Prevalence of Eating Disorders in the Psychiatric Emergency Room S. JAMES R. AIMEE
JOHNSON, HILLARD,
M.D. M.D.
A random sample of 143 patients from a centralized psychiatric emergency service with a catchment area ofone million people was studied. A two-stage interview was conducted for diagnosis ofDSM-lll-R eating disorders. Ofthose reporting active bingeing. 14.5% were men. and 22.4% were women. No cases ofanorexia nervosa were discovered. Bulimia nervosa was diagnosed in 3.0% ofthe women and 2.6% ofthe men. Race and marital status were unrelated to bingeing or to any eating disorder diagnosis. Many patients never had discussed their eating behaviors before with a therapist.
ating disorders typically have been diagnosed and treated in the white, middle-toupper socioeconomic classes.' This has been the case particularly among student populations. Recent research on college students, in fact, has suggested that eating disorders have such high prevalence rates, that they may be considered a significant public health problem on college campuses, with 6.5% to 18.6% of women having met DSM-III criteria for a history of bulimia. 2 Zuckerman et al} however, reported a much lower prevalence rate, with bulimia nervosa reported in only 4% of college women. In a recent study of college students, Schotte and Stunkard4 found a difference between clinically significant bulimia and bulimic behaviors. According to their findings, only 1.3% of women and 0.1 % of men meeting diagnostic criteria for bulimia, although a large percentage (10.1 % of women and 15% of men) reported binge eating at least twice weekly. Another, longitudinal, study of college women reported a lower, stable prevalence of DSM-III-R bulimia in this population (2.9%3.3%) due to new cases being offset by partial
E
remissions.~
Eating disorders have been associated with significant morbidity and, in fact, with mortality.6 VOLUME 31 • NUMBER 3· SUMMER 1990
They likewise have been associated with serious psychopathology,7 as well as with a concurrent high prevalence of affective disorders. 8 Eating disorders seldom are diagnosed in emergency rooms,9 and, indeed, the groups in which eating disorders commonly are diagnosed are not representative of the typical psychiatric emergency service (PES) population. 10 However, recent research has suggested that eating disorders are not limited to the upper socioeconomic classes by any means, as evidenced by studies of bingo players I and suburban women shoppers. I I The number of eating disorders diagnosed in the PES at the University of Cincinnati has been very low in the past. In the present study, we attempt to assess the prevalence of these disorders in the psychiatric emergency room.
Received March 29. 1989; revised September I I, 1989; accepted October 16. 1989. From the Depanment of Psychiatry, University of Cincinnati, Cincinnati, Ohio. Address reprint requests to Dr. Johnson, University of Cincinnati, Depanment of Psychiatry (ML 559), 231 Bethesda Avenue, Cincinnati, OH 45267~559. Copyright © 1990 The Academy of Psychosomatic Medicine.
337
Eating Disorders
METHODS Over a three-week period, subjects were selected from patients presenting to the University Hospital PES, the only 24-hour, seven-day-a-week psychiatric emergency facility in an urban catchment area of one million people. It is the largest center in the area for psychiatric evaluation, although other centers exist where emergency medicine physicians will see patients with psychiatric problems. Approximately 25 patients a day are seen in the PES. The population seen here is similar to psychiatric emergency room populations described in Cleveland, 12 New Haven,13 and Durham,'4 consisting primarily of young adults and lower socioeconomic status patients. Anyone 13 years of age or older may register as a patient. The service is the main point of entry into the state hospital system and the University Hospital, as well as a significant point of entry into other private hospitals and into the community mental health system. Subjects were selected from a random sample of shifts over a three-week period. Shifts were scattered over weekdays and weekends and included day, evening, and night shifts. An initial screening questionnaire, which included demographic information and two eating disorder screening questions, was given to all patients between 18 and 45 years of age. The initial screening was conducted by triage nurses when patients presented in the PES. We used screening questions from the Structured Clinical Interview for DSM-III-R (SCID)15 as follows: I) "Have you ever had eating binges during which you ate a lot of food in a short time?" and 2) "Have you ever weighed a lot less than other people thought you ought to weigh?" The answers were a choice of "definitely yes," "probably yes," or "no." If a patient was unable to participate due to psychosis or for any other reason, this also was noted. Patients who answered "definitely yes" or "probably yes" to either question were given a scheduled interview with ten items. Included in this interview were specific questions about severity, duration, and frequency of eating binges, as well as about any efforts made to counteract 338
