Behac. Res. Ther. Vol. 29, No. 2, pp, 113-116, 1991 Printed in Great Britain. 411 rights reserved
Copyright
OBSESSIVE-COMPULSIVE SYMPTOMS DISORDERS
0005-7967191 $3.00 + 0.00 c’ 1991 Pergamon Press plc
IN EATING
THOMASA. FAHY Institute
of Psychiatry,
De Crespigny
Park,
Denmark
(Received 20 September
Hill, London
SE5 8AF, England
1990)
Summary-Obsessive-compulsive symptoms were measured in a consecutive series of new referrals with anorexia nervosa (n = 29) and bulimia nervosa (rt = 77). In contrast with previous reports, there was no significant difference on MOCI scores between eating disorder groups and normal controls. A consecutive series of 38 patients with bulimia nervosa then entered a structured treatment programme. Poor outcome cases had a higher score on the MOCI-doubting sub-scale. However, there was no significant difference in obsessive-compulsive scores between those who were binge-free and those who were bingeing daily at the end of treatment and there was no significant in outcome between high and low-scorers on the MOCI. This study fails to support the view that the eating disorders are a subtype of OCD. Previous conflicting results are attributed to selection bias and the effects of low body weight.
An
overlap between the psychopathological features of anorexia nervosa and obsessional-compulsive disorder (OCD), long noted by clinicians (Palmer & Jones, 1939; DuBois, 1949), is also suggested by psychometric investigations using standardised instruments to measure obsessionality. On the Leyton Obsessional Inventory (LOI) anorectics’ symptom scores fall between normals and OCD patients (Smart, Beumont & George, 1976; Solyom, Freeman & Miles, 1982). Solyom et al. (1982) found that approximately half of their patients qualified for a diagnosis of OCD based on non-food and body-related symptoms. Similarly, a high rate of past anorexia nervosa (11 “A) has been reported in a series of 151 female OCD patients (Kasvikis Tsakiris, Marks, Basoglu & Noshirvani, 1986), although there is little evidence that OCD patients have higher average Eating Attitudes Test scores than other neurotic patients (Joffe & Swinson, 1987). In the most detailed review of the evidence to date, Holden (1990) concludes that there is some overlap between the phenomenology of anorectic and obsessional symptoms, that obsessional personality traits are over-represented in those with anorexia nervosa and that such symptoms may be exacerbated by starvation (Garfinkel & Garner, 1982). However, he also argues that the anorectic’s preoccupations with food, weight and body shape are unlike obsessive ruminations in that they are typically ego syntonic, they are not usually resisted and they frequently give rise to considerable feelings of pleasure. In addition to raising interesting nosological issues, the question of a relationship between anorexic and obsessional symptoms may be of immediate clinical relevance. Halmi, Broadland and Loney (1973) found that very poor outcome anorexics had more obsessive-compulsive traits on clinical assessment, whereas Stonehill and Crisp (1977) reported that poor outcome cases had significantly higher obsessionality scores on the Middlesex Hospital Questionnaire. The relationship of obsessional symptoms to the phenomenology and outcome of bulimia nervosa is poorly understood. Anorexics with bulimic symptoms have fewer obsessional symptoms (Beumont, 1977) and have marginally lower obsessionality scores than restrictors (Beumont, 1977; Solyom et al., 1982; Stonehill & Crisp, 1977). ‘Bulimic-anorexics’ also have lower LO1 resistance scores (Solyom et al., 1982). In a study of normal weight bulimics, Johnson and Holloway (1988) found them to have lower LOI scores than ‘bulimic-anorectics’, but both groups scored higher than controls. METHOD This study had two main aims, firstly to record the severity of obsessive-compulsive symptoms in different types of eating disorders and secondly to assess the influence of obsessive-compulsive symptoms on the outcome of treatment of bulimia nervosa. 113
