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Non-eating disorders psychopathology in children and adolescents with eating disorders: Implications for malnutrition and symptom severity
Journal of Psychosomatic Research 60 (2006) 257 – 261
Non-eating disorders psychopathology in children and adolescents with eating disorders: Implications for malnutrition and symptom severity Brett McDermottT, David Forbes, Chris Harris, Julie McCormack, Peter Gibbon Princess Margaret Hospital for Children, School of Paediatrics and Child Health, University of Western Australia, Perth, Western Australia Received 17 August 2004; accepted 2 August 2005
Abstract Objectives: To compare the general psychopathology in an eating disorders (ED) and a child mental health outpatient sample and investigate the implications of comorbidity on psychological and physical measures of ED severity. Methods: One hundred thirty-six children and adolescents with a DSM-IV ED diagnosis were compared with age- and gender-matched controls. Measures included the Eating Disorders Examination and the Child Behavior Checklist. Results: The ED group had lower general and externalizing psychopathology scores and no difference in internalizing (anxiety–depression) symptoms. Of the anorexia nervosa group,
49% experienced comorbid psychopathology. This group had significantly higher ED psychopathology, longer duration of illness, and more gastrointestinal symptoms, but no difference in malnutrition status. Eating disorders not otherwise specified (EDNos) group measures were less influenced by comorbidity status. Conclusions: Anxiety–depressive symptoms are very common in children and adolescents with EDs. Comorbidity status influences illness severity, especially in the anorexia nervosa group. The management implications of these findings are discussed. D 2006 Elsevier Inc. All rights reserved.
Keywords: Anorexia nervosa; Comorbidity; Children; Adolescents
Introduction Anorexia nervosa is the third most common chronic condition of adolescence [1] and is associated with significant psychological, physical, social, and family impairment. Despite developing predominantly in the adolescent years, there are limited studies investigating this age group. Few reports of child and adolescent onset anorexia nervosa have described the breadth of general psychopathology in this clinical group, despite such knowledge being potentially influential to assessment strategies and the type of treatments offered. General psychopathology research of adult populations has mainly studied comorbid anorexia nervosa and depression, although comorbid social phobia, agoraphobia, and obsessive-compulsive disorder have also been reported
T Corresponding author. University of Queensland and Kids in Mind Research: Mater Centre for Service Research in Mental Health, Mater Child and Youth Mental Health Service, Raymond Terrace, South Brisbane 7010, Australia. Tel.: +61 07 3840 1640; fax: +61 07 3840 1644. E-mail address: [email protected] (B. McDermott). 0022-3999/06/$ – see front matter D 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.jpsychores.2005.08.004
[1,2]. Significant positive associations have been reported between measures of depressive and eating disorders (ED) psychopathology in college undergraduate women [3] and patients with EDs [4,5]. Rates of comorbid depression in individuals with EDs vary from 15% to 50% [5] depending on the study rigor. Using semistructured diagnostic interviews, rates of lifetime affective disorders have been reported as high as 88% in female patients with bulimia nervosa [6]. Behaviors typically associated with depression have also been documented in ED samples, more commonly bulimia than anorexia nervosa [7]. Self-mutilation has been reported in individuals with binge-purge anorexia nervosa (9.2%) and restricting anorexia nervosa (1.5%) [8], and self-poisoning appears very common (34%) [9]. The attempted suicide rate was reported to be 23.1% in individuals with EDs [10]. Such risk-taking behavior in part explains the finding of Nielsen et al. [11] of a significant increase in the standardized mortality rate for individuals with anorexia nervosa. There has been less general psychopathology research with children and adolescents, and the findings are more equivocal. In community samples of adolescents, the
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depression–ED psychopathology relationship has been replicated [12–14], refuted [15], and the possibility advanced that dysthymia may be more strongly associated with EDs than major depressive disorder [14]. In clinical samples of individuals with anorexia nervosa, using retrospective case note audit designs the prepubertal onset anorexia nervosa group had more premorbid maladjustment than the postpubertal onset group. Further, the prepubertal onset group experienced similar maladjustment levels to a bneuroticQ inpatient comparison group [16]. In another retrospective study, 56% of 15-year-olds with anorexia nervosa were diagnosed with depression, although study limitations include lack of a standardized measure and failure to control for malnutrition [17]. In the 119 outcome studies reviewed by Steinhausen [18], non-ED diagnoses, mainly depressive, anxiety, substance, and personality disorders, were frequently noted at follow-up. Little is known how comorbidity at the time of initial treatment for EDs is related to prognosis. The aim of this study was to compare the general psychopathology in children and adolescents with an ED with a clinical child mental health control group and investigate the implications of comorbid general psychopathology with psychological and physical measures of ED severity.
