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A comparison of clinical features among Japanese eating-disordered women with obsessive-compulsive disorder
A Comparison of Clinical Features Among Japanese Eating-Disordered Women With Obsessive-Compulsive Disorder Hisato Matsunaga, Akira Miyata, Yoko Iwasaki, Tokuzo Matsui, Kayo Fujimoto, and Nobuo Kiriike Clinical features, such as obsessive-compulsive disorder (OCD) symptoms, were investigated in Japanese women with DSM-III-R eating disorders (EDs) and concurrent OCD in comparison to age-matched women with OCD. Sixteen women with restricting anorexia nervosa (AN), 16 with bulimia nervosa (BN), and 16 with both AN and BN (BAN) showed commonality in a more elevated prevalence of OCD symptoms of symmetry and order compared with 18 OCD women. Among the personality disorders (PDs), likewise, obsessive-compulsive PD (OCPD) was more prevalent in
each ED group compared with the OCD group. However, aggressive obsessions were more common in both BN and BAN subjects compared with AN subjects. Subjects with bulimic symptoms were also distinguished from AN subjects by impulsive features in behavior and personality. Thus, an elevated prevalence of aggressive obsessions along with an admixture of impulsive and compulsive features specifically characterized the clinical features of bulimic subjects with OCD.
HE RELATIONSHIP between eating disorder (ED) and obsessive-compulsive disorder (OCD) has been extensively investigated. Patients with EDs often count calories obsessively; they are preoccupied with their body, and ruminate incessantly about food. Uncontrollable binge eating and purging episodes in bulimics may be a type of compulsion. ~,2Aside from symptoms pertaining to food, body image, and ritualized eating behaviors, women with EDs have a high prevalence of obsessive-compulsive symptoms or OCD. OCD has been found to occur in 11% to 69% of women with anorexia nervosa (AN) 3-7 and in 3% to 43% of women with bulima nervosa (BN). 1,3,8q° Conversely, about 10% of female patients with OCD were reported to have a history of EDs. I1,t2 Taken together, these findings indicate that a close linkage may exist between ED and OCD. A substantial number of people with EDs have sufficient primary obsessive-compulsive symptoms to qualify for a diagnosis of OCD. OCD symptomatology in anorexics has been characterized by some studies, 6,13A4 but it remains unclear as to whether OCD symptomatology differs in anorexics and bulimics. In addition, the relationship between the comorbidity of OCD and the clinical features of EDs has not been well discussed. OCD symptomatology may be influenced by the surrounding culture. However, recent studies suggest that OCD symptoms are stable cross-culturally. 15 Our group previously found similarities in OCD symptoms between OCD patients in Japan 16 and the Western world. T M Therefore, in this study, we assessed OCD symptomatology and a variety of clinical features in Japanese ED patients with a
diagnosis of concurrent OCD in comparison to ageand gender-matched patients with OCD. These results were compared among each ED subtype to examine the relationship between comorbid OCD and the clinical features of EDs.
T
Copyright© 1999by W.B. Saunders Company
METHOD
Subjects The subjects were 16 women with AN, 16 with BN, and 16 with both AN and BN (BAN) diagnosed according to DSMIII-R criteria. 19 Subjects were selected from 130 ED patients consecutively admitted to the Department of Neuropsychiatry at Osaka City University Medical School Hospital from July 1995 to March 1997, on the condition that even after excluding food and body-related symptoms and ritualized eating behaviors, they concurrently met DSM-HI-R criteria for OCD assessed by the Japanese version of the Structured Clinical Interview for DSM-III-R-Patient Edition (SCID-P). 2° A relatively high interrater reliability for the current diagnosis of OCD using the SCID-P Japanese version (kappa 0.72) was found in our previous studyfl I Patients were excluded from this study if (1) they were less than 18 years old, (2) they met DSM-III-R criteria for ED-NOS, or (3) their current ED duration was less than 6 months at the date of these assessments. All male ED patients with a diagnosis of concurrent OCD (one patient with AN and two patients with BAN) were also excluded, because OCD symptomatology may be influenced by gender. 22 Eighteen age-matched women who met DSM-III-R criteria for OCD were recruited to constitute a control group. All of these women were also consecutively admitted to our hospital, had no history of EDs, and were symptomatic for at least 6 months. After a
From the Department of Neuropsychiatry, Osaka City University Medical School, Osaka, Japan. Address reprint requests to Hisato Matsunaga, M.D., Department of Neuropsychiatry, Osaka City University Medical School, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan. Copyright © 1999 by W.B. Saunders Company 0010-440X/99/4005-0007510. 00/0
ComprehensivePsychiatry,Vol. 40, No. 5 (September/October), 1999: pp 337-342
337
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M A T S U N A G A ET AL
complete description of the study, written informed consent was obtained from each participant.
Zung's Self-rating Depression Scale (SDS) 30 were also administered to all subjects for assessment of anxiety and depressive symptoms, respectively.