All new referrals to the Maudsley Hospital Eating Disorder Clinic were asked to complete the following assessments: The Muudsley Obsessive-~~~pulsiz)~ Inoentory (MOCI). This 30 item questionnaire records the existence of different obsessional-compulsive complaints and gives subscores for four types of complaints; checking, washing, slowness/repetition and doubting/conscientiousness (Hodgson & Rachman, 1977; Sternberger & Burns, 1990). The questionnaire effectively distinguishes obsessional from non-obsessional neurotics, it has good test-retest reliability and the total score correlates significantly (0.6) with the Leyton Symptom Score. Control data were obtained from norms established for a non-student sample by Dent and Salkovskis (1986). The Eating Attitudes Test (EAT) (Garner & Garfinkel, 1979), measures the symptoms of anorexia nervosa, The ~~~~~~~~~~~~~~~~g~~~~~~ Test (BITE) (Henderson & Freeman, 1987), measures bulimic symptomato~ogy and behaviaur. After a thorough clinical assessment, DSM-11 IR diagnoses (APA, 1985) were established and those with anorexia nervosa (N t= 29) or bulimia nervosa (n = 77) were entered into this study. Bulimic patients who had a previous history of anorexia nervosa (n = 23) were identified as it was hypothesised that these patients would have higher obsessionality scores than other bulimics. A consecutive series of 38 patients with bulimia nervosa then entered a structured treatment programme. These patients were asked to complete food diaries, in which they entered details of all food consumed during the course of treatment. Binges and self-induced vomiting were recorded on the self-monitoring sheets. After a 2 week assessment period, patients entered an 8 week course of cognitive-~hav~our thereapy, an abbreviated form of the treatment described by Fairburn (1985). Changes in binge frequency during treatment were derived from the food diaries. RESULTS The MOCI-total and subscale scores were derived for 29 anorexics, 44 bulimics and 23 bulimics with a history of anorexia. These scores were compared with normative data on 36 patients by Dent and Salkovskis (1986). One-way analysis of variance with Scheffe’s procedure revealed no significant differences in obsessive-compulsive scores between eating disorder groups (Table I). t-Tests comparing the eating disorder groups with the normal sample revealed no significant differences. On the EAT score, the bulimic patients with a previous history of anorexia had a higher score than the anorexics (P = 0.007), but there were no significant differences between other groups. On the BITE-severity and symptom scores, both bulimic groups had sign~~cant~y higher scores than the anorexic group (P < O.OOl), but the difference between bulimic subgroups feel1short of significance. The relevance of obsessive-compulsive symptoms in treatment response of bulimic patients was assessed by comparing patients with good and poor treatment outcome (Table 2). Good outcome Fable
I. Obsessinnality
(MOCI)
Anonxia ~RW”SI+ (2% ~_-________ SD X Tail Chxking Cleaning SlOWtleSs Doubting Age BITE Severity
swres
7.4 2.0 1.6 2.9 2.9 24.5
(4.8) (2.2) (1.4) (1.1)
4.3
(4.8)
15.9
(7.8) (18.3)
BITE Symptom
15.0
EAT
45.4
*Data from Dent and Salkovskis
and age of eating disnrdcr
Bulimia nervosa with previous anorexia nervosa (23) _-__--__ X SD 1.3 2.0 I.6 2.9 3.2 23.9
(5.3) (2.0) (1.7) (0.9)
(1W
patients
Bulimia nervosil (44) --.. .._,l_l____ X SD 7.0 2.0 I.6 2.6
2.9
(3.8) (1.7) (1,4) (1.0)
(1.9)
(3.7)
24.5
(4.8)
(4.2)
13.7
(5.2)
24.8
(3.9)
24.2
(S.5)
59.4
(15.2)
50.5
(17.5)
(19861, non-student
sample.
