDE scores. Due to the unequal subject numbers, an LSD post hoc comparison with p<0.01 was selected. ED inpatients scored significantly higher on the restraint concern subscale than the ED outpatients (F(2,104)= 4.25, p=0.01). Anxiety disorder participants scored significantly lower on the eating concern subscale than the

ED inpatients or ED outpatients (F(2,104)= 4.54, p=0.01). Scores for the EDE subscales were compared for all eating disorder participants with an anxiety disorder and those without an anxiety diagnosis. Anxiety disorder unit participants with eating disorders were not included in these analyses. The mean (± sd) scores are presented in Table 8.20. No significant differences were found between these scores. Furthermore, a logistic regression analysis was conducted to assess whether these five variables significantly predicted whether or not an anxiety disorder was diagnosed, however none of these variables, either separately or together were found to be significant.

Table 8.19 Summary of EDE scores across the ED sample (N=107) Eating Disorder Unit Anxiety Disorder Unit EDE Subscales Inpatient Outpatient ED Only (n=50) (n=50) (n=7) Restraint Concern

Mean (± sd) 4.5 (± 0.9)* 3.9 (± 1.1) 3.7 (± 1.0) Eating Concern

Mean (± sd) 3.9 (± 1.1) 3.9 (± 1.3) 2.5 (± 1.4)§ Shape Concern

Mean (± sd) 4.4 (± 1.6) 4.6 (± 1.2) 3.97 (± 0.8) Weight Concern

Mean (± sd) 4.2 (± 1.6) 4.6 (± 1.1) 3.6 (± 0.6) Global Score

Mean (± sd) 4.3 (± 0.97) 4.2 (± 1.0) 3.5 (± 0.6) * P<0.01 v ED Outpatient group § P<0.01 v ED Inpatient & Outpatient group

195 Table 8.20 Summary of EDE scores across the Comorbid ED and ED only groups (N=100) EDE Subscales Comorbid ED and AD ED only (n=65) (n=35) Restraint Concern 4.3 (± 1.1) 4.0 (± 0.96) Mean (± sd) Eating Concern 3.9 (± 1.1) 3.8 (± 1.3) Mean (± sd) Shape Concern 4.6 (± 1.2) 4.5 (± 1.3) Mean (± sd) Weight Concern 4.4 (± 1.4) 4.4 (± 1.4) Mean (± sd) Global Score 4.3 (± 0.99) 4.2 (± 1.0) Mean (± sd)

196 CHAPTER 9 DISCUSSION

This final chapter provides an overview of the current study and discusses the results in relation to the previously outlined objectives and hypotheses. The results are also compared to the findings of several key papers in this area, including Godart et al. (2000), Godart et al. (2003), Black-Becker et al. (2004) and Kaye, Bulik, Thornton, Barbarich, Masters & the Price Foundation Collaborative Group (2004). The strengths and limitations of the current study as well as directions for future research are also discussed.

9.1 Research Overview A thorough review of the literature revealed that the prevalence of anxiety disorders amongst individuals with eating disorders is high. Furthermore, many studies reported that the onset of an anxiety disorder tended to predate the onset of eating disorder pathology, which suggested that anxiety may play an important role in the etiology of eating disorders. That led some researchers to speculate that childhood anxiety may represent one important genetically mediated pathway towards the development of an eating disorder.

Unfortunately, much of the available research in this area has been plagued with methodological limitations. These limitations may account for the striking variability in prevalence rates of anxiety and eating disorder comorbidity reported in the literature. The presence of such limitations certainly limit the usefulness of research findings, which is of concern given the potential value that this research has in furthering the assessment and evidence-based treatment procedures for eating disorders.

Similarly, despite the recent interest in the comorbidity between eating and anxiety disorders, few studies have investigated the prevalence of eating pathology amongst individuals presenting for treatment of an anxiety disorder. This has led some researchers to suggest that eating pathology may be going unidentified and thus untreated in specialist anxiety treatment units.

197

As discussed in previous chapters, the interest in anxiety and eating disorder comorbidity has stemmed from the suggestion that anxiety may not only play a role in the etiology of eating pathology, but also in the maintenance of eating disorders. In particular, this link has been made between PTSD and eating pathology, whereby recurrent bingeing and purging behaviours assist with the blocking out and avoidance of intrusive, painful memories. This suggestion is strengthened by the research reporting that trauma is a non- specific risk factor for the development of an eating disorder. However, despite this, many of the investigations into the prevalence of anxiety disorders amongst patients with eating disorders have failed to include an assessment of PTSD or the experience of trauma. One may speculate therefore, that where an individual’s eating disorder serves to minimize anxiety symptoms, the treatment of eating pathology in the absence of addressing anxiety symptoms, may render treatment ineffective.

As previously highlighted, much of the research into anxiety and eating disorder comorbidity has tended to focus heavily on several of the anxiety disorders, namely OCD and social phobia. Studies investigating the prevalence of OCD have generally found extremely high rates amongst individuals with eating disorders, particularly AN. Given the low prevalence rates of OCD reported in the community (between 0.5 – 2.5%; American Psychiatric Association, 2000), it is necessary to consider whether the diagnosis of obsessive and compulsive symptoms in the eating disorders is reflective of a true OCD as opposed to symptoms directly related to the eating pathology or secondary to malnutrition. Unfortunately in some instances, the research has failed to demonstrate that it has adequately drawn this distinction. In particular, it is often unclear whether a distinction has been made between ego-syntonic and ego-dystonic obsessive and compulsive symptoms. Given the research indicating high rates of OCPD amongst individuals with eating disorders, this further complicates the picture, and again highlights the importance of utilising assessment measures and procedures that will clearly distinguish between OCD, OCPD and obsessions and compulsion either related to the eating pathology or secondary to malnutrition. In this regard, a semi-structured

198 interview may be useful as it enables clinicians to use their own clinical judgment to determine whether diagnoses are met, and to ask further questions if necessary.

It is these considerations that led to the development of the current research. To the author’s knowledge, this is the first and largest study of its kind to be conducted on an Australian clinical population. There are also few studies worldwide that have investigated all anxiety disorders across all the eating disorder subtypes, as most exclude EDNOS diagnoses, and many exclude one or more of the anxiety disorders. As previously discussed, the EDNOS diagnostic category was included in the DSM-IV as a residual eating disorder category, however the research to date indicates that many individuals with eating disorders now fall into this category. Consequently, exclusion of such individuals may result in an inaccurate representation of the eating disorder clinical population. The less stringent exclusion criteria employed in the current study may mean that the present results are more clinically relevant than previous studies in this area.

There were several objectives of the current study. The first aim was to investigate the prevalence of anxiety disorders amongst an inpatient and outpatient eating disorder sample, using well standardized measures to assess for all of the DSM-IV anxiety disorders and confirm diagnoses. The second aim was to clearly establish the temporal relationship between the onset of comorbid eating and anxiety disorders. The final aim was to investigate the prevalence of eating pathology amongst an outpatient anxiety disorder sample, and investigate the temporal relationship between the two disorders.

9.2 Summary and Interpretation of the Results Our objective, to investigate the prevalence between comorbid anxiety and eating disorders, was achieved. The researchers hypothesized that anxiety disorders would be prevalent amongst our eating disorder sample, and this was supported. Our findings confirm the high prevalence of anxiety and eating disorders amongst both inpatient and outpatient eating disorder samples, and across all eating disorder subtypes. Furthermore, our results are consistent with previously published research in this area notwithstanding the methodological limitations inherent in many of these studies. The current study found

199 high rates of anxiety comorbidity amongst the eating disorders, comparable to previous studies in this area. Given that our study investigated all 8 of the DSM-IV anxiety disorders, compared with other studies, many of which included only 4-5 diagnoses, it is not surprising our rates are high. We found 74% of our inpatient ED sample and 56% of our outpatient ED sample met criteria for at least one anxiety disorder, and this difference did not reach statistical significance. Across the entire ED sample, 65% met criteria for at least one anxiety disorder, for AN 69%, for BN 71% and for EDNOS 57.5%. In a study conducted on an Australian community sample of 10,641 adult males and females, 12 month prevalence of any anxiety disorder was 5.6% (Andrews et al, 2001). Across the female adult sample, the 12 month prevalence rate increased to 12.1% (Australian Bureau of Statistics, 1997).

Although we anticipated finding a greater prevalence of anxiety disorders amongst the inpatient ED sample compared with the outpatient sample, the difference was not significant. Furthermore, the inpatient and outpatient samples did not differ significantly except in regards to reported antidepressant medications (higher in the inpatient sample), BMI (lower in the inpatient sample) and laxative abuse (greater in the inpatient sample). These differences are not surprising given the well documented observations that inpatient ED samples have a greater severity of symptoms than outpatient samples. Although depression scores were not significantly different between the inpatient and outpatient samples, this may be explained by the fact that the inpatient sample reported a higher frequency of prescribed antidepressant medications than the outpatient sample, thus perhaps reducing their depression scores in the preceding 7 days. It should be noted that as a clinical assessment for a mood disorder was not conducted, comorbid depression could not be confirmed across the sample.

In respect of differences across the eating disorder subtypes for the entire sample, not surprisingly, the AN sample had significantly lower BMI scores than those in the BN or EDNOS samples. This is to be expected given that most of the participants with AN were in the inpatient sample. The EDNOS sample also reported a statistically greater amount

200 of excessive exercise use than those in the AN or BN sample. No other significant differences were found amongst the ED subtypes.

In terms of anxiety disorder diagnoses, 65% of the entire ED sample (74% of the inpatient ED sample and 56% of the outpatient ED sample) met DSM-IV criteria for a current primary DSM-IV anxiety disorder diagnosis. Similar rates of anxiety disorders were also observed across all the ED subtypes (69% of the AN sample, 71% of the BN sample and 57.5% of the EDNOS sample). A significant proportion of the sample also met criteria for secondary anxiety disorders (42% of the inpatient sample, 26% of the outpatient sample and 34% of the entire ED sample). Subthreshold anxiety disorders were also identified in 12-18% of the entire sample. It is important to note that our diagnoses excluded any possible anxiety symptoms related to the eating pathology. For example, in social phobia, a fear of eating and drinking in public, and in GAD, any excessive, uncontrollable worry related to food, weight or shape, or secondary to the eating disorder, such as health concerns as a result of the ED, were not considered to be part of an anxiety disorder.

The research objective to explore the temporal relationship between the onset of eating and anxiety pathology was also achieved. Regarding the temporal onset of anxiety disorders, the majority (65%) of the inpatient sample and outpatient sample (75%) reported the onset of the anxiety disorder to precede the onset of the eating disorder. For the overall ED sample 69% reported the onset of the anxiety disorder to precede the onset of the eating disorder. In terms of eating disorder subtypes, the majority of the AN (78%), BN (60%) and EDNOS (65%) samples reported the onset of the anxiety disorder to proceed the onset of the eating disorder, and there was no significant difference found between the subtypes. These results are commensurate with those obtained in other studies investigating the temporal relationship between eating disorders and anxiety disorders (Toner et al., 1988; Brewerton et al., 1995; Bulik et al., 1996; and Godart et al., 2000).

201 The research objective to identify which of the anxiety disorders was most prevalent was also achieved. As expected, the prevalence of social phobia was particularly high across the entire sample (42%) and across all ED subtypes. In fact, it was the most commonly diagnosed anxiety disorder across the entire sample (Inpatient: 38%; Outpatient 46%) and all ED subtypes (AN: 26%; BN: 33%; EDNOS: 25%). It must be noted that these diagnoses excluded any reported fears of eating or drinking in public or fears related to weight or shape concerns. Interestingly, this is up to 15 times higher than the 12 month prevalence rate for social phobia (3%) from a large Australian adult female community sample (Australian Bureau of Statistics, 1997). Our findings for AN tend to be on a par with those reported by Kaye, Bulik, Thornton, Barbarich, Masters & the Price Foundation Collaborative Group (2004), Laessle et al. (1987); Laessle et al. (1989) and Herpertz- Dahlman (1996). Our findings for BN are consistent with social phobia rates reported by Laessle et al. (1987) and Bulik et al. (1996).

The diagnosis of PTSD was also particularly high across the entire sample (26%), with just over a quarter of inpatients (27%) and 25% of the outpatients meeting criteria. Rates for PTSD across the ED subtypes were also comparable (AN: 18%; BN: 14%; EDNOS 17.5%). This finding is particularly interesting given that PTSD has so frequently been excluded from previous studies. Furthermore, this prevalence rate is likely to be an underestimate of the true rates of PTSD given that almost 19% of women who reported having experienced a trauma were unable to continue the assessment due to their distress. This rate is up to 6 times higher than the 12 month prevalence rate (4.3%) of an Australian adult female community sample (Australian Bureau of Statistics, 1997). Notwithstanding the few available studies investigating PTSD in ED samples, our findings are comparable to those PTSD rates reported for AN, BN and EDNOS participants in the study by Turnbull et al. (1997). There were no diagnoses of ASD across the entire sample.

The diagnosis of GAD was also high amongst the entire ED sample (23%), with fairly similar rates being reported across the inpatient (22%) and outpatient (25%) samples and ED subtypes (AN: 15%; BN: 24%; EDNOS 10%). Our findings for GAD amongst our

202 AN and BN sample are slightly higher than those reported by Kaye, Bulik, Thornton, Barbarich, Masters & the Price Foundation Collaborative Group (2004), however our findings for the EDNOS sample were comparable to that study. Our findings regarding rates of GAD across this sample is up to 6 times higher than the 12 month prevalence rate (3.7%) of an Australian adult female community sample (Australian Bureau of Statistics, 1997).

Interestingly, we found relatively low rates of Panic Disorder with and without Agoraphobia across the entire ED sample (3%) compared with those rates reported by Godart et al. (2000). Our findings are comparable to those reported by Lilenfeld et al. (1998) of 4% across their AN and BN sample. One reason for our low rates of reported panic disorder, was that we consistently excluded any panic symptoms related to food, weight or shape concerns. It was noted that most of the sample reported experiencing panic attacks, however upon further questioning in many cases they denied fearing the symptoms or future panic attacks, as would be expected for a diagnosis of panic disorder. Furthermore, Agoraphobia was not diagnosed if fears were related to food related situations (supermarkets, food courts etc) in the absence of fear about the actual symptoms. Our rates of Panic Disorder across the ED sample are comparable to the 12 month prevalence rate (2%) of an Australian adult female community sample (Australian Bureau of Statistics, 1997).

Similarly low rates of specific phobias were also reported across the entire sample (2%), which was surprising given the previously reported rates of between 12 – 45% for AN and 12 – 46% for BN (Hudson et al., 1983; Laessle et al., 1987; Lilenfeld et al., 1998; Godart et al., 2000). Our findings were comparable to those of an earlier study by Piran et al. (1985) of rates of phobias of between 0 – 3% across their AN and BN sample.

Of interest were the rates of OCD found in our study. It was hypothesized that we would also find OCD to be prevalent amongst our sample, however this was not supported. In contrast to a number of previous studies reporting high rates of OCD amongst ED samples, we found only 5% of our entire ED sample met criteria for OCD. OCD rates did

203 not differ significantly across inpatient (5%) and outpatient (4%) samples. Most of the OCD cases were identified in the AN group (5%) and there was one diagnoses of OCD in the EDNOS sample (2.5%). Interestingly, we did not find a single case of OCD amongst the inpatient or outpatient BN sample. Previous studies have reported rates of OCD for AN between 9.5 – 69% (Hudson et al., 1983; Piran et al., 1985; Laessle et al., 1987; Laessle et al., 1989; Fornari et al., 1992; Thornton & Russell, 1997; Godart et al., 2000; Iwasaki et al., 2000; Speranza et al., 2001; Milos et al., 2002; Godart et al., 2003; Kaye, Bulik, Thornton, Barbarich, Masters & the Price Foundation Collaborative Group, 2004), however our reported rate for AN is lower still. Furthermore, when considering the rate of OCD amongst AN (37%) reported in another Australian study (Thornton & Russell, 1997), our rates appear extremely low. One explanation for this would be that previous studies may have over diagnosed rates of OCD, perhaps including obsessive and compulsive symptoms that are related to eating disorder pathology as opposed to true OCD diagnosis.

Another possibility for this difference, given our reported rates of possible OCPD (6%), is that symptoms potentially related to obsessive compulsive personality constructs may have been diagnosed as OCD. Studies investigating the prevalence of OCPD amongst eating disorder samples have reported rates of between 3 – 83% (Kasvikis et al., 1986). Caution must be applied to the observation of OCPD in our study, given that no formal measures to assess for OCPD diagnoses were employed. Prevalence rates of OCPD in community samples are estimated to be around 1%, whilst estimates in mental health settings vary between 3 – 10% (American Psychiatric Association, 2000).

Our findings for OCD prevalence rates amongst our BN and EDNOS sample are comparable to the lowest rates presented in previous studies. Studies investigating the prevalence of OCD amongst BN samples have reported between 0 – 44% (Hudson et al., 1983; Piran et al., 1985; Laessle et al., 1987; Laessle et al., 1989; Fornari et al., 1992; Thornton & Russell, 1997; Lilenfeld et al., 1998; Godart et al., 2000; Speranza et al., 2001; Milos et al., 2002; Kaye, Bulik, Thornton, Barbarich, Masters & the Price Foundation Collaborative Group, 2004). Furthermore, our rates of OCD across the BN

204 and EDNOS sample are comparable to the 12 month prevalence rate (0.4%) of an Australian adult female community sample (Australian Bureau of Statistics, 1997).

Previous retrospective studies determining age of onset of psychiatric diagnoses have faced criticism as the reliability of the data based on participants’ recall may be questionable. Further, there are often inconsistencies in the determination of the age of onset, which sometimes refers to the age when the first symptom occurred and sometimes to the age when all criteria for the disorder were met (Wittchen & Essau, 1993). In the current study we recorded the earliest age of onset for a number of anxiety disorders as 5 years of age1, in line with previous research in this area (Kaye, Bulik, Thornton, Barbarich, Masters & the Price Foundation Collaborative Group, 2004), and only diagnosed onset when all criteria for the disorder were met.

In the inpatient sample, the average age of onset for the anxiety disorders was 15 years compared with almost 18 years for the onset of the eating disorder pathology. This was slightly lower for the outpatient sample, with the average age of onset for the anxiety disorder being 12 years compared with almost 17 years for the onset of the eating disorder pathology. Although there was no significant difference between age of onset for anxiety disorder pathology for each of the specific anxiety disorders across the inpatient and outpatient samples, social phobia in the inpatient sample had a mean age of onset of just over 12 years, followed by GAD at 15 years and PTSD at almost 18 years. The mean age of onset for panic disorder (with and without agoraphobia) was 27 years, however there were only 2 participants diagnosed in this group. For the one participant diagnosed with specific phobia, age of onset was recorded at 5 years of age. For the outpatient sample, social phobia and PTSD had a mean age of onset of almost 12 years, followed by GAD at almost 15 years.

For the entire ED sample, the average age of onset for any anxiety disorder was almost 14 years compared with just over 17 years for the onset of the eating disorder pathology.

1 As discussed in section 6.5.3, the age of onset was set at 5 years of age when participants reported that the onset of the anxiety disorder was “for as long as I could remember”. This was based on the assumption that childhood recollections may be limited prior to this age, in line with previous research in this area (Kaye, Bulik, Thornton, Barbarich, Masters & the PFCG, 2004).

205 Although there was no significant differences between age of onset of anxiety disorder pathology for each of the specific anxiety disorders across the entire sample, social phobia had a mean age of onset of just over 12 years, GAD had a mean age of onset of 15 years and PTSD had a mean age of onset of just over 15 years. Although rates of OCD were small, the mean age of onset was just under 10 years of age. In respect of age of onset of anxiety disorders across the eating disorder subtypes, there were no significant differences found. The age of onset for each of the anxiety disorder diagnoses for participants with AN was just over 10 years of age for social phobia, almost 17 years of age for PTSD and just over 24 years of age for GAD. Although the prevalence rate for OCD was low, the mean age of onset was 11.5 years of age. For BN, the mean age of onset for social phobia was almost 12 years, for GAD the mean age was almost 11 years and for PTSD the mean age was almost 15 years. For EDNOS the mean age of onset for social phobia was 18.5 years, for GAD it was 15 years and for PTSD, almost 13 years of age.

Finally, one of our hypotheses was that comorbid anxiety and eating disorder groups would differ from ED only groups in terms of clinical characteristics and severity of symptoms. In line with this hypothesis, we found that significantly more of the inpatient comorbid eating disorder and anxiety sample reported purgative abuse than the eating disorder only sample. This is consistent with previous findings confirming increased vomiting (Carter & Duncan, 1984) and laxative abuse (Weltzin, Bulik, McConaha & Kaye, 1995) amongst individuals with comorbid anxiety and eating pathology. Furthermore, across the entire ED sample, the mean number of reported episodes of excessive exercise was higher in the comorbid eating disorder and anxiety group than in the ED only group. Although there is an absence of research into the use of excessive exercise amongst individuals with ED and comorbid anxiety disorders, one might hypothesise that exercise could be used in a similar manner to other avoidance or self harm behaviours, that enable an individual to regulate affect.

Surprisingly, amongst the outpatient sample, a greater number of reported episodes of objective binge eating was found in the ED only sample compared with the comorbid

206 anxiety and ED group. Although this difference only just met significance, it is nevertheless surprising given the literature suggesting that increased levels of bingeing behaviour have been observed in individuals with comorbid anxiety.

These results must be interpreted with caution, due to the fact that our comorbid anxiety and eating disorder only groups contained individuals with AN, BN and EDNOS diagnoses. Thus, any significant differences in clinical ED symptoms (such as bingeing and purging) could be attributed to their ED diagnosis, and not necessarily to the presence or absence of anxiety pathology. In an attempt to control for this, we calculated individual EDE scores to compare eating pathology between comorbid and ED only groups. More recently, treatment for eating disorders has emphasised a transdiagnostic approach and, there have been some suggestions that research investigating anxiety presentations irrespective of eating disorder diagnosis may assist in broadening our current understanding of comorbidity between anxiety and eating disorders (Pallister & Waller, 2008).

The rationale for investigating EDE scores across the groups was to eliminate the possibility that severity of eating pathology, as indicated by BMI, binge purge and exercise behaviours, may have been influenced by eating disorder diagnoses and therefore any differences could not reliably be attributed to the presence or absence of an anxiety disorder diagnosis. Furthermore, rather than conducting a series of analyses and increasing the possibility of committing a type I error, logistic regression was used to investigate whether any of the scores on the EDE subscale significantly predicted whether or not an anxiety disorder was diagnosed. We found that none of these variables, either separately or together were found to be significant. Although it has previously been suggested that individuals with comorbid diagnoses display more severe clinical symptomatology, our findings, based on the EDE scores, did not support this.

In relation to the rates of eating disorder pathology amongst the outpatient anxiety sample, we found that 13.5% of the sample met criteria for EDNOS, which included diagnoses of subthreshold AN, subthreshold BN and BED. It must be noted that this rate

207 may be an underestimate as 3 participants identified as having potential eating pathology were unable to be assessed further to confirm an eating disorder diagnosis. Unfortunately there is not a comparable Australian community sample to compare these rates with. However, our findings are comparable to the 12% of probable eating disorder cases reported by Black Becker et al (2004). Furthermore, our findings are far higher than the 0.5% - 4% prevalence of AN, BN and BED reported in other studies (Wilfley, Agras, Telch, Rossiter, Schneider, Cole, Sifford & Raeburn, 1993; Hsu, 1996; Wilson & Pike, 2001).

The presentation of a range of anxiety diagnoses in our anxiety patient sample inhibits inferences being drawn regarding the prevalence of eating pathology amongst the specific anxiety disorders. Nevertheless, our findings are indicative of the presence of significant eating pathology amongst women presenting for anxiety treatment. A larger sample size across each of the anxiety disorder categories would improve statistical power and would potentially enable inferences to be drawn regarding the differences in clinical eating and anxiety symptoms between the anxiety participants with comorbid eating disorders and the eating disorder groups with comorbid anxiety.

9.3 Recruitment and assessment procedures One of the difficulties faced in conducting this study was in terms of recruitment of participants. At one of the inpatient recruitment sites, only 3 (16%) of the 18 patients approached consented. The main reason for refusal was that patients were already involved in a number of research projects being undertaken in the unit. Subsequently it was decided to cease recruitment at this site due to concerns that the sample would not be sufficiently representative of the inpatient population. Furthermore, across all the sites many of the patients had already completed a number of questionnaires for other research studies and were therefore disinclined to participate in further research. In hindsight, collaboration with other researchers to share common assessment measures may have reduced the burden on participants and thus increased willingness to participate.

208 In addition, the lengthy nature of the assessment procedure in the current study (between 1.5 – 4 hours) may have discouraged potential participants. At initial stages in this study, a package of self-report questionnaires, including the EDI-3, DASS-21 and several anxiety measures (discussed in previous chapters) were also given to participants to complete. Unfortunately, after completing 30 assessments, the response rate for the participants completing the full set of measures was less than 60%, with a number of participants failing to complete these prior to discharge from hospital. Subsequently, the ANSOCQ, EDBQ & Anxiety self –report measures were excluded from the study. Feedback from participants also suggested that following participation in such a lengthy assessment interview, they were less inclined to spend up to an additional 1 hour completing self-report questionnaires, particularly as they had already completed some of these same questionnaires for other research studies. Subsequently the researchers decided to eliminate all questionnaires except for the DASS-21 (which could be completed in 5 minutes following the assessment) and the EDI-3 (which they could return at a later date). It is unlikely that discontinuing these questionnaires would have had any affect on the results, as the participants who completed the full set of measures, did so following the assessment interview. However, had we not discontinued these questionnaires, it is likely that participation would have been substantially affected. Furthermore, given that participants who were recruited from inpatient units were disinclined to complete the full set of questionnaires, it is likely that outpatients would have been even less likely to complete them.

Although the researchers were interested in comparing EDI-3 results across the sample, the low completion rate for this questionnaire (< 40%) hindered adequate numbers for final analysis, and was subsequently excluded. Given the primary aim of the current research was to complete thorough assessments for both eating and anxiety pathology to determine diagnosis, the additional self-report measures (with the exception of the DASS-21 to assess depressive symptomatology) placed an unnecessary burden on participants.

209 9.4 Strengths of the current research A significant strength of the current study is that, to the best of the author’s knowledge, it is the first study of its kind to investigate anxiety and eating disorder comorbidity across an inpatient and outpatient eating disorder sample (including all ED diagnoses) as well as across an anxiety disorder sample (including all Anxiety diagnoses). It is also the largest study of its kind to be conducted on an Australian clinical population. Furthermore, the use of well standardised, internationally accepted diagnostic instruments for the assessment of anxiety and eating pathology is also a significant strength, as it has avoided the methodological limitations of previous research failing to employ adequate assessment measures.

An unpublished study investigating the same inpatient eating disorder population as included in the current study found rates of diagnosed anxiety disorders in only 14% of patients, based on the admission assessment notes (Dean, 2006). This same study reported a higher rate of diagnosed mood disorders, with 38% of the sample meeting criteria for major depressive disorder and 14% meeting criteria for a subthreshold mood disorder (Dean, 2006). This is despite the current study finding a rate of 74% of any anxiety disorder diagnosis in the same population. This indicates that current eating disorder assessment procedures may focus primarily on eating and mood disorder pathology, perhaps only including an anxiety diagnosis if the symptoms are obvious. This is not surprising given the focus in the literature on comorbidity of mood disorders amongst individuals with eating disorders. However the research also suggests that a comorbid anxiety disorder may be related to poorer treatment response and outcomes in individuals with eating pathology. Thus, a strength of the present research is in highlighting not only the prevalence of eating and anxiety comorbidity but the need for conducting a thorough assessment of anxiety disorders and establishing the temporal relationship between both disorders. It is also clear from this and previous research that a thorough understanding of the etiological and maintaining factors of eating pathology is crucial for developing a formulation and framework for treatment.

210 This study has also met its objective of identifying which anxiety disorders are most prevalent in an eating disorder population. In contrast to much of the previous research in this area, the current study assessed for all DSM-IV anxiety disorders. Consistent with previous research, social phobia was the most prevalent of the anxiety disorders. Interestingly, PTSD and GAD were also prevalent, despite often being excluded from assessment in other research. This research also sought to understand the relationship between OCD and eating disorders, and found that in contrast to many previous studies, OCD was not prevalent in the current sample. What was extremely clear from conducting the current research, was that many of the participants reported obsessions and compulsions, however these were, in the majority of cases, determined to be directly related to the eating disorder pathology, or a possible indication of personality traits consistent with a diagnosis of OCPD. A key difference between the obsessions and compulsions reported by participants with and participants without a diagnosis of OCD (excluding those purely related to food, shape and weight) was that for many, the obsessions and compulsions were ego syntonic. In this regard, many reported that they did not find the obsessions and compulsions distressing. Indeed, they found them helpful. This is in clear contrast to the typically distressing, time consuming and ego dystonic obsessions and compulsions reported in OCD. The current study has clearly identified this difference.

The few exclusion criteria the present research employed in recruitment of participants, was also a significant strength. All patients who were well enough to attend the assessment were included in this study. The only patients excluded from the present study were those with serious medical complications as a result of their eating disorder, or those who were acutely suicidal. Consequently, the current sample provides a good representation of the type of patients treated at the inpatient and outpatient units included in this study. While the inclusion of participants with all DSM-IV eating disorder diagnoses (except binge eating disorder in the eating disorder sample), varying treatment histories and duration of illness length, enables a greater generalization of the results. Furthermore, this study did not exclude participants with other comorbid conditions, such as alcohol abuse or personality disorders, due to the recognition that often individuals

211 with anxiety disorders will also have additional comorbid diagnoses. It is hoped that the less stringent exclusion criteria utilised in this study will increase the clinical efficacy of the current results.

A final strength of this research was that only the author conducted all of the assessments on participants presenting with an eating disorder or potential eating disorder. Apart from fewer than 15 ADIS-IV assessments conducted on the anxiety sample (only those without possible or comorbid eating pathology), the author conducted all assessments on anxiety participants as well. This increased the likelihood that the assessments were conducted in a consistent manner, eliminating potential difficulties associated with clinician variables.

9.5 Limitations of the current research Besides the absence of a community control group, there are a number of limitations which can be raised regarding the current research which are identified below.

There were difficulties with participants completing self-report questionnaires. In the initial phase of the study, a number of additional self-report questionnaires examining eating and anxiety symptomatology were also included. At an early stage it became clear that there were far too many for participants to complete, and subsequently, these were excluded from the study. Furthermore, across the entire sample, completion rates for the EDI-3 were also low. There were several possible reasons for this including the time consuming nature of the assessment interview (between 1.5 – 4 hours), many participants already participating in other research projects requiring the completion of either the EDI-2 or the EDI-3, and therefore being less motivated to complete it again, and the researcher was unable to ask participants to complete the EDI-3 at the time of the interview due to the lengthy nature of this questionnaire. Participants were asked to return the questionnaire at a later date, and subsequently, motivation to do this was possibly low. In hindsight, collaborating with the other researchers to avoid overlapping questionnaires, may have increased completion rates. The information gained from these questionnaires would have been extremely valuable, especially with regards to symptom severity.

212

Participants were not followed up over time to assess anxiety symptoms post treatment. After commencing this study, we thought it would be interesting to investigate this aspect, by following up participants 6 months post assessment, to reassess anxiety and eating disorder symptomatology. Unfortunately, as we had not initially sought consent from participants to do this, it proved too difficult to obtain consent at a later stage, as many of the participants were either uncontactable, or did not consent to follow up. This is clearly an area for potential research in the future.

The objectives of this study did not set out to include an analysis of differences of reported anxiety disorders amongst the eating disorder subtypes, nevertheless had the subject numbers been higher in each of these groups, this would have been an interesting analysis to consider. The fewer number of BN participants in the inpatient sample was not surprising, as individuals with BN are more likely to be treated in an outpatient setting. Furthermore, the higher number of EDNOS diagnoses (almost double) compared with BN diagnoses in the outpatient setting appears consistent with previous research reporting that EDNOS is the most frequently diagnosed of the eating disorder subtypes in outpatient settings (Martin et al., 2000; Ricca et al., 2001; Turner & Bryant-Waugh, 2004).

The researchers also chose to report the age at onset as the age at which all criteria for a DSM-IV anxiety or eating disorders were met. In some cases, individuals may have demonstrated subthreshold diagnoses at earlier ages. The present study also investigated the current diagnoses of eating and anxiety pathology. An investigation of lifetime diagnoses may have yielded higher prevalence rates, and this would have been an interesting investigation in terms of lifetime eating disorder diagnoses amongst the anxiety sample.

The current study did not incorporate a measure to formally assess for OCPD. Unfortunately the decision to assess for possible DSM-IV OCPD diagnoses was decided after the study had commenced. Nevertheless, when possible OCPD symptoms were

213 highlighted in the course of the clinical interview, the researcher endeavored to closely assess these as per the DSM-IV diagnostic criteria. The use of a formal measure would have ensured greater consistency and reliability, which is why the researchers have been hesitant to assign a formal diagnosis and referred only to possible OCPD cases identified.

Inherent to the design of the current study is the retrospective diagnostic procedure used to provide the time of onset for clinically significant anxiety and eating disorders. The obvious problems with this procedure, as noted in many previous studies, is the memorization biases that may have affected the ability for someone to recognize the symptoms of a disorder and recall the time of onset (Godart et al., 2000). Furthermore, as discussed in previous research, there are difficulties associated with interpreting the appearance chronology of anxiety and eating pathology (Godart et al., 2000).

Although the DASS was administered to assess for depressive symptomatology, we did not formally assess for the presence of a comorbid mood disorder. Likewise, substance use disorders were also not assessed. Both of these disorders are clearly implicated in the eating disorders, and have been widely studied in this population. Given the already lengthy assessment process involved in the previous study, an additional interview to confirm mood and substance disorders may have been too great a burden on participants. Nevertheless, this is clearly a limitation of the present study.

As criticisms of previous studies have stemmed from the exclusion of certain anxiety disorders when investigating comorbidity amongst the eating disorders, this study set out to include all DSM-IV diagnoses regardless of frequency of presentation. We found that 13.5% of women presenting for anxiety disorder treatment also met criteria for a current eating disorder, and their primary anxiety diagnoses included all DSM-IV disorders except for Panic Disorder, Agoraphobia and Acute Stress Disorder. A significant limitation however, is the small number of participants with comorbid eating and anxiety disorders in each of the specific anxiety disorder groups. This precluded tests of effects within individual diagnostic categories, thus limiting the ability to compare and draw

214 conclusions. Subsequently, future research should replicate this study with larger sample sizes.

Studies involving clinical samples may overestimate the rates of comorbidity as individuals with comorbid diagnoses may be more likely to seek treatment than those with only a single diagnosis. The present study attempted to reduce the possibility that comorbidity was a result of severity by including an inpatient and outpatient eating disorder sample. Nevertheless, it could be argued that the results from the present study may be limited in terms of their general application to community samples. Notwithstanding this potential limitation, the results from the current study are likely to provide an accurate reflection of the levels and temporal pattern of eating and anxiety comorbidity observed in clinical treatment settings.

9.6 Clinical Implications arising from the research Over the last decade there has been an increase in the awareness that comorbidity in the eating disorders may have significant implications on the assessment and treatment procedures in this field. Despite this increased awareness, the research conducted in this area to date has been limited, and has suffered from methodological problems limiting ability to draw generalizations from the results.

The current study clearly demonstrates that not only do many eating disorder patients have comorbid anxiety disorders, but up to 70% of patients with eating disorders have a pre-existing anxiety disorder. While other studies have found similarly high rates of comorbid anxiety, it is interesting that a similar high level of anxiety comorbidity was prevalent despite the low rates of OCD diagnosed across our sample. This knowledge is extremely important in the treatment of eating pathology, as it suggests that symptoms which previously have been understood as relating to the eating disorder (such as social withdrawal, fear in social situations) may instead be related to a pre-existing anxiety disorder. Conversely, symptoms previously identified as relating to a comorbid anxiety disorder (such as OCD), may actually, be secondary to the eating pathology or malnutrition.

215

The speculation that anxiety may play a role in the onset and maintenance of eating pathology suggests that addressing eating disorder symptomatology in the absence of anxiety treatment, may reduce the overall efficacy of treatment outcomes. This raises the question as to whether it is possible for an eating disorder patient to achieve complete recovery in the absence of treatment for the anxiety symptoms. This is particularly salient if the eating disorder functions to assist with the management of anxiety symptomatology.

The clinical implications of the current study are twofold. Firstly, when conducting an eating disorder assessment, clinicians must be cognisant of assessing for anxiety symptoms and where relevant, establishing a temporal chronology of onset of both disorders. Secondly, the possible etiological and maintenance factors must be considered when undertaking a clinical formulation and planning treatment.

This thesis has also highlighted that eating pathology may be common in women presenting for treatment of anxiety disorders. Clinically, this is extremely important, as an individual presenting for treatment of an anxiety disorder may not necessarily disclose eating pathology. Nevertheless, it is clear from the current research that eating pathology and anxiety disorders often co-occur and therefore, eating pathology must also be assessed in order to adequately formulate and provide treatment for the individual presenting for anxiety treatment. Consequently, it is recommended that all future assessments of anxiety disorders include screening for eating disorder pathology. Given that the ADIS-IV does not include an assessment for eating pathology, it may be useful to follow Black-Becker et al. (2004) and incorporate a skip out condition on the EDE-Q to reduce the burden on patients. It is noted that the EDE-Q demonstrates high sensitivity and specificity for detecting eating disorder case status (Black-Becker et al., 2004) suggesting that the use of the EDE-Q, which is a relatively time efficient self-report questionnaire to complete, may be useful as a screening measure for eating disorder pathology.

216 One important clinical issue which has been highlighted in this research (although not included in the aims and objectives of the current study) is the possibility that the present DSM-IV classification system for the eating disorders is insufficient. Our findings, in line with previous research and clinical settings, found that a significant number of participants were diagnosed with the residual EDNOS category. Given that this is currently considered a category for atypical eating pathology, the fact that 40% of our sample was comprised of this diagnosis, suggests that the present DSM-IV classification system for eating disorders is not functioning as intended. In our study, the women diagnosed with EDNOS did not necessarily demonstrate less severe eating disorder symptoms or experience less distress, nevertheless, their symptoms did not fit the criteria for AN or BN. This is of particular concern as generally, a DSM-IV Not Otherwise Specified Category is indicative of a less severe form of a disorder. Thus, individuals with EDNOS may be overlooked in treatment planning or the provision of services, in circumstances where their symptoms and distress warrant as much priority as an AN or BN patient. With the planned publication of DSM-V imminent, this is clearly an extremely important aspect to address. Suggestions may include greater flexibility in criteria, removing the amenorrhea criteria for AN and the removal of criteria for minimum binge episodes per week for BN. Furthermore, as has been previously discussed elsewhere, differences between binge/purge and restricting patients within the ED categories, in terms of treatment and outcome, may suggest that diagnostic criteria should reflect these differences. The findings of the current study indicate that there is a need to consider alternatives to the current diagnostic classification system for eating disorders. This may include making the criteria for existing categories more flexible or moving to a transdiagnostic approach.

9.7 Directions for Future Research The findings of the current study raise important questions regarding the etiological and prognostic factors associated with eating disorders, which should be addressed in future research. A number of potential directions for future research are discussed below.

217 Firstly, our study has raised the possibility that the diagnosis and treatment of anxiety pathology in patients with eating disorders may be crucial for successful treatment of the eating pathology. In order to address this, future studies should focus on investigating treatment response amongst individuals with comorbid anxiety and eating disorders. Of particular interest would be whether individuals respond better to treatment when treatment includes addressing both eating and anxiety disorders, compared with treatment focusing on the eating pathology only. Furthermore, research should also follow up patients to assess anxiety symptoms over time and post treatment.