Assessment Procedures Each subject provided information regarding the demographic profile and clinical features related to her disorder. Assessment of global functioning for each subject was performed using the DSM-III-R Axis V Global Assessment of Functioning Scale (GAFS) by one of the authors (H.M, or A.M.) who was extensively trained to provide reliable GAFS scores. The lifetime incidence of impulsive behaviors, such as suicide attempts, self-harm, and shoplifting, were assessed in each subject by a method we have previously used.23 Articles related to food were excluded from the evaluation of shoplifting in ED subjects. With respect to alcohol and drug use in all subjects, we assessed the lifetime comorbidity of DSM-III-R substance abuse or dependence using the SCID-P.2° OCD symptoms in each subject were assessed using the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS)24,25 in a Japanese version.26 This assessment was performed in a semistructured interview by one of the authors (Y.I.) who was trained under the supervision of senior psychiatrists according to the instructions of the developers.24 For the identification of current OCD symptoms in each patient, up to three primary obsessions and compulsions were listed using the Y-BOCS symptom checklist. OCD-like symptoms related to EDs were omitted from Y-BOCS scoring. The severity of OCD symptoms was assessed using the Y-BOCS severity rating scale. The 10 items of the Japanese version of the Y-BOCS have been verified collectively to constitute a reliable instrument for assessing OCD symptom severity.26 Personality disorders (PDs) were subsequently evaluated using the Japanese version of the Structured Clinical Interview for DSM-III-R PDs (SCID-II). 27 The acceptable reliability levels for each PD diagnosis obtained by the SC1D-II Japanese version were previously described in ED subjects,28 as well as OCD subjects. 16 The Manifest Anxiety Scale (MAS) 29 and
Data Analysis Significant mean group differences for parametric variables were evaluated using one-way analysis of variance statistical procedures. For categorical data, chi-square tests with 1 dfand Yates' correction for discontinuity or Fisher's exact test (for minimum expected cell size -<5) were used. Significance was set at a P level less than .05.
RESULTS Table 1 shows the demographic profile and clinical features of the participants. There were no significant differences between the four groups for age at onset, duration of illness, or years of education. BAN subjects were significantly older than AN subjects (F = 2.24, df = 3,62, P < .05). A significantly lower GAFS score was found in the BAN group versus both the AN (P < .05) and OCD (P < .01) groups, as well as in the BN group versus the OCD group (P < .05). The mean body mass index of the BN and OCD groups was significantly higher than that of the AN or BAN group (F = 62.90, df = 3,62, P < .01). The BAN and BN groups had significantly higher mean scores on both the MAS and the SDS than the AN or OCD group. Table 2 shows specific categories of the primary obsessions and compulsions assessed by the Y-
Table 1. Demographic Profile, Clinical Features, and Psychometric Test Results Parameter Age (yr) Age at onset (yr) Duration of illness (yr) Education (yr) GAFS score (axis V) Single (divorced)/married (n) Body mass index Current frequency of binge eating (weekly) Current frequency of vomiting (weekly) MAS score SDS score Y-BOCS score Total
Obsession Compulsion
AN (n = 16) 22.3 18.6 3.6 12.9 50.6
~ 4.3 _~ 2.7 -+ 4.1 + 1.8 -+ 11,5
BAN (n = 16) _+ 4.3t _+ 3.4 _+ 3.9 -- 2.5 _+ 8.9tll
OCD (n = 18) 24.0 +_ 3.4 18.7 +_ 4.3 5.3 _+ 2.6 13.4 _+ 1.7 54.7 - 9.2 15 (1)/3 19.5 _+ 1.4 --25.8 ~ 6.0
14.3 _+ 1.5$11 0 0 24.4 _+ 5.4
14,3 7,5 7.3 31.9
+_ 1.4$1L _+ 3.0* _+ 3.1" -+ 7.0*¶
25.0 +_ 2.7 19.5 _+ 3.6 5.5 _+ 3.9 13.6 _+ 2,6 44.3 _+ 9,2LI 15 (1)/1 21.5 _+ 2,4 7.4 _+ 2,8" 7.4 _+ 2.6* 31.0 +_ 6.8t¶
53.7 +_ 7.1
63.1 +- 6.2"11
60.1 _+ 7.6t¶
54.2 _+ 8,0
22.0 _+ 5.6 11.3 _+ 2.8 10.7 +_ 2.9
24.3 _+ 6.2 12.0 _+ 3.2 12.3 +_ 3.1
23.2 _+ 4.5 11.7 _+ 2.3 11.5 ± 2.2
25.4 ± 3.4 12.6 _+ 1.7 12.8 +_ 1.8
15 (1)/1
25.8 20.3 5.4 13.0 37.5
BN (n = 16)
14 (2)/2
NOTE. Values are the mean +- SD and were statistically tested by 1-way analysis of variance and Scheffe test. * P < .01, t P < .05 v A N . S P < . 0 1 , § P < . 0 5 vBN. liP< . 0 1 , ¶ P < .05 vOCD.