them. Questions screening for anorexia nervosa also were included. The questions in the interview were adopted from the SCID. 15 After triage, patients were referred to a therapist for psychiatric evaluation. This could have been either an M.S.W. social worker or an M.D. The therapist evaluating the patient was given the task of conducting the scheduled interview. Seven individuals were excluded from the study because of their refusal to participate; 16 were unable because of dementia, florid psychosis, or mental retardation. When the testing was approximately halfway finished, we decided that it also would be interesting to assess whether or not subjects were receiving treatment for eating disorders. Sixteen patients received a 14-item scheduled interview instead of the usual IO-item interview. These patients were asked questions about past and current treatment of eating disorders, as well as about their history of psychiatric treatment, including whether or not they had tried to get help with their eating behaviors in the past. Rates of eating disorders by DSM-III-R criteria were computed. Confidence intervals for rates were computed on the basis of the Poisson distribution. '6 Chi-square values were calculated without Yates' correction. RESULTS A higher prevalence of eating disorders was found than originally was expected. Active bingeing within the past year was reported by 22.4.% ofthe women and 14.5% ofthe men, with 10.4% of the women and 6.6% ofthe men reporting that they were bingeing at least twice weekly (Table I). Of the women, 4.5%, compared to 5.3% of the men, reported bingeing on a daily basis within the past year. Of the 76 men surveyed, 6.6% reported purging behavior (such as taking laxatives, fasting, and exercising excessively) within the past year, compared to 9.0% of the 67 women surveyed, while 2.6% of the men admitted to purging behavior at least twice a month, as opposed to 1.5% of the women. Daily purging behavior was reported by 1.3% of the men and by 1.5% of the women. PSYCHOSOMATICS
Johnson and Hillard
The prevalence of any current eating disorder was 13.3% (95% confidence interval 8.0%20.8%). We found no cases of anorexia nervosa. DSM-III-R bulimia nervosa was diagnosed in 3.0% of the female patients and 2.6% of the male patients (Table 2). Atypical eating disorders showed the highest prevalence rates, with 12.0% of the women and 9.2% of the men being diagnosed with eating disorders that do not clearly meet DSM-III-R criteria for anorexia nervosa and bulimia nervosa. We made all diagnoses of atypical eating disorders. Patients had to fulfill at least three of the DSM-III-R criteria for bulimia nervosa, including active bingeing, or they had to fulfill at least two of the criteria for anorexia nervosa, including low weight. One person was diagnosed "near anorexia nervosa." Another person fulfilled one criterion (low weight) for anTABLE I. Cumulative bingeing and purging frequencies in male and female patients Cumulative Percentage Frequencyrrime Period Females (N=67) Al least I/yr
lImo 2/mo I/wk 2wk I/day Males (N=76) At least I/yr
lImo 2/mo I/wk 2/wk I/day
Bingeing
Purging
22.4 20.9 16.4 11.9 10.4 4.5
9.0 4.5 1.5 1.5 1.5 1.5
14.5 9.2 7.9 6.6 6.6 5.3
6.6 5.3 2.6 1.3 J.3 1.3
orexia nervosa and three for bulimia nervosa and was diagnosed "near bulimia nervosa." AII other subjects given the diagnosis "near bulimia nervosa" had normal weight. When chi-square analysis for race, sex, and marital status was done, these factors were not found to be related to bingeing or to any eating disorder diagnosis. Chi-square values were as follows: sex, X2=O.34; race, X2= 1.44; marital status, X2=O.11 (for all, df= I; all p not significant). AII 16 subjects diagnosed with atypical eating disorders reported active bingeing. However, only six of these individuals satisfied the DSMIII-R criteria for frequency of binge-eating episodes, that is, a minimum average of two binge-eating episodes a week for at least three months. Seven individuals reported efforts to counteract the binges, but in only two cases did frequency occur together with purging behaviors. Of 16 subjects who received the 14-item interview to assess treatment history, 12 reported no history of treatment and noted that they had not made their eating behaviors an issue in their current therapy. Only one subject was currently receiving treatment for an eating disorder; three had a history of treatment for this problem. In addition, we were able to determine the PES diagnoses for 16 of 19 patients whom we diagnosed with eating disorders (Table 3). AII patients were assigned one or more DSM-III-R diagnoses, other than eating disorder, upon evaluation in the PES. Affective disorders were diagnosed most frequently (eight cases). There were seven cases of substance abuse disorders, and five individuals were diagnosed with personality
