Eating Behaviors 2 (2001) 193 – 207
Obsessive compulsive disorders in eating disorders Mario Speranza*, Maurice Corcos, Nathalie Godart, Gwenael Loas, Olivier Guilbaud, Philippe Jeammet, Martine Flament Adolescent and Young Adult Psychiatry Department, Institut Mutualiste Montsouris, 42 Bd Jourdan, 75014 Paris, France
Abstract Objective: The aim of this study is to explore current and lifetime prevalence of obsessive compulsive disorders (OCD) in eating disorder (ED) subgroups and subtypes defined by the DSM-IV and to study the chronology of appearance of these disorders taking into account the role played by denutrition. Method: Current and lifetime prevalence were investigated using the Mini International Neuropsychiatric Interview (MINI) and the Yale –Brown Obsessive Compulsive Scale in a sample of 89 DSM-IV ED patients (58 AN and 31 BN) and 89 matched controls. Results: Current and lifetime prevalence of OCD in ED was significantly higher than in general population (15.7% and 19% vs. 0% and 1.1%, P < .05). Anorexic patients presented a slightly higher current and lifetime comorbidity than bulimic patients (19% and 22.4% vs. 9.7% and 12.9%, n.s.). Purging anorexia was the diagnostic subtype, which presented the higher prevalences (29% and 43%), followed by restrictive anorexia (16%) and purging bulimia (13%). In the great majority of cases (65%), OCD diagnosis preceded ED diagnosis. Finally, OCD current prevalence and Y-BOCS scores of underweight patients were not significantly higher than normal-weight patients, suggesting that there were only limited links between denutrition and obsessionality. D 2001 Elsevier Science Ltd. All rights reserved. Keywords: Obsessive compulsive disorders; Eating disorders; Comorbidity; Prevalence; DSM-IV; Y-BOCS
1. Introduction A significant proportion of patients suffering from eating disorders (EDs) present a comorbidity with anxiety disorders (between 35% and 77% according to Godart, Flament, * Corresponding author. Centre Hospitalier Interde´partemental de Psychiatrie de l’Enfant et de l’Adolescent, Fondation Valle´e, 7 rue Bense´rade, 94257 Gentilly, France. Tel.: +33-145154780; fax: +33-145154789. E-mail address:
[email protected] (M. Speranza). 1471-0153/01/$ – see front matter D 2001 Elsevier Science Ltd. All rights reserved. PII: S 1 4 7 1 - 0 1 5 3 ( 0 1 ) 0 0 0 3 5 - 6
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& Jeammet, 1996; Halmi et al., 1991; Hudson, Pope, Yurgelon-Todd, et al., 1987). Among the anxiety disorders, obsessive compulsive disorders (OCD) are the third most frequently diagnosis observed in ED with rates fluctuating depending on diagnostic criteria and evaluation tools used (Godart et al., 1996; Halmi et al., 1991; Keck et al., 1990). If only controlled and standardized studies using DSM-III-R or DSM-IV criteria are considered, the rates of current prevalence of OCD vary between 3% and 43% for anorexia and between 0% and 29% for bulimia (Godart, Flament, Lecrubier, & Jeammet, 2000; Herzog, Keller, Sacks, Yeh, & Lavori, 1992; Rastam, Gillberg, & Gillberg, 1995; Thornton & Russel, 1997) and the rates of lifetime prevalence vary between 9% and 63% for anorexia and between 0% and 43% for bulimia (Braun, Sunday, & Halmi, 1994; Godart et al., 2000; Rastam et al., 1995; Thornton & Russel, 1997). These rates are significantly different from those of the control groups (Halmi et al., 1991; Rastam et al., 1995). However, studies, which have used specific pathological groups (such as depressed, drug addicted, or other anxious nonobsessive groups) as control groups, have not revealed significant differences (Bushnell et al., 1994; Hudson et al., 1987; Schwalberg, Barlow, Alger, & Howard, 1992). Up to now, with the exception of the study conducted by Fornari, Kaplan, Sandberg, et al. (1992), which revealed a significant difference in the OCD lifetime prevalence between purging anorexics (66%) and restrictive anorexics (25%), no other published study has found significant differences in the current or lifetime prevalence of OCD between anorexia and bulimia or between the various diagnostic subtypes (restrictive or purging anorexia and purging or nonpurging bulimia), which are not often differentiated in the literature (Table 1). Moreover, none of the published studies has yet investigated OCD prevalence in the ED diagnostic subtypes defined by the DSM-IV. Studies concerning the chronology of appearance of OCD and ED are even rarer and