Methods Participants Over a 3-year period, 136 children and adolescent were diagnosed with an ED after a comprehensive assessment including a semistructured interview by a child psychiatrist or psychologist, a detailed physical review by a pediatric gastroenterologist, dietary and anthropometric assessment, and completion of the Eating Disorders Examination (EDE) [19]. The study participation rate of 80% represents 109 individuals with complete EDs and general psychopathology data. Individuals with missing data did not significantly differ from participants on age, diagnosis, ED psychopathology, or malnutrition. The average age of the ED sample (106 female, 3 male) was 14.5 years (S.D. 1.9 years, range 7–18 years). Of this group, 49 were diagnosed with anorexia nervosa, 46 with ED not otherwise specified (EDNos) and 14 with bulimia nervosa. The control group consisted of 109 patients who attended general mental health outpatient services at the same hospital as the ED sample. For each ED patient an age- and gender-matched control, who was first assessed during the same week as the ED patient, was randomly selected. The case notes of controls were reviewed by a child psychiatrist to ensure the controls did not have an ED diagnosis or experience prominent ED symptoms such as fasting or bingeing. Diagnoses of the control group were predominantly depression and other mood disorders, anxiety and adjustment disorders. More
information regarding the range of psychiatric services at this site and the typical clinical population has been previously published [20]. Measures The measure of general psychopathology was the Child Behavior Checklist (CBCL) [21], a 120-item questionnaire completed by the principal caregiver of both controls and ED patients on the day of their first clinical assessment. The CBCL measures the presence or absence of emotional and behavioral problems and areas of competence. The CBCL generates three summary scores: total problem, internalizing and externalizing scores, and subscales for anxiety/depression, somatic, social, withdrawn, thought, attention, aggression, and delinquency. CBCL subscale scores are bnormalizedQ based upon a normal distribution with a mean of 50 and a standard deviation of 10. A score of N 60 indicates that an individual falls out of the normal range for that subscale. Eating disorders psychopathology was measured by the EDE, a 62-question semistructured interview of ED behaviors, emotions, and attitudes [19]. For children 13 years and younger, the administration of items measuring the importance of shape and weight was modified according to the instructions described by Bryant-Waugh et al. [22]. Other measures utilized in this study were percent weight for height at initial assessment, patient or parent report of kilograms weight lost at presentation, gastrointestinal (GI) symptom score that summarizes GI symptoms at initial presentation [23], duration of illness (in months) prior to presentation, and the age of the patient at menarche. Statistical analysis Eating disorder vs. control group status was analyzed as a nominal variable; ED diagnoses as an ordinal variable. General psychopathology was analyzed both as a nominal (case vs. noncase) variable using published CBCL cutoff scores and as continuous variables using total and subscale scores. Analysis of variance (ANOVA) was used, and statistical significance set at the .05 probability level. SPSS version 10 was used to analyze data.
Results Comparison between the ED and control group The control group had significantly greater general and externalizing (aggression and delinquency) psychopathology than the ED group as a whole (Table 1). Rates of internalizing psychopathology (anxiety and depression) are no different between the ED and control groups. When analyzed as a categorical variable (caseTotal = total T score N60; casesubscale = internalizing and externalizing
B. McDermott et al. / Journal of Psychosomatic Research 60 (2006) 257 –261
scores N 67), significantly more controls met total psychopathology case criteria than the ED group (70.6% vs. 63.3%), a difference that was more pronounced for externalizing symptoms (14.7% vs. 38.5%). There was no difference in meeting case criteria for internalizing disorders (51.4% vs. 54.1%). When considering controls vs. specific ED diagnostic groups (Table 1), the anorexia nervosa group has a significantly lower total psychopathology score [ F(217) = 6.505, P =.000] and externalizing score [ F(216) =9.255, P =.000]. None of the ED groups differed from general child mental health controls on internalizing symptoms. Comparison within ED diagnostic groups The EDNos and bulimia nervosa groups consistently validated higher general, internalizing and externalizing psychopathology scores than the anorexia group (Table 1). Analysis by case status found significantly fewer individuals with anorexia nervosa met case criteria on total psychopathology (48.9% vs. EDNos 73.9% and bulimia nervosa 78.6%). Results were similar for internalizing cutoffs (anorexia nervosa 38.8%, EDNos 65.2%, and bulimia nervosa 53.8%). Only one individual with anorexia nervosa met case criteria for an externalizing disorder (anorexia nervosa 2.0%, EDNos 26.1%, and bulimia nervosa 23.1%). Implications of comorbid general psychopathology on psychological and physical manifestations of EDs Table 2 summarizes ED psychopathology and medical indices in individuals with anorexia nervosa who meet case criteria on the CBCL total psychopathology scale (comorbid-AN) vs. those with anorexia nervosa and no comorbidity (non-comorbid-AN). The comorbid-AN group reported significantly higher total EDE scores and EDE eating, shape, and weight concerns. There were no differences on the EDE dietary restraint scale. The non-comorbid-AN
Table 1 General psychopathology by ED diagnosis and control group status
Anorexia nervosa (n = 49) EDNos (n = 46) Bulimia nervosa (n = 14) Total eating disorders (n = 109) Controls (n = 109) a
Total T score
Internalizing T score
Externalizing T score
58.22 (10.62)a
62.65 (12.20)
50.10 (8.52)b
64.26 (8.01) 64.21 (10.76)
68.15 (10.13) 67.53 (11.12)
56.74 (10.66) 56.84 (9.62)
61.54 (9.99)
65.58 (11.45)
53.74 (10.09)
65.76 (10.35)c
65.57 (12.21)
60.33 (12.72)d
Comparison ED diagnostic group vs. controls, ANOVA F(217) = 6.505, P = .000. b Comparison ED diagnostic group vs. controls, ANOVA F(216) = 9.255, P = .000. c Comparison total ED vs. control, t(216) = 3.062, P = .002. d Comparison total ED vs. control, t(215) = 4.225, P = .000.
