Anxiety disorders in subjects seeking treatment for eating disorders: a DSM-IV controlled study

Psychiatry Research 117(2003) 245–258

0165-1781/03/$ - see front matter� 2003 Elsevier Science Ireland Ltd. All rights reserved.doi:10.1016/S0165-1781(03)00038-6

Anxiety disorders in subjects seeking treatment for eatingdisorders: a DSM-IV controlled study

Nathalie T. Godart *, Martine F. Flament , Florence Curt , Fabienne Perdereau ,a, b a a

Francois Lang , Jean Luc Venisse , Olivier Halfon , Paul Bizouard , Gwenole Loas ,c d e f g´¸Maurice Corcos , Philippe Jeammet , Jacques Fermaniana h i

Department of Psychiatry, Institut Mutualiste Montsouris, 42 boulevard Jourdan, 75014 Paris, Francea

INSERMyCNRS UMR 7593, Hopital de la Salpetriere, Paris, Franceb ˆ ˆ `Centre Hospitalier Universitaire de Saint Etienne, Service de Psychiatrie, 23, Bd Pasteur, 42055 Saint Etienne cedex 2, Francec

Hopital Saint Jacques, Unite des Addictions, BP 1005, 44035 Nantes cedex 01, Franced ˆ ´Service Universitaire de Psychiatrie de l’Enfant et de l’Adolescent, SUPEA Unite de Recherche, 25 A Rue du Bugnon,e ´ ´

1005 Lausanne, SwitzerlandCentre Hospitalier Universitaire de Besancon, Hopital Saint Jacques, Service de Psychiatrie, 2, place Saint Jacques,f ¸ ˆ

25030 Besancon cedex, France¸Secteur Hospitalo-Universitaire, CHS P. Pinel, Route de Paris Dury, 80044 Amiens cedex, Franceg

Department of Psychiatry, Institut Mutualiste Montsouris, Paris, Franceh

Department of Biostatistics, Hopital Necker, Paris, Francei ˆ

Received 25 July 2001; received in revised form 4 March 2002; accepted 9 June 2002

Abstract

Women who were referred with an eating disorder(ED) were compared with a matched normal control group toanswer the following questions: What are the frequencies of anxiety disorders in cases of anorexia and bulimianervosa diagnosed according to DSM-IV criteria? Are anxiety disorders significantly more frequent among womenwith an eating disorder than among women from the community? We assessed the frequencies of six specific anxietydisorders among 271 women with a current diagnosis of anorexia or bulimia nervosa and 271 controls, using theMini-International Neuropsychiatric Interview, French DSM-IV version. A lifetime comorbidity with at least oneanxiety disorder was found in 71% of both the anorexic and the bulimic subjects, significantly higher than thepercentage of controls with an anxiety disorder. The prevalence was significantly higher in the eating disorder groupsthan in controls for most types of anxiety disorder, and between 41.8 and 53.3% of comorbid cases had an anxietydisorder preceding the onset of the eating disorder. Anxiety disorders are significantly more frequent in subjects witheating disorders than in volunteers from the community, a finding that has important etiological and therapeuticimplications.� 2003 Elsevier Science Ireland Ltd. All rights reserved.

Keywords: Eating disorders; Anorexia nervosa; Bulimia nervosa; Anxiety disorders; Comorbidity; Age of onset

*Corresponding author. Tel.:q33-1-56-61-69-35; fax:q33-1-56-61-69-34.E-mail address: [email protected](N.T. Godart).

246 N.T. Godart et al. / Psychiatry Research 117 (2003) 245–258

1. Introduction

Comorbidity between eating disorders and anx-iety disorders is an important issue as regards boththe pathogenesis and the treatment of these disor-ders(Bulik, 1995; Herzog et al., 1996; Wonderlichand Mitchell, 1997). However, the frequencies ofanxiety disorders in subjects seeking treatment foran eating disorder are still uncertain. When limitingour search to the 1985–2002 period(in order toget sufficiently homogeneous diagnostic criteriafor both categories of disorders, most often RDC,DSM-III, DSM-III-R, or DSM-IV criteria), wefound 24 studies(Piran et al., 1985; Walsh et al.,1985; Hudson et al., 1987; Laessle et al., 1987;Hudson et al., 1988; Powers et al., 1988; Laessleet al., 1989; Keck et al., 1990; Fornari et al., 1992;Herzog et al., 1992; Schwalberg et al., 1992;Bossert-Zaudig et al., 1993; Brewerton et al., 1993;Braun et al., 1994; Bushnell et al., 1994; Brewer-ton et al., 1995; Thiel et al., 1995; Bulik et al.,1996; Grilo et al., 1996; Bulik et al., 1997;Thornton and Russell, 1997; Lilenfeld et al., 1998;Godart et al., 2000; Iwasaki et al., 2000) investi-gating the prevalence of anxiety disorders amonginpatients or outpatients with a current diagnosisof an eating disorder who were referred to spe-cialized clinics for treatment, who were placed ona waiting list, or who volunteered for research(wedo not consider here studies conducted in thecommunity or follow-up studies of patients witheating disorders).The methods and findings of previous studies

