Anxiety disorders in anorexia nervosa and bulimia nervosa.docx
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Anxietydisordersinanorexianervosaandbulimianervosa
Anxietydisordersinanorexianervosaandbulimianervosa:
co-morbidityandchronologyofappearance
N.T.Godart1,M.F.Flament2,Y.Lecrubier3andP.Jeammet1
1DepartmentofPsychiatry,InstitutMutualisteMontsouris,Paris,France
2CNRSUMR7593,HôpitalLaSalpêtrière,Paris,France
3INSERMU302,HôpitalLaSalpêtrière,Paris,France
Availableonline22May2000.
Abstract
Theobjectivesofthestudyweretoassesslifetimeprevalenceofspecificanxietydisorders,andtheirageofonsetrelativetothatofeatingdisorders(ED),inaFrenchsampleofpatientswithanorexianervosa(AN)orbulimianervosa(BN).Weassessedfrequenciesofsevenanxietydisordersandchildhoodhistoriesofseparationanxietydisorderamong63subjectswithacurrentDSM-IVdiagnosisofanED,usingtheCompositeInternationalDiagnosticInterview(CIDI).Eighty-threepercentofsubjectswithANand71%ofthosewithBNhadatleastonelifetimediagnosisofananxietydisorder.Byfar,themostfrequentwassocialphobia(55%oftheanorexicsand59%ofthebulimics).Whenpresent,theco-morbidanxietydisorderhadpredatedtheonsetoftheEDin75%ofsubjectswithAN,and88%ofsubjectswithBN.Ourresultsareconsistentwiththoseofstudiesconductedinothercountries,andshowthatananxietydisorderfrequentlyexistsbeforeanED.ThishastobetakeninconsiderationforsuccessfultreatmentofpatientswithANorBN.
AuthorKeywords:
ageofonset;anorexianervosa;anxietydisorders;bulimianervosa;co-morbidity;socialphobia
ArticleOutline
1.Introduction
2.Materialandmethods
2.1.Subjects
2.2.Assessmentinstruments
2.3.Statisticalanalysis
3.Results
3.1.Diagnosticgroups
3.2.Socio-demographiccharacteristics
3.3.Prevalenceandageofonsetofanxietydisorders
3.4.Numberoflifetimeanxietydisorders
3.5.Chronologyofappearanceofanxietyandeatingdisorders
4.Discussion
Acknowledgements
AppendixA
References
1.Introduction
Patientswitheatingdisorders(ED)frequentlyexhibitanxietysymptoms.Thosewithanorexianervosa(AN)oftenpresentobsessionsorcompulsionsunrelatedtofoodpreoccupations(washingrituals,counting,phobicobsessions,etc.).Youngwomenwithbulimianervosa(BN)fearsocialcontacts,althoughtheyjustifytheirinabilitytomeetnewpeopleortoparticipateinsocialgatheringsbytheireffortstohidetheirdisturbedeatingbehaviors [12].However,JohnsonandLarson [18]havesuggestedthattheproblemcouldbeconsideredinversely:
theEDcouldoccurinresponsetoapre-existinganxietydisorder.Fornarietal. [13]alsostatedthatanxietycouldcontributetotheonsetandmaintenanceofanED,eventhoughthespecificnatureoftherelationshipbetweenEDandanxietydisordersisstillunknown.
PublishedstudieswhichexaminedtheprevalenceofanxietydisordersinsubjectswithEDareveryheterogeneousintermsofmethodsand,therefore,results [26,29and31].PossiblesourcesofvariabilitybetweenstudiesincludesubjectshavingeitheracurrentorpastdiagnosisofED,diagnosticcriteriausedforEDandanxietydisorders,assessmentinstruments,samplesource(community-based,referred,treatmentstudy),samplesize,etc.Inaddition,thenumberofanxietydisordersassessedinthevariousstudiesrangesfromtwo [20]tofivedisorders [26],whichobviouslychangestheestimateoftheoverallrateofanxietydisordersinEDsubjects.
Despitemethodologicaldiscrepancies,previousstudieshaveconsistentlyshownahighco-morbiditybetweenEDandanxietydisorderswithprevalenceratesforanxietydisordersgenerallytwoorthreetimesgreaterthanthosereportedinthecommunity [13,23and26].Inwomenfromthecommunity,anxietydisordersarethemostcommonmentaldisorders,withanoveralllifetimeprevalencerangingfrom12.7to18.1% [34].Alifetimediagnosisofatleastoneanxietydisorderhasbeenfoundin13to75%ofwomenwithBN [14and26],and20to55%ofthosewithAN [14and23].ThemostcommonassociatedanxietydisordersfoundinsubjectswithBNweregeneralizedanxietydisorder(0to55% [3and26])andsocialphobia(4to56% [20and23]).InpatientswithAN,thetwomostfrequentco-morbidanxietydisordershavebeenshowntobesocialphobia(3to54% [3and27])andobsessivecompulsivedisorder(OCD)(3to66% [13and14]).
