[Predictive factors in social adaptation disorders in anorexic and bulimic patients]

A lifetime diagnosis of at least one anxiety disorder has been found in 13% to 75% of women with BN (Herzog, Keller, Sacks, Yeh, & Lavori, 1992; Schwalberg, Barlow, Alger, & Howard, 1992), and in 20% to 55% of women with AN, (Herzog et al., 1992, Laessle et al., 1989). Wittchen et al., 1998) have observed that the frequency and degree of disabilities and impairments associated with mental disorders in adolescence are strongly related to comorbidity (notably with anxiety disorders). However, as noted by Wonderlich et al., 1997, no study has compared ED individuals with and without comorbid anxiety disorders in terms of clinical or general functioning. The current study was designed to determine whether social avoidance symptoms and/or comorbid lifetime anxiety disorders were predictive factors of social disability in subjects with ED (AN or BN). We focused on two main dimensions of social adaptation, regarding social and professional life. 63 subjects with anorexia nervosa or bulimia nervosa were assessed for lifetime diagnoses of anxiety disorders, childhood history of separation anxiety disorder, social avoidance symptoms, and social disability. Sociodemographic characteristics, lifetime diagnoses of ED and anxiety disorders, and ages at onset of each disorder present, were assessed using the French version of the Composite International Diagnostic Interview (CIDI) (Robins et al., 1988; WHO, 1990). In addition, childhood history of separation anxiety disorder, not included in the CIDI, was assessed using the appropriate section of the Schedule for Schizophrenia and Affective Disorders Lifetime Version--Modified for the study of Anxiety Disorders (SADS-LA-R) (Endicott, Spitzer, 1978; Mannuzza, Fyer, Klein, 1985). Social anxiety symptoms were measured on Liebowitz Social Phobia Scale (Liebowitz, 1987). Social adjustment was assessed using a semi-structured interview, the Groningen Social Disabilities Schedule-Second version (GSDS-II) (Wiersma, De Jong, Ormel, & Kraaij Kamp, 1990). For each of the two outcome variables regarding disability, the Social role and the Occupational role, all subsets logistic regression analysis was performed in accordance to Hosmer and Lemeshow's guidelines (Hosmer and Lemeshow, 1989). Our total sample of 63 subjects included 29 subjects with AN restricting type (27 women, 2 men; 7% with a past history of BN) and 34 subjects with BN purging type (all women; 53% with history of a previous episode of AN). On the Groningen Social Disabilities Schedule, 86% of the anorexics and 65% of the bulimics had disability regarding the "social role", and 86% and 61%, respectively, disability regarding the "occupational role". Using all subsets logistic regression analyses, predictive factors of disability were: 1) for the social role, social avoidance symptom score (p < 0.002) and diagnosis of separation anxiety disorder (p < 0.01); 2) for the occupational role, number of lifetime anxiety disorders (p < 0.01) and diagnosis of separation anxiety disorder (p < 0.06). The present study clearly demonstrates that social avoidance and anxiety disorders are common and important features in the clinical presentation of subjects with AN or BN, and that they can have a negative impact on both their social and their occupational adaptation. Chronicity is a major risk in the ED, in terms of medical and sometimes lethal complications, but also because of the social consequences of these disorders. It is therefore important, in subjects with ED, to identify comorbid conditions linked to social disability, in order to improve global outcome. Recognizing and treating comorbid anxiety disorders in subjects with AN or BN could give better results than treating only the ED, in terms of social as well as global psychopathological outcome.