Mood disorders in eating disorder patients: Prevalence and chronology of ONSET.

OBJECTIVES: In a clinical population, we estimated the frequency of mood disorders among 271 patients suffering from Anorexia Nervosa (AN) and Bulimia Nervosa (BN) in comparison to a control group matched for age and gender. METHOD: The frequency of mood disorders was measured using the Mini International Neuropsychiatric Interview (MINI), DSM-IV version. RESULTS: Mood disorders were more frequent among eating disorder (ED) patients than among controls, with a global prevalence of the order of 80% for each ED group. The majority of the mood disorders comorbid with ED were depressive disorders (MDD and dysthymia). The relative chronology of onset of these disorders was equivocal, because mood disorders in some cases preceded and in others followed the onset of the eating disorders. LIMITATIONS: Our sample was characterized by patients with severe ED and high comorbidities, and thus do not represent the entire population of AN or BN. This also may have resulted in an overestimation of prevalence. CONCLUSION: Mood disorders appear significantly more frequently in patients seeking care for ED than in controls. These results have implications for the assessment and treatment of ED patients, and for the aetio-pathogenesis of these disorders.

Expressed emotion measure adaptation into a foreign language.

Expressed emotion (EE) measures have been created in English; adaptation into a foreign language is difficult. The aim of this study was to adapt the five minutes speech sample (FMSS), with a designed procedure ensuring optimum quality of the adaptation, and thus better trans-cultural validity. A strategy for improving inter-rater agreement comprised three phases: (1) phase of initial ratings (70 French samples), (2) experimental phase in two steps: ratings of 40 other samples in French, followed by analysis of differences between the French-language ratings and English-language ratings and (3) final rating phase of the initial 70 samples. For each phase, the κ coefficients measuring inter-rater agreement were calculated and compared using a bootstrap procedure. The improvements between these scorings were significant at p < 0.05 (phase 2 initial versus phase 2 final and phases 1 versus 3). The French inter-rater agreement significantly improved after this procedure.

Detemining factors for target weights in an anorexia nervosa inpatient program for adolescents and young adults: study on the links between theory-based hypotheses and the realities of clinical practice.

BACKGROUND: The aim is to study if the determination of target weights in a clinical therapeutic contract which guides weight gain for adolescent inpatients with anorexia nervosa (AN) is based on clearly pre-defined, objective clinical elements. METHOD: Treating psychiatrists completed patient information questionnaires for 139 anorexic adolescent inpatients. These questionnaires included information related to factors that the clinical team had hypothesized to be decisive in weight contract determination. Comparative statistical procedures evaluated whether these factors were in fact decisive in clinical practice. RESULTS: The two weight objectives comprising our therapeutic contract (separation end weight and final discharge weight) were significantly related to the clinical variables tested: separation end weight was explained by the theoretical separation end weight, the range of contract, and the desires of the patient and her parents; final discharge weight was explained by patient body mass index before AN and by the desires of the patient and her parents. CONCLUSION: The therapeutic contract is based on objective criteria and implemented by our team in accordance with its theoretical design. It is therefore possible to establish goal weights in a defined and reliable manner.

Family history of anxiety and mood disorders in anorexia nervosa: review of the literature.

OBJECTIVE: To provide a critical review of the research on mood and anxiety disorders in relatives of individuals with anorexia nervosa (AN). In the first section, we explore methodological issues with these studies. In the second section, we present results. METHOD: A Medline search identified studies published on family history of mood and anxiety disorders in AN, and was complemented by a manual search. Only studies from 1980 to 2006 using strict diagnostic criteria for the disorders were included [Feighner and Halmi criteria for AN, Reasearch Diagnostic Criteria (RDC), Diagnostic and Statistical Manual of Mental Disorders - Third Edition - Revised (DSM-III-R) or DSM - Fourth Edition (DSM-IV) for anorexia and other disorders]. RESULTS: A review of the research methods used in the studies revealed a number of methodological problems. Therefore, we provide only a description of the prevalence of mood and anxiety disorders in relatives of individuals with AN. CONCLUSIONS: In the light of the methodological issues uncovered, the value of the results of these studies and their implications for further study are considered.