TABLE 2. Percentage of psychiatric emergency service (PES) patients with specific eating disorders by diagnosis Females (N=67) Diagnosis
N
%
Anorexia nervosa
0
0
Bulimia nervosa
2
3.0
95% Cia
Males (N=76) N
%
0
0
(0.36-10.8)
2
2.6
95%CI
(0.31-9.4)
Near anorexia nervosa
I
1.5
(0.04--8.4)
0
0
Near bulimia nervosa
7
10.5
(4.2-21.6)
7
9.2
(3.7-19.0)
10
14.9
(7.2-27.4)
9
11.8
(5.4-22.4)
Total "CI=confidence interval
VOLUME 31 • NUMBER 3· SUMMER 1990
339
Eating Disorders
TABLE 3. Concurrent psychiatric diagnoses or patients with eating disorders (N=16) Number or Patients'
Diagnosis Personality disorders Affective disorders Post traumatic stress disorder Substance abuse disorders Impulse control disorder Adjustment disorder with depressed mood Schizophrenia AIDS dementia No concurrent diagnosis
5 8 I 7 I 2 4 I 0
"Total number of diagnoses is greater than total number of patients since some received multiple diagnoses.
disorders. Only one individual who met the criteria for an eating disorder on our screen received an eating disorder diagnosis from PES clinicians. One individual was diagnosed with probable AIDS dementia. For his diagnosis. major depression was ruled out. He had symptoms of bulimia nervosa. but not anorexia nervosa. DISCUSSION Disordered eating behaviors appear to be much more prevalent in the psychiatric emergency room than previously thought. a somewhat surprising finding in a setting which primarily sees members of lower socioeconomic groups. Although a high proportion of subjects reported active bingeing. the prevalence of DSMIII-R bulimia nervosa was much lower. Most commonly diagnosed were atypical. bulimiform eating disorders. which did not meet DSM-III-R criteria for bulimia nervosa or anorexia nervosa. Concurrent psychiatric diagnoses among eating disorder patients in this population are the same ones reportedly associated with them in a variety of other populations. s.17 . ls Many patients had not told their therapists about their eating behaviors. Methodological limitations must be considered when interpreting the results of this study. We did not ask patients who binged to define clearly what they felt was an eating binge. which could contribute to false positive or false negative 340
results. Another limitation might be the influence of data collection methods. Data were collected by a number of different therapists in a crowded and busy emergency room. and the possibility must be considered that not all patients with eating disorders may have been diagnosed. Further research using a more systematic data collection method would help to decrease the possibility of error in this respect. The implications of the study are that eating disorders are underdiagnosed in the emergency room and that more attention should be paid to screening for these disorders in the emergency evaluation. Unless they appear grossly over- or underweight. patients often are not asked about eating behaviors. Most therapists also do not expect to find eating disorders in this population. A possible method of preliminary screening for eating disorders in the emergency room might include one or two questions in every evaluation. For example. questions similar to the ones we asked. regarding bingeing activity or weight history. might be appropriate. In this way more individuals with eating disorders can be diagnosed appropriately. while clinicians can avoid other. inappropriate diagnoses for patients. With more accurate diagnoses. a greater number of individuals with eating disorders can be referred for various available treatments that have been shown to be effective. 19 The prevalence of DSM-III-R atypical eating disorders in our study was quite high compared to the prevalence of "typical" eating disorders. An interesting question is whether or not those patients diagnosed with atypical eating disorders actually can be regarded as having clinically significant disorders. Six individuals diagnosed with atypical eating disorders satisfied the DSM-II1-R frequency criteria for bulimia nervosa. with another seven reporting efforts to counteract the binges. Although frequency and purging occurred together in only two cases. it is likely that the symptoms noted above were a cause of considerable discomfort to the patients and would represent a source of significant physical and emotional distress to them. The group studied is not socioeconomically PSYCHOSOMATICS
Johnson and Hillard
comparable to most groups in which eating disorders have been studied. In view of this. one must question whether or not symptoms cluster differently in the lower socioeconomic classes. It is possible that cross-cultural differences exist in presenting symptoms, which may lead to diagnostic difficulties. Indeed. the issue of whether or
not current definitions of eating disorders are appropriate must be considered; it should not simply be assumed that eating disorders are less of a problem in lower socioeconomic classes. Further research on eating disorders in this population will help to answer these questions more clearly.
