Psychiatric comorbidity and inpatient treatment history in bulimic subjects

Abstract

Bulimia nervosa (BN) is often associated with other forms of psychopathology. There is a need to clarify which specific factors of psychopathology are linked with the referral to psychiatric or psychotherapeutic inpatient treatment. This study examined which factors of psychopathology are linked with the referral of BN patients to inpatient treatment while controlling for history of suicide attempts and history of underweight. 126 females with a current diagnosis of BN purging type were assessed with the Structured Clinical Interview for DSM-IV and interviewed about their history of treatment for the BN, history of weight, and history of suicide attempts. Logistic regressions were conducted to examine whether psychiatric comorbidity, suicide attempts, and underweight were associated with inpatient treatment history. Axis I comorbidity in general, but no specific axis I disorder, was associated with inpatient history. Axes II comorbidity, especially Cluster B disorders and to a lesser degree depressive/negativistic personality disorders, was associated with a history of inpatient treatment. History of suicide attempts was also linked with inpatient experience, but history of underweight was not. The results showed that BN patients with specific types of comorbidity are more likely to be hospitalized than others.

Introduction

Bulimia nervosa (BN) is the most prevalent of eating disorders, affecting between 1% and 3% of adolescent and young adult women [1]. Clinical experience and research indicates that BN patients often present a complex psychopathological picture with high levels of psychiatric comorbidity both on axes I and II [2], [3]. When determining what type of treatment to offer, clinicians consider how the disorder has affected the patient's social integration and ability to work, previous failed attempts of therapy, and the severity of the patient's disorder, of which one aspect is presence and type of comorbidity. Thus, persons attending more intense treatment settings, such as psychiatric or psychotherapeutic inpatient treatment facilities, tend to have higher levels of psychopathology. To this end, it has been shown that eating disorder inpatients have higher levels of anxiety, depression, and somatization [4], and higher rates of personality disorders [5], [6] than outpatients. The existing research investigating differences of psychopathology between inpatient and noninpatient eating disorder samples has not employed systematic assessments of psychiatric comorbidity. In addition, while findings of differences in levels of psychopathology have been reported, the significance of the type of comorbidity for referral of BN patients to inpatient treatment has not previously been systematically examined. Identifying the specific psychopathological characteristics that are associated with psychiatric or psychotherapeutic inpatient treatment would help to better understand referral processes, and help in tailoring appropriate treatment programs or support existing standards of care in the treatment of BN.

This study was designed to examine which specific types of psychopathology are found in BN subjects with inpatient experience as compared to BN subjects without such experience. Assessing the whole range of axes I and II comorbidity made it possible to examine specific types of comorbidity for links with inpatient experience while controlling for other forms of psychopathology. Deliberate self-harming behavior, such as suicide attempts [7] and severe underweight [8], are considered indications for hospitalization of eating disorder patients. Because suicidality or starvation behavior may be confounded with axes I or II comorbidity, past suicidal behavior or episodes of underweight are factors that ought to be controlled when examining psychopathological characteristics for associations with psychiatric or psychotherapeutic inpatient treatment.

In the existing literature it is customary to classify subjects based on their current treatment referral status (i.e., inpatient, outpatient, nonpatient). The current referral status, however, is transitory. As a consequence, clinical outpatient samples frequently include cases with past hospitalizations [2], [9]. To classify subjects into groups that are homogenous with regard to treatment experience, in this study each person's entire treatment history was taken into account when determining her status as an ‘inpatient’ or a person without inpatient experience.