and controls
--__
Controls* (36) llill x SD
5.9 1.5 1.3 2.6 2.4 2X.6
0.5) ft.41 (1.5) (1.2) (1-l) (12.9)
Obsessive-compulsive symptoms Table 2. MOCI score of bulimics Good
115
with good and poor response
outcome’ n = 17
to treatment
Poor outcome n =21 I-Test
MOCI
scores
X
Total Checking Washing Slowness Doubting
5.0 I.3 1.4 2.6 2.3
SD
X
(3.4) (1.6) (1.1) (1.0) (1.4)
1.6 1.9 1.8 2.8 3.5
SD
P
(5.1) (1.7) (1.8) (0.8) (1.7)
0.082 0.257 0.389 0.667 0.025
*Good outcome = two binge-vomit episodes or less during the final 2 weeks of treatment. Poor outcome = more than two binge-vomit episodes. Table 3. Clinical and psychometric features of bulimics with excellent or very poor outcome after treatment Measures at start of treatment MOC MOCCH MOCL MOCS MOCD EAT BITE symptom BITE severity
Asymptomatic n=8
Table 4. Outcome
Daily bingeing n = IO
Binge frequency at start of treatment
r-Test X
SD
X
SD
5.0 1.5 1.7 2.6 2.2 55.5
(4.3) (1.2) (1.4) (0.9) (1.5) (21.7)
7.3 1.6 1.4 2.5 3.5 60.1
(3.9) (1.6) (1.1) (0.5) (1.6) (14.4)
0.26 I 0.880 0.568 0.738 0.105 0.617
25.6
(2.8)
25. I
(4.8)
0.777
13.0
(5.0)
16.1
(4.2)
0.182
P
of patients with high (MOCI-total normal obsessionality scores
210)
Binge change during treatment
Total-MOCI
X
SD
X
SD
MOCI > 7 @=I6 MOCI < 7 n = 22
9.1
(7.4)
3.6
(7.2)
(11.2)
7.7
13.0 0.2916
P*
MOCI > IO n=9 MOCI < IO n = 29
7.4 12.5 0.1304
P*
*Mann-Whitney
and
(9.0) 0.341 I
(5.7)
2.3
(10.6)
7.1
(8.5) (8.2) 0.4959
U-Test.
was defined as less than four binge-vomit episodes during the final 2 weeks of treatment (n = 17, 45%) poor outcome was defined as four or more episodes (n = 21, 55%). Poor outcome cases had higher MOCI-total scores (P = 0.082) and significantly higher scores on the doubting sub-score (P = 0.025). The MOCI scores of patients with the best and worst outcome were also compared (Table 3). There was no significant difference in obsessive-compulsive scores between those who were binge-free (n = 8, 21%) and those who were bingeing daily (n = 10, 26%) at the end of treatment. Differences in outcome could not be accounted for by differences in severity of symptoms at the start of treatment, as measured by EAT and BITE scores. The outcome of the subgroup of bulimics with high MOCI scores was then compared with normal scorers. On a normal sample (Dent & Salkovskis, 1986), 95% confidence limits for total-MOCI are between 4.7 and 7.0. The outcome of cases with MOCI-total scores of 3 7 (n = 16), and 3 10 (n = 9) was compared with low-scorers (Table 4). The average binge frequency was lower in high scorers at the start of treatment and these patients had lower average improvement in bingeing during treatment. DISCUSSION
This study fails to support the view that anorexia nervosa is a subtype of OCD. Obsessive-compulsive complaints were more common in patients with eating disorders than normal controls or other non-obsessional neurotics (Hodgson & Rachman, 1977). The MOCI scores of eating disorder patients in this study are consistent with those recorded by Weiss and Ebert (1983) in a group of 15 bulimics. The MOCI also failed to distinguish between anorexics and bulimics, although previous reports have found differences using the LOI. The absence of a significant difference between eating disorder cases and normals may reflect the absence of a selection bias in this study, which included consecutive new referrals to the outpatients department. Previous studies have recruited some or all Ss from inpatient units (Smart et al., 1976; Beumont, 1977), and are therefore likely to include more patients with severe illnesses and other psychiatric disorders. Further evidence that high obsessive-compulsive scores may reflect selection bias comes from Channon and DeSilva’s study of anorexic inpatients (1985). In this sample of 45 low weight patients, average total-MOCI score was higher than for anorexics in the current study
THOMAS A. FAHK
116
(9.9 SD = 8.09 vs 7.4 SD = 4.8).After
treatment and weight restoration, there was a significant reduction in MOCI scores (9.7 SD = 7.22) to a level comparable to the current study. These lower scores were maintained at 1 yr follow-up. The combination of weight and shape related cognitive distortions and obsessional rigidity may perpetuate bulimia. Alternatively, obsessionality may be central to the genesis of the disorder by exaggerating conceptual simplicity and concreteness. This view is partially supported by the results of Johnson and Holloway (1988) who found that a group of 15 bulimics were characterised by high scores on the LOI, but low scores on standardised tests which are purported to measure conceptual organisation, including the ability to perform tasks which require abstract, independent and relativistic processing of information in social situations. It is not clear if such impaired conceptual organisation is allied with the distorted cognitions which are addressed in cognitive therapy, but if this is the case, those patients with high obsessionality scores may have severe illnesses which are especially resistant to treatment. However, patients with high MOCI scores in this study did not show a tendency towards greater severity of bingeing; indeed the opposite effect is suggested by the results presented in Table 4. High obsessional symptom scores are present in a minority of cases where they may reflect low body weight and coincidental psychopathology. However, high MOCI scores do not predict poor response to treatment, a finding which has also been demonstrated in anorexia nervosa (Channon & de Silva, 1985). AcknoM,/e~lRements-I am very grateful