References I. Pope HG. Champoux RF. Hudson n: Eating disorder and socioeconomic class: anorexia nervosa and bulimia in nine communities. J Nen- Ment Dis 175:62~23. 1987 2. Pope HG. Hudson n. Yurgelun-Todd D. et al: Prevalence of anorexia nervosa and bulimia in three student populations. International Journal of Eating Disorders 3:45-51, 1984 3. Zuckerman DM. Colby A. Ware NC. et al: The prevalence of bulimia among college students. Am J Public Health 76:1135-1137.1986 4. Scholle DE. Stunkard AJ: Bulimia vs bulimic behaviors on a college campus. JAMA 258:1213-1215,1987 5. Drenowski A. Yee D. Kahn D: Bulimia in college women: incidence and recovery rates. Am J Psychiatry 145:753-755. 1988 6. Mitchell JE, Nyle RL. Ecken ED: Frequency and duration of binge-eating episodes in patients with bulimia. Am J Psychiatry 138:835-836. 1981 7. Johnson C, Tobin D. Enright A: Prevalence and clinical characteristics of borderline patients in an eating-disordered population. J Clin Psychiatry 50:9-15. 1989 8. Levy AB, Dixon KN, Stem SL: How are depression and bulimia related? AmJ Psychiatry 146:162-169. 1989 9. Mezzich JE. Fabrega H. Coffman G. et al: DSM-III disorders in a large sample of psychiatric patients: frequency and specificity of diagnoses. Am J Psychiatry 146:212-219.1989 10. Hillard JR, Siomowitz M. Levi L: A retrospective study of adolescents' visits to a general hospital psychiatric emergency service. Am J Psychiatry 144:432-436. 1987
VOLUME 31· NUMBER 3· SUMMER 1990
11. Pope HG. Hudson n. Yurgelun-Todd D: Anorexia and bulimia among 300 suburban women shoppers. Am J Psychiatry 141:292-294. 1984 12. Tyson RL. Miller SI. Browning CH: A study of psychiatric emergencies. I: Demographic data. Psychiatr Med 1:349-357.1970 13. Bristol IN. Giller EJr. Docheny JP: Trends in emergency psychiatry in the last two decades. Am J Psychiatry 138: 623-628. 1981 14. Hillard JR. Ramm D. Zung WW. et al: Suicide in a psychiatric emergency room population. Am J Psychiatry 140:459-462.1983 15. Spitzer RL. Williams J. Gibbon M: Structured clinical interview for DSM-III-R. patient version. 1987. Biometrics Research Depanment. New York State Psychiatric Institute. 722 West I68th Street. New York. New York. 10032 16. Lilienfeld A. Lilienfeld D: Foundations of Epidemiol· ogy. New York. Oxford University Press. 1980. pp 336338 17. Hudson n. Pope HG. Jones JM. et al: Phenomenologic relationships of eating disorders to major affective disorder. Psychiatry Res 9:345-354. 1983 18. Hatsukami D. Eckert E. Mitchell JE. et al: Affective disorder and substance abuse in women with bulimia. Psychol Med 14:701-704. 1984 19. Pope HG. Hudson n. Jones JM: Antidepressant treatment of bulimia: preliminary experience and practical recommendations. J Clin PsychopharmacoI3:274-281, 1983
341
JOHNSON, HILLARD,
M.D. M.D.
