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Prevalence, incidence, and natural course of anorexia and bulimia nervosa among adolescents and young adults

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Abstract

We aimed to assess the prevalence, incidence, age-of-onset and diagnostic stability of threshold and subthreshold anorexia nervosa (AN) and bulimia nervosa (BN) in the community. Data come from a prospective-longitudinal community study of 3021 subjects aged 14–24 at baseline, who were followed up at three assessment waves over 10 years. Eating disorder (ED) symptomatology was assessed with the DSM-IV/M-CIDI at each wave. Diagnostic stability was defined as the proportion of individuals still affected with at least symptomatic eating disorders (EDs) at follow-ups. Baseline lifetime prevalence for any threshold ED were 2.9 % among females and 0.1 % among males. For any subthreshold ED lifetime prevalence were 2.2 % for females and 0.7 % for males. Symptomatic expressions of EDs (including core symptoms of the respective disorder) were most common with a lifetime prevalence of 11.5 % among females and 1.8 % among males. Symptomatic AN showed the earliest onset with a considerable proportion of cases emerging in childhood. 47 % of initial threshold AN cases and 42 % of initial threshold BN cases showed at least symptomatic expressions of any ED at any follow-up assessment. Stability for subthreshold EDs and symptomatic expressions was 14–36 %. While threshold EDs are rare, ED symptomatology is common particularly in female adolescents and young women. Especially threshold EDs are associated with a substantial risk for stability. A considerable degree of symptom fluctuation is characteristic especially for subthreshold EDs.

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Notes

  1. Definitions of core symptoms for AN and BN were based on the structure of the DIA-X/M-CIDI and its skipping rules. Due to the implementation of skipping rules the DIA-X/M-CIDI does not allow for the assessment of other AN criteria (B–D) independently from AN criterion A. Furthermore, the M-DIA-X/M-CIDI does not allow for assessing other BN criteria (B–E) independently from BN criterion A. Symptomatic AN was defined as AN criterion A (underweight) plus one further AN criterion to ensure that weight loss was not only due to physical complications but also to fear of weight gain or other weight and shape concerns typical for AN.

References

  1. Berkman ND, Lohr KN, Bulik CM (2007) Outcomes of eating disorders: a systematic review of the literature. Int J Eat Disord 40:293–309

    Article  PubMed  Google Scholar 

  2. Hudson JI, Hiripi E, Pope HG, Kessler RC (2007) The prevalence and correlates of eating disorders in the national comorbidity survey replication. Biol Psychiatry 61:348–358

    Article  PubMed  Google Scholar 

  3. Stice E, Marti CN, Shaw H, Jaconis M (2009) An 8-year longitudinal study of the natural history of threshold, subthreshold, and partial eating disorders from a community sample of adolescents. J Abnorm Psychol 118:587–597

    Article  PubMed  PubMed Central  Google Scholar 

  4. Stice E, Marti CN, Rohde P (2012) Prevalence, incidence, impairment, and course of the proposed DSM-5 eating disorder diagnoses in an 8-year prospective community study of young women. J Abnorm Psychol. doi:10.1037/a0030679

    PubMed  PubMed Central  Google Scholar 

  5. Field AE, Sonneville KR, Micali N et al (2012) Prospective association of common eating disorders and adverse outcomes. Pediatrics 130:e289–e295

    Article  PubMed  PubMed Central  Google Scholar 

  6. Striegel-Moore RH (2003) Eating disorders in white and black women. Am J Psychiatry 160:1326–1331

    Article  PubMed  Google Scholar 

  7. Herzog DB, Greenwood DN, Dorer DJ, Flores AT, Ekeblad ER, Richards A, Blais MA, Keller M (2000) Mortality in eating disorders: a descriptive study. Int J Eat Disord 28:20–26

    Article  CAS  PubMed  Google Scholar 

  8. Gustavsson A, Svensson M, Jacobi F et al (2011) Cost of disorders of the brain in Europe 2010. Eur Neuropsychopharmacol 21:718–779

    Article  CAS  PubMed  Google Scholar 

  9. Favaro A (2003) The spectrum of eating disorders in young women: a prevalence study in a general population sample. Psychosom Med 65:701–708

    Article  PubMed  Google Scholar 

  10. Kessler RC, Berglund PA, Chiu WT et al (2013) The prevalence and correlates of binge eating disorder in the World Health Organization World Mental Health Surveys. Biol Psychiatry. doi:10.1016/j.biopsych.2012.11.020