on the prevalence of anorexia nervosa in womenwith eating disorders have been reviewed else-where (Godart et al., 2002). Results are verydifferent across studies. For example, the lifetimeprevalence of at least one anxiety disorder variesfrom 25 (Keck et al., 1990) to 75% (Schwalberget al., 1992) in bulimia nervosa and from 23(Laessle et al., 1987) to 54% (Piran et al., 1985)in anorexia nervosa. Only six of the 24 studieshave included control groups and because anxietydisorders are among the most frequent disordersin women from the community—with an overalllifetime prevalence from 12.7 to 18.1%(Wittchenand Essau, 1993)—it is not clear whether anxietydisorders are more frequent in women with ano-

rexia or bulimia nervosa than in women from thecommunity.Many studies on comorbidity between eating

and anxiety disorders suffer from general meth-odological limitations (Mitchell et al., 1991;Schwalberg et al., 1992; Godart et al., 2002);therefore, the findings are not strong and compar-isons are often inconclusive. The number of anxi-ety disorders taken into consideration varies fromtwo to six across studies, and in the few controlledstudies, the control groups are not matched to thepatients for age or other important characteristics(Bulik et al., 1997).Taking into account these considerations, and as

there was only one published study using DSM-IV criteria to date(Iwasaki et al., 2000) (with nocontrol group), we designed this project of acontrolled study between a large group of referredwomen with eating disorders and a matched con-trol group to answer the following questions:(1)What are the frequencies of all types of anxietydisorders in anorexia nervosa and bulimia nervosadiagnosed according to DSM-IV criteria?(2) Areanxiety disorders significantly more frequentamong women with eating disorders than amongwomen from the community(see below for defi-nition)? (3) What is the chronology of appearanceof the anxiety disorder and the eating disorder?

2. Methods

2.1. Subjects

Women seeking treatment for an eating disorderwere recruited as part of a larger French multicen-ter study on addictive disorders(eating disorder,alcohol dependence and illicit drug dependence;INSERM Network on Addictive Disorders no.494013) (Godart et al., 1999; Flament et al.,1999). Inclusion criteria for subjects with eatingdisorders were as follows: all consecutive femaleinpatients or outpatients, referred to one of theNetwork clinics (listed in Appendix A) with acurrent DSM-IV diagnosis of anorexia or bulimianervosa, aged 15–30 years for anorexia nervosa,and 15–40 years for bulimia nervosa. Controlsubjects were recruited among patients referred toother departments of the same hospitals for a

247N.T. Godart et al. / Psychiatry Research 117 (2003) 245–258

benign somatic disorder(e.g. stomatology),employees or students during systematic healthvisits, and high school or college students. Exclu-sion criteria for both subjects with eating disordersand control subjects were a psychotic disorder andinability to read or fill out the questionnaires.Additional exclusion criteria for the patients wereas follows: a chronic or severe somatic disorderwith possible effects on eating or weight(e.g.diabetes mellitus). Additional exclusion criteria forthe controls were as follows: a lifetime DSM-IVdiagnosis of anorexia or bulimia nervosa, alcoholabuse or dependence, illicit drug abuse or depend-ence; and chronic or severe somatic disorder; orhospitalization for a suicide attempt or severeaccident(situations are often linked to depressiveor other psychiatric illnesses).Controls were matched to the patients for sex,

age(age of the patient"1 year for 15–24 yearsold, and"2 years for 25–40 years old, to takeinto account the significant variability of psychicand social characteristics in adolescents and youngadults compared to adults) and socio-professionalstatus, according to the following five broad cate-gories defined by the French National Institute ofStatistics and Economic Studies(INSEE): (1)farmers and workers;(2) artisans, merchants andemployees;(3) managers and academic profes-sionals; (4) high school and university students;(5) unemployed adults. Within group 4, controlswere matched to the patients according to whetherthey were high school or university students. Thestudy group includes 271 women with an eatingdisorder(166 with anorexia nervosa and 105 withbulimia nervosa) and 271 individually matchedcontrol women.

2.2. Ethical aspects

The protocol had been approved by the Consul-tative Committee for Protection of Personsinvolved in Biomedical Research(CCPPRB) ofHospital Cochin Port Royal, Paris. After full infor-mation was provided, all subjects(and legal rep-resentatives for those below 18 years of age) gavewritten consent regarding their participation in thestudy. All data obtained were anonymous.

2.3. Assessment instruments

After socio-demographic information was col-lected, clinical diagnoses were made using theMini International Neuropsychiatric Interview(MINI; French DSM-IV Version 4.1) (Lecrubieret al., 1997; Sheehan et al., 1997, 1998), a struc-tured diagnostic interview derived from the Com-posite International Diagnostic Interview(CIDI)(Wittchen et al., 1991). The MINI Version 4.1 for‘Lifetime disorders’ explores all criteria for themain Axis I diagnoses of DSM-IV(AmericanPsychiatric Association, 1994). The diagnosticconcordance between the MINI and the CIDI hasbeen shown to be good to very good, the specific-ity and sensitivity of the MINI good, and its inter-rater reliability very good(0.88–1) (Lecrubier etal., 1997). Clinicians participating in the study allwere expert in the field of eating disorders andhad been trained for the use of the MINI by oneof the authors of the instrument(E. Weiller,INSERM U302, Paris).The disorders explored by the MINI in this

study are the following: lifetime eating disorderwthe interview was expanded to explore DSM-IVdiagnostic types for anorexia nervosa(restrictingtype or AN-R and binge eatingypurging type orAN-BN) and bulimia nervosa(binge eatingypurg-ing type or BN-P and non-purging type or BN-NP)x; panic disorder (lifetime); agoraphobia(lifetime); social phobia (lifetime); obsessive–compulsive disorder(OCD) (lifetime); generalizedanxiety disorder(GAD) (in the past 6 months);and post-traumatic stress disorder(current). Foreach disorder present, the MINI explores age ofonset and age of remission, if any(age at whichthe subject first and last met diagnostic criteria forthe disorder). Based on the MINI, we have defined‘at least one anxiety disorder’ as the presence ofone or more of the six anxiety disorders assessed.When reporting lifetime frequencies, we considersubjects with a current andyor past disorder. Acurrent disorder is one present the month precedingthe evaluation except for GAD(past 6 months).In addition, past history of separation anxietydisorder(not included in the MINI) was exploredby a clinical interview, based on a checklist ofDSM-IV criteria.


