The depressive symptoms of bulimia nervosa PJ Cooper and CG Fairburn The British Journal of Psychiatry 1986 148: 268-274 Access the most recent version at doi:10.1192/bjp.148.3.268
References
Reprints/ permissions You can respond to this article at Email alerting service Downloaded from
Article cited in: http://bjp.rcpsych.org/cgi/content/abstract/148/3/268#otherarticles To obtain reprints or permission to reproduce material from this paper, please write to
[email protected] http://bjp.rcpsych.org/cgi/eletter-submit/148/3/268 Receive free email alerts when new articles cite this article - sign up in the box at the top right corner of the article or click here bjp.rcpsych.org on July 11, 2011 Published by The Royal College of Psychiatrists
To subscribe to The British Journal of Psychiatry go to: http://bjp.rcpsych.org/subscriptions/
British Journal of Psychiatry (1986), 148, 268—274
The Depressive Symptoms of Bulimia Nervosa PETERJ. COOPERand CHRISTOPHERG. FAIRBURN
Standardised measuresof mental state were used to compare patients with bulimia nervosawith those with major depressivedisorder. The two groups were found to be similar in terms of severity of psychiatric disturbance, as measured by the Mont gomery Et Asberg Scale and the Present State Examination. Noteworthy sympto matic differences
were a greater frequency
of obsessional
ruminations
and anxiety
amongst the first group, and a greater frequency of depressed mood, apparent sadness, and suicidal ideation amongst the second. Discriminant function analyses revealed that the two patient groups had a different pattern of symptoms. Examina tion of the character of the psychiatric symptoms of patients with bulimia nervosa suggests that the anxiety and depressive symptoms are likely to be secondary to the eating disorder itself, rather than of primary significance. Bulimia nervosa (BN) is an eating disorder in which
each of these lines of evidence is open to question, if
a profound and distressing loss of control over eating results in episodes of bulimia (Russell, 1979; Fairburn, 1983). Body weight usually lies within the normal range due to a variety of compensatory behaviour, including self-induced vomiting, purga
it were confirmed that bulimia is closely related to the affective disorders, this would have major impli cations for our understanding of the condition. This paper is concerned with the first line of
tive abuse and extreme dieting. Accompanying the behavioural disturbance are grossly abnormal atti tudes to body shape and weight and to food and eat
ing, as well as a wide range of neurotic symptoms (Fairburn & Cooper, 1984a). Bulimia nervosa appears to be a common disorder
(Fairburn & Cooper, 1982; Fairburn & Cooper, 1984b). A recent survey of young adult women found
that its prevalence
Fairburn,
was 1—¿2°lo (Cooper
instruments,
&
and to compare their symptoms
with
those of patients with major depressive disorder.
1983). In the United States a similar
syndrome—'bulimia'—is included (American Psychiatric Association,
evidence; i.e. the character of depressive symptoms of patients with BN. Whilst it has been noted (Russell, 1979; Pyle eta!, 1981; Fairburn, 1983)that depressive symptoms are common amongst these patients, there have been no systematic phenomeno logical studies. The aim of the present investigation was to describe the depressive symptoms of a sample of these patients using well-established assessment
Method
in DSM III 1980); and it
The cases of bulimia nervosa
has a prevalence rate similar to that of BN (Pyle et A letter wassent to all generalpractitionersin the Oxford a!, 1983). area requesting the referral of patients for possible inclu Four lines of evidence have been used to argue sion in a study of the treatment of BN. They were asked to that the syndrome bulimia is ‘¿closely related to' or ‘¿a refer patients aged over 17 years who complained of havinglost control over eating and who used self-induced form of' major affective disorder (Hudson et a!, vomiting as a means of compensating for overeating. 1983a, 1984). Firstly, depressive symptoms are Local psychiatrists also agreed to refer all such patients. common amongst patients with bulimia (Pyle et a!, Patients were asked to attend for a two hour assessment 1981). Secondly, family history studies have interview to elicit biographical data together with infor revealed a high prevalence of affective disorder mation for a clinical diagnosis; and a standardised assess amongst these patients' relatives (Hudson et a!, ment of mental state was made by an experienced research 1983b). Thirdly, tests of neuroendocrine such as the dexamethasone suppression
function, test, have
assistant who had been trained in the use of the various measures. Each interview was tape-recorded. Patients also completed certain self-report questionnaires.
shown similarities between these patients and those with
affective
disorder
(Hudson
et al,
1983a).