    PubMed Central  Google Scholar 

  11. Wade TD, Bergin JL, Tiggemann M, Bulik CM, Fairburn CG (2006) Prevalence and long-term course of lifetime eating disorders in an adult Australian twin cohort. Aust N Z J Psychiatry 40:121–128

    Article  PubMed  Google Scholar 

  12. Jacobi F, Wittchen H-U, Hölting C, Höfler M, Pfister H, Müller N, Lieb R (2004) Prevalence, co-morbidity and correlates of mental disorders in the general population: results from the German Health Interview and Examination Survey (GHS). Psychol Med 34:597–611

    Article  CAS  PubMed  Google Scholar 

  13. Faravelli C, Ravaldi C, Truglia E, Zucchi T, Cosci F, Ricca V (2006) Clinical epidemiology of eating disorders: results from the Sesto Fiorentino Study. Psychother Psychosom 75:376–383

    Article  CAS  PubMed  Google Scholar 

  14. Kessler RC, Barker PR, Colpe LJ et al (2003) Screening for serious mental illness in the general population. Arch Gen Psychiatry 60:184–189

    Article  PubMed  Google Scholar 

  15. Granillo MT, Grogan-Kaylor A, Delva J, Castillo M (2011) Eating disorders among a community-based sample of Chilean female adolescents. J Res Adolesc 21:762–768

    Article  PubMed  PubMed Central  Google Scholar 

  16. Lewinsohn PM, Striegel-Moore RH, Seeley JR (2000) Epidemiology and natural course of eating disorders in young women from adolescence to young adulthood. J Am Acad Child Adolesc Psychiatry 39:1284–1292

    Article  CAS  PubMed  Google Scholar 

  17. Swanson SA, Crow SJ, Le Grange D, Swendsen J, Merikangas KR (2011) Prevalence and correlates of eating disorders in adolescents: results from the national comorbidity survey replication adolescent supplement. Arch Gen Psychiatry 68:714–723

    Article  PubMed  Google Scholar 

  18. American Psychiatric Association (2000) Diagnostic and statistical manual of mental disorders. Text revision (DSM-IV-TR), 4th edn. American Psychiatric Publishing Inc, Washington DC

    Google Scholar 

  19. Ravens-Sieberer PDU, Kurth B-M, KiGGS Study Group, Bella Study Group (2008) The mental health module (BELLA study) within the German Health Interview and Examination Survey of Children and Adolescents (KiGGS): study design and methods. Eur Child Adolesc Psychiatry 17:10–21

    Article  PubMed  Google Scholar 

  20. Wille DPN, Hölling DPH, Vloet TD, Ravens-Sieberer PDU, Bella Sudy Group (2008) Disordered eating behaviour and attitudes, associated psychopathology and health-related quality of life: results of the BELLA study. Eur Child Adolesc Psychiatry 17:82–91

    PubMed  Google Scholar 

  21. Keel PK, Brown TA (2010) Update on course and outcome in eating disorders. Int J Eat Disord 43:195–204

    Article  PubMed  Google Scholar 

  22. Crow MD, Peterson PD, Swanson SM et al (2009) Increased mortality in bulimia nervosa and other eating disorders. Am J Psychiatry 166:1342–1346

    Article  PubMed  Google Scholar 

  23. Fichter MM, Quadflieg N, Hedlund S (2006) Twelve-year course and outcome predictors of anorexia nervosa. Int J Eat Disord 39:87–100

    Article  PubMed  Google Scholar 

  24. Fichter MM, Quadflieg N (2004) Twelve-year course and outcome of bulimia nervosa. Psychol Med 34:1395–1406

    Article  PubMed  Google Scholar 

  25. Herzog DB, Dorer DJ, Keel PK, Sewlwyn SE, Ekeblad E, Flores A, Greenwood DN, Burwell R, Keller MB (1999) Recovery and relapse in anorexia and bulimia nervosa: a 7.5-year follow-up study. J Am Acad Child Adolesc Psychiatry 38:829–837

    Article  CAS  PubMed  Google Scholar 

  26. Löwe B, Zipfel S, Buchholz C, Dupont Y, Reas DL, Herzog W (2001) Long-term outcome of anorexia nervosa in a prospective 21-year follow-up study. Psychol Med 31:881–890

    Article  PubMed  Google Scholar 

  27. Agras WS, Crow S, Mitchell JE, Halmi K, Bryson S (2009) A 4-year prospective study of eating disorder NOS compared with full eating disorder syndromes. Int J Eat Disord 42:565–570