Table 2 Implications of psychopathology
general
259
psychopathology
comorbidity
on
ED
Comorbid Non-comorbid Comorbid anorexia anorexia EDNos Non-comorbid (n=24) (n=25) (n=34) EDNos (n=12) EDE Total Restraint Eat concern Shape concern Weight concern
3.37a 3.90 2.64b 3.38a 3.11a
2.26 3.42 1.74 2.23 1.66
3.13 3.42 2.50 3.69 2.93
2.55 2.65 2.35 2.65 2.53
Percent wt/ht Duration Weight loss (kg) GI symptoms Age menarche
73.00 11.64b 14.97 9.62b 12.37
70.48 6.42 11.12 6.56 12.79
89.90 8.64 9.14 10.42a 12.74
82.64 9.04 9.91 5.17 11.91
a b
P b.004. P b.03.
group was not more pathological on any measure. The comorbid-AN group also experienced significantly longer duration of illness prior to assessment and significantly more GI symptoms at assessment. The comorbid-AN group was not associated with age at menarche, amount of weight loss, or malnutrition. Results of analysis of the comorbid internalizing symptom-AN group were identical to comorbid total psychopathology. An analysis of the comorbid externalizing symptom-AN group was not undertaken given the rarity of this group (n =1). Individuals with an EDNos diagnosis were far less influenced by the presence of comorbidity. There was no significant relationship between the comorbid-EDNos and non-comorbid EDNos total psychopathology score, EDE total score, or any EDE subscale. Similarly, there was no relationship with duration of illness, weight loss, malnutrition, or age of menarche. As is the case with anorexia nervosa, there was a significant association [t(43) = 3.284, P =.002] between comorbid-EDNos and GI symptoms. Analysis of the comorbid internalizing symptom-EDNos group found similar results: no relationship with EDE scores or physical indices other than a significantly higher report of GI symptoms in the comorbid group. For medical indices, this pattern was repeated for comorbid externalizing symptom-EDNos. However, there was a uniform trend for higher EDE psychopathology scores for the comorbid externalizing symptoms group that reached significance for the EDE total, restraint, and shape concern subscales. An analysis of comorbid-bulimia nervosa was not undertaken given the small sample size.