OnlyafewinvestigatorshaveexaminedthetemporalrelationshipbetweenEDandanxietydisorders,yieldingdivergentresults.Inthreestudies,atleastoneanxietydisorder(amongfourorfiveassessed)hadpredatedtheonsetofeitherANorBNinapproximatelytwo-thirdsofthecases [5,8and32].However,inanotherstudyincluding105EDpatients,63%oftherestrictinganorexicsand33%ofthebulimicsdevelopedtheirEDbeforeanyanxietydisorder,affectivedisorder,oralcohol/substancedependence [3].Inasomewhatdifferentperspective,sincetheywerelookingspecificallyatanxietydisorderswithchildhoodonset,Deepetal. [9]studiedretrospectively24long-termrecoveredANpatients:
11(46%)hadanhistoryofachildhoodanxietydisorder(separationanxietydisorder,overanxiousdisorder,simplephobia,socialphobia)priortotheonsetofAN.Afewstudieshavelookedatthetimeofonsetforspecificco-morbidanxietydisorders.Whenpresent,socialphobiawasanteriortotheEDin10/10bulimicpatientsinonestudy [4],andin11/14(79%)anorexicorbulimicpatientsinanother [3].Kasvikisetal. [19]reportedthatfor16patientswithco-morbidOCDandAN,OCDhadpredatedtheEDin40%ofthecases,whereasFahyetal. [10],inalargeseries(N=105)ofOCDpatients,found12withco-morbidAN:
forthose,theageofonsetwasthesameforbothdisorders,andlowerthantheageofonsetofOCDforsubjectswithoutco-morbidAN.
Thecurrentstudywasdesigned:
1)toassesslifetimeprevalenceofalltypesofanxietydisorders,andchildhoodhistoryofseparationanxietydisorder,insubjectswithacurrentdiagnosisofANorBN;2)incaseofco-morbidity,toascertaintheageofonsetoftheanxietydisorderrelativetothatoftheED.Weexpectedtofindahighco-morbiditybetweenEDandanxietydisorders,especiallysocialphobia.Ourhypothesiswasthatwhenbothdisorderswerepresent,theanxietydisorderhadmostoftenpredatedtheonsetoftheED.
2.Materialandmethods
2.1.Subjects
WerecruitedsubjectswithacurrentDSM-IVdiagnosis [2]ofANorBN,inseveralclinicalcentersspecializinginthetreatmentofEDintheParisarea(seeAppendixA).Eighty-twosubjectsconsecutivelyadmittedforanEDwereassessedforinclusion.SixdidnotfulfillalldiagnosticcriteriaforeitherANorBN,threepatientswithANandtenwithBNrefusedtoparticipate.Theremaining63subjectswereincludedinthestudy:
29(27womenand2men)hadAN(restrictingtype),and34womenhadBN(purgingtype).Allanorexicswereinpatients,andallbulimicswereoutpatients,whichistheusualmodeoftreatmentofEDpatientsintherecruitmentsites.Informedconsentwasobtainedfromallsubjectsbeforeparticipatinginthestudy.
2.2.Assessmentinstruments
Toassesssocio-demographiccharacteristics,lifetimediagnosesofEDandanxietydisorders,andagesatonsetofeachdisorder,weusedtheFrenchversionoftheCompositeInternationalDiagnosticInterview(CIDI) [30and38].TheCIDIisafullystandardizedinterviewdesignedforassessingmentaldisorders,whichhasshowngoodreliabilityindifferentculturesanddifferentlanguages [37].TheCIDIexploressevendiagnosesofanxietydisorders:
generalizedanxietydisorder,agoraphobia,panicdisorderwithoutagoraphobia,panicdisorderwithagoraphobia,simplephobia,socialphobia,OCD.TheFrenchversionoftheCIDI,atthetimeofthestudy,wasgeneratingDSM-III-Rdiagnoses [1].Tonoteisthefactthat,inDSM-III-R,fearofexhibitingabnormaleatingbehaviorcouldnotberecordedasasymptomofsocialphobia,andideasorimpulsesaboutfoodcouldnotberecordedasobsessive-compulsivesymptoms.ForEDonly,weaddedquestionstoassessalsoDSM-IVcriteria.TheCIDIrecordstheyoungestageatwhichtheindividualfulfilledthecriteriaforeachdisorderpresent.Allsubjectswerepersonallyinterviewedbyoneoftheauthors(NG),whohadbeentrainedforuseoftheCIDIbyanexperiencedWorldHealthOrganisation(WHO)trainer(EmmanuelleWeiller,INSERMU302,Paris).TheANpatientswereassessedduringthesecondpartoftheirinpatienttreatment(halfwayormoretoweightrestoration).TheBNpatients(allnormalweight)wereinterviewedafteroutpatienttreatmenthadbeenestablished.
Inaddition,childhoodhistoryofseparationanxietydisorder,notincludedintheCIDI,wasassessedusingtheappropriatesectionoftheScheduleforSchizophreniaandAffectiveDisordersLifetimeVersion–ModifiedforthestudyofAnxietyDisorders(SADS-LA-R [25],translatedintoFrench,initsDSM-III-Rversion,byLeboyer,TeheraniandLépine).Thisinterviewschedulescoresthediagnosisofseparationanxietydisorderas‘absent',‘possible'or‘definite'.Whenthedisorderwaspossibleordefinite,wedidnotinquireaboutageofonsetwhich,bydefinition,hastobebefore18yearsofage(usuallymuchyounger)andisdifficulttoascertainretrospectivelyfromthesubjecthimself.
2.3.Statisticalanalysis
WeconsideredseparatelytheANandBNgroups.Thediagnosisof‘atleastoneanxietydisorder'wasacombinationofthesevenpossibleanxietydiagnosesassessedwiththeCIDI.Childhoodhistoryofseparationanxietydisorderwasscoredseparately.
LifetimeandcurrentprevalenceofanxietydisordersinthetwoEDgroupswerecomparedusingthechi-squaretest,orFisher'sexactte