Secondly, one of the strengths of our study was that all anxiety disorders were thoroughly investigated across all eating disorder subtypes. Although we did not find support for the prevalence of OCD amongst eating disorder populations, we did find that PTSD was prevalent. Further research should aim to investigate this further, and in particular, research investigating PTSD and eating disorder comorbidity should examine the type of trauma experienced, to see whether certain types of trauma are more likely to be associated with eating pathology. In this regard, it would be particularly interesting to test the possibility that certain eating disorder behaviours (such as bingeing and purging) are used to regulate affect, or as a coping strategy for anxiety symptoms, such as intrusive memories.

In addition to the suggestions above, it is clear from the current study that anxiety disorders are prevalent across the full spectrum of eating disorders. Given the more recent emphasis on transdiagnostic approaches to the treatment of eating pathology, further research investigating anxiety presentations irrespective of eating disorder diagnosis may assist in broadening our current understanding of comorbidity between anxiety and eating disorders.

Furthermore, in order to obtain a thorough understanding of the etiological and prognostic relationship between eating and anxiety disorders, it is necessary not only to investigate the prevalence in eating disorder populations but also anxiety populations. The current study has provided support for the suggestion that comorbidity may be high

218 in anxiety populations and it is clear that future research into the prevalence of eating pathology amongst anxiety populations would be very informative.

Finally, our study has provided the rationale for using standardized structured assessment instruments to thoroughly investigate the prevalence of anxiety and eating disorder comorbidity. Questions have clearly been raised regarding the methodological limitations inherent in previous research and the possibility that this has resulted in distorted prevalence rates, in particular amongst certain anxiety disorders. Future research should avoid these limitations by only using sound methodological procedures and instruments. Having consistent standards across studies will improve the ability to compare results across studies, thus improving clinical understanding of this important area.

9.8 Conclusion To the best of the author’s knowledge, the current study is the largest to date on an Australian sample investigating comorbidity patterns in anxiety and eating disorders. It is the only Australian study, and one of a few worldwide, to consider the prevalence of eating disorders amongst an anxiety population. It is also one of the few such studies worldwide to include assessment for all DSM-IV anxiety disorders.

The current study adds to previous research in this area by investigating the full range of DSM-IV anxiety disorders, using thorough assessment measures to distinguish between anxiety and eating pathology, and by considering the temporal relationship between comorbid disorders.

The aims and objectives, to investigate the comorbidity and temporal relationship between anxiety and eating disorders, were accomplished.

The author hopes that this study will improve clinical understanding of the etiological, maintenance and prognostic factors associated with eating disorders thereby significantly improving treatment and therapeutic outcomes. Such improved clinical understanding

219 should reduce the devastating health consequences and high mortality rates currently associated with the eating disorders.

220 REFERENCES

Australian Bureau of Statistics. (1997). The national survey of mental health and well being, Australia. Australian Government Publishing Service: Canberra.

Agras, W.S., Telch, C.F., Arnow, B., Eldredge, K. & Marnell, M. (1997). One-year follow-up of cognitive – behavioural therapy for obese individuals with binge eating disorder. Journal of Consulting and Clinical Psychology, 65, 343 – 347.

Agras, W.S. & Telch, C.F. (1998). The effects of caloric deprivation and negative affect on binge eating in obese binge eating-disordered women. Behavior Therapy, 29, 491 – 503.

Agras, W.S., Walsh, B.T., Fairburn, C.G., Wilson, G.T. & Kraemer, H.C. (2000). A multicentre comparison of cognitive-behavioural therapy and interpersonal therapy for bulimia nervosa. Archives of General Psychiatry, 57, 459 – 466.

Agras, W.S., Brandt, H.A., Bulik, C.M., Dolan-Sewell, R., Fairburn, C.G., Halmi, K.A. Herzog, D.B., Jimerson, D.C., Kaplan, A.S., Kaye, W.H. le Grange, D., Lock, J., Mitchell, J.E., Rudorfer, M.V., Street, L.L., Striegel-Moore, R., Vitousek, K.M., Walsh, T.B. & Wilfley, D.E. (2004). Report of the National Institutes of Health Workshop on Overcoming Barriers to Treatment Research in Anorexia Nervosa. International Journal of Eating Disorders, 35, 509 – 521.

American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders, 3rd Ed. American Psychiatric Association: Washington, DC.

American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders, 3rd Rev Ed. American Psychiatric Association: Washington, DC.

221 American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders, 4th Ed (DSM-IV-TR). American Psychiatric Association: Washington, DC. Andersen, A.E., Bowers, W.A. & Watson, T. (2001). A slimming program for eating disorders not otherwise specified: Reconceptualising a confusing, residual diagnostic category. Psychiatric Clinics of North America, 24, 271 – 280.

Andrews, G., Henderson, S. & Hall, W. (2001). Prevalence, comorbidity, disability and service utilization: overview of the Australian National Mental Health Survey. British Journal of Psychiatry, 178, 145 – 153.

Andrews, G., Creamer, M., Crino, R., Hunt, C., Lampe, L. & Page, A. (2003). The treatment of anxiety disorders: clinician guides and patient manuals. Cambridge University Press: UK.

Antony, M.M. & Rowa, K. (2005). Evidenced-based assessment of anxiety disorders in adults. Psychological Assessment, 17, 256 – 266.

Arnow, B., Kenardy, J. & Agras, W.S. (1992). Binge eating among the obese: a descriptive study. Journal of Behavioural Medicine, 15, 155 – 170.

Ball, J. & Mitchell, P. (2004). A randomized controlled study of cognitive behaviour therapy and behavioural family therapy for anorexia nervosa patients. Eating Disorders, 12, 303 – 314.

Baran, S.A., Weltzin, T.E. & Kaye, W.H. (1995). Low discharge weight and outcome in anorexia nervosa. American Journal of Psychiatry, 152, 1070 – 1072.

Barlow, D.H. & Cerny, J.A. (1988). Psychological treatment of panic. Guilford Press: New York.

222 Bastiani, A.M., Rao, R., Weltzin, T. and Kaye, W.H. (1995). Perfectionism in anorexia nervosa. International Journal of Eating Disorders, 17, 147 – 152.

Bastiani, A.M., Altemus, M., Pigott, T., Rubenstein, C., Weltzin, T.E., & Kaye, W.H. (1996). Comparison of obsession and compulsion in patients with anorexia nervosa and obsessive-compulsive disorder. Biological Psychiatry, 39, 966–969.

Bates, G. (2007). Beyond cognitive behaviour therapy in the treatment of anxiety disorders: a case study of social anxiety disorder. In: Castle, D., Hood, S. & Kyrios, M. (Eds). Anxiety Disorders: current controversies, future directions. Australian Postgraduate Medicine: Australia.

Beck, A.T. (1967). Depression: Causes & Treatment. University of Pennsylvania Press: Philadelphia.

Beck, A.T., Steer, R.A., & Brown, G.K. (1996). Manual for the Beck Depression Inventory-II. San Antonio, TX: Psychological Corporation.

Berkman, N., Bulik, C., Brownley, K., & Lohr, K. (2006). Eating disorders treatment and outcomes. Agency for Healthcare Research and Quality: Rockville, MD.

Berkman, N., Lohr, K.N. & Bulik, C. (2007). Outcomes of eating disorders: a systematic review of the literature. International Journal of Eating Disorders, 40, 293 – 309.

Berkson, J. (1946). Limitations of the applications of fourfold table analysis to hospital data. Biometrics, 2, 47 – 53.

Beumont, P.J., Abraham, S.F., Argall, W.J., George, C.W., & Glaun, D.E. (1978). The onset of anorexia nervosa. Australian and New Zealand Journal of Psychiatry, 12, 145– 149.

223 Bibb, J., & Chambless, D. L. (1986). Alcohol use and abuse among diagnosed agoraphobics. Behaviour Research and Therapy, 24, 49–58.

Black Becker, C., DeViva, J. & Zayfert, C. (2004). Eating disorder symptoms among female anxiety disorder patients in clinical practice: the importance of comorbidity assessment. Journal of Anxiety Disorders, 18(3), 255 – 275.

Blinder, B.J., Chaitlin, B.F. and Goldstein, R. (Eds). (1988). The eating disorders: medical and psychological bases of diagnosis and treatment. PMA Publications: New York.

Blinder, B.J., Cumella, E.J. and Sanathara, V. (2006). Psychiatric comorbidities of female inpatients with eating disorders. Psychosomatic Medicine, 68, 454 – 462.

Bond, F.W. & Bunce, D. (2000). Mediators of change in emotion-focused and problem- focused worksite stress management interventions. Journal of Occupational Health Psychology, 5, 156 – 163.

Borge, F.M., Hoffart, A., Sexton, H., Clark, D.M., Markowitz, J.C. & McManus., F. (2007). Residential cognitive therapy versus residential interpersonal therapy for social phobia: A randomized clinical trial. Journal of Anxiety Disorders, Article in Press.

Boutelle, K.N. (1998). The use of exposure with response prevention in a male anorexic. Journal of Behavior Therapy and Experimental Psychiatry, 29, 79 – 84.

Bowen, R. C., Cipywnyk, D., D'Arcy, C., & Keegan, D. (1984). Alcoholism, anxiety disorders, and agoraphobia. Alcoholism: Clinical and Experimental Research, 8, 48–50.

Braun, D.L., Sunday, S. & Halmi, K.A. (1994). Psychiatric comorbidity in patients with eating disorders. Psychological Medicine, 24, 859 – 867.

224 Brewerton, T.D., Lydiard, R.B., Ballenger, J.C. & Herzog, D.B. (1993). Eating disorders and social phobia. Archives of General Psychiatry, 50, 70.

Brewerton, T.D. (1995). Toward a unified theory of serotonin dysregulation in eating and related disorders. Psychoneuroendocrinology, 20, 561 – 590.

Brewerton, T.D., Lydiard, R.B., Herzog, D.B., Brotman, A., O’Neil, P. & Ballenger, J.C. (1995). Comorbidity of axis I psychiatric disorders in bulimia nervosa. Journal of Clinical Psychiatry, 56, 77 – 80.

Brown, T.A. & Barlow, D.H. (1992). Comorbidity among anxiety disorders: implications for treatment and DSM-IV. Journal of Consulting and Clinical Psychology, 60, 835 – 844.

Brown, T.A., Antony, M.M. and Barlow, D.H. (1992). Psychometric properties of the Penn State Worry Questionnaire in a clinical anxiety disorders sample. Behaviour Research and Therapy, 30, 33–37.

Brown, T.A., Moras, K., Zinbarg, R.E. and Barlow, D.H. (1993). Diagnostic and symptom distinguishability of generalized anxiety disorder and obsessive-compulsive disorder. Behavior Therapy, 24, 227–240.

Brown, T.A. DiNardo, P.A. & Barlow, D.H. (1994). Anxiety disorders interview schedule for DSM-IV (ADIS-IV). San Antonio, TX: The Psychological Corporation.

Brown, T.A., Campbell, L.A., Lehman, C.L., Grisham, J.R. & Mancill, R.B. (2001). Current and lifetime comorbidity of the DSM-IV anxiety and mood disorders in a large clinical sample. Journal of Abnormal Psychology, 110, 585 – 599.

Brumberg, J.J. (1988). Fasting girls: the emergence of anorexia nervosa as a modern disease. Harvard University Press: Cambridge.

225 Bulik, C.M. (1995). Anxiety disorders and eating disorders: a review of their relationship. New Zealand Journal of Psychology, 24, 51 – 62.

Bulik C.M, Sullivan, P., Carter, A. & Joyce, P. (1996). Lifetime anxiety disorders in women with bulimia nervosa. Comprehensive Psychiatry, 37 (5), 368-374.

Bulik C.M, Sullivan, P., Fear, J.L. & Joyce, P. (1997). Eating disorders and antecedent anxiety disorders: a controlled study. Acta Psychiatrica Scandinavica, 96, 101 - 107.

Bulik C.M, Sullivan, P., Fear, J.L. & Pickering, A. (1997). Predictors of the development of bulimia nervosa in women with anorexia nervosa. Journal of Nervous and Mental Disease, 185, 704 – 707.

Bulik, C.M., Sullivan, P.F. & Kendler, K.S. (1998). Heritability of binge eating and broadly defined bulimia nervosa. Biological Psychiatry, 44, 1210 – 1218.

Bulik C.M, Sullivan, P., Fear, J.L. & Pickering, A. (2000). Outcome of anorexia nervosa: eating attitudes, personality, and parental bonding. International Journal of Eating Disorders, 28, 139 - 147.

Bulik, C.M, Wade, T. & Kendler, K. (2000). Characteristics of monozygotic twins discordant for bulimia nervosa. International Journal of Eating Disorders, 29, 1 - 10.

Bulik, C.M. (2002). Anxiety, depression and eating disorders. In Fairburn, C.G. & Brownell, K.D. (Eds). Eating disorders and obesity: a comprehensive handbook. The Guilford Press: New York.

Bulik, C.M., Tozzi, F., Anderson, C. Mazzeo, S.E., Aggen, S.H. & Sullivan, P.F. (2003). The relation between eating disorders and components of perfectionism. American Journal of Psychiatry, 160, 366 – 368.

226 Bulik, C.M. (2003). Anxiety, depression and eating disorders. In Treasure, J., Schmidt, U. & van Furth, E. (Eds), Handbook of Eating Disorders (pp193 – 198). Wiley: Chichester, UK.

Bulik, C.M., Reba, L., Siega-Riz, A. & Reichborn-Kjennerud, T. (2005). Anorexia Nervosa: definition, epidemiology and cycle of risk. International Journal of Eating Disorders, 37, S2 – S9.

Burns, G.L., Keortge, S.G., Formea, G.M. & Sternberger, L.G. (1996). Revision of the Padua inventory of obsessive-compulsive disorder symptoms: distinctions between worry, obsessions and compulsions. Behaviour Research and Therapy, 34, 163–173.

Bushnell, J.A., Wells, J.E., McKenzie, J.M., Hornblow, A.R., Oakley, M.A & Joyce, P.R. (1994). Bulimia comorbidity in the general population and in the clinic. Psychological Medicine, 24, 605 – 611.

Carroll, J.M., Touyz, S.W., & Beumont, P.J.V. (1996). Specific comorbidity between bulimia nervosa and personality disorders. International Journal of Eating Disorders, 19, 159-170.

Carter, J.A. & Duncan, P.A. (1984). Binge-eating and vomiting: a survey of a high school population. Psychology in the Schools, 21, 198 – 203.

Carter, J., Blackmore, E., Sutandar-Pinnock, K. & Woodside, D. (2004). Relapse in anorexia nervosa: a survival analysis. Psychological Medicine, 34, 671 – 679.

Cartwright-Hatton, S. & Wells, A. (1997). Beliefs about worry and intrusions: the Meta- Cognitions Questionnaire and its correlates. Journal of Anxiety Disorders, 11, 279 – 296.

Casper, R.C. (1983). On the emergence of bulimia nervosa as a syndrome: a historical view. International Journal of Eating Disorders, 2, 3 – 16

227 Casper, R.C., & Jabine, L.N. (1986). Psychological functioning in anorexia nervosa: A comparison between anorexia nervosa patients on follow-up and their sisters. In Lacey, J.H. & Sturgeon, D.A. (Eds.). Proceedings of the 15th European Conference on Psychosomatic Research. Libbey: London.

Chambless, D.L., Caputo, G.S., Bright, P. & Gallagher, R. (1984). Assessment of fear of fear of agoraphobics. The Bodily sensations questionnaire and the agoraphobic cognitions questionnaire. Journal of Consulting and Clinical Psychology, 52, 1090 – 1097.

Chambless, D. L., Cherney, J., Caputo, G. C., & Rheinstein, B. J. G. (1987). Anxiety disorders and alcoholism: A study with inpatient alcoholics. Journal of Anxiety Disorders, 1, 29–40.

Channon, S., de Silva, P., Hemsley, D., & Perkins, R. (1989). A controlled trial of cognitive-behavioural and behavioural treatment of anorexia nervosa. Behaviour Research and Therapy, 27,529–535.

Chen, E., Touyz, S. W., Beumont, P., Fairburn, C. G., Griffiths, R., Butow, P., Russell, J., Schotte, D.E., Gertler, R. & Basten, C. (2003). Comparison of group and individual cognitive-behavioral therapy for patients with bulimia nervosa. International Journal of Eating Disorders, 33,241–254.

Chesler, B.E. (1995). The impact of stress, fear of fatness, and panic disorder with agoraphobia in eating disorder symptomatology: a case study. International Journal of Eating Disorders, 18, 195 – 198.

Clausen, L. (2004). Time course of symptom remission in eating disorders. International Journal of Eating Disorders, 36, 296 – 306.

228 Cooper, Z. & Fairburn, C.G. (1987). The Eating Disorder Examination: a semi-structured interview for the assessment of the specific psychopathology of eating disorders. International Journal of Eating Disorders, 6, 1-8.

Cooper, P.J., Taylor, M.J., Cooper, Z. & Fairburn, C.G. (1987). The development and validation of the Body Shape Questionnaire. International Journal of Eating Disorders, 6, 485 - 494.

Cooper, Z. Cooper, P.J. & Fairburn, C.G. (1989). The validity of the Eating Disorder Examination and its subscales. The British Journal of Psychiatry, 154, 807 - 812.

Cooper, M. Cohen-Tovee, E., Todd, G., Wells, A. & Tovee, M. (1997). The eating disorder belief questionnaire: preliminary development. Behaviour, Research and Therapy, 35, 381 – 388.

Couturier, J. & Lock, J. (2006). What is recovery in adolescent anorexia nervosa? International Journal of Eating Disorders, 39, 550 – 555.

Crafti, N. (2002). Integrating cognitive behaviour and interpersonal approaches in a group program for the eating disorders: measuring effectiveness in a naturalistic setting. Behaviour Change, 19, 22 – 38.

Crawford, J.R. & Henry, J.D. (2003). The depression anxiety stress scales (DASS): Normative data and latent structure in a large non-clinical sample. British Journal of Clinical Psychology, 42, 111 – 131.

Crow, S.J., Agras, W.S., Halmi, K.A, Mitchell, J.E. & Kraemer, H.C. (2002). Full syndromal versus subthreshold anorexia nervosa, bulimia nervosa and binge eating disorder: a multicentre study. International Journal of Eating Disorders, 32, 309 – 318.

229 DaCosta, M. & Halmi, K.A. (1992). Classification of anorexia nervosa: question of subtypes. International Journal of Eating Disorders, 11, 305 – 311.

Dahl, S. (1989). Acute response to rape: a PTSD variant. Acta Psychiatrica Scandinavica, 335, 56 – 62.

Dansky, B.S., Brewerton, T.D., Kilpatrick, D.G. & O’Neil, P.M. (1997). The national women’s study: relationship of victimization and posttraumatic stress disorder to bulimia nervosa. International Journal of Eating Disorders, 21, 213–228.

Dare, C., & Eisler, I. (1997). Family therapy for anorexia nervosa. In Garner, D. & Garfinkel, P. E. (Eds.), Handbook of treatment for eating disorders (2nd ed., pp. 333– 349). Wiley: Chichester, England.

Davey, G.C.L. (1993). A comparison of three worry questionnaires. Behaviour Research and Therapy, 31, 51–56.

Dean, H.Y. (2006). Brief Inpatient treatment for eating disorders: can motivational enhancement therapy improve outcome?. Unpublished manuscript.

Deep, A.L., Nagy, L.M., Weltzin, T.E., Rao, R. & Kaye. W.H. (1995). Premorbid onset of psychopathology in long term recovered anorexia nervosa. International Journal of Eating Disorders, 17, 291 - 297.

Deter, H.C & Herzog, W. (1994). Anorexia nervosa in a long-term perspective: results of the Heidelberg-Mannheim study. Psychosomatic Medicine, 56, 20 – 27.

Deter, H.C., Schellberg, D., Kopp, W., Friederich, H.C. & Herzog, W. (2005). Predictability of a favorable outcome in anorexia nervosa. European Psychiatry, 20, 165 – 172.

230 DiClemente, C.C. & Prochaska, J.O. (1998). Toward a comprehensive, trans-theoretical model of change. In W.R. Miller & N. Heather (Eds.), Treating Addictive Behaviours

(2nd Ed.; pp3 – 24). Plenum Press: New York.

DiGiuseppe, R., Simon, K.S., McGowan, L. & Gardner, F. (1990). A comparative outcome study of four cognitive therapies in the treatment of social anxiety. Journal of Rational-Emotive and Cognitive-Behavior Therapy, 8, 129 – 146.

DiTomasso, R.A. & Gosch, E.A. (2002). Anxiety Disorders: A practitioner’s guide to comparative treatments. Springer Publishing Company: New York.

Du Fort, G.G., Newman, S.C. & Bland, R.C. (1993). Psychiatric comorbidity and treatment seeking: sources of selection bias in the study of clinical populations. Journal of Nervous and Mental Disease, 181, 467 – 474.

Eckert, E.D., Halmi, K.A., Marchi, P., Grove, W. & Crosby, R. (1995). Ten-year follow- up of anorexia nervosa: clinical course and outcome. Psychological Medicine, 25, 143 – 156.

Eddy, K.T., Keel, P.K., Dorer, D.J., Delinsky, S.S., Franco, D.L. & Herzog, D.B. (2002). A longitudinal comparison of anorexia nervosa subtypes. International Journal of Eating Disorders, 31, 191 – 201.

Eisler, I., Dare, C., Hodes, M., Russell, G., Dodge, E., & le Grange, D. (2000). Family therapy for adolescent anorexia nervosa: The results of a controlled comparison of two family interventions. Journal of Child Psychology and Psychiatry and Allied Disciplines, 41,727–736.

Elkin, I., Shea, M. T., Watkins, J. T., Imber, S. D., Sotsky, S. M., Collins, J. F., Glass, D. R., Pilkonis, P. A., Leber, W. R. & Docherty, J. P. (1989). National Institute of

231 Mental Health Treatment of Depression Collaborative Research Program: General effectiveness of treatments. Archives of General Psychiatry, 46, 971–982.

Esplen, M.J., Garfinkel, P.E., Olmsted, M., Gallop, R.M. & Kennedy, S. (1998). A randomized controlled trial of guided imagery in bulimia nervosa. Psychological Medicine, 28, 1347 – 1357.

Fahy, T.A., Osacar, A. & Marks, I. (1993). History of eating disorders in female patients with obsessive-compulsive disorder. International Journal of Eating Disorders, 14, 439 – 443.

Fairburn, C. G., Marcus, M. D., & Wilson, G. T. (1993). Cognitive behaviour therapy for binge eating and bulimia nervosa: A comprehensive treatment manual. In C. G. Fairburn & G. T. Wilson (Eds.), Binge eating: Nature, assessment and treatment (pp. 361–404). Guilford Press: New York.

Fairburn, C. G., Jones, R., Peveler, R. C., Hope, R. A., & O'Connor, M. (1993). Psychotherapy and bulimia nervosa: The longer-term effects of interpersonal psychotherapy, behaviour therapy and cognitive behaviour therapy. Archives of General Psychiatry, 50,419–428.

Fairburn, C.G. & Cooper, Z. (1993). The Eating Disorder Examination, 12th Ed. In Fairburn, C.G. & Wilson, G.T. (Eds). Binge Eating: Nature, Assessment and Treatment. Guilford Press: New York.

Fairburn, C.G. & Beglin, S.J (1994). Assessment of eating disorders: Interview of self- report questionnaire? International Journal of Eating Disorders, 16, 363 – 370.

Fairburn, C.G., Norman, P.A., Welch, S.L., O’Connor, M.E., Doll, H.A. & Peveler, R.C. (1995). A prospective study of outcome in bulimia nervosa and the long-term effects of three psychological treatments. Archives of General Psychiatry, 52, 304-312.

232

Fairburn, C.G. (1997). Eating Disorders. In Clark, D.M. and Fairburn, C.G. (Eds.), Science and practice of cognitive behaviour therapy. Oxford University Press: UK.

Fairburn, C. G., Shafran, R., & Cooper, Z. (1999). A cognitive behavioural theory of anorexia nervosa. Behaviour Research and Therapy, 37,1–13.

Fairburn, C.G., Cooper, Z., Doll, H.A. & Welch, S.L. (1999). Risk factors for anorexia nervosa: three integrated case control comparisons. Archives of General Psychiatry, 56, 468-476.

Fairburn, C.G., Cooper, Z., Doll, H.A., Norman, P. & O’Connor, M. (2000). The natural course of bulimia nervosa and binge eating disorder in young women. Archives of General Psychiatry, 57, 659-665.

Fairburn, C. G., & Walsh, B.T. (2002). Atypical eating disorders (eating disorders not otherwise specified). In C.G. Fairburn & K.D. Brownell (Eds.), Eating Disorders and Obesity: a comprehensive handbook (pp 171 – 177). Guilford Press: New York

Fairburn, C. G., & Harrison, P. J. (2003). Eating disorders. Lancet, 361,407–416.

Fairburn, C. G., Cooper, Z., & Shafran, R. (2003). Cognitive behaviour therapy for eating disorders: A “transdiagnostic” theory and treatment. Behaviour Research and Therapy, 41,509–529.

Fairburn, C.G., Stice, E., Cooper, Z., Doll, H.A., Norman, P. & O’Connor, M. (2003). Understanding persistence in bulimia nervosa: a 5-year naturalistic study. Journal of Consulting and Clinical Psychology, 71, 103-109.

Fairburn, C. G. (2005). Evidence-based treatment of anorexia nervosa. International Journal of Eating Disorders, 37 (Suppl.), S26–S30.

233

Fairburn, C.G. & Bohn, K. (2005). Eating disorder NOS (EDNOS): an example of the troublesome “not otherwise specified” (NOS) category in DSM-IV. Behaviour Research and Therapy, 43, 691 – 701.

Fallon, P. & Wonderlich, S.A. (1997). Sexual abuse and other forms of trauma. In D.M. Garner & P.E. Garfinkel (Eds.), Handbook of treatment for eating disorders (2nd ed., pp. 394 – 414). Guilford: New York.

Faravelli, C., Giugni, A., Salvatori, S. & Ricca, V. (2004). Psychopathology after rape, American Journal of Psychiatry, 161 (8), 1483 – 1485.

Feighner, J.P. (1999). Overview of antidepressants currently used to treat anxiety disorders. Journal of Clinical Psychiatry, 60, 18 – 22.

Felgoise, S.H., Nezu, C.M & Nezu, A.M. (2002). Problem solving Therapy. In DiTomasso, R.A. & Gosch, E.A. (Eds). Anxiety disorders: a practitioners guide to comparative treatments. Springer: New York.

Fichter, M.M., Eleton, M., Engel, K., Meyer A.E., Mall H. & Poustka, F. (1991). Structured interview for anorexia and bulimia nervosa (SIAB): development of a new instrument for the assessment of eating disorders. International Journal of Eating Disorders, 10, 571- 592.

Fichter, M. & Quadflieg, N. (1997). Six-year course of bulimia nervosa. International Journal of Eating Disorders, 22, 361-384.

Fichter, M., Quadflieg, N. & Gnutzmann, A. (1998). Binge eating disorder: treatment outcome over a six-year course. Journal of Psychosomatic Research, 44, 385-405.

234 Fichter, M. & Quadflieg, N. (2004). Twelve-year course and outcome of bulimia nervosa. Psychological Medicine, 34, 1395-1406.

Fichter, M., Quadflieg, N. & Hedlund, S. (2006). Twelve-year course and outcome predictors of anorexia nervosa. International Journal of Eating Disorders, 39, 87-100.

Field, A., Herzog, D., Keller, M., West, J., Nussbaum, K & Colditz, G. (1997). Distinguishing recovery from remission in a cohort of bulimic women: how should asymptomatic periods be described? Journal of Clinical Epidemiology, 50, 1339 – 1345.

First, M.B., Spitzer, R.L., Gibbon, M.A. & Williams, J.B.W. (1997). Structured Clinical Interview for DSM-IV. New York State Psychiatric Institute: New York.

Foa, E.B. & Kozak, M.J. (1986). Emotional processing of fear: exposure to corrective information. Psychological Bulletin, 99, 20 – 35.

Foa, E.B, Cashman, L., Jaycox, L., & Perry, K. (1997). The validation of a self-report measure of PTSD: The Posttraumatic Diagnostic Scale. Psychological Assessment, 9, 445-451.

Fornari, V., Kaplan, M., Sandberg, D.E., Matthews, M., Skolnick, N. & Katz, J. (1992). Depressive and anxiety disorders in anorexia nervosa and bulimia nervosa. International Journal of Eating Disorders, 12, 21 – 29.

Franko, D.L., Wonderlich, S.A., Little, D. & Herzog, D.B. (2004). Diagnosis and classification of eating disorders: what’s new. In J.K. Thompson (Ed.), Handbook of eating disorders and obesity (pp 58 – 80). Wiley: New York.

Friedman, C. J., Shear, M. K., & Frances, A. J. (1987). DSM–III personality disorders in panic patients. Journal of Personality Disorders, 1, 132–135.

235 Garfinkel, P.E., Kennedy, S. & Kaplan, A.S. (1995). Views on classification and diagnosis of eating disorders. Canadian Journal of Psychiatry, 40, 445 – 456.

Garfinkel, P.E., Lin, E., Goering, P., Spegg, C., Goldbloom, D.S., Kennedy, S., Kaplan, A.S. & Woodside, D.B. (1995). Bulimia nervosa in a Canadian community sample: prevalence and comparison of subgroups. American Journal of Psychiatry, 152, 1052 – 1058.

Garfinkel, P.E., Lin, E., Goering, P., Spegg, C., Goldbloom, D.S., Kennedy, S., Kaplan, A.S. & Woodside, D.B. (1996). Should amenorrhea be necessary for the diagnosis of anorexia nervosa? Evidence from a Canadian community sample. British Journal of Psychiatry, 168, 500 – 506.

Garner, D. M. & Garfinkel, P.E. (1979). The eating attitudes test: an index of the symptoms of anorexia nervosa. Psychological Medicine, 9, 273 – 279.

Garner, D. M., & Bemis, K. M. (1982). A cognitive-behavioral approach to anorexia nervosa. Cognitive Therapy and Research, 6,123–150.

Garner, D.M., Olmsted, M.P., Bohr, Y. & Garfinkel, P.E. (1982). The eating attitudes test: psychometric features and clinical correlates. Psychological Medicine, 12, 871 – 878.

Garner, D. M., Olmsted, M. P., & Polivy, J. (1983). Development and validation of multidimensional eating disorders inventory for and anorexia nervosa and bulimia. International Journal of Eating Disorders, 2, 15-34.

Garner, D. M., & Bemis, K. M. (1985). Cognitive therapy for anorexia nervosa. In Garner, D. M.& Garfinkel, P. E. (Eds.), Handbook of psychotherapy for anorexia nervosa and bulimia (pp. 107–146). Wiley: Chichester, England.

236 Garner, D.M. (1993). Pathogenesis of anorexia nervosa. Lancet, 341, 1631 – 1635.

Garner, D.M. (1995). Assessment of eating disorder psychopathology. In Brownell, K.D. & Fairburn, C.G. (Eds). Eating disorders and obesity (pp. 117 – 121). Guilford Press: New York.

Garner, D.M., Vitousek, K., & Pike, K. M. (1997). Cognitive behavioral therapy for anorexia nervosa. In Garner, D. M. & Garfinkel, P. E. (Eds.), Handbook of treatment for eating disorders (2nd ed., pp. 91–144). Wiley: Chichester, England.

Garner, D.M. (2004). Eating Disorder Inventory -3 Professional Manual. Psychological Assessment Resources: Florida, USA.

Gartner, A.F., Marcus, R.N., Halmi, K. & Loranger, A.W. (1989). DSM-III-R personality disorders in patients with eating disorders. American Journal of Psychiatry, 146, 1585 – 1591.

Ghaderi, A. (2006). Does individualization matter? A randomized ctrial of standardized (focused) versus individualized (broader) cognitive behaviour therapy for bulimia nervosa. Behaviour Research and Therapy, 44, 273 – 288.

Gillberg, C., Råstam, M. & Gillberg, I.C. (1994a). Anorexia nervosa: physical health and neurodevelopment at 16 and 21 years. Developmental Medicine & Child Neurology, 36, 139 – 147.

Gillberg, C., Råstam, M. & Gillberg, I.C. (1994b). Anorexia nervosa outcome: 6 year controlled longitudinal study of 51 cases including a population cohort. Journal of American Academy of Child Adolescent Psychiatry, 33, 729 - 739.

Gillberg, C., Råstam, M. & Gillberg, I.C. (1995). Anorexia nervosa 6 years after onset. I. Personality Disorders. Comprehensive Psychiatry, 36, 61 - 69.

237

Gleaves, D.H & Eberenz, K.P. (1994). Sexual abuse histories among treatment resistant bulimia nervosa patients. International Journal of Eating Disorders, 15, 227 – 231.

Gleaves, D.H., Eberenz, K.P. & May, M.C. (1998). Scope and significance of posttraumatic symptomatology among women hospitalized for an eating disorder. International Journal of Eating Disorders 24, 147–156.

Godart, N., Flament, M., Lecrubier, Y & Jeammet, P. (2000). Anxiety Disorders in AN and bulimia nervosa: comorbidity and chronology of appearance. European Psychiatry, 15, 38 – 45.

Godart, N., Flament, M., Perereau, F. & Jeammet, P. (2002). Comorbidity between eating disorders and anxiety disorders: a review. International Journal of Eating Disorders, 32, 253 – 270.

Godart N.T., Flament M.F., Curt F., Perdereau F., Lang F., Venisse J.L., Halfon O., Bizouard P., Loas G., Corcos M., Jeammet P. & Fermanian J. (2003). Anxiety disorders in subjects seeking treatment for eating disorders: a DSM-IV controlled study. Psychiatry Research, 117, 245–258.

Godart, N., Berthoz, S., Perereau, F. & Jeammet, P. (2006). Comorbidity of anxiety disorders with eating disorders and OCD (Letter to the Editor). American Journal of Psychiatry, 163 (2), 326.

Godart, N., Berthoz, S., Rein, Z., Perereau, F., Lang, F., Venisse, J., Halfon, O., Bizouard, P., Loas, G., Corcos, M., Jeammet, P., Flament, M. & Curt, F. (2006). Does the frequency of anxiety and depressive disorders differ between diagnostic subtypes of anorexia nervosa and bulimia? International Journal of Eating Disorders, 39, 772 – 228.

238 Goldstein, A.J. & Chambless, D.L. (1978). A reanalysis of agoraphobia. Behavior Therapy, 9, 47 – 59.

Goldstein, R.D. & Gruenberg, A.M. (2002). In R.A., Di Tomasso, & E.A., Gosch (Eds). Anxiety Disorders: A practitioner’s guide to comparative treatments. (pp206 – 222). Springer Publishing Company: New York.

Goodman, W.K., Price, L.H., Rasmussen, S.A., Mazure, C., Fleishmann, R.L., Hill, C.L., Heninger, G.R. & Charney, D.S. (1989). The Yale-Brown Obsessive Compulsive Scale, I: development, use and reliability. Archives of General Psychiatry, 46, 1006 – 1011.

Goodman, W.K., Price, L.H., Rasmussen, S.A., Mazure, C., Delgado, P., Heninger, G.R. & Charney, D.S. (1989). The Yale-Brown Obsessive Compulsive Scale, II: validity. Archives of General Psychiatry, 46, 1012 – 1016.

Goodwin, R & Fitzgibbon, M. (2002). Social phobia as a barrier to treatment for eating disorders. International Journal of Eating Disorders, 32, 103 – 106.

Gormally, J., Black, S., Daston, S. & Rardin, D. (1982). The assessment of binge eating severity among obese persons. Addictive Behaviors, 7, 47 – 55.

Gowers, S.G. & Smyth, B. (2004). The impact of a motivational assessment interview on initial response to treatment in adolescent anorexia nervosa. European Eating Disorders Review, 12, 87 – 93.

Grave, R.D. & Calugi, S. (2007). Eating disorder not otherwise specified in an inpatient unit: the impact of altering the DSM-IV criteria for anorexia nervosa and bulimia nervosa. European Eating Disorders Review, 15, 340 – 349.

Green, M. A., & Curtis, G. C. (1988). Personality disorders in panic patients: Response to termination of anti-panic medication. Journal of Personality Disorders, 2, 303–314.

239

Grisham, J.R., Brown, T.A. & Campbell, L.A. (2004). The Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV). In M.J. Hilsenroth & D.L. Segal (Eds). Comprehensive Handbook of Psychological Assessment, Volume 2. (pp163 – 177). John Wiley & Sons: New Jersey.

Gross, J., Rosen, J.C., Leitenberg, H. and Willmuth, M.E. (1986). Validity of the eating attitudes test and the eating disorders inventory in bulimia nervosa. Journal of Consulting and Clinical Psychology, 54, 875–876.

Habermas, T. (1989). The psychiatric history of anorexia nervosa and bulimia nervosa: weight concerns and bulimic symptoms in early case reports. International Journal of Eating Disorders, 8, 259 – 273.

Habermas, T. (2005). On the uses of history in psychiatry: diagnostic implications for anorexia nervosa. International Journal of Eating Disorders, 38, 167 – 182.

Halmi, K.A., Brodland, G., & Loney, J. (1973). Prognosis in anorexia nervosa. Annals of Internal Medicine, 78, 907–909.

Halmi, K., Eckert, E., Marchi, P., Sampugnaro, V., Apple, R. & Cohen, J. (1991). Comorbidity of psychiatric diagnoses in anorexia nervosa. Archives of General Psychiatry, 48, 712 – 718.

Halmi, K., Sunday, S., Strober, M., Kaplan, A., Woodside, B., Fichter, M., Treasure, J., Berrettini, W. and Kaye, W. (2000). Perfectionism in anorexia nervosa: variation by clinical subtype, obsessionality, and pathological eating behavior. American Journal of Psychiatry, 157, 1799 – 1805.

Halmi, K., Sunday, S., Klump, K., Strober, M., Leckman, J., Fichter, M., Kaplan, A., Woodside, B., Treasure, J., Berrettini, W., Al Shabboat, M., Bulik, C. & Kaye, W.

240 (2003). Obsessions and compulsions in anorexia nervosa subtypes. International Journal of Eating Disorders, 33, 308–319.

Halmi, K., Agras, W.S., Crow, S., Mitchell, J., Wilson, G.T., Bryson, S.W. & Kraemer, H.C. (2005). Predictors of treatment acceptance and completion in anorexia nervosa: Implications for future study designs. Archives of General Psychiatry, 62, 776 – 781.

Hayes, S.C., Strosahl, K.D. & Wilson, K.G. (1999). Acceptance and commitment therapy: an experiential approach to behaviour change. Guilford: New York.

Hayes, S.C., Pankey, J. & Gregg, J. (2002). In R.A., DiTomasso & E.A., Gosch.(Eds) Anxiety Disorders: A practitioner’s guide to comparative treatments. (pp110 – 136). Springer Publishing Company: New York.

Hayes, S.C., Luoma, J.B., Bond, F.W., Masuda, A. & Lillis, J. (2006). Acceptance and commitment therapy: Model, process and outcomes. Behaviour Research and Therapy, 44, 1 – 25.

Henry, J.D. & Crawford, J.R. (2005). The short –form version of the Depression Anxiety Stress Scales (DASS-21): Construct validity and normative data in a large non-clinical sample. British Journal of Clinical Psychology, 44, 227 – 239.

Herpertz-Dahlmann, B., Wewetzer, C., Schulz, E. & Remschmidt, H. (1996). Course and outcome in adolescent anorexia nervosa. International Journal of Eating Disorders, 19, 335 – 345.

Herzog, D.B., Norman, D.K., Rigotti, N.A. & Pepose, M. (1986). Frequency of bulimic behaviours and associated social maladjustment in female graduate students. Journal of Psychiatric Research, 20, 355 – 361.

241 Herzog, D.B., Keller, M.B., Lavori, P.W., Kenny, G.M. & Sacks, N.R. (1992). The prevalence of personality disorders in 210 women with eating disorders. Journal of Clinical Psychiatry, 53, 147 – 152.

Herzog, D.B., Keller, M.B., Sacks, N.R., Yeh, C.J. and Lavori, P.W.(1992). Psychiatric comorbidity in treatment seeking anorexics and bulimics. Journal of the American Academy of Child and Adolescent Psychiatry, 31, 810 – 818.

