Disturbances of Weight Control Behaviours and Psychological Functioning in Individuals Presenting to an Outpatient Eating Disorder Unit: A Descriptive Study

Richard O’Kearney, Robert Gertler, Janet Conti and Marian Duff

The behavioural, psychological and demographic characteristsics of a sample of 169 patients presenting to a speciality eating disorder outpatient clinic are described. While disturbances of weight control inwolwing restrictiwe eating are common within the sample, overeating and behawiours compensating for dietary failures are distributed more variably. The severity of these behawioural disturbances suggest that approximately 50 per cent of these patients would be currently classified as subclinical. Despite this, the psychological profile of the sample is equiwalent to diagnosed eating disordered samples and identifies significant amounts of psychopathology. The study argues for a broadening of the empirical approaches to the understanding and treatment of all patients with disorders of eating and weight control.

INTRODUCTION

Descriptive studies of the behavioural and psychological disturbances of eating disordered patients have generally taken as their starting point the DSM-I11 or DSM-111-R classifications of anorexia nervosa (AN) and bulimia nervosa (BN) (Garner et al., 1990; Kennedy and Garfinkel, 1989; Mitchell et al., 1991; Turnbull et al., 1989). With few exceptions (Lacey, 1992) the studies report on samples drawn from populations defined by these syndromes which are based on cutoffs for the frequency and severity of disordered eating and weight control behaviours together with associated psychological symptoms.

While such a strategy increases reliability and reduces the likelihood of reporting on false positives, if the criteria for classification are too narrow it produces data which may be of only ‘special’ relevance (Shaw and Garfinkel, 1990). The apparent homogeneities created by the syndromal method of diagnosis risks impeding progress towards a fuller understanding of the underlying pathologies and the development of effective treatments for the substantive problems. A number of established clinical researchers in eating disorders have called for a broadening of the data base (Fairburn et al., 1993;

CCC 1072-4133/95/020080-13 0 1995 by John Wiley & Sons, Ltd. and Eating Disorders Association

European Eating Disorders Review 3(2), 80-92 (1995)

Description of an Outpatient Eating Disorder Sample

Mitchell, 1992; Wilson, 1992). One group, in some of their work, are disregarding ‘existing diagnostic distinctions in order to start with rhe whole cake rather than just part of it’ (Fairburn et al., 1993 p. 159).

The dangers of the increasingly too narrow typology of eating disorders is demonstrated by the relative paucity of published research on eating disorders not otherwise specified. EDNO’s heterogeneous and uncharacterized population, plus the fact that it is a residual category defined by ommission, seem to make it particularly unattractive to researchers. But the facts are that individuals who do not fulfil the criteria for AN or BN but are suffering extreme distress because of an eating disorder are common in clinical settings (Beumont et ul., 1994; Fairburn et al., 1993; Herzog et d., 1993; Yager et ul., 1987).

From the perspective of clinicians faced with the task of providing optimal treatment procedures and programmes for all patients presenting with eating disorders the clinical utility of the expanding empirical literature on BN, AN and, more recently, binge eating disorder (BED) may be limited if the ‘researched’ population does not represent the population presenting with the problem. Matching treatment to patients based on diagnosis is the most common treatment decision making heuristic used in psychiatry. It is most valid when (a) the diagnostic classification defines a group homogeneous with respect to features which determine treatment response and (b) there are powerful treatments available for this group. Unfortunately, at present, neither of these conditions are met for eating disorders. As Garner et al. (1993) conclude for the treatment of BN ‘At this time little is known about the active ingredients of treatment and the predictors of response to treatment’ (p. 45). These conclusions apply for each category of eating disorder.

The call for a broadening of the data base for eating disorders highlights the need for inclusive descriptive accounts of the phenomena encountered by clinicians who have the task of providing services to patients with disordered eating. This paper goes someway to meeting this need by describing some of the demographic, behavioural and psychological characteristics of a large sample of patients presenting for help at an outpatient eating disorder service.

METHOD

Information was collected as part of the assessment procedures for patients referred to the tertiary referral Eating Disorders Unit outpatient service of Royal Prince Alfred Hospital, Sydney, over the period from October 1991 to June 1993. Patients require a referral from a medical practitioner to obtain an assessment interview and are required to undergo a medical screen including full blood count and electrolytes.