Discussion In summary, the child and adolescent ED group experienced lower levels of total and externalizing psychopathology than the child and adolescent mental health clinical
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control group. However, the ED group had levels of internalizing psychopathology (anxiety and depressive symptoms) similar to clinical controls. There were differences in general psychopathology across ED diagnostic groups, with the lowest rates in the anorexia nervosa group. This did not replicate the findings of Speranza et al. [4] of no differences between ED diagnostic groups. Individuals with anorexia nervosa and comorbid mental health symptoms also experienced higher ED symptom scores rated on the EDE, more GI symptoms, and a longer duration of illness but not greater weight loss or concurrent malnutrition at assessment. Individuals with EDNos and comorbid non-ED mental health symptoms did not experience higher ED psychopathology and had no increased duration of illness. Like the anorexia-comorbid group, the EDNos-comorbid group also experienced more GI symptoms than those without comorbidity. From a clinical perspective, the findings suggest that comorbid non-ED symptoms should be assessed: at first assessment, approximately 50% of children and adolescents with an ED will also meet case criteria for anxiety and depression, a rate varying from approximately 40% in children with anorexia nervosa to 54– 65% in children with bulimia nervosa and EDNos. These rates of depressive symptoms are consistent with the findings from longitudinal adolescent clinical [18] and community [13] studies. Externalizing symptoms including disruptive behavior are much less common; in individuals with anorexia nervosa these symptoms are very uncommon. The occurrence of comorbid psychopathology has several possible explanations; in anorexia nervosa it may reflect illness chronicity or shared causal factors including familial factors [24]. The relationship may be a reportage effect; in a study of young women with anorexia nervosa the authors’ conclusion from a variance analysis was the significant influence of depressive symptoms on ED psychopathology [25]. Our results suggest depressive symptoms are not related to malnutrition. The presence of comorbidity has some application as a marker of ED psychopathology severity. The more severe and diverse (internalizing and externalizing) psychopathology in the EDNos group may reflect an individual with more general distress and unhappiness rather than a focus on specific weight, shape, and dietary concerns. Study limitations include the reliance on the CBCL as the principal measure of psychopathology. Whilst the CBCL demonstrates moderate correspondence with diagnostic categories [26], a diagnostic instrument and measure of impairment [26] would further clarify non-ED mental health diagnoses in this group. A larger sample size is required to test more complex associations with comorbid status. A longitudinal research design is needed to assess psychopathology changes during the development of anorexia nervosa from EDNos. This cross-sectional data suggest that as ED symptoms rise externalizing symptoms markedly decrease. This may be a manifestation of the control
necessary to maintain the dietary restriction typical of anorexia nervosa. These findings have a number of management implications. Comorbidity, especially of internalizing symptoms, may increase resistance to change and increase difficulty in engaging with the ED therapist and treatment team. Initial therapeutic endeavors may need to target non-ED symptoms such as depressive symptoms. The unexpected finding of no link between comorbidity and malnutrition status is consistent with the finding of North and Gowers [27] that comorbidity was not related to a poorer prognosis at 2-year follow-up. Future research should further explore the relationship between comorbidity and outcome in child and adolescent samples, and include both parent and youth report data to obtain a more complete understanding of the breadth of general psychopathology in these age groups.
References [1] Lucas AR, Beard CM, O’Fallon WM, Kurlan LT. 50 year trends in the incidence of anorexia nervosa in Rochester: a population based study. Am J Psychiatry 1991;148:917 – 22. [2] Lennkh C, Strnad A, Bailer U, Biener D, Fodor G, de Zwaan M. Comorbidity of obsessive compulsive disorder in patients with eating disorders. Eat Weight Disord 1998;3:37 – 41. [3] Grubb HJ, Sellers MI, Waligroski K. Factors related to depression and eating disorders: self esteem, body image, and attractiveness. Psychol Rep 1993;72:1003 – 10. [4] Speranza M, Corcos M, Atger F, Paterniti S, Jeammet P. Binge eating behaviours and weight control strategies. Eat Weight Disord 2003; 8:201 – 6. [5] Laessle RG, Kittl S, Fichter MM, Wittchen H, Pirike KM. Major affective disorder in anorexia nervosa and bulimia: a descriptive diagnostic study. Br J Psychiatry 1987;151:785 – 9. [6] Walsh BT, Roose SP, Glassman AH, Gladis M, Sadik C. Bulimia and depression. Psychosom Med 1985;2:123 – 31. [7] Goddard KA, van den Berk PAH, Raphael FJ, McCluskey SE, Lacey JH. Eating disorders in women admitted to hospital following deliberate self poisoning. Acta Psychiatr Scand 1997;95:140 – 4. [8] Garfinkel PE, Moldofsky H, Garner DM. The heterogeneity of anorexia nervosa. Bulimia as a distinct subgroup. Arch Gen Psychiatry 1980;37:1036 – 40. [9] Yellowlees AJ. Anorexia and bulimia in anorexia nervosa: a study of psychosocial functioning and associated psychiatric symptomatology. Br J Psychiatry 1985;146:648 – 52. [10] Viesselman JO, Roig M. Depression and suicidality in eating disorders. J Clin Psychol 1985;46:118 – 24. [11] Nielsen S, Moller-Madsen S, Isager T, Jorgensen J, Pagsberg K, Theander S. Standardized mortality in eating disorders: a quantitative summary of previously published and new evidence. J Psychosom Res 1998;44:413 – 34. [12] Lee AM, Lee S. Disordered eating and its psychosocial correlates among Chinese adolescent females in Hong Kong. Int J Eat Disord 1996;20:177 – 83. [13] Patton GC, Coffey C, Sawyer M. The outcome of adolescent eating disorders: findings from the Victorian Adolescent Health Cohort Study. Eur Child Adolesc Psychiatry 2003;12:125 – 9. [14] Zaider TL, Johnson JG, Cockell SJ. Psychiatric comorbidity associated with eating disorders symptomatology. Int J Eat Disord 2000;28:58 – 67.