Table 1Description of anorexia nervosa, bulimia nervosa and control groups

Age Duration of Body mass index(years) illness(years) (kgym )2

Mean"S.D. Mean"S.D. Mean"S.D.(range) (range) (range)

Anorexia nervosa subtypesAN-R (Ns111) 19.3"3.0 2.4"2.0 14.9"1.9a

(15–29) (0–11) (11.0–20.3)Controls for AN-R(ns111) 19.5"3.2 20.7"2.4

(15–29) (16.6–28.0)AN-BN (ns111) 20.6"3.0 3.5"2.9 15.6"2.0a

(16–27) (0–13) (11.6–20.6)Controls for AN-BN(ns111) 20.7"3.0 21.5"3.0

(15–27) (15.6–32.8)

Bulimia nervosa subtypesBN-NP (ns19) 24.6"6.9 7.4"7.5 24.8"4.2b

(17–40) (0–24) (20.0–34.0)Controls for BN-NP(ns19) 24.5"6.9 20.6"1.6

(16–41) (17.6–24.1)BN-P (ns86) 22.8"4.5 4.9"4.0 20.3"3.3

(15–35) (0–18) (13.8–32.0)Controls for BN-P(ns86) 22.7"4.6 21.0"2.6

(15–35) (16.8–29.7)

Abbreviations: AN-R, anorexia nervosa, restricting type; AN-BN, anorexia nervosa, binge-eatingypurging type; BN-NP, bulimianervosa, nonpurging type; BN-P, bulimia nervosa, purging type.

Significant comparisons between anorexia nervosa subtypes and controls(P-0.001, Student’s pairedt-test).a

Significant comparisons between bulimia nervosa subtypes and controls(P-0.001, Student’s pairedt-test).b

The body mass index(BMI) or Quetelet’s indexwas calculated as(weight in kilograms)y(squaredsize in meters) (Rolland-Cachera et al., 1991).

2.4. Statistical analysis

Quantitative variables were described usingmean, standard deviation(S.D.) and range. Qual-itative variables were described using proportionsand percentages. The 95% confidence intervals ofthe frequenciesp of anxiety disorders inn subjectswere calculated as usual(P"1.96 4 pqyn) ifnPG5 andn(1yP)G5. Otherwise, the confidenceintervals were given by Pearson and Hartley(1984) tables.The proportions of subjects with comorbid dis-

orders were compared in the eating disorder andthe control groups using the McNemar pairedt-test. The mean of the differences between subjectsand controls was compared to zero using theStudentt-paired test; when the hypothesis of the

normality of differences was not admissible, weused the Wilcoxon non-parametric test. To com-pare means of independent samples, we used theusual Student’st-test or, if the underlying hypoth-eses were not verified, the Mann–Whitney test.The level of significance wasas0.05. Data werecollected and analyzed using SPSS 10 software(Statistical Package for the Social Sciences).

3. Results

3.1. Characteristics of the subjects

The 271 eating disorder patients are divided intofour groups according to DSM-IV current diagno-sis: 111 AN-R, 55 AN-BN, 86 BN-P, and 19 BN-NP. Inpatients accounted for 81% of the AN-Rand 64.8% of the AN-BN, while outpatientsaccounted for 84.2% of the BN-NP and 75.6% ofthe BN-P. Table 1 describes the main characteris-tics of subjects in each clinical and control group.


Table 2Lifetime prevalence of anxiety disorders in anorexia nervosa and control

Anorexia nervosa Anorexia nervosa Anorexia nervosa Anorexia nervosaRestricting type Restricting type Binge-eatingy Binge-eatingy(Ns111) (Ns111) purging type purging type

N % N % (Ns55) (Ns55)

wCI 95%xa wCI 95%xa N % N %wCI 95%xa wCI 95%xa

At least one anxiety 79 71.2b 15 13.5 39 70.9b 17 30.9disorder w62.6–79.7x w7.0–20.0x w58.5–83.3x w18.3–43.5x

Agoraphobia 22 19.8b 3 2.7 15 27.3c 4 7.3w12.3–27.3x w1.1–7.7x w15.1–39.4x w2.0–17.6x

Panic disorder 14 12.6c 3 2.7 13 23.6 0 0.0w6.3–18.9x w1.1–7.7x w12.0–35.2x w0.0–6.5x

Social phobia 42 37.8b 6 5.4 23 41.8b 7 12.7w28.7–47.0x w2.7–11.4x w28.4–55.3x w5.3–24.5x

Obsessive–compulsive 27 24.3b 3 2.7 13 23.6c 3 5.4disorder w16.2–32.4x w1.1–7.7x w12.0–35.2x w1.1–15.1x