contradictory (Fahy, Osacar, & Marks, 1993; Kasvikis, Taskiris, Marks, Basoglu, & Noshirvani, 1986). The only two recent studies involving significant samples report divergent results: Thornton and Russel (1997) showed that, in 86% of the cases, OCD precedes ED. Godart et al. (2000) found that only 33% of ED cases were preceded by OCD (limited to anorexics). In 50% of cases, OCD appeared later than the ED. Kasvikis et al. (1986) and Rubenstein, Pigott, L’Heureux, Hill, and Murphy (1992) showed that patients who present an OCD associated with an ED are not only younger, but also exhibit an earlier OCD onset than patients without an associated ED. These last observations concerning the chronology of appearance of the disorders run counter to the assumption that denutrition could play a determining role in the genesis of obsessional symptomatology and suggest that obsessional symptomatology could be a risk factor in the appearance of EDs (Pollice, Kaye, Greeno, & Weltzin, 1997). Studies seem to support the idea of an obsessive compulsive symptomatology related to a subjacent psychobiological feature, independently of the nutritional state (Srivasagam et al., 1995). If weight recovery can improve obsessive compulsive symptoms, the latter persist, however, at significantly higher levels than standard rates, even after a long period of weight stabilization (Strober et al., 1980). Denutrition, thus, although being an element of aggravation of obsessional symptomatology, cannot entirely explain its presence. The aim of this study, stemming from these contradictory data found in the literature, is to bring new empirical data to the study of the correlations between OCD and ED by exploring, in a significant clinical sample, the current and lifetime OCD comorbidity in the diagnostic
Halmi et al., 1991
Keck et al., 1990
Powers, Coovert, Brightwell, & Stevens, 1988 Laessle, Wittchen, Fichter, & Pirke, 1989
47 AN (, in and outpatients)
Toner, Garfinkel, & Garner, 1988
ED 1724 NON 51 NOS 2 ANAN-R 14 BN– BN nw (normal weight)
62 ED (, inpatients)
2120 AN-R – BN 27 AN BN 23 BN h AN (past anorexia) 69 BN (, outpatients or via advertising)
91 ED (, outpatients)
active 1513 AN AN wr (after weight recovery) 19 AN past (in remission over 1 year) 30 BN (, via advertising)
Samples
Author
Table 1 Current and lifetime comorbidity of OCD in ED
DSM-III-R, DIS-III
DSM-III-R, SCID
DSM-III, CIDI
DSM-III-R, SCID P/II
DSM-III-R, DIS-III
Diagnostic criteria and interviews AN 17%
Current prevalence
ED 29.4% NON 20.8% NOS 20% AN-R – BN 0% AN BN nw 35.7%
ED 25.8%
ED 5.9% NON 4.2% NOS 20% AN-R – BN 0% AN BN nw 28.6%
ED 11.3%
9.5% AN-R – BN 10% AN 18.5% BN h AN 13% BN BN 13% BN 10%
ED 13.18%
active 26.7% AN active 20% AN AN wr 38.5% AN wr 15.4% AN past 36.8% AN past 15.8% BN 3.3%
AN 34.4%
Lifetime prevalence
(continued on next page)
Controlled study: depressed patients and controls. Nonsignificant difference Controlled study. Significant difference with controls. Nonsignificant difference between subgroups
Nonsignificant difference between subgroups
Noncontrolled study
Controlled study. Significant difference with controls
Notes
M. Speranza et al. / Eating Behaviors 2 (2001) 193–207 195
Braun et al., 1994
Brewerton, Lydiard, Herzog, et al., 1995
Bushnell et al., 1994
4190 AN-R – BN 98 AN 105 EDBN(, inpatients)
Herzog et al., 1992
59 BN (,)
3422 AN-R – BN 31 AN BN 18 BN 20 BN h AN (past anorexia) (, epidemiological sample)
229 ED (, outpatients)
Fornari et al., 1992
DSM-III-R, SCID
DSM-III, DIS
DSM-III-R, SCID-P, SCID-II
DSM-III-R, SADS-L
DSM-III-R, SADS-L
2020 BN BED 63 ED (60 , 3 < outpatients)
DSM-III-R, SCID-P, SCID-II
Diagnostic criteria and interviews
DSM-III-R, ADIS-R
24 BN (, inpatients)
Samples
40 BN (, in and outpatients)
Bossert-Zaudig, Zaudig, Junker, et al., 1993 Schwalberg et al., 1992
Author
Table 1 (Continued)
BN 3%
20.58% AN-R AN – BN BN 12.9%18.18% BN h AN 22.2% BN 9%
ED 18.1%
25% AN-R – BN 66% AN BN 42.9%
ED 42.9%
BED 4.5%
BN 15%
BN 4.2%
Lifetime prevalence
5% AN – BN 3% AN BN 1%
ED 3%
BED 4.5%
BN 10%
Current prevalence
Controlled study: depressed and addicted patients. Nonsignificant difference Noncontrolled study.
Nonsignificant difference between subgroups
Nonsignificant difference between subgroups
Nonsignificant difference between AN-B and AN-R
Controlled study: anxiety disorders; Nonsignificant difference.
Noncontrolled study
Notes
196 M. Speranza et al. / Eating Behaviors 2 (2001) 193–207
29 AN-R (inpatients: 27 ,, 2