B. McDermott et al. / Journal of Psychosomatic Research 60 (2006) 257 –261 [15] Canals J, Carbajo G, Fernandez J, Marti-Henneberg C, Domenech E. Biopsychopathologic risk profile of adolescents with eating disorders symptoms. Adolescence 1996;31(122):443 – 50. [16] Jacobs BW, Isaccs S. Prepubertal anorexia nervosa. J Child Psychol Psychiatry 1986;27:237 – 50. [17] Fosson A, Knibbs J, Byant-Waugh R, Lask B. Early onset anorexia nervosa. Arch Dis Child 1987;62:114 – 8. [18] Steinhausen H-C. The outcome of anorexia nervosa in the twentieth century. Am J Psychiatry 2002;159:1284 – 93. [19] Cooper Z, Fairburn C. The eating disorder examination: a semistructured interview for the assessment of the specific psychopathology of eating disorders. Int J Eat Disord 1987;6:1 – 8. [20] McDermott BM, McKelvey R, Roberts L, Davies L. Severity of children’s psychopathology and impairment and its relationship to treatment setting. Psychiatr Serv 2002;53:57 – 62. [21] Achenbach TM. Manual for the child behaviour checklist and 1991 profile. Burlington (VT)7 Department of Psychiatry, University of Vermont, 1991.
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[22] Bryant-Waugh RJ, Cooper PJ, Taylor CL, Lask BD. The use of the eating disorder examination with children: a pilot study. Int J Eat Disord 1996;19:391 – 7. [23] Forbes DA, Turner JM, Batik M, Palmer LG, McDermott BM. Gastrointestinal symptoms in adolescent eating disorders. J Pediatr Gastroenterol Nutr 2000;31:109. [24] Mangweth B, Hudson JI, Pope HG, Hausmann A, De Col C, Laird NM, Beibl W, Tsuang MT. Family study of the aggregation of eating disorders and mood disorders. Psychol Med 2003; 33:1319 – 23. [25] Bizeul C, Brun JM, Rigaud D. Depression influences the EDI scores in anorexia nervosa patients. Eur Psychiatry 2003;18:119 – 23. [26] Gould MS, Bird H, Staghezza-Jaramillo B. Correspondence between statistically derived behaviour problem syndromes and child psychiatric diagnoses in a community sample. J Abnorm Child Psychol 1993;21:287 – 313. [27] North C, Gowers S. Anorexia nervosa, psychopathology and outcome. Int J Eat Disord 1999;26:386 – 91.
Non-eating disorders psychopathology in children and adolescents with eating disorders: Implications for malnutrition and symptom severity Brett McDermottT, David Forbes, Chris Harris, Julie McCormack, Peter Gibbon Princess Margaret Hospital for Children, School of Paediatrics and Child Health, University of Western Australia, Perth, Western Australia Received 17 August 2004; accepted 2 August 2005
Abstract Objectives: To compare the general psychopathology in an eating disorders (ED) and a child mental health outpatient sample and investigate the implications of comorbidity on psychological and physical measures of ED severity. Methods: One hundred thirty-six children and adolescents with a DSM-IV ED diagnosis were compared with age- and gender-matched controls. Measures included the Eating Disorders Examination and the Child Behavior Checklist. Results: The ED group had lower general and externalizing psychopathology scores and no difference in internalizing (anxiety–depression) symptoms. Of the anorexia nervosa group,
49% experienced comorbid psychopathology. This group had significantly higher ED psychopathology, longer duration of illness, and more gastrointestinal symptoms, but no difference in malnutrition status. Eating disorders not otherwise specified (EDNos) group measures were less influenced by comorbidity status. Conclusions: Anxiety–depressive symptoms are very common in children and adolescents with EDs. Comorbidity status influences illness severity, especially in the anorexia nervosa group. The management implications of these findings are discussed. D 2006 Elsevier Inc. All rights reserved.
