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Article 7: Bulimia Nervosa in Adolescents: A Disorder in Evolution? Archives of Pediatrics & Adolescent Medicine

Copyright 2004 by the American Medical Association. All Rights Reserved.
Applicable FARS/DFARS Restrictions Apply to Government Use. American Medical
Association, 515 N. State St, Chicago, IL 60610.

Volume 158(5), May 2004, p 478-482

Abstract

Background: There are few reports that describe the manifestation of bulimia
nervosa (BN) among adolescents. Moreover, none make reference to the comparative
clinical manifestation of adolescent BN and adolescent anorexia nervosa. Nor are
any reports available of how distinct partial-syndrome BN cases are from those
that meet full diagnostic criteria for BN.

Objectives: To describe 3 groups of adolescents, those with a full-syndrome
eating disorder (BN and anorexia nervosa) or partial-syndrome BN, and to compare
these groups along demographic, general psychopathology, and eating disorder
variables.

Design: The study population included 120 adolescents with eating disorders who
were initially seen at The University of Chicago Eating Disorders Program,
Chicago, Ill, for treatment. All participants completed an assessment prior to
treatment.

: Weight and height were obtained from all participants. Participants also
completed a baseline demographic questionnaire (eg, menstrual status, ethnicity,
family status), Beck Depression Inventory, Rosenberg Self-Esteem Scale, and the
Eating Disorder Examination.

: Partial-syndrome BN cases are clinically quite similar to their full-syndrome
counterparts. Only objective binge eating episodes and purge frequency
distinguished BN and partial-syndrome BN cases. Anorexia nervosa cases, on the
other hand, were quite distinct from BN and partial-syndrome BN cases on almost
all variables.

Conclusion: Early recognition and swift treatment of eating disorders in
adolescents, regardless of whether a diagnostic threshold is met, are imperative
because they will lead to early intervention thereby potentially improving
eating disorder recovery rates.

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Bulimia nervosa (BN) affects as many as 3% of young women 1 and usually arises
in adolescence with the peak age of onset reported to occur between 15.7 years 2
and 18.1 years. 3 Key features are binge eating followed by inappropriate
compensatory behaviors such as self-induced vomiting, laxative or diuretic
misuse, fasting, and excessive exercise. Episodes of overeating are accompanied
by feelings of loss of control, guilt, and remorse. Patients overvalue shape and
weight and, as in anorexia nervosa (AN), often make repeated attempts to lose
weight. 4,5

Recent reports have described alarmingly high numbers of adolescents with BN.
6,7 The relative frequency of premenarchal BN in children is particularly
disconcerting. 8 Partial-syndrome eating disorders are even more common. Early
studies of dieting and binge eating behaviors in community samples have shown
that 10% to 50% of adolescent girls and boys frequently engage in binge eating
behavior. 9,10 Applying stringent diagnostic criteria to community samples,
studies have found that only 1% to 5% of adolescent girls surveyed qualify for a
diagnosis of BN. 11 This prompts the argument that children and adolescents may
have partial syndromes that do not fall as neatly into extant Diagnostic and
Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) eating disorder
categories as adults. 12 This poses a diagnostic dilemma for conducting
treatment outcome investigations in this younger age population especially
because partial-syndrome cases may go on to develop the full syndrome in time.

Research comparing the demographics of adolescent BN to adult BN has been
limited. Recent findings suggest that both patient populations are represented
across racial and socioeconomic groups. 13 While boys represent approximately
one fifth of adolescents with BN, 14 about one tenth of adults with BN are men.
5

There are also few reports available specifically describing the clinical
manifestation of BN among adolescents. Full-syndromal BN is more common among
young adults than among adolescents. 12 A recent comparison of adolescents and
young adults first seen for eating disorder treatment revealed that adults
report more binge eating and laxative use than their adolescent counterparts. 15
There are no published reports available examining how distinct partial-syndrome
BN (PBN) cases might be from those that meet full diagnostic criteria. In
addition, no reports make specific reference to how the clinical manifestation
of BN in adolescents compares with that of adolescents with AN.

Therefore, the purpose of the present investigation was to describe and compare
the demographic and clinical manifestations of adolescents with BN, PBN, and AN.
This description could better inform the physician in making diagnostic and
treatment decisions.

METHODS

PARTICIPANTS

Participants were selected from 142 consecutive adolescent referrals to an
eating disorder research-based treatment service at The University of Chicago,
Chicago, Ill. Of these 142 patients, 42 (29.6%) met interview-based DSM-IV 16
criteria for AN, 38 (26.8%) met DSM-IV criteria for BN, and 62 (43.7%) were
eating disorder not otherwise specified (EDNOS). Of the EDNOS cases, 40 met
study criteria for PBN (ie, not meeting full DSM-IV criteria for BN [which
requires binge eating and purging twice per week for 3 months], but binge eating
or purging at a frequency of at least once per week for 6 months). The remaining
22 EDNOS cases were excluded (15 with partial AN, 4 with PBN who did not satisfy
the above-mentioned criteria, and 3 with binge eating disorder). Appropriate
institutional review board approval for this project was obtained and corresponding
consent procedures followed.