JAPANESE EATING-DISORDERED WOMEN WITH OCD
339
Table 2. Comparison of Obsessive-CompulsiveSymptoms AN (n = 16) Symptom Obsession Aggressive Contamination Sexual Hoarding/saving Religious Symmetry/exactness Somatic Miscellaneous Compulsion Cleaning/washing Checking Repeated rituals Counting Ordering/arranging Hoarding/collecting Miscellaneous
No.
%
2 9
BAN (n = 16)
6N (n = 16)
OCD(n = 18)
No.
%
No.
%
No.
%
12.5 56.3
7 7 2 1
43.8 43.8 12.5 6.3
8 7 1 1
50.0 43.8 6.3 6.3
7 13 1 2
38,9 72,2 5,6 11,1
11 2 6
68.8* 12.5 50.0
8 2 7
50.0 12.5 43.5
8 1 6
50.0 6.3 37.5
1 4 1 9
5.6 22.2 5.6 50.0
8 5 2 2 11
50.0 31.3 12.5 12.5 68.8*
7 8 2 3 8 1 5
43.8 50.0 12.5 18.8 50.0 6.3 31.3
6 8 2 3 7
37.5 50,0 12.5 18.8 43.8
11 12 6 3 4
61.1 66.7 33.3 16.7 22,2
37,5
5
0 0 0
0
0 5
31.3
0
0 6
0 27.6
NOTE. Comparisons were made using chi-square tests with 1 dfand Yates' correction for discontinuity. Fisher's exact test was used for factors with an expected cell frequency <5. * P < .05 vOCD.
BOCS symptom checklist in each group. Obsessions for symmetry and exactness were the most prevalent OCD symptoms across subtypes of EDs. When all ED subjects were considered together, contamination was the next most frequently cited obsession, followed by miscellaneous and aggressive obsessions. Ordering and arranging compulsions were the most commonly identified, followed by cleaning/washing, checking, and miscellaneous compulsions. In comparing the distribution of each obsessive or compulsive symptom between these ED groups, the BAN and BN groups were more likely than the AN group to have aggressive obsessions. Obsessions for symmetry and exactness and compulsions for ordering and arranging were significantly more frequent in the AN group versus the OCD group. With respect to the severity scores of the YBOCS, all participants in this study attained the minimum score of 16 or higher for clinically significant OCD symptoms. There were no significant differences in the mean total and obsession or compulsion subtotal scores among the four groups, although the OCD group tended to have higher mean scores than the other groups (Table 1). Table 3 shows a comparison of the lifetime incidence of impulsive behaviors and prevalence of comorbid PDs between these groups. The BAN group showed a significantly higher incidence for
suicidal attempts and self-harm (each by Fisher's exact test, P < .05) than the AN group. They were also more likely to have a higher incidence of shoplifting and a higher lifetime prevalence of drug abuse or dependence than the AN group. BN subjects also showed a trend for a higher incidence of suicidal attempts, self-harm, and shoplifting compared with AN subjects. However, no significant differences were found in the lifetime incidence for these behaviors between the OCD group and the ED groups. With respect to PDs, there were no significant differences in the prevalence of cluster A (paranoid, schizoid, and schizotypal) PDs between the four groups. Cluster B PDs (antisocial, borderline [BPD], histrionic, and narcissistic), occurred at significantly higher rates in the BAN group versus the AN group (Fisher's exact test, P < .05). Both the BAN and BN groups showed a trend for a higher prevalence of BPD versus subjects in the AN group. In each group, cluster C (avoidant, dependent, obsessive-compulsive, [OCPD], and passiveaggressive) PDs were the most frequently diagnosed among the three clusters of PDs, and OCPD was more commonly diagnosed in each subtype of ED compared with the OCD group. In particular, the AN group was significantly more likely than the OCD group to meet criteria for OCPD (Fisher's exact test, P < .05).
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MATSUNAGA ET AL
Table 3. Comparison of Impulsive Behaviors and Comorbid PDs AN (n = 16) Parameter Impulsive behavior Suicide attempts Self-harm Shoplifting Alcohol abuse/dependence Drug abuse/dependence PD Cluster A Cluster B BPD Cluster C OCPD Avoidant
BAN (n = 16)
BN (n = 16)
OCD(n = 18)
No.
%
No.
%
No.
%
No.
1 2 2
6.3 12.5 12.5
7 9 6 2 4
43.8* 56.3* 37.5 12.5 25.0
5 8 5 2 1
38.5 50.0 38.5 12.5 6.3
3 4 4 1 1
16.7 22.2 22.2 5.6 5.6
6.3 6.3 6.3 75.0 43.8 31.3
1 7 5 9 4 4
6.3 43.8* 31.3 56.3 25.0 25.0
1 6 4 7 4 4
6.3 37.5 25.0 43.8 25.0 25.0
3 4 3 7 2 4
16.7 22.2 16.7 38.9 11.1 * 22.2
0 0 1 1 1 12 7 5
%
NOTE. Comparisons were made using chi-square tests with 1 dfand Yates' correction for discontinuity. Fisher's exact test was used for factors with an expected cell frequency <5. * P < .05 v A N .