to W. P. de Silva, I. Eisler and Professor
G. Russell.
REFERENCES American Psychiatric Association (1985). DSM-IIIR in deoeloptnenr. Washington, D.C.: American Psychiatric Press. Beumont, P. J. V. (1977). Further categorization of patients with anorexia nervosa. Australian and New Zealand Journal of P.vychiarry, 11, 223-226. Channon, S. & de Silva, W. P. (1985). Psychological correlates of weight gain in patients anorexia nervosa. Journul of Psychiatric Research, 19, 267-27 I. Cooper, J. (1970). The Leyton Obsessional Inventory. Psychological Medicine, I, 48-64. Dent, H. R. & Salkovskis. P. M. (1986). Clinical measures of depression and obsessionality in non-clinical populations. Behaciour Research and Therapy, 24, 689491. DuBois, F. (1949). Compulsion neurosis with cachexia (anorexia nervosa). American Journal of Psychiatry. 106, 107-I 15. Fairburn, C. (1985). Cognitive behavioural treatment for bulimia. In Garner, D. M. & Garfinkel, P. E. (Eds), Handbook of psycholherapy for anorexia nercosa and bulimia. New York: Guilford Press. Garner, D. M. & Garfinkel, P. E. (1979). The eating attitudes test: An index of the symptoms of anorexia nervosa. Psychological Medicine, 9, 213S219. Halmi, K., Brodland, G. & Loney, J. (1973). Prognosis in anorexia nervosa. Annals of Internal Medicine, 78, 907-909. Henderson, M. & Freeman, C. P. L. (1987). A self-rating scale for bulimia. The Bite. British Journal of Psychiatry, 150. 18-24. Hodgson, R. J. & Rachman, S. (1977). Obsessional-compulsive complaints. Behauiour Research and Therapy, 1.5, 389-395. Holden, N. (1990). Is anorexia nervosa an obsessive-compulsive disorder? British Journal of Psychiatry, 157, l--5. Joffe. R. T. & Swinson, R. P. (1987). Eating attitudes test scores of patients with obsessive-compulsive disorder. American Journal qf Ps)~chialry, 144, 15 IO-1 5 1 I. Johnson, N. S. & Holloway, E. L. (1988). Conceptual complexity and obsessionality in bulimic women, Journal qf Counseiling Psychology, 35. 251-257. Kasvikis, Y. G., Tsakiris, F., Marks, 1. M., Basoglu, M. & Noshirvani, H. F. (1986). Past history of anorexia nervosa in women with obsessive compulsive disorder. Internarional Journal of Eating Disorders, 5, 1069S1075. Palmer, D. H. & Jones, S. M. (1939). Anorexia nervosa as a manifestation of compulsive neurosis. Archirres qf Neurology and Psychiatry, 41, 856-960. Smart, D. E., Beumont, P. J. V. & George, G. C. W. (1976). Some personality characteristics of patients with anorexia nervosa. Brifish Journal of Psychiatry, 128, 5760. Solyom, L., Freeman, R. & Miles, J. E. (1982). A comparative psychometric study of anorexia nervosa and obsessive neurosis. Canadian Journal of Psychiatry, 27, 282-286. Sternberger, L. G. & Burns, G. L. (1990). Compulsive activity checklist and the Maudsley Obsessional-Compulsive Inventory: Psychometric properties of the two measures of obsessive-compulsive disorder. Behaoiour Therapy. 21, 117-127. Stonehill, E. & Crisp, A. H. (1977). Psychoneurotic characteristics of patients with anorexia nervosa before and after treatment and at follow-up 4-7 years later. Journal of Psychosomatic Research, 21, 187-193. Weiss, S. R. & Ebert, M. H. (1983). Psychological and behavioural characteristics of normal-weight bulimics and normal-weight controls. Psychosomatic Medicine, 45, 293-303.