    Article  PubMed  PubMed Central  Google Scholar 

  28. Bohon C, Stice E, Burton E (2009) Maintenance factors for persistence of bulimic pathology: a prospective natural history study. Int J Eat Disord 42:173–178

    Article  PubMed  PubMed Central  Google Scholar 

  29. Fairburn CG, Cooper Z, Doll HA, Norman P, O’Connor M (2000) The natural course of bulimia nervosa and binge eating disorder in young women. Arch Gen Psychiatry 57:659–665

    Article  CAS  PubMed  Google Scholar 

  30. Grilo CM, Pagano ME, Skodol AE, Sanislow CA, McGlashan TH, Gunderson JG, Sout RL (2007) Natural course of bulimia nervosa and of eating disorder not otherwise specified: 5-year prospective study of remissions, relapses, and the effects of personality disorder psychopathology. J Clin Psychiatry 68:738–746

    Article  PubMed  PubMed Central  Google Scholar 

  31. Couturier J, Lock J (2006) What is recovery in adolescent anorexia nervosa? Int J Eat Disord 39:550–555

    Article  PubMed  Google Scholar 

  32. Couturier J, Lock J (2006) What is remission in adolescent anorexia nervosa? A review of various conceptualizations and quantitative analysis. Int J Eat Disord 39:175–183

    Article  PubMed  Google Scholar 

  33. Keel PK, Baxter MG, Heatherton TF, Joiner TE (2007) A 20-year longitudinal study of body weight, dieting, and eating disorder symptoms. J Abnorm Psychol 116:422–432

    Article  PubMed  Google Scholar 

  34. Fairburn CG, Bohn K (2005) Eating disorder NOS (EDNOS): an example of the troublesome “not otherwise specified” (NOS) category in DSM-IV. Behav Res Ther 43:691–701

    Article  PubMed  PubMed Central  Google Scholar 

  35. Fairburn CG, Cooper Z, Bohn K, O’Connor ME, Doll HA, Palmer RL (2007) The severity and status of eating disorder NOS: implications for DSM-V. Behav Res Ther 45:1705–1715

    Article  PubMed  PubMed Central  Google Scholar 

  36. Fitzgibbon ML, Sánchez-Johnsen LA, Martinovich Z (2003) A test of the continuity perspective across bulimic and binge eating pathology. Int J Eat Disord 34:83–97

    Article  PubMed  Google Scholar 

  37. Schmidt U, Lee S, Perkins S et al (2008) Do adolescents with eating disorder not otherwise specified or full-syndrome bulimia nervosa differ in clinical severity, comorbidity, risk factors, treatment outcome or cost? Int J Eat Disord 41:498–504

    Article  PubMed  Google Scholar 

  38. American Psychiatric Association (2013) Diagnostic and statistical manual of mental disorders: Dsm-5. American Psychiatric Publishing Inc, Washington DC

    Book  Google Scholar 

  39. Wittchen H-U, Perkonigg A, Lachner G, Nelson CB (1998) Early developmental stages of psychopathology study (EDSP): objectives and design. Eur Addict Res 4:18–27

    Article  CAS  PubMed  Google Scholar 

  40. Lieb R, Isensee B, von Sydow K, Wittchen H-U (2000) The early developmental stages of psychopathology study (EDSP): a methodological update. Eur Addict Res 6:170–182

    Article  CAS  PubMed  Google Scholar 

  41. Beesdo-Baum K, Knappe S, Asselmann, E, et al. The “Early Developmental Stages of Psychopathology (EDSP) study”: A 20 years review of methods and findings. Soc Psychiatry Psychiatr Epidemiol in press

  42. Wittchen H-U, Nelson CB, Lachner G (1998) Prevalence of mental disorders and psychosocial impairments in adolescents and young adults. Psychol Med 28:109–126

    Article  CAS  PubMed  Google Scholar 

  43. Wittchen H-U, Pfister H (1997) DIA-X-Interviews: Manual für Screening-Verfahren und Interview; Interviewheft Längsschnittuntersuchung (DIA-X-Lifetime); Ergänzungsheft (DIA-X- Lifetime); Interviewheft Querschnittsuntersuchung (DIA-X-12 Monate); Ergänzungsheft (DIA-X-12 Monate); PD-Programm zur Durchfürhung des Interviews (Längs- und Querschnittuntersuchung); Auswertungsprogramm. Swetz & Zeitlinger, Frankfurt