[Mood and anxiety disorders in relatives of anorexia nervosa patients: a review]. / Antécédents familiaux de troubles anxieux et de troubles de l'humeur dans l'anorexie mentale.

UNLABELLED: In the literature, no review concerning the family comorbidity of mood and anxiety disorders of anorexic subjects exists. However, this data can be important for the comprehension of this disorder and for the assumption of responsibility. OBJECTIVE: We conducted a critical literature review on studies assessing the prevalence of anxiety disorders (AD) and mood disorders in relatives of anorexia nervosa (AN) subjects. In the first part, we discuss methodological issues relevant to these comorbidity studies. In the second part, taking into account the methodological considerations raised, we summarise the findings of these studies. METHOD: We performed a manual and computerised search (Medline) for all published studies on the frequency of MD and AD in AN relatives and MD or AD, limiting our search to the 1980-2002 period, in order to get sufficiently homogeneous diagnostic criteria for both categories of disorders (most often RDC, DSM III, DSM III-R, or DSM IV criteria). RESULTS: We review methodological issues regarding population sources, general methodological procedures, diagnostic criteria for AN, MD and AD, diagnostic instruments, age of subjects and course of the eating disorder. DISCUSSION: We discuss the results taking into account the methodological problems observed. We give implications for reviewing the results of published studies and planning future research.

Comorbidity studies of eating disorders and mood disorders. Critical review of the literature.

OBJECTIVE: We conducted a critical literature review of studies assessing the prevalence of mood disorders (MD) in subjects with eating disorders (ED; anorexia nervosa and bulimia nervosa). In the first part of this article, we discuss methodological issues relevant to comorbidity studies between ED and MD. In the second part, we summarize the findings of these studies in light of the methodological considerations raised. METHOD: A manual computerised search (Medline) was performed for all published studies on comorbidity between ED and MD. In order to have sufficiently homogeneous diagnostic criteria for both categories of disorders, this search was limited to articles published between 1985 and 2006. RESULTS: Too few studies include control groups, few studies compared diagnostic subgroups of ED subjects, and results are scarce or conflicting. DISCUSSION: The results are discussed in the light of the methodological problems observed. The implications when reviewing the results of published studies and planning future research are set out.

[Relations between alexithymia and anhedonia: a study in eating disordered and control subjects]. / Etude des relations entre alexithymie et anhédonie chez des femmes présentant des troubles du comportement alimentaire et chez des témoins.

INTRODUCTION: Alexithymia and anhedonia both refer to a deficit in emotion regulation. Although these 2 concepts have been conceptualized to be closely linked, very few studies aimed at examining carefully their interrelations. OBJECTIVES: Therefore, the purpose of the present study was to investigate the relationships between scores on alexithymia and anhedonia self-reports, and to assess whether the results were influenced by the presence of an emotional disorder. LITERATURE FINDINGS: The 20-item Toronto Alexithymia Scale is the self-report most frequently used to assess alexithymia. Nevertheless, the results of recent studies comparing the psychometric properties of the TAS-20 and another alexithymia self-report - the Bermond-Vorst Alexithymia Questionnaire (BVAQ) - have recommended the BVAQ over the TAS-20. DESIGN: Thus, both questionnaires were included in the present study. In addition, since depression and anxiety may influence the correlations between alexithymia and anhedonia scores, we also measured depression and anxiety and these scores were used to control for their potential confounding effect in the analyses. Two groups of participants were included in this study: 46 eating disordered female patients (ED) and 198 female control subjects. All the participants filled up the Bermond-Vorst Alexithymia Questionnaire-form B (BVAQ-B), the 20-item Toronto Alexithymia Scale (TAS-20), the Chapman and Chapman Social Anhedonia Scale (SAS) and Physical Anhedonia Scale (PAS), the 13-item Beck Depression Inventory (BDI) and the Spielberger State and Trait Anxiety Inventory (STAI-Y). The analyses consisted, first, in establishing the matrix of correlations between these self-reports total scores, using Pearson's coefficients of correlation. Then, TAS-20, BVAQ-B, SAS and PAS scores were correlated, adjusting for BDI and STAI scores, using partial correlation analyses. Mean scores comparisons according to the group of participants, and to the presence/absence of alexithymia, as well as to the presence/absence of anhedonia were performed using ANCOVAs or Mann-Whitney tests. RESULTS: As predicted, BDI and STAI scores were found significantly and positively correlated with alexithymia and anhedonia scores in both participant groups. After controlling for depression and anxiety scores, TAS-20 and PAS scores remained significantly correlated, but not TAS-20 and SAS scores. BVAQ-B scores remained significantly correlated with PAS and SAS scores in the control group, but only with the PAS scores in the ED group. ED patients had higher alexithymia and anhedonia scores than the controls. In total, among the alexithymic individuals, 8.9% were social anhedonics, and 31.1% had a physical anhedonia. Conversely, among the participants with a physical anhedonia, two third were alexithymics. The same proportion of participants with a social anhedonia was alexithymic (66.7%). CONCLUSION: The results of the present study are informed about the relationships between alexithymia and anhedonia. They also stress the need to rely on several alexithymia measurements, and they further demonstrate the necessity to compare the associations between different affect regulation dimensions in normal and psychopathological disorders.

