Eating Disorder Symptoms in Affective Disorder Patricia Neely Wold Department of Psychiatry, Brown University Accepted October 7, 1991
Patients with Major Affective Disorder (MAD), Secondary Depression, Panic Disorder, and bulimia with and without MAD, were given the Eating Disorder Inventory, the Beck Depression Inventory, and the General Behavior Inventory at presentation. It was found that patients with MAD have a triad of eating disorder symptoms: a disturbance in interoceptive awareness, the sense of ineffectiveness, and a tendency toward bulimia. The data supported the concept that the sense of ineffectiveness is secondary to major depression. A disturbance in interoceptive awareness exists independently in bulimia nervosa and in MAD providing a common diathesis from which bulimia may arise given family and social pressure. Bulimics with MAD do not respond to treatment as readily as those without MAD. It is recomended that these two groups be treated separately.
Keywords: eating disorder symptoms, affective disorder
Numerous studies have addressed the relationship between bulimia nervosa and affective disorder. These have centered around clinical observations which include: a family history of affective disorder in both syndromes compared to that of controls (Hudson et al 1987a; Mitchell et al 1986; Stern et al 1984); pharmacological comparisons (Agras et al 1987; Delgado et al 1990; Devlin et al 1989; Mitchell et al 1984; Walsh et al 1985b), electroencephalography (Hudson et al 1987b; Levy et al 1985; Walsh et al 1985a; Weilburg et al 1985); and, neuroendocrine abnormalities (Levy et al 1987; Lindy et al 1985; Mussisi and Garfinkel 1985; Perez et al 1988). It has been proposed by some (Bruch 1972; Delgado et al 1990; Hudson et al 1987c; Piran et al 1985) that bulimia nervosa may be a variant of affective disorder or that there may be a common diathesis. However, not all agree with this (Cooper et al 1985; Johnson-Savine et al 1984; Levy et al 1987; Steiger et al 1990; Swift et al 1986; Swift et al 1985; Wilson et al 1987). Levy et al (1989), in a recent review concluded that bulimia nervosa is not a variant of depression. They stated that studies with adequate controls failed to demonstrate differences between bulimic and control samples. Steiger et al (1990) found that Address reprint requests to: Dr. Patricia Neely Wold, Clinical Assistant Professor, Department of Psychiatry, Brown University, 355 Thayer Street, Providence, RI, 02906.
J Psychiatr Neurosci, VoL 16, No. 4, 1991
cognitions in eating disorders are highly dysfunctional and similar to those presumed to be typical of depression. However, comorbidity was not ruled out in their study. They noted that the sense of ineffectiveness was present in other diagnoses, in contrast to Bruch's (1972) contention that this is a hallmark of eating disorders. They suggest that common psychological processes explain the comorbidity between eating, affective, and character disorders. Cooper et al (1985) and Norring (1990) have indicated that the scales, other than Drive for Thinness, Bulimia, and Body Dissatisfaction, correlate with ego functioning and overall mental health regardless of the presence of eating disorders, but the existence of major depression was not specified. A previous study (Wold 1985) showed that patients' perceptions of family attitudes toward weight differs between eating disordered patients and those with affective disorder. Bulimia with and without depression seems to respond to most antidepressants (Devlin et al 1989), although most trials have concentrated on short term improvement in behavioral symptoms. Delgado et al (1990) present data to demonstrate that an adequate supply of tryptophan in the diet is required for antidepressants to be effective, a factor that may impinge on results of studies where this factor is not controlled. Further light might be shed on this subject by looking at eating disorder symptomatology in affective and panic disorders. This study is designed to focus on which eating
Eating Disorder Symptoms in Affective Disorder
disorder symptoms exist within depressive symptoms and/ MAD which may predispose patients to develop bulimia. A second and related objective is to observe which eating disorder symptoms remit as depression is treated in both depression and bulimia nervosa with and without MAD. This may clarify which symptoms that bulimic patients have which are strictly secondary to depression.