A random sample of 143 patients from a centralized psychiatric emergency service with a catchment area ofone million people was studied. A two-stage interview was conducted for diagnosis ofDSM-lll-R eating disorders. Ofthose reporting active bingeing. 14.5% were men. and 22.4% were women. No cases ofanorexia nervosa were discovered. Bulimia nervosa was diagnosed in 3.0% ofthe women and 2.6% ofthe men. Race and marital status were unrelated to bingeing or to any eating disorder diagnosis. Many patients never had discussed their eating behaviors before with a therapist.
ating disorders typically have been diagnosed and treated in the white, middle-toupper socioeconomic classes.' This has been the case particularly among student populations. Recent research on college students, in fact, has suggested that eating disorders have such high prevalence rates, that they may be considered a significant public health problem on college campuses, with 6.5% to 18.6% of women having met DSM-III criteria for a history of bulimia. 2 Zuckerman et al} however, reported a much lower prevalence rate, with bulimia nervosa reported in only 4% of college women. In a recent study of college students, Schotte and Stunkard4 found a difference between clinically significant bulimia and bulimic behaviors. According to their findings, only 1.3% of women and 0.1 % of men meeting diagnostic criteria for bulimia, although a large percentage (10.1 % of women and 15% of men) reported binge eating at least twice weekly. Another, longitudinal, study of college women reported a lower, stable prevalence of DSM-III-R bulimia in this population (2.9%3.3%) due to new cases being offset by partial
E
remissions.~
Eating disorders have been associated with significant morbidity and, in fact, with mortality.6 VOLUME 31 • NUMBER 3· SUMMER 1990
They likewise have been associated with serious psychopathology,7 as well as with a concurrent high prevalence of affective disorders. 8 Eating disorders seldom are diagnosed in emergency rooms,9 and, indeed, the groups in which eating disorders commonly are diagnosed are not representative of the typical psychiatric emergency service (PES) population. 10 However, recent research has suggested that eating disorders are not limited to the upper socioeconomic classes by any means, as evidenced by studies of bingo players I and suburban women shoppers. I I The number of eating disorders diagnosed in the PES at the University of Cincinnati has been very low in the past. In the present study, we attempt to assess the prevalence of these disorders in the psychiatric emergency room.
Received March 29. 1989; revised September I I, 1989; accepted October 16. 1989. From the Depanment of Psychiatry, University of Cincinnati, Cincinnati, Ohio. Address reprint requests to Dr. Johnson, University of Cincinnati, Depanment of Psychiatry (ML 559), 231 Bethesda Avenue, Cincinnati, OH 45267~559. Copyright © 1990 The Academy of Psychosomatic Medicine.
337
Eating Disorders
METHODS Over a three-week period, subjects were selected from patients presenting to the University Hospital PES, the only 24-hour, seven-day-a-week psychiatric emergency facility in an urban catchment area of one million people. It is the largest center in the area for psychiatric evaluation, although other centers exist where emergency medicine physicians will see patients with psychiatric problems. Approximately 25 patients a day are seen in the PES. The population seen here is similar to psychiatric emergency room populations described in Cleveland, 12 New Haven,13 and Durham,'4 consisting primarily of young adults and lower socioeconomic status patients. Anyone 13 years of age or older may register as a patient. The service is the main point of entry into the state hospital system and the University Hospital, as well as a significant point of entry into other private hospitals and into the community mental health system. Subjects were selected from a random sample of shifts over a three-week period. Shifts were scattered over weekdays and weekends and included day, evening, and night shifts. An initial screening questionnaire, which included demographic information and two eating disorder screening questions, was given to all patients between 18 and 45 years of age. The initial screening was conducted by triage nurses when patients presented in the PES. We used screening questions from the Structured Clinical Interview for DSM-III-R (SCID)15 as follows: I) "Have you ever had eating binges during which you ate a lot of food in a short time?" and 2) "Have you ever weighed a lot less than other people thought you ought to weigh?" The answers were a choice of "definitely yes," "probably yes," or "no." If a patient was unable to participate due to psychosis or for any other reason, this also was noted. Patients who answered "definitely yes" or "probably yes" to either question were given a scheduled interview with ten items. Included in this interview were specific questions about severity, duration, and frequency of eating binges, as well as about any efforts made to counteract 338