Herzog, D.B., Nussbaum, K.M. & Marmour, A.K. (1996). Comorbidity and outcome in eating disorders. Psychiatric Clinics of North America, 19, 843 – 859.

Herzog, D.B., Field, A.E., Keller, M.B., West, J.C., Robbins, W.M., Staley, J. & Colditz, G. (1996). Subtyping eating disorders: is it justified? Journal of the American Academy of Child and Adolescent Psychiatry, 35, 928 – 936.

Herzog, D.B., Dorer, D.J., Keel, P.K., Selwyn, S.E., Ekeblad, E.R., Flores, A.T., Greenwood, D., Burwell, R. & Keller, M. (1999) Recovery and relapse in anorexia and bulimia nervosa: a 7.5 year follow up study. Journal of the American Academy of Child & Adolescent Psychiatry, 38, 829 – 837.

Herzog, D.B. & Delinsky, S.S. (2001). Classification of eating disorders. In Striegel- Moore, R.H. & Smolak, L. (Eds.), Eating disorders: innovative directions in research and practice (pp31 – 50). American Psychological Association: Washington, DC.

Hesselbrock, M. N., Meyer, R. E., & Keener, J. J. (1985). Psychopathology in hospitalized alcoholics. Archives of General Psychiatry, 42, 1050–1055.

Hills, A. (2008). Foolproof guide to statistics using SPSS (3rd Ed). Pearson Education Australia: Australia.

242 Hinrichson, H., Wright, F., Waller, G. & Meyer, C. (2003). Social anxiety and coping strategies in the eating disorders. Eating Behaviors, 4, 117 - 126.

Hinrichson, H., Waller, G. & van Gerko, K. (2004). Social phobia and agoraphobia in the eating disorders: associations with eating attitudes and behaviours. Eating Behaviors, 5, 285 - 290.

Hodgson, R.J. & Rachman, S. (1977). Obsessional compulsive complaints. Behavior Research and Therapy, 10, 181 – 189.

Holden, M. (1990). Is anorexia nervosa an obsessive-compulsive disorder? British Journal of Psychiatry, 157, 1–5.

Holderness, C., Brooks-Gunn, J. & Warren, M. (1994). Comorbidity of eating disorders and substance abuse: Review of the literature. International Journal of Eating Disorders, 16, 1–34.

Hollander, E. & Wong, C.M. (1995). Obsessive compulsive spectrum disorders. Journal of Clinical Psychiatry, 56, 3 – 6.

Horowitz, M.J., Wilner, N. & Alvarez, W. (1979). Impact of events scale: a measure of subjective distress. Psychosomatic Medicine, 41, 209 – 218.

Hsu, G., Kaye, W. & Weltzin, T. (1993). Are the eating disorders related to obsessive compulsive disorders. International Journal of Eating Disorders, 14, 305 – 318.

Hsu, G.L.K. (1996). Epidemiology of the eating disorders. Psychiatric Clinics of North America, 19, 681 – 700.

Hudson, J. I., Pope, H. G., Jonas, J. M., & Yurgelun-Todd, D. (1983). Phenomenologic relationship of eating disorders to major affective disorder. Psychiatry Research, 9, 345– 354.

243 Hudson, J. I., Pope, H. G., Yurgelun-Todd, D., Jonas, J. M., & Frankenburg, F. R. (1987). A controlled study of lifetime prevalence of affective and other psychiatric disorders in bulimic outpatients. American Journal of Psychiatry, 144, 1283 - 1287.

Ivarsson, T., Råstam, M., Wentz, E., Gillberg, I.C., & Gillberg, C. (2000). Depressive disorders in teenage-onset anorexia nervosa: a controlled longitudinal, partly community- based study. Comprehensive Psychiatry, 41, 398 - 403.

Iwasaki, Y., Matsunaga, H., Kiriike, N., Tanaka, H. & Matsui, T. (2000). Comorbidity of axis I disorders among eating-disordered subjects in Japan. Comprehensive Psychiatry, 41, 454–460.

Jacobi, C., Hayward, C., de Zwaan, M., Kraemer, H.C. & Agras, W.S. (2004). Coming to terms with risk factors for eating disorders: application of risk terminology and suggestions for a general taxonomy. Psychological Bulletin, 130, 19 – 65.

Johnson, J.G., Cohen, P., Kasen, S. & Brook, J.S. (2002). Childhood adversities associated with risk for eating disorders or weight problems during adolescence or early adulthood. American Journal of Psychiatry, 159, 394 – 400.

Kant, G.L., D’Zurilla, T.J. & Maydeau-Olivares, A. (1997). Social problem solving as a mediator of stress-related depression and anxiety in middle-aged and elderly community residents. Cognitive Therapy and Research, 21, 73 – 96.

Kasvikis, Y.G., Tsakiris, F., Marks, I.M., Basoglu, M. & Noshirvani, H.F. (1986). Past history of anorexia nervosa in women with obsessive compulsive disorder. International Journal of Eating Disorders, 5, 1069 – 1075.

Katzman, M.A. & Lee, S. (1997). Beyond body image: the integration of feminist and transcultural theories in the understanding of self starvation. International Journal of Eating Disorders, 22, 385 – 394.

244

Kaye, W.H., Greeno, C.G., Moss, H., Fernstrom, J., Fernstrom, M., Lilenfeld, L.R., Weltzin, T.E. & Mann, J.J. (1998). Alterations in serotonin activity and psychiatric symptoms after recovery from bulimia nervosa. Archives of General Psychiatry, 55, 927 – 935.

Kaye, W.H., Bulik, C., Thornton, L., Barbarich, N., Masters, K. & the Price Foundation Collaborative Group (2004). Comorbidity of anxiety disorders with anorexia and bulimia nervosa. The American Journal of Psychiatry, 161, 2215 – 2221.

Kaye, W.H., Devlin, B., Barbarich, N., Bulik, C., Thornton, L., Bacanu, S.A., Fichter, MM., Halmi, K.A., Kaplan, A.S., Strober, M., Woodside, D.B., Bergen, A.W., Crow, S., Mitchell, J., Rotondo, A., Mauri, M., Cassano, G., Keel, P., Plotnicov, K., Pollice, C., Klump, K.L., Lilenfeld, L.R., Ganjei, J.K., Quadflieg, N. & Berrettini, W.H. (2004). genetic analysis of bulimia nervosa: methods and sample description. International Journal of Eating Disorders, 35, 556 – 570.

Keck, P., Pope, H., Hudson, J., McElroy, S., Yurgelun-Todd, D. & Hundert, E. (1990). A controlled study of phenomenology and family history in outpatients with bulimia nervosa. Comprehensive Psychiatry, 31, 275 – 283.

Keel, P.K & Mitchell, J.E. (1997). Outcome in bulimia nervosa. American Journal of Psychiatry, 154, 313 – 321.

Keel, P.K; Mitchell, J.E., Miller, K.B., Davis, T.L. & Crow, S.J. (1999). Long-term outcome of bulimia nervosa. Archives of General Psychiatry, 56, 63 – 69.

Keel, P.K., Mitchell, J.E., Davis, T.L., Fieselman, S. & Crow, S.J. (2000). Impact of definitions on the description and prediction of bulimia nervosa outcome. International Journal of Eating Disorders, 28, 377 – 386.

245 Keel, P.K., Dorer, D.J., Eddy, K.T., Franko, D., Charatan, D.L., & Herzog, D.B. (2003). Predictors of mortality in the eating disorders. Archives of General Psychiatry, 60, 179 – 183.

Keel, P.K., Dorer, D.J., Franko, D., Jackson, S.C., & Herzog, D.B. (2005). Post remission predicators of relapse in eating disorders. American Journal of Psychiatry, 162, 2263 - 2268.

Kendall, P.C. & Clarkin, J.F. (1992). Comorbidity and treatment implications. Journal of Consulting and Clinical Psychology, 60, 833 – 834.

Kendler, K.S., MacLean, C., Neale, M.C., Kessler, R.C., Heath, A. & Eaves, L.J. (1991). The genetic epidemiology of bulimia nervosa. American Journal of Psychiatry, 148, 1627 – 1637.

Kendler, K.S., Walters, E.E., Neale, M.C, Kessler, R.C., Heath, A.C. & Eaves, L.J. (1995). The structure of the genetic and environmental risk factors for six major psychiatric disorders in women: Phobia, generalized anxiety disorder, panic disorder, bulimia, major depression and alcoholism. Archives of General Psychiatry, 52, 374 – 383.

Kennedy, S.H. & Garfinkel, P.E. (1992). Advances in diagnosis and treatment of anorexia nervosa and bulimia nervosa. Canadian Journal of Psychiatry, 5, 309 – 315.

Keys, A., Brozek, J., Henschel, A., Mickelson, O., & Taylor, H. L. (1950). The biology of human starvation (Vol. 1). University of Minnesota Press: Minneapolis.

Killick, S. & Allen, C. (1997). Shifting the balance – motivational interviewing to help behaviour change in people with bulimia nervosa. European Eating Disorders Review, 5, 33 – 41.

246 Kleifield, E. I., Wagner, S., & Halmi, K. A. (1996). Cognitive-behavioral treatment of anorexia nervosa. Psychiatric Clinics of North America, 19,715–737.

Klein, D.A. & Walsh, B.T. (2003). Eating disorders. International Review of Psychiatry, 15, 205-216.

Klerman, G. L., Weissman, M. M., Rounsaville, B. J. & Chevron, E. S. (1984). Interpersonal psychotherapy of depression. Basic Books: New York.

Klerman, G. (1990). Approaches to the phenomena of comorbidity. In J.D. Maser & C.R. Cloniger (Eds.), Comorbidity of mood and anxiety disorders (pp. 13 – 37). American Psychiatric Press: Washington DC.

Koenigsberg, H. W., Kaplan, R. D., Gilmore, M. M., & Cooper, A. M. (1985). The relationship between syndrome and personality disorder in DSM–III; Experience with 2,462 patients. American Journal of Psychiatry, 142, 207–212.

Kozyk, J.C., Touyz, S.W., & Beumont, P.J.V. (1998). Is there a relationship between bulimia nervosa and hazardous alcohol use? International Journal of Eating Disorders, 24, 95-99.

Kraemer, H. C., Wilson, G. T., Fairburn, C. G., & Agras, W. S. (2002). Mediators and moderators of treatment effects in randomized clinical trials. Archives of General Psychiatry, 59,877–883.

Kulka, R. A., Schlenger, W. E., Fairbank, J. A., Hough, R. L., Jordan, B. K., Marmar, C. R., & Weiss, D. S. (1990). Trauma and the Vietnam War generation. Brunner/Mazel: New York

247 Ladouceur, R., Freeston, M.H., Dumont, J., Letarte, H., Rheaume, J., Gagnon, F. and Thibodeau, N. (1992). Penn State Worry Questionnaire: Validity and reliability of a French translation. Canadian Psychology, 33, 236.

Laessle, R., Kittl, S., Fichter, M., Wittchen, H., & Pirke, K. (1987). Major affective disorder in anorexia nervosa and bulimia. A descriptive diagnostic study. British Journal of Psychiatry, 151, 785 – 789.

Laessle, R., Wittchen, H., Fichter, M. and Pirke, K. (1989). The significance of subgroups of bulimia and anorexia nervosa: lifetime frequency of psychiatric disorders. International Journal of Eating Disorders, 8, 569 – 574.

Lee, S., Ho, T.P & Hsu, L.K.G. (1993). Fat phobic and non-fat phobic anorexia nervosa: a comparative study of 70 Chinese patients in Hong Kong. Psychological Medicine, 23, 999 – 1017.

le Grange, D., Eisler, I., Dare, C., & Russell, G. F. M. (1992). Evaluation of family treatments in adolescent anorexia nervosa: A pilot study. International Journal of Eating Disorders, 12,347–357.

Leonard, B.E. (1998). Fundamentals of psychopharmacology (2nd ed.). Wiley: Chichester.

Levy, R.K. (1997). The transtheoretical model of change: an application to bulimia nervosa. Psychotherapy, 34, 278 – 285.

Lilenfeld, L.R, Kaye, W., Greeno, C., Merikangas, K., Plotnicov, K., Pollice, C., Rao, R., Strober, M., Bulik, C. & Nagy, L. (1998). A controlled family study of anorexia nervosa and bulimia nervosa: psychiatric disorders in first-degree relatives and effects of proband comorbidity. Archives of General Psychiatry, 55, 603 – 610.

248 Lilenfeld, L.R, Stein, D., Bulik, C.M., Strober, M., Plotnicov, K., Pollice, C., Rao, R., Merikangas, K.R., Nagy, L. and Kaye, W.H. (2000). Personality traits among currently eating disordered, recovered and never ill first-degree female relatives of bulimic and control women. Psychological Medicine, 30, 1399 – 1410.

Linehan, M.M. (1993a). Cognitive behavior therapy of borderline personality disorder. Guilford Press: New York.

Linehan, M.M. (1993b). Skills training manual for treating borderline personality disorder. Guilford Press: New York.

Lipsitz, J. D., Markowitz, J. C., & Cherry, S. (1997). Manual for interpersonal psychotherapy of social phobia. Columbia University College of Physicians and Surgeons: New York (Unpublished manuscript)

Lipschitz, D.S., Winegar, R.K., Hartnick, E., Foote, B. & Southwick, S.M. (1999). Posttraumatic stress disorder in hospitalised adolescents: psychiatric comorbidity and clinical correlates. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 385 – 392.

Lock, J., & le Grange, D. (2005). Family-based treatment of eating disorders. International Journal of Eating Disorders, 37(Suppl.), S64–S67.

Lockwood, R., Lawson, R. & Waller, G. (2004). Compulsive features in the eating disorders: a role for trauma?. The Journal of Nervous and Mental Diseases, 192(3), 247 – 249.

Lovibond, S.H. & Lovibond, P.F. (1995). Manual for the depression anxiety and stress scales. Psychology Foundation: Sydney.

249 Luce, K.H. & Crowther, J.H. (1999). The reliability of the eating disorder examination – self-report questionnaire version (EDE-Q). International Journal of Eating Disorders, 25, 349- 351.

Mantero, M. & Crippa, L. (2002). Eating Disorders and chronic post traumatic stress disorder: issues of psychopathology and comorbidity. European Eating Disorders Review, 10, 1 – 16.

Martin, C.K., Williamson, D.A. & Thaw, J.M. (2000). Criterion validity of the multiaxial assessment of eating disorders symptoms. International Journal of Eating Disorders, 28, 303 – 310.

Masheb, R. M., & Grilo, C. M. (2000). Binge eating disorder: A need for additional diagnostic criteria. Comprehensive Psychiatry, 41,159–162.

Matsunaga, H., Miyaga, A., Iwasaki, H., Matsui, T., Fujimoto, K. & Kiriike, N. (1999). A comparison of clinical features among Japanese eating disordered women with obsessive compulsive disorder. Comparative Psychiatry, 40, 337 – 342.

Matsunaga, H., Kaye, W. H., McConaha, C., Plotnicov, K., Pollice, C., & Rao, R. (2000). Personality disorders among subjects recovered from eating disorders. International Journal of Eating Disorders, 27, 353–357.

Mattick, R.P. & Clark, J.C. (1989). Development and validation of measures of social phobia, scrutiny, fear and social interaction anxiety. Unpublished manuscript.

Mavissakalian, M., & Hamann, M. S. (1986). DSM–III personality disorder in agoraphobia. Comprehensive Psychiatry, 27, 471–479.

Mazure, C.N., Halmi, K.A., Sunday, S.R, Romano, S. & Einhorn, A. (1994). The Yale Brown Cornell Eating Disorder Scale: development, use, reliability and validity. Journal of Psychiatric Research, 28, 425 – 445.

250 McIntosh, V. V. W., Jordan, J., Carter, F. A., Luty, S. E., McKenzie, J. M., Bulik, C. M., Frampton, C. & Joyce, P. (2005). Three psychotherapies for anorexia nervosa: A randomized, controlled trial. American Journal of Psychiatry, 162,741–747.

McNeil, D.W., Ries, B.J. & Turk, C.L. (1995). Behavioural assessment: self-report, physiology & overt behaviour. In: Heimberg, R.G., Liebowitz, M.R., Hope, D.A. & Schneier, F.R. (Eds.) Social Phobia: diagnosis, assessment and treatment (pp202 – 232). Guilford Press: NY.

Meadows, E.A. & Phipps, K.A. (2002). Cognitive – Behavioural treatment. In: R.A. DiTomasso & E.A. Gosch, Anxiety Disorders: A practitioner’s guide to comparative treatments. Springer Publishing Company: New York.

Meyer, T.J., Miller, M.L., Metzger, R.L. and Borkovec, T.D., (1990). Development and validation of the Penn State Worry Questionnaire. Behaviour Research and Therapy, 28, 487–495.

Micali, N. & Heyman, I. (2006). Comorbidity of anxiety with eating disorders and OCD (Letter to the Editor). American Journal of Psychiatry, 163 (2), 326 – 327.

Miller, W.R. & Rollnick, S. (1991). Motivational interviewing: preparing people to change addictive behavior. Guilford Press: New York.

Milos, G., Spindler, A., Ruggiero, G., Klaghofer, R. & Schnyder, U. (2002). Comorbidity of obsessive-compulsive disorders and duration of eating disorders. International Journal of Eating Disorders, 31, 284 – 289.

Milos, G., Spindler, A., & Schnyder, U. (2004). Psychiatric comorbidity and Eating Disorder Inventory (EDI) profiles in eating disorder patients. Canadian Journal of Psychiatry, 49, 179 – 184.

Milos, G., Spindler, A., Schnyder, U. & Fairburn, C.G. (2005). Instability of eating disorder diagnoses: a prospective study. British Journal of Psychiatry, 187, 573 – 578.

251 Mitchell, M.J., Speckert, S.M. & de Zwaan, M. (1991). Comorbidity and medical complication of bulimia nervosa. Journal of Clinical Psychiatry, 52, 13 – 20.

Moras, K., DiNardo, P.A, Brown, T.A. & Barlow, D.H. (1991). Comorbidity and depression among the DSM-III-R anxiety disorders, Manuscript submitted for publication.

Morgan, H.G. & Russell, G.F.M. (1975). Value of family background and clinical features as predictors of long term outcome in anorexia nervosa: four year follow-up study of 41 patients. Psychological Medicine, 5, 355 – 371.

Mowrer, O.H. (1939). Stimulus response theory of anxiety. Psychological Review, 46, 553 – 565.

Myers, S.G. & Wells, A. (2005). Obsessive –compulsive symptoms: the contribution of metacognitions and responsibility. Journal of Anxiety Disorders, 19, 806 – 817.

Nevonen, L. & Broberg, A. G. (2006). A comparison of sequenced individual and group psychotherapy for patients with bulimia nervosa. International Journal of Eating Disorders, 39,117–127.

Nezu, A.M. & Ronan, G.F. (1985). Life stress, current problems, problem solving and depressive symptoms: an integrative model. Journal of Consulting and Clinical Psychology, 53, 693 – 697.

Nezu, A.M., Nezu, C.M., Saraydarian, L., Kalman, K. & Ronan, G.F. (1986). Social problem solving as a moderator variable between negative life stress and depressive symptoms. Cognitive Therapy and Research, 10, 489- 498.

Nezu, A.M & Ronan, G.F. (1988). Problem solving as a moderator of stress-related depressive symptoms: a prospective analysis. Journal of Counseling Psychology, 35, 134 – 138.

252 Nilsson, E.W., Gillberg, C., Gillberg, I.C. & Råstam, M. (1999). Ten year follow up of adolescent-onset anoexia nervosa: personality disorders. Journal American Academy of Child Adolescent Psychiatry, 38, 1389 – 1395.

Nilsson, K., & Hagglof, B. (2005). Long-term follow-up of adolescent anorexia nervosa in northern Sweden. European Eating Disorders Review, 13,89–100.

O’Brien, K.M. & Vincent, N.K. (2003). Psychiatric comorbidity in anorexia and bulimia nervosa: nature, prevalence and causal relationships. Clinical Psychology Review, 23, 57 – 74.

Olmsted, M., Kaplan, A. & Rockert, W. (2005). Defining remission and relapse in bulimia nervosa. International Journal of Eating Disorders, 38, 1 – 6.

Orsillo, Susan M. (2001). Measures for acute stress disorder and posttraumatic stress disorder. In M.M. Antony & S.M. Orsillo (Eds.). Practitioner's guide to empirically based measures of anxiety (pp. 255-307). KluwerAcademic/Plenum: New York.

Pallister, E. & Waller, G. (2008). Anxiety and eating disorders: understanding the overlap. Clinical Psychology Review, 28, 366 – 386.

Palmer, R.L. (1993). Weight concern should not be a necessary criterion for the eating disorders: A polemic. International Journal of Eating Disorders, 14, 459 – 465.

Palmer, R.L. (2005). Concepts of eating disorders. In: Treasure, J., Schmidt, U. &van Furth, E. (Eds). Handbook of Eating Disorders (pp 1-10). Chichester: Wiley.

Peterson, C.B., & Miller, K.B. (2005) Assessment of eating disorders. In Wonderlich, S. Mitchell, J. de Zwaan, M. & Steiger, H. (Eds), Eating Disorders Review Part I (pp105 – 126). Radcliffe: Oxford, UK.

Pike, K.M., Loeb, K, Vitousek, K. (1996). Cognitive behaviour therapy for anorexia and bulimia nervosa. In: Thompson, J.K. (Ed). Body image, eating disorders and obesity: an

253 integrative guide for assessment and treatment (pp 253 – 302). American Psychological Association: Washington.

Pike, K.M., Walsh, B.T., Vitousek, K., Wilson, G.T. & Bauer, J. (2003). Cognitive behavior therapy in the post hospitalization treatment of anorexia nervosa. American Journal of Psychiatry, 160, 2046 – 2049.

Pike, K.M. (2005). Assessment of anorexia nervosa. International Journal of Eating Disorders, 37 (Supplementary), 22 – 25.

Piran, N., Kennedy, S., Garfinkel, P. & Owens, M. (1985). Affective disturbance in the eating disorders. Journal of Nervous and Mental Disease, 173, 395 – 400.

Piran, N., Lerner, P., Garfinkel, P.E., Kennedy, S.H. & Brouilette, C. (1988). Personality disorders in anorexic patients. International Journal of Eating Disorders, 7, 589 – 599.

Polivy, J.H. & Herman, C.P. (1993). Etiology of binge eating: psychological mechanisms. In Fairburn, C.G. & Wilson, G.T. (Eds). Binge Eating: Nature, Assessment and Treatment (pp173 – 205). Guilford Press: New York,.

Pollice, C., Kaye, W.H., Greeno, C. & Weltzin, T.E. (1997). Relationship of depression, anxiety, and obsessionality to state of illness in anorexia nervosa. International Journal of Eating Disorders, 21, 367 – 376.

Powers, P., Coovert, D., Brightwell, D. & Stevens, B. (1988). Other psychiatric disorders among bulimic patients. Comprehensive Psychiatry, 29, 503 – 508.

Pratt, E.M., Niego, S.H. & Agras, W.S. (1998). Does the size of the binge matter? International Journal of Eating Disorders, 24, 307 – 312.

Pribor, E.F. & Dinwiddie, S.H. (1992). Psychiatric correlates of incest in childhood. American Journal of Psychiatry, 149, 52 – 56.

254 Prochaska, J.O. & DiClimente, C.C. (1992). The transtheoretical approach. In Norcross, J.C. & Goldfield, I.L. (Eds.). Handbook of psychotherapy integration (pp. 300 – 334). Basic Books: New York.

Procopio, C.A., Holm-Denoma, J.M., Gordon, K.H. & Joiner, T.E. (2006). Two – three year stability and interrelations of bulimiotypic indicators and depressive and anxious symptoms in middle-aged women. International Journal of Eating Disorders, 39, 312 – 319.

Putnam, F. & Trickett, P. (1997). Psychobiological effects of sexual abuse: a longitudinal study. Annals of the New York Academy of Sciences, 821, 150 – 159.

Pyle, R.L., Mitchell, J.E., & Eckert, E.D. (1981). Bulimia: A report of 34 cases. Journal of Clinical Psychiatry, 42, 60–64.

Råstam, M. (1992). Anorexia nervosa in 51 Swedish adolescents: Premorbid problems and comorbidity. Journal of the American Academy of Child and Adolescent Psychiatry, 31, 819–829.

Råstam, M., Gillberg, C. & Gillberg C. (1995). Anorexia nervosa 6 years after onset: part II. Co-morbid psychiatric problems. Comprehensive Psychiatry, 36(1), 70 – 76.

Råstam, M., Gillberg, C., Wentz, E. (2003). Outcome of teenage-onset anorexia nervosa in a Swedish community based sample. European Child and Adolescent Psychiatry, 12 (Supplementary), 178 – 190.

Reich, J., Noyes, R., & Troughton, E. (1987). Dependent personality disorder associated with phobic avoidance in patients with panic disorder. American Journal of Psychiatry, 144, 323–326.

Ricca, V., Mannucci, E., Mezzani, B., Di Bernado, M., Zucchi, T., Paionni, A., Placidi, G.P., Rotella, C.M. & Faravello, C. (2001). Eating and weight disorder psychopathological and clinical features of outpatients with an eating disorder not otherwise specified. Eating and Weight Disorder, 6, 157 – 165.

255

Rieger, E., Touyz, S.W., Schotte, D., Beumont, P., Russell, J., Clarke, S., Kohn, M., & Griffiths, R. (2000). Development of an instrument to assess readiness to recover in anorexia nervosa. International Journal of Eating Disorders, 28, 387-396.

Rieger, E., Touyz, S.W., Swain, T. & Beumont, P.J.V. (2001). Cross- cultural research on anorexia nervosa: assumptions regarding the role of body weight. International Journal of Eating Disorders, 29, 205 – 215.

Roemer, L. (2001). Measures of anxiety and related constructs. In: Antony, M.M., Orsillo, S.M. & Roemer, L. (Eds.) Practitioners guide to empirically based measures of anxiety (pp49 – 79). Springer: New York.

Roemer, L. & Orsillo, S.M. (2002). Expanding our conceptualization of and treatment for generalized anxiety disorder: Integrating mindfulness/acceptance based approaches with existing cognitive – behavioural models. Clinical Psychology: Science and Practice, 9, 54 – 68.

Root, M.P.P. & Fallon, P. (1989). Treating the victimized bulimic. Journal of Interpersonal Violence, 4, 90 – 100.

Rorty, M., Yager, J. & Rossotto, E. (1994). Childhood sexual, physical and psychological abuse in bulimia nervosa. American Journal of Psychiatry, 151, 1122 – 1126.

Rosen, J.C., Srebnik, D., Saltzberg, E. & Wendt, S. (1991). Development of a Body Image Avoidance Questionnaire. Psychological Assessment, 3, 32 – 37.

Rossiter, E.M. & Agras, W.S. (1990). An empirical test of the DSM-III-R definition of binge. International Journal of Eating Disorders, 9, 513 – 518.

Rossiter, E.M., Agras, W.S., Telch, C.F. & Schneider, J.A. (1993). Cluster B personality disorder characteristics predict outcome in the treatment of bulimia nervosa. International Journal of Eating Disorders, 13, 349 – 357.

256 Rothenberg, A. (1986). Eating disorder as a modern obsessive-compulsive syndrome. Psychiatry, 49, 45 – 53.

Russell, G. F. M., Szmukler, G. I., Dare, C., & Eisler, I. (1987). An evaluation of family therapy in anorexia nervosa and bulimia nervosa. Archives of General Psychiatry, 44,1047–1056.

Ryle, A. (2004). The contribution of cognitive analytic therapy to the treatment of borderline personality disorder. Journal of Personality Disorders, 18, 3 – 25.

Saccomani, L., Savoini, M., Cirrincione, M., Vercellino, F. & Ravera, G. (1998). Long- term outcome of children and adolescents with anorexia nervosa: study of comorbidity. Journal of Psychosomatic Research, 44, 565 – 571.

Safer, D.L., Telch, C.F. & Agras, W.S. (2001). Dialectical behavior therapy for bulimia nervosa. American Journal of Psychiatry, 158, 632 – 634.

Sanavio, E. (1988). Obsessions and compulsions: The Padua Inventory. Behaviour Research and Therapy, 26. 169 - 177.

Sanci, L., Coffey, C., Olsson, C., Reid, S., Carlin, J. & Patton, G. (2008). Childhood sexual abuse and eating disorders in females: findings from the Victorian adolescent health cohort study. Archives of Pediatrics & Adolescent Medicine, 162, 261 – 267.

Sanderson, W. C., & Wetzler, S. (1991). Chronic anxiety and generalized anxiety disorder: Issues in comorbidity. In R. M. Rapee & D. H. Barlow (Eds.), Chronic anxiety, generalized anxiety disorder, and mixed anxiety depression (pp. 119–135). Guilford Press: New York.

Schukit, M. A., Tipp, J. E., Anthenelli, R. M., Bucholz, K. K., Hesselbrock, V. M., & Nurnberger, J. I., Jr. (1996). Anorexia nervosa and bulimia nervosa in alcohol-dependent men and women and their relatives. American Journal of Psychiatry, 153, 74–82.

257 Schwalberg, M., Barlow, D., Alger, S. & Howard, L. (1992). Comparison of bulimics, obese binge eaters, social phobics and individuals with panic disorder on comorbidity across DSM-III-R anxiety disorders. Journal of Abnormal Psychology, 101, 4675 – 4681.

Serrano, E., Castro, J., Ametller, L., Martinez, E., & Toro, J. (2004). Validity of a measure of readiness to recover in Spanish adolescent patients with anorexia nervosa. Psychology and Psychotherapy Theory Research and Practice, 77, 91- 99.

Serfaty, M.A., Turkington, D., Heap, M., Ledsham, L. & Jolley, E. (1999). Cognitive therapy versus dietary counseling in the outpatient treatment of anorexia nervosa: effects of the treatment phase. European Eating Disorders Review, 7, 334 – 350.

Serpell, L., Livingstone, A., Neiderman, M. & Lask, B. (2002). Anorexia nervosa: obsessive–compulsive disorder, obsessive–compulsive personality disorder, or neither? Clinical Psychology Review, 22, 647 – 669.

Shafran, R., Keel, P.K., Haedt, A. & Fairburn, C.G. (in press). Psychological treatments for eating disorders. In Halmi, K. & Schmidt, U (Eds.), Cambridge handbook of effective treatments in psychiatry: Eating disorders. Cambridge University Press: Cambridge, England.

Silberg, J.L. & Bulik, C.M. (2005). The developmental association between eating disorders symptoms and symptoms of depression and anxiety in juvenile twin girls. Journal of Child Psychology and Psychiatry, 46, 1317 – 1326.

Smolak, L., & Murnen, S. K. (2002). A meta-analytic examination of the relationship between child sexual abuse and eating disorders. International Journal of Eating Disorders, 31, 136–150.

258 Solyom, L., Freeman, R.J. & Miles, J.E (1982). A comparative psychometric study of anorexia nervosa and obsessive neurosis. Canadian Journal of Psychiatry, 27, 282 – 286.

Speranza, M., Corcos, M., Godart, N., Loas, G., Guilbaud, O., Jeammet, P. & Flament, M. (2001). Obsessive compulsive disorders in eating disorders. Eating Behaviours, 2(3), 193 – 207.

Srinivasagam, N.M., Kaye, W.H., Plotnicov, K.H., Greeno, C., Weltzin, T.E. & Radhika, R. (1995). Persistent perfectionism, symmetry and exactness after long term recovery from anorexia nervosa. American Journal of Psychiatry, 152, 1630 – 1634.

Steiger, H., & Zanko, M. (1990). Sexual traumata among eating disordered, psychiatric, and normal female groups. Journal of Interpersonal Violence, 5, 74–86.

Steinhausen, H. C. (2002). The outcome of anorexia nervosa in the 20th century. American Journal of Psychiatry, 159,1284–1293.

Steketee, G. (1990). Personality traits and disorders in obsessive–compulsives. Journal of Anxiety Disorders, 4, 351–364.

Sternberger, L.G. & Burns, G.L. (1990). Maudsley obsessional-compulsive inventory: obsessions and compulsions in a non-clinical sample, Behaviour Research and Therapy 28, 337–340.

Stice, E. & Agras, W.S. (1999). Subtyping bulimics along dietary restraint and negative affect dimensions. Journal of Consulting and Clinical Psychology, 67, 460 – 469.

Stice, E., Telch, C.F. & Rizvi, S.L. (2000). Development and validation of the Eating Disorder Diagnostic Scale: a brief self-report measure of anorexia, bulimia and binge eating disorder. Psychological Assessment, 12, 123 – 131.

259 Stice, E. & Fairburn, C.G. (2003). Dietary and dietary-depressive subtypes of bulimia nervosa show differential symptom presentation, social impairment, comorbidity, and course of illness. Journal of Consulting and Clinical Psychology, 71, 1090 – 1094.

Striegel-Moore, R.H., Garvin, V., Dohm, F.A. & Rosenheck, R. (1999). Eating disorders in a national sample of hospitalized female and male veterans: detection rates and psychiatric comorbidity. International Journal of Eating Disorders, 25 (4), 405–414.

Strober, M. (1984). Stressful life events associated with bulimia in anorexia nervosa. Empirical findings and theoretical speculations. International Journal of Eating Disorders, 3, 3–16.

Strober, M. (1997). Consultation and therapeutic engagement in severe anorexia nervosa. In: Garner, D.M. & Garfinkel, P.E. (Eds). Handbook of treatment for eating disorders (pp229 – 247). Guilford Press: New York.

Strober, M. Freeman, R. & Morrell, W. (1997). The long term course of severe anorexia nervosa in adolescents: survival analysis of recovery, relapse and outcome predictors over 10-15 years in a prospective study. Empirical findings and theoretical speculations. International Journal of Eating Disorders, 22, 339–360.

Strober, M. Freeman, R., Lampert, C. & Diamond, J. (2007). The association of anxiety disorders and obsessive compulsive personality disorder with anorexia nervosa: evidence from a family study with discussion of nosological and neurological evidence. . Empirical findings and theoretical speculations. International Journal of Eating Disorders, 40, S46–S51.

Stunkard, A.J. & Albaum, J.M. (1981). The accuracy of self reported weights. American Journal of Clinical Nutrition, 34, 1593 – 1599.

260 Stunkard, A.J. & Messick, S. (1985). The Three-Factor Eating Questionnaire to measure dietary restraint, disinhibition and hunger. Journal of Psychosomatic Research, 29, 71 – 83.

Sullivan, P.F., Bulik, C.M., Fear, J.L. & Pickering, A. (1998). Outcome of anorexia nervosa: a case-control study. American Journal of Psychiatry, 155, 939 – 946.

Sutandar-Pinnock, K., Blake, W.D., Carter, J.C., Olmsted, M.P. & Kaplan, A.S. (2003). Perfectionism in anorexia nervosa: a 6 – 24 month follow up study. International Journal of Eating Disorders, 33, 225 - 229.

Swinbourne, J.M. & Touyz, S.W. (2007). The comorbidity of eating disorder and anxiety disorders: a review. European Eating Disorders Review, 15, 253 – 274.

Telch, C. F. & Agras, W. S. (1996). Do emotional states influence binge eating in the obese? International Journal of Eating Disorders, 20, 271 – 279.

Telch, C. F., Agras, W. S., & Linehan, M. M. (2000). Group dialectical behavior therapy for binge eating disorder: a preliminary uncontrolled trial. Behavior Therapy, 31, 569– 582.

Telch, C. F., Agras, W. S., & Linehan, M. M. (2001). Dialectical behavior therapy for binge eating disorder. Journal of Consulting and Clinical Psychology, 69,1061–1065.

Thiel, A,T., Züger, M., Jacoby, G. & Schüßler, G. (1998). Thirty month outcome in patients with anorexia or bulimia nervosa and concomitant obsessive-compulsive disorder. American Journal of Psychiatry, 155, 244 – 249.

Thompson, K., Crosby, R., Wonderlich, S., Mitchell, J., Redlin, J., Demuth, G., Smyth, J. & Haseltine, B. (2003). Psychopathology and sexual trauma in childhood and adulthood. Journal of Trauma Stress, 16, 35 – 38.

261

Thompson – Brenner, H. & Westen, D. (2005). A naturalistic study of psychotherapy for bulimia nervosa, part 1: comorbidity and therapeutic outcome. The Journal of Nervous and Mental Diseases, 193, 573-584.

Thornton, C. & Russell, J. (1997). Obsessive compulsive comorbidity in the dieting disorders. International Journal of Eating Disorders, 21(1), 83 – 87.

Thyer, B. A., Parrish, R. T., Himle, J., Cameron, O. G., Curtis, G. C., & Nesse, R. M. (1986). Alcohol abuse among clinically anxious patients. Behaviour Research and Therapy, 24, 357–359.

Toner, B.B., Garfinkel, P.E. & Garner, D.M. (1988). Affective and anxiety disorders in the long-term follow-up of anorexia nervosa. International Journal of Psychiatry in Medicine 18, 357–364.

Torem, M.S. & Curdue, K. (1988). PTSD presenting as an eating disorder. Stress Medicine, 4, 139-142.

Tozzi, F., Sullivan, P., Fear, J., McKenzie, J. & Bulik, C. (2003). Causes and recovery in anorexia nervosa: the patient’s perspective. International Journal of Eating Disorders, 33, 143–154.

Treasure, J. & Campbell, I. (1994). The case for biology in the aetiology of anorexia nervosa. Psychological Medicine, 24, 3 – 8.

Treasure, J. & Ward, A. (1997). A practical guide to the use of motivational interviewing in anorexia nervosa. European Eating Disorders Review, 5, 102 – 114.

262 Turnbull, S.J., Troop, N.A. & Treasure, J.L. (1997). The prevalence of posttraumatic stress disorder and its relation to childhood adversity in subjects with eating disorders. European Eating Disorders Review, 5, 270–277.

Turner, H. & Bryant-Waugh, R. (2004). Eating disorder not otherwise specified (ednos): profiles of clients presenting at a community eating disorder service. European Eating Disorders Review, 12, 18 – 26.

Vanderlinden, J. & Vandereycken, W. (1997). Trauma, dissociation and impulse dyscontrol in eating disorders. Brunner/Mazel: Bristol. van Deth, R. & Vandereyecken, W. (1991). Was nervosa consumption a precursor of anorexia nervosa? Journal of the History of Medicine and Allied Sciences, 46, 3 – 19. van Gerko, K., Hughes, M.L., Hamill, M. & Waller, G. (2005). Reported childhood sexual abuse and eating-disordered cognitions and behavious. Child Abuse and Neglect, 29, 375 – 382.

van Strien, T., Frijters, J.E., Bergers, G.P & Defares, P. (1986). The Dutch Eating Behaviour Questionnaire (DEBQ) for assessment of restrained, emotional and external eating behaviour. International Journal of Eating Disorders, 5, 295 – 315.

Vitousek, K.M. (1995). Cognitive behavioural therapy for anorexia nervosa. In: Brownell, K.D. & Fairburn, C.G. (Eds). Eating disorders and obesity: a comprehensive handbook (pp324 – 329). Guilford Press: New York.

Vitousek, K. M., Watson, S. & Wilson, G.T. (1998). Enhancing motivation for change in treatment – resistant eating disorders. Clinical Psychology Review, 18, 391 – 420.

263 Vitousek, K. M., & Gray, J. A. (2005). Eating disorders. In G. O. Gabbard, J. S. Beck, & J. Holmes (Eds.) Oxford textbook of psychotherapy (pp. 177–202). Oxford University Press, Oxford, England.