MEASURES

Each participant completed a comprehensive assessment battery at the time of
initial examination and was offered a course of treatment on completing this
evaluation.

Demographic Variables

These variables include weight, height, duration of illness, race/ethnicity
(white, African American, Hispanic, and Asian), and family status (intact,
divorced, single, reconstituted). Menstrual status was categorized in 3 groups:
absent (primary or secondary amenorrhea), irregular (1-2 cycles in the past 3
months), or regular (3 cycles in the past 3 months).

General Psychopathology

Depression was assessed with the Beck Depression Inventory, 17 a 21-question
scale that has been used in numerous studies of adolescent depression. 18,19
Self-esteem was assessed with the Rosenberg Self-Esteem Scale, 20 a widely used
self-report instrument of 10 items. The Rosenberg Self-Esteem Scale has been
used in previous BN treatment studies and has been found to be a robust
predictor of outcome. 21

Eating Disorder Psychopathology

Participants completed the Eating Disorder Examination (EDE) (C. G. Fairburn,
MD, and Z. Cooper, PhD, unpublished data, 2000), a standardized, psychometrically
sound, well-tested semi-structured clinical interview that measures the severity
of the characteristic psychopathology of eating disorders and generates
operational (DSM-IV-based) definitions of eating disorder diagnoses. 22
Recently, the EDE has been used with adolescents. 23

With the EDE, the trained interviewer assesses the severity of psychopathology
along 4 subscales: restraint, eating concern, shape concern, and weight concern.
In addition, the EDE assesses the frequency of key eating disorder behaviors
including objective bulimic episodes (OBEs) (These are defined as eating an
unusually large amount of food in a circumscribed period with an accompanying
feeling of loss of control over eating. The interviewer determines whether an
eating episode is objectively large using established guidelines [C. G.
Fairburn, MD, and Z. Cooper, PhD, unpublished data, 2000] that incorporate the
amount eaten given the context and what others in a similar situation [eg,
holidays] would consume. If the amount presented in the interview is ambiguous,
a consensus may be reached among trained interviewers to determine whether it
meets operational criteria for "large".); subjective bulimic episodes (SBEs)
(These are defined as not objectively large in terms of food quantity as would
be defined for OBE but characterized by patients thinking that they have
overeaten accompanied by feeling out of control.); and purging (eg, self-induced
vomiting). The OBE is equivalent to the DSM-IV definition of a binge episode in
the diagnostic criteria for BN. The EDE was primarily used to generate the
diagnoses of AN, BN, and PBN.

DATA ANALYSIS

Differences in categorical demographic variables were examined using [chi]2
statistics. Race/ethnicity and family status were each collapsed into 2 groups
(eg, non-Hispanic white vs nonwhite and intact family vs nonintact family).
Continuous variables were examined using a series of 1-way analyses of variance.
To control for type I error in multiple comparisons, a Bonferroni correction was
applied to this set of analyses.

RESULTS

DEMOGRAPHIC VARIABLES

The mean (SD) age of the participants (N = 120) was 15.7 (2.2) years (range,
9-19) and the mean (SD) illness duration was 19.1 (16.3) months (range, 2-78).
The majority of the sample was female (113 [94.2%]), non-Hispanic white (91
[75.8%]), and from intact families (87 [72.9%]). Results are summarized in Table
1. Post hoc analyses showed that there were no differences in age between
patients with BN and patients with PBN or between patients with PBN and patients
with AN. However, patients with BN were significantly older than those with AN
(PP

----------------------------------------------
Table 1. Patient Characteristics for Bulimia Nervosa (BN), Partial-Syndrome
Bulimia Nervosa (PBN), and Anorexia Nervosa (AN)*
----------------------------------------------

Across groups, most patients were female: BN, 36 (94.7%); PBN, 39 (97.5%); and
AN, 38 (90.5%), ([chi]22 = 1.87; P22 = 2.006; P22 = 11.28; P22 = 31.22; P

GENERAL PSYCHOPATHOLOGY

Significant differences between patients with BN, PBN, and AN were reported for
self-esteem as assessed with the Rosenberg Self-Esteem Scale (PPPPPP

----------------------------------------------
Table 2. General Psychopathology for Patients With Bulimia Nervosa (BN),
Partial-Syndrome Bulimia Nervosa (PBN), and Anorexia Nervosa (AN)*
----------------------------------------------

EATING DISORDER SYMPTOMS

Results are summarized in Table 3. Significant differences between the groups
were reported across all variables examined (PPPP PPP values

----------------------------------------------
Table 3. Eating Disorder Examination (EDE) Symptoms*
----------------------------------------------