Generalized anxiety 54 48.6b 4 3.6 25 45.4b 6 10.9disorder w39.2–58.1x w1.4–9.0x w31.9–59.0x w4.1–22.2x

Post-traumatic stress 2 1.8 0 0.0 4 7.3 1 1.8disorder w0.6–6.4x w0.0–3.3x w2.0–17.6x w0.0–9.7x

wCI 95%x: 95% Confidence interval of the frequency.a

Significant comparisons between anorexia nervosa subtypes and controls.P-0.001 McNemar test.b

P-0.05 McNemar test.c

The mean age and BMI of patients are comparedwith those of controls. The anorexia nervosa groupand subgroups(AN-R and AN-BN) have very lowaverage BMI, significantly different(P-0.0001)from that of controls. Subjects with BN-P have anaverage BMI that does not significantly differ fromthat of controls, unlike subjects with BN-NP,whose BMI is significantly higher than in controls(P-0.0001). Among the 166 anorexics, six havea history of BN (4y111s3.6% of AN-R and 2y55s3.8% of AN-BN), and among the 105 bulim-ics, 34 have a history of AN(4y19s21% ofBN-NP and 30y86s34% of BN-P).On the occupational level, 82.9% of the AN-R

and 63.9% of the AN-BN are students, while57.9% of the BN-P and 53.9% of the BN-NP areemployed. Most patients are single(80.2% of BN-P; 89.5% of BN-P; 85.2% of AN-BN; and 98% ofAN-R), and the proportion of single females inthe AN-R group is significantly higher than thatin the control group(88%). Few patients(fourBN-NP and four BN-P) have children.

3.2. Frequencies of anxiety disorders

Overall, 71% of both the anorexics and thebulimics have a lifetime comorbidity with at leastone anxiety disorder, which is significantly higher(P-0.001) than the percentage of controls withan anxiety disorder. Across the study sites, nosignificant difference was found regarding preva-lence of any diagnosis assessed by the MINI,neither for patients nor for controls.Tables 2 and 3 present the frequencies observed

for each anxiety disorder in the two subgroups ofanorexia, and their respective controls. All anxietydisorders(except panic disorder and post-traumaticstress disorder) are significantly more frequent inAN-R and AN-BN subjects than in their controlsfor both lifetime(Table 2) and current frequencies(Table 3). Most of the disorders are still currentat the time of assessment. The most frequentanxiety disorders among AN-R and AN-BN sub-jects are GAD, social phobia and OCD.Tables 4 and 5 present the observed frequencies

for each anxiety disorder in BN-P and BN-NP


Table 3Current prevalence of anxiety disorders in anorexia nervosa patients and control subjects

Anorexia nervosa Controls Anorexia nervosa Controlsrestricting type (Ns111) binge-eatingy (Ns55)(Ns111)

N %purging type

N %

N %wCI 95%xa (Ns55) wCI 95%xa

wCI 95%xaN %

wCI 95%xa


Agoraphobia 16 14.4b 2 1.8 11 20.0c 1 1.8w7.8–21.0x w0.6–6.4x w9.1–3.09x w0.0–9.7x

Panic disorder 6 5.4 0 0.0 8 14.5 0 0.0w2.7–11.4x w0.0–3.3x w4.9–24.2x w0.0–6.5x

Social phobia 34 30.6b 3 2.7 18 32.7c 5 9.1w21.9–39.3x w1.1–7.7x w19.9–45.5x w3.0–19.9x

Obsessive–compulsive 19 17.1b 2 1.8 12 21.8c 1 1.8disorder w10.0–24.2x w0.6–6.4x w10.5–33.1x w0.0–9.7x

Generalized anxiety 54 48.6b 4 3.6 25 45.4b 6 10.9disorder w39.2–58.1x w1.4–9.0x w31.9–59.0x w4.1–22.2x



Significant comparisons between anorexia nervosa subtypes and controls.P-0.001, McNemar test.b

P-0.01, McNemar test.c

subjects, and their respective controls. The overallfrequency of anxiety disorder is significantly(P-0.001) higher in BN-P and BN-NP women thanin controls, both when lifetime(Table 4) andcurrent frequencies(Table 5) are considered. Com-paring the frequencies observed in Tables 4 and 5,we see that the anxiety disorders are mostly oralways current. In the BN-P group, lifetime diag-noses of all anxiety disorders(except OCD andpost-traumatic stress disorder) are significantlymore frequent than in the control group. The mostfrequent lifetime diagnosis is social phobia, whichconcerns 36% of both BN-P and BN-NP women(Table 4).Moreover, among the individuals with a lifetime

anxiety disorder, as many as five distinct anxietydisorders(of the six assessed) are observed insome anorexic and bulimic subjects, comparedwith a maximum of three disorders(which is rare)in the controls: 58%(43y79) of AN-R subjectshave two or more lifetime anxiety disorders com-pared with 27%(4y15) of their controls (P-

0.05); 69% (27y39) of the AN-BN have two ormore anxiety disorders compared with 12%(2y17) of their controls(P-0.0001); 59% (30y51)of the BN-P and 58.8%(6y14) of the BN-NPhave two or more anxiety disorders, comparedwith 35%(6y17) and 2y2 of their controls, respec-tively (these latter proportions do not differsignificantly).Childhood history of separation anxiety disorder

is frequent in women with eating disorders(18.2%AN-R; 12.7% AN-BN; 32.9% BN-P; and 21.1%BN-NP), significantly more common(P-0.01)than in controls, except for BN-NP.We compared the four control groups for life-

time and current prevalence of each anxiety dis-order. No significant difference was found for anydisorder. However, the control groups for AN-Rand AN-BN differed from each other for bothcurrent and lifetime frequencies of ‘at least oneanxiety disorder’(Ps0.007). Among each diag-nostic type of eating disorder, inpatients and out-patients were compared for frequencies of all