DISCUSSION Although there are some methodological limitations such as a small sample size in this study, some similarities were observed among subtypes of EDs with concurrent OCD. For example, taking into account the mean Y-BOCS score in the OCD group, ED subjects manifested an almost similar magnitude of severity compared with OCD patients, regardless of the type of ED. Bastiani et al.13 reported that anorexics had similar functional impairment from primary OCD symptoms as indicated by the total Y-BOCS score (19 ___9) in comparison to OCD patients (22 ___6). Thus, if ED patients have a diagnosis of OCD, they would have a similar functional impairment from primary OCD symptoms as observed in OCD patients. In terms of OCD symptoms, obsessions for symmetry or exactness and compulsions for ordering/arranging were more commonly found in all subtypes of EDs compared with the OCD group. Previous research with restricting anorexics found that OCD symptoms of symmetry, exactness, ordering, and arranging were the most common symptoms in the Western world, 6A3,14as well as Japan? ! Thus, commonalities may exist in the types of OCD symptoms experienced by people with EDs, regardless of ED subtype or cultural or ethnic differences. Some reports have speculated that obsessive concern with symmetry and exactness may represent the obsessive traits of temperament and personality. 14'31 Among OCD symptoms, only these symptoms were identified to be significantly related to OCPD. 32 Although OCPD is considered unneces-
sary for the development of OCD in patients with OCD, 33all elevated obsessional personality is speculated to be a vulnerable factor for developing OCD symptoms in restricting anorexics. 21,31,34 In this study, OCPD was more commonly found in all ED subtypes compared with the OCD group. Taken together, in contrast to subjects with OCD, the features related to obsessionality in our ED subjects may have some causal significance for the development of OCD not only in anorexics but also in bulimics. On the other hand, both the BAN and BN groups showed a trend for a higher prevalence of aggressive obsessions compared with the AN group, although the BAN and AN groups shared a low weight status. Thus, an association between aggressive obsessions and binge eating and/or purging behavior was observed in ED subjects. Jarry and Vaccarino 35 hypothesized that low levels of serotonin (5-HT) may be associated with bulimia and OCD symptoms characterized by feelings of impulsivity and lack of inhibition, in contrast to the elevated 5-HT functions commonly associated with restricting AN and avoidant-oriented OCD symptoms such as checking and washing. Thus, an increased prevalence of aggressive obsessions in bulimics may represent a differential OCD symptomatology in bulimics versus restricting anorexics. However, in this study, similarities in OCD symptoms, such as symptoms of symmetry and order, were found in all subtypes of EDs, suggesting that a distinction of OCD symptomatology among ED subtypes may not be so clear-cut. In
JAPANESE EATING-DISORDERED WOMEN WITH OCD
341
addition, it is unclear as to whether there may be some Japanese cultural influences on this finding. Both the BAN and BN groups were more likely than the AN group to have impulsive behaviors in their lifetime, such as self-harm, suicide attempts, or shoplifting other than food. Compared with restricting anorexics, both groups also showed a significantly increased prevalence of cluster B PDs, with a common trend for a higher rate of BPD. In contrast to restricting anorexics, who are traditionally characterized as rigid and constrained, behaviors related to impulsivity may be expressive of some diametrically opposite nature in bulimics. 36 In fact, multiple patterns of impulsive dyscontrol in bulimics have been characterized as a multiimpulsive form of bulimia, 37 and impulsive problems in bulimic subjects are prevalent similarly in Japan 23 and the Western world. 38,39 Likewise, cluster B PDs, especially BPD, have been transculturally reported to be more prominent in subjects with bulimic symptoms compared with restricting anorexics.3,28,36,4° Thus, despite the coexistence of OCD, subjects with bulimic symptoms in this study show characteristics of impulsive features similar to those generally described in bulimics. Taken together, the findings indicate that in comparison to restricting anorexics with concurrent OCD, bulimic subjects with OCD are more strongly characterized as having features of both the impulsive and the compulsive ends of the impulsivecompulsive spectrum. 41 This finding is consistent with the report by McElroy et al., 42 who found high comorbidity for both OCD and impulse-control
disorders in patients with bulimia. Newton et al. 43 suggested that both a higher level of impulsivity and the number of impulsive behaviors among bulimics were positively correlated with obsessionality. However, the mechanism for such a phenomenon is still unclear, and the cross-sectional design of this study limits our discussion of this issue. In addition, some impulsive features, such as a pattern of self-mutilation, are characterized by a mixture of both compulsive and impulsive features,44 and impulsive behaviors may have a compulsive nature or may lie between the impulsive and compulsive poles. In conclusion, compared with age- and gendermatched OCD patients, Japanese subjects with EDs and concurrent OCD commonly showed a more elevated prevalence of OCD symptoms related to symmetry, exactness, and order, regardless of the type of ED. Likewise, OCPD was more commonly found in all ED subtypes compared with the OCD group. However, a trend for a higher prevalence of aggressive obsession in subjects with bulimic symptoms was observed as a phenomenon different from that in restricting anorexics. Despite the coexistence of OCD, bulimic subjects in this study show characteristics of impulsive behavior and personality similar to those generally described in BN subjects. Thus, compared with restricting anorexics, bulimic subjects with OCD may be more strongly characterized by an admixture of impulsive and compulsive features. However, it is unclear as to whether there may be some Japanese cultural influence on these findings.