Vize, C. M., & Cooper, P. J. (1995). Sexual abuse in patients with eating disorders, patients with depression and normal controls: A comparative study. British Journal of Psychiatry, 167, 80–85. von Holle, A., Poyastro-Pinheiro, A., Thornton, L., Klump, K., Berrettini, W.H., Brandt, H., Crawford, S., Crow, S., Fichter, M.M., Halmi, K.A., Johnson, C., Kaplan, A.S., Keel, P., La Via, M., Mitchell, J., Strober, M., Woodside, B., Kaye, W.H. & Bulik, C.M. (2008). Temporal patterns of recovery across eating disorder subtypes. Australian and New Zealand Journal of Psychiatry, 42, 108 – 117. von Ranson, K.M., Kaye, W.H., Weltzin, T.E., Rao, R. & Matsunaga, H. (1999). Obsessive-compulsive disorder symptoms before and after recovery from bulimia nervosa. The American Journal of Psychiatry, 156, 1703 – 1708.

Wade, T.D., Bulik, C.M., Prescott, C.A. & Kendler, K.S. (2004). Sex influences on shared risk factors for bulimia nervosa and other psychiatric disorders. Archives of General Psychiatry, 62, 251 – 256.

Wade, T.D., Crosby, R.D., & Martin, N.G. (2006). Use of latent profile analysis to identify eating disorder phenotypes in an adult Australian twin cohort. Archives of General Psychiatry, 63, 1377 – 1384.

Waller, G. (1992). Sexual abuse and the severity of bulimic symptomatology. British Journal of Psychiatry, 161, 90–93.

264 Waller, G., Halek, C. & Crisp, A.H. (1993). Sexual abuse as a factor in anorexia nervosa: evidence from two separate case series. Journal of Psychosomatic Research, 37, 873 – 879.

Waller, G., Hamilton, K., Rose, N., Sumra, J., & Baldwin, G. (1993). Sexual abuse and body-image distortion in the eating disorders. British Journal of Clinical Psychology, 32, 350–352.

Waller, G. (2008). A transdiagnostic model of the eating disorders: a new way to open the egg? European Eating Disorders Review, 16, 165 – 172.

Walsh, B. T., Roose, S. P., Glassman, A. H., Gladis, M., & Sadik, C. (1985). Bulimia and depression. Psychosomatic Medicine, 47, 123–131.

Walsh, B.T. (2008). Recovery from eating disorders. Australian and New Zealand Journal of Psychiatry, 42, 95 – 96.

Walters, E.E. & Kendler, K.S. (1995). Anorexia nervosa and anorexic-like syndromes in a population-based female twin sample. American Journal of Psychiatry, 152, 64 – 71.

Watson, D. & Friend, R. (1969). Measurement of social-evaluative anxiety. Journal of Consulting and Clinical Psychology, 33, 448 – 457.

Watson, T. & Andersen, A. (2003). A critical examination of the amenorrhea and weight criteria for diagnosing anorexia nervosa. Acta Psychiatrica Scandinavica, 108, 175.

Wei ss, D . , & M ar mar , C. (1997). T he I mpact of Event Scal e-Revi sed. In Wilson, J. & Keane, T. (Eds.), A ssessi ng psychological trauma and PTSD (pp399- 411). Guildford: N ew Y or k.

Weissman, M. M., Markowitz, J. C., & Klerman, G. L. (2000). Comprehensive guide to interpersonal psychotherapy. Basic Books: New York.

265

Welch, S. L., & Fairburn, C. G. (1994). Sexual abuse and bulimia nervosa: Three integrated case control comparisons. American Journal of Psychiatry, 151, 402–407.

Wells, A. (1997). Cognitive therapy of anxiety disorders: a practice manual and conceptual guide. John Wiley & Sons: UK.

Wells, A. &. Papageorgiou, C. (1998). Relationships between worry, obsessive compulsive symptoms and metacognitive beliefs. Behaviour Research and Therapy, 36, 899–913.

Weltzin, T.E., Bulik, C.M., McConaha, C.W. & Kaye, W.H. (1995). Laxative withdrawal and anxiety in bulimia nervosa. International Journal of Eating Disorders, 17, 141 – 146.

Wentz, E., Gillberg, I.C., Gillberg, C., & Råstam, M. (2000). Ten-year follow up of adolescent-onset anorexia nervosa: physical health and neurodevelopment. Developmental Medicine of Child Neurology, 42, 328 – 333.

Wentz, E., Gillberg, C., Gillberg, I.C., & Råstam, M. (2001). Ten-year follow up of adolescent anorexia nervosa: psychiatric disorder and overall functioning scales. Journal of Child Psychology & Psychiatry, 42, 613 – 622.

Widiger, T.A., Frances, A.J., Harris, M., Jacobsberg, L.B., Fryer, M.R., & Manning, D. (1991). Comorbidity among axis II disorders. In J. Oldham (Ed)., Personality Disorders: New Perspectives on diagnostic validity (pp. 163 – 194). American Psychiatric Press: Washington, DC.

Wilfley, D. E., Agras, W. S., Telch, C. F., Rossiter, E. M., Schneider, J. A., Cole, A. G., Sifford, L. & Raeburn, S.D. (1993). Group cognitive-behavioral therapy and group interpersonal psychotherapy for the non-purging bulimic individual: A controlled comparison. Journal of Consulting and Clinical Psychology, 61,296–305.

266 Wilfley, D. E., Friedman, M.A., Dounchis, J.Z., Stein, R.I., Welch, R.R. & Ball, S.A. (2000). Comorbid psychopathology in binge eating disorder: relation to eating disorder severity at baseline and following treatment. Journal of Consulting and Clinical Psychology, 68, 641 – 649.

Wilfley, D. E., Welch, R. R., Stein, R. I., Spurrell, E. B., Cohen, L. R., Saelens, B. E., Dounchis, J. Z; Frank, M.A., Wiseman, C.V. & Matt, G.E. (2002). A randomized comparison of group cognitive-behavioral therapy and group interpersonal psychotherapy for the treatment of overweight individuals with binge eating disorder. Archives of General Psychiatry, 59,713–721.

Williamson, D. (1990). Assessment of eating disorders: obesity, anorexia and bulimia nervosa. Pergamon Press: New York.

Wilson, G.T. & Smith, D. (1989). Assessment of bulimia nervosa: an evaluation of the Eating Disorder Examination. International Journal of Eating Disorders, 8, 173 – 179.

Wilson, G.T. & Eldredge, K.L. (1991). Frequency of binge eating in bulimic patients: diagnostic validity. International Journal of Eating Disorders, 10, 557 – 561.

Wilson, G.T. & Pike, K.M (2001). Eating disorders. In Barlow, D.H. (Ed), Clinical Handbook of Psychological Disorders (3rd ed, pp332 – 375). The Guilford Press: New York.

Wilson, G. T., & Fairburn, C. G. (2002). Eating disorders. In Nathan, P. E. & Gorman, J. M. (Eds.), Treatments that work (2nd ed., pp. 559–592). Oxford University Press: New York.

Wilson, G. T., Grilo. C.M. & Vitousek, K.M. (2007). Psychological treatment of eating disorders. American Psychologist, 62, 199 – 216.

267 Wittchen, H.U. & Essau, C.A. (1993). Epidemiology of anxiety disorders. In Michels, R. (Ed), Psychiatry. (pp 1 – 23). J.B Lippincott: Philadelphia.

Wittchen, H.U., Stein, M.B. & Kessler, R.C. (1999). Social fears and social phobia in a community sample of adolescents and young adults: prevalence, risk factors and comorbidity. Psychological Medicine, 29, 309 – 323.

Wolff, G., & Serpell, L. (1998). A cognitive model and treatment strategies for anorexia nervosa. In Hoek, H. W., Treasure, J. L. & Katzman, M. A. (Eds.), Neurobiology in the treatment of eating disorders (pp. 407–429). Wiley: Chichester.

Wonderlich, S.A., Swift, W.J., Slotnick, H.B. & Goodman, S. (1990). DSM-IIIR personality disorders in eating disorders subtypes. International Journal of Eating Disorders, 9, 607–616.

Wonderlich, S.A. & Mitchell, J.E. (1997). Eating disorders and comorbidity: empirical, conceptual and clinical implications. Psychopharmacology Bulletin, 33, 381 – 390.

Wonderlich, S.A., Joiner, T.E., Keel, P., Williamson, D. & Crosby, R. (2007). Eating disorder diagnoses: empirical approaches to classification. American Psychologist, 62, 1676 – 180.

Woolsey, M.M. (2002). Eating disorders: a clinical guide to counseling and treatment. American Dietetic Association: Chicago.

Zilberg, N.J., Weiss, D.S. & Horowitz, M.J. (1982). Impact of events scale: a cross- validation study and some empirical evidence supporting a conceptual model of stress response syndromes. Journal of Consulting and Clinical Psychology, 50, 407 – 414.

Zipfel, S., Lowe, B., Reas, D.L., Deter, H., & Herzog, W. (2000). Long-term prognosis in anorexia nervosa: lessons from a 21-year follow-up study. The Lancet, 355, 721-722.

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269

APPENDIX A

University of Sydney Participant Information Sheet version 1, 2 & 3 University of Sydney Participant Consent Form version 1, 2 & 3

270 Version 1

Psychology Clinic School of Psychology University of Sydney ______PARTICIPANT INFORMATION SHEET

Research Project

The Comorbidity Between Eating Disorders and Anxiety Disorders

The focus of this research is on the prevalence of people who have both an eating disorder and an anxiety disorder. Specifically, this study will focus on the severity of symptoms in people with both an eating disorder and an anxiety disorder, and whether there is a difference depending on whether they present to an anxiety unit or an eating disorder unit.

This study is being conducted by Jessica Swinbourne, Psychologist, and will form the basis for the degree of Doctorate of Psychology / Masters of Science at The University of Sydney under the supervision of Professor Stephen Touyz, Professor of Clinical Psychology at the University of Sydney.

The study will involve an assessment of anxiety and eating disorders and may require you to complete some questionnaires. It is anticipated that the time taken for the assessment and questionnaires will be between 2 – 3 hours.

Being in this study is completely voluntary and you are not under any obligation to consent. You are free to withdraw at any time, and there is no penalty should you decide to do so.

All aspects of this study, including results, will be strictly confidential and only the researchers and treatment providers will have access to information on participants, except as required by law. A report of the study may be submitted for publication, but individual participants will not be identifiable in such a report.

Should you have any questions or concerns regarding this research please contact Jessica Swinbourne, Psychologist, on Ph: (02) 9351 5952.

Any person with concerns or complaints about the conduct of this research study can contact Ms Gail Briody, Manager, Ethics Administration, University of Sydney on (02) 9351 4811 or email [email protected].

This information sheet is for you to keep

271 Version 1

Psychology Clinic School of Psychology University of Sydney ______PARTICIPANT CONSENT FORM

I, ______, give consent to my participation in the research project Name (please print)

The Comorbidity Between Eating Disorders and Anxiety Disorders.

In giving my consent I acknowledge that:

1. The procedures required for the project and the time involved have been explained to me, and any questions I have about the project have been answered to my satisfaction. 2. I have read the Participant Information Sheet and have been given the opportunity to discuss the information and my involvement in the project with the researcher/s. 3. I understand that my participation in this study is voluntary and I can withdraw at any time, without affecting my relationship with the researcher(s) or treatment providers now or in the future. 4. I understand that my involvement is strictly confidential and no information about me will be used in any way that reveals my identity.

Signed:

Name: ......

Date: ......

Should you have any questions or concerns regarding this research please contact Jessica Swinbourne, Psychologist, on Ph: (02) 9351 5952.

272 Version 2

Psychology Clinic School of Psychology University of Sydney PARTICIPANT INFORMATION SHEET Research Project The Comorbidity Between Eating Disorders and Anxiety Disorders

The focus of this research is on the prevalence of women who have both an eating disorder and an anxiety disorder. This study will consider the symptoms of eating and anxiety disorder, the treatment received and treatment outcome and whether there is a difference depending on whether someone has a comorbid disorder or not.

This study is being conducted by Jessica Swinbourne, Psychologist, and will form the basis for the degree of Doctorate of Psychology / Doctor of Philosophy at The University of Sydney under the supervision of Professor Stephen Touyz, Professor of Clinical Psychology at the University of Sydney.

The study will involve an assessment of anxiety and eating disorders and may require you to complete some questionnaires. The study will also involve a 6 month follow up after completing treatment, and will involve further assessment of anxiety and eating disorders and the completion of questionnaires. It is anticipated that the time taken for the assessment and questionnaires will be between 1½ – 3 hours on both occasions.

This study would also involve review of medical records during your treatment to investigate the treatment you received and treatment outcome.

Being in this study is completely voluntary and you are not under any obligation to consent. You are free to withdraw at any time, and there is no penalty should you decide to do so. All aspects of this study, including results, will be strictly confidential and only the researchers and treatment providers will have access to information on participants, except as required by law. A report of the study may be submitted for publication, but individual participants will not be identifiable in such a report.

Should you have any questions or concerns regarding this research please contact Jessica Swinbourne, Psychologist, on Ph: (02) 9351 5952. Any person with concerns or complaints about the conduct of this research study can contact Ms Gail Briody, Manager, Ethics Administration, University of Sydney on (02) 9351 4811 or email [email protected].

This information sheet is for you to keep

273 Version 2

Psychology Clinic School of Psychology University of Sydney ______PARTICIPANT CONSENT FORM I, ______, give consent to my participation in the research project Name (please print)

The Comorbidity Between Eating Disorders and Anxiety Disorders.

In giving my consent I acknowledge that:

Signed: ......

Name: ......

Date: ......

Should you have any questions or concerns regarding this research please contact Jessica Swinbourne, Psychologist, on Ph: (02) 9351 5952.

274 Version 3

Psychology Clinic School of Psychology University of Sydney ______PARTICIPANT INFORMATION SHEET

Research Project

The Comorbidity Between Eating Disorders and Anxiety Disorders

Being in this study is completely voluntary and you are not under any obligation to consent. You are free to withdraw at any time, and there is no penalty should you decide to do so.

Should you have any questions or concerns regarding this research please contact Jessica Swinbourne, Psychologist, on Ph: (02) 9351 5952.

This information sheet is for you to keep

275 Version 3

Psychology Clinic School of Psychology University of Sydney ______PARTICIPANT CONSENT FORM

I, ______, give consent to my participation in the research project Name (please print)

The Comorbidity Between Eating Disorders and Anxiety Disorders.

In giving my consent I acknowledge that:

5. The procedures required for the project and the time involved have been explained to me, and any questions I have about the project have been answered to my satisfaction. 6. I have read the Participant Information Sheet and have been given the opportunity to discuss the information and my involvement in the project with the researcher/s. 7. I understand that my participation in this study is voluntary and I can withdraw at any time, without affecting my relationship with the researcher(s) or treatment providers now or in the future. 8. I understand that my involvement is strictly confidential and no information about me will be used in any way that reveals my identity.

Signed:

Name: ......

Date: ......

Should you have any questions or concerns regarding this research please contact Jessica Swinbourne, Psychologist, on Ph: (02) 9351 5952.

276

APPENDIX B

Northside Clinic Participant Information Sheet Northside Clinic Participant Consent Form

277

Psychology Clinic School of Psychology University of Sydney ______PARTICIPANT INFORMATION SHEET

Research Project

The Dual Diagnosis of Eating Disorders and Anxiety Disorders

The focus of this research is on the prevalence of people who have both an eating disorder and an anxiety disorder (dual diagnosis). Specifically, this study will focus on the severity of symptoms in people with both an eating disorder and an anxiety disorder, and whether there is a difference depending on whether they present to an anxiety unit or an eating disorder unit.

Being in this study is completely voluntary and you are not under any obligation to consent. You are free to withdraw at any time, and there is no penalty should you decide to do so.

Should you have any questions or concerns regarding this research please contact Jessica Swinbourne, Psychologist, on Ph: (02) 9351 5952.

This information sheet is for you to keep

278

Psychology Clinic School of Psychology University of Sydney ______PARTICIPANT CONSENT FORM

I, ______, give consent to my participation in the research project Name (please print)

The Dual Diagnosis of Eating Disorders and Anxiety Disorders.

In giving my consent I acknowledge that:

Signed:

Name: ......

Date: ......

Should you have any questions or concerns regarding this research please contact Jessica Swinbourne, Psychologist, on Ph: (02) 9351 5952.

279

APPENDIX C

SWAHS Anxiety Clinic Participant Information Sheet SWAHS Anxiety Clinic Participant Consent Form SWAHS Eating Disorders Day Program Participant Information Sheet SWAHS Eating Disorders Day Program Clinic Participant Consent Form

280

APPENDIX D

University of Sydney Ethical Approval for Research 23/5/2005 University of Sydney Ethical Approval of modification 7/9/2005 University of Sydney Ethical Approval of modification 19/5/2006 University of Sydney Ethical Approval of modification 19/4/2007 University of Sydney Ethical Approval of modification 22/6/2007

281

APPENDIX E

Westmead Health SAC Approval for Research 16/12/2005 SWAHS HREC request for clarification 23/2/2006 SWHAS HREC Approval for Research 29/3/2006 SWAHS HREC Approval of modification 16/8/2007

282

APPENDIX F

Northside Clinic Ethical Approval for Research 23/6/2006

283

APPENDIX G

Assessment Measures Demographics Questionnaire Depression Anxiety Stress Scale (DASS-21) Eating Disorder Examination Questionnaire (EDE-Q) Eating Disorder Inventory -3 (EDI-3) Eating Attitude Test (EAT-40) Eating Disorder Examination (EDE) Anxiety Disorder Interview Schedule (ADIS-IV)

284

DEMOGRAPHICS

Date of Interview:______

Name: ______Date of birth: ______Ethnic Origin: ______Sex: M / F Marital Status: ______Children: ______Age Sex ______

Occupational History: Current: ______Prior: ______

Education: ______Medication NAME FOR DOSE

285 DASS - 21

Please read each statement and circle a number 0, 1, 2 or 3 which indicates how much the statement applied to you over the past week. There are no right or wrong answers. Do not spend too much time on any statement.

The rating scale is as follows: 0 Did not apply to me at all 1 Applied to me to some degree, or some of the time 2 Applied to me to a considerable degree, or a good part of time 3 Applied to me very much, or most of the time

1 I found it hard to wind down 0 1 2 3

2 I was aware of dryness of my mouth 0 1 2 3

3 I couldn't seem to experience any positive feeling at all 0 1 2 3

4 I experienced breathing difficulty (eg, excessively rapid breathing, 0 1 2 3 breathlessness in the absence of physical exertion)

5 I found it difficult to work up the initiative to do things 0 1 2 3

6 I tended to over-react to situations 0 1 2 3

7 I experienced trembling (eg, in the hands) 0 1 2 3

8 I felt that I was using a lot of nervous energy 0 1 2 3

9 I was worried about situations in which I might panic and make a fool of myself 0 1 2 3

10 I felt that I had nothing to look forward to 0 1 2 3

11 I found myself getting agitated 0 1 2 3

12 I found it difficult to relax 0 1 2 3

13 I felt down-hearted and blue 0 1 2 3

14 I was intolerant of anything that kept me from getting on with what I was doing 0 1 2 3 15 I felt I was close to panic 0 1 2 3

16 I was unable to become enthusiastic about anything 0 1 2 3

17 I felt I wasn't worth much as a person 0 1 2 3

18 I felt that I was rather touchy 0 1 2 3

19 I was aware of the action of my heart in the absence of physical 0 1 2 3 exertion (eg, sense of heart rate increase, heart missing a beat)

20 I felt scared without any good reason 0 1 2 3

21 I felt that life was meaningless 0 1 2 3

286 EDE-Q

Instructions The following questions are concerned with the PAST FOUR WEEKS ONLY (28 days). Please read each question carefully and circle the appropriate number on the right. Please answer all the questions. On how many days out of the past No 1 – 5 6 – 12 13 – 15 16 – 22 23-27 Every 28 days…… Days days days days days days day 1. Have you been deliberately 0 1 2 3 4 5 6 trying to limit the amount of food you eat to influence your shape or weight? 2. Have you gone for long periods 0 1 2 3 4 5 6 of time (8 hours or more) without eating anything in order to influence your shape or weight? 3. Have you tried to avoid eating 0 1 2 3 4 5 6 any foods which you like in order to influence your shape or weight? 4. Have you tried to follow definite 0 1 2 3 4 5 6 rules regarding your eating in order to influence your shape or weight; for example, a calorie limit, a set amount of food, or rules about what or when you should eat? 5. Have you wanted your stomach 0 1 2 3 4 5 6 to be empty? 6. Has thinking about food or its 0 1 2 3 4 5 6 calorie content made it much more difficult to concentrate on things you are interested in; for example, read, watch TV or follow a conversation?

287 On how many days out of the past No 1 – 5 6 – 12 13 – 15 16 – 22 23-27 Every 28 days…… Days days days days days days day 7. Have you been afraid of losing 0 1 2 3 4 5 6 control over your eating? 8. Have you had episodes of binge 0 1 2 3 4 5 6 eating? 9. Have you eaten in secret? (do not 0 1 2 3 4 5 6 count binges.) 10. Have you definitely wanted 0 1 2 3 4 5 6 your stomach to be flat? 11. Has thinking about shape or 0 1 2 3 4 5 6 weight made it much more difficult to concentrate on things you are interested in; for example, read, watch TV or follow a conversation? 12. Have you had a definite fear 0 1 2 3 4 5 6 that you might gain weight or become fat? 13. Have you felt fat? 0 1 2 3 4 5 6 14. Have you had a strong desire to 0 1 2 3 4 5 6 lose weight?

OVER THE PAST FOUR WEEKS (28 DAYS) 0 – None of the times 15. On what proportion of times that you have eaten 1 – A few of the times have you felt guilty because of the effect on your shape 2 – Less than half the times or weight? (Do not count binges.) (Circle the number 3 – Half the times which applies.) 4 – More than half the times 5 – Most of the time 6 – Every time

288 16. Over the past four weeks (28 days), have there been any time when you have felt that you have eaten what other people would regard as an unusually large amount of food given the circumstances? (Please put appropriate number in box.)

0 – No [ ] 1 – Yes [ ] 17. How many such episodes have you had over the past four weeks? [ ] [ ] [ ]

18 During how many of these episodes of overeating did you have a sense of having lost control over your eating? [ ] [ ] [ ] ______19. Have you had other episodes of eating in which you have had a sense of having lost control and eaten too much, but have not eaten an unusually large amount of food given the circumstances? 0 – No [ ] 1 – Yes [ ]

20. How many such episodes have you had over the past four weeks? [ ] [ ] [ ]

21. Over the past four weeks have you made yourself sick (vomit) as a means of controlling your shape or weight? 0 – No [ ] 1 – Yes [ ]

22. How many times have you done this over the past four weeks? [ ] [ ] [ ]

289

23. Have you taken laxatives as a means of controlling your shape or weight? 0 – No [ ] 1 – Yes [ ]

24. How many times have you done this over the past four weeks? [ ] [ ] [ ]

25. Have you taken diuretics (water tablets) as a means of controlling your shape or weight? 0 – No [ ] 1 – Yes [ ]

26. How many times have you done this over the past four weeks? [ ] [ ] [ ]

27. Have you exercised hard as a means of controlling your shape or weight? 0 – No [ ] 1 – Yes [ ]

28. How many times have you done this over the past four weeks? [ ] [ ] [ ]

290

MODERATELY NOT AT ALL AT NOT

OVER THE PAST FOUR WEEKS MARKEDLY SLIGHTLY (28 DAYS) (please circle the number which best describes your behaviour

29. Has your weight influenced how 0 1 2 3 4 5 6 you think about (judge) yourself as a person? 30. Has your shape influenced how 0 1 2 3 4 5 6 you think about (judge) yourself as a person? 31. How much would it upset you if 0 1 2 3 4 5 6 you had to weigh yourself once a week for the next four weeks? 32. How dissatisfied have you felt 0 1 2 3 4 5 6 about your weight? 33. How dissatisfied have you felt 0 1 2 3 4 5 6 about your shape? 34. How concerned have you been 0 1 2 3 4 5 6 about other people seeing you eat? 35. How uncomfortable have you felt 0 1 2 3 4 5 6 seeing your body; for example in the mirror, in shop window reflections, while undressing or taking a bath or shower? 35. How uncomfortable have you felt 0 1 2 3 4 5 6 about others seeing your body; for example in communal changing rooms, when swimming or wearing tight clothes?

291

292

EAT – 40

Instructions: Please place an (X) in the column which applies best to each of the numbered statements . Most of the questions directly relate to food or eating, although other types of questions have been included. Please answer each question carefully.

Always Very Often Sometimes Rarely Never Often 1. Like eating with other people 2. Prepare foods for others but do not eat what I cook 3. Become anxious prior to eating 4. Am terrified about being overweight 5. Avoid eating when I am hungry 6. Find myself preoccupied with food 7. Have gone on eating binges where I feel that I may not be able to stop 8. Cut my food into small pieces 9. Aware of the calorie content of foods that I eat 10.Particularly avoid foods with a high carbohydrate content (eg. bread, potatoes, rice etc) 11.Feel bloated after meals 12. Feel that others would prefer if I ate more 13.Vomit after I have eaten 14. Feel extremely guilty after eating 15. Am preoccupied with a desire to be thinner 16. Exercise strenuously to burn off calories 17. Weigh myself several times a day 18. Like my clothes to fit tightly 19. Enjoy eating meat 20. Wake up early in the morning 21. Eat the same food day after day 22. Think about burning up calories when I exercise 23. Have regular menstrual periods 25. Am preoccupied with the thought of having fat on my body

26. Take longer than others to eat my meals 27. Enjoy eating at restaurants 28. Take laxatives 29. Avoid foods with sugar in them 30. Eat diet foods

293 Always Very Often Sometimes Rarely Never Often 31. Feel that food controls my life 32. Display self control around food 33.Feel that others pressure me to eat 34. Give too much time and thought to food 35. Suffer from constipation 36. Feel uncomfortable after eating sweets 37. Engage in dieting behaviour 38. Like my stomach to be empty 39. Enjoy trying new rich foods 40. Have the impulse to vomit after meals

294

APPENDIX H

Excluded Assessment Measures Beck Depression Inventory – II (BDI-II) Anorexia Nervosa Stages Of Change –Questionnaire (ANSOC-Q) Eating Disorder Belief Questionnaire (EDBQ) Metacognitions questionnaire (MCQ) Penn State Worry questionnaire (PSWQ) Social interaction anxiety scale (SIAS) Social phobia scale (SPS) Fear of negative evaluation scale (FNE) Agoraphobic cognitions questionnaire (ACQ) Body sensations questionnaire (BCQ) Padua Inventory (PI-WSUR) Yale – Brown obsessive compulsive scale (Y-BOCS) Maudsley Obsessional Compulsive inventory (MOCI) Posttraumatic diagnostic scale (PDS) Impact of Events Scale Revised (IES-R)

295 ANSOC – Q

Instructions: Each of the items below is made up of 5 statements. For each item, please read the five statements carefully. Then select the statement (or statements) which best describe/s your current attitude or behavior (not how you have been in the past or how you would like to be).

1.The following statements refer to gaining weight:

a) as far as I am concerned, I do not need to gain weight b) In some ways I think that I might be better off if I gained weight c) I have decided that I will attempt to gain weight d) At the moment I am putting in a lot of effort into gaining weight e) I am working to maintain the weight gains I have made

2.The following statements refer to body weight:

a) as far as I am concerned, I do not need to weigh at least _____kg (insert your minimal normal weight) b) In some ways I think that I might be better off if I weighed at least _____kg c) I have decided that I will attempt to reach at least _____kg d) At the moment I am putting in a lot of effort to reach at least _____kg e) I am working to maintain a weight of at least _____kg

3. The following statements refer to parts of the body which may particularly concern you in terms of weight gain (such as hips, thighs, stomach, or buttocks):

a) There is not way I would be prepared to gain weight on these body parts b) Sometimes I think I would be prepared to gain weight on these body parts c) I have decided that I am prepared to gain weight on these body parts d) I am presently trying to gain weight on these body parts e) I am working to maintain the weight I gained on these body parts

4. The following statements refer to your appearance:

a) I do not want to be a normal weight because I would be less satisfied with my appearance at a weight of at least _____kg (insert your minimal normal weight) b) I have occasionally thought about being a normal weight because in some ways I would be more satisfied with my appearance at a weight of at least _____kg c) I have decided to reach a normal weight because I would be more satisfied with my appearance at a weight of at least _____kg d) I am presently trying to reach a normal weight because I will be more satisfied with my appearance at a weight of at least _____kg e) I am working to maintain a normal weight because I am more satisfied with my appearance at a weight of at least _____kg

296 5. The following statements refer to your health:

a) I do not need to be a normal weight because there are no risks to my health when I weigh below _____kg (insert your minimal normal weight) b) I have occasionally thought about being a normal weight because of the risks to my health when I weigh below _____kg c) I have decided to reach a normal weight because of the risks to my health when I weigh below _____kg d) I am presently trying to reach a normal weight because of the risks to my health when I weigh below _____kg e) I am working to maintain a normal weight because of the risks to my health when I weigh below _____kg

6. The following statements refer to the importance of body shape and weight:

a) I do not exaggerate the importance of my body shape or weight in determining my happiness and success b) Sometimes I think that I exaggerate the importance of my body shape or weight in determining my happiness and success c) I have decided that I need to reduce the importance that I place on my body shape or weight in determining my happiness and success d) I often try to challenge the importance that I place on my body shape or weight in determining my happiness and success e) I have succeeded in reducing my tendency to place too much importance on my body shape or weight in determining my happiness and success and want it to stay this way

7. The following statements refer to a fear of fatness:

a) My fear of becoming fat is not excessive b) I occasionally think that my fear of becoming fat is excessive c) I have decided that I need to do something about the fear I have of becoming fat because it is controlling me d) I know that my fear of becoming fat has caused problems and now I am trying to correct this e) I have succeeded in reducing my fear of becoming fat and I want it to stay this way

8. The following statements refer to weight loss:

a) I would prefer to lose more weight b) Sometimes I think that it might be time to stop losing weight c) I have decided that it is time to stop losing weight d) I am trying to stop losing weight e) I have managed to stop losing weight and hope to stay this way

297 9. The following statements refer to body fat versus muscle:

a) I might think about gaining muscle on purpose, but I would never think of gaining fat on purpose b) Sometimes I think that I may need to gain some fat even though I would prefer to have only muscle c) I have decided that to be healthy I need to have some fat on my body d) I realize that I need to have some fat on my body and I am working to achieve this e) I have managed to increase the level of fat on my body which I am trying to maintain

10. The following statements refer to the rate of weight gain:

a) There is no way I would be prepared to gain at least 1kg a week b) Sometimes I think I would be prepared to gain at least 1kg a week c) I have decided that in general it would be best for me to gain at least 1kg a week d) I am putting in a lot of effort to gain at least 1kg a week e) I am working to maintain my weight by would be prepared to gain at least 1kg a week if necessary

11. The following statements refer to certain shape and weight standards which you may have for evaluating your body (such as only being satisfied with your body when your stomach is flat or when you are below a certain weight):

a) The standards I use to evaluate my body are not too strict b) Sometimes I think that the standards I use to evaluate my body may be too strict c) I have decided that the standards I use to evaluate my body are too strict and need to be changed d) I am putting in a lot of effort to change the strict standards which I use to evaluate my body e) I have managed to let go of the strict standards which I used in the past to evaluate my body and am hoping to keep it this way

12. The following statements refer to certain foods which you may avoid eating (such as food high in calories or fat, red meat or dairy products):

a) There are certain foods which I strictly avoid and would not even consider eating b) There are certain foods which I try to avoid, although sometimes I think that it might be okay to eat them occasionally c) I think that I am too strict in the foods which I allow myself to eat and have decided that I will attempt to eat foods which I usually avoid d) I am putting in a lot of effort to regularly eat foods which I usually avoid e) I used to avoid eating certain foods which I now eat regularly

13. The following statements refer to daily food consumption:

298 a) There is not need for me to eat 3 standard-size meals and a snack each day b) Sometimes I think that I should eat 3 standard-size meals and a snack each day c) I have decided that I need to eat 3 standard-size meals and a snack each day d) I am putting in a lot of effort to eat 3 standard-size meals and a snack each day e) I am working to maintain a current eating pattern which includes 3 standard-size meals and a snack each day

14. The following statements refer to time spent thinking about food and your weight (such as thoughts about becoming fat, counting the calories or fat content of food, or calculating the amount of energy used when exercising):

a) There is nothing wrong with the amount of time I spend thinking about food and my weight b) The amount of time I spend thinking about food and my weight is a problem sometimes c) I have decided that I need to use strategies to help me reduce the amount of time I spend thinking about food and my weight d) I am using strategies to help me reduce the amount of time I spend thinking about food and my weight e) I used to spend too much time thinking about food and my weight which I have managed to reduce and am working to keep it this way

15. The following statements refer to certain eating behaviors (such as needing to eat food at a specific rate or time, moving around on the plate, being unable to eat all food on a plate, taking longer than others to eat meals, having difficulty eating with others, needing to chew food a certain number of times or needing to stick to the same food plan each day):

a) There is nothing that I need to change about the way I eat my meals b) I sometimes think that I need to change aspects of the way I eat my meals c) I have decided that I will try to change aspects of the way I eat my meals d) I am putting a lot of effort to change aspects of the way I eat my meals e) I have succeeded in changing aspects of the way I eat my meals and want it to stay this way

16. The following statements refer to feelings associated with eating (such as feeling guilty) and not eating (such as feeling in control):

a) There is no need for me to change the feelings I associate with eating and not eating b) I sometimes think that I need to change the feelings I associate with eating and not eating c) I have decide that I will try to change the feelings I associate with eating and not eating d) I am putting in a lot of effort to change the feelings I associate with eating and not eating

299 e) I have succeeded in changing the feelings I associate with eating and not eating and want it to stay this way

18.The following statements refer to methods which you may use to control your weight (such as restricting your eating, exercising, vomiting, taking laxatives or other pills). You may select more than one statement for the different methods you use to control your weight. Please indicate which weight control method/s you are referring to in the blank space/s provided.

a) There is nothing seriously wrong with the methods (______) I use to control my weight b) I have been thinking that there may be problems associated with the methods (______) I use to control my weight c) I have decide that I will attempt to stop using certain methods (______) to control my weight d) I am putting in a lot of effort to stop using certain methods (______) to control my weight e) I have managed to stop using certain methods (______) to control my weight and I would like it to stay this way

19.The following statements refer to certain characteristics (such as perfectionism, low self esteem or feeling a need for control):

a) I do not have any problems in the way I approach life which I need to work on b) I sometimes think that I may have certain problems in the way I approach life which I need to work on c) I have certain problems in the way I approach life which I have decided to work on d) I am actively working on problems in the way I approach life e) The problems in the way I approach life I have improved and I am trying to keep it this way

20. The following statements refer to relationship problems (such as relationships with family or friends):

a) I do not have any problems in my relationships with others which I need to work on b) I sometimes think that I may have certain problems in my relationships with others which I need to work on c) I have certain problems in my relationships with others which I have decided to work on d) I am actively working on problems in my relationships with others e) The problems in my relationships with others have improved and I am trying to keep it this way

300 EDBQ

Instructions: Choose the rating (place a mark on the line) that best describes what you usually believe or what you believe most of the time. Base your response of what you emotionally feel or believe and not on what you rationally believe to be true.

0------100 I don’t usually I am usually completely believe this at all convinced that this is true

1. I’m stupid 0------100 2. I’m no good 0------100 3. I’m a failure 0------100 4. I’m useless 0------100 5. I’m dull 0------100 6. I’m not a likeable person 0------100 7. I’m all alone 0------100 8. I don’t like myself very much 0------100 9. I’m unlovable 0------100 10. I’m ugly 0------100 11. If my thighs are firm it means I’m a better person 0------100 12. If my hips are narrow it means I’m successful 0------100 13. If my bottom is small people will take me seriously 0------100 14. If I gain weight it means I’m a bad person 0------100 15. If I gain weight I’m nothing 0------100 16. If my body shape is in proportion people will love me 0------100 17. If my hips are thin people will approve of me 0------100 18. If I lose weight people will be friendly and want to get to know me 0------100

301 19. If I lose weight people will care about me 0------100 20. If I lose weight I’ll count more in the world 0------100 21. If my stomach is flat I’ll be more desirable 0------100 22. If my flesh is firm I’m more attractive 0------100 23. If my body is lean I can feel good about myself 0------100 24. If I eat desserts or puddings I’ll get fat 0------100 25. Body fat/flabbiness is disgusting 0------100 26. If I eat bad foods such as fats, sweets, bread and cereals they will turn into fat 0------100 27. If I’ve eating something I have to get rid of it as soon as possible 0------100 28. If I binge and vomit I can stay in control 0------100 29. If I eat three meals a day like other people I’ll gain weight 0------100 30. If I eat normally I’ll gain weight 0------100 31. If I stay hungry I can guard against losing control and getting fat 0------100 32. If I eat a forbidden food I won’t be able to stop 0------100

302 MCQ

Instructions: This questionnaire is concerned with beliefs people have about their thinking. Listed below are a number of beliefs that people have expressed. Please read each item and say how much you generally agree with it by colouring in the circle under the appropriate number. Please respond to all the items, there are no right or wrong answers. 1 2 3 4 Do not agree Agree slightly Agree moderately Agree very much

1. Worrying helps me to avoid problems in the future…………………..    

2. My worrying is dangerous for me……………………………………..    

3. l have difficulty knowing if I have actually done something or just imagined it……………………………………………………………….    

4. I think a lot about my thoughts………………………………………..    

5. l could make myself sick with worrying………………………….…...    

6. I am aware of the way my mind works when l am thinking through a problem…………………………………………………………………..    

7. If I did not control a worrying thought, and then it happened, it would be my fault……………………………………………………………….    

8. If I let my worrying thoughts get out of control, they will end up controlling me……………………………………………………………    

9. l need to worry in order to remain organised………………………….    

10. I have little confidence in my memory for words and names………..    

11. My worrying thoughts persist, no matter how I try to stop them……………………………………………………………………...    

12. Worrying helps me to get things sorted out in my mind…………….    

13. I cannot ignore my worrying thoughts……………………………….    

14. I monitor my thoughts………………………………………………..    

303 15. I should be in control of my thoughts all of the time………………...    

16. My memory can mislead me at times………………………………..    

17. I could be punished for not having certain thoughts………….……...    

18. My worrying could make me go mad………………………………..    

19. If I do not stop my worrying thoughts, they could come true……….    

20. I rarely question my thoughts………………………………………..    

21. Worrying puts my body under a lot of stress………………………...    

22. Worrying helps me to avoid disastrous situations…………………...    

23. l am constantly aware of my thinking………………………………..    

24. I have a poor memory………………………………………………..    

25. l pay close attention to the way my mind works……………………..    

26. People who do not worry, have no depth…………………………….    

27. Worrying helps me cope……………………………………………..    

28. I imagine having not done things and then doubt my memory for doing them……………………………………………………………….    

29. Not being able to control my thoughts is a sign of weakness.……….    

30. If l did not worry, I would make more mistakes……………………..    

31. I find it difficult to control my thoughts………………………….….    

32. Worrying is a sign of a good person…………………………………    

33. Worrying thoughts enter my head against my will…………………..    

34. If I could not control my thoughts I would go crazy………………...    

35. l will lose out in life if l do not worry…………………………….….    

36. When l start worrying I cannot stop………………………………….    

37. Some thoughts will always need to be controlled……………………    

304

38. I need to worry, in order to get things done………………………….    

39. I will be punished for not controlling certain thoughts………………    

40. My thoughts interfere with my concentration………………………..    

41. It is alright to let my thoughts roam free…………………………….    

42. I worry about my thoughts…………………………………………...    

43. I am easily distracted………………………………………………...    

44. My worrying thoughts are not productive…………………………...    

45. Worry can stop me from seeing a situation clearly………………….    

46. Worrying helps me to solve problems……………………………….    

47. I have little confidence in my memory for places…………………...    

48. My worrying thoughts are uncontrollable…………………………...    

49. It is bad to think certain thoughts……………………………….……    

50. If I do not control my thoughts, I may end up embarrassing myself...    

51. I do not trust my memory……………………………………………    

52. I do my clearest thinking when I am worrying………………………    

53. My worrying thoughts appear automatically………………………...    

54. l would be selfish if I never worried…………………………………    

55. If l could not control my thoughts, I would not be able to function…    

56. I need to worry, in order to work well……………………………….    

57. l have little confidence in my memory for actions…………………..    