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The psychological and behavioural assessment procedure involved a clinical interview by a psychiatric registrar or a dietitian. In addition, information was obtained by means of self-report on current behavioural disturbances, psychological dysfunction specifically related to eating disorders and general psychopathology.

The self-report instruments used are:

(1) A self-report measure of behaviour related to recent eating and weight control behaviours. This inventory involves reports of dietary restriction (frequency of skipping meals and of fasting for>8h), degree of experienced loss of control over eating, frequency of overeating episodes, duration of overeating, degree of distress associated with overeating, frequency of various compensatory behaviours (vomiting, laxative use, use of diet pills and diuretic use), frequency of exercising as a weight control technique, and frequency of alcohol and other drug use.

(2) The Eating Disorder Inventory 2, ED1 2 (Garner, 1991) assesses the depth of psychological factors commonly connected with eating disorders. It contains 91 items which cluster into eight validated subscales (drive for thinness, bulimia, body dissatisfaction, ineffectiveness, perfectionism, interpersonal distrust, interoceptive awareness, maturity fears) and three provisional subscales (ascetism, impulse regulation and social insecurity).

(3) General psychological dysfunction was assessed via the Beck Depression Inventory, BDI (3eck and Steer, 1987) and the Symptom Check-Iist 90 (SCL 90) (Derogatis, 1979). Both are frequently used, reliable and valid clinical instruments for screening and assessing presenting symptomatology and for evaluating change. The total score on the BDI reflects severity of depression. The SCL 90 contains nine scales (somatization, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism) which provide severity measures for the occurrence of associated symptoms pattern. The SCL 90 also provides a global index of psychiatric symptoms.

RESULTS

One hundred and sixty-nine individuals were assessed with both interview and self-report instruments between October 1991 and June 1993. Table 1 presents information on some demographic variables. While 75 per cent of the sample were in their 20s (59.4percent) or teenage years (15.6percent), a significant proportion (25 per cent) were over 30. About half (47.4 per cent) had received at least one previous treatment for an eating disorder, and 39. I per cent had been treated previously for another psychological or behavioural problem.

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Table 1. Frequency and percentage distribution for sex, age, marital status and occupation

No %

Sex Female Male

Single Married Separated/divorced

Age range 15-19 20-24 25-29 30-39 > 40

Occupation Unemployed Domestic Student Blue collar White collar Professional

Marital status

166 98.2 3 1.8

113 73.9 23 15.0 17 11.1

25 15.6 58 36.3 37 23.1 33 20.6

7 4.3

21 13.5 7 4.5

37 23.9 20 12.9 51 32.9 19 12.3

These latter problems included depression, drug or alcohol dependence, and the effects of a history of sexual assault. Previous management of their eating disorder was provided primarily by psychiatrists (28 per cent) and psychologists (23 per cent), but dietitians (18 per cent) and general practitioners (18 per cent) also provided treatment. Drug and alcohol counsellors (43 per cent) and psychiatrists (3 1 per cent) supplied the majority of previous treatments for other types of emotional disturbances. The majority of individuals (57 per cent) identified their eating/dieting behaviours as the reason for their current presentation. Mood disturbance was a frequent (24 per cent) motive for seeking help. A small but not insignificant proportion (1 1 per cent) presented requesting help with weight lost.

Table 2 documents the distribution of the sample’s presenting, lowest, and highest body mass index (BMI). At presentation, a significant percentage of the sample (35.5 per cent) was underweight with 13.4 per cent in the very under- weight category. A smaller number (8.7 per cent) had current BMIs (< 17.5) which would put them within the weight threshold for anorexia nervosa. The report of lowest adult weight indicates that a large percentage (40 per cent) was

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Table 2. Frequency distribution and mean and standard deviation of presenting, lowest and highest adulthood BMIs

At presentation Lowest Highest

BMI range No. Yo NO. % NO. %

< 17.9 (very underweight) 20 13.42 56 39.72 3 2.21 18.0- 19.9 (underweight) 33 22.14 32 22.69 7 5.14 20.0-24.9 (normal) 64 42.95 47 33.33 57 41.91 25.0-29.9 (overweight) 19 12.75 2 1.41 43 31.62 2 30.0 (obese) 13 8.72 4 2.83 26 19.11

Mean 22.57 19.03 25.71 Standard deviation 5.97 3.74 6.19

previously very underweight with a third of the sample having a lowest previous weight below the AN threshold. The distribution of highest BMIs shows that 50 per cent of the sample were previously overweight and for about 20 per cent their highest adult weight was in the obese range.