Resolving a disagreement in a clinical team: overcoming conflicting views about the role of family therapy in an outpatient treatment programme for anorexia nervosa.

In the Adolescent Psychiatry Department at the Institut Mutualiste Montsouris, Paris, as is also observed in the literature, the outcome for anorexic patients can sometimes be catastrophic, regardless of treatments proposed. This disturbing finding led us to reassess our therapeutic treatment strategies, in an effort to improve patient outcome. The multidimensional treatment program implemented in the Department includes parent counselling, but not the whole family in a family therapy procedure. It has been demonstrated better outcome for patients who underwent family therapy in comparison to patients who underwent individual therapy. This raised the question of whether family therapy could improve our outpatient programme. This paper describes here how a research programme was developed to resolve a disagreement in our clinical team as to whether family therapy should be added to the existing care programme. The paper describes the difficulties encountered by our team, and the experimental design chosen to resolve the debate. Data will not be set out here.

[Are anxiety or depressive disorders more frequent among one of the anorexia or bulimia nervosa subtype?]. / La fréquence des troubles anxio-dépressifs diffère-t-elle entre les types diagnostiques d'anorexie mentale et de boulimie?

UNLABELLED: Our objective was to answer the following question: are there differences between diagnostic groups of eating disorders (ED) for the prevalence of depressive and anxiety disorders, when clinical differences between the groups are taken into account (ie age of subjects, ED duration, inpatient or outpatient status, and Body Mass Index)? METHOD: We evaluated the frequency of anxiety disorders and depressive disorders in 271 subjects presenting with a diagnosis of either anorexia nervosa or bulimia, using the Mini International Neuropsychiatric Interview (MINI), DSM IV version. We compared the prevalences between sub-groups of anorexics (AN-R and AN-BN), between sub-groups of bulimics (BN-P and BN-NP) and between anorexics and bulimics while adjusting for the variables defined below. RESULTS: Current or lifetime comorbidity of anxiety and depressive disorders did not differ between AN-Rs and AN-BNs, nor between BN-Ps and BN-NPs. Only current diagnoses of agoraphobia and obsessive-compulsive disorder were significantly more frequent in anorexics than in bulimics. CONCLUSION: The greater frequency of comorbidity between obsessive-compulsive disorder and AN compared to BN, already well documented, is not questioned. The remaining anxiety disorders are equally frequent among all the diagnostic types of ED.

[The weight contract during the hospitalization of anorexic patients]. / Le contrat de poids lors d'une hospitalisation pour anorexie mentale.

The weight contract is a traditional practice of the classical modalities of hospitalization of anorexics subjects. However, it is usually practised using different methods according to hospitals. It was explained on the theoretical side by our team but never exposed in its practical side. We propose to explain here in detail our practice of the weight contract. The information reported in this article is the result of articles review published by the professor Jeammet's team and of information resulting from meetings with experts of this team. First of all, we will expose the current context of care in the institut mutualiste Montsouris as well as the negotiation of the weight contract. Then, we will expose the method of care regarding somatic aspects, renutrition, body care, chemotherapy and family preoccupation. Lastly, we will explain in which situations the contract is sometimes renegotiated. In conclusion, we will summarize the utility of such a tool.