them. Questions screening for anorexia nervosa also were included. The questions in the interview were adopted from the SCID. 15 After triage, patients were referred to a therapist for psychiatric evaluation. This could have been either an M.S.W. social worker or an M.D. The therapist evaluating the patient was given the task of conducting the scheduled interview. Seven individuals were excluded from the study because of their refusal to participate; 16 were unable because of dementia, florid psychosis, or mental retardation. When the testing was approximately halfway finished, we decided that it also would be interesting to assess whether or not subjects were receiving treatment for eating disorders. Sixteen patients received a 14-item scheduled interview instead of the usual IO-item interview. These patients were asked questions about past and current treatment of eating disorders, as well as about their history of psychiatric treatment, including whether or not they had tried to get help with their eating behaviors in the past. Rates of eating disorders by DSM-III-R criteria were computed. Confidence intervals for rates were computed on the basis of the Poisson distribution. '6 Chi-square values were calculated without Yates' correction. RESULTS A higher prevalence of eating disorders was found than originally was expected. Active bingeing within the past year was reported by 22.4.% ofthe women and 14.5% ofthe men, with 10.4% of the women and 6.6% ofthe men reporting that they were bingeing at least twice weekly (Table I). Of the women, 4.5%, compared to 5.3% of the men, reported bingeing on a daily basis within the past year. Of the 76 men surveyed, 6.6% reported purging behavior (such as taking laxatives, fasting, and exercising excessively) within the past year, compared to 9.0% of the 67 women surveyed, while 2.6% of the men admitted to purging behavior at least twice a month, as opposed to 1.5% of the women. Daily purging behavior was reported by 1.3% of the men and by 1.5% of the women. PSYCHOSOMATICS
Johnson and Hillard
The prevalence of any current eating disorder was 13.3% (95% confidence interval 8.0%20.8%). We found no cases of anorexia nervosa. DSM-III-R bulimia nervosa was diagnosed in 3.0% of the female patients and 2.6% of the male patients (Table 2). Atypical eating disorders showed the highest prevalence rates, with 12.0% of the women and 9.2% of the men being diagnosed with eating disorders that do not clearly meet DSM-III-R criteria for anorexia nervosa and bulimia nervosa. We made all diagnoses of atypical eating disorders. Patients had to fulfill at least three of the DSM-III-R criteria for bulimia nervosa, including active bingeing, or they had to fulfill at least two of the criteria for anorexia nervosa, including low weight. One person was diagnosed "near anorexia nervosa." Another person fulfilled one criterion (low weight) for anTABLE I. Cumulative bingeing and purging frequencies in male and female patients Cumulative Percentage Frequencyrrime Period Females (N=67) Al least I/yr
lImo 2/mo I/wk 2wk I/day Males (N=76) At least I/yr
lImo 2/mo I/wk 2/wk I/day
Bingeing
Purging
22.4 20.9 16.4 11.9 10.4 4.5
9.0 4.5 1.5 1.5 1.5 1.5
14.5 9.2 7.9 6.6 6.6 5.3
6.6 5.3 2.6 1.3 J.3 1.3
orexia nervosa and three for bulimia nervosa and was diagnosed "near bulimia nervosa." AII other subjects given the diagnosis "near bulimia nervosa" had normal weight. When chi-square analysis for race, sex, and marital status was done, these factors were not found to be related to bingeing or to any eating disorder diagnosis. Chi-square values were as follows: sex, X2=O.34; race, X2= 1.44; marital status, X2=O.11 (for all, df= I; all p not significant). AII 16 subjects diagnosed with atypical eating disorders reported active bingeing. However, only six of these individuals satisfied the DSMIII-R criteria for frequency of binge-eating episodes, that is, a minimum average of two binge-eating episodes a week for at least three months. Seven individuals reported efforts to counteract the binges, but in only two cases did frequency occur together with purging behaviors. Of 16 subjects who received the 14-item interview to assess treatment history, 12 reported no history of treatment and noted that they had not made their eating behaviors an issue in their current therapy. Only one subject was currently receiving treatment for an eating disorder; three had a history of treatment for this problem. In addition, we were able to determine the PES diagnoses for 16 of 19 patients whom we diagnosed with eating disorders (Table 3). AII patients were assigned one or more DSM-III-R diagnoses, other than eating disorder, upon evaluation in the PES. Affective disorders were diagnosed most frequently (eight cases). There were seven cases of substance abuse disorders, and five individuals were diagnosed with personality