  44. World Health Organization (1990) Composite International Diagnostic Interview (CIDI): a. CIDI-interview (version 1.0), b. CIDI-user manual, c. CIDI-training manual, d. CIDI-computer programs. World Health Organization, Geneva

  45. Wittchen H-U, Lachner G, Wunderlich U, Pfister H (1998) Test-retest reliability of the computerized DSM-IV version of the Munich-Composite International Diagnostic Interview (M-CIDI). Soc Psychiatry Psychiatr Epidemiol 33:568–578

    Article  CAS  PubMed  Google Scholar 

  46. Kromeyer-Hauschild K, Wabitsch M, Kunze D et al (2001) Perzentile für den Body-mass-Index für das Kindes-und Jugendalter unter Heranziehung verschiedener deutscher Stichproben. Monatsschr Kinderheilkd 149:807–818

    Article  Google Scholar 

  47. Hebebrand J, Himmelmann GW, Heseker H, Hesker H, Schäfer H, Remschmidt H (1996) Use of percentiles for the body mass index in anorexia nervosa: diagnostic, epidemiological, and therapeutic considerations. Int J Eat Disord 19:359–369

    Article  CAS  PubMed  Google Scholar 

  48. Fisher M, Schneider M, Burns J, Symons H, Mandel FS (2001) Differences between adolescents and young adults at presentation to an eating disorders program. J Adolesc Health 28:222–227

    Article  CAS  PubMed  Google Scholar 

  49. Kordy H, Krämer B, Palmer RL, Papezaova H, Pellet J, Richard M, Trasure J, Action COST, COST Action B6 (2002) Remission, recovery, relapse, and recurrence in eating disorders: conceptualization and illustration of a validation strategy. J Clin Psychol 58:833–846

    Article  PubMed  Google Scholar 

  50. Wittchen H-U, Lieb R, Schuster P, Oldehinkel AJ (1999) When is onset? Investigations into early developmental stages of anxiety and depressive disorders. In: Rapoport JL (ed) Childhood Onset of “Adult” Psychopathology: Clinical and Research Advances. American Psychiatric Press, Washington, DC, pp 259–302

    Google Scholar 

  51. Beesdo K, Bittner A, Pine DS, Stein MB, Höfler M, Lieb R, Wittchen H-U (2007) Incidence of social anxiety disorder and the consistent risk for secondary depression in the first three decades of life. Arch Gen Psychiatry 64:903–912

    Article  PubMed  Google Scholar 

  52. Beesdo K, Pine DS, Lieb R, Wittchen H-U (2010) Incidence and risk patterns of anxiety and depressive disorders and categorization of generalized anxiety disorder. Arch Gen Psychiatry 67:47–57

    Article  PubMed  Google Scholar 

  53. Tozzi F, Thornton LM, Klump KL et al (2005) Symptom fluctuation in eating disorders: correlates of diagnostic crossover. Am J Psychiatry 162:732–740

    Article  PubMed  Google Scholar 

  54. StataCorp (2012) Stata statistical software: release 12.1. Stata Corporation, College Station

  55. Royall RM (1986) Model robust confidence intervals using maximum likelihood estimators. Int Stat Rev Int Stat 54:221–226

    Article  Google Scholar 

  56. Thornton C, Russell J, Hudson J (1998) Does the Composite International Diagnostic Interview underdiagnose the eating disorders? Int J Eat Disord 23:341–345

    Article  CAS  PubMed  Google Scholar 

  57. Ohlmer R, Jacobi C, Fittig E (2012) Diagnosing underweight in adolescent girls: should we rely on self-reported height and weight? Eat Behav 13:1–4

    Article  PubMed  Google Scholar 

  58. Strother E, Lemberg R, Stanford SC, Turberville D (2012) Eating disorders in men: underdiagnosed, undertreated, and misunderstood. Eat Disord 20:346–355

    Article  PubMed  PubMed Central  Google Scholar 

  59. Killen JD, Taylor CB, Hayward C, Haydel KF, Wilson DM, Hammer L, Kraemer H, Blair-Greiner A, Strachowski D (1996) Weight concerns influence the development of eating disorders: a 4-year prospective study. J Consult Clin Psychol 64:936–940

    Article  CAS  PubMed  Google Scholar 

  60. Mikolajczyk RT, Richter M (2008) Associations of behavioural, psychosocial and socioeconomic factors with over- and underweight among German adolescents. Int J Public Health 53:214–220

    Article  PubMed  Google Scholar 

  61. Neumark-Sztainer D, Hannan PJ (2000) Weight-related behaviors among adolescent girls and boys: results from a national survey. Arch Pediatr Adolesc Med 154:569–577