[Comorbidity between eating disorders and anxiety disorders: results]. / Comorbidité des troubles du comportement alimentaire et des troubles anxieux. Deuxième partie: résultats.

Taking into account the methodological problems underlined in the first part of this paper, the current review aims to answer three questions: 1) Is there convincing evidence that anxiety disorders (AD) are more frequent among women with eating disorders (ED) than among women from the community? 2) Is there convincing evidence that prevalence of AD differs across diagnostic types or subtypes of ED? 3) What is the chronology of appearance of the two disorders? We performed a manual and computerized search (Medline) for all published studies on comorbidity between ED and AD (1985-2002 period), and selected the most relevant studies. An increased risk for AD in subjects with ED has been shown in several community studies, but studies conducted in referred subjects have led to inconstant findings. The answer to the questions remains uncertain, because too few studies included control groups and few studies have compared diagnostic subgroups of ED subjects, with scarce or conflicting results.

[Comorbidity between eating disorders and anxiety disorders. First part: methodological review]. / Comorbidité entre les troubles du comportement alimentaire et les troubles anxieux. Première partie: revue méthodologique.

UNLABELLED: The objective of our work is to conduct a critical literature review on studies assessing the prevalence of anxiety disorders (AD) in subjects with eating disorders (ED) (anorexia nervosa and bulimia nervosa). In the first part (this paper), we will discuss methodological issues relevant to comorbidity studies between ED and AD. METHOD: We performed a manual and computerised search (Medline) for all published studies on comorbidity between ED and AD, limiting our search to the 1985-2002 period, in order to get sufficiently homogeneous diagnostic criteria for both categories of disorders (most often RDC, DSM III, DSM Ill-R, or DSM IV criteria). RESULTS: We review methodological issues regarding population sources, general methodological procedures, diagnostic criteria for ED and AD, diagnostic instruments, age of subjects and course of the eating disorder. DISCUSSION: We give implications for reviewing the results of published studies and planing future research.

[Comorbidity between eating disorders and mood disorders: review]. / Comorbidité des troubles alimentaires et des troubles de l'humeur. Revue de la littérature: problèmes méthodologiques et données.

OBJECTIVE: Comorbidity between eating disorders (ED) and mood disorders is a major issue when evaluating and treating patients with anorexia nervosa (AN) or bulimia nervosa (BN). In the literature, estimated comorbidity rates of mood disorders in subjects with ED differ widely across studies. Obviously, it is difficult to compare results from various sources because of differences in methods of assessment of depressive symptoms and in diagnostic criteria for both ED and mood disorders. Furthermore, few studies have included control groups, and, since mood disorders are among the most frequent psychiatric disorders in women--with an average estimated lifetime prevalence of 23.9 % (Kessleret al., 1994)--, it is not clear, yet, whether mood disorders are more common among women with an ED (AN or BN) than among women from the community. The only review articles we found on the relationships between ED and mood disorders survey different types of arguments in favour of a link between both categories of disorders, including symptoms, personal and family comorbidity, overlap in biological findings, and treatment results, but do not review in detail available comorbidity data. The aim of this paper is to conduct a critical literature review on studies assessing the prevalence of mood disorders in subjects with an ED (AN or BN). In the first part, we will discuss methodological issues relevant to comorbidity studies between ED and mood disorders, and select the most reliable studies. In the second part, taking into account these methodological considerations raised, we summarize the findings of these studies. METHOD: We performed a manual and computerized search (Medline) for all published studies on comorbidity between ED and AD, limiting our search to the 1985-2002 period, in order to get sufficiently homogeneous diagnostic criteria for both categories of disorders. RESULTS: Too few studies include control groups and few studies have compared diagnostic subgroups of ED subjects, with scarce or conflicting results. DISCUSSION: We reviewed numerous studies here and conclude simply that there are many arguments in favor of elevated rates of MD in ED subjects, but there is no convincing evidence yet. Many questions are left unanswered or have conflicting responses. Our review highlights the need for further studies, which should address several requisites: comorbidity studies should be designed with this as a specific goal, rather than as a secondary aim within other types of studies (such as treatment studies, follow-up studies, etc.). Kendler et al. (1991) state that individuals with two disorders are more likely to present for treatment than individuals with one, therefore, comorbidity rates (which are not in agreement with a special etiologic relationship between BN and depression) may be exaggerated in clinical population results. New studies should include control subjects, matched (at least) for sex and age with ED subjects. Studies should evaluate prevalence of all types of MD in order to yield comparable estimates of MD in general. Comorbidity studies should be conducted on both current and recovered patients, compared to subjects from the community. It is still necessary to demonstrate specificity of findings, i.e. that early onset MD are of specific etiological importance to ED and do not simply increase the risk of later psychopathology in general. Studies should be conducted on larger samples, and all diagnostic subgroups should be considered (restrictive and bulimic anorexics, bulimics with and without history of AN, with or without purging). Multivariate comparisons should be performed, taking into account subject age, sex (if men are included), in- and outpatient status, course of illness, and other possibly relevant variables. Thus, more reliable estimates of the frequency of MD in subjects with ED could provide us with valuable etiologic, therapeutic and prognostic information.