Keywords: Anorexia nervosa; Comorbidity; Children; Adolescents
Introduction Anorexia nervosa is the third most common chronic condition of adolescence [1] and is associated with significant psychological, physical, social, and family impairment. Despite developing predominantly in the adolescent years, there are limited studies investigating this age group. Few reports of child and adolescent onset anorexia nervosa have described the breadth of general psychopathology in this clinical group, despite such knowledge being potentially influential to assessment strategies and the type of treatments offered. General psychopathology research of adult populations has mainly studied comorbid anorexia nervosa and depression, although comorbid social phobia, agoraphobia, and obsessive-compulsive disorder have also been reported
T Corresponding author. University of Queensland and Kids in Mind Research: Mater Centre for Service Research in Mental Health, Mater Child and Youth Mental Health Service, Raymond Terrace, South Brisbane 7010, Australia. Tel.: +61 07 3840 1640; fax: +61 07 3840 1644. E-mail address: [email protected] (B. McDermott). 0022-3999/06/$ – see front matter D 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.jpsychores.2005.08.004
[1,2]. Significant positive associations have been reported between measures of depressive and eating disorders (ED) psychopathology in college undergraduate women [3] and patients with EDs [4,5]. Rates of comorbid depression in individuals with EDs vary from 15% to 50% [5] depending on the study rigor. Using semistructured diagnostic interviews, rates of lifetime affective disorders have been reported as high as 88% in female patients with bulimia nervosa [6]. Behaviors typically associated with depression have also been documented in ED samples, more commonly bulimia than anorexia nervosa [7]. Self-mutilation has been reported in individuals with binge-purge anorexia nervosa (9.2%) and restricting anorexia nervosa (1.5%) [8], and self-poisoning appears very common (34%) [9]. The attempted suicide rate was reported to be 23.1% in individuals with EDs [10]. Such risk-taking behavior in part explains the finding of Nielsen et al. [11] of a significant increase in the standardized mortality rate for individuals with anorexia nervosa. There has been less general psychopathology research with children and adolescents, and the findings are more equivocal. In community samples of adolescents, the
258
B. McDermott et al. / Journal of Psychosomatic Research 60 (2006) 257–261
depression–ED psychopathology relationship has been replicated [12–14], refuted [15], and the possibility advanced that dysthymia may be more strongly associated with EDs than major depressive disorder [14]. In clinical samples of individuals with anorexia nervosa, using retrospective case note audit designs the prepubertal onset anorexia nervosa group had more premorbid maladjustment than the postpubertal onset group. Further, the prepubertal onset group experienced similar maladjustment levels to a bneuroticQ inpatient comparison group [16]. In another retrospective study, 56% of 15-year-olds with anorexia nervosa were diagnosed with depression, although study limitations include lack of a standardized measure and failure to control for malnutrition [17]. In the 119 outcome studies reviewed by Steinhausen [18], non-ED diagnoses, mainly depressive, anxiety, substance, and personality disorders, were frequently noted at follow-up. Little is known how comorbidity at the time of initial treatment for EDs is related to prognosis. The aim of this study was to compare the general psychopathology in children and adolescents with an ED with a clinical child mental health control group and investigate the implications of comorbid general psychopathology with psychological and physical measures of ED severity.
Methods Participants Over a 3-year period, 136 children and adolescent were diagnosed with an ED after a comprehensive assessment including a semistructured interview by a child psychiatrist or psychologist, a detailed physical review by a pediatric gastroenterologist, dietary and anthropometric assessment, and completion of the Eating Disorders Examination (EDE) [19]. The study participation rate of 80% represents 109 individuals with complete EDs and general psychopathology data. Individuals with missing data did not significantly differ from participants on age, diagnosis, ED psychopathology, or malnutrition. The average age of the ED sample (106 female, 3 male) was 14.5 years (S.D. 1.9 years, range 7–18 years). Of this group, 49 were diagnosed with anorexia nervosa, 46 with ED not otherwise specified (EDNos) and 14 with bulimia nervosa. The control group consisted of 109 patients who attended general mental health outpatient services at the same hospital as the ED sample. For each ED patient an age- and gender-matched control, who was first assessed during the same week as the ED patient, was randomly selected. The case notes of controls were reviewed by a child psychiatrist to ensure the controls did not have an ED diagnosis or experience prominent ED symptoms such as fasting or bingeing. Diagnoses of the control group were predominantly depression and other mood disorders, anxiety and adjustment disorders. More
information regarding the range of psychiatric services at this site and the typical clinical population has been previously published [20]. Measures The measure of general psychopathology was the Child Behavior Checklist (CBCL) [21], a 120-item questionnaire completed by the principal caregiver of both controls and ED patients on the day of their first clinical assessment. The CBCL measures the presence or absence of emotional and behavioral problems and areas of competence. The CBCL generates three summary scores: total problem, internalizing and externalizing scores, and subscales for anxiety/depression, somatic, social, withdrawn, thought, attention, aggression, and delinquency. CBCL subscale scores are bnormalizedQ based upon a normal distribution with a mean of 50 and a standard deviation of 10. A score of N 60 indicates that an individual falls out of the normal range for that subscale. Eating disorders psychopathology was measured by the EDE, a 62-question semistructured interview of ED behaviors, emotions, and attitudes [19]. For children 13 years and younger, the administration of items measuring the importance of shape and weight was modified according to the instructions described by Bryant-Waugh et al. [22]. Other measures utilized in this study were percent weight for height at initial assessment, patient or parent report of kilograms weight lost at presentation, gastrointestinal (GI) symptom score that summarizes GI symptoms at initial presentation [23], duration of illness (in months) prior to presentation, and the age of the patient at menarche. Statistical analysis Eating disorder vs. control group status was analyzed as a nominal variable; ED diagnoses as an ordinal variable. General psychopathology was analyzed both as a nominal (case vs. noncase) variable using published CBCL cutoff scores and as continuous variables using total and subscale scores. Analysis of variance (ANOVA) was used, and statistical significance set at the .05 probability level. SPSS version 10 was used to analyze data.