COMMENT

This study aimed to provide a description of adolescents initially seen with
symptoms of BN. Almost half (58 [48%]) of the patients who were initially seen
at our clinic with BN symptoms did not meet full criteria for BN. Our findings
revealed that patients with BN and patients with PBN showed more similarities
than differences, with the only difference being the 2 diagnostic items;
patients with BN reported significantly higher frequencies of binge eating and
purging. This echoes the findings of a recent study of adult BN and PBN. 24

Contrary to the cognitive model of BN, 25 which postulates that binge eating is
usually followed by purging, patients in our study who were initially seen with
PBN purged in the absence of objectively large binge eating episodes. That is,
patients with PBN reported a relatively low average of 0.9 OBE per week but 4.5
purge episodes during the same period. However, examining OBEs plus SBEs,
patients in the PBN group purged every time they perceived food intake as a
binge (OBEs plus SBEs equals, on average, 6.1 binge eating episodes per week
followed by 4.5 purge episodes during the same period). The same was true for
patients with BN (OBEs plus SBEs equals, on average, 10.6 binge eating episodes
per week followed by 11.3 purge episodes during the same period). This finding
is consistent with 2 previous reports 26,27 questioning the validity of making a
distinction between objective and subjective binge eating and suggests that DSM
diagnostic criteria should emphasize purging more than binge eating, especially
for younger patients.

While patients with BN reported significantly more objectively large binge
episodes than patients with PBN, the latter reported almost double the amount of
subjectively large binge episodes compared with their counterparts with BN (21
vs 11 episodes in 28 days; P

In addition to binge and purge frequencies, menstrual irregularities in this
patient population also are of concern. As expected, the majority of AN cases
reported an absence of menses, but more than a third of patients with BN and
nearly half of patients with PBN also reported menstrual irregularities. This is
in keeping with the rate that has been previously reported in the literature. 28
While menstrual irregularities are common in immediately postmenarchal
adolescents, the mean age of patients with BN and patients with PBN with
menstrual disruption or irregularity was 15.9 years, a point in adolescent
development where regular menstrual cycles should have been established for many
teenagers. 29 There was no age difference between those adolescents with BN and
adolescents with PBN with and those without menstrual abnormalities (15.9 years
vs 16.4 years).

Patients with AN differed from those with BN and PBN on almost every variable
examined. Patients with AN were significantly younger and had lower body mass
indexes than patients with BN. Patients with AN more frequently came from intact
families as opposed to patients with BN or patients with PBN. This finding has
potential clinical implications in that the few available treatment studies for
adolescent AN, 30-32 one small case series, 33 and one case study of family-based
treatment for adolescent BN 34 all include parents. Consequently, we do not know
whether family-based strategies will be appropriate for this clinical population,
given that relatively large numbers of patients with BN are not embedded in
intact family structures and single-parent families are significantly more
represented.

These findings have significant nosologic implications. Given that there are
more similarities than differences between patients with BN and patients with
PBN, it seems reasonable not to view PBN as a separate diagnostic entity.
Moreover, as these partial syndrome cases are initially seen with similar
general and eating disorder psychopathologies as their full syndrome counterparts,
except in the cases of OBEs and purge frequency, it makes little sense for
treatment to be any less aggressive for patients with PBN than for patients with
BN. There are clear indications that early recognition and treatment for
adolescent AN 34,35 bodes favorably in terms of treatment outcome. While there
are no published treatment trials available for adolescent BN, it is clinically
feasible to advocate the same degree of urgency for both BN and PBN. For
adolescents with AN, it has been shown that involving parents in weight
restoration can be fruitful in recovery. 30-32 Future research will reveal
whether similar family-based treatment strategies can also be helpful for
adolescents with BN or whether interventions originally designed for adults with
BN (eg, cognitive behavior therapy) will be more useful.

Results from this study are based on a clinical sample and may not generalize to
community samples of adolescent eating disorders. This limitation may be
especially pertinent to the patients with BN and the patients with PBN; while
AN, a visible disease, may be more readily brought to clinical attention, BN
behaviors often remain secretive and undetected for many years. Nevertheless,
these data demonstrate that, at least within a clinical population, BN onsets
for many cases during midadolescence and, similar to AN, pose substantial
psychiatric and medical morbidity. Bulimia nervosa in adolescents seems to be a
disorder in evolution (ie, there is considerable fluidity within and between
diagnostic groups). The likelihood that someone with a subthreshold manifestation
may go on to develop a full-blown syndrome remains a pertinent research
question.

What This Study Adds

There are few reports that describe the clinical manifestation of BN in
adolescents. None of these reports make reference to the comparative manifestation
of adolescents with AN or those who do not meet full criteria for BN. This study
therefore adds to the sparse data on adolescents with BN.

This study provides a description of a large cohort of adolescents with eating
disorders. There are few differences between adolescents with BN and those who
do not meet full criteria for this disorder. Adolescents with BN are quite
distinct from their counterparts with AN both in terms of weight and binge/purge
symptoms as well as demographic variables. Early recognition and swift treatment
of eating disorders in adolescents, regardless of whether a diagnostic threshold
is met, is imperative because they will lead to early intervention thereby
potentially improving eating disorder recovery rates.

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