Copyright
OBSESSIVE-COMPULSIVE SYMPTOMS DISORDERS
0005-7967191 $3.00 + 0.00 c’ 1991 Pergamon Press plc
IN EATING
THOMASA. FAHY Institute
of Psychiatry,
De Crespigny
Park,
Denmark
(Received 20 September
Hill, London
SE5 8AF, England
1990)
Summary-Obsessive-compulsive symptoms were measured in a consecutive series of new referrals with anorexia nervosa (n = 29) and bulimia nervosa (rt = 77). In contrast with previous reports, there was no significant difference on MOCI scores between eating disorder groups and normal controls. A consecutive series of 38 patients with bulimia nervosa then entered a structured treatment programme. Poor outcome cases had a higher score on the MOCI-doubting sub-scale. However, there was no significant difference in obsessive-compulsive scores between those who were binge-free and those who were bingeing daily at the end of treatment and there was no significant in outcome between high and low-scorers on the MOCI. This study fails to support the view that the eating disorders are a subtype of OCD. Previous conflicting results are attributed to selection bias and the effects of low body weight.
An
overlap between the psychopathological features of anorexia nervosa and obsessional-compulsive disorder (OCD), long noted by clinicians (Palmer & Jones, 1939; DuBois, 1949), is also suggested by psychometric investigations using standardised instruments to measure obsessionality. On the Leyton Obsessional Inventory (LOI) anorectics’ symptom scores fall between normals and OCD patients (Smart, Beumont & George, 1976; Solyom, Freeman & Miles, 1982). Solyom et al. (1982) found that approximately half of their patients qualified for a diagnosis of OCD based on non-food and body-related symptoms. Similarly, a high rate of past anorexia nervosa (11 “A) has been reported in a series of 151 female OCD patients (Kasvikis Tsakiris, Marks, Basoglu & Noshirvani, 1986), although there is little evidence that OCD patients have higher average Eating Attitudes Test scores than other neurotic patients (Joffe & Swinson, 1987). In the most detailed review of the evidence to date, Holden (1990) concludes that there is some overlap between the phenomenology of anorectic and obsessional symptoms, that obsessional personality traits are over-represented in those with anorexia nervosa and that such symptoms may be exacerbated by starvation (Garfinkel & Garner, 1982). However, he also argues that the anorectic’s preoccupations with food, weight and body shape are unlike obsessive ruminations in that they are typically ego syntonic, they are not usually resisted and they frequently give rise to considerable feelings of pleasure. In addition to raising interesting nosological issues, the question of a relationship between anorexic and obsessional symptoms may be of immediate clinical relevance. Halmi, Broadland and Loney (1973) found that very poor outcome anorexics had more obsessive-compulsive traits on clinical assessment, whereas Stonehill and Crisp (1977) reported that poor outcome cases had significantly higher obsessionality scores on the Middlesex Hospital Questionnaire. The relationship of obsessional symptoms to the phenomenology and outcome of bulimia nervosa is poorly understood. Anorexics with bulimic symptoms have fewer obsessional symptoms (Beumont, 1977) and have marginally lower obsessionality scores than restrictors (Beumont, 1977; Solyom et al., 1982; Stonehill & Crisp, 1977). ‘Bulimic-anorexics’ also have lower LO1 resistance scores (Solyom et al., 1982). In a study of normal weight bulimics, Johnson and Holloway (1988) found them to have lower LOI scores than ‘bulimic-anorectics’, but both groups scored higher than controls. METHOD This study had two main aims, firstly to record the severity of obsessive-compulsive symptoms in different types of eating disorders and secondly to assess the influence of obsessive-compulsive symptoms on the outcome of treatment of bulimia nervosa. 113