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each ED group compared with the OCD group. However, aggressive obsessions were more common in both BN and BAN subjects compared with AN subjects. Subjects with bulimic symptoms were also distinguished from AN subjects by impulsive features in behavior and personality. Thus, an elevated prevalence of aggressive obsessions along with an admixture of impulsive and compulsive features specifically characterized the clinical features of bulimic subjects with OCD.
HE RELATIONSHIP between eating disorder (ED) and obsessive-compulsive disorder (OCD) has been extensively investigated. Patients with EDs often count calories obsessively; they are preoccupied with their body, and ruminate incessantly about food. Uncontrollable binge eating and purging episodes in bulimics may be a type of compulsion. ~,2Aside from symptoms pertaining to food, body image, and ritualized eating behaviors, women with EDs have a high prevalence of obsessive-compulsive symptoms or OCD. OCD has been found to occur in 11% to 69% of women with anorexia nervosa (AN) 3-7 and in 3% to 43% of women with bulima nervosa (BN). 1,3,8q° Conversely, about 10% of female patients with OCD were reported to have a history of EDs. I1,t2 Taken together, these findings indicate that a close linkage may exist between ED and OCD. A substantial number of people with EDs have sufficient primary obsessive-compulsive symptoms to qualify for a diagnosis of OCD. OCD symptomatology in anorexics has been characterized by some studies, 6,13A4 but it remains unclear as to whether OCD symptomatology differs in anorexics and bulimics. In addition, the relationship between the comorbidity of OCD and the clinical features of EDs has not been well discussed. OCD symptomatology may be influenced by the surrounding culture. However, recent studies suggest that OCD symptoms are stable cross-culturally. 15 Our group previously found similarities in OCD symptoms between OCD patients in Japan 16 and the Western world. T M Therefore, in this study, we assessed OCD symptomatology and a variety of clinical features in Japanese ED patients with a
diagnosis of concurrent OCD in comparison to ageand gender-matched patients with OCD. These results were compared among each ED subtype to examine the relationship between comorbid OCD and the clinical features of EDs.
T
Copyright© 1999by W.B. Saunders Company
METHOD
Subjects The subjects were 16 women with AN, 16 with BN, and 16 with both AN and BN (BAN) diagnosed according to DSMIII-R criteria. 19 Subjects were selected from 130 ED patients consecutively admitted to the Department of Neuropsychiatry at Osaka City University Medical School Hospital from July 1995 to March 1997, on the condition that even after excluding food and body-related symptoms and ritualized eating behaviors, they concurrently met DSM-HI-R criteria for OCD assessed by the Japanese version of the Structured Clinical Interview for DSM-III-R-Patient Edition (SCID-P). 2° A relatively high interrater reliability for the current diagnosis of OCD using the SCID-P Japanese version (kappa 0.72) was found in our previous studyfl I Patients were excluded from this study if (1) they were less than 18 years old, (2) they met DSM-III-R criteria for ED-NOS, or (3) their current ED duration was less than 6 months at the date of these assessments. All male ED patients with a diagnosis of concurrent OCD (one patient with AN and two patients with BAN) were also excluded, because OCD symptomatology may be influenced by gender. 22 Eighteen age-matched women who met DSM-III-R criteria for OCD were recruited to constitute a control group. All of these women were also consecutively admitted to our hospital, had no history of EDs, and were symptomatic for at least 6 months. After a
From the Department of Neuropsychiatry, Osaka City University Medical School, Osaka, Japan. Address reprint requests to Hisato Matsunaga, M.D., Department of Neuropsychiatry, Osaka City University Medical School, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan. Copyright © 1999 by W.B. Saunders Company 0010-440X/99/4005-0007510. 00/0
ComprehensivePsychiatry,Vol. 40, No. 5 (September/October), 1999: pp 337-342
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M A T S U N A G A ET AL
complete description of the study, written informed consent was obtained from each participant.
Zung's Self-rating Depression Scale (SDS) 30 were also administered to all subjects for assessment of anxiety and depressive symptoms, respectively.