TABLE 2. Percentage of psychiatric emergency service (PES) patients with specific eating disorders by diagnosis Females (N=67) Diagnosis
N
%
Anorexia nervosa
0
0
Bulimia nervosa
2
3.0
95% Cia
Males (N=76) N
%
0
0
(0.36-10.8)
2
2.6
95%CI
(0.31-9.4)
Near anorexia nervosa
I
1.5
(0.04--8.4)
0
0
Near bulimia nervosa
7
10.5
(4.2-21.6)
7
9.2
(3.7-19.0)
10
14.9
(7.2-27.4)
9
11.8
(5.4-22.4)
Total "CI=confidence interval
VOLUME 31 • NUMBER 3· SUMMER 1990
339
Eating Disorders
TABLE 3. Concurrent psychiatric diagnoses or patients with eating disorders (N=16) Number or Patients'
Diagnosis Personality disorders Affective disorders Post traumatic stress disorder Substance abuse disorders Impulse control disorder Adjustment disorder with depressed mood Schizophrenia AIDS dementia No concurrent diagnosis
5 8 I 7 I 2 4 I 0
"Total number of diagnoses is greater than total number of patients since some received multiple diagnoses.
disorders. Only one individual who met the criteria for an eating disorder on our screen received an eating disorder diagnosis from PES clinicians. One individual was diagnosed with probable AIDS dementia. For his diagnosis. major depression was ruled out. He had symptoms of bulimia nervosa. but not anorexia nervosa. DISCUSSION Disordered eating behaviors appear to be much more prevalent in the psychiatric emergency room than previously thought. a somewhat surprising finding in a setting which primarily sees members of lower socioeconomic groups. Although a high proportion of subjects reported active bingeing. the prevalence of DSMIII-R bulimia nervosa was much lower. Most commonly diagnosed were atypical. bulimiform eating disorders. which did not meet DSM-III-R criteria for bulimia nervosa or anorexia nervosa. Concurrent psychiatric diagnoses among eating disorder patients in this population are the same ones reportedly associated with them in a variety of other populations. s.17 . ls Many patients had not told their therapists about their eating behaviors. Methodological limitations must be considered when interpreting the results of this study. We did not ask patients who binged to define clearly what they felt was an eating binge. which could contribute to false positive or false negative 340
results. Another limitation might be the influence of data collection methods. Data were collected by a number of different therapists in a crowded and busy emergency room. and the possibility must be considered that not all patients with eating disorders may have been diagnosed. Further research using a more systematic data collection method would help to decrease the possibility of error in this respect. The implications of the study are that eating disorders are underdiagnosed in the emergency room and that more attention should be paid to screening for these disorders in the emergency evaluation. Unless they appear grossly over- or underweight. patients often are not asked about eating behaviors. Most therapists also do not expect to find eating disorders in this population. A possible method of preliminary screening for eating disorders in the emergency room might include one or two questions in every evaluation. For example. questions similar to the ones we asked. regarding bingeing activity or weight history. might be appropriate. In this way more individuals with eating disorders can be diagnosed appropriately. while clinicians can avoid other. inappropriate diagnoses for patients. With more accurate diagnoses. a greater number of individuals with eating disorders can be referred for various available treatments that have been shown to be effective. 19 The prevalence of DSM-III-R atypical eating disorders in our study was quite high compared to the prevalence of "typical" eating disorders. An interesting question is whether or not those patients diagnosed with atypical eating disorders actually can be regarded as having clinically significant disorders. Six individuals diagnosed with atypical eating disorders satisfied the DSM-II1-R frequency criteria for bulimia nervosa. with another seven reporting efforts to counteract the binges. Although frequency and purging occurred together in only two cases. it is likely that the symptoms noted above were a cause of considerable discomfort to the patients and would represent a source of significant physical and emotional distress to them. The group studied is not socioeconomically PSYCHOSOMATICS
Johnson and Hillard
comparable to most groups in which eating disorders have been studied. In view of this. one must question whether or not symptoms cluster differently in the lower socioeconomic classes. It is possible that cross-cultural differences exist in presenting symptoms, which may lead to diagnostic difficulties. Indeed. the issue of whether or
not current definitions of eating disorders are appropriate must be considered; it should not simply be assumed that eating disorders are less of a problem in lower socioeconomic classes. Further research on eating disorders in this population will help to answer these questions more clearly.
