Brief report
Lifetime co-morbidity with different subtypes of eating disorders in 148 females with bipolar disorders

https://doi.org/10.1016/j.jad.2009.06.007Get rights and content

Abstract

Objectives

To evaluate the impact of Eating Disorders (EDs) lifetime co-morbidity among female with Bipolar Disorders (BDs) and to compare clinical and cognitive features among EDs subgroups.

Method

A hundred and forty eight women with a lifetime history of Diagnostic and Statistical Manual, Fourth Edition (DSM-IV)-defined Bipolar-I, Bipolar-II and/or Cyclothymia, were consecutively enrolled to determinate the prevalence of co-morbid DSM-IV-defined Anorexia Nervosa [AN], Bulimia Nervosa [BN] or Binge Eating Disorder [BED]. Measures included the Structured Clinical Interview for the DSM-IV Axis I Disorders (SCID-I), the Clinical Global Impression (CGI) rating scale, the Eating Disorder Examination Questionnaire (EDE-Q) and BMI record.

Results

Forty six patients (31%) reported lifetime history of at least one ED: AN was the most common ED (n = 23, 15.5%), followed by BED (n = 21, 14.2%), and BN (n = 8, 5.4%); 6 patients (4.1%) reported multiple lifetime EDs. As expected, BMI was highest in BED patients and lowest in those with AN. Clinical characteristics were similar in the 3 groups, while rapid cycling and co-morbid drug abuse were more common in BED compared to AN or No-ED group. As expected cognitive eating symptoms assessed by the EDE-Q were all more represented in AN than in No-ED patients. AN and BED only differed in restricting behavior and weight concerns.

Conclusions

Our results prompt for the recognition of co-morbid EDs among bipolar patients, indicating that BED, along with other EDs, may influence in different ways both clinical characteristics and course of the illness. Further perspective studies are necessary to better define the relationships between different EDs and Bipolar Spectrum disorders.

Introduction

Anorexia Nervosa (AN), Bulimia Nervosa (BN) and Binge Eating Disorder (BED) are frequently associated with Mood Disorders, particularly with Major Depression. Higher rates of Eating Disorders (EDs) compared to general population have also been reported among Bipolar Disorder (BD) patients (Kawa et al., 2005, Krishnan, 2005, McElroy et al., 2005). Moreover, the prevalence of EDs not meeting the formal criteria for AN or BN, such as ‘Eating Disorders Not Otherwise Specified’ (EDNOS) or sub-threshold ED Spectrum disorders is considerably higher in BD patients (up to 3.6 to 10%) (McElroy et al., 2006). EDNOS and BED have also been associated with marked distress and functional impairment (Darby et al., 2007). EDs co-morbidity has been indicated as a possible marker for increased symptom load and burden in bipolar patients (Wildes et al., 2007). Co-morbid EDs have been also associated with early onset, high rates of obesity (McElroy et al., 2002), suicidal ideation (Post et al., 2003) residual symptoms (MacQueen et al., 2003) and worsening course of bipolar illness (McElroy et al., 2001, Wildes et al., 2007).

Several studies have focused on the relationships between different subtypes of EDs and BPs (Akiskal et al., 2006, McElroy et al., 2006, McElroy et al., 2005). A strong association has been shown for BN, Bipolar II disorder (BP-II) (Lunde et al., 2009) and related “soft”-bipolar spectrum disorders, such as cyclothymia (Benazzi and Akiskal, 2008, Perugi et al., 1990). To our knowledge, comparisons between different subtypes of EDs in BD patients are not yet reported. The aim of the current study was to investigate the prevalence of AN, BN and BED among female patients with BD and to assess the clinical impact of such co-morbidity. Considering that EDs are much more frequent in women than in men (F:M, 4.2:1 for AN and 11.4:1 for BN) (Woodside et al., 2001), we just enrolled females in order to exclude a possible gender effect.

Section snippets

Participants

148 female outpatients and inpatients, aged ≥ 18 years (mean = 46.8 sd = 13.1), were consecutively enrolled at the San Martino University Hospital of Genova and its facilities (121 subjects), the Galliera Hospital of Genova (18 subjects), the Sarzana Psychiatric Mental Health Center “ASL 5” (9 subjects). Inpatients and outpatients ratio was approximately 1:1. All, but two, were of Italian and Caucasian ethnicities. All the patients met DSM-IV-TR diagnostic criteria for Bipolar I (n = 35, 31%), Bipolar

Results

Forty-six patients (31% of the cases) reported lifetime history of at least one EDs defined according to DSM-IV criteria: 23 met lifetime DSM-IV criteria for AN (15.5%), 8 for BN (5.4%), 21 for BED (14.2%); and 6 patients reported lifetime history of multiple ED; 2 were AN + BN (1.3%), 1 was AN + BN + BED (0.7%), and 3 were BED + BN (2%). Only 2 (1.3%) patients had BN without BED or AN, so we decided to include them into the AN group.

The age of onset of mood disorder was similar among the 3 groups (

Discussion

In interpreting our results, some methodological limitations must be taken into account. Since this study was conducted in a routine clinical service, clinicians who evaluated these patients could not be held entirely blind to the various measures administered. On the other hand, we submit that unintended biases due to lack of blindness were kept to a minimum using systematic semi-structured and structured instruments. The absence of the therapeutic history represents another limit of our study

Role of funding source

Data collection and statistical analysis were supported by the Department of Neurological Sciences, Ophthalmology and Genetics — Section of Psychiatry, University of Genova (Italy).

Conflict of interest

The authors report no conflict of interest relevant to this work.

Acknowledgement

The authors acknowledge Mrs. Rita Santi Amantini for her secretary service.

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