58. I have difficulty keeping my mind focused on one thing for a long time………………………………………………………………………    

59. If a bad thing happens which I have not worried about, I feel     responsible……………………………………………………………….

305

60. It would not be normal, if I did not worry……………………….…..    

61. I constantly examine my thoughts…………………………………...    

62. If I stopped worrying, l would become glib, arrogant and offensive………………………………………………………………….    

63. Worrying helps me to plan the future more effectively……………...    

64. I would be a stronger person if I could worry less…………………...    

65. It would be stupid and complacent not to worry…………………….    

306 PSWQ

Instructions: Listed below are a number of statements about how much and under what circumstances you find that you worry. Using the 5-point scale shown below, please rate the extent to which the behaviour described by each statement has been typical of you by colouring in the circle that best reflects your response.

1 2 3 4 5 not at all very typical typical of me of me

1. If I do not have enough time to do everything, I do not worry about it…………………………………     

2. My worries overwhelm me………………………..     

3. I do not tend to worry about things………………..     

4. Many situations make me worry…………………..     

5. I know I should not worry about things, but I just cannot help it………………………………………     

6. When I am under pressure I worry a lot…………...     

7. I am always worrying about something…………...     

8. I find it easy to dismiss worrisome thoughts………     

9. As soon as I finish one task, I start to worry about everything else I have to do……………………….     

10. I never worry about anything……………………...     

11. When there is nothing more I can do about a concern, I do not worry about it anymore…………     

12. I have been a worrier all my life…………………..     

13. I notice that I have been worrying about things…..     

14. Once I start worrying I cannot stop……………….     

307 15. I worry all the time………………………………...     

16. I worry about projects until they are all done….….     

308 SIAS

Instructions: For each question please colour in a circle to indicate the degree to which you feel the statement is characteristic or true of you. DO NOT tick, cross or circle your answer. Please use a blue or black pen. DO NOT use a pencil. The rating scale is as follows:

0 1 2 3 4 Not at all true Slightly characteristic Moderately Very characteristic Extremely true or characteristic or true of me. characteristic or or true of me characteristic of of me true of me me

1. I get nervous if I have to speak to someone in authority (eg,      teacher, boss)…………………………………… 2. I have difficulty making eye-contact with others……………      3. I become tense if I have to talk about myself or my feelings……      4. I find it difficult mixing comfortably with the people I work with      5. I find it easy to make friends of my own age…………………….      6. I tense-up if I meet an acquaintance in the street……...……      7. When mixing socially, I am uncomfortable………………..….      8. I feel tense if I am alone with just one person……………...…      9. I am at ease meeting people at parties, etc…………….………      10. I have difficulty talking with other people…………………….      11. I find it easy to think of things to talk about…………………..      12. I worry about expressing myself in case I appear awkward...……      13. I find it difficult to disagree with another’s point of view……      14. I have difficulty talking to an attractive person of the opposite      sex.… 15. I find myself worrying that I won’t know what to say in social      situations…………………………………………… 16. I am nervous mixing with people I don’t know well…………      17. I feel I’ll say something embarrassing when talking……………      18. When mixing in a group I find myself worrying I will be      ignored…………………………………………………………. 19. I am tense mixing in a group……......      20. I am unsure whether to greet someone I know only slightly……     

309 SPS

Instructions: For each question, please colour in a circle to indicate the degree to which you feel the statement is characteristic or true of you. DO NOT tick, cross or circle your answer. Please use a blue or black pen. DO NOT use a pencil. The rating scale is as follows:

0 1 2 3 4 Not at all true Slightly characteristic Moderately Very characteristic Extremely true or characteristic or true of me. characteristic or or true of me characteristic of of me true of me me

1. I become anxious if I have to write in front of other people……      2. I become self-conscious when using public toilets…………….      3. I can suddenly become aware of my own voice and of others      listening to me … 4. I get nervous that people are staring at me as I walk down the      street... 5. I fear I may blush when I am with others......      6. I feel self-conscious if I have to enter a room where others are      already seated … 7. I worry about shaking or trembling when I’m watched by other      people ……… 8. I would get tense if I had to sit facing people on a bus or a      train……. 9. I get panicky that others might see me faint, or get sick or      ill…….…. 10. I would find it difficult to drink something if in a group of      people….. 11. It would make me feel self-conscious to eat in front of a stranger at      a restaurant 12. I am worried people will think my behaviour odd ......      13. I would get tense if I had to carry a tray across a crowded      cafeteria… 14. I worry I’ll lose control of myself in front of other people ......      15. I worry I might do something to attract the attention of other      people... 16. When in an elevator, I am tense if people look at me ....………      17. I can feel conspicuous standing in a line………………      18. I can get tense when speaking in front of other      people………………. 19. I worry my head will shake or nod in front of others ......      20. I feel awkward and tense if I know people are watching me..     

310 FNE Instructions: read each of the following statements carefully and in each case indicate whether or not the statement applies to you by circling either “T” for true or “F” for false. There are no right or wrong answers, and no trick questions. Please answer every question, even if you are not completely sure of the answer.

1. I rarely worry about seeming foolish to others…………………….. T F 2. I worry about what people will think of me even when I know it doesn’t make any difference…………………………………………………….… T F 3. I become tense and jittery if I know someone is sizing me up……... T F 4. I am unconcerned even if I know people are forming an unfavourable impression of me……………………………………………………………..…. T F 5. I feel very upset when I commit some social error…………….…… T F 6. The opinions that important people have of me cause me little concern………………………………………………………………. T F 7. I am often afraid that I may look ridiculous or make a fool of myself………………………………………………………………… T F 8. I react very little when other people disapprove of me………………. T F 9. I am frequently afraid of other people noticing my shortcomings….… T F 10. The disapproval of others would have little effect on me………..…... T F 11. If someone is evaluating me I tend to expect the worst…………..….. T F 12. I rarely worry about what kind of impression I am making on someone………………………………………………………..…. T F 13. I am afraid that others will not approve of me……………………...… T F 14. I am afraid that people will find fault with me……………………...… T F 15. Other people’s opinions of me do not bother me………………….…. T F 16. I am not usually upset if I do not please someone………………….... T F 17. When I am talking to someone, I worry about what they may be thinking about me……………………………………………………………..… T F 18. I feel that you can’t help making social errors sometimes, so why worry about it…………………………………………………………..…….… T F 19. I am usually worried about what kind of impression I make……….… T F 20. I worry a lot about what my superiors think of me……………………. T F 21. If I know someone is judging me, it has little effect on me………….… T F 22. I worry that others will think I am not worthwhile………………….….. T F 23. I worry very little about what others may think of me……………….… T F 24. Sometimes I think I am too concerned with what other people think of me…………………………………………………………….... T F 25. I often worry that I will say or do the wrong things…………………..… T F 26. I am often indifferent to the opinion others have of me……………….... T F 27. I am usually confident that others will have a favourable impression of me………………………………………………………... T F 28. I often worry that people who are important won’t think very much of me……………………………………………………………... T F 29. I brood about the opinions my friends have about me………………..… T F 30. I become tense and jittery if I know I am being judged by my superiors………………………………………………………..…… T F

311

ACQ

Instructions: This questionnaire contains a list of thoughts people might have at times when they are feeling nervous, frightened or anxious. Using the 5-point scale shown below rate the degree to which you experience each thought when you are in situations where you have been very nervous, frightened or anxious. 1 2 3 4 5 |______|______|______|______| The thought Occurs about The thought never occurs half the time always occurs

Again, please colour in the circle next to your response. DO NOT tick, cross or circle your answer. Use a blue or black pen. DO NOT use a pencil or liquid paper. 1. I am going to throw up     

2. I am going to pass out     

3. I must have a brain tumour     

4. I must have a brain tumour     

5. I will choke to death     

6. I am going to act foolishly     

7. I am going blind     

8. I will not be able to control myself     

9. I will hurt someone     

10. I am going to have a stroke     

11. I am going to go crazy     

12. I am going to scream     

13. I am going to babble or talk funny     

14. I will be paralyzed by fear     

312

BSQ Instructions: this questionnaire contains a list of sensations people might have at times when they are feeling nervous, frightened or anxious. Using the 5 – point scale shown below rate the degree to which you are worried or frightened by the sensations when you are in situations where you have been very nervous, frightened or anxious.

1 2 3 4 5 Not frightened or Extremely frightened Worried by this by this sensation Sensation

1. Heart palpitations………………………………………….1 2 3 4 5 2. Pressure in your chest……………………………………..1 2 3 4 5 3. Numbness in your arms or legs……………………………1 2 3 4 5 4. Tingling in your fingertips………………………………. 1 2 3 4 5 5. Numbness in another part of your body …………………..1 2 3 4 5 6. Feeling short of breath……………………………………..1 2 3 4 5 7. Dizziness……………………………………………………1 2 3 4 5 8. Blurred or distorted vision………………………………….1 2 3 4 5 9. Nausea………………………………………………………1 2 3 4 5 10. Butterflies in your stomach ………………………………...1 2 3 4 5 11. Knots in your stomach ……………………………………..1 2 3 4 5 12. A lump in your throat ………………………………………1 2 3 4 5 13. Wobbly or rubber legs ……………………………………...1 2 3 4 5 14. Sweating ……………………………………………………1 2 3 4 5 15. Dry throat ……………………………………………….….1 2 3 4 5 16. Feeling disoriented and confused ………………………….1 2 3 4 5 17. Feeling disconnected from your body ……………………..1 2 3 4 5

313 PI-WSUR

Instructions: The following statements refer to thoughts and behaviours which may occur to everyone in everyday life. For each statement, colour in the circle under the number which best seems to fit you and the degree of disturbance which such thoughts or behaviours may create. Rate your replies as follows:

0 1 2 3 4 Not at all A little Quite a lot A lot Very much

1 I feel my hands are dirty when I touch money………………………      2 I think even slight contact with bodily secretions (perspiration, saliva, urine, etc.) may contaminate my clothes or somehow harm      me . . . . . …………………………………………………………….. 3 I find it difficult to touch an object when I know it has been touched      by strangers or by certain people …………………………………… 4 I find it difficult to touch garbage or dirty things.. …………………      5 I avoid using public toilets because I am afraid of disease and contamination………………………………………………………      … 6 I avoid using public telephones because I am afraid of contagion and      disease ……………………………………………………………… 7 I wash my hands more often and longer than necessary ……………      8 I sometimes have to wash or clean myself simply because I think I      may be dirty or ‘contaminated’……………………………………… 9 If I touch something I think is ‘contaminated’ I immediately have to      wash or clean myself ……………………………………………….. 10 If an animal touches me I feel dirty and immediately have to wash      myself or change my clothing……………………………………….. 11 I feel obliged to follow a particular order in dressing, undressing and washing      myself……………………………………………………….. 12 Before going to sleep I have to do certain things in a certain order….      13 Before going to bed I have to hang up or fold my clothes in a special      way.…………………………………………………………………..

14 I have to do things several times before I think they are properly      done………………………………………………………………….. 15 I tend to keep on checking things more often than necessary………..      16 I check and re-check gas and water taps and light switches after      turning them off……………………………………………………… 17 I return home to check doors, windows, drawers, etc. to make sure     

314 they are properly shut. ………………………………….…… 18 I keep on checking forms, documents, cheques in detail to make      sure I have filled them in correctly………………………………… 19 I keep on going back to see that matches, cigarettes, etc. are properly extinguished……………………………………….     

20 When I handle money I count and recount it several times ……….      21 I check letters carefully many times before posting them      …………… 22 Sometimes I am not sure I have done things which in fact I know I      have done ……………………..……………………………. 23 When I read, I have the impression I have missed something important and must go back and re-read the passage at least two or      three times…………………………………………………………… 24 I imagine catastrophic consequences as a result of absent-      mindedness or minor errors which I make ………………………….. 25 I think or worry at length about having hurt someone without      knowing it……………………………………………………………. 26 When I hear about a disaster, I think somehow it is my      fault………………………………………………………………….. 27 I sometimes worry at length for no reason that I have hurt myself or      have some disease…………………………………………………… 28 I get upset or worried at the sight of knives, daggers, and other      pointed objects……………………………………………….……… 29 When I hear about suicide or crime, I am upset for a long time and      find it difficult to stop thinking about it………………………………

30 I invent useless worries about germs and disease……………………      31 When I look down from a bridge or a very high window, I feel an      impulse to throw myself into space………………………………….. 32 When I see a train approaching, I sometimes think I could throw myself under it’s      wheels……………………………………………… 33 At certain moments, I am tempted to tear my clothes off in public…….…………………………………………………………      … 34 While driving I sometimes feel an impulse to drive the car into      someone or something……………………………………………….. 35 Seeing weapons excites me and makes me think violent      thoughts……………………………………………………………… 36 I sometimes feel the need to break or damage things for no      reason….

315 37 I sometimes have an impulse to steal other people’s belongings,      even if they are of no use to me…………………………..…………. 38 I am sometimes almost irresistibly tempted to steal something from      the supermarket……………………………………………………… 39 I sometimes have an impulse to hurt defenseless children or      animals….……………………………………………………………

316

Y-BOCS

Instructions: Please complete the following questions, choosing only one number per item. Scores should reflect the composite effect of all obsessive compulsive symptoms. Rate the average occurrence of each item during the prior week up to and including now by colouring in the appropriate circle.

Your most frequent obsessions: ……………………………………………………………………………………………… ………………………………………………………………………………… …

Your most frequent compulsions: ……………………………………………………………………………………………… ……………………………………………………………………………………

Obsession Rating Scale

- Range of Severity -

Item 0hrs / 0 – 1 – 3hrs/day 3 – 8hrs/day 8+ hrs/day day 1hrs/day 1 Time spent on      obsessions None Mild Definite but Substantial Incapacitating manageable impairment 2 Interference from      obsessions None Little Moderate Severe Near constant 3 Distress from      obsessions Always Much Some Often yield Completely resist resistance resistance yield 4 Resistance to      obsessions Comple Much Some control Little control No control te control control 5 Control over      obsessions

317

Compulsion Rating Scale

- Range of Severity -

Item 0hrs / day 0 – 1 – 3hrs/day 3 – 8hrs/day 8+ hrs/day 1hrs/day 1 Time spent on      compulsions None Mild Definite but Substantial Incapacitating manageable impairment 2 Interference from      compulsions None Little Moderate Severe Near constant 3 Distress from      compulsions Always Much Some Often yield Completely resist resistance resistance yield 4 Resistance to      compulsions Complete Much Some control Little control No control control control 5 Control over      compulsions

318 MOCI

Instructions: Please answer each question by putting a circle around the “True” or the “False” following the question. There are no right or wrong answers, and no trick questions. Work quickly and do not think too long about the exact meaning of the question. 1. I avoid using public telephone because of possible contamination True False 2. I frequently get nasty thoughts and have difficulty getting rid of True False them 3. I am more concerned than most people about honesty True False 4. I am often late because I can’t seem to get through everything on True False time 5. I don’t worry unduly about contamination if I touch an animal True False 6. I frequently have to check things (eg. gas or water taps, doors etc) True False several times 7. I have a very strict conscience True False 8. I find that almost every day I am upset by unpleasant thoughts that True False come into my mind against my will 9. I do not worry unduly if I accidentally bump into somebody True False 10. I usually have serious doubts about the simple everyday things I True False do 11.Neither of my parent was very strict during my childhood True False 12.I tend to get behind in my work because I repeat things over and True False over again 13. I use an average amount of soap True False 14. Some numbers are extremely unlucky True False 15.I do not check letters over and over again before posting them True False 16.I do not take a long time to dress in the morning True False 17. I am not excessively concerned about cleanliness True False 18.One of my major problems is that I pay too much attention to True False detail 19. I can use well-kept toilets without any hesitation True False 20.My major problem is repeated checking True False 21.I am not unduly concerned about germs and diseases True False 22.I do not tend to check things more than once True False 23.I do not stick to a very strict routine when doing ordinary things True False 24.My hands do not feel dirty after touching money True False 25.I do not usually count when doing a routine task True False 26. I take a rather long time to complete my washing in the morning True False 27.I do not use a great deal of antiseptics True False 28.I spend a lot of time every day checking things over and over True False again 29. Hanging and folding my clothes at night does not take a long time True False 30. Even when I do something very carefully I often feel that it is not True False right

319

PDS

Please indicate how many of the following events you have witnessed or experienced: . Accident or fire . Natural diaster . Nonsexual assault (known assailant) . Nonsexual assault (unknown assailant) . Sexual assault (known assailant) . Sexual assault (unknown assailant) . Combat or war zone . Sexual abuse . Imprisonment . Torture . Life-threatening illness . Other

Please indicate which of the above events has disturbed you most in the past month and briefly describe the event in the space provided. ______

Please refer to the above event when answering the following questions. 1. Was there any physical injury to yourself as a result of the event? Yes / No 2. Was there any physical injury to someone else as a result of the event? Yes / No

320

3. Did you feel that your life or someone else’s life was in danger at the time of this event? Yes / No 4. Did you have a feeling of helplessness or terror at the time of the event? Yes / No

The following items refer to the frequency with which you have experienced these symptoms in the past month: 0 1 2 3 Once in a while Some of the time Half the time Almost always Once a week or less 2 times / week 3 – 4 times / week 5 + times / week

1. Having upsetting thoughts or images about the traumatic event that came into your head when you didn’t want them to 2. Having bad dreams or nightmares about the traumatic event 3. Reliving the traumatic event, acting or feeling as if it was happening again 4. Feeling emotionally upset when you were reminded of the traumatic event (eg feeling scared, sad, angry, guilty etc) 5. Experiencing physical reactions when you were reminded of the traumatic event (eg breaking out in a sweat, heart beating fast) 6. Trying not to think about, or have feelings about the traumatic event 7. Trying to avoid activities, people or places that remind you of the traumatic event 8. In ability to recall an important aspect of the trauma 9. Having much less interest or participating much less often in important activities 10. Feeling distant or cut off from people around you 11. Feeling emotionally numb (for example being unable to cry or unable to have loving feelings) 12. Feeling as if your future plans or hopes will not come true (for example you will not have a career, marriage, children or a long life) 13. Having trouble falling or staying asleep

321 14. Feeling irritable or having fits of anger 15. Having trouble concentrating (for example drifting in and out of conversations, losing track of a story on television, forgetting what you read) 16. Being overly alert (for example checking to see who is around you , being uncomfortable with your back to a door etc) 17. Being jumpy and easily startled (for example when someone walks up behind you)

Please indicate whether your symptoms have interfered with the following areas within the past month :

1. Work Yes / No 2. Household duties Yes / No 3. Friendships Yes / No 4. Family relationships Yes / No 5. Fun and leisure activities Yes / No 6. Schoolwork Yes / No 7. Sex life Yes / No 8. General satisfaction with life Yes / No 9. Overall level of functioning Yes / No

322

IES – Revised

Instructions: Below is a list of difficulties people sometimes have after stressful life events. Please read each item, and then indicate how distressing each difficulty has been for you DURING THE PAST SEVEN DAYS with respect to ______, how much were you distressed or bothered by these difficulties?

Not at A little Quite a Moderately Extremely all bit bit Any reminder brought back 0 1 2 3 4 feelings about it I had trouble staying asleep 0 1 2 3 4 Other things kept making 0 1 2 3 4 me think about it I felt irritable and angry 0 1 2 3 4 I avoided letting myself get upset when I thought about 0 1 2 3 4 it or was reminded of it I thought about it when I 0 1 2 3 4 didn’t mean to I felt as if it hadn’t 0 1 2 3 4 happened or wasn’t real I stayed away from 0 1 2 3 4 reminders about it Pictures about it popped 0 1 2 3 4 into my mind I was jumpy and easily 0 1 2 3 4 startled I tried not to think about it 0 1 2 3 4 I was aware that I still had a lot of feelings about it, but I 0 1 2 3 4 didn’t deal with them My feelings about it were 0 1 2 3 4 kind of numb I found myself acting or feeling as though I was 0 1 2 3 4 back at that time

323 Not at A little Quite a Moderately Extremely all bit bit I had trouble falling asleep 0 1 2 3 4 I had waves of strong 0 1 2 3 4 feelings about it I tried to remove it from my 0 1 2 3 4 memory I had trouble concentrating 0 1 2 3 4 Reminders of it caused me to have physical reactions, such as sweating, trouble 0 1 2 3 4 breathing, nausea, or a pounding heart I had dreams about it 0 1 2 3 4 I felt watchful or on-guard 0 1 2 3 4

I tried not to talk about it 0 1 2 3 4

324

APPENDIX I

Statistical Analyses

All statistical analyses may be found on the disc located in the sleeve on the back cover

Table of Contents

1. DEMOGRAPHIC STATISTICS & CLINICAL CHARACTERISTICS

1.1 DESCRIPTIVE STATISTICS 326 Inpatient ED Sample 326 Outpatient ED Sample 336 Entire ED Sample 348 Outpatient Anxiety Sample 371 Entire Sample Table of Means 379

2. THE PREVALENCE OF ANXIETY DISORDERS

2.1 DESCRIPTIVE STATISTICS Inpatient ED Sample 319 Outpatient ED Sample 336 Entire ED Sample 348 Outpatient Anxiety Sample 371 Entire Sample Table of Means 379

3. THE TEMPORAL RELATIONSHIP BETWEEN ED & AD

3.1 DESCRIPTIVE STATISTICS Inpatient ED Sample 319 Outpatient ED Sample 336

325 Entire ED Sample 348 Outpatient Anxiety Sample 371 Entire Sample Table of Means 379

4. COMPARISONS ACROSS THE SAMPLE

4.1 CHI- SQUARE ANALYSES Comparison of frequency of AD across sample 381 ED Inpatient and Outpatient Comparisons 382 ED Subtype Comparisons 392 Entire ED Sample Comparisons 399 4.2 INDEPENDENT SAMPLES T-TESTS & MANN WHITNEY U TESTS 409

Comparison between Inpatient & Outpatient ED 409 Comorbid AD & ED compared with ED only 411 EDE scores comparison across entire sample 417

4.3 ANALYSIS OF VARIANCE (ANOVA) 418 Inpatient & Outpatient ED sample comparisons 418 Entire ED sample comparisons of ED symptoms across AD 424 Entire ED sample comparisons of EDE scores 426

4.4 LOGISTIC REGRESSION ANALYSES 429

326 1. DEMOGRAPHIC STATISTICS & CLINICAL CHARACTERISTICS 1.1 DESCRIPTIVE STATISTICS

INPATIENT ED WHOLE SAMPLE

Statistics

Children Education ED Length ED Ons et Ag e (number) (Years) (Months) BMI Ag e (Ye ars ) N Valid 50 50 50 49 50 49 Missing 0 0 0 1 0 1 Me an 25.38 .26 14.20 88.29 17.2698 17.96 Std. Deviati on 8.263 .922 2.030 78.481 3.23910 6.324 Minimum 18 0 11 3 12.55 11 Maximum 56 4 20 276 25.50 43

Statistics

Secondary Time Between Anxiety Length Anxiety Length Anxiety Onset Anxiety Dx and (Months) (Months) Age (Years ) ED (Months) N Valid 50 50 37 24 Missing 0 0 13 26 Mean 93.70 54.96 15.19 89.42 Std. Deviation 88.939 97.219 9.015 59.598 Minimum 0 0 5 12 Maximum 288 360 43 264

Statistics

No of No of No of Days Episodes No of Days Episodes Binging Binging Vomiting vomiting Ex ercise Per Ex ercise Days per Month per Month per Month per month Day (Minutes) Per Month N Valid 50 50 50 50 50 50 Missing 0 0 0 0 0 0 Mean 5.38 13.42 9.22 36.30 52.00 11.00 Std. Deviation 9.659 28.912 11.710 73.544 84.201 13.482 Minimum 0 0 0 0 0 0 Maximum 28 140 28 280 400 30

327

Childre n (number)

Cumulative Frequency Percent Valid Percent Percent Valid 0 46 92.0 92.0 92.0 2 1 2.0 2.0 94.0 3 1 2.0 2.0 96.0 4 2 4.0 4.0 100.0 To tal 50 100.0 100.0

Marital Status

Cumulative Frequency Percent Valid Percent Percent Valid Married 5 10.0 10.0 10.0 Single 36 72.0 72.0 82.0 cohabiting 2 4.0 4.0 86.0 Separated 1 2.0 2.0 88.0 Di vorce d 2 4.0 4.0 92.0 Partner (non cohabiting) 4 8.0 8.0 100.0 To tal 50 100.0 100.0

Employme nt Status

Cumulative Frequency Percent Valid Perc ent Percent Valid employ ed 23 46.0 46.0 46.0 unemployed 15 30.0 30.0 76.0 F/T Student 12 24.0 24.0 100.0 To tal 50 100.0 100.0

De pre ssion Le vels

Cumulative Frequency Percent Valid Perc ent Percent Valid Normal 6 12.0 13.6 13.6 Mild 4 8.0 9.1 22.7 Moderate 10 20.0 22.7 45.5 S e vere 7 14.0 15.9 61.4 Ex Severe 17 34.0 38.6 100.0 To tal 44 88.0 100.0 Missing Sy stem 6 12.0 To tal 50 100.0

328 Antidepressant Medication

Cumulative Frequency Percent Valid Percent Percent Valid Antidepres sant 37 74.0 74.0 74.0 Medication No Antidepress ant 13 26.0 26.0 100.0 Medication To tal 50 100.0 100.0

Ea ting Disorder Dia gnos is

Cumulative Frequency Percent Valid Percent Percent Valid AN R 19 38.0 38.0 38.0 AN BP 14 28.0 28.0 66.0 BN 6 12.0 12.0 78.0 ED NOS 11 22.0 22.0 100.0 To tal 50 100.0 100.0

Binging

Cumulative Frequency Percent Valid Percent Percent Valid No 31 62.0 62.0 62.0 Ye s 19 38.0 38.0 100.0 To tal 50 100.0 100.0

Laxative Use

Cumulative Frequency Percent Valid Percent Percent Valid No 38 76.0 76.0 76.0 Ye s 12 24.0 24.0 100.0 To tal 50 100.0 100.0

Exercise Use

Cumulative Frequency Percent Valid Percent Percent Valid No 28 56.0 56.0 56.0 Ye s 22 44.0 44.0 100.0 To tal 50 100.0 100.0

329 INPATIENT ED COMORBID AD & ED ONLY

Statistics

Children Education ED Length Anxiety Length Ag e (number) (Years) (Months) (Months) BMI N Valid 37 37 37 37 37 37 Missing 0 0 0 0 0 0 Me an 25.70 .19 14.24 92.49 126.62 17.5662 Std. Deviati on 7.356 .811 1.992 77.714 80.513 3.27953 Minimum 18 0 11 8 5 12.55 Maximum 46 4 19 276 288 25.50

Statistics

Secondary Time Between Anxiety Length ED Onset Anxiety Onset Anxiety Dx and (Months) Age (Years ) Age (Years ) ED (Months) N Valid 37 37 37 24 Missing 0 0 0 13 Mean 74.27 17.95 15.19 89.42 Std. Deviation 106.727 6.472 9.015 59.598 Minimum 0 11 5 12 Maximum 360 43 43 264

Statistics

No of No of No of Days Episodes No of Days Episodes Binging Binging Vomiting vomiting Ex ercise Per Ex ercise Days per Month per Month per Month per month Day (Minutes) Per Month N Valid 37 37 37 37 37 37 Missing 0 0 0 0 0 0 Mean 5.16 13.59 9.51 39.51 61.35 11.78 Std. Deviation 9.625 31.756 11.357 81.351 93.338 13.505 Minimum 0 0 0 0 0 0 Maximum 28 140 28 280 400 30

330 Children (number)

Cumulative Frequency Percent Valid Percent Percent Valid 0 35 94.6 94.6 94.6 3 1 2.7 2.7 97.3 4 1 2.7 2.7 100.0 To tal 37 100.0 100.0

Marital Status

Cumulative Frequency Percent Valid Percent Percent Valid Married 3 8.1 8.1 8.1 Single 26 70.3 70.3 78.4 cohabiting 2 5.4 5.4 83.8 Separated 1 2.7 2.7 86.5 Di vorce d 2 5.4 5.4 91.9 Partner (non cohabiting) 3 8.1 8.1 100.0 To tal 37 100.0 100.0

Employme nt Status

Cumulative Frequency Percent Valid Perc ent Percent Valid employ ed 16 43.2 43.2 43.2 unemployed 13 35.1 35.1 78.4 F/T Student 8 21.6 21.6 100.0 To tal 37 100.0 100.0

Antidepressant Medication

Cumulative Frequency Percent Valid Percent Percent Valid Antidepres sant 30 81.1 81.1 81.1 Medication No Antidepress ant 7 18.9 18.9 100.0 Medication To tal 37 100.0 100.0

331 De pre ssion Le vels

Cumulative Frequency Percent Valid Perc ent Percent Valid Normal 2 5.4 6.3 6.3 Mild 3 8.1 9.4 15.6 Moderate 6 16.2 18.8 34.4 S e vere 5 13.5 15.6 50.0 Ex Severe 16 43.2 50.0 100.0 To tal 32 86.5 100.0 Missing Sy stem 5 13.5 To tal 37 100.0

Ea ting Disorder Dia gnos is

Cumulative Frequency Percent Valid Percent Percent Valid AN R 12 32.4 32.4 32.4 AN BP 11 29.7 29.7 62.2 BN 6 16.2 16.2 78.4 ED NOS 8 21.6 21.6 100.0 To tal 37 100.0 100.0

ED Onset Age (Years)

Cumulative Frequency Percent Valid Percent Percent Valid 11 1 2.7 2.7 2.7 12 1 2.7 2.7 5.4 14 5 13.5 13.5 18.9 15 11 29.7 29.7 48.6 16 3 8.1 8.1 56.8 17 2 5.4 5.4 62.2 18 4 10.8 10.8 73.0 19 4 10.8 10.8 83.8 20 2 5.4 5.4 89.2 25 1 2.7 2.7 91.9 30 1 2.7 2.7 94.6 38 1 2.7 2.7 97.3 43 1 2.7 2.7 100.0 To tal 37 100.0 100.0

332 Binging

Cumulative Frequency Percent Valid Percent Percent Valid No 23 62.2 62.2 62.2 Ye s 14 37.8 37.8 100.0 To tal 37 100.0 100.0

Vomiting

Cumulative Frequency Percent Valid Percent Percent Valid No 16 43.2 43.2 43.2 Ye s 21 56.8 56.8 100.0 To tal 37 100.0 100.0

Laxative Use

Cumulative Frequency Percent Valid Percent Percent Valid No 25 67.6 67.6 67.6 Ye s 12 32.4 32.4 100.0 To tal 37 100.0 100.0

Exercise Use

Cumulative Frequency Percent Valid Percent Percent Valid No 19 51.4 51.4 51.4 Ye s 18 48.6 48.6 100.0 To tal 37 100.0 100.0

333

INPATIENT ED NO ANXIETY

Statistics

No of No of No of Days Episodes No of Days Episodes ED Length ED Onset Binging Binging Vomiting vomiting Ex ercise Per Ex ercise Days (Months) BMI Age (Years ) per Month per Month per Month per month Day (Minutes) Per Month N Valid 12 13 12 13 13 13 13 13 13 Missing 1 0 1 0 0 0 0 0 0 Mean 75.33 16.4262 18.00 3.85 10.77 8.38 27.15 25.38 8.77 Std. Deviation 82.880 3.08762 6.120 7.755 19.430 13.112 45.927 42.154 13.700 Minimum 3 14.02 13 0 0 0 0 0 0 Maximum 240 24.60 36 28 58 28 125 120 30

Ea ting Disorder Diagnosis

Cumulative Frequency Percent Valid Perc ent Percent Valid ANR 7 53.8 53.8 53.8 ANBP 3 23.1 23.1 76.9 EDNOS 3 23.1 23.1 100.0 To tal 13 100.0 100.0

Laxative Use

Cumulative Frequency Percent Valid Percent Percent Valid No 13 100.0 100.0 100.0

Exercise Use

Cumulative Frequency Percent Valid Percent Percent Valid No 9 69.2 69.2 69.2 Ye s 4 30.8 30.8 100.0 To tal 13 100.0 100.0

334 OUTPATIENT ED WHOLE SAMPLE

Statistics

Children Education ED Length Anxiety Length Ag e (number) (Years) BMI (Months) (Months) N Valid 50 50 50 50 50 50 Missing 0 0 0 0 0 0 Me an 25.04 .38 13.60 20.4196 99.08 95.04 Std. Deviati on 6.398 .923 2.050 3.17167 76.771 108.281 Range 27 4 9 13.51 330 480 Minimum 18 0 10 15.44 6 0 Maximum 45 4 19 28.95 336 480

Statistics

Secondary Time Between Anxiety Length ED On set Anxiety Ons et An xiety Dx a nd (Months) Ag e (Ye ars ) Ag e (Ye ars ) ED (Months ) N Valid 50 50 28 21 Missing 0 0 22 29 Me an 41.28 16.78 12.25 88.71 Std. Deviati on 94.742 4.713 7.250 52.927 Range 480 25 35 216 Mi ni m u m 0 9 5 24 Maximum 480 34 40 240

Statistics

No of No of No of Days Episodes No of Days Episodes Binging Binging Vomiting vomiting Exercis e Per Exercis e Days per Month per Month per Month per month Day (Minutes) Per Month N Valid 50 50 50 50 50 50 Missing 0 0 0 0 0 0 Me an 9.94 15.08 9.88 22.60 27.90 9.08 Std. Deviati on 11.506 21.824 12.257 45.648 42.858 12.383 Range 28 84 28 280 150 28 Mi ni m u m 0 0 0 0 0 0 Maximum 28 84 28 280 150 28

335

Childre n (number)

Cumulative Frequency Percent Valid Percent Percent Valid 0 40 80.0 80.0 80.0 1 6 12.0 12.0 92.0 3 3 6.0 6.0 98.0 4 1 2.0 2.0 100.0 To tal 50 100.0 100.0

336

OUTPATIENT ED – COMORBID AD & ED

Statistics

Children Education ED Length Anxiety Length Ag e (number) (Years) (Months) (Months) BMI N Valid 28 28 28 28 28 28 Missing 0 0 0 0 0 0 Me an 26.29 .46 13.89 116.04 169.71 20.4139 Std. Deviati on 6.782 1.071 2.061 86.864 90.198 2.74228 Minimum 18 0 10 6 12 16.45 Maximum 45 4 18 336 480 28.95

Statistics ED Onset Age (Years) Statistics N Valid 28 Missing 0 Anxiety Ons et Age (Years) Mean 16.64 N Valid 28 Std. Deviation 4.724 Missing 0 Minimum 10 Me an 12.25 Maximum 33 Std. Deviation 7.250

Childre n (number)

Cumulative Frequency Percent Valid Percent Percent Valid 0 22 78.6 78.6 78.6 1 3 10.7 10.7 89.3 3 2 7.1 7.1 96.4 4 1 3.6 3.6 100.0 To tal 28 100.0 100.0

337 Statistics

No of No of No of Days Episodes No of Days Episodes Binging Binging Vomiting vomiting Ex ercise Per Ex ercise Days per Month per Month per Month per month Day (Minutes) Per Month N Valid 28 28 28 28 28 28 Missing 0 0 0 0 0 0 Mean 6.86 9.75 9.61 16.32 32.14 8.36 Std. Deviation 10.550 18.360 12.282 25.456 50.943 12.221 Minimum 0 0 0 0 0 0 Maximum 28 84 28 84 150 28

Marital Status

Cumulative Frequency Percent Valid Percent Percent Valid Married 6 21.4 21.4 21.4 Single 15 53.6 53.6 75.0 cohabiting 3 10.7 10.7 85.7 Di vorce d 1 3.6 3.6 89.3 Partner (non cohabiting) 3 10.7 10.7 100.0 To tal 28 100.0 100.0

Employme nt Status

Cumulative Frequency Percent Valid Perc ent Percent Valid employ ed 11 39.3 39.3 39.3 unemployed 4 14.3 14.3 53.6 F/T Student 13 46.4 46.4 100.0 To tal 28 100.0 100.0

Antidepressant Medication

Cumulative Frequency Percent Valid Percent Percent Valid Antidepres sant 14 50.0 50.0 50.0 Medication No Antidepress ant 14 50.0 50.0 100.0 Medication To tal 28 100.0 100.0

338 Ea ting Disorder Diagnosis

Cumulative Frequency Percent Valid Perc ent Percent Valid ANR 4 14.3 14.3 14.3 BN 9 32.1 32.1 46.4 EDNOS 15 53.6 53.6 100.0 To tal 28 100.0 100.0

De pre ssion Le vels

Cumulative Frequency Percent Valid Perc ent Percent Valid Normal 5 17.9 18.5 18.5 Mild 3 10.7 11.1 29.6 Moderate 5 17.9 18.5 48.1 S e vere 6 21.4 22.2 70.4 Ex Severe 8 28.6 29.6 100.0 To tal 27 96.4 100.0 Missing Sy stem 1 3.6 To tal 28 100.0

Binging

Cumulative Frequency Percent Valid Percent Percent Valid No 17 60.7 60.7 60.7 Ye s 11 39.3 39.3 100.0 To tal 28 100.0 100.0

Vomiting

Cumulative Frequency Percent Valid Percent Percent Valid No 14 50.0 50.0 50.0 Ye s 14 50.0 50.0 100.0 To tal 28 100.0 100.0

339 Laxative Use

Cumulative Frequency Percent Valid Percent Percent Valid No 26 92.9 92.9 92.9 Ye s 2 7.1 7.1 100.0 To tal 28 100.0 100.0

Exercise Use

Cumulative Frequency Percent Valid Percent Percent Valid No 18 64.3 64.3 64.3 Ye s 10 35.7 35.7 100.0 To tal 28 100.0 100.0

OUTPATIENT ED – NO ANXIETY GROUP

Statistics

No of No of Episodes Episodes ED Length ED Onset Binging vomiting Ex ercise Per (Months) BMI Age (Years ) per Month per month Day (Minutes) N Valid 22 22 22 22 22 22 Missing 0 0 0 0 0 0 Mean 77.50 20.4268 16.95 21.86 30.59 22.50 Std. Deviation 56.390 3.71528 4.806 24.328 62.525 29.911 Minimum 6 15.44 9 0 0 0 Maximum 192 28.67 34 84 280 90

Laxative Use

Cumulative Frequency Percent Valid Percent Percent Valid No 22 100.0 100.0 100.0

340 Ea ting Disorder Dia gnos is

Cumulative Frequency Percent Valid Percent Percent Valid AN R 1 4.5 4.5 4.5 AN BP 1 4.5 4.5 9.1 BN 6 27.3 27.3 36.4 ED NOS 14 63.6 63.6 100.0 To tal 22 100.0 100.0

ENTIRE ED SAMPLE (INPATIENT AND OUTPATIENT)

Marital Status

Cumulative Frequency Percent Valid Percent Percent Valid Married 12 12.0 12.0 12.0 Single 66 66.0 66.0 78.0 cohabiting 7 7.0 7.0 85.0 Separated 2 2.0 2.0 87.0 Di vorce d 3 3.0 3.0 90.0 Partner (non cohabiting) 10 10.0 10.0 100.0 To tal 100 100.0 100.0

Employme nt Status

Cumulative Frequency Percent Valid Perc ent Percent Valid employ ed 41 41.0 41.0 41.0 unemployed 26 26.0 26.0 67.0 F/T Student 33 33.0 33.0 100.0 To tal 100 100.0 100.0

Antidepressant Medication

Cumulative Frequency Percent Valid Percent Percent Valid Antidepres sant 57 57.0 57.0 57.0 Medication No Antidepress ant 43 43.0 43.0 100.0 Medication To tal 100 100.0 100.0

341

Ea ting Disorder Dia gnos is

Cumulative Frequency Percent Valid Percent Percent Valid AN R 24 24.0 24.0 24.0 AN BP 15 15.0 15.0 39.0 BN 21 21.0 21.0 60.0 ED NOS 40 40.0 40.0 100.0 To tal 100 100.0 100.0