Results Comparison between the ED and control group The control group had significantly greater general and externalizing (aggression and delinquency) psychopathology than the ED group as a whole (Table 1). Rates of internalizing psychopathology (anxiety and depression) are no different between the ED and control groups. When analyzed as a categorical variable (caseTotal = total T score N60; casesubscale = internalizing and externalizing
B. McDermott et al. / Journal of Psychosomatic Research 60 (2006) 257 –261
scores N 67), significantly more controls met total psychopathology case criteria than the ED group (70.6% vs. 63.3%), a difference that was more pronounced for externalizing symptoms (14.7% vs. 38.5%). There was no difference in meeting case criteria for internalizing disorders (51.4% vs. 54.1%). When considering controls vs. specific ED diagnostic groups (Table 1), the anorexia nervosa group has a significantly lower total psychopathology score [ F(217) = 6.505, P =.000] and externalizing score [ F(216) =9.255, P =.000]. None of the ED groups differed from general child mental health controls on internalizing symptoms. Comparison within ED diagnostic groups The EDNos and bulimia nervosa groups consistently validated higher general, internalizing and externalizing psychopathology scores than the anorexia group (Table 1). Analysis by case status found significantly fewer individuals with anorexia nervosa met case criteria on total psychopathology (48.9% vs. EDNos 73.9% and bulimia nervosa 78.6%). Results were similar for internalizing cutoffs (anorexia nervosa 38.8%, EDNos 65.2%, and bulimia nervosa 53.8%). Only one individual with anorexia nervosa met case criteria for an externalizing disorder (anorexia nervosa 2.0%, EDNos 26.1%, and bulimia nervosa 23.1%). Implications of comorbid general psychopathology on psychological and physical manifestations of EDs Table 2 summarizes ED psychopathology and medical indices in individuals with anorexia nervosa who meet case criteria on the CBCL total psychopathology scale (comorbid-AN) vs. those with anorexia nervosa and no comorbidity (non-comorbid-AN). The comorbid-AN group reported significantly higher total EDE scores and EDE eating, shape, and weight concerns. There were no differences on the EDE dietary restraint scale. The non-comorbid-AN
Table 1 General psychopathology by ED diagnosis and control group status
Anorexia nervosa (n = 49) EDNos (n = 46) Bulimia nervosa (n = 14) Total eating disorders (n = 109) Controls (n = 109) a
Total T score
Internalizing T score
Externalizing T score
58.22 (10.62)a
62.65 (12.20)
50.10 (8.52)b
64.26 (8.01) 64.21 (10.76)
68.15 (10.13) 67.53 (11.12)
56.74 (10.66) 56.84 (9.62)
61.54 (9.99)
65.58 (11.45)
53.74 (10.09)
65.76 (10.35)c
65.57 (12.21)
60.33 (12.72)d
Comparison ED diagnostic group vs. controls, ANOVA F(217) = 6.505, P = .000. b Comparison ED diagnostic group vs. controls, ANOVA F(216) = 9.255, P = .000. c Comparison total ED vs. control, t(216) = 3.062, P = .002. d Comparison total ED vs. control, t(215) = 4.225, P = .000.
Table 2 Implications of psychopathology
general
259
psychopathology
comorbidity
on
ED
Comorbid Non-comorbid Comorbid anorexia anorexia EDNos Non-comorbid (n=24) (n=25) (n=34) EDNos (n=12) EDE Total Restraint Eat concern Shape concern Weight concern
3.37a 3.90 2.64b 3.38a 3.11a
2.26 3.42 1.74 2.23 1.66
3.13 3.42 2.50 3.69 2.93
2.55 2.65 2.35 2.65 2.53
Percent wt/ht Duration Weight loss (kg) GI symptoms Age menarche
73.00 11.64b 14.97 9.62b 12.37
70.48 6.42 11.12 6.56 12.79
89.90 8.64 9.14 10.42a 12.74
82.64 9.04 9.91 5.17 11.91
a b
P b.004. P b.03.