Assessment Procedures Each subject provided information regarding the demographic profile and clinical features related to her disorder. Assessment of global functioning for each subject was performed using the DSM-III-R Axis V Global Assessment of Functioning Scale (GAFS) by one of the authors (H.M, or A.M.) who was extensively trained to provide reliable GAFS scores. The lifetime incidence of impulsive behaviors, such as suicide attempts, self-harm, and shoplifting, were assessed in each subject by a method we have previously used.23 Articles related to food were excluded from the evaluation of shoplifting in ED subjects. With respect to alcohol and drug use in all subjects, we assessed the lifetime comorbidity of DSM-III-R substance abuse or dependence using the SCID-P.2° OCD symptoms in each subject were assessed using the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS)24,25 in a Japanese version.26 This assessment was performed in a semistructured interview by one of the authors (Y.I.) who was trained under the supervision of senior psychiatrists according to the instructions of the developers.24 For the identification of current OCD symptoms in each patient, up to three primary obsessions and compulsions were listed using the Y-BOCS symptom checklist. OCD-like symptoms related to EDs were omitted from Y-BOCS scoring. The severity of OCD symptoms was assessed using the Y-BOCS severity rating scale. The 10 items of the Japanese version of the Y-BOCS have been verified collectively to constitute a reliable instrument for assessing OCD symptom severity.26 Personality disorders (PDs) were subsequently evaluated using the Japanese version of the Structured Clinical Interview for DSM-III-R PDs (SCID-II). 27 The acceptable reliability levels for each PD diagnosis obtained by the SC1D-II Japanese version were previously described in ED subjects,28 as well as OCD subjects. 16 The Manifest Anxiety Scale (MAS) 29 and
Data Analysis Significant mean group differences for parametric variables were evaluated using one-way analysis of variance statistical procedures. For categorical data, chi-square tests with 1 dfand Yates' correction for discontinuity or Fisher's exact test (for minimum expected cell size -<5) were used. Significance was set at a P level less than .05.
RESULTS Table 1 shows the demographic profile and clinical features of the participants. There were no significant differences between the four groups for age at onset, duration of illness, or years of education. BAN subjects were significantly older than AN subjects (F = 2.24, df = 3,62, P < .05). A significantly lower GAFS score was found in the BAN group versus both the AN (P < .05) and OCD (P < .01) groups, as well as in the BN group versus the OCD group (P < .05). The mean body mass index of the BN and OCD groups was significantly higher than that of the AN or BAN group (F = 62.90, df = 3,62, P < .01). The BAN and BN groups had significantly higher mean scores on both the MAS and the SDS than the AN or OCD group. Table 2 shows specific categories of the primary obsessions and compulsions assessed by the Y-
Table 1. Demographic Profile, Clinical Features, and Psychometric Test Results Parameter Age (yr) Age at onset (yr) Duration of illness (yr) Education (yr) GAFS score (axis V) Single (divorced)/married (n) Body mass index Current frequency of binge eating (weekly) Current frequency of vomiting (weekly) MAS score SDS score Y-BOCS score Total
Obsession Compulsion
AN (n = 16) 22.3 18.6 3.6 12.9 50.6
~ 4.3 _~ 2.7 -+ 4.1 + 1.8 -+ 11,5
BAN (n = 16) _+ 4.3t _+ 3.4 _+ 3.9 -- 2.5 _+ 8.9tll
OCD (n = 18) 24.0 +_ 3.4 18.7 +_ 4.3 5.3 _+ 2.6 13.4 _+ 1.7 54.7 - 9.2 15 (1)/3 19.5 _+ 1.4 --25.8 ~ 6.0
14.3 _+ 1.5$11 0 0 24.4 _+ 5.4
14,3 7,5 7.3 31.9
+_ 1.4$1L _+ 3.0* _+ 3.1" -+ 7.0*¶
25.0 +_ 2.7 19.5 _+ 3.6 5.5 _+ 3.9 13.6 _+ 2,6 44.3 _+ 9,2LI 15 (1)/1 21.5 _+ 2,4 7.4 _+ 2,8" 7.4 _+ 2.6* 31.0 +_ 6.8t¶
53.7 +_ 7.1
63.1 +- 6.2"11
60.1 _+ 7.6t¶
54.2 _+ 8,0
22.0 _+ 5.6 11.3 _+ 2.8 10.7 +_ 2.9
24.3 _+ 6.2 12.0 _+ 3.2 12.3 +_ 3.1
23.2 _+ 4.5 11.7 _+ 2.3 11.5 ± 2.2
25.4 ± 3.4 12.6 _+ 1.7 12.8 +_ 1.8
15 (1)/1
25.8 20.3 5.4 13.0 37.5
BN (n = 16)
14 (2)/2
NOTE. Values are the mean +- SD and were statistically tested by 1-way analysis of variance and Scheffe test. * P < .01, t P < .05 v A N . S P < . 0 1 , § P < . 0 5 vBN. liP< . 0 1 , ¶ P < .05 vOCD.
JAPANESE EATING-DISORDERED WOMEN WITH OCD
339
Table 2. Comparison of Obsessive-CompulsiveSymptoms AN (n = 16) Symptom Obsession Aggressive Contamination Sexual Hoarding/saving Religious Symmetry/exactness Somatic Miscellaneous Compulsion Cleaning/washing Checking Repeated rituals Counting Ordering/arranging Hoarding/collecting Miscellaneous
No.
%
2 9
BAN (n = 16)
6N (n = 16)
OCD(n = 18)
No.