All new referrals to the Maudsley Hospital Eating Disorder Clinic were asked to complete the following assessments: The Muudsley Obsessive-~~~pulsiz)~ Inoentory (MOCI). This 30 item questionnaire records the existence of different obsessional-compulsive complaints and gives subscores for four types of complaints; checking, washing, slowness/repetition and doubting/conscientiousness (Hodgson & Rachman, 1977; Sternberger & Burns, 1990). The questionnaire effectively distinguishes obsessional from non-obsessional neurotics, it has good test-retest reliability and the total score correlates significantly (0.6) with the Leyton Symptom Score. Control data were obtained from norms established for a non-student sample by Dent and Salkovskis (1986). The Eating Attitudes Test (EAT) (Garner & Garfinkel, 1979), measures the symptoms of anorexia nervosa, The ~~~~~~~~~~~~~~~~g~~~~~~ Test (BITE) (Henderson & Freeman, 1987), measures bulimic symptomato~ogy and behaviaur. After a thorough clinical assessment, DSM-11 IR diagnoses (APA, 1985) were established and those with anorexia nervosa (N t= 29) or bulimia nervosa (n = 77) were entered into this study. Bulimic patients who had a previous history of anorexia nervosa (n = 23) were identified as it was hypothesised that these patients would have higher obsessionality scores than other bulimics. A consecutive series of 38 patients with bulimia nervosa then entered a structured treatment programme. These patients were asked to complete food diaries, in which they entered details of all food consumed during the course of treatment. Binges and self-induced vomiting were recorded on the self-monitoring sheets. After a 2 week assessment period, patients entered an 8 week course of cognitive-~hav~our thereapy, an abbreviated form of the treatment described by Fairburn (1985). Changes in binge frequency during treatment were derived from the food diaries. RESULTS The MOCI-total and subscale scores were derived for 29 anorexics, 44 bulimics and 23 bulimics with a history of anorexia. These scores were compared with normative data on 36 patients by Dent and Salkovskis (1986). One-way analysis of variance with Scheffe’s procedure revealed no significant differences in obsessive-compulsive scores between eating disorder groups (Table I). t-Tests comparing the eating disorder groups with the normal sample revealed no significant differences. On the EAT score, the bulimic patients with a previous history of anorexia had a higher score than the anorexics (P = 0.007), but there were no significant differences between other groups. On the BITE-severity and symptom scores, both bulimic groups had sign~~cant~y higher scores than the anorexic group (P < O.OOl), but the difference between bulimic subgroups feel1short of significance. The relevance of obsessive-compulsive symptoms in treatment response of bulimic patients was assessed by comparing patients with good and poor treatment outcome (Table 2). Good outcome Fable
I. Obsessinnality
(MOCI)
Anonxia ~RW”SI+ (2% ~_-________ SD X Tail Chxking Cleaning SlOWtleSs Doubting Age BITE Severity
swres
7.4 2.0 1.6 2.9 2.9 24.5
(4.8) (2.2) (1.4) (1.1)
4.3
(4.8)
15.9
(7.8) (18.3)
BITE Symptom
15.0
EAT
45.4
*Data from Dent and Salkovskis
and age of eating disnrdcr
Bulimia nervosa with previous anorexia nervosa (23) _-__--__ X SD 1.3 2.0 I.6 2.9 3.2 23.9
(5.3) (2.0) (1.7) (0.9)
(1W
patients
Bulimia nervosil (44) --.. .._,l_l____ X SD 7.0 2.0 I.6 2.6
2.9
(3.8) (1.7) (1,4) (1.0)
(1.9)
(3.7)
24.5
(4.8)
(4.2)
13.7
(5.2)
24.8
(3.9)
24.2
(S.5)
59.4
(15.2)
50.5
(17.5)
(19861, non-student
sample.
and controls
--__
Controls* (36) llill x SD
5.9 1.5 1.3 2.6 2.4 2X.6
0.5) ft.41 (1.5) (1.2) (1-l) (12.9)
Obsessive-compulsive symptoms Table 2. MOCI score of bulimics Good
115
with good and poor response
outcome’ n = 17
to treatment
Poor outcome n =21 I-Test
MOCI
scores
X
Total Checking Washing Slowness Doubting
5.0 I.3 1.4 2.6 2.3
SD
X
(3.4) (1.6) (1.1) (1.0) (1.4)
1.6 1.9 1.8 2.8 3.5
SD
P
(5.1) (1.7) (1.8) (0.8) (1.7)
0.082 0.257 0.389 0.667 0.025
*Good outcome = two binge-vomit episodes or less during the final 2 weeks of treatment. Poor outcome = more than two binge-vomit episodes. Table 3. Clinical and psychometric features of bulimics with excellent or very poor outcome after treatment Measures at start of treatment MOC MOCCH MOCL MOCS MOCD EAT BITE symptom BITE severity
Asymptomatic n=8
Table 4. Outcome
Daily bingeing n = IO
Binge frequency at start of treatment
r-Test X
SD
X
SD
5.0 1.5 1.7 2.6 2.2 55.5
(4.3) (1.2) (1.4) (0.9) (1.5) (21.7)
7.3 1.6 1.4 2.5 3.5 60.1
(3.9) (1.6) (1.1) (0.5) (1.6) (14.4)
0.26 I 0.880 0.568 0.738 0.105 0.617
25.6
(2.8)
25. I
(4.8)
0.777
13.0
(5.0)
16.1
(4.2)
0.182
P
of patients with high (MOCI-total normal obsessionality scores
210)
Binge change during treatment
Total-MOCI
X
SD
X
SD
MOCI > 7 @=I6 MOCI < 7 n = 22
9.1
(7.4)
3.6
(7.2)
(11.2)
7.7
13.0 0.2916
P*
MOCI > IO n=9 MOCI < IO n = 29
7.4 12.5 0.1304
P*
*Mann-Whitney
and
(9.0) 0.341 I
(5.7)
2.3
(10.6)
7.1
(8.5) (8.2) 0.4959
U-Test.