METHODOLOGY Consecutive patients in a private practice were given the Beck Depression Inventory (BDI) (Beck et al 1961), the General Behavior Inventory (GBI) (Depue 1981), and the Eating Disorders Inventory (EDI) (Gamer et al 1983) as part of their diagnostic work-up. Since many referrals are from non medical therapists, the sample is probably more likely to contain people with depression than would a general outpatient population. Since most bulimic patients are female, only female patients were included in all groups. The BDI was utilized to assess current depressive symptoms and the GBI to differentiate major depression or bipolar illness from depressions secondary to life events. A previous study (Wold 1990), showed that the cut-off score recommended for this test does in fact screen out secondary depressions or grief reactions. Diagnoses were also assessed by clinical interview of one and one-half hour duration by an experienced interviewer using a semi-structured interview for the DSM-HI-R criteria for subtypes of affective disorder, panic disorder, and bulimia. Patients with panic disorder were included to see whether symptomatology measured by the EDI is specific only to eating disorders and depression or whether it might also be related to anxiety or nonspecific stress. None of these patients presented with current eating disorder symptomatology. These patients and those with affective disorder were screened for life time eating disorder symptomatology. The GBI uses a two dimensional scoring system with separate scores on depression and on hypomania and biphasic items combined. It identifies unipolar, chronic intermittent depression, bipolar, hyperthymia and non-cases or secondary depressions. The EDI is a self report test which asks the patient to rate the frequency of distorted attitudes about food and weight. The diagnoses using both the GBI, where applicable, and clinical interview were as follows: 13 patients with Panic Disorder (PD), 37 with Major Affective Disorder (MAD), 8 bipolar and 29 unipolar, 18 with secondary depression (SD), and 23 with Bulimia Nervosa (BU), 9 with MAD and 14 with SD. Among patients with MAD, ages ranged from 19-56, in the SD group 27-58, and among bulimics 1847. Eleven patients were excluded because of insufficient data, being on medication, or no Axis I symptomatology. It was possible to get data when improvement had occurred on 20 MAD patients and on 14 of the bulimics. Patients were considered improved when the BDI had dropped 10 points or was below 17. All of the patients had been treated with antidepressants, mostly tricyclics, and concomitant dynamic psychotherapy, relating present issues with child-
hood experiences. Bulimics were in addition asked to keep track of their food intake to correlate binge-purge events with feelings. The issue was not how improvement had occurred, but rather what eating disorder symptomatology remained when depression remitted as measured by Beck scores. The t test for small samples was used as a measure of significance of the differences between the diagnostic groups. Since there was no significant difference between bipolar and unipolar MAD on the EDI, these groups were combined.
RESULTS Patients with panic disorder did not differ from secondary depressive reactions in eating disorder symptomatology with the one exception that SD patients were more inclined to bulimic symptomatology than the PD group, resulting in a significance level of .05 when MAD patients were compared to PD but not SD patients. Consequently, further comparisons were made only between bulimia nervosa with and without MAD secondary depressive symptoms not meriting the diagnosis of major depression, and major affective disorder. Patients with MAD had significantly more symptomatology than the SD group on the BDI (p < .02), as well as the Interoceptive Awareness (IA), and the Ineffectiveness (I) scales of the EDI at the .01 level of significance, while the Interpersonal Distrust (ID) scale differed at the .05 level (Table 1). Nineteen of these patients tended to eat more when depressed although not fulfilling Table 1 Major Affective Disorder BDI 35 36 26 12 15 34 30 28 35 41 46 32 23 33 31 41 21 28 24 25
4 4 1 8 2 18 3 3 2 7 5 7 7 7 2 13 8 2 1 8
8 6 0 3 2 7 1 2 0 3 2 2 4 11 0 0 2 0 0 6
26 10 3
11 20 17 2 0 16 7 25 8 25 20 11 15 20 18 21
2 8 0 1 3 11 3 7 1 5 4 3 8 8 6 8 0 1 1 2
9 10 7 11 12 11 11 7 3 0 13 10 4 15
1 10 9
9.9*** 2.9 5.8 3.1
M 29.8** 5.6 SD 8.5 4.3
0 4 4 8 12 22 16 12 9 6 5 17 18 12 6 14 6 16
Differs from SD at pC.01 *** Differs from SD at p < .02 ** Differs from SD at p