Table 4Lifetime prevalence of anxiety disorders in bulimia nervosa patients and control subjects

Bulimia nervosa Controls forbulimia nervosa

Bulimia nervosa Controls for bulimianervosanon-purging type

non-purging typepurging type

purging type(Ns19)(Ns19)

(Ns86)(Ns86)

N % N % N % N %wCI 95%xa wCI 95%xa wCI 95%xa wCI 95%xa


Agoraphobia 3 15.8 0 0.0 15 17.4c 4 4.7w3.4–39.6x w0.0–17.6x w9.3–25.6x w1.3–11.5x

Panic disorder 4 21.1 1 5.3 18 20.9b 4 4.7w6.0–45.6x w0.1–26.0x w12.2–29.7x w1.3–11.5x

Social phobia 7 36.8 0 0.0 31 36.0b 7 8.1w16.3–61.6x w0.0–17.6x w25.7–46.4x w3.3–16.0x

Obsessive–compulsive 3 16.7 1 5.3 8 9.4 3 3.5disorder w3.6–41.4x w0.1–26.0x w4.1–17.7x w0.7–9.9x

Generalized anxiety 5 26.3 2 10.5 28 32.6b 6 7.0disorder w9.1–51.2x w1.3–33.1x w22.4–42.7x w2.6–14.6x



Significant comparisons between anorexia nervosa subtypes and controls.P-0.001, McNemar test.b


anxiety disorders. No single difference was foundregarding the AN-R and BN-NP subjects. Amongthe other groups, lifetime frequencies of someanxiety disorders were significantly higher amonginpatientswAN-BN: social phobia(P-0.0001) andOCD (P-0.05); BN-P: panic disorder(P-0.01),social phobia(P-0.05) and agoraphobia(Ps0.051)x.

3.3. Chronology of appearance of eating disordersand anxiety disorders

Among comorbid cases, 41.8%(33y79) of theAN-R and 48.7%(19y39) of the AN-BN had atleast one anxiety disorder preceding the occurrenceof anorexia (1 year or more before onset ofanorexia nervosa), and 51.9%(27y52) of the BN-P and 53.3%(8y15) of the BN-NP had at leastone anxiety disorder preceding the occurrence ofbulimia. Social phobia most often occurred beforeBN-P or BN-NP (in 67.7 and 71.4% of cases,respectively) and before AN-R or AN-BN(in 51.2and 60.9% of cases, respectively).

Other anxiety disorders appeared more oftensimultaneously with(same year) or after (at least1 year) the onset of the eating disorder: this is thecase for panic disorder(in 69.3% of AN-R co-morbid cases; 92.3% of AN-BN; 65.6% of BN-P;and 100% of BN-NP cases); OCD in AN (61%of AN-R and 53.4% of AN-BN cases); and GADin AN and BN-P(91.6% of AN-R; 75% of AN-BN; and 67.1% of BN-P cases).

4. Discussion

4.1. Comorbidity of eating disorders and anxietydisorders

To our knowledge, this is the first publishedstudy that has used DSM-IV criteria to comparecurrent and lifetime prevalences of anxiety disor-ders in referred subjects with an eating disorderand individually matched controls. The resultsshow a significantly higher overall frequency ofanxiety disorders in all diagnostic types of eatingdisorder (AN-R, AN-BN, BN-NP, BN-P) com-


Table 5Current prevalence of anxiety disorders in bulimia nervosa patients and control subjects

Bulimia nervosa Control bulimia Bulimia nervosa Control bulimianon-purging type nervosa purging type nervosa(Ns19) non-purging type (Ns86) purging type

N %(Ns19)

N %(Ns86)

wCI 95%xaN %

wCI 95%xaN %

wCI 95%xa wCI 95%xa

At least one anxiety 13 72.2b 2 10.5 50 58.1c 12 13.9disorder w46.5–90.3x w1.3–33.1x w47.5–68.8x w6.5–21.4x

Agoraphobia 3 15.8 0 0.0 8 9.3 3 3.5w3.4–39.6x w0.0–17.6x w3.0–15.6x w0.7–9.9x

Panic disorder 3 15.8 0 0.0 11 12.8d 2 2.3w3.4–39.6x w0.0–17.6x w5.6–20.0x w0.3–8.1x

Social phobia 7 36.8 0 0.0 25 29.1c 3 3.5w16.3–61.6x w0.0–17.6x w19.3–38.9x w0.7–9.9x

Obsessive–compulsive 3 16.7 5.3 5 5.9 1 1.2disorder w3.6–41.1x w0.1–26.0x w1.9–13.0x w0.0–6.3x

Generalized anxiety 5 26.3 2 10.5 28 32.6c 6 7.0disorder w9.1–51.2x w1.3–33.1x w22.4–42.7x w2.6–14.6x



Significant comparisons between bulimia nervosa subtypes and controls.P-0.01, McNemar test.b


P-0.05, McNemar test.d

pared with the frequency in controls. Furthermore,comorbidity with anxiety disorders is in most casescurrent, which is also the case for the anxietydisorders seen in controls. This is not surprising,in view of the typical age of onset of the disordersconsidered, most often adolescence or early adult-hood(Lewinsohn et al., 2000), which correspondsto the age range of subjects assessed in the currentstudy.