%
No.
%
No.
%
12.5 56.3
7 7 2 1
43.8 43.8 12.5 6.3
8 7 1 1
50.0 43.8 6.3 6.3
7 13 1 2
38,9 72,2 5,6 11,1
11 2 6
68.8* 12.5 50.0
8 2 7
50.0 12.5 43.5
8 1 6
50.0 6.3 37.5
1 4 1 9
5.6 22.2 5.6 50.0
8 5 2 2 11
50.0 31.3 12.5 12.5 68.8*
7 8 2 3 8 1 5
43.8 50.0 12.5 18.8 50.0 6.3 31.3
6 8 2 3 7
37.5 50,0 12.5 18.8 43.8
11 12 6 3 4
61.1 66.7 33.3 16.7 22,2
37,5
5
0 0 0
0
0 5
31.3
0
0 6
0 27.6
NOTE. Comparisons were made using chi-square tests with 1 dfand Yates' correction for discontinuity. Fisher's exact test was used for factors with an expected cell frequency <5. * P < .05 vOCD.
BOCS symptom checklist in each group. Obsessions for symmetry and exactness were the most prevalent OCD symptoms across subtypes of EDs. When all ED subjects were considered together, contamination was the next most frequently cited obsession, followed by miscellaneous and aggressive obsessions. Ordering and arranging compulsions were the most commonly identified, followed by cleaning/washing, checking, and miscellaneous compulsions. In comparing the distribution of each obsessive or compulsive symptom between these ED groups, the BAN and BN groups were more likely than the AN group to have aggressive obsessions. Obsessions for symmetry and exactness and compulsions for ordering and arranging were significantly more frequent in the AN group versus the OCD group. With respect to the severity scores of the YBOCS, all participants in this study attained the minimum score of 16 or higher for clinically significant OCD symptoms. There were no significant differences in the mean total and obsession or compulsion subtotal scores among the four groups, although the OCD group tended to have higher mean scores than the other groups (Table 1). Table 3 shows a comparison of the lifetime incidence of impulsive behaviors and prevalence of comorbid PDs between these groups. The BAN group showed a significantly higher incidence for
suicidal attempts and self-harm (each by Fisher's exact test, P < .05) than the AN group. They were also more likely to have a higher incidence of shoplifting and a higher lifetime prevalence of drug abuse or dependence than the AN group. BN subjects also showed a trend for a higher incidence of suicidal attempts, self-harm, and shoplifting compared with AN subjects. However, no significant differences were found in the lifetime incidence for these behaviors between the OCD group and the ED groups. With respect to PDs, there were no significant differences in the prevalence of cluster A (paranoid, schizoid, and schizotypal) PDs between the four groups. Cluster B PDs (antisocial, borderline [BPD], histrionic, and narcissistic), occurred at significantly higher rates in the BAN group versus the AN group (Fisher's exact test, P < .05). Both the BAN and BN groups showed a trend for a higher prevalence of BPD versus subjects in the AN group. In each group, cluster C (avoidant, dependent, obsessive-compulsive, [OCPD], and passiveaggressive) PDs were the most frequently diagnosed among the three clusters of PDs, and OCPD was more commonly diagnosed in each subtype of ED compared with the OCD group. In particular, the AN group was significantly more likely than the OCD group to meet criteria for OCPD (Fisher's exact test, P < .05).
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Table 3. Comparison of Impulsive Behaviors and Comorbid PDs AN (n = 16) Parameter Impulsive behavior Suicide attempts Self-harm Shoplifting Alcohol abuse/dependence Drug abuse/dependence PD Cluster A Cluster B BPD Cluster C OCPD Avoidant
BAN (n = 16)
BN (n = 16)
OCD(n = 18)
No.
%
No.
%
No.
%
No.
1 2 2
6.3 12.5 12.5
7 9 6 2 4
43.8* 56.3* 37.5 12.5 25.0
5 8 5 2 1
38.5 50.0 38.5 12.5 6.3
3 4 4 1 1
16.7 22.2 22.2 5.6 5.6
6.3 6.3 6.3 75.0 43.8 31.3
1 7 5 9 4 4
6.3 43.8* 31.3 56.3 25.0 25.0
1 6 4 7 4 4
6.3 37.5 25.0 43.8 25.0 25.0
3 4 3 7 2 4
16.7 22.2 16.7 38.9 11.1 * 22.2
0 0 1 1 1 12 7 5
%
NOTE. Comparisons were made using chi-square tests with 1 dfand Yates' correction for discontinuity. Fisher's exact test was used for factors with an expected cell frequency <5. * P < .05 v A N .