De pre ssion Le vels

Cumulative Frequency Percent Valid Perc ent Percent Valid Normal 16 16.0 17.2 17.2 Mild 8 8.0 8.6 25.8 Moderate 22 22.0 23.7 49.5 S e vere 14 14.0 15.1 64.5 Ex Severe 33 33.0 35.5 100.0 To tal 93 93.0 100.0 Missing Sy stem 7 7.0 To tal 100 100.0

Binging

Cumulative Frequency Percent Valid Percent Percent Valid No 54 54.0 54.0 54.0 Ye s 46 46.0 46.0 100.0 To tal 100 100.0 100.0

Vomiting

Cumulative Frequency Percent Valid Percent Percent Valid No 49 49.0 49.0 49.0 Ye s 51 51.0 51.0 100.0 To tal 100 100.0 100.0

342 Laxative Use

Cumulative Frequency Percent Valid Percent Percent Valid No 86 86.0 86.0 86.0 Ye s 14 14.0 14.0 100.0 To tal 100 100.0 100.0

Exercise Use

Cumulative Frequency Percent Valid Percent Percent Valid No 59 59.0 59.0 59.0 Ye s 41 41.0 41.0 100.0 To tal 100 100.0 100.0

Statistics

Children Education ED Length Anxiety Length Ag e (number) (Years) (Months) BMI (Months) N Valid 100 100 100 99 100 100 Missing 0 0 0 1 0 0 Me an 25.21 .32 13.90 93.74 18.8447 94.37 Std. Deviati on 7.354 .920 2.052 77.415 3.56050 98.584 Range 38 4 10 333 16.40 480 Minimum 18 0 10 3 12.55 0 Maximum 56 4 20 336 28.95 480

Childre n (number)

Cumulative Frequency Percent Valid Percent Percent Valid 0 86 86.0 86.0 86.0 1 6 6.0 6.0 92.0 2 1 1.0 1.0 93.0 3 4 4.0 4.0 97.0 4 3 3.0 3.0 100.0 To tal 100 100.0 100.0

343 Statistics

Secondary Time Between Anxiety Length ED On set Anxiety Ons et An xiety Dx a nd (Months) Ag e (Ye ars ) Ag e (Ye ars ) ED (Months ) N Valid 100 99 65 45 Missing 0 1 35 55 Me an 48.12 17.36 13.92 89.09 Std. Deviati on 95.750 5.572 8.369 55.948 Range 480 34 38 252 Mi ni m u m 0 9 5 12 Maximum 480 43 43 264

Statistics

No of No of No of Days Episodes No of Days Episodes Binging Binging Vomiting vomiting Ex ercise Per Ex ercise Days per Month per Month per Month per month Day (Minutes) Per Month N Valid 100 100 100 100 100 100 Missing 0 0 0 0 0 0 Mean 7.66 14.25 9.55 29.45 39.95 10.04 Std. Deviation 10.815 25.498 11.930 61.285 67.564 12.915 Minimum 0 0 0 0 0 0 Maximum 28 140 28 280 400 30

DEPRESSION LEVELS COMORBID ED & AD vs ED ONLY

Anxiety Dx No Yes Depres sion Depres sion Levels Levels Count Count Normal 9 7 Mild 2 6 Moderate 11 11 S e vere 3 11 Ex Severe 9 24

344 TRAUMA ACROSS ED SUBTYPES

Eating Disorder Diagnos is AN BN EDNOS Tra uma Tra uma Tra uma Count Count Count No Trauma Reported 27 16 25 Trauma Reported 12 5 15

OCPD ACROSS ED SUBTYPES

Eating Disorder Diagnos is AN BN ED NOS Possible Possible Possible OC PD OC PD OC PD Diagnosis Diagnosis Diagnosis Count Count Count No 36 21 37 Ye s 3 3

345

ENTIRE ED SAMPLE – COMORBID AD & ED GROUP

Statistics

No of No of Eating Episodes Episodes Dis order ED Length ED Onset Binging vomiting Ex ercise Per Diagnosis (Months) BMI Age (Years ) per Month per month Laxative Us e Day (Minutes) N Valid 65 65 65 65 65 65 65 65 Missing 0 0 0 0 0 0 0 0 Mean 2.69 102.63 18.7929 17.38 12.37 29.52 .22 48.77 Std. Deviation 1.198 81.967 3.35291 5.779 26.735 64.265 .414 78.790 Minimum 1 6 12.55 10 0 0 0 0 Maximum 4 336 28.95 43 140 280 1 400

Ea ting Disorder Dia gnos is

Cumulative Frequency Percent Valid Percent Percent Valid AN R 16 24.6 24.6 24.6 AN BP 11 16.9 16.9 41.5 BN 15 23.1 23.1 64.6 ED NOS 23 35.4 35.4 100.0 To tal 65 100.0 100.0

Laxative Use

Cumulative Frequency Percent Valid Percent Percent Valid No 51 78.5 78.5 78.5 Ye s 14 21.5 21.5 100.0 To tal 65 100.0 100.0

346

ENTIRE ED SAMPLE – NO ANXIETY GROUP

Statistics

No of No of Eating Episodes Episodes Dis order ED Length ED Onset Binging vomiting Ex ercise Per Diagnosis (Months) BMI Age (Years ) per Month per month Day (Minutes) Laxative Us e N Valid 35 34 35 34 35 35 35 35 Missing 0 1 0 1 0 0 0 0 Mean 2.91 76.74 18.9409 17.32 17.74 29.31 23.57 .00 Std. Deviation 1.245 65.683 3.96698 5.238 22.986 56.231 34.376 .000 Minimum 1 3 14.02 9 0 0 0 0 Maximum 4 240 28.67 36 84 280 120 0

Ea ting Disorder Dia gnos is

Cumulative Frequency Percent Valid Percent Percent Valid AN R 8 22.9 22.9 22.9 AN BP 4 11.4 11.4 34.3 BN 6 17.1 17.1 51.4 ED NOS 17 48.6 48.6 100.0 To tal 35 100.0 100.0

Laxative Use

Cumulative Frequency Percent Valid Percent Percent Valid No 35 100.0 100.0 100.0

347 ENTIRE ED SAMPLE ACROSS ED SUBTYPES

Re port

Eating Disorder Education ED Length ED Onset Diagnosis Age (Years ) (Months) BMI Age (Years ) AN Mean 26.28 14.13 89.10 15.5841 18.82 N 39 39 39 39 39 Std. Deviation 9.055 2.028 80.948 1.05975 6.893 BN Mean 23.67 13.90 87.33 21.4276 16.38 N 21 21 21 21 21 Std. Deviation 4.351 1.841 54.777 2.78233 2.924 EDNOS Mean 24.98 13.68 101.82 20.6678 16.44 N 40 40 39 40 39 Std. Deviation 6.723 2.200 84.926 3.07958 4.946 To tal Mean 25.21 13.90 93.74 18.8447 17.36 N 100 100 99 100 99 Std. Deviation 7.354 2.052 77.415 3.56050 5.572

Marital Status

Childre n (number)

Cumulative Frequency Percent Valid Percent Percent Valid 0 86 86.0 86.0 86.0 1 6 6.0 6.0 92.0 2 1 1.0 1.0 93.0 3 4 4.0 4.0 97.0 4 3 3.0 3.0 100.0 To tal 100 100.0 100.0

348 Employme nt Status

Cumulative Frequency Percent Valid Perc ent Percent Valid employ ed 41 41.0 41.0 41.0 unemployed 26 26.0 26.0 67.0 F/T Student 33 33.0 33.0 100.0 To tal 100 100.0 100.0

De pre ssion Le vels

Binging

Cumulative Frequency Percent Valid Percent Percent Valid No 54 54.0 54.0 54.0 Ye s 46 46.0 46.0 100.0 To tal 100 100.0 100.0

Vomiting

Cumulative Frequency Percent Valid Percent Percent Valid No 49 49.0 49.0 49.0 Ye s 51 51.0 51.0 100.0 To tal 100 100.0 100.0

349 Laxative Use

Cumulative Frequency Percent Valid Percent Percent Valid No 86 86.0 86.0 86.0 Ye s 14 14.0 14.0 100.0 To tal 100 100.0 100.0

Exercise Use

Cumulative Frequency Percent Valid Percent Percent Valid No 59 59.0 59.0 59.0 Ye s 41 41.0 41.0 100.0 To tal 100 100.0 100.0

Marital Status

Cumulative Frequency Percent Valid Percent Percent Valid Married 4 10.3 10.3 10.3 Single 25 64.1 64.1 74.4 cohabiting 4 10.3 10.3 84.6 Separated 2 5.1 5.1 89.7 Di vorce d 2 5.1 5.1 94.9 Partner (non cohabiting) 2 5.1 5.1 100.0 To tal 39 100.0 100.0

Childre n (number)

Cumulative Frequency Percent Valid Percent Percent Valid 0 33 84.6 84.6 84.6 1 3 7.7 7.7 92.3 2 1 2.6 2.6 94.9 3 1 2.6 2.6 97.4 4 1 2.6 2.6 100.0 To tal 39 100.0 100.0

350 Employme nt Status

Cumulative Frequency Percent Valid Perc ent Percent Valid employ ed 17 43.6 43.6 43.6 unemployed 13 33.3 33.3 76.9 F/T Student 9 23.1 23.1 100.0 To tal 39 100.0 100.0

De pre ssion Le vels

Cumulative Frequency Percent Valid Perc ent Percent Valid Normal 5 12.8 14.3 14.3 Mild 3 7.7 8.6 22.9 Moderate 8 20.5 22.9 45.7 S e vere 5 12.8 14.3 60.0 Ex Severe 14 35.9 40.0 100.0 To tal 35 89.7 100.0 Missing Sy stem 4 10.3 To tal 39 100.0

Binging

Cumulative Frequency Percent Valid Percent Percent Valid No 31 79.5 79.5 79.5 Ye s 8 20.5 20.5 100.0 To tal 39 100.0 100.0

Vomiting

Cumulative Frequency Percent Valid Percent Percent Valid No 24 61.5 61.5 61.5 Ye s 15 38.5 38.5 100.0 To tal 39 100.0 100.0

Laxative Use

Cumulative Frequency Percent Valid Percent Percent Valid No 33 84.6 84.6 84.6 Ye s 6 15.4 15.4 100.0 To tal 39 100.0 100.0

351

Exercise Use

Cumulative Frequency Percent Valid Percent Percent Valid No 24 61.5 61.5 61.5 Ye s 15 38.5 38.5 100.0 To tal 39 100.0 100.0

Marital Status

Cumulative Frequency Percent Valid Percent Percent Valid Married 2 9.5 9.5 9.5 Single 15 71.4 71.4 81.0 Di vorce d 1 4.8 4.8 85.7 Partner (non cohabiting) 3 14.3 14.3 100.0 To tal 21 100.0 100.0

Childre n (number)

Cumulative Frequency Percent Valid Percent Percent Valid 0 21 100.0 100.0 100.0

Employme nt Status

Cumulative Frequency Percent Valid Perc ent Percent Valid employ ed 10 47.6 47.6 47.6 unemployed 4 19.0 19.0 66.7 F/T Student 7 33.3 33.3 100.0 To tal 21 100.0 100.0

352 Depression Levels

Cumulative Frequency Percent Valid Percent Percent Valid Normal 3 14.3 14.3 14.3 Mi l d 1 4.8 4.8 19.0 Moderate 6 28.6 28.6 47.6 Se vere 4 19.0 19.0 66.7 Ex Severe 7 33.3 33.3 100.0 To tal 21 100.0 100.0

Binging

Cumulative Frequency Percent Valid Percent Percent Valid Ye s 21 100.0 100.0 100.0

Vomiting

Cumulative Frequency Percent Valid Percent Percent Valid No 3 14.3 14.3 14.3 Ye s 18 85.7 85.7 100.0 To tal 21 100.0 100.0

Laxative Use

Cumulative Frequency Percent Valid Percent Percent Valid No 18 85.7 85.7 85.7 Ye s 3 14.3 14.3 100.0 To tal 21 100.0 100.0

Exercise Use

Cumulative Frequency Percent Valid Percent Percent Valid No 16 76.2 76.2 76.2 Ye s 5 23.8 23.8 100.0 To tal 21 100.0 100.0

353

EDNOS

Marital Status

Cumulative Frequency Percent Valid Percent Percent Valid Married 6 15.0 15.0 15.0 Single 26 65.0 65.0 80.0 cohabiting 3 7.5 7.5 87.5 Partner (non cohabiting) 5 12.5 12.5 100.0 To tal 40 100.0 100.0

Childre n (number)

Cumulative Frequency Percent Valid Percent Percent Valid 0 32 80.0 80.0 80.0 1 3 7.5 7.5 87.5 3 3 7.5 7.5 95.0 4 2 5.0 5.0 100.0 To tal 40 100.0 100.0

Employme nt Status

Cumulative Frequency Percent Valid Perc ent Percent Valid employ ed 14 35.0 35.0 35.0 unemployed 9 22.5 22.5 57.5 F/T Student 17 42.5 42.5 100.0 To tal 40 100.0 100.0

De pre ssion Le vels

Cumulative Frequency Percent Valid Perc ent Percent Valid Normal 8 20.0 21.6 21.6 Mild 4 10.0 10.8 32.4 Moderate 8 20.0 21.6 54.1 S e vere 5 12.5 13.5 67.6 Ex Severe 12 30.0 32.4 100.0 To tal 37 92.5 100.0 Missing Sy stem 3 7.5 To tal 40 100.0

354

Binging

Cumulative Frequency Percent Valid Percent Percent Valid No 23 57.5 57.5 57.5 Ye s 17 42.5 42.5 100.0 To tal 40 100.0 100.0

Vomiting

Cumulative Frequency Percent Valid Percent Percent Valid No 22 55.0 55.0 55.0 Ye s 18 45.0 45.0 100.0 To tal 40 100.0 100.0

Laxative Use

Cumulative Frequency Percent Valid Percent Percent Valid No 35 87.5 87.5 87.5 Ye s 5 12.5 12.5 100.0 To tal 40 100.0 100.0

Exercise Use

Cumulative Frequency Percent Valid Percent Percent Valid No 19 47.5 47.5 47.5 Ye s 21 52.5 52.5 100.0 To tal 40 100.0 100.0

355

ENTIRE ED SAMPLE PURGATIVE ABUSE

Anxiety Disorder Diagnos is Panic with Ag Panic w/o Ag Social Phobia GAD OC D Specific Phobia PTSD Laxative Laxative Laxative Laxative Laxative Laxative Laxative Vomiting Us e Vomiting Us e Vomiting Us e Vomiting Us e Vomiting Us e Vomiting Us e Vomiting Us e Count Count Count Count Count Count Count Count Count Count Count Count Count Count No 1 1 1 12 21 8 12 2 3 1 1 6 12 Ye s 1 15 6 7 3 1 11 5

ENTIRE ED SAMPLE TABLES OF MEANS

Re port

Eating Disorder ED Length Anxiety Length ED On set Anxiety Ons et Diagnosis (Months) (Months) BMI Ag e (Ye ars ) Ag e (Ye ars ) AN R Me an 90.04 83.50 15.3083 19.42 16.94 N 24 24 24 24 16 Std. Deviati on 87.392 92.984 1.19604 7.306 12.546 AN BP Me an 87.60 108.00 16.0253 17.87 14.45 N 15 15 15 15 11 Std. Deviati on 72.349 100.502 .59936 6.300 7.891 BN Me an 87.33 102.29 21.4276 16.38 12.00 N 21 21 21 21 15 Std. Deviati on 54.777 84.736 2.78233 2.924 4.209 ED NOS Me an 101.82 91.63 20.6678 16.44 12.83 N 39 40 40 39 23 Std. Deviati on 84.926 109.901 3.07958 4.946 6.807 To tal Me an 93.74 94.37 18.8447 17.36 13.92 N 99 100 100 99 65 Std. Deviati on 77.415 98.584 3.56050 5.572 8.369

356 Re port

No of No of No of Days Episodes No of Days Episodes Eating Disorder Binging Binging Vomiting vomiting Exercis e Per Exercis e Days Diagnosis per Month per Month per Month per month Day (Minutes) Per Month AN R Me an .00 .00 .08 .08 43.75 9.33 N 24 24 24 24 24 24 Std. Deviati on .000 .000 .408 .408 84.843 13.483 AN BP Me an 7.73 24.00 15.67 63.73 59.33 11.47 N 15 15 15 15 15 15 Std. Deviati on 10.977 35.189 10.588 82.948 104.092 13.341 BN Me an 22.52 38.76 21.71 64.33 22.86 4.86 N 21 21 21 21 21 21 Std. Deviati on 7.954 32.221 10.330 78.026 45.403 9.891 ED NOS Me an 4.43 6.28 6.55 15.90 39.38 12.65 N 40 40 40 40 40 40 Std. Deviati on 7.442 11.099 10.382 45.996 45.660 13.400 To tal Me an 7.66 14.25 9.55 29.45 39.95 10.04 N 100 100 100 100 100 100 Std. Deviati on 10.815 25.498 11.930 61.285 67.564 12.915

Re port

No of No of No of Days Episodes No of Days Episodes Eating Disorder Binging Binging Vomiting vomiting Exercis e Per Exercis e Days Diagnosis per Month per Month per Month per month Day (Minutes) Per Month AN Me an 2.97 9.23 6.08 24.56 49.74 10.15 N 39 39 39 39 39 39 Std. Deviati on 7.676 24.416 10.019 59.322 91.694 13.293 BN Me an 22.52 38.76 21.71 64.33 22.86 4.86 N 21 21 21 21 21 21 Std. Deviati on 7.954 32.221 10.330 78.026 45.403 9.891 ED NOS Me an 4.43 6.28 6.55 15.90 39.38 12.65 N 40 40 40 40 40 40 Std. Deviati on 7.442 11.099 10.382 45.996 45.660 13.400 To tal Me an 7.66 14.25 9.55 29.45 39.95 10.04 N 100 100 100 100 100 100 Std. Deviati on 10.815 25.498 11.930 61.285 67.564 12.915

357 OUTPATIENT ANXIETY - WHOLE SAMPLE

Statistics

Children Education Ag e (number) (Years) N Valid 52 52 44 Missing 0 0 8 Me an 34.67 .96 13.45 Std. Deviati on 12.309 1.400 2.444 Range 52 6 14 Minimum 18 0 7 Maximum 70 6 21

Statistics

Anxiety Secondary Employment Antidepres sa Dis order Depres sion Anxiety Marital Status Status nt Medication Diagnosis Levels Diagnosis Tra uma N Valid 52 52 52 52 52 52 52 Missing 0 0 0 0 0 0 0 Mean 2.62 1.62 1.69 3.79 2.71 .94 .12 Range 6 4 1 7 4 7 1 Minimum 1 0 1 1 1 0 0 Maximum 7 4 2 8 5 7 1

Childre n (number)

Cumulative Frequency Percent Valid Percent Percent Valid 0 30 57.7 57.7 57.7 1 6 11.5 11.5 69.2 2 9 17.3 17.3 86.5 3 5 9.6 9.6 96.2 5 1 1.9 1.9 98.1 6 1 1.9 1.9 100.0 To tal 52 100.0 100.0

358 Ma rita l Status

Cumulative Frequency Percent Valid Perc ent Percent Valid Married 11 21.2 21.2 21.2 Single 26 50.0 50.0 71.2 cohabiting 6 11.5 11.5 82.7 Separated 1 1.9 1.9 84.6 Di vorc e d 2 3.8 3.8 88.5 W idowed 1 1.9 1.9 90.4 Partner (non cohabiting) 5 9.6 9.6 100.0 To tal 52 100.0 100.0

Employment Status

Cumulative Frequency Percent Valid Percent Percent Valid 0 2 3.8 3.8 3.8 employed 25 48.1 48.1 51.9 unemployed 17 32.7 32.7 84.6 F/T Student 7 13.5 13.5 98.1 Retired 1 1.9 1.9 100.0 To tal 52 100.0 100.0

Antidepressant Medication

Cumulative Frequency Percent Valid Percent Percent Valid Antidepres sant 16 30.8 30.8 30.8 Medication No Antidepress ant 36 69.2 69.2 100.0 Medication To tal 52 100.0 100.0

Depression Levels

Cumulative Frequency Percent Valid Percent Percent Valid Normal 21 40.4 40.4 40.4 Mi l d 4 7.7 7.7 48.1 Moderate 9 17.3 17.3 65.4 Se vere 5 9.6 9.6 75.0 Ex Severe 13 25.0 25.0 100.0 To tal 52 100.0 100.0

359 Anxiety Disorder Diagnosis

Cumulative Frequency Percent Valid Perc ent Percent Valid Panic with Ag 9 17.3 17.3 17.3 Social Phobia 15 28.8 28.8 46.2 GAD 9 17.3 17.3 63.5 OCD 12 23.1 23.1 86.5 Specific Phobia 3 5.8 5.8 92.3 PTSD 3 5.8 5.8 98.1 ASD 1 1.9 1.9 100.0 To tal 52 100.0 100.0

Secondary Anxiety Diagnosis

Cumulative Frequency Percent Valid Percent Percent Valid None 39 75.0 75.0 75.0 Panic with AG 1 1.9 1.9 76.9 Panic w/o Ag 2 3.8 3.8 80.8 Social Phobia 5 9.6 9.6 90.4 GAD 1 1.9 1.9 92.3 OC D 1 1.9 1.9 94.2 Specific Phobia 1 1.9 1.9 96.2 PTSD 2 3.8 3.8 100.0 To tal 52 100.0 100.0

Tr auma

Cumulative Frequency Percent Valid Percent Percent Valid No Trauma Reported 46 88.5 88.5 88.5 Trauma Reported 6 11.5 11.5 100.0 To tal 52 100.0 100.0

360 OUTPATIENT ANXIETY - ED ONLY GROUP

Statistics

Children Education ED Length Anxiety Length Ag e (number) (Years) BMI (Months) (Months) N Valid 7 7 7 7 7 7 Missing 0 0 0 0 0 0 Me an 31.29 .86 13.00 27.6686 147.43 197.14 Std. Deviati on 12.829 1.215 1.155 12.44426 105.916 161.125 Minimum 19 0 11 17.60 72 24 Maximum 47 3 15 51.15 348 504

Statistics

Secondary Time Between Anxiety Length ED Onset Anxiety Onset Anxiety Dx and (Months) Age (Years ) Age (Years ) ED (Months) N Valid 7 7 7 5 Missing 0 0 0 2 Mean 25.71 19.00 14.86 96.00 Std. Deviation 68.034 9.933 9.227 49.477 Minimum 0 9 5 36 Maximum 180 40 32 156

Statistics

No of No of No of Days Episodes No of Days Episodes Binging Binging Vomiting vomiting Ex ercise Per Ex ercise Days per Month per Month per Month per month Day (Minutes) Per Month N Valid 7 7 7 7 7 7 Missing 0 0 0 0 0 0 Mean 8.86 9.29 .14 .57 22.86 9.71 Std. Deviation 13.120 12.867 .378 1.512 29.277 13.238 Minimum 0 0 0 0 0 0 Maximum 28 28 1 4 60 28

361

Age

Cumulative Frequency Percent Valid Percent Percent Valid 19 1 14.3 14.3 14.3 20 1 14.3 14.3 28.6 22 1 14.3 14.3 42.9 24 1 14.3 14.3 57.1 40 1 14.3 14.3 71.4 47 2 28.6 28.6 100.0 To tal 7 100.0 100.0

Childre n (number)

Cumulative Frequency Percent Valid Percent Percent Valid 0 4 57.1 57.1 57.1 1 1 14.3 14.3 71.4 2 1 14.3 14.3 85.7 3 1 14.3 14.3 100.0 To tal 7 100.0 100.0

Ma rita l Status

Cumulative Frequency Percent Valid Perc ent Percent Valid Married 2 28.6 28.6 28.6 Single 4 57.1 57.1 85.7 Partner (non cohabiting) 1 14.3 14.3 100.0 To tal 7 100.0 100.0

Employme nt Status

Cumulative Frequency Percent Valid Perc ent Percent Valid employ ed 4 57.1 57.1 57.1 unemployed 1 14.3 14.3 71.4 F/T Student 2 28.6 28.6 100.0 To tal 7 100.0 100.0

362 Depression Levels

Cumulative Frequency Percent Valid Percent Percent Valid Normal 2 28.6 28.6 28.6 Moderate 2 28.6 28.6 57.1 Se vere 1 14.3 14.3 71.4 Ex Severe 2 28.6 28.6 100.0 To tal 7 100.0 100.0

Antidepressant Medication

Cumulative Frequency Percent Valid Percent Percent Valid Antidepres sant 2 28.6 28.6 28.6 Medication No Antidepress ant 5 71.4 71.4 100.0 Medication To tal 7 100.0 100.0

OUTPATIENT ANXIETY - ED ONLY GROUP Ea ting Disorder Dia gnos is

Cumulative Frequency Percent Valid Percent Percent Valid ED NOS 7 100.0 100.0 100.0

Anxiety Dis orde r Diagnosis

Cumulative Frequency Percent Valid Percent Percent Valid Social Phobia 1 14.3 14.3 14.3 GAD 1 14.3 14.3 28.6 OC D 3 42.9 42.9 71.4 Specific Phobia 1 14.3 14.3 85.7 PTSD 1 14.3 14.3 100.0 To tal 7 100.0 100.0

363 Te mporal Relations hip betw een ED a nd Anxie ty

Cumulative Frequency Percent Valid Percent Percent Valid Anxiety before ED 5 71.4 71.4 71.4 Anxiety after ED 2 28.6 28.6 100.0 To tal 7 100.0 100.0

Secondary Anxiety Diagnosis

Cumulative Frequency Percent Valid Percent Percent Valid None 6 85.7 85.7 85.7 Social Phobia 1 14.3 14.3 100.0 To tal 7 100.0 100.0

Se condary Anx iety Length (Months)

Cumulative Frequency Percent Valid Percent Percent Valid 0 6 85.7 85.7 85.7 180 1 14.3 14.3 100.0 To tal 7 100.0 100.0

Temporal Relationship secondary anxiety and ED

Cumulative Frequency Percent Valid Percent Percent Valid N/A 6 85.7 85.7 85.7 Anxiety before ED 1 14.3 14.3 100.0 To tal 7 100.0 100.0

Subclinical AD

Cumulative Frequency Percent Valid Percent Percent Valid None 7 100.0 100.0 100.0

364 Binging

Cumulative Frequency Percent Valid Percent Percent Valid No 2 28.6 28.6 28.6 Ye s 5 71.4 71.4 100.0 To tal 7 100.0 100.0

Vomiting

Cumulative Frequency Percent Valid Percent Percent Valid No 6 85.7 85.7 85.7 Ye s 1 14.3 14.3 100.0 To tal 7 100.0 100.0

Laxative Use

Cumulative Frequency Percent Valid Percent Percent Valid No 7 100.0 100.0 100.0

Exercise Use

Cumulative Frequency Percent Valid Percent Percent Valid No 4 57.1 57.1 57.1 Ye s 3 42.9 42.9 100.0 To tal 7 100.0 100.0

Tr auma

Cumulative Frequency Percent Valid Percent Percent Valid No Trauma Reported 4 57.1 57.1 57.1 Trauma Reported 3 42.9 42.9 100.0 To tal 7 100.0 100.0

Possible OCPD Diagnosis

Cumulative Frequency Percent Valid Percent Percent Valid No 7 100.0 100.0 100.0

365

ENTIRE SAMPLE TABLES OF MEANS

Re port

Children Education Facility Age (number) (Years ) ED Inpatient Mean 25.38 .26 14.20 N 50 50 50 Std. Deviation 8.263 .922 2.030 ED Outpatient Mean 25.04 .38 13.60 N 50 50 50 Std. Deviation 6.398 .923 2.050 Anxiety Patient Mean 34.67 .96 13.45 N 52 52 44 Std. Deviation 12.309 1.400 2.444 To tal Mean 28.45 .54 13.76 N 152 152 144 Std. Deviation 10.340 1.144 2.181

Re port

ED Length Anxiety Length ED Onset Anxiety Onset Facility (Months) (Months) BMI Age (Years ) Age (Years ) ED Inpatient Mean 88.29 93.70 17.2698 17.96 15.19 N 49 50 50 49 37 Std. Deviation 78.481 88.939 3.23910 6.324 9.015 ED Outpatient Mean 99.08 95.04 20.4196 16.78 12.25 N 50 50 50 50 28 Std. Deviation 76.771 108.281 3.17167 4.713 7.250 Anxiety Patient Mean 19.85 27.96 6.3562 19.00 14.86 N 52 52 52 7 7 Std. Deviation 62.462 87.550 12.70985 9.933 9.227 To tal Mean 68.29 71.65 14.5723 17.47 14.01 N 151 152 152 106 72 Std. Deviation 80.517 99.799 9.90993 5.898 8.391

366 Re port

No of No of No of Days Episodes No of Days Episodes Binging Binging Vomiting vomiting Exercis e Per Exercis e Days Facility per Month per Month per Month per month Day (Minutes) Per Month ED Inpatient Me an 5.38 13.42 9.22 36.30 52.00 11.00 N 50 50 50 50 50 50 Std. Deviati on 9.659 28.912 11.710 73.544 84.201 13.482 ED Outpatient Me an 9.94 15.08 9.88 22.60 27.90 9.08 N 50 50 50 50 50 50 Std. Deviati on 11.506 21.824 12.257 45.648 42.858 12.383 Anxiety Patient Me an 1.19 1.25 .02 .08 3.08 1.31 N 52 52 52 52 52 52 Std. Deviati on 5.438 5.452 .139 .555 12.763 5.641 To tal Me an 5.45 9.80 6.29 19.40 27.34 7.05 N 152 152 152 152 152 152 Std. Deviati on 9.805 21.785 10.673 51.556 57.930 11.721

367 2. THE PREVALENCE OF ANXIETY DISORDERS 2.1 DESCRIPTIVE STATISTICS

INPATIENT ED WHOLE SAMPLE

Primary Anxiety Disorder Diagnosis Cumulative Frequency Percent Valid Percent Percent Valid None 13 26.0 26.0 26.0 Panic with Ag 1 2.0 2.0 28.0 Panic w/o Ag 1 2.0 2.0 30.0 Social Phobia 14 28.0 28.0 58.0 GAD 8 16.0 16.0 74.0 OCD 2 4.0 4.0 78.0 Specific Phobia 1 2.0 2.0 80.0 PTSD 10 20.0 20.0 100.0 Total 50 100.0 100.0

Secondary Anxiety Diagnosis

Cumulative Frequency Percent Valid Percent Percent Valid None 45 90.0 90.0 90.0 Social Phobia 1 2.0 2.0 92.0 GAD 2 4.0 4.0 96.0 OC D 1 2.0 2.0 98.0 Specific Phobia 1 2.0 2.0 100.0 To tal 50 100.0 100.0

Secondary Anxiety Diagnosis

Cumulative Frequency Percent Valid Percent Percent Valid None 29 58.0 58.0 58.0 Panic with AG 1 2.0 2.0 60.0 Social Phobia 10 20.0 20.0 80.0 GAD 7 14.0 14.0 94.0 OC D 2 4.0 4.0 98.0 PTSD 1 2.0 2.0 100.0 To tal 50 100.0 100.0

368 Subclinical AD

Cumulative Frequency Percent Valid Percent Percent Valid None 44 88.0 88.0 88.0 GAD 1 2.0 2.0 90.0 OC D 3 6.0 6.0 96.0 Specific Phobia 2 4.0 4.0 100.0 To tal 50 100.0 100.0

Tr auma

Cumulative Frequency Percent Valid Percent Percent Valid No Trauma Reported 34 68.0 68.0 68.0 Trauma Reported 16 32.0 32.0 100.0 To tal 50 100.0 100.0

Possible OCPD Diagnosis

Cumulative Frequency Percent Valid Percent Percent Valid No 47 94.0 94.0 94.0 Ye s 3 6.0 6.0 100.0 To tal 50 100.0 100.0

369

INPATIENT ED COMORBID AD & ED ONLY

Secondary Anxiety Diagnosis

Cumulative Frequency Percent Valid Percent Percent Valid None 16 43.2 43.2 43.2 Panic with AG 1 2.7 2.7 45.9 Social Phobia 10 27.0 27.0 73.0 GAD 7 18.9 18.9 91.9 OC D 2 5.4 5.4 97.3 PTSD 1 2.7 2.7 100.0 To tal 37 100.0 100.0

Anxiety Disorder Diagnosis

Cumulative Frequency Percent Valid Perc ent Percent Valid Panic with Ag 1 2.7 2.7 2.7 Panic w/o Ag 1 2.7 2.7 5.4 Social Phobia 14 37.8 37.8 43.2 GAD 8 21.6 21.6 64.9 OCD 2 5.4 5.4 70.3 Specific Phobia 1 2.7 2.7 73.0 PTSD 10 27.0 27.0 100.0 To tal 37 100.0 100.0

Secondary Anxiety Diagnosis

Cumulative Frequency Percent Valid Percent Percent Valid None 32 86.5 86.5 86.5 Social Phobia 1 2.7 2.7 89.2 GAD 2 5.4 5.4 94.6 OC D 1 2.7 2.7 97.3 Specific Phobia 1 2.7 2.7 100.0 To tal 37 100.0 100.0

370 Subclinical AD

Cumulative Frequency Percent Valid Perc ent Percent Valid None 32 86.5 86.5 86.5 OCD 3 8.1 8.1 94.6 Specific Phobia 2 5.4 5.4 100.0 To tal 37 100.0 100.0

Tr auma

Cumulative Frequency Percent Valid Percent Percent Valid No Trauma Reported 22 59.5 59.5 59.5 Trauma Reported 15 40.5 40.5 100.0 To tal 37 100.0 100.0

Possible OCPD Diagnosis

Cumulative Frequency Percent Valid Percent Percent Valid No 36 97.3 97.3 97.3 Ye s 1 2.7 2.7 100.0 To tal 37 100.0 100.0

371

OUTPATIENT ED – COMORBID AD & ED

Anxiety Dis orde r Dia gnosis

Cumulative Frequency Percent Valid Percent Percent Valid Social Phobia 13 46.4 46.4 46.4 GAD 7 25.0 25.0 71.4 OC D 1 3.6 3.6 75.0 PTSD 7 25.0 25.0 100.0 To tal 28 100.0 100.0

Secondary Anxiety Diagnosis

Cumulative Frequency Percent Valid Percent Percent Valid None 15 53.6 53.6 53.6 Panic w/o Ag 1 3.6 3.6 57.1 Social Phobia 8 28.6 28.6 85.7 GAD 3 10.7 10.7 96.4 OC D 1 3.6 3.6 100.0 To tal 28 100.0 100.0

Secondary Anxiety Diagnosis

Cumulative Frequency Percent Valid Percent Percent Valid None 27 96.4 96.4 96.4 Specific Phobia 1 3.6 3.6 100.0 To tal 28 100.0 100.0

Subclinical AD

Cumulative Frequency Percent Valid Percent Percent Valid None 25 89.3 89.3 89.3 Panic with AG 2 7.1 7.1 96.4 Social Phobia 1 3.6 3.6 100.0 To tal 28 100.0 100.0

372

Tr auma

Cumulative Frequency Percent Valid Percent Percent Valid No Trauma Reported 16 57.1 57.1 57.1 Trauma Reported 12 42.9 42.9 100.0 To tal 28 100.0 100.0

Possible OCPD Diagnosis

Cumulative Frequency Percent Valid Percent Percent Valid No 27 96.4 96.4 96.4 Ye s 1 3.6 3.6 100.0 To tal 28 100.0 100.0

Secondary Anxiety Diagnosis

Cumulative Frequency Percent Valid Percent Percent Valid None 28 100.0 100.0 100.0

ENTIRE ED SAMPLE (INPATIENT AND OUTPATIENT)

Anxiety Dis orde r Diagnosis

Cumulative Frequency Percent Valid Percent Percent Valid None 35 35.0 35.0 35.0 Panic with Ag 1 1.0 1.0 36.0 Panic w/o Ag 1 1.0 1.0 37.0 Social Phobia 27 27.0 27.0 64.0 GAD 15 15.0 15.0 79.0 OC D 3 3.0 3.0 82.0 Specific Phobia 1 1.0 1.0 83.0 PTSD 17 17.0 17.0 100.0 To tal 100 100.0 100.0

373

Se condary Anxiety Diagnosis

Cumulative Frequency Percent Valid Percent Percent Valid None 66 66.0 66.0 66.0 Panic with AG 1 1.0 1.0 67.0 Panic w/o Ag 1 1.0 1.0 68.0 Social Phobia 18 18.0 18.0 86.0 GAD 10 10.0 10.0 96.0 OCD 3 3.0 3.0 99.0 PTSD 1 1.0 1.0 100.0 To tal 100 100.0 100.0

Secondary Anxiety Diagnosis

Cumulative Frequency Percent Valid Percent Percent Valid None 94 94.0 94.0 94.0 Social Phobia 1 1.0 1.0 95.0 GAD 2 2.0 2.0 97.0 OC D 1 1.0 1.0 98.0 Specific Phobia 2 2.0 2.0 100.0 To tal 100 100.0 100.0

Subclinical AD

Cumulative Frequency Percent Valid Percent Percent Valid None 85 85.0 85.0 85.0 Panic with AG 2 2.0 2.0 87.0 Social Phobia 2 2.0 2.0 89.0 GAD 4 4.0 4.0 93.0 OC D 5 5.0 5.0 98.0 Specific Phobia 2 2.0 2.0 100.0 To tal 100 100.0 100.0

Tr auma

Cumulative Frequency Percent Valid Percent Percent Valid No Trauma Reported 68 68.0 68.0 68.0 Trauma Reported 32 32.0 32.0 100.0 To tal 100 100.0 100.0

374 Possible OCPD Diagnosis

Cumulative Frequency Percent Valid Percent Percent Valid No 94 94.0 94.0 94.0 Ye s 6 6.0 6.0 100.0 To tal 100 100.0 100.0

OUTPATIENT ANXIETY - ED ONLY GROUP Ea ting Disorder Dia gnos is

Cumulative Frequency Percent Valid Percent Percent Valid ED NOS 7 100.0 100.0 100.0

Anxiety Dis orde r Diagnosis

Te mporal Relations hip betw een ED a nd Anxie ty

Cumulative Frequency Percent Valid Percent Percent Valid Anxiety before ED 5 71.4 71.4 71.4 Anxiety after ED 2 28.6 28.6 100.0 To tal 7 100.0 100.0

375 Secondary Anxiety Diagnosis

Cumulative Frequency Percent Valid Percent Percent Valid None 6 85.7 85.7 85.7 Social Phobia 1 14.3 14.3 100.0 To tal 7 100.0 100.0

Se condary Anx iety Length (Months)

Cumulative Frequency Percent Valid Percent Percent Valid 0 6 85.7 85.7 85.7 180 1 14.3 14.3 100.0 To tal 7 100.0 100.0

Temporal Relationship secondary anxiety and ED

Cumulative Frequency Percent Valid Percent Percent Valid N/A 6 85.7 85.7 85.7 Anxiety before ED 1 14.3 14.3 100.0 To tal 7 100.0 100.0

Subclinical AD

Cumulative Frequency Percent Valid Percent Percent Valid None 7 100.0 100.0 100.0

Binging

Cumulative Frequency Percent Valid Percent Percent Valid No 2 28.6 28.6 28.6 Ye s 5 71.4 71.4 100.0 To tal 7 100.0 100.0

Vomiting

Cumulative Frequency Percent Valid Percent Percent Valid No 6 85.7 85.7 85.7 Ye s 1 14.3 14.3 100.0 To tal 7 100.0 100.0

376

Laxative Use

Cumulative Frequency Percent Valid Percent Percent Valid No 7 100.0 100.0 100.0

Exercise Use

Cumulative Frequency Percent Valid Percent Percent Valid No 4 57.1 57.1 57.1 Ye s 3 42.9 42.9 100.0 To tal 7 100.0 100.0

