20. Risk of several psychiatric disorders was increased in relatives of anorexics and bulimics, Evidence-Based Mental Health
(C) British Medical Journal 1999.
Volume 2(1), February 1999, p 29
Risk of several psychiatric disorders was increased in relatives of anorexics
Woodside, Blake MD, FRCPC
The Toronto Hospital Toronto, Ontario, Canada
Lilenfeld LR, Kaye WH, Greeno CG, et al. A controlled family study of anorexia
nervosa and bulimia nervosa. Psychiatric disorders in first-degree relatives and
effects of proband comorbidity. Arch Gen Psychiatry 1998 Jul;55:603-10
Source of funding: National Institute on Alcohol Abuse and Alcoholism.
For correspondence: Dr WH Kaye, Department of Psychiatry, University of
Pittsburgh Medical Center, 3811 O'Hara Street, Pittsburgh, PA 15213-2593, USA.
Fax +1 412 624 6618.
In patients with anorexia nervosa or bulimia nervosa what are the familial
patterns of psychiatric disorders?
Case control study.
Inpatient and outpatient eating disorder programmes at Western Psychiatric
Institute and Clinic, Pittsburgh, Pennsylvania, USA.
26 women (mean age 25 y) with DSM-III-R criteria for anorexia nervosa (including
93 relatives), 47 women (mean age 25 y) with DSM-III-R criteria for bulimia
nervosa (including 177 relatives), and 44 women (mean age 26 y) with no history
of an eating disorder (including 190 relatives). Controls were matched by age
and postal code to cases.
Assessment of risk factors
Lifetime prevalence rates of eating disorders (Eating Disorders Family History
Interview), mood disorders, substance use disorders, anxiety disorders (Schedule
for Affective Disorders and Schizophrenia-Lifetime Version [or the school age
version for those DSM-III-R Personality Disorders, and the Personality Disorders
Examination) were determined using face to face interviews or by telephone.
Interviewers were blinded to the identity of the families.
Main outcome measure
Risk of disorders among first degree relatives.
After adjustment for sex, age, and interview type, relatives of patients with
anorexia and bulimia had increased risk of major depressive disorder, clinically
subthreshold forms of an eating disorder, generalised anxiety disorder, and
obsessive-compulsive disorder (table). The risk of substance dependence was
reduced among relatives of patients with anorexia compared with relatives of
patients with bulimia (risk ratio [RR] 0.5, 95% CI 0.3 to 1.0), and familial
aggregation was independent of bulimia. The risk of obsessive-compulsive
personality disorder was increased only among relatives of patients with
anorexia (RR 3.6, CI 1.6 to 8.0), and evidence existed that these 2 disorders
may have shared familial risk factors. Both major depression and obsessive-compulsive
disorder appeared to be transmitted independently from eating disorders.
Table. Adjusted risk ratios (95% CI) for disorders among first degree
relatives of patients with eating disorders and those without
Risk of major depression disorder, subthreshold eating disorders, generalised
anxiety disorder, and obsessive-compulsive disorder was increased in first
degree relatives of patients with anorexia nervosa or bulimia nervosa compared
with patients without these disorders.
This study represents an important advance in the study of the heritability of
eating disorders. It was carefully designed and the analytical approach is state
of the art.
The key findings relate to which disorders might have shared genetic vulnerabilities.
Despite controversy over the exact association between anorexia nervosa and
bulimia nervosa, only a few attempts have been made to sort out whether they
share genetic vulnerabilities or are inherited as separate conditions. Previous
work in this area has been ambiguous or suggested separate inheritance. 1-4
Investigation of the co-inheritance of other psychiatric disorders and eating
disorders is one strategy to investigate this, and it is of interest given the
high rates of familial occurrence in individuals with anorexia nervosa and
bulimia nervosa. This study confirms other work suggesting separate transmission
for major depression and substance use, and adds obsessive-compulsive disorder
to this list. Of interest, however, is the finding that obsessive-compulsive
personality disorder (OCPD) may share some genetic risk factors with anorexia
nervosa, and in fact may be a risk factor for its development.
Such findings may have clinical relevance that could eventually lead to the
development of strategies for identifying individuals at risk of developing
eating disorders, at whom preventative strategies could be more efficiently
targeted. In addition, this will have implications for treatment programmes, for
example suggesting an aggressive therapeutic approach to the treatment of OCPD
in those recovering from anorexia nervosa. Such a strategy would emphasise the
need for an integrative approach to the treatment of eating disorders-one which
requires an understanding of the biology and psychology of the illnesses.
1. Strober M. J Psychosom Res 1980;24:353-59.
2. Strober M, Lampert C, Morrell W, et al. Int J Eat Disord 1990;9:239-53.
3. Strober M. Substance abuse disorder and bulimia nervosa: familial vulnerability.
Presented at the International Conference on Eating Disorders; April 27, 1995;
New York, NY.
4. Woodside DB, Field LL, Garfinkel PE, et al. Comp Psychiatry 1998;39:261-4.