Lastly, it has been reported that patients with
The diagnosis of bulimia nervosa
bulimia respond to treatment with antidepressant drugs (Pope et a!, 1983; Walsh et al, 1982). While
A strict operational definition of bulimia nervosa was used, based on the diagnostic criteria of Russell (1979):
268
THE DEPRESSIVE SYMPTOMS
(i) The patient had to deny having control over her eating and report having experienced at least four episodes
of bulimia or ‘¿binge-eating' over the previous four weeks, as well as an average of at least one binge a week over the
previous six months. The following definition of a binge was given: ‘¿We use the term binge to refer to episodes of uncontrolled eating in which a huge amount of food is con sumed, often rapidly and in secret. These episodes usually end because of stomach pain, interruption by others, running out of food supplies, or vomiting. Although the actual eating may be enjoyable, afterwards one invariably feels disgusted, guilty and depressed'.
(ii) The patient had to report havingmade herselfsick on at least four occasions over the past four weeks, and on average, at least once a week over the previous six months. On each occasion, the vomiting had to be induced rather than spontaneous, and be performed either as a method of weight control or to compensate for having overeaten, or both. Patients who did not practice self-induced vomiting
were excluded. Thus, this definition of BN is somewhat narrower than Russell's, since it did not include people who use purgatives weight control.
rather than vomiting
as a means of
269
OF BULIMIA NERVOSA
(Pearson r) for the individual MADRS items ranged from 0.45 to 1.00; and for the MADRS total score there was almost perfect agreement (r = 0.97). A similar high corre lation was obtained for the PSE total score (r = 0.96), and the agreement between the two raters on the presence or absence of each PSE symptom was equally good. For II PSE symptoms there was perfect agreement that the symptom was either present or absent. For the remainder the mean kappa was 0.94 (range 0.60 to 1.00). This paper is concerned with the non-specific psycho
pathology of the patients; their overall clinical characteris tics and specific psychopathology have been described elsewhere (Fairburn & Cooper, l984a). The cases of major depressive disorder
A colleague (Dr. 3. Teasdale) requested all Oxfordshire general practitioners to refer for possible inclusion in a study of cognitive therapy for depression patients between the ages of 16 and 60 with a score of over 20 on the Beck
Depression Inventory (Beck et a!, 1961). These were assessed
by
a psychiatrist
using
the
Present
State
Examination (Wing et a!, 1974), the Hamilton Rating
1984a, for the operational definition).
Scale for Depression (HRSD) (Hamilton, 1960), and the MADRS. Patients who fulfilled Research Diagnostic Criteria for unipolar primary major depressive disorder
(iv) The patient had to weigh at least 80010 of the matched population mean weight (MPMW)(Geigy, 1962).
were
(iii) The patient had to exhibit psychopathology sugges tive of a morbid fear of fatness (see Fairburn
& Cooper,
(Spitzer et a!, 1978) and scored 14 or more on the HDRS considered
eligible
Measures Specific psychopathology: A semi-structured pre-coded interview was used to assess the psychopathology charac teristic of patients with BN. The major items were: fear of fatness, pursuit of weight loss, sensitivity to weight gain, body image disparagement, binge-eating, self-induced
vomiting, use of purgatives or exercise for weight control, frequency of weighing, desired weight, anxiety in eating related situations,
and the avoidance
of such situations.
In addition to the interview, two self-report question naires were used to assess the specific psychopathology: the Eating Attitudes Test (EAT) (Garner & Garfinkel, 1979), a measure of abnormal eating habits and abnormal attitudes to food, eating, body weight and shape (Button & Whitehouse, 1981; Garner et a!, 1982); and the Three Factor Eating Questionnaire (Stunkard & Messick, 1981), from which a measure of ‘¿dietary restraint' was derived.
Non-specific psychopathology: The principal measures were as follows: (a) The Present State Examination (PSE) (Wing et a!, 1974), a standardised interview for assessing the presence or absence of symptoms within the neuroses and func tional psychoses. (b) The Montgomery & Asberg Depres
sion Rating Scale (MADRS) (Montgomery & Asberg, 1979), a sensitive measure of depression. An assessment was made of the inter-rater reliability of the MADRS and PSE data. All interviews were tape
for
inclusion
in the
study
(Teasdale et a!, 1984).
Results The bulimia nervosa sample Forty-six
patients
referred
for treatment
were sent an
appointment, and all but three attended; 35 fulfilled the diagnostic criteria for BN. All also fulfilled DSM III criteria for the syndrome bulimia (American Psychiatric Association, 1980).
The primary major depressive disorder sample Forty-four patients (40 of them women) were assessed and found to fulfil the selection criteria for major depressive disorder. Their age range was 23 to 59, (mean = 37.9, sd= 10.0), as compared
with an age range of 18 to 35 for
the BN sample (mean age = 23.5, sd = 4.4). The average ages of the two patient groups were significantly different (t=7.76, df=73, P