Tr auma

Cumulative Frequency Percent Valid Percent Percent Valid No Trauma Reported 4 57.1 57.1 57.1 Trauma Reported 3 42.9 42.9 100.0 To tal 7 100.0 100.0

Possible OCPD Diagnosis

Cumulative Frequency Percent Valid Percent Percent Valid No 7 100.0 100.0 100.0

377 3. THE TEMPORAL RELATIONSHIP BETWEEN ED & AD 3.1 DESCRIPTIVE STATISTICS

INPATIENT ED WHOLE SAMPLE

Te mporal Relations hip betw een ED a nd Anxie ty

Cumulative Frequency Percent Valid Percent Percent Valid N/A 13 26.0 26.0 26.0 Anxiety before ED 24 48.0 48.0 74.0 Anxiety and ED 7 14.0 14.0 88.0 same time Anxiety after ED 6 12.0 12.0 100.0 To tal 50 100.0 100.0

Temporal Relationship secondary anxiety and ED

Cumulative Frequency Percent Valid Percent Percent Valid N/A 29 58.0 58.0 58.0 Anxiety before ED 11 22.0 22.0 80.0 Anxiety and ED 6 12.0 12.0 92.0 same time Anxiety after ED 4 8.0 8.0 100.0 To tal 50 100.0 100.0

Te mporal Relationship secondary anxiety and ED

Cumulative Frequency Percent Valid Percent Percent Valid N/ A 45 90.0 90.0 90.0 Anxiety before ED 3 6.0 6.0 96.0 Anxiety after ED 2 4.0 4.0 100.0 To tal 50 100.0 100.0

INPATIENT ED COMORBID AD & ED ONLY

378

Te mporal Relations hip betw een ED a nd Anxie ty

Cumulative Frequency Percent Valid Percent Percent Valid Anxiety before ED 24 64.9 64.9 64.9 Anxiety and ED 7 18.9 18.9 83.8 same time Anxiety after ED 6 16.2 16.2 100.0 To tal 37 100.0 100.0

Temporal Relationship secondary anxiety and ED

Cumulative Frequency Percent Valid Percent Percent Valid N/A 16 43.2 43.2 43.2 Anxiety before ED 11 29.7 29.7 73.0 Anxiety and ED 6 16.2 16.2 89.2 same time Anxiety after ED 4 10.8 10.8 100.0 To tal 37 100.0 100.0

Te mporal Relationship secondary anxiety and ED

Cumulative Frequency Percent Valid Percent Percent Valid N/ A 32 86.5 86.5 86.5 Anxiety before ED 3 8.1 8.1 94.6 Anxiety after ED 2 5.4 5.4 100.0 To tal 37 100.0 100.0

379

INPATIENT ED AGE OF ONSET FOR AD ACROSS WHOLE SAMPLE AND ED SUBTYPES

Ca se Processing Summary

Cases Inc luded Ex cluded To tal N Percent N Percent N Percent Anxiety Onset Age (Years ) * Anxiety 37 100.0% 0 .0% 37 100.0% Dis order Diagnosis

Re port Anxiety Onset Age (Years) Anxiety Dis order Mean N Std. Deviation Minimum Maximum PanicDi with i Ag 35.00 1 . 35 35 Panic w/o Ag 19.00 1 . 19 19 Social Phobia 12.71 14 6.707 5 30 GAD 15.38 8 12.258 5 43 OCD 11.50 2 7.778 6 17 Specific Phobia 5.00 1 . 5 5 PTSD 17.90 10 7.680 10 34 To tal 15.19 37 9.015 5 43

Ca se Processing Summary

Cases Inc luded Ex cluded To tal N Percent N Percent N Percent Anxiety Onset Age (Years ) * Anxiety 23 69.7% 10 30.3% 33 100.0% Dis order Diagnosis

380 Re port Anxiety Onset Age (Years ) Anxiety Disorder Me an N Std. Deviati on Minimum Maximum Panic with Ag 35.00 1 . 35 35 Social Phobia 10.89 9 4.567 5 16 GAD 20.50 4 16.114 5 43 OC D 11.50 2 7.778 6 17 Specific Phobia 5.00 1 . 5 5 PTSD 18.17 6 8.681 10 34 To tal 15.30 23 10.088 5 43

EDNOS

Ca se Processing Summary

Cases Inc luded Ex cluded To tal N Percent N Percent N Percent Anxiety Onset Age (Years ) * Anxiety 8 72.7% 3 27.3% 11 100.0% Dis order Diagnosis

Re port Anxiety Onset Age (Years) Anxiety Dis order Mean N Std. Deviation Minimum Maximum PanicDi w/o i Ag 19.00 1 . 19 19 Social Phobia 20.00 3 9.539 11 30 GAD 5.00 1 . 5 5 PTSD 20.00 3 6.245 15 27 To tal 18.00 8 8.053 5 30

381 BN ONLY

Ca se Processing Summary

Cases Inc luded Ex cluded To tal N Percent N Percent N Percent Anxiety Onset Age (Years ) * Anxiety 6 100.0% 0 .0% 6 100.0% Dis order Diagnosis

Re port Anxiety Onset Age (Years) Anxiety Dis order Mean N Std. Deviation Minimum Maximum SocialDi Phobia i 10.00 2 5.657 6 14 GAD 12.00 3 3.606 8 15 PTSD 10.00 1 . 10 10 To tal 11.00 6 3.578 6 15

382

INPATIENT ED TEMPORAL RELATIONSHIP AD & ED ACROSS THE ED SUBTYPES

Anxiety Disorder Diagnos is Specifi c None Panic with Ag Social Phobia GAD OC D Phobia PTSD Temporal Temporal Temporal Temporal Temporal Temporal Temporal Relationship Relationship Relationship Relationship Relationship Relationship Relationship between ED between ED between ED between ED between ED between ED between ED and Anxiety and Anxiety and Anxiety and Anxiety and Anxiety and Anxiety and Anxiety Count Count Count Count Count Count Count N/A 10 Anxiety before ED 8 2 2 1 5 Anxiety and ED 1 2 same time Anxiety after ED 1 1

Anxiety Dis order Diagnosis Social Phobia GAD PTSD Temporal Temporal Temporal Relationship Relationship Relationship between ED between ED between ED and Anxiety and Anxiety and Anxiety Count Count Count Anxiety before ED 1 2 1 Anxiety and ED 1 1 same time

EDNOS

Anxiety Disorder Diagnosis None Panic w/o Ag Social Phobia GAD PTSD Temporal Temporal Temporal Temporal Temporal Relationship Relationship Relationship Relationship Relationship between ED between ED between ED between ED between ED and Anxiety and Anxiety and Anxiety and Anxiety and Anxiety Count Count Count Count Count N/ A 3 Anxiety before ED 1 1 Anxiety and ED 1 1 same time Anxiety after ED 1 1 2

383

OUTPATIENT ED – COMORBID AD & ED Te mporal Relations hip betw een ED a nd Anxie ty

Cumulative Frequency Percent Valid Percent Percent Valid Anxiety before ED 21 75.0 75.0 75.0 Anxiety and ED 3 10.7 10.7 85.7 same time Anxiety after ED 4 14.3 14.3 100.0 To tal 28 100.0 100.0

Temporal Relationship secondary anxiety and ED

Cumulative Frequency Percent Valid Percent Percent Valid N/A 15 53.6 53.6 53.6 Anxiety before ED 10 35.7 35.7 89.3 Anxiety and ED 1 3.6 3.6 92.9 same time Anxiety after ED 2 7.1 7.1 100.0 To tal 28 100.0 100.0

Temporal Relationship secondary anxiety and ED

Cumulative Frequency Percent Valid Percent Percent Valid N/A 27 96.4 96.4 96.4 Anxiety before ED 1 3.6 3.6 100.0 To tal 28 100.0 100.0

OUTPATIENT ED ONSET AGE FOR EACH AD ACROSS ED SUBTYPES

384 Re port Anxiety Onset Age (Years) Anxiety Dis order Mean N Std. Deviation Minimum Maximum SocialDi Phobia i 6.00 1 . 6 6 GAD 31.50 2 12.021 23 40 PTSD 9.00 1 . 9 9 To tal 19.50 4 15.546 6 40

Ca se Processing Summary

Cases Inc luded Ex cluded To tal N Percent N Percent N Percent Anxiety Onset Age (Years ) * Anxiety 9 60.0% 6 40.0% 15 100.0% Dis order Diagnosis

Re port Anxiety Onset Age (Years) Anxiety Dis order Mean N Std. Deviation Minimum Maximum SocialDi Phobia i 12.60 5 4.393 6 17 GAD 8.50 2 4.950 5 12 PTSD 17.00 2 .000 17 17 To tal 12.67 9 4.664 5 17

EDNOS

Ca se Processing Summary

Cases Inc luded Ex cluded To tal N Percent N Percent N Percent Anxiety Onset Age (Years ) * Anxiety 15 51.7% 14 48.3% 29 100.0% Dis order Diagnosis

385 Re port Anxiety Onset Age (Years) Anxiety Dis order Mean N Std. Deviation Minimum Maximum Social Phobia 11.86 7 5.080 5 18 GAD 7.33 3 2.517 5 10 OCD 6.00 1 . 6 6 PTSD 10.00 4 1.633 8 12 To tal 10.07 15 4.114 5 18

WHOLE SAMPLE

Ca se Processing Summary

Cases Inc luded Ex cluded To tal N Percent N Percent N Percent Anxiety Onset Age (Years ) * Anxiety 28 100.0% 0 .0% 28 100.0% Dis order Diagnosis

Re port Anxiety Onset Age (Years) Anxiety Dis order Mean N Std. Deviation Minimum Maximum Social Phobia 11.69 13 4.733 5 18 GAD 14.57 7 12.817 5 40 OCD 6.00 1 . 6 6 PTSD 11.86 7 3.716 8 17 To tal 12.25 28 7.250 5 40

386 OUTPATIENT ED TEMPORAL RELATIONSHIP FOR AD & ED

Anxiety Disorder Diagnosis None Social Phobia GAD PTSD Temporal Temporal Temporal Temporal Relationship Relationship Relationship Relationship between ED between ED between ED between ED and Anxiety and Anxiety and Anxiety and Anxiety Count Count Count Count N/A 2 Anxiety before ED 1 1 1 Anxiety after ED 1

EDNOS

Anxiety Disorder Diagnosis None Social Phobia GAD OCD PTSD Temporal Temporal Temporal Temporal Temporal Relationship Relationship Relationship Relationship Relationship between ED between ED between ED between ED between ED and Anxiety and Anxiety and Anxiety and Anxiety and Anxiety Count Count Count Count Count N/ A 14 Anxiety before ED 6 3 1 3 Anxiety and ED 1 same time Anxiety after ED 1

387 ENTIRE ED SAMPLE (INPATIENT AND OUTPATIENT)

Te mporal Relations hip betw een ED a nd Anxie ty

Cumulative Frequency Percent Valid Percent Percent Valid N/A 35 35.0 35.0 35.0 Anxiety before ED 45 45.0 45.0 80.0 Anxiety and ED 10 10.0 10.0 90.0 same time Anxiety after ED 10 10.0 10.0 100.0 To tal 100 100.0 100.0

Temporal Relationship secondary anxiety and ED

Cumulative Frequency Percent Valid Percent Percent Valid N/A 66 66.0 66.0 66.0 Anxiety before ED 21 21.0 21.0 87.0 Anxiety and ED 7 7.0 7.0 94.0 same time Anxiety after ED 6 6.0 6.0 100.0 To tal 100 100.0 100.0

Te mporal Relationship secondary anxiety and ED

Cumulative Frequency Percent Valid Percent Percent Valid N/ A 94 94.0 94.0 94.0 Anxiety before ED 4 4.0 4.0 98.0 Anxiety after ED 2 2.0 2.0 100.0 To tal 100 100.0 100.0

ENTIRE ED SAMPLE AGE OF ONSET OF AD ACROSS THE ED SUBTYPES

388 Ca se Processing Summary

Cases Inc luded Ex cluded To tal N Percent N Percent N Percent Anxiety Onset Age (Years ) * Anxiety 27 69.2% 12 30.8% 39 100.0% Dis order Diagnosis

Re port Anxiety Onset Age (Years ) Anxiety Disorder Me an N Std. Deviati on Minimum Maximum PanicDi with i Ag 35.00 1 . 35 35 Social Phobia 10.40 10 4.575 5 16 GAD 24.17 6 14.730 5 43 OC D 11.50 2 7.778 6 17 Specific Phobia 5.00 1 . 5 5 PTSD 16.86 7 8.649 9 34 To tal 15.93 27 10.784 5 43

Re port Anxiety Onset Age (Years) Anxiety Dis order Mean N Std. Deviation Minimum Maximum SocialDi Phobia i 11.86 7 4.451 6 17 GAD 10.60 5 4.037 5 15 PTSD 14.67 3 4.041 10 17 To tal 12.00 15 4.209 5 17

EDNOS

389 Ca se Processing Summary

Cases Inc luded Ex cluded To tal N Percent N Percent N Percent ED Onset Age (Years ) * Anxiety 39 97.5% 1 2.5% 40 100.0% Dis order Diagnosis

Re port ED Onset Age (Years ) Anxiety Disorder Me an N Std. Deviati on Minimum Maximum NoneDi i 17.19 16 5.504 9 34 Panic w/o Ag 16.00 1 . 16 16 Social Phobia 18.50 10 5.543 12 33 GAD 15.00 4 2.828 11 17 OC D 15.00 1 . 15 15 PTSD 12.86 7 1.952 10 15 To tal 16.44 39 4.946 9 34

390 ENTIRE ED SAMPLE

Ca se Processing Summary

Cases Inc luded Ex cluded To tal N Percent N Percent N Percent Anxiety Onset Age (Years ) * Anxiety 65 100.0% 0 .0% 65 100.0% Dis order Diagnosis

Re port Anxiety Onset Age (Years) Anxiety Dis order Mean N Std. Deviation Minimum Maximum Panic with Ag 35.00 1 . 35 35 Panic w/o Ag 19.00 1 . 19 19 Social Phobia 12.22 27 5.753 5 30 GAD 15.00 15 12.071 5 43 OCD 9.67 3 6.351 6 17 Specific Phobia 5.00 1 . 5 5 PTSD 15.41 17 6.911 8 34 To tal 13.92 65 8.369 5 43

ENTIRE ED SAMPLE TEMPORAL RELATIONSHIP AD & ED ACROSS ED SUBTYPES

Eating Dis order Diagnosis AN BN EDNOS Temporal Temporal Temporal Relationship Relationship Relationship between ED between ED between ED and Anxiety and Anxiety and Anxiety Count Count Count N/ A 12 6 17 Anxiety before ED 21 9 15 Anxiety and ED 3 4 3 same time Anxiety after ED 3 2 5

391 4. COMPARISONS ACROSS THE SAMPLE 4.1 CHI- SQUARE ANALYSES

ENTIRE ED SAMPLE COMPARISON OF FREQUNCIES OF AD

Type Of Tre atment

Observed N Expected N Residual Inpatient 37 32.5 4.5 Outpatient 28 32.5 -4.5 To tal 65

Test Statistics

Type Of Treatment Chi-Squarea 1.246 df 1 Asymp. Sig. .264 a. 0 cells (.0%) have expected frequencies less than 5. The minimum expected cell frequency is 32.5.

ENTIRE ED SAMPLE COMPARISON OF FREQUENCY OF AD ACROSS ED SUBTYPES

EDTYP E

Observed N Expected N Residual AN 27 21.7 5.3 BN 15 21.7 -6.7 ED NOS 23 21.7 1.3 To tal 65

Te st Statistics

EDTYPE Chi-Squarea 3.446 df 2 Asymp. Sig. .179 a. 0 c ells (.0%) have expected frequencies les s than 5. The minimum expec ted cell frequenc y is 21.7.

392 COMPARISON OF DIFFERNECES BETWEEN INPATIENT AND OUTPATIENT ED TEMPORAL RELATIONSHIP BETWEEN AD & ED

Type of Tre atment

Observed N Expected N Residual Inpatient 24 22.5 1.5 Outpatient 21 22.5 -1.5 To tal 45

Test Statistics

Type of Treatment Chi-Squarea .200 df 1 Asymp. Sig. .655 a. 0 cells (.0%) have expected frequencies less than 5. The minimum expected cell frequency is 22.5.

393 ED INPATIENT AND OUTPATIENT EMPLOYMENT COMPARISONS

Case Processing Summary

Cases Valid Missing To tal N Percent N Percent N Percent TREATMENT * 100 100.0% 0 .0% 100 100.0% Employment

TREATMENT * Employment Cros stabulation

Employment Employed Unemployed FT Student To tal TREATMENT Inpatient Count 23 15 12 50 Expected Count 20.5 13.0 16.5 50.0 % withi n TREATMENT 46.0% 30.0% 24.0% 100.0% % within Employment 56.1% 57.7% 36.4% 50.0% % of Total 23.0% 15.0% 12.0% 50.0% Outpatient Count 18 11 21 50 Expected Count 20.5 13.0 16.5 50.0 % withi n TREATMENT 36.0% 22.0% 42.0% 100.0% % within Employment 43.9% 42.3% 63.6% 50.0% % of Total 18.0% 11.0% 21.0% 50.0% To tal Count 41 26 33 100 Expected Count 41.0 26.0 33.0 100.0 % withi n TREATMENT 41.0% 26.0% 33.0% 100.0% % within Employment 100.0% 100.0% 100.0% 100.0% % of Total 41.0% 26.0% 33.0% 100.0%

Chi-Square Te sts

Asymp. Sig. Value df (2-sided) Pearson Chi-Square 3.680a 2 .159 Lik elihood Ratio 3.715 2 .156 Linear-by-Linear 2.645 1 .104 As soc iation N of Valid Cases 100 a. 0 c ells (.0%) have expected count less than 5. The minimum expected count is 13.00.

394 Symmetric Measures

Va l ue Approx. Sig. Nominal by Phi .192 .159 Nominal Cramer's V .192 .159 N of Valid Cases 100 a. Not ass uming the null hypothesis. b. Us ing the asymptotic standard error as suming the null hypothesis.

ED INPATIENT AND OUTPATIENT TREATMENT COMPARISONS

Case Processing Summary

Cases Valid Missing To tal N Percent N Percent N Percent TREATMENT * 100 100.0% 0 .0% 100 100.0% Employment

TREATMENT * Employment Cros stabulation

395 Chi-Square Te sts

Symmetric Measures

ED INPATIENT AND OUTPATIENT MARITAL COMPARISONS

Case Processing Summary

Cases Valid Missing To tal N Percent N Percent N Percent TR EAT MEN T * MAR ITAL 95 100.0% 0 .0% 95 100.0%

396 TREATMENT * MARITAL Cros stabulation

MARITAL Married Single To tal TREATMENT Inpatient Count 11 36 47 Expected Count 14.3 32.7 47.0 % withi n TREATMENT 23.4% 76.6% 100.0% % withi n MARITAL 37.9% 54.5% 49.5% % of Total 11.6% 37.9% 49.5% Outpatient Count 18 30 48 Expected Count 14.7 33.3 48.0 % withi n TREATMENT 37.5% 62.5% 100.0% % withi n MARITAL 62.1% 45.5% 50.5% % of Total 18.9% 31.6% 50.5% To tal Count 29 66 95 Expected Count 29.0 66.0 95.0 % withi n TREATMENT 30.5% 69.5% 100.0% % withi n MARITAL 100.0% 100.0% 100.0% % of Total 30.5% 69.5% 100.0%

Chi-Square Tes ts

Asymp. Sig. Exact Sig. Exact Sig. Va l ue df (2-sided) (2-sided) (1-sided) Pearson Chi-Square 2.225b 1 .136 Continuity Correctiona 1.610 1 .205 Likelihood Ratio 2.242 1 .134 Fis her's Exact Test .182 .102 Linear-by-Linear 2.201 1 .138 Association N of Valid Cases 95 a. Computed only for a 2x2 table b. 0 cells (.0%) have expected count less than 5. The minimum expected count is 14. 35.

Symmetric Measures

Va l ue Approx. Sig. Nominal by Phi -.153 .136 Nominal Cramer's V .153 .136 N of Valid Cases 95 a. Not ass uming the null hypothesis. b. Us ing the asymptotic standard error as suming the null hypothesis.

397

ED INPATIENT AND OUTPATIENT CHILDREN COMPARISONS

TREAT MENT

Observed N Expected N Residual Inpatient 4 7.0 -3.0 Outpatient 10 7.0 3.0 To tal 14

Te st Statistics

TREATMENT Chi-Squarea 2.571 df 1 Asymp. Sig. .109 a. 0 c ells (.0%) have expected frequencies les s than 5. The minimum expec ted cell frequenc y is 7.0.

ED INPATIENT AND OUTPATIENT MEDICATION COMPARISONS

TREAT MENT

Observed N Expected N Residual Inpatient 37 28.5 8.5 Outpatient 20 28.5 -8.5 To tal 57

Te st Statistics

TREATMENT Chi-Squarea 5.070 df 1 Asymp. Sig. .024 a. 0 c ells (.0%) have expected frequencies les s than 5. The minimum expec ted cell frequenc y is 28.5.

398

ED INPATIENT AND OUTPATIENT DEPRESSION COMPARISONS Case Processing Summary

Cases Valid Missing To tal N Percent N Percent N Percent TREATMENT * 93 100.0% 0 .0% 93 100.0% DEPRESSION SCORE

TREAT MENT * DEPRESS ION SCORE Cros stab ulati on

DEPRESSION SCORE Normal Mild - Mod Se v - E x Se v To tal TREATMENT Inpatient Count 6 14 24 44 Expected Count 7.6 14.2 22.2 44.0 % withi n TREATMENT 13.6% 31.8% 54.5% 100.0% % withi n DEPRESSION 37.5% 46.7% 51.1% 47.3% SC ORE % of Total 6.5% 15.1% 25.8% 47.3% Outpatient Count 10 16 23 49 Expected Count 8.4 15.8 24.8 49.0 % withi n TREATMENT 20.4% 32.7% 46.9% 100.0% % withi n DEPRESSION 62.5% 53.3% 48.9% 52.7% SC ORE % of Total 10.8% 17.2% 24.7% 52.7% To tal Count 16 30 47 93 Expected Count 16.0 30.0 47.0 93.0 % withi n TREATMENT 17.2% 32.3% 50.5% 100.0% % withi n DEPRESSION 100.0% 100.0% 100.0% 100.0% SC ORE % of Total 17.2% 32.3% 50.5% 100.0%

Chi-Square Te sts

Asymp. Sig. Value df (2-sided) Pearson Chi-Square .888a 2 .641 Lik elihood Ratio .896 2 .639 Linear-by-Linear .837 1 .360 As soc iation N of Valid Cases 93 a. 0 c ells (.0%) have expected count less than 5. The minimum expected count is 7.57.

399 Symmetric Measures

Va l ue Approx. Sig. Nominal by Phi .098 .641 Nominal Cramer's V .098 .641 N of Valid Cases 93 a. Not ass uming the null hypothesis. b. Us ing the asymptotic standard error as suming the null hypothesis.

ED INPATIENT AND OUTPATIENT BINGEING AND PURGING COMPARISONS

TREAT MENT

Observed N Expected N Residual Inpatient 19 23.0 -4.0 Outpatient 27 23.0 4.0 To tal 46

Te st Statistics

TREATMENT Chi-Squarea 1.391 df 1 Asymp. Sig. .238 a. 0 c ells (.0%) have expected frequencies les s than 5. The minimum expec ted cell frequenc y is 23.0.

VOMITING

TREAT MENT

Observed N Expected N Residual Inpatient 25 25.5 -.5 Outpatient 26 25.5 .5 To tal 51

400 Te st Statistics

TREATMENT Chi-Squarea .020 df 1 Asymp. Sig. .889 a. 0 c ells (.0%) have expected frequencies les s than 5. The minimum expec ted cell frequenc y is 25.5.

LAXATIVE ABUSE

TREAT MENT

Observed N Expected N Residual Inpatient 12 7.0 5.0 Outpatient 2 7.0 -5.0 To tal 14

Te st Statistics

TREATMENT Chi-Squarea 7.143 df 1 Asymp. Sig. .008 a. 0 c ells (.0%) have expected frequencies les s than 5. The minimum expec ted cell frequenc y is 7.0.

EXCESSIVE EXERCISE

TREAT MENT

Observed N Expected N Residual Inpatient 22 20.5 1.5 Outpatient 19 20.5 -1.5 To tal 41

401 Te st Statistics

TREATMENT Chi-Squarea .220 df 1 Asymp. Sig. .639 a. 0 c ells (.0%) have expected frequencies les s than 5. The minimum expec ted cell frequenc y is 20.5.

402

ED SUBTYPE EMPLOYMENT COMPARISONS

Case Processing Summary

Cases Valid Missing To tal N Percent N Percent N Percent ED * EMPLOYMENT 100 100.0% 0 .0% 100 100.0%

ED * EMPLOYMENT Cros stabulation

EMPLOYMENT EMPLOYED UNEMPLOED FT STUDENT To tal ED AN Count 17 13 9 39 Expected Count 16.0 10.1 12.9 39.0 % within ED 43.6% 33.3% 23.1% 100.0% % within EMPLOYMENT 41.5% 50.0% 27.3% 39.0% % of Total 17.0% 13.0% 9.0% 39.0% BN Count 10 4 7 21 Expected Count 8.6 5.5 6.9 21.0 % within ED 47.6% 19.0% 33.3% 100.0% % within EMPLOYMENT 24.4% 15.4% 21.2% 21.0% % of Total 10.0% 4.0% 7.0% 21.0% ED NOS Count 14 9 17 40 Expected Count 16.4 10.4 13.2 40.0 % within ED 35.0% 22.5% 42.5% 100.0% % within EMPLOYMENT 34.1% 34.6% 51.5% 40.0% % of Total 14.0% 9.0% 17.0% 40.0% To tal Count 41 26 33 100 Expected Count 41.0 26.0 33.0 100.0 % within ED 41.0% 26.0% 33.0% 100.0% % within EMPLOYMENT 100.0% 100.0% 100.0% 100.0% % of Total 41.0% 26.0% 33.0% 100.0%

403 Chi-Square Tests

Asymp. Sig. Ex act Sig. Ex act Sig. Point Value df (2-sided) (2-sided) (1-sided) Probability Pearson Chi-Square 4.283a 4 .369 .377 Lik elihood Ratio 4.318 4 .365 .382 Fis her's Ex act Tes t 4.202 .384 Linear-by-Linear b 2.097 1 .148 .151 .084 .018 As soc iation N of Valid Cas es 100 a. 0 c ells (.0%) have expected count less than 5. The minimum ex pected c ount is 5.46. b. The standardiz ed s tatis tic is 1.448.

Symmetric Measures

Value Approx . Sig. Ex act Sig. Nominal by Phi .207 .369 .377 Nominal Cramer's V .146 .369 .377 N of Valid Cases 100 a. Not as suming the null hypothesis. b. Us ing the asymptotic standard error assuming the null hypothesis.

404

ED SUBTYPE MARITAL COMPARISONS

Case Processing Summary

Cases Valid Missing To tal N Percent N Percent N Percent ED * MARIT AL 100 100.0% 0 .0% 100 100.0%

ED * MARITAL Cros stabulation

MARITAL MARRIED SIN GLE To tal ED AN Count 10 29 39 Expected Count 11.3 27.7 39.0 % within ED 25.6% 74.4% 100.0% % withi n MARITAL 34.5% 40.8% 39.0% % of Total 10.0% 29.0% 39.0% BN Count 5 16 21 Expected Count 6.1 14.9 21.0 % within ED 23.8% 76.2% 100.0% % withi n MARITAL 17.2% 22.5% 21.0% % of Total 5.0% 16.0% 21.0% ED NOS Count 14 26 40 Expected Count 11.6 28.4 40.0 % within ED 35.0% 65.0% 100.0% % withi n MARITAL 48.3% 36.6% 40.0% % of Total 14.0% 26.0% 40.0% To tal Count 29 71 100 Expected Count 29.0 71.0 100.0 % within ED 29.0% 71.0% 100.0% % withi n MARITAL 100.0% 100.0% 100.0% % of Total 29.0% 71.0% 100.0%

405 Chi-Square Te sts

Asymp. Sig. Value df (2-sided) Pearson Chi-Square 1.188a 2 .552 Lik elihood Ratio 1.179 2 .555 Linear-by-Linear .838 1 .360 As soc iation N of Valid Cases 100 a. 0 c ells (.0%) have expected count less than 5. The minimum expected count is 6.09.

Symmetric Measures

Va l ue Approx. Sig. Nominal by Phi .109 .552 Nominal Cramer's V .109 .552 N of Valid Cases 100 a. Not ass uming the null hypothesis. b. Us ing the asymptotic standard error as suming the null hypothesis.

406

ED SUBTYPE BINGEING AND PURGING COMPARISONS

BINGEING

Observed N Expected N Residual AN 8 15.3 -7.3 BN 21 15.3 5.7 ED NOS 17 15.3 1.7 To tal 46

Te st Statistics

ED Chi-Squarea 5.783 df 2 Asymp. Sig. .056 a. 0 c ells (.0%) have expected frequencies les s than 5. The minimum expec ted cell frequenc y is 15.3.

VOMITING

Observed N Expected N Residual AN 15 17.0 -2.0 BN 18 17.0 1.0 ED NOS 18 17.0 1.0 To tal 51

Te st Statistics

ED Chi-Squarea .353 df 2 Asymp. Sig. .838 a. 0 c ells (.0%) have expected frequencies les s than 5. The minimum expec ted cell frequenc y is 17.0.

407 LAXATIVE ABUSE

Observed N Expected N Residual AN 6 4.7 1.3 BN 3 4.7 -1.7 ED NOS 5 4.7 .3 To tal 14

Test Statistics

ED Chi-Squarea 1.000 df 2 As ym p . Si g. .607 Exact Sig. .710 Point Probability .211 a. 3 cells (100.0%) have expected frequencies les s than 5. The minimum expected cell frequency is 4.7.

PURGATIVE ABUSE TOTAL

Type Of Tre atment

Observed N Expected N Residual Comorbid ED and AD 49 32.5 16.5 ED Onl y 16 32.5 -16.5 To tal 65

Test Statistics

Type Of Treatment Chi-Squarea 16.754 df 1 Asymp. Sig. .000 a. 0 cells (.0%) have expected frequencies less than 5. The minimum expected cell frequency is 32.5.

408 EXCESSIVE EXERCISE

Observed N Expected N Residual AN 15 13.7 1.3 BN 5 13.7 -8.7 ED NOS 21 13.7 7.3 To tal 41

Te st Statistics

ED Chi-Squarea 9.561 df 2 Asymp. Sig. .008 a. 0 c ells (.0%) have expected frequencies les s than 5. The minimum expec ted cell frequenc y is 13.7.

Observed N Expected N Residual AN 15 18.0 -3.0 ED NOS 21 18.0 3.0 To tal 36

Te st Statistics

ED Chi-Squarea 1.000 df 1 Asymp. Sig. .317 a. 0 c ells (.0%) have expected frequencies les s than 5. The minimum expec ted cell frequenc y is 18.0.

Observed N Expected N Residual AN 15 10.0 5.0 BN 5 10.0 -5.0 To tal 20

409 Te st Statistics

ED Chi-Squarea 5.000 df 1 Asymp. Sig. .025 a. 0 c ells (.0%) have expected frequencies les s than 5. The minimum expec ted cell frequenc y is 10.0.

ENTIRE ED SAMPLE COMPARISON OF AD FREUQENCY

Type Of Tre atment

Observed N Expected N Residual Inpatient 37 32.5 4.5 Outpatient 28 32.5 -4.5 To tal 65

Test Statistics

Type Of Treatment Chi-Squarea 1.246 df 1 Asymp. Sig. .264 a. 0 cells (.0%) have expected frequencies less than 5. The minimum expected cell frequency is 32.5.

Social Phobia

Type Of Tre atment

Observed N Expected N Residual Inpatient 14 13.5 .5 Outpatient 13 13.5 -.5 To tal 27

410 Test Statistics

Type Of Treatment Chi-Squarea .037 df 1 Asymp. Sig. .847 a. 0 cells (.0%) have expected frequencies less than 5. The minimum expected cell frequency is 13.5.

PTSD

Type Of Tre atment

Observed N Expected N Residual Inpatient 10 8.5 1.5 Outpatient 7 8.5 -1.5 To tal 17

Test Statistics

Type Of Treatment Chi-Squarea .529 df 1 Asymp. Sig. .467 a. 0 cells (.0%) have expected frequencies less than 5. The minimum expected cell frequency is 8.5.

GAD

Type Of Tre atment

Observed N Expected N Residual Inpatient 8 7.5 .5 Outpatient 7 7.5 -.5 To tal 15

411 Test Statistics

Type Of Treatment Chi-Squarea .067 df 1 Asymp. Sig. .796 a. 0 cells (.0%) have expected frequencies less than 5. The minimum expected cell frequency is 7.5.

OCD

Type Of Tre atment

Observed N Expected N Residual Inpatient 2 1.5 .5 Outpatient 1 1.5 -.5 To tal 3

Test Statistics

Typ e Of Treatment Chi-Squarea .333 df 1 As ym p . Si g. .564 Exact Sig. 1.000 Point Probability .750 a. 2 cells (100.0%) have expected frequencies les s than 5. The minimum expected cell frequency is 1.5.

412 ENTIRE ED SAMPLE COMPARISON OF TEMPORAL RELATIONSHIP BETWEEN AD AND ED

Case Processing Summary

Cases Valid Missing To tal N Percent N Percent N Percent TREATMENT * Tem pRel 65 100.0% 0 .0% 65 100.0%

TREATMENT * TempRel Crossta bula tion

TempRel Before Same Time Aft er To tal TREATMENT Inpatient Count 24 7 6 37 Expected Count 25.6 5.7 5.7 37.0 % within TREATMENT 64.9% 18.9% 16.2% 100.0% % within TempRel 53.3% 70.0% 60.0% 56.9% % of Total 36.9% 10.8% 9.2% 56.9% Outpatient Count 21 3 4 28 Expected Count 19.4 4.3 4.3 28.0 % within TREATMENT 75.0% 10.7% 14.3% 100.0% % within TempRel 46.7% 30.0% 40.0% 43.1% % of Total 32.3% 4.6% 6.2% 43.1% To tal Count 45 10 10 65 Expected Count 45.0 10.0 10.0 65.0 % within TREATMENT 69.2% 15.4% 15.4% 100.0% % within TempRel 100.0% 100.0% 100.0% 100.0% % of Total 69.2% 15.4% 15.4% 100.0%

Chi-Square Tests

Asymp. Sig. Ex act Sig. Ex act Sig. Point Value df (2-sided) (2-sided) (1-sided) Probability Pearson Chi-Square .972a 2 .615 .645 Lik elihood Ratio .998 2 .607 .645 Fis her's Ex act Tes t .955 .645 Linear-by-Linear b .411 1 .522 .620 .321 .109 As soc iation N of Valid Cas es 65 a. 2 c ells (33.3%) have ex pec ted count less than 5. The minimum expected count is 4.31. b. The standardiz ed s tatis tic is -.641.

413 Symmetric Measures

Value Approx . Sig. Ex act Sig. Nominal by Phi .122 .615 .645 Nominal Cramer's V .122 .615 .645 N of Valid Cases 65 a. Not as suming the null hypothesis. b. Us ing the asymptotic standard error assuming the null hypothesis.

COMPARISON OF PURGATIVE ABUSE FOR SOCIAL PHOBIA, GAD & PTSD

Observed N Expected N Residual Social Phobia 21 15.7 5.3 PTSD 10 15.7 -5.7 GAD 16 15.7 .3 To tal 47

Te st Statistics

AD Chi-Squarea 3.872 df 2 Asymp. Sig. .144 a. 0 c ells (.0%) have expected frequencies les s than 5. The minimum expec ted cell frequenc y is 15.7.

414 ENTIRE ED SAMPLE COMPARISON OF TEMPORAL RELATIONSHIP OF AD AND ED ACROSS ED SUBTYPES (ALL AD)

Case Processing Summary

Cases Valid Missing To tal N Percent N Percent N Percent ED DX * TEMP REL 65 100.0% 0 .0% 65 100.0%

ED DX * TEMP REL Cros stabulation

TEMP REL Before Same time Aft er To tal ED AN Count 21 3 3 27 DX Expected Count 18.7 4.2 4.2 27.0 % within ED DX 77.8% 11.1% 11.1% 100.0% % within TEMP REL 46.7% 30.0% 30.0% 41.5% % of Total 32.3% 4.6% 4.6% 41.5% BN Count 9 4 2 15 Expected Count 10.4 2.3 2.3 15.0 % within ED DX 60.0% 26.7% 13.3% 100.0% % within TEMP REL 20.0% 40.0% 20.0% 23.1% % of Total 13.8% 6.2% 3.1% 23.1% ED NOS Count 15 3 5 23 Expected Count 15.9 3.5 3.5 23.0 % within ED DX 65.2% 13.0% 21.7% 100.0% % within TEMP REL 33.3% 30.0% 50.0% 35.4% % of Total 23.1% 4.6% 7.7% 35.4% To tal Count 45 10 10 65 Expected Count 45.0 10.0 10.0 65.0 % within ED DX 69.2% 15.4% 15.4% 100.0% % within TEMP REL 100.0% 100.0% 100.0% 100.0% % of Total 69.2% 15.4% 15.4% 100.0%

415 Chi-Square Tests

Asymp. Sig. Ex act Sig. Ex act Sig. Point Value df (2-sided) (2-sided) (1-sided) Probability Pearson Chi-Square 3.132a 4 .536 .571 Lik elihood Ratio 2.912 4 .573 .610 Fis her's Ex act Tes t 3.064 .572 Linear-by-Linear b 1.216 1 .270 .303 .158 .041 As soc iation N of Valid Cas es 65 a. 6 c ells (66.7%) have ex pec ted count less than 5. The minimum expected count is 2.31. b. The standardiz ed s tatis tic is 1.103.

Symmetric Measures

Value Approx . Sig. Ex act Sig. Nominal by Phi .220 .536 .571 Nominal Cramer's V .155 .536 .571 N of Valid Cases 65 a. Not as suming the null hypothesis. b. Us ing the asymptotic standard error assuming the null hypothesis.

416 ENTIRE ED SAMPLE COMPARISON OF DEPRESSION ACROSS ED SUBTYPES

Case Processing Summary

Cases Valid Missing To tal N Percent N Percent N Percent ED Typ e * 93 100.0% 0 .0% 93 100.0% DEPRESSION SCORE

Chi-Square Tests

Asymp. Sig. Ex act Sig. Ex act Sig. Point Value df (2-sided) (2-sided) (1-sided) Probability Pearson Chi-Square .978a 4 .913 .919 Lik elihood Ratio .966 4 .915 .919 Fis her's Ex act Tes t 1.008 .928 Linear-by-Linear b .780 1 .377 .394 .211 .042 As soc iation N of Valid Cas es 93 a. 1 c ells (11.1%) have ex pec ted count less than 5. The minimum expected count is 3.61. b. The standardiz ed s tatis tic is -.883.

Symmetric Measures

Value Approx . Sig. Ex act Sig. Nominal by Phi .103 .913 .919 Nominal Cramer's V .073 .913 .919 N of Valid Cases 93 a. Not as suming the null hypothesis. b. Us ing the asymptotic standard error assuming the null hypothesis.