[Is depressive disorder linked to anxiety disorder among anorexics and bulimics?]. / L'existence d'un épisode dépressif majeur est-elle liée à la présence de troubles anxieux chez les anorexiques et les boulimiques?

UNLABELLED: The primaty objective is to determine whether the presence anxiety disorders is related to depressive comorbidity in subjects suffering from ED, while taking into account certain variables which may be related to depression [subjects' age, ED duration, prior incidents of anorexia nervosa in BN subjects, inpatient or outpatient status, nutritional state (as measured by Body Mass Index or BMI)]. Our secondary objective is to evaluate the relative chronology of the onset of anxiety disorders and depressive disorders in anorexic and bulimic subjects. METHOD: We evaluated the frequency of depressive disorders in 271 subjects presenting with a diagnosis of either anorexia nervosa or bulimia, using the Mini International Neuropsychiatric Interview (MINI), DSM IV version. RESULTS: While univariate analyses show that nearly all anxiety disorders are related to major depressive episode (MDE), a separate analysis of each anxiety disorder reveals that they do not all have the same influence in terms of risk of onset of MDE in anorexics and bulimics, when adjusted for univariate variables related to MDE (subjects' age, ED duration, prior incidents of anorexia nervosa in BN subjects, inpatient or outpatient status, nutritional state). Current generalized anxiety is significantly related to lifetime presence of MDE in AN subjects, and to current MDE in AN and BN subjects. Generalized anxiety is the most frequent disorder in AN and BN subjects to according our study; it also appears to be one of the principal predictive factors for MDE, which is 2.4 to 4.2 times more frequent when GAD is present. Diagnosis of OCD has its own particular effect on lifetime risk for MDE in AN subjects, regardless of GAD: it increases the risk of depression by 3.5. It is one of the most frequent anxiety disorders among AN subjects, present in nearly a quarter of them. In bulimics, when GAD is excluded, two factors are related to current diagnosis of MDE: panic disorder and subjects' inpatient or outpatient status. Hospitalized bulimics are diagnosed with current MDE 4.4 times more often than those seen as.

[Validity of the BVAQ: a study in eating disorder patients and controls]. / Validité du questionnaire d'alexithymie de Bermond et Vorst: étude chez des sujets présentant des troubles du comportement alimentaire et chez des témoins.