was defined as less than four binge-vomit episodes during the final 2 weeks of treatment (n = 17, 45%) poor outcome was defined as four or more episodes (n = 21, 55%). Poor outcome cases had higher MOCI-total scores (P = 0.082) and significantly higher scores on the doubting sub-score (P = 0.025). The MOCI scores of patients with the best and worst outcome were also compared (Table 3). There was no significant difference in obsessive-compulsive scores between those who were binge-free (n = 8, 21%) and those who were bingeing daily (n = 10, 26%) at the end of treatment. Differences in outcome could not be accounted for by differences in severity of symptoms at the start of treatment, as measured by EAT and BITE scores. The outcome of the subgroup of bulimics with high MOCI scores was then compared with normal scorers. On a normal sample (Dent & Salkovskis, 1986), 95% confidence limits for total-MOCI are between 4.7 and 7.0. The outcome of cases with MOCI-total scores of 3 7 (n = 16), and 3 10 (n = 9) was compared with low-scorers (Table 4). The average binge frequency was lower in high scorers at the start of treatment and these patients had lower average improvement in bingeing during treatment. DISCUSSION
This study fails to support the view that anorexia nervosa is a subtype of OCD. Obsessive-compulsive complaints were more common in patients with eating disorders than normal controls or other non-obsessional neurotics (Hodgson & Rachman, 1977). The MOCI scores of eating disorder patients in this study are consistent with those recorded by Weiss and Ebert (1983) in a group of 15 bulimics. The MOCI also failed to distinguish between anorexics and bulimics, although previous reports have found differences using the LOI. The absence of a significant difference between eating disorder cases and normals may reflect the absence of a selection bias in this study, which included consecutive new referrals to the outpatients department. Previous studies have recruited some or all Ss from inpatient units (Smart et al., 1976; Beumont, 1977), and are therefore likely to include more patients with severe illnesses and other psychiatric disorders. Further evidence that high obsessive-compulsive scores may reflect selection bias comes from Channon and DeSilva’s study of anorexic inpatients (1985). In this sample of 45 low weight patients, average total-MOCI score was higher than for anorexics in the current study
THOMAS A. FAHK
116
(9.9 SD = 8.09 vs 7.4 SD = 4.8).After
treatment and weight restoration, there was a significant reduction in MOCI scores (9.7 SD = 7.22) to a level comparable to the current study. These lower scores were maintained at 1 yr follow-up. The combination of weight and shape related cognitive distortions and obsessional rigidity may perpetuate bulimia. Alternatively, obsessionality may be central to the genesis of the disorder by exaggerating conceptual simplicity and concreteness. This view is partially supported by the results of Johnson and Holloway (1988) who found that a group of 15 bulimics were characterised by high scores on the LOI, but low scores on standardised tests which are purported to measure conceptual organisation, including the ability to perform tasks which require abstract, independent and relativistic processing of information in social situations. It is not clear if such impaired conceptual organisation is allied with the distorted cognitions which are addressed in cognitive therapy, but if this is the case, those patients with high obsessionality scores may have severe illnesses which are especially resistant to treatment. However, patients with high MOCI scores in this study did not show a tendency towards greater severity of bingeing; indeed the opposite effect is suggested by the results presented in Table 4. High obsessional symptom scores are present in a minority of cases where they may reflect low body weight and coincidental psychopathology. However, high MOCI scores do not predict poor response to treatment, a finding which has also been demonstrated in anorexia nervosa (Channon & de Silva, 1985). AcknoM,/e~lRements-I am very grateful
to W. P. de Silva, I. Eisler and Professor
G. Russell.
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