    Article  CAS  PubMed  Google Scholar 

  62. Swanson SA, Brown TA, Crosby RD, Keel PK (2014) What are we missing? The costs versus benefits of skip rule designs. Int J Methods Psychiatr Res 23:474–485

    Article  PubMed  Google Scholar 

  63. Jacobi C, Fittig E, Bryson SW, Bryson SW, Wilfey D, Kraemer HC, Taylor CB (2011) Who is really at risk? Identifying risk factors for subthreshold and full syndrome eating disorders in a high-risk sample. Psychol Med 41:1939–1949

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  64. Jacobi C, Hayward C, de Zwaan M, Kraemer HC, Agras WS (2004) Coming to terms with risk factors for eating disorders: application of risk terminology and suggestions for a general taxonomy. Psychol Bull 130:19–65

    Article  PubMed  Google Scholar 

  65. Taylor CB, Sharpe T, Shisslak C, Bryson S, Estes LS, Gray N, McKnight KM, Crago M, Kraemer HC, Killen JD (1998) Factors associated with weight concerns in adolescent girls. Int J Eat Disord 24:31–42

    Article  CAS  PubMed  Google Scholar 

  66. Ben-Tovim DI, Walker K, Gilchrist P, Freeman R, Kalucy R, Esterman A (2001) Outcome in patients with eating disorders: a 5-year study. The Lancet 357:1254–1257

    Article  CAS  Google Scholar 

  67. Telch CF, Stice E (1998) Psychiatric comorbidity in women with binge eating disorder: prevalence rates from a non-treatment-seeking sample. J Consult Clin Psychol 66:768–776

    Article  CAS  PubMed  Google Scholar 

  68. Jacobi C, Völker U, Trockel MT, Taylor CB (2012) Effects of an Internet-based intervention for subthreshold eating disorders: a randomized controlled trial. Behav Res Ther 50:93–99

    Article  PubMed  Google Scholar 

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Acknowledgments

This work is part of the Early Developmental Stages of Psychopathology (EDSP) Study and is funded by the German Federal Ministry of Education and Research (BMBF) Project No. 01EB9405/6, 01 EB 9901/6, EB01016200, 01EB0140 and 01EB0440. Part of the field work and analyses were also additionally supported by grants of the Deutsche Forschungsgemeinschaft (DFG) LA1148/1-1, WI2246/1-1, WI 709/7-1 and WI 709/8-1. Furthermore, the research leading to these results has received funding from the European Community’s Seventh Framework Programme (FP7/2007-2013) under Grant Agreement No. 245009. Principal investigators are Dr. Hans-Ulrich Wittchen and Dr. Roselind Lieb. Core staff members of the EDSP group are Dr. Kirsten von Sydow, Dr. Gabriele Lachner, Dr. Axel Perkonigg, Dr. Peter Schuster, Dr. Michael Höfler, Dipl.-Psych. Holger Sonntag, Dr. Tanja Brückl, Dipl.-Psych. Elzbieta Garczynski, Dr. Barbara Isensee, Dr. Agnes Nocon, Dr. Chris Nelson, Dipl.-Inf. Hildegard Pfister, Dr. Victoria Reed, Dipl.-Soz. Barbara Spiegel, Dr. Andrea Schreier, Dr. Ursula Wunderlich, Dr. Petra Zimmermann, Dr. Katja Beesdo-Baum, Dr. Antje Bittner, Dr. Silke Behrendt and Dr. Susanne Knappe. Scientific advisors are Dr. Jules Angst (Zurich), Dr. Jürgen Margraf (Basel), Dr. Günther Esser (Potsdam), Dr. Kathleen Merikangas (NIMH, Bethesda), Dr. Ron Kessler (Harvard, Boston) and Dr. Jim van Os (Maastricht).

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Supplementary material 1 (PDF 169 kb) ESM_1: Table ST1.1. Operationalization in the DSM-IV/M-CIDI criteria for eating disorders

Supplementary material 2 (PDF 428 kb) ESM_2: Tables ST2.1 to 2.7. Dropout analyses

Supplementary material 3 (PDF 261 kb) ESM_3: Tables ST3.1 to 3.3. Sensitivity analyses

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Nagl, M., Jacobi, C., Paul, M. et al. Prevalence, incidence, and natural course of anorexia and bulimia nervosa among adolescents and young adults. Eur Child Adolesc Psychiatry 25, 903–918 (2016). https://doi.org/10.1007/s00787-015-0808-z

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