4.2. Anorexia nervosa

The prevalence(71%) of ‘at least one anxietydisorder’ in anorexia nervosa is at the upper limitof estimates given in the literature according toDSM-III-R or DSM-IV criteria: 26(Iwasaki et al.,2000) to 72%(Godart et al., 2000) for AN-R, and55% for AN-BN (Laessle et al., 1989).Variousmethodological factors might explain differencesbetween studies. The first factor regards the typeof treatment received: the filtering effect occurringin the pathway to either inpatient or outpatient

care may contribute to excess rates of comorbidityamong inpatients. Thus, the first study cited, withthe lowest prevalence of anxiety disorders(Laessleet al., 1989), concerns 21 AN-R and 20 AN-BNoutpatients, while the study with the highest prev-alence(Godart et al., 2000) concerns 29 AN-Rinpatients, and the current study includes bothinpatients and outpatients. We saw in the resultsthat among AN-BN and BN-P, some anxiety dis-orders are significantly more frequent. The secondfactor is, obviously, the total number of disorderstaken into consideration for ‘at least one anxietydisorder.’ Indeed, the study with the lowest prev-alence of anxiety disorders does not assess GAD(Laessle et al., 1989), while the study with thehighest prevalence does(Godart et al., 2000), andthe current study shows that GAD is the mostfrequent form of anxiety disorder in anorexicpatients (AN-R: 48.6%; AN-BN: 45.5%), eventhough it uses DSM-IV diagnostic criteria forGAD, which specify that ‘the focus of anxiety andworry is not confined to features of another Axis


I disorder, e.g. the anxiety or worry is not aboutgaining weight.’ To our knowledge, there are onlythree studies in the literature that have exploredthe frequency of GAD in anorexic patients: onereporting, similarly to ours, that GAD is morefrequent among AN-R subjects than among con-trols (31 vs. 2%,P-0.03) (Lilenfeld et al., 1998);and the second reporting a lifetime prevalence of24%, also in AN-R(Godart et al., 2000). Thethird (Iwasaki et al., 2000) reports low rates,perhaps linked to cultural factors not discussed inthe article concerning this disorder, of 19% forAN-R and 13% for AN-BP.The second anxiety disorder most frequently

found in anorexia is social phobia(AN-R: 30.6%;AN-BN: 32.7%). These results agree with previousfindings in the literature. According to past studies,the lifetime prevalence of social phobia in AN-Ris 24% in outpatients(Laessle et al., 1989), 33%in a mixed inpatient and outpatient sample(Lil-enfeld et al., 1998) and 55% in an inpatient sample(Godart et al., 2000), and social phobia is morefrequent in AN-R(inpatients and outpatients) thanin controls(31 vs. 5%,P-0.03) (Lilenfeld et al.,1998). The only exception in the literature is thelow prevalence of 6% for AN-R in a mixedinpatient and outpatient sample(Iwasaki et al.,2000), perhaps also linked to cultural factors.Our results confirm that OCD, the anxiety dis-

order most often assessed in comorbidity studiesof anorexic patients, is more frequent in anorexiathan in controls. Lilenfeld et al.(1998) foundhigher rates in AN-R than in controls(62 vs. 5%,P-0.05). Our results are lower: 17.5% for AN-Rand 21.8% for AN-BN. However, they are in therange of results found in previous studies usingDMS-III-R or DSM-IV criteria for AN-R w8% in62 inpatients and outpatients(Iwasaki et al., 2000);25% in 24 AN-R outpatients(Fornari et al., 1992);21% in 29 AN-R inpatients(Godart et al., 2000);and 37% among 35 AN-R inpatients(Thorntonand Russell, 1997)x. Concerning AN-BN, the fre-quency in the current study is near the 28% ofIwasaki et al.(2000) and below the 66% reportedby Fornari et al.(1992). We found significantlyhigher rates of agoraphobia and panic disorder inanorexic subjects than in controls, while the fre-quency of panic disorder did not differ between

AN-R and controls in a previous study(Lilenfeldet al., 1998). We did not find in the literature anystudy comparing the frequency of agoraphobiabetween referred anorexics and controls, but onestudy in the community(Walters and Kendler,1995) showed that subjects with ‘possible clinicalanorexia’ had a risk of suffering from panic dis-order 3.4 times greater than of normal controls(P-0.001). These results are in accordance withours.

4.3. Bulimia nervosa

Like the anorexics, 71% of the bulimics had atleast one lifetime anxiety disorder, significantlymore than in controls. Those results are in contrastwith two previous studies. Hudson et al.(1987)found no difference between bulimics and normalcontrols regarding overall prevalence of anxietydisorders, but subjects were outpatients or volun-teers for research, and only two anxiety disorders(OCD and agoraphobia) were assessed. Bulik etal. (1997) did not find an increased prevalence ofanxiety disorders(six diagnoses considered) in agroup of 116 bulimic outpatients, but the studyused exclusion criteria—current psychoactive med-ication, severe major depression and severe alcoholdependence—that may possibly have excludedsubjects with comorbid anxiety disorders. On theother hand, our results are in accordance withthose of a community study(Garfinkel et al.,1995) showing that lifetime anxiety disorders(fivedisorders: social phobia, GAD, agoraphobia, panicdisorder and simple phobia) were more frequentin 55 subjects with bulimia nervosa(58.2%) thanin controls(26%) (P-0.001).The most frequent anxiety disorder in BN is

social phobia(BN-P: 36.8%; BN-NP: 36%). Thisresult confirms similar findings in many previousstudies, where prevalence estimates range from 15(Lilenfeld et al., 1998) to 59% (Godart et al.,2000), consistent with two controlled studies ineither referred patients(Bulik et al., 1997) or fromthe community(Garfinkel et al., 1995) showing asignificantly higher rate of social phobia inbulimics.The second most frequent anxiety disorder in

bulimia is GAD (BN-NP: 26.3%; BN-P: 32.6%).