UNLABELLED: Alexithymia core features are the difficulties in identifying and describing feelings; the difficulties in distinguishing feelings from the bodily sensations of emotional arousal; an impaired symbolization, as evidenced by a paucity of fantasies and other imaginative activity; and a tendency to focus on external events rather than inner experience. Several measures of alexithymia have been developed, including interviewer-rated questionnaires and self-report questionnaires. Among the self-report questionnaires, the 20-item Toronto Alexithymia scale (TAS-20) is the most commonly used, but it fails to measure all the core features of alexithymia. A recently developed instrument, the Bermond-Vorst Alexithymia Questionnaire (BVAQ), allows the measurement of the alexithymia core features, as well as an additional one. It appeared to present good psychometric properties, notably the abbreviated BVAQ-form B. The results of recent studies comparing the psychometric properties of the TAS-20 and the BVAQ have recommended the BVAQ over the TAS-20. However, this questionnaire needed further validation. OBJECTIVES: Thus, the aim of the present study was to determine the convergent, discriminant and concurrent validity of the Bermond-Vorst Alexithymia Questionnaire -- form B (BVAQ-B) in a clinical sample of 59 eating disorder patients, as well as in 191 controls. The TAS-20 constituted the gold standard for the assessment of the BVAQ-B' convergent validity. To compare the concurrent validity of the BVAQ-B and the TAS-20, participants also completed several self-reports investigating different dimensions of emotion regulation capacities: the 13-item Beck Depression Inventory (BDI), the Spielberger State and Trait Anxiety Inventory (STAI-form Y), as well as the Chapman and Chapman Physical and Social Anhedonia Scales (PAS and SAS). One way analyses of variance were used for mean scores comparisons. Convergent validity was determined using Pearson coefficients of correlation. RESULTS: Results of the analyses suggested the BVAQ-B has a satisfying convergent and discriminant validity. This was observed in both the clinical and control samples. Moreover, the comparison of the convergent validity of the BVAQ-B and the TAS-20 revealed several differences between these two alexithymia self-report questionnaires. The BVAQ-B appeared less sensitive to the subjective emotional state of the participants than the TAS-20. Whereas it was argued the TAS-20 overlaps with other emotional state scores, the BVAQ-B would allow to measure alexithymia more specifically. In addition, the present results allowed to further determine the relations between alexithymia and other dimensions of emotion regulation capacities. The analyses confirmed that alexithymia is linked to other emotion regulation dimensions such as depression and anxiety. Moreover, alexithymia was associated with physical and social anhedonia, two dimensions that received less interest in the alexithymia literature to date. This study also showed that control and clinical sample have different emotion regulation capacities. Eating disorder patients were not only more alexithymic and more depressed, but also more anxious and more anhedonic than the controls. Finally, this study revealed that alexithymia differs whether the alexithymic individuals are patients or controls. Healthy alexithymic individuals (ie, individuals categorized as alexithymic in the control group) seemed characterised by a selective deficit of emotional cognition, with sparing of emotional experience (Bermond's type II alexithymia). Alexithymics individuals of the eating -disorder group seemed particularly unabled to experience affect. This pattern could correspond to Bermond's type I alexithymia, which is characterised by the absence of emotional experience and, consequently, by the absence of the cognition accompanying the emotion. In summary, results of the present study add to the literature debating on whether alexithymia is similar in different types of population.

Predictive factors of social disability in anorexic and bulimic patients.

OBJECTIVES: The purpose of this study was to determine whether subjects suffering from anorexia nervosa (AN) or bulimia nervosa (BN) would demonstrate more severe social disability than a control group; and whether social disability could be best explained as a function of the eating disorder itself or as a function of comorbid anxiety or depressive disorders. METHOD: Subjects were 166 AN subjects, 105 BN subjects and 271 control subjects matched for age, sex and socio-economic status. Prevalence of anxiety or depressive disorders was assessed (through the Mini International Neuropsychiatric Interview), and social functioning was measured (through the Groningen scale). RESULTS: The majority of AN and BN subjects demonstrated social disability in the "social role" (leisure time, time spent with friends) and the "occupational role" (work or educational activities). A regression analysis was employed to uncover predictive factors of social disability. Eating disorders (AN and BN), anxiety disorders and depression accounted for a large portion of social disability. DISCUSSION: Anxiety and depressive disorders appear to play an important role in the type of social disability demonstrated in eating disorder patients. Therapeutic implications are discussed.

Treatment of adolescent patients with eating disorders: description of a psychodynamic approach in clinical practice.

Anorexia nervosa (AN) is now usually considered to be a multifactorial disorder, and there is a consensus among clinicians that its treatment should be aimed at restoring weight, altering anorexic attitudes, treating any medical complications, supporting and treating the family, enhancing autonomy, facilitating identity formation, and increasing self-esteem by means of psychotherapy. The practical aspects of such treatments not only vary from country to country, but sometimes also from one treatment team to another. International meetings dedicate considerable discussion to the subject but, as it seems to be relatively ignored in the published literature, we here describe the main elements of our own method.

[Predictive factors in social adaptation disorders in anorexic and bulimic patients]. / Facteurs prédictifs de l'inadaptation sociale chez les patients anorexiques et boulimiques.