417 ENTIRE ED SAMPLE COMPARISON OF DEPRESSION FOR COMORBID ED & AD AND ED ONLY GROUPS Case Processing Summary

Cases Valid Missing To tal N Percent N Percent N Percent ED Typ e * 93 100.0% 0 .0% 93 100.0% DEPRESSION SCORE

ED Typ e * DEP RES SION S CORE Crosstab ulation

DE PRE SS ION SCORE Normal Mild - Mod Sev - Ex Sev To tal ED Typ e Comorb ED and Anxiety Count 7 17 35 59 Ex pec ted Count 10.2 19.0 29.8 59.0 % within E D Ty pe 11.9% 28.8% 59.3% 100.0% % within DEPRESSION 43.8% 56.7% 74.5% 63.4% SCORE % of Total 7.5% 18.3% 37.6% 63.4% Adjusted Residual -1. 8 -.9 2.2 ED Only Count 9 13 12 34 Ex pec ted Count 5.8 11.0 17.2 34.0 % within E D Ty pe 26.5% 38.2% 35.3% 100.0% % within DEPRESSION 56.3% 43.3% 25.5% 36.6% SCORE % of Total 9.7% 14.0% 12.9% 36.6% Adjusted Residual 1.8 .9 -2. 2 To tal Count 16 30 47 93 Ex pec ted Count 16.0 30.0 47.0 93.0 % within E D Ty pe 17.2% 32.3% 50.5% 100.0% % within DEPRESSION 100.0% 100.0% 100.0% 100.0% SCORE % of Total 17.2% 32.3% 50.5% 100.0%

Chi-Square Te sts

Asymp. Sig. Value df (2-sided) Pearson Chi-Square 5.732a 2 .057 Lik elihood Ratio 5.736 2 .057 Linear-by-Linear 5.624 1 .018 As soc iation N of Valid Cases 93 a. 0 c ells (.0%) have expected count less than 5. The minimum expected count is 5.85.

418 Symmetric Measures

Va l ue Approx. Sig. Nominal by Phi .248 .057 Nominal Cramer's V .248 .057 N of Valid Cases 93 a. Not ass uming the null hypothesis. b. Us ing the asymptotic standard error as suming the null hypothesis.

ENTIRE ED SAMPLE COMPARISON OF TRAUMA ACROSS ED SUBTYPES Type Of Tre atment

Observed N Expected N Residual AN 12 10.7 1.3 BN 5 10.7 -5.7 ED NOS 15 10.7 4.3 To tal 32

Test Statistics

Type Of Treatment Chi-Squarea 4.938 df 2 Asymp. Sig. .085 a. 0 cells (.0%) have expected frequencies less than 5. The minimum expected cell frequency is 10.7.

419

4.2 INDEPENDENT SAMPLES T -TESTS

INPATIENT ED COMPARED WITH OUTPATIENT ED

AGE /EDUCATION

Group Sta tistics

St d. Error Facility N Mean Std. Deviation Mean Age ED Inpatient 50 25.38 8.263 1.169 ED Outpatient 50 25.04 6.398 .905 Education (Years) ED Inpatient 50 14.20 2.030 .287 ED Outpatient 50 13.60 2.050 .290

Independent Samples Test

Levene's Test for Equality of Variances t-test for Equality of Means 95% Confidence Interval of the Me an Std. Error Di fference F Sig. t df Sig. (2-tailed) Di fference Di fference Lower Upper Ag e Equal variances 2.802 .097 .230 98 .819 .340 1.478 -2.593 3.273 as sumed Equal variances .230 92.220 .819 .340 1.478 -2.595 3.275 not ass umed Education (Years) Equal variances .461 .499 1.470 98 .145 .600 .408 -.210 1.410 as sumed Equal variances 1.470 97.991 .145 .600 .408 -.210 1.410 not ass umed

420

ED LENGTH / BMI / ED ONSET AGE

Group Statistics

Std. Error Facility N Me an Std. Deviati on Me an ED Length (Months) ED Inpatient 49 88.29 78.481 11.212 ED Outpatient 50 99.08 76.771 10.857 BMI ED Inpatient 50 17.2698 3.23910 .45808 ED Outpatient 50 20.4196 3.17167 .44854 ED Ons et Age (Years ) ED Inpatient 49 17.96 6.324 .903 ED Outpatient 50 16.78 4.713 .667

Independent Sample s Te st

421 INPATIENT ED COMORBID AD & ED COMPARED WITH ED ONLY

Group Sta tistics

St d. Error Comorbid ED and AD N Mean Std. Deviation Mean ED Length (Months ) Comorbid ED and AD 37 92.49 77.714 12.776 ED Only 12 75.33 82.880 23.925 ED Onset Age (Years) Comorbid ED and AD 37 17.95 6.472 1.064 ED Only 12 18.00 6.120 1.767 BMI Comorbid ED and AD 37 17.5662 3.27953 .53915 ED Only 13 16.4262 3.08762 .85635 No of Episodes Comorbid ED and AD 37 14.35 31.756 5.221 Binging per Month ED Only 13 10.77 19.430 5.389 No of Episodes Comorbid ED and AD 37 39.51 81.351 13.374 vomiting per month ED Only 13 27.15 45.927 12.738 Ex ercise Per Day Comorbid ED and AD 37 61.35 93.338 15.345 (Minutes) ED Only 13 25.38 42.154 11.691

Independent Samples Test

Levene's Test for Equality of Variances t-test for Equality of Means 95% Confidence Interval of the Me an Std. Error Di fference F Sig. t df Sig. (2-tailed) Di fference Di fference Lower Upper ED Length (Months) Equal variances .110 .741 .654 47 .516 17.153 26.229 -35.612 69.919 as sumed Equal variances .632 17.727 .535 17.153 27.123 -39.893 74.199 not ass umed ED Onset Age (Years) Equal variances .066 .798 -.025 47 .980 -.054 2.123 -4.325 4.217 as sumed Equal variances -.026 19.637 .979 -.054 2.062 -4.361 4.253 not ass umed BMI Equal variances .545 .464 1.094 48 .279 1.14006 1.04224 -.95550 3.23562 as sumed Equal variances 1.127 22.234 .272 1.14006 1.01194 -.95729 3.23741 not ass umed No of Episodes Equal variances .436 .512 .381 48 .705 3.582 9.404 -15.326 22.490 Binging per Month as sumed Equal variances .477 34.860 .636 3.582 7.503 -11.652 18.816 not ass umed No of Episodes Equal variances .714 .402 .517 48 .607 12.360 23.891 -35.676 60.396 vomiting per month as sumed Equal variances .669 37.749 .507 12.360 18.469 -25.038 49.757 not ass umed Exercis e Per Day Equal variances 2.548 .117 1.335 48 .188 35.967 26.933 -18.186 90.119 (Minutes) as sumed Equal variances 1.864 44.719 .069 35.967 19.291 -2.894 74.828 not ass umed

422 OUTPATIENT ED COMORBID AD & ED COMPARED WITH ED ONLY

Mann-Whitney Test

Ra nks

Comorbid ED and AD N Mean Rank Sum of Ranks ED Length (Months) Comorbid ED and AD 28 28.32 793.00 ED Onl y 22 21.91 482.00 To tal 50 BMI Comorbid ED and AD 28 25.75 721.00 ED Onl y 22 25.18 554.00 To tal 50 No of Episodes Comorbid ED and AD 28 21.29 596.00 Binging per Month ED Onl y 22 30.86 679.00 To tal 50

No of Episodes Comorbid ED and AD 28 24.71 692.00 vomiting per month ED Onl y 22 26.50 583.00 To tal 50 Exercis e Per Day Comorbid ED and AD 28 25.68 719.00 (Minutes) ED Onl y 22 25.27 556.00 To tal 50

Test Statisticsa

No of No of Episodes Episodes ED Length Binging vomiting Exercis e Per (Months) BMI per Month per month Day (Minutes) Mann-Whitney U 229.000 301.000 190.000 286.000 303.000 Wilcoxon W 482.000 554.000 596.000 692.000 556.000 Z -1.548 -.137 -2.429 -.456 -.112 Asymp. Sig. (2-tailed) .122 .891 .015 .648 .911 Exact Sig. (2-tailed) .124 .896 .015 .654 .917 Exact Sig. (1-tailed) .062 .448 .007 .327 .461 Point Probability .001 .004 .000 .004 .004 a. Grouping Variable: Comorbid ED and AD

423 Group Sta tistics

St d. Error Comorbid ED and AD N Mean Std. Deviation Mean ED Length (Months ) Comorbid ED and AD 28 116.04 86.864 16.416 ED Only 22 77.50 56.390 12.022 ED Onset Age (Years) Comorbid ED and AD 28 16.64 4.724 .893 ED Only 22 16.95 4.806 1.025 BMI Comorbid ED and AD 28 20.4139 2.74228 .51824 ED Only 22 20.4268 3.71528 .79210 No of Episodes Comorbid ED and AD 28 9.75 18.360 3.470 Binging per Month ED Only 22 21.86 24.328 5.187 No of Episodes Comorbid ED and AD 28 16.32 25.456 4.811 vomiting per month ED Only 22 30.59 62.525 13.330 Ex ercise Per Day Comorbid ED and AD 28 32.14 50.943 9.627 (Minutes) ED Only 22 22.50 29.911 6.377

Independent Samples Test

Levene's Test for Equality of Variances t-test for Equality of Means 95% Confidence Interval of the Me an Std. Error Di fference F Sig. t df Sig. (2-tailed) Di fference Di fference Lower Upper ED Length (Months) Equal variances 2.748 .104 1.802 48 .078 38.536 21.387 -4.467 81.538 as sumed Equal variances 1.894 46.523 .064 38.536 20.347 -2.409 79.480 not ass umed ED Onset Age (Years) Equal variances .004 .948 -.230 48 .819 -.312 1.356 -3.038 2.415 as sumed Equal variances -.229 44.873 .820 -.312 1.359 -3.049 2.425 not ass umed BMI Equal variances 3.172 .081 -.014 48 .989 -.01289 .91298 -1.84855 1.82277 as sumed Equal variances -.014 37.484 .989 -.01289 .94657 -1.92999 1.90421 not ass umed No of Episodes Equal variances 1.365 .248 -2.008 48 .050 -12.114 6.034 -24.246 .018 Binging per Month as sumed Equal variances -1.941 38.071 .060 -12.114 6.240 -24.746 .518 not ass umed No of Episodes Equal variances 3.493 .068 -1.100 48 .277 -14.269 12.977 -40.362 11.823 vomiting per month as sumed Equal variances -1.007 26.477 .323 -14.269 14.172 -43.375 14.836 not ass umed Exercis e Per Day Equal variances 5.401 .024 .787 48 .435 9.643 12.258 -15.004 34.289 (Minutes) as sumed Equal variances .835 44.801 .408 9.643 11.548 -13.619 32.904 not ass umed

424 ENTIRE ED SAMPLE COMORBID AD & ED COMPARED WITH ED ONLY

Group Sta tistics

St d. Error Anxiety N Mean Std. Deviation Mean ED Length (Months ) Comorb ED & AD 65 102.63 81.967 10.167 ED Only 34 76.74 65.683 11.265 ED Onset Age (Years) Comorb ED & AD 65 17.38 5.779 .717 ED Only 34 17.32 5.238 .898 BMI Comorb ED & AD 65 18.7929 3.35291 .41588 ED Only 35 18.9409 3.96698 .67054 No of Episodes Comorb ED & AD 65 12.37 26.735 3.316 Binging per Month ED Only 35 17.74 22.986 3.885 No of Episodes Comorb ED & AD 65 29.52 64.265 7.971 vomiting per month ED Only 35 29.31 56.231 9.505 Ex ercise Per Day Comorb ED & AD 65 48.77 78.790 9.773 (Minutes) ED Only 35 23.57 34.376 5.811

Independent Samples Test

Levene's Test for Equality of Variances t-test for Equality of Means 95% Confidence Interval of the Me an Std. Error Di fference F Sig. t df Sig. (2-tailed) Di fference Di fference Lower Upper ED Length (Months) Equal variances 3.167 .078 1.593 97 .114 25.895 16.258 -6.372 58.163 as sumed Equal variances 1.707 80.959 .092 25.895 15.174 -4.296 56.087 not ass umed ED Onset Age (Years) Equal variances .099 .754 .052 97 .959 .061 1.185 -2.292 2.414 as sumed Equal variances .053 73.116 .958 .061 1.149 -2.229 2.351 not ass umed BMI Equal variances 2.395 .125 -.197 98 .844 -.14793 .75013 -1.63655 1.34068 as sumed Equal variances -.187 60.437 .852 -.14793 .78904 -1.72601 1.43014 not ass umed No of Episodes Equal variances .144 .705 -1.005 98 .317 -5.374 5.346 -15.982 5.234 Binging per Month as sumed Equal variances -1.052 79.236 .296 -5.374 5.108 -15.541 4.793 not ass umed No of Episodes Equal variances .005 .945 .016 98 .987 .209 12.914 -25.419 25.836 vomiting per month as sumed Equal variances .017 78.116 .987 .209 12.405 -24.487 24.904 not ass umed Exercis e Per Day Equal variances 8.783 .004 1.799 98 .075 25.198 14.008 -2.601 52.996 (Minutes) as sumed Equal variances 2.216 94.920 .029 25.198 11.370 2.626 47.770 not ass umed

425 INPATIENT ED LENGTH OF ED COMORBID AD & ED COMPARED WITH ED ONLY

Group Sta tistics

Independent Samples Test

426 INPATIENT & OUTPATIENT ED COMPARISON BETWEEN ED & AD LENGTH / ONSET

Group Sta tistics

St d. Error Facility N Mean Std. Deviation Mean ED Length (Months ) ED Inpatient 37 92.49 77.714 12.776 ED Outpatient 28 116.04 86.864 16.416 Anxiety Length (Months ) ED Inpatient 37 126.62 80.513 13.236 ED Outpatient 28 169.71 90.198 17.046 ED Onset Age (Years) ED Inpatient 37 17.95 6.472 1.064 ED Outpatient 28 16.64 4.724 .893 Anxiety Onset Age (Years) ED Inpatient 37 15.19 9.015 1.482 ED Outpatient 28 12.25 7.250 1.370

Indepe nde nt Samples Te st

Levene's Test for Equality of Varianc es t-test for Equality of Means 95% Confidenc e Interval of the Mean St d. Error Difference F Sig. t df Sig. (2-tailed) Difference Difference Lower Upper ED Length (Months ) Equal variances .040 .842 -1.150 63 .255 -23.549 20.480 -64.475 17.376 as sumed Equal variances -1.132 54.593 .263 -23.549 20.802 -65.244 18.145 not ass umed Anxiety Length (Months ) Equal variances .353 .554 -2.029 63 .047 -43.093 21.241 -85.539 -.647 as sumed Equal variances -1.997 54.512 .051 -43.093 21.581 -86.351 .166 not ass umed ED Onset Age (Years) Equal variances .443 .508 .899 63 .372 1.303 1.450 -1.594 4.200 as sumed Equal variances .938 62.939 .352 1.303 1.389 -1.472 4.079 not ass umed Anxiety Onset Age (Years Equal variances .914 .343 1.413 63 .163 2.939 2.080 -1.218 7.096 as sumed Equal variances 1.456 62.733 .150 2.939 2.018 -1.095 6.973 not ass umed

427 ED ENTIRE SAMPLE EDE SCORES COMPARISON (comorbid AD & ED vs ED only)

Group Statistic s

Std. Error Anxiety Diagnos is N Me an Std. Deviati on Me an Restraint Concern Score No 35 4.034 .9647 .1631 Ye s 65 4.311 1.1220 .1392 Eating Concern Score No 35 3.823 1.3362 .2259 Ye s 65 3.951 1.1495 .1426 Shape Concern Score No 35 4.471 1.2963 .2191 Ye s 65 4.594 1.2176 .1510 Weight Concern Score No 35 4.434 1.4279 .2414 Ye s 65 4.412 1.3536 .1679 Global Score No 35 4.214 1.0327 .1746 Ye s 65 4.329 .9858 .1223

Independent Samples Test

Levene's Test for Equality of Variances t-test for Equality of Means 95% Confidence Interval of the Me an Std. Error Difference F Sig. t df Sig. (2-tailed) Difference Difference Lower Upper Restraint Concern Score Equal variances 1.110 .295 -1.232 98 .221 -.2765 .2243 -.7217 .1687 as sumed Equal variances -1.290 79.236 .201 -.2765 .2144 -.7032 .1502 not ass umed Eating Concern Score Equal variances 1.676 .198 -.501 98 .617 -.1279 .2553 -.6345 .3786 as sumed Equal variances -.479 61.324 .634 -.1279 .2671 -.6619 .4061 not ass umed Shape Concern Score Equal variances .049 .825 -.469 98 .640 -.1224 .2611 -.6406 .3958 as sumed Equal variances -.460 66.057 .647 -.1224 .2661 -.6537 .4089 not ass umed Weight Concern Score Equal variances .120 .729 .076 98 .940 .0220 .2893 -.5521 .5961 as sumed Equal variances .075 66.586 .941 .0220 .2940 -.5649 .6089 not ass umed Global Score Equal variances .000 .993 -.547 98 .586 -.1149 .2101 -.5320 .3021 as sumed Equal variances -.539 66.981 .591 -.1149 .2131 -.5404 .3105 not ass umed

428 4.3 ANALYIS OF VARIANCE (ANOVA)

INPATIENT AND OUTPATIENT ED SAMPLE COMPARISONS ACROSS THE ED SUBTYPES

Descriptives

95% Confidence Interval for Me an N Me an Std. Deviati on Std. Error Lower Bound Upper Bound Mi ni m u m Maximum Ag e AN 39 26.28 9.055 1.450 23.35 29.22 18 56 BN 21 23.67 4.351 .950 21.69 25.65 18 32 ED NOS 40 24.98 6.723 1.063 22.82 27.13 18 45 To tal 100 25.21 7.354 .735 23.75 26.67 18 56 BMI AN 39 15.5841 1.05975 .16970 15.2406 15.9276 12.55 17.10 BN 21 21.4276 2.78233 .60715 20.1611 22.6941 17.80 28.95 ED NOS 40 20.6678 3.07958 .48692 19.6829 21.6526 15.44 28.67 To tal 100 18.8447 3.56050 .35605 18.1382 19.5512 12.55 28.95

Te st of Homoge neity of Variance s

Levene Statisti c df1 df2 Sig. Ag e 4.624 2 97 .012 BMI 16.064 2 97 .000

ANOVA

Sum of Squares df Mean Square F Sig. Ag e Between Groups 97.051 2 48.525 .895 .412 Within Groups 5257.539 97 54.201 To tal 5354.590 99 BMI Between Groups 687.670 2 343.835 58.783 .000 Within Groups 567.371 97 5.849 To tal 1255.041 99

429 Post Hoc Tests

Multiple Comparisons Games -Howell

Mean (I) Eating Disorder (J) Eating Disorder Difference 95% Confidenc e Interval Dependent Variable Diagnosis Diagnosis (I-J) St d. Error Sig. Lower Bound Upper Bound Age AN BN 2.615 1.733 .294 -1.55 6.79 EDNOS 1.307 1.798 .748 -3.00 5.61 BN AN -2.615 1.733 .294 -6.79 1.55 EDNOS -1.308 1.425 .631 -4.74 2.12 EDNOS AN -1.307 1.798 .748 -5.61 3.00 BN 1.308 1.425 .631 -2.12 4.74 BMI AN BN -5.84352* .63042 .000 -7.4215 -4.2655 EDNOS -5.08365* .51565 .000 -6.3305 -3.8368 BN AN 5.84352* .63042 .000 4.2655 7.4215 EDNOS .75987 .77829 .595 -1.1270 2.6468 EDNOS AN 5.08365* .51565 .000 3.8368 6.3305 BN -.75987 .77829 .595 -2.6468 1.1270 *. The mean difference is significant at the .05 level.

BMI ACROSS ED SUBTYPES

Between-Subjects Factors

Value Label N Eating Disorder 1 AN 39 Diagnosis 3 BN 21 4 ED NOS 40

De scri ptive Statistics Dependent Variable: BMI Eating Disorder Mean Std. Deviation N AN 15.5841 1.05975 39 BN 21.4276 2.78233 21 EDNOS 20.6678 3.07958 40 To tal 18.8447 3.56050 100

Le vene's Test of Equa lity of Error Va riancesa Dependent Variable: BMI F df1 df2 Sig. 16.064 2 97 .000 Tests the null hypothes is that the error variance o the dependent variable is equal across groups. a. Design: Intercept+ED

430 Te sts of Betw een-Subjects Effects Dependent Variable: BMI Ty pe III Sum Partial Eta Noncent. Observed a Source of Squares df Mean Square F Sig. Squared Parameter Power Correc ted Model 687.670b 2 343.835 58.783 .000 .548 117.567 1.000 Intercept 33858.324 1 33858.324 5788.549 .000 .984 5788.549 1.000 ED 687.670 2 343.835 58.783 .000 .548 117.567 1.000 Error 567.371 97 5.849 To tal 36767.313 100 Correc ted Total 1255.041 99 a. Computed using alpha = .05 b. R Squared = .548 (Adjusted R Squared = .539)

Estimated Marginal Means

Ea ting Disorder Diagnosis Dependent Variable: BMI Eating Dis order 95% Confidenc e Interval Diagnosis Mean St d. Error Lower Bound Upper Bound AN 15.584 .387 14.815 16.353 BN 21.428 .528 20.380 22.475 EDNOS 20.668 .382 19.909 21.427

Post Hoc Tests

Eating Disorder Diagnosis

Multiple Comparisons Dependent Variable: BMI Games -Howell

Mean (I) Eating Disorder (J) Eating Disorder Di fference 95% Confidenc e Interval Diagnosis Diagnosis (I-J) St d. Error Sig. Lower Bound Upper Bound AN BN -5.8435* .63042 .000 -7.4215 -4.2655 EDNOS -5.0836* .51565 .000 -6.3305 -3.8368 BN AN 5.8435* .63042 .000 4.2655 7.4215 EDNOS .7599 .77829 .595 -1.1270 2.6468 EDNOS AN 5.0836* .51565 .000 3.8368 6.3305 BN -.7599 .77829 .595 -2.6468 1.1270 Based on observed means. *. The mean differenc e is significant at the .05 level.

431 Descriptives

95% Confidenc e Interval for Mean N Mean Std. Deviation St d. Error Lower Bound Upper Bound Minimum Maximum Education (Years) AN 39 14.13 2.028 .325 13.47 14.79 11 20 BN 21 13.90 1.841 .402 13.07 14.74 11 19 EDNOS 40 13.68 2.200 .348 12.97 14.38 10 19 To tal 100 13.90 2.052 .205 13.49 14.31 10 20 ED Length (Months ) AN 39 89.10 80.948 12.962 62.86 115.34 7 288 BN 21 87.33 54.777 11.953 62.40 112.27 6 216 EDNOS 39 101.82 84.926 13.599 74.29 129.35 3 336 To tal 99 93.74 77.415 7.781 78.30 109.18 3 336 ED Onset Age (Years) AN 39 18.82 6.893 1.104 16.59 21.06 13 43 BN 21 16.38 2.924 .638 15.05 17.71 12 22 EDNOS 39 16.44 4.946 .792 14.83 18.04 9 34 To tal 99 17.36 5.572 .560 16.25 18.48 9 43

Te st of Homogeneity of Var ianc es

Levene Statisti c df1 df2 Sig. Education (Years) .360 2 97 .699 ED Length (Months) 1.803 2 96 .170 ED Onset Age (Years) 2.109 2 96 .127

ANOVA

Sum of Squares df Mean Square F Sig. Education (Years) Between Groups 4.057 2 2.028 .476 .622 Within Groups 412.943 97 4.257 To tal 417.000 99 ED Length (Months) Between Groups 4247.172 2 2123.586 .350 .706 Within Groups 583080.0 96 6073.750 To tal 587327.2 98 ED Onset Age (Years) Between Groups 136.623 2 68.312 2.256 .110 Within Groups 2906.286 96 30.274 To tal 3042.909 98

432 Post Hoc Tests

Multiple Compa risons Tu key H SD

Me an (I) Eating Disorder (J) Eating Disorder Di fference 95% Confidence Interval Dependent Variable Diagnosis Diagnosis (I-J) Std. Error Sig. Lower Bound Upper Bound Education (Years) AN BN .223 .558 .916 -1.11 1.55 ED NOS .453 .464 .594 -.65 1.56 BN AN -.223 .558 .916 -1.55 1.11 ED NOS .230 .556 .910 -1.09 1.55 ED NOS AN -.453 .464 .594 -1.56 .65 BN -.230 .556 .910 -1.55 1.09 ED Length (Months) AN BN 1.769 21.094 .996 -48.45 51.99 ED NOS -12.718 17.649 .752 -54.73 29.30 BN AN -1.769 21.094 .996 -51.99 48.45 ED NOS -14.487 21.094 .772 -64.70 35.73 ED NOS AN 12.718 17.649 .752 -29.30 54.73 BN 14.487 21.094 .772 -35.73 64.70 ED Onset Age (Years) AN BN 2.440 1.489 .235 -1.11 5.98 ED NOS 2.385 1.246 .140 -.58 5.35 BN AN -2.440 1.489 .235 -5.98 1.11 ED NOS -.055 1.489 .999 -3.60 3.49 ED NOS AN -2.385 1.246 .140 -5.35 .58 BN .055 1.489 .999 -3.49 3.60

Homogeneous Subsets

Ed uca tion (Ye ars) a,b Tukey HSD Subset for alpha Eating Dis order = .05 Diagnosis N 1 EDNOS 40 13.68 BN 21 13.90 AN 39 14.13 Sig. .668 Means for groups in homogeneous subs ets are displayed. a. Us es Harmonic Mean Sample Size = 30.531. b. The group sizes are unequal. The harmonic mean of the group siz es is us ed. Type I error levels are not guaranteed.

433 ED Le ngth (Months) a,b Tukey HSD Subset for alpha Eating Dis order = .05 Diagnosis N 1 BN 21 87.33 AN 39 89.10 EDNOS 39 101.82 Sig. .750 Means for groups in homogeneous subs ets are displayed. a. Us es Harmonic Mean Sample Size = 30.333. b. The group sizes are unequal. The harmonic mean of the group siz es is us ed. Type I error levels are not guaranteed.

ED On se t Age (Ye a rs) a,b Tukey HSD Subset for alpha Eating Dis order = .05 Diagnosis N 1 BN 21 16.38 EDNOS 39 16.44 AN 39 18.82 Sig. .201 Means for groups in homogeneous subs ets are displayed. a. Us es Harmonic Mean Sample Size = 30.333. b. The group sizes are unequal. The harmonic mean of the group siz es is us ed. Type I error levels are not guaranteed.

434 ENTIRE ED SAMPLE COMPARISON BETWEEN ED SYMPTOMS ACROSS ALL AD DIAGNOSES

Descriptives

95% Confidence Interval for Me an N Me an Std. Deviati on Std. Error Lower Bound Upper Bound Minimum Maximum BMI Panic with Ag 1 16.5500 . . . . 16.55 16.55 Panic w/o Ag 1 17.8200 . . . . 17.82 17.82 Social Phobia 27 18.5037 2.98146 .57378 17.3243 19.6831 12.55 24.20 GAD 15 19.5087 3.96999 1.02505 17.3102 21.7072 13.99 28.95 OC D 3 16.7033 1.82511 1.05373 12.1695 21.2372 15.60 18.81 Specific Phobia 1 13.8000 . . . . 13.80 13.80 PTSD 17 19.4724 3.52899 .85591 17.6579 21.2868 14.43 25.50 To tal 65 18.7929 3.35291 .41588 17.9621 19.6237 12.55 28.95 ED Length (Months) Panic with Ag 1 252.00 . . . . 252 252 Panic w/o Ag 1 36.00 . . . . 36 36 Social Phobia 27 84.74 69.116 13.301 57.40 112.08 6 276 GAD 15 94.40 93.599 24.167 42.57 146.23 24 336 OC D 3 52.00 13.856 8.000 17.58 86.42 36 60 Specific Phobia 1 144.00 . . . . 144 144 PTSD 17 139.94 84.140 20.407 96.68 183.20 15 300 To tal 65 102.63 81.967 10.167 82.32 122.94 6 336 ED Ons et Age (Years ) Panic with Ag 1 18.00 . . . . 18 18 Panic w/o Ag 1 16.00 . . . . 16 16 Social Phobia 27 18.04 5.687 1.095 15.79 20.29 12 38 GAD 15 18.33 7.678 1.982 14.08 22.59 11 43 OC D 3 16.00 1.732 1.000 11.70 20.30 15 18 Specific Phobia 1 14.00 . . . . 14 14 PTSD 17 16.00 4.924 1.194 13.47 18.53 10 30 To tal 65 17.38 5.779 .717 15.95 18.82 10 43 No of Episodes Panic with Ag 1 .00 . . . . 0 0 Binging per Month Panic w/o Ag 1 .00 . . . . 0 0 Social Phobia 27 17.67 36.102 6.948 3.39 31.95 0 140 GAD 15 16.00 23.213 5.994 3.14 28.86 0 84 OC D 3 .00 .000 .000 .00 .00 0 0 Specific Phobia 1 .00 . . . . 0 0 PTSD 17 5.12 9.823 2.382 .07 10.17 0 36 To tal 65 12.37 26.735 3.316 5.74 18.99 0 140 No of Episodes Panic with Ag 1 .00 . . . . 0 0 vomiting per month Panic w/o Ag 1 25.00 . . . . 25 25 Social Phobia 27 46.33 92.566 17.814 9.72 82.95 0 280 GAD 15 19.07 34.483 8.903 -.03 38.16 0 112 OC D 3 3.00 5.196 3.000 -9.91 15.91 0 9 Specific Phobia 1 .00 . . . . 0 0 PTSD 17 20.47 25.373 6.154 7.43 33.52 0 84 To tal 65 29.52 64.265 7.971 13.60 45.45 0 280 Exercis e Per Day Panic with Ag 1 .00 . . . . 0 0 (Minutes) Panic w/o Ag 1 .00 . . . . 0 0 Social Phobia 27 37.78 56.795 10.930 15.31 60.25 0 150 GAD 15 26.00 47.929 12.375 -.54 52.54 0 150 OC D 3 70.00 45.826 26.458 -43.84 183.84 30 120 Specific Phobia 1 120.00 . . . . 120 120 PTSD 17 84.12 120.834 29.306 21.99 146.24 0 400 To tal 65 48.77 78.790 9.773 29.25 68.29 0 400

435 Te st of Homogeneity of Var ianc es

Levene Statisti c df1 df2 Sig. BMI 1.048a 3 58 .378 ED Length (Months) 1.470b 3 58 .232 ED Onset Age (Years) .599c 3 58 .618 No of Episodes d 3.110 3 58 .033 Binging per Month No of Episodes e 4.691 3 58 .005 vomiting per month Exercis e Per Day f 2.625 3 58 .059 (Minutes) a. Groups with only one case are ignored in computing the test of homogeneity of variance for BMI. b. Groups with only one case are ignored in computing the test of homogeneity of variance for ED Length (Months) . c. Groups with only one case are ignored in computing the test of homogeneity of variance for ED Onset Age (Years). d. Groups with only one case are ignored in computing the test of homogeneity of variance for No of Episodes Binging per Month . e. Groups with only one case are ignored in computing the test of homogeneity of variance for No of Episodes vomiting per month . f. Groups with only one case are ignored in computing the test of homogeneity of variance for Exercise Per Day (Minutes ) .

ANOVA

Sum of Squares df Mean Square F Sig. BMI Between Groups 61.796 6 10.299 .908 .495 Within Groups 657.691 58 11.339 To tal 719.487 64 ED Length (Months) Between Groups 69475.412 6 11579.235 1.863 .103 Within Groups 360509.7 58 6215.685 To tal 429985.1 64 ED Onset Age (Years) Between Groups 77.088 6 12.848 .362 .900 Within Groups 2060.296 58 35.522 To tal 2137.385 64 No of Episodes Between Groups 2767.374 6 461.229 .622 .712 Binging per Month Within Groups 42975.765 58 740.961 To tal 45743.138 64 No of Episodes Between Groups 14537.047 6 2422.841 .563 .758 vomiting per month Within Groups 249781.2 58 4306.572 To tal 264318.2 64 Exercis e Per Day Between Groups 43463.107 6 7243.851 1.187 .326 (Minutes) Within Groups 353838.4 58 6100.663 To tal 397301.5 64

436 ENTIRE SAMPLE COMPARISON OF EDE SCORES

Descriptives

95% Confidenc e Interval for Mean N Mean Std. Deviation St d. Error Lower Bound Upper Bound Minimum Maximum Restraint Conc ern Score ED Inpatient 50 4.492 .9435 .1334 4.224 4.760 1.8 6.0 ED Outpatient 50 3.936 1.1302 .1598 3.615 4.257 1.6 6.0 Anxiety Patient 7 3.743 1.0114 .3823 2.808 4.678 1.8 4.8 To tal 107 4.183 1.0708 .1035 3.978 4.388 1.6 6.0 Eating Concern Sc ore ED Inpatient 50 3.916 1.1118 .1572 3.600 4.232 1.4 6.0 ED Outpatient 50 3.896 1.3175 .1863 3.522 4.270 1.4 6.0 Anxiety Patient 7 2.457 1.3986 .5286 1.164 3.751 1.0 4.6 To tal 107 3.811 1.2705 .1228 3.568 4.055 1.0 6.0 Shape Concern Sc ore ED Inpatient 50 4.454 1.2418 .1756 4.101 4.807 1.3 5.9 ED Outpatient 50 4.648 1.2441 .1759 4.294 5.002 1.0 6.0 Anxiety Patient 7 3.971 .7588 .2868 3.270 4.673 2.8 5.0 To tal 107 4.513 1.2209 .1180 4.279 4.747 1.0 6.0 W eight Concern Sc ore ED Inpatient 50 4.288 1.5692 .2219 3.842 4.734 1.0 6.0 ED Outpatient 50 4.552 1.1447 .1619 4.227 4.877 1.6 6.0 Anxiety Patient 7 3.629 .6370 .2407 3.039 4.218 2.6 4.2 To tal 107 4.368 1.3498 .1305 4.110 4.627 1.0 6.0 Global Score ED Inpatient 50 4.298 .9747 .1378 4.021 4.575 2.4 5.7 ED Outpatient 50 4.280 1.0321 .1460 3.987 4.573 1.7 5.9 Anxiety Patient 7 3.471 .5707 .2157 2.944 3.999 2.8 4.4 To tal 107 4.236 .9957 .0963 4.045 4.426 1.7 5.9

Te st of Homoge neity of Varia nce s

Levene Statisti c df1 df2 Sig. Restraint Concern Score 1.238 2 104 .294 Eating Concern Score 1.324 2 104 .271 Shape Concern Score 1.164 2 104 .316 Weight Concern Score 5.753 2 104 .004 Global Score 1.087 2 104 .341

437 ANOVA

Sum of Squares df Mean Square F Sig. Restraint Concern Score Between Groups 9.181 2 4.590 4.249 .017 Within Groups 112.349 104 1.080 To tal 121.530 106 Eating Concern Score Between Groups 13.743 2 6.871 4.541 .013 Within Groups 157.364 104 1.513 To tal 171.107 106 Shape Concern Score Between Groups 3.138 2 1.569 1.054 .352 Within Groups 154.863 104 1.489 To tal 158.002 106 Weight Concern Score Between Groups 5.840 2 2.920 1.621 .203 Within Groups 187.292 104 1.801 To tal 193.132 106 Global Score Between Groups 4.381 2 2.190 2.262 .109 Within Groups 100.704 104 .968 To tal 105.085 106

438

Post Hoc Tests

Multiple Compa risons LSD

Me an Difference 99% Confidence Interval Dependent Variable (I) Faci lity (J) Facility (I-J) Std. Error Sig. Lower Bound Upper Bound Restraint Concern Score ED Inpatient ED Outpatient .5560* .2079 .009 .011 1.101 Anxiety Patient .7491 .4194 .077 -.351 1.850 ED Outpatient ED Inpatient -.5560* .2079 .009 -1.101 -.011 Anxiety Patient .1931 .4194 .646 -.907 1.294 Anxiety Patient ED Inpatient -.7491 .4194 .077 -1.850 .351 ED Outpatient -.1931 .4194 .646 -1.294 .907 Eating Concern Score ED Inpatient ED Outpatient .0200 .2460 .935 -.626 .666 Anxiety Patient 1.4589* .4964 .004 .156 2.761 ED Outpatient ED Inpatient -.0200 .2460 .935 -.666 .626 Anxiety Patient 1.4389* .4964 .005 .136 2.741 Anxiety Patient ED Inpatient -1.4589* .4964 .004 -2.761 -.156 ED Outpatient -1.4389* .4964 .005 -2.741 -.136 Shape Concern Score ED Inpatient ED Outpatient -.1940 .2441 .428 -.834 .446 Anxiety Patient .4826 .4924 .329 -.810 1.775 ED Outpatient ED Inpatient .1940 .2441 .428 -.446 .834 Anxiety Patient .6766 .4924 .172 -.616 1.969 Anxiety Patient ED Inpatient -.4826 .4924 .329 -1.775 .810 ED Outpatient -.6766 .4924 .172 -1.969 .616 Weight Concern Score ED Inpatient ED Outpatient -.2640 .2684 .328 -.968 .440 Anxiety Patient .6594 .5416 .226 -.762 2.080 ED Outpatient ED Inpatient .2640 .2684 .328 -.440 .968 Anxiety Patient .9234 .5416 .091 -.498 2.344 Anxiety Patient ED Inpatient -.6594 .5416 .226 -2.080 .762 ED Outpatient -.9234 .5416 .091 -2.344 .498 Global Score ED Inpatient ED Outpatient .0180 .1968 .927 -.498 .534 Anxiety Patient .8266 .3971 .040 -.215 1.869 ED Outpatient ED Inpatient -.0180 .1968 .927 -.534 .498 Anxiety Patient .8086 .3971 .044 -.233 1.851 Anxiety Patient ED Inpatient -.8266 .3971 .040 -1.869 .215 ED Outpatient -.8086 .3971 .044 -1.851 .233 *. The mean difference is s ignificant at the .01 level.

439

4.4 LOGISTIC REGRESSION ANALYSES

Case Processing Summary a Unweighted Cases N Percent Selected Cases Included in Analysis 100 100.0 Mis sing Cases 0 .0 To tal 100 100.0 Unselected Cas es 0 .0 To tal 100 100.0 a. If weight is in effect, s ee class ification table for the total number of cases.

De pendent Varia ble Encoding

Original Value Internal Value No 0 Yes 1

Block 0: Beginning Block

Classification Table a,b

Predicted

Anxiety Diagnos is Percentage Observed No Ye s Correct Step 0 Anxiety Diagnos is No 0 35 .0 Ye s 0 65 100.0 Overall Percentage 65.0 a. Constant is included in the model. b. The cut value is .500

Va riables in the Equa tion

B S.E. W ald df Sig. Ex p(B) Step 0 Constant .619 .210 8.718 1 .003 1.857

440 Va riables not in the Equa tion

Sc ore df Sig. Step Variables RESTRAINT 1.526 1 .217 0 EA TING .256 1 .613 SHAPE .224 1 .636 W EIGHT .006 1 .939 GLOBAL .304 1 .581 Overall Statistics 5.842 5 .322

Block 1: Method = Enter

Omnibus Tests of Mode l Coeffic ients

Chi-square df Sig. Step 1 Step 5.936 5 .313 Block 5.936 5 .313 Model 5.936 5 .313

Model Summar y

-2 Log Cox & Snel l Nagelkerke Step likelihood R Square R Square 1 123.553a .058 .079 a. Es timation terminated at iteration number 4 because parameter estimates changed by les s than .001.

Classification Table a

Predicted

Anxiety Diagnos is Percentage Observed No Ye s Correct Step 1 Anxiety Diagnos is No 3 32 8.6 Ye s 7 58 89.2 Overall Percentage 61.0 a. The cut value is .500

441 Variables in the Equation

95.0% C.I.for EXP(B) B S.E. Wa ld df Sig. Exp(B) Lower Upper

Stepa RESTRAINT 3.968 2.166 3.355 1 .067 52.874 .757 3692.064 1 EATING 3.658 2.166 2.853 1 .091 38.792 .556 2706.218 SHAPE 4.047 2.246 3.245 1 .072 57.215 .700 4673.592 WEIGH T 3.451 2.259 2.333 1 .127 31.537 .376 2642.997 GL OBAL -14.943 8.798 2.885 1 .089 .000 .000 9.973 Constant .067 1.035 .004 1 .948 1.070 a. Variable(s) entered on step 1: RESTRAINT, EATING, SHAPE, WEIGHT, GLOBAL.

442