This disorder is significantly more frequent in BN-P than in controls, while there was no significantdifference in a previous study comparing referredbulimics (13%) with controls (2%) (Lilenfeld etal., 1998). However, results from community stud-ies (Kendler et al., 1991; Garfinkel et al., 1995)are in accordance with ours, showing that theprevalence of GAD is higher in BN subjects thanin controls (10.9 vs. 2.5%,P-0.001 in the firststudy, and odds ratios2.61 in the second study).We did not reproduce the results of past studies

(Hudson et al., 1987; Lilenfeld et al., 1998)showing that BN subjects had significantly(P-0.05) higher rates of OCD than controls(33 vs.7%, and 21 vs. 5%, respectively).The frequencies of panic disorder(BN-P:

20.9%; BN-NP: 21.1%) and agoraphobia(BN-P:17.4%; BN-NP: 15,8%) appear high comparedwith past studieswbetween 4(Lilenfeld et al.,1998) and 7% (Godart et al., 2000) for panicdisorder, and from 0(Schwalberg et al., 1992) to34% (Godart et al., 2000) for agoraphobiax. Ourresults, showing that purging bulimics significantlymore often have agoraphobia and panic disorderthan do controls, are in contradiction with thoseof Lilenfeld et al. (1998), but are supported bystudies in the community: Garfinkel et al.(1995)found a significantly(P-0.001) higher lifetimefrequency of agoraphobia and panic disorder inbulimics (37.5 and 20%, respectively) than incontrols (7.5 and 2%); and Walters and Kendler(1995) showed that the prevalence of panic dis-order was increased by three in bulimics.Unlike the results of Lilenfeld et al.(1998),

who showed a significantly higher lifetime preva-lence of post-traumatic stress disorder in bulimicsthan in controls (30 vs. 7%), no differenceappeared in the current study. We do not knowwhether divergent findings are linked to culturaldifferences between countries, or merely reflectthe fact that only current post-traumatic stressdisorder was assessed in this study.

4.4. Number of comorbid anxiety disorders

The evidence that both the anorexics and thebulimics with lifetime diagnosis(es) of anxietydisorder most often have several distinct comorbid

anxiety disorder(58% of AN-R, 59% of BN-Pand BN-NP, and 69% of AN-BN have two ormore anxiety disorders) is puzzling. It might bedue, in part, to the possible overlap betweenanxiety disorders, as evidenced by the 12–35% ofcontrols who also have several distinct diagnosesof anxiety disorder. This, in turn, may reflect eithersymptom overlap or shared risk for several anxietydisorders in the same individual. In the community,it has been shown that subjects, especially adoles-cents, who have several concomitant anxiety dis-orders suffer from particularly severe socialmaladjustment(Wittchen et al., 1998). This hasalso been shown in clinical populations of eatingdisorders(Flament et al., 2001). It might be thatsuffering from several anxiety disorders also makesthe person at particular risk for developing second-ary disorders, notably eating disorder. Also, wedid not measure the severity of anxiety disorder,when present, in the eating disorder and controlsubjects. It is possible that the number of concom-itant diagnoses of anxiety disorder is a reflectionof greater severity of anxiety symptoms in general,or of greater vulnerability for anxiety disorders.Although this is hard to disentangle, it is temptingto speculate that severity of shared risk factors(for both anxiety disorder and eating disorder)might be responsible for the severity andyor num-ber of comorbid diagnoses.

4.5. Chronology of appearance of the anxietydisorder relative to the eating disorder

To interpret the chronology of appearance ofanxiety disorders and eating disorders, we have toconsider the following:(i) the average age at onsetof eating disorder is usually younger in anorexianervosa(means17 years) than in bulimia nervosa(means18 years) (American Psychiatric Associ-ation, 1994); (ii) the age at onset of each anxietydisorder also varies according to the disorderconsideredwe.g. social phobia generally starts dur-ing childhood, while GAD appears in late adoles-cence or early adulthood, on average at 20 yearsof age(American Psychiatric Association, 1994)x.Therefore, it is difficult to know whether therelative chronology of appearance between anxietydisorder and eating disorder(e.g. social phobia


most often precedes the onset of eating disorder)derives from the natural course of the two disordersor whether it may contribute to explain the linkbetween them. Although the limited number ofsubjects with anxiety disorder among controls inthe current study did not permit us to compareages at onset of anxiety disorder between eatingdisorder subjects and controls, this would be inter-esting to investigate in a further study: an unusu-ally precocious age at onset of anxiety disordercould be linked to the development of a secondaryeating disorder, as suggested for OCD in one study(Fahy et al., 1993).In addition, several authors have stressed that

