Elsevier

Psychiatry Research

Volume 117, Issue 3, 25 March 2003, Pages 245-258
Psychiatry Research

Anxiety disorders in subjects seeking treatment for eating disorders: a DSM-IV controlled study

https://doi.org/10.1016/S0165-1781(03)00038-6Get rights and content

Abstract

Women who were referred with an eating disorder (ED) were compared with a matched normal control group to answer the following questions: What are the frequencies of anxiety disorders in cases of anorexia and bulimia nervosa diagnosed according to DSM-IV criteria? Are anxiety disorders significantly more frequent among women with an eating disorder than among women from the community? We assessed the frequencies of six specific anxiety disorders among 271 women with a current diagnosis of anorexia or bulimia nervosa and 271 controls, using the Mini-International Neuropsychiatric Interview, French DSM-IV version. A lifetime comorbidity with at least one anxiety disorder was found in 71% of both the anorexic and the bulimic subjects, significantly higher than the percentage of controls with an anxiety disorder. The prevalence was significantly higher in the eating disorder groups than in controls for most types of anxiety disorder, and between 41.8 and 53.3% of comorbid cases had an anxiety disorder preceding the onset of the eating disorder. Anxiety disorders are significantly more frequent in subjects with eating disorders than in volunteers from the community, a finding that has important etiological and therapeutic implications.

Introduction

Comorbidity between eating disorders and anxiety disorders is an important issue as regards both the pathogenesis and the treatment of these disorders (Bulik, 1995, Herzog et al., 1996, Wonderlich and Mitchell, 1997). However, the frequencies of anxiety disorders in subjects seeking treatment for an eating disorder are still uncertain. When limiting our search to the 1985–2002 period (in order to get sufficiently homogeneous diagnostic criteria for both categories of disorders, most often RDC, DSM-III, DSM-III-R, or DSM-IV criteria), we found 24 studies (Piran et al., 1985, Walsh et al., 1985, Hudson et al., 1987, Laessle et al., 1987, Hudson et al., 1988, Powers et al., 1988, Laessle et al., 1989, Keck et al., 1990, Fornari et al., 1992, Herzog et al., 1992, Schwalberg et al., 1992, Bossert-Zaudig et al., 1993, Brewerton et al., 1993, Braun et al., 1994, Bushnell et al., 1994, Brewerton et al., 1995, Thiel et al., 1995, Bulik et al., 1996, Grilo et al., 1996, Bulik et al., 1997, Thornton and Russell, 1997, Lilenfeld et al., 1998, Godart et al., 2000, Iwasaki et al., 2000) investigating the prevalence of anxiety disorders among inpatients or outpatients with a current diagnosis of an eating disorder who were referred to specialized clinics for treatment, who were placed on a waiting list, or who volunteered for research (we do not consider here studies conducted in the community or follow-up studies of patients with eating disorders).

The methods and findings of previous studies on the prevalence of anorexia nervosa in women with eating disorders have been reviewed elsewhere (Godart et al., 2002). Results are very different across studies. For example, the lifetime prevalence of at least one anxiety disorder varies from 25 (Keck et al., 1990) to 75% (Schwalberg et al., 1992) in bulimia nervosa and from 23 (Laessle et al., 1987) to 54% (Piran et al., 1985) in anorexia nervosa. Only six of the 24 studies have included control groups and because anxiety disorders are among the most frequent disorders in women from the community—with an overall lifetime prevalence from 12.7 to 18.1% (Wittchen and Essau, 1993)—it is not clear whether anxiety disorders are more frequent in women with anorexia or bulimia nervosa than in women from the community.

Many studies on comorbidity between eating and anxiety disorders suffer from general methodological limitations (Mitchell et al., 1991, Schwalberg et al., 1992, Godart et al., 2002); therefore, the findings are not strong and comparisons are often inconclusive. The number of anxiety disorders taken into consideration varies from two to six across studies, and in the few controlled studies, the control groups are not matched to the patients for age or other important characteristics (Bulik et al., 1997).

Taking into account these considerations, and as there was only one published study using DSM-IV criteria to date (Iwasaki et al., 2000) (with no control group), we designed this project of a controlled study between a large group of referred women with eating disorders and a matched control group to answer the following questions: (1) What are the frequencies of all types of anxiety disorders in anorexia nervosa and bulimia nervosa diagnosed according to DSM-IV criteria? (2) Are anxiety disorders significantly more frequent among women with eating disorders than among women from the community (see below for definition)? (3) What is the chronology of appearance of the anxiety disorder and the eating disorder?

Section snippets

Subjects

Women seeking treatment for an eating disorder were recruited as part of a larger French multicenter study on addictive disorders (eating disorder, alcohol dependence and illicit drug dependence; INSERM Network on Addictive Disorders no. 494013) (Godart et al., 1999, Flament et al., 1999). Inclusion criteria for subjects with eating disorders were as follows: all consecutive female inpatients or outpatients, referred to one of the Network clinics (listed in Appendix A) with a current DSM-IV

Characteristics of the subjects

The 271 eating disorder patients are divided into four groups according to DSM-IV current diagnosis: 111 AN-R, 55 AN-BN, 86 BN-P, and 19 BN-NP. Inpatients accounted for 81% of the AN-R and 64.8% of the AN-BN, while outpatients accounted for 84.2% of the BN-NP and 75.6% of the BN-P. Table 1 describes the main characteristics of subjects in each clinical and control group. The mean age and BMI of patients are compared with those of controls. The anorexia nervosa group and subgroups (AN-R and

Comorbidity of eating disorders and anxiety disorders

To our knowledge, this is the first published study that has used DSM-IV criteria to compare current and lifetime prevalences of anxiety disorders in referred subjects with an eating disorder and individually matched controls. The results show a significantly higher overall frequency of anxiety disorders in all diagnostic types of eating disorder (AN-R, AN-BN, BN-NP, BN-P) compared with the frequency in controls. Furthermore, comorbidity with anxiety disorders is in most cases current, which is

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