References I. Pope HG. Champoux RF. Hudson n: Eating disorder and socioeconomic class: anorexia nervosa and bulimia in nine communities. J Nen- Ment Dis 175:62~23. 1987 2. Pope HG. Hudson n. Yurgelun-Todd D. et al: Prevalence of anorexia nervosa and bulimia in three student populations. International Journal of Eating Disorders 3:45-51, 1984 3. Zuckerman DM. Colby A. Ware NC. et al: The prevalence of bulimia among college students. Am J Public Health 76:1135-1137.1986 4. Scholle DE. Stunkard AJ: Bulimia vs bulimic behaviors on a college campus. JAMA 258:1213-1215,1987 5. Drenowski A. Yee D. Kahn D: Bulimia in college women: incidence and recovery rates. Am J Psychiatry 145:753-755. 1988 6. Mitchell JE, Nyle RL. Ecken ED: Frequency and duration of binge-eating episodes in patients with bulimia. Am J Psychiatry 138:835-836. 1981 7. Johnson C, Tobin D. Enright A: Prevalence and clinical characteristics of borderline patients in an eating-disordered population. J Clin Psychiatry 50:9-15. 1989 8. Levy AB, Dixon KN, Stem SL: How are depression and bulimia related? AmJ Psychiatry 146:162-169. 1989 9. Mezzich JE. Fabrega H. Coffman G. et al: DSM-III disorders in a large sample of psychiatric patients: frequency and specificity of diagnoses. Am J Psychiatry 146:212-219.1989 10. Hillard JR, Siomowitz M. Levi L: A retrospective study of adolescents' visits to a general hospital psychiatric emergency service. Am J Psychiatry 144:432-436. 1987
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11. Pope HG. Hudson n. Yurgelun-Todd D: Anorexia and bulimia among 300 suburban women shoppers. Am J Psychiatry 141:292-294. 1984 12. Tyson RL. Miller SI. Browning CH: A study of psychiatric emergencies. I: Demographic data. Psychiatr Med 1:349-357.1970 13. Bristol IN. Giller EJr. Docheny JP: Trends in emergency psychiatry in the last two decades. Am J Psychiatry 138: 623-628. 1981 14. Hillard JR. Ramm D. Zung WW. et al: Suicide in a psychiatric emergency room population. Am J Psychiatry 140:459-462.1983 15. Spitzer RL. Williams J. Gibbon M: Structured clinical interview for DSM-III-R. patient version. 1987. Biometrics Research Depanment. New York State Psychiatric Institute. 722 West I68th Street. New York. New York. 10032 16. Lilienfeld A. Lilienfeld D: Foundations of Epidemiol· ogy. New York. Oxford University Press. 1980. pp 336338 17. Hudson n. Pope HG. Jones JM. et al: Phenomenologic relationships of eating disorders to major affective disorder. Psychiatry Res 9:345-354. 1983 18. Hatsukami D. Eckert E. Mitchell JE. et al: Affective disorder and substance abuse in women with bulimia. Psychol Med 14:701-704. 1984 19. Pope HG. Hudson n. Jones JM: Antidepressant treatment of bulimia: preliminary experience and practical recommendations. J Clin PsychopharmacoI3:274-281, 1983
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