anxiety andyor depressive symptoms may appearduring malnutrition states. Some studies havereported an overlap on the symptom level(Keyset al., 1950; Pollice et al., 1997), but no specificsyndrome type study has been conducted. It ispossible that a disorder occurring after the onsetof an eating disorder might be the consequence ofsevere malnutrition. Indeed, the rates of anxietydisorder in subjects with an eating disorder seemto vary according to nutritional status since, infollow-up studies (where most subjects havereturned to normal eating and normal weight),current prevalence rates of anxiety disorder aremuch lower than in acutely ill eating disordersubjects. For example, in a study of 51 anorexicsubjects re-examined on average 6 years after theonset of their eating disorder, only 19% werecurrently suffering from an anxiety disorder(Ras-tam et al., 1995). Therefore, we cannot excludethat, at least in some cases, an anxiety disordercontemporaneous with an eating disorder mightpotentially be an artifact of malnutrition, especiallyfor GAD, OCD and or social phobia, which arethe most frequent diagnoses found in the currentstudy. This underlines the importance of studyingthe relative chronology of onset of anxiety andeating disorders, not only retrospectively, but alsoprospectively.

4.6. Limitations of the study

We are aware of several limitations to the currentstudy. First, recruitment was done among patientsreferred to clinics highly specialized for the treat-

ment of eating disorder. The referrals thereforemight not represent the entire population of ano-rexic or bulimic subjects, but rather the moresevere forms of eating disorder. Second, as for allstudies including retrospective diagnosis of pastdisorders, memorization or reconstruction biasesmight have influenced subjects’ report. Because ofthis, it was not attempted to make past diagnosisof GAD (which is known to be relatively unrelia-ble, in addition to the disorder being rare inchildhood), but this, in turn, may have underesti-mated the frequency of GAD antedating the eatingdisorder. Also because of rarity, the diagnosis ofpost-traumatic stress disorder was the other diag-nosis only assessed currently. Third, the controlswere selected to be free from any eating disorder,but also from alcohol or drug dependence, whichmight have reduced the frequency of anxiety dis-orders in the control groups, and hence increasedthe difference between clinical and control groups.However, as discussed earlier, results in both theeating disorder group and in the control group arecomparable to those of previous clinical and com-munity studies, respectively. Fourth, unlike theother diagnostic groups(Ns55–111), the BN-NPgroup only included 19 subjects; nevertheless,results from this group are of particular interest,because no previous study has ever included thisdiagnostic subtype of bulimia nervosa. Fifth, thediagnosis of separation anxiety disorder came froman unstructured clinical evaluation based on achecklist of DSM-IV criteria, because no struc-tured instrument for this diagnostic category wasavailable in French when we began the study.Finally, prevalence rates of anxiety disorder dif-fered to some extent across the four control groups,including one significant difference between thecontrols for AN-R and AN-BN regarding thefrequency of ‘at least one anxiety disorder’; thismight be due to some sampling hazard, but it doesnot seem related to a real difference for anyspecific diagnosis of anxiety disorder(for whichno significant difference emerged).

4.7. Conclusion

The study shows that anxiety disorders aresignificantly more frequent among women seeking


treatment for an eating disorder than among care-fully matched controls. Comorbidity is high withmost types of anxiety disorder in both anorexianervosa and bulimia nervosa. After having provid-ed convincing evidence of comorbidity betweeneating disorder and anxiety disorder, future studies(possibly prospective) should aim at exploring thenature of the relationship between the two cate-gories of disorders. The links might include(i)common shared vulnerability,(ii) a form of anxi-ety disorder such as social phobia being a riskfactor for an eating disorder, and(iii ) an anxietydisorder such as GAD being a secondary disorderto an eating disorder. It is likely, also, that therelationship between eating and anxiety disordersmight be partially mediated by a common relation-ship with depressive disorders, which are well-known associated disorders to the eating disorders.In any case, recognizing the presence and potentialseverity of an anxiety disorder in subjects seekingtreatment for an eating disorder has many thera-peutic implications, and is crucial for the long-term prognosis of anorexic and bulimic women.

Appendix A: List of sites and investigators(INSERM Network n 49401; coordination: P.Jeammet, M. Corcos, M. Flament)

Institut Mutualiste Montsouris-Departement de´Psychiatrie de l’Enfant et de l’Adolescent, Paris

Pr Ph. Jeammet, Drs M. Corcos, M. Flament, F.Atger, N. Godart, F. Perdereau, D. Miocque,F. Curt, C. Dugre-Le Bigre´

Hopital Saint Jacques-Unite des Addictions,ˆ ´Nantes

Pr J.L. Venisse, Drs N. Mammar, M. Rousseau

Secteur Hospitalo-Universitaire-CHS P. Pinel,Amiens

Pr G. Loas, Drs A. Verrier, M. Gayant

Centre Hospitalier Universitaire de SaintEtienne-Service de Psychiatrie

Prs F. Lang, J. Pellet

Service Universitaire de Psychiatrie de l’Enfantet de l’Adolescent, Lausanne

Pr O. Halfon, Drs M. Bolognini, Ph. Stephan,J. Laget, B. Plancherel

Centre Hospitalier Universitaire de Besancon-¸Hopital Saint Jacques-Service de Psychiatrieˆ

Pr P. Bizouard, Drs S. Nezelof, Y. Taccoen

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Anxiety disorders in subjects seeking treatment for eating disorders: a DSM-IV controlled study

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