A lifetime diagnosis of at least one anxiety disorder has been found in 13% to 75% of women with BN (Herzog, Keller, Sacks, Yeh, & Lavori, 1992; Schwalberg, Barlow, Alger, & Howard, 1992), and in 20% to 55% of women with AN, (Herzog et al., 1992, Laessle et al., 1989). Wittchen et al., 1998) have observed that the frequency and degree of disabilities and impairments associated with mental disorders in adolescence are strongly related to comorbidity (notably with anxiety disorders). However, as noted by Wonderlich et al., 1997, no study has compared ED individuals with and without comorbid anxiety disorders in terms of clinical or general functioning. The current study was designed to determine whether social avoidance symptoms and/or comorbid lifetime anxiety disorders were predictive factors of social disability in subjects with ED (AN or BN). We focused on two main dimensions of social adaptation, regarding social and professional life. 63 subjects with anorexia nervosa or bulimia nervosa were assessed for lifetime diagnoses of anxiety disorders, childhood history of separation anxiety disorder, social avoidance symptoms, and social disability. Sociodemographic characteristics, lifetime diagnoses of ED and anxiety disorders, and ages at onset of each disorder present, were assessed using the French version of the Composite International Diagnostic Interview (CIDI) (Robins et al., 1988; WHO, 1990). In addition, childhood history of separation anxiety disorder, not included in the CIDI, was assessed using the appropriate section of the Schedule for Schizophrenia and Affective Disorders Lifetime Version--Modified for the study of Anxiety Disorders (SADS-LA-R) (Endicott, Spitzer, 1978; Mannuzza, Fyer, Klein, 1985). Social anxiety symptoms were measured on Liebowitz Social Phobia Scale (Liebowitz, 1987). Social adjustment was assessed using a semi-structured interview, the Groningen Social Disabilities Schedule-Second version (GSDS-II) (Wiersma, De Jong, Ormel, & Kraaij Kamp, 1990). For each of the two outcome variables regarding disability, the Social role and the Occupational role, all subsets logistic regression analysis was performed in accordance to Hosmer and Lemeshow's guidelines (Hosmer and Lemeshow, 1989). Our total sample of 63 subjects included 29 subjects with AN restricting type (27 women, 2 men; 7% with a past history of BN) and 34 subjects with BN purging type (all women; 53% with history of a previous episode of AN). On the Groningen Social Disabilities Schedule, 86% of the anorexics and 65% of the bulimics had disability regarding the "social role", and 86% and 61%, respectively, disability regarding the "occupational role". Using all subsets logistic regression analyses, predictive factors of disability were: 1) for the social role, social avoidance symptom score (p < 0.002) and diagnosis of separation anxiety disorder (p < 0.01); 2) for the occupational role, number of lifetime anxiety disorders (p < 0.01) and diagnosis of separation anxiety disorder (p < 0.06). The present study clearly demonstrates that social avoidance and anxiety disorders are common and important features in the clinical presentation of subjects with AN or BN, and that they can have a negative impact on both their social and their occupational adaptation. Chronicity is a major risk in the ED, in terms of medical and sometimes lethal complications, but also because of the social consequences of these disorders. It is therefore important, in subjects with ED, to identify comorbid conditions linked to social disability, in order to improve global outcome. Recognizing and treating comorbid anxiety disorders in subjects with AN or BN could give better results than treating only the ED, in terms of social as well as global psychopathological outcome.

Comorbidity between eating disorders and anxiety disorders: a review.

OBJECTIVE: We conducted a critical literature review on studies assessing the prevalence of anxiety disorders (AD) in subjects with eating disorders (ED) (anorexia nervosa and bulimia nervosa). In the first part, we discuss methodological issues relevant to comorbidity studies between ED and AD. In the second part, taking into account these methodological considerations raised, we summarize the findings of these studies. METHOD: We performed a manual and computerized search (Medline) for all published studies on comorbidity between ED and AD, limiting our search from 1985-2001 to get sufficiently homogeneous diagnostic criteria for both categories of disorders. RESULTS: Too few studies include control groups and few studies have compared diagnostic subgroups of ED subjects, with scarce or conflicting results. DISCUSSION: We discuss the results taking into account the methodological problems observed. We give guidelines for reviewing the results of published studies and planing future research.