group was not more pathological on any measure. The comorbid-AN group also experienced significantly longer duration of illness prior to assessment and significantly more GI symptoms at assessment. The comorbid-AN group was not associated with age at menarche, amount of weight loss, or malnutrition. Results of analysis of the comorbid internalizing symptom-AN group were identical to comorbid total psychopathology. An analysis of the comorbid externalizing symptom-AN group was not undertaken given the rarity of this group (n =1). Individuals with an EDNos diagnosis were far less influenced by the presence of comorbidity. There was no significant relationship between the comorbid-EDNos and non-comorbid EDNos total psychopathology score, EDE total score, or any EDE subscale. Similarly, there was no relationship with duration of illness, weight loss, malnutrition, or age of menarche. As is the case with anorexia nervosa, there was a significant association [t(43) = 3.284, P =.002] between comorbid-EDNos and GI symptoms. Analysis of the comorbid internalizing symptom-EDNos group found similar results: no relationship with EDE scores or physical indices other than a significantly higher report of GI symptoms in the comorbid group. For medical indices, this pattern was repeated for comorbid externalizing symptom-EDNos. However, there was a uniform trend for higher EDE psychopathology scores for the comorbid externalizing symptoms group that reached significance for the EDE total, restraint, and shape concern subscales. An analysis of comorbid-bulimia nervosa was not undertaken given the small sample size.
Discussion In summary, the child and adolescent ED group experienced lower levels of total and externalizing psychopathology than the child and adolescent mental health clinical
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control group. However, the ED group had levels of internalizing psychopathology (anxiety and depressive symptoms) similar to clinical controls. There were differences in general psychopathology across ED diagnostic groups, with the lowest rates in the anorexia nervosa group. This did not replicate the findings of Speranza et al. [4] of no differences between ED diagnostic groups. Individuals with anorexia nervosa and comorbid mental health symptoms also experienced higher ED symptom scores rated on the EDE, more GI symptoms, and a longer duration of illness but not greater weight loss or concurrent malnutrition at assessment. Individuals with EDNos and comorbid non-ED mental health symptoms did not experience higher ED psychopathology and had no increased duration of illness. Like the anorexia-comorbid group, the EDNos-comorbid group also experienced more GI symptoms than those without comorbidity. From a clinical perspective, the findings suggest that comorbid non-ED symptoms should be assessed: at first assessment, approximately 50% of children and adolescents with an ED will also meet case criteria for anxiety and depression, a rate varying from approximately 40% in children with anorexia nervosa to 54– 65% in children with bulimia nervosa and EDNos. These rates of depressive symptoms are consistent with the findings from longitudinal adolescent clinical [18] and community [13] studies. Externalizing symptoms including disruptive behavior are much less common; in individuals with anorexia nervosa these symptoms are very uncommon. The occurrence of comorbid psychopathology has several possible explanations; in anorexia nervosa it may reflect illness chronicity or shared causal factors including familial factors [24]. The relationship may be a reportage effect; in a study of young women with anorexia nervosa the authors’ conclusion from a variance analysis was the significant influence of depressive symptoms on ED psychopathology [25]. Our results suggest depressive symptoms are not related to malnutrition. The presence of comorbidity has some application as a marker of ED psychopathology severity. The more severe and diverse (internalizing and externalizing) psychopathology in the EDNos group may reflect an individual with more general distress and unhappiness rather than a focus on specific weight, shape, and dietary concerns. Study limitations include the reliance on the CBCL as the principal measure of psychopathology. Whilst the CBCL demonstrates moderate correspondence with diagnostic categories [26], a diagnostic instrument and measure of impairment [26] would further clarify non-ED mental health diagnoses in this group. A larger sample size is required to test more complex associations with comorbid status. A longitudinal research design is needed to assess psychopathology changes during the development of anorexia nervosa from EDNos. This cross-sectional data suggest that as ED symptoms rise externalizing symptoms markedly decrease. This may be a manifestation of the control
necessary to maintain the dietary restriction typical of anorexia nervosa. These findings have a number of management implications. Comorbidity, especially of internalizing symptoms, may increase resistance to change and increase difficulty in engaging with the ED therapist and treatment team. Initial therapeutic endeavors may need to target non-ED symptoms such as depressive symptoms. The unexpected finding of no link between comorbidity and malnutrition status is consistent with the finding of North and Gowers [27] that comorbidity was not related to a poorer prognosis at 2-year follow-up. Future research should further explore the relationship between comorbidity and outcome in child and adolescent samples, and include both parent and youth report data to obtain a more complete understanding of the breadth of general psychopathology in these age groups.
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