DISCUSSION Although there are some methodological limitations such as a small sample size in this study, some similarities were observed among subtypes of EDs with concurrent OCD. For example, taking into account the mean Y-BOCS score in the OCD group, ED subjects manifested an almost similar magnitude of severity compared with OCD patients, regardless of the type of ED. Bastiani et al.13 reported that anorexics had similar functional impairment from primary OCD symptoms as indicated by the total Y-BOCS score (19 ___9) in comparison to OCD patients (22 ___6). Thus, if ED patients have a diagnosis of OCD, they would have a similar functional impairment from primary OCD symptoms as observed in OCD patients. In terms of OCD symptoms, obsessions for symmetry or exactness and compulsions for ordering/arranging were more commonly found in all subtypes of EDs compared with the OCD group. Previous research with restricting anorexics found that OCD symptoms of symmetry, exactness, ordering, and arranging were the most common symptoms in the Western world, 6A3,14as well as Japan? ! Thus, commonalities may exist in the types of OCD symptoms experienced by people with EDs, regardless of ED subtype or cultural or ethnic differences. Some reports have speculated that obsessive concern with symmetry and exactness may represent the obsessive traits of temperament and personality. 14'31 Among OCD symptoms, only these symptoms were identified to be significantly related to OCPD. 32 Although OCPD is considered unneces-
sary for the development of OCD in patients with OCD, 33all elevated obsessional personality is speculated to be a vulnerable factor for developing OCD symptoms in restricting anorexics. 21,31,34 In this study, OCPD was more commonly found in all ED subtypes compared with the OCD group. Taken together, in contrast to subjects with OCD, the features related to obsessionality in our ED subjects may have some causal significance for the development of OCD not only in anorexics but also in bulimics. On the other hand, both the BAN and BN groups showed a trend for a higher prevalence of aggressive obsessions compared with the AN group, although the BAN and AN groups shared a low weight status. Thus, an association between aggressive obsessions and binge eating and/or purging behavior was observed in ED subjects. Jarry and Vaccarino 35 hypothesized that low levels of serotonin (5-HT) may be associated with bulimia and OCD symptoms characterized by feelings of impulsivity and lack of inhibition, in contrast to the elevated 5-HT functions commonly associated with restricting AN and avoidant-oriented OCD symptoms such as checking and washing. Thus, an increased prevalence of aggressive obsessions in bulimics may represent a differential OCD symptomatology in bulimics versus restricting anorexics. However, in this study, similarities in OCD symptoms, such as symptoms of symmetry and order, were found in all subtypes of EDs, suggesting that a distinction of OCD symptomatology among ED subtypes may not be so clear-cut. In
JAPANESE EATING-DISORDERED WOMEN WITH OCD
341
addition, it is unclear as to whether there may be some Japanese cultural influences on this finding. Both the BAN and BN groups were more likely than the AN group to have impulsive behaviors in their lifetime, such as self-harm, suicide attempts, or shoplifting other than food. Compared with restricting anorexics, both groups also showed a significantly increased prevalence of cluster B PDs, with a common trend for a higher rate of BPD. In contrast to restricting anorexics, who are traditionally characterized as rigid and constrained, behaviors related to impulsivity may be expressive of some diametrically opposite nature in bulimics. 36 In fact, multiple patterns of impulsive dyscontrol in bulimics have been characterized as a multiimpulsive form of bulimia, 37 and impulsive problems in bulimic subjects are prevalent similarly in Japan 23 and the Western world. 38,39 Likewise, cluster B PDs, especially BPD, have been transculturally reported to be more prominent in subjects with bulimic symptoms compared with restricting anorexics.3,28,36,4° Thus, despite the coexistence of OCD, subjects with bulimic symptoms in this study show characteristics of impulsive features similar to those generally described in bulimics. Taken together, the findings indicate that in comparison to restricting anorexics with concurrent OCD, bulimic subjects with OCD are more strongly characterized as having features of both the impulsive and the compulsive ends of the impulsivecompulsive spectrum. 41 This finding is consistent with the report by McElroy et al., 42 who found high comorbidity for both OCD and impulse-control
disorders in patients with bulimia. Newton et al. 43 suggested that both a higher level of impulsivity and the number of impulsive behaviors among bulimics were positively correlated with obsessionality. However, the mechanism for such a phenomenon is still unclear, and the cross-sectional design of this study limits our discussion of this issue. In addition, some impulsive features, such as a pattern of self-mutilation, are characterized by a mixture of both compulsive and impulsive features,44 and impulsive behaviors may have a compulsive nature or may lie between the impulsive and compulsive poles. In conclusion, compared with age- and gendermatched OCD patients, Japanese subjects with EDs and concurrent OCD commonly showed a more elevated prevalence of OCD symptoms related to symmetry, exactness, and order, regardless of the type of ED. Likewise, OCPD was more commonly found in all ED subtypes compared with the OCD group. However, a trend for a higher prevalence of aggressive obsession in subjects with bulimic symptoms was observed as a phenomenon different from that in restricting anorexics. Despite the coexistence of OCD, bulimic subjects in this study show characteristics of impulsive behavior and personality similar to those generally described in BN subjects. Thus, compared with restricting anorexics, bulimic subjects with OCD may be more strongly characterized by an admixture of impulsive and compulsive features. However, it is unclear as to whether there may be some Japanese cultural influence on these findings.
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