The frequencies and proportions of the sample currently engaging in various dieting, overeating and compensatory behaviours is provided in Table 3. Eighty- four per cent of the sample exercised some restraint over their eating in the preceding 4 weeks. For 30 per cent the degree of self-reported restraint was moderate to severe. Episodes of overeating were reported by 74 per cent with over half (54 per cent) identifying overeating as a regular ( >weekly) experience. Moderate or severe subjective loss of control over their eating was experienced by 66 per cent of the sample and episodes of overeating were felt to be moderately to extremely distressing for 68 per cent of the group.

The most common method of compensation for experienced overeating was vomiting. For 50.6 per cent the frequencies of vomiting was greater than once per week while 39 per cent reported not vomiting in the preceding 4 weeks. Laxative use was prominent in 23 per cent but use of diet pills or diuretics occurred only in a small proportion (7.4 per cent and 5.6 per cent respectively). There was some overlap in the type of compensatory behaviours used with 14 per cent engaging in both laxative abuse and vomiting regularly. Eight and half per cent were exclusive laxative abusers. Exercise was reported as a frequent (> daily) means of weight control for 31 per cent although an equivalent number reported not exercising in the preceding 4 weeks. Current heavy use of alcohol was disclosed by 6 per cent with moderate use in a further 20 per cent.

The descriptive breakdown of responses to the Eating Disorder Inventory are presented in Table 4. The frequencies are reported according to the quartile classifications documented in the ED1 2 manual (Garner, 1991) for the combined AN and BN eating disordered standardization sample. They represent the

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Table 3. Frequency annd percentage for eating disturbances, compensatory behaviours, exercise and alcohol use

No. % No. %

Restraint None Minimal Mild Moderate Severe

Overeat frequency Minimal Mild Moderate Severe

Perceived loss of control None Mild (< 4/week) Moderate (> 4/week) Severe (> daily)

Degree of distress None Mild Moderate Extreme

Vomiting Never Occasionally (< l/week) Sometimes (> l/week) Frequently (> l/day)

25 15.2 42 25.5 47 28.7 35 21.3 15 8.4

43 26.2 33 20.1 76 46.3 12 7.3

32 19.5 23 14.0 80 48.8 29 17.7

42 25.6 11 6.7 35 21.3 76 46.3

64 39.0 17 10.4 54 32.9 29 17.7

Laxatives Never 117 71.3 Once 9 5.5 Sometimes 31 18.9 Frequently 7 4.2

Diet pills Never 152 92.6 Occasionally (< l/week) 2 1.3

Frequently (> l/day) 3 1.8

Never 154 94.4 Occasionally 6 3.7 Sometimes 3 1.8

Sometimes (> l/week) 7 4.3

Diuretics

Frequently 0 0 Exercise

Never 62 37.8 Occasionally 17 10.4 Sometimes 33 20.7 Frequently 51 31.1

Never 62 38.0 Occasionally 59 36.2 Sometimes 33 20.2

Use alcohol

Frequently 9 5.5

percentage of the current sample whose scores on the subscales fall within the standardization sample’s quartile limits. Only data for the validated subscales are presented. The distribution of the present sample is not different to the ED1 standardization sample on the psychological measures of drive for thinness, body dissatisfaction, ineffectiveness, and interoceptive awareness (x2 = 1.55, 3.99,2.90,3.38 respectively). However, a significantly larger proportion of the current group obtained low scores on the bulimia and perfectionism subscales ( x2= 15.07, 16.07) and high scores on the interpersonal distrust and maturity fears subscales (x2=8.06, 26.47).

Table 5 provides details of the sample’s self-report of psychological symptoms from the BDI and the SCL 90. The table gives the frequencies of subjects in each of the BDI severity of depression classifications and the means and standard

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Table 4. Percentage of sample falling in quartile range of ED1 standardization sample for each subscale, together with subscale mean and standard deviation

Quartile

1st 2nd 3rd 4th Mean SD

Drive for thinness Bulimia Body dissatisfaction Ineffectiveness Perfectionism Interpersonal distrust Interoceptive awareness Maturity fears

27.3 24.8 20.0 27.9 41.8 18.8 20.0 19.4* 18.2 22.4 30.9 28.5 19.4 29.1 26.0 25.5 41.8 23.0 19.4 15.8* 14.5 22.5 32.1 30.9* 30.9 18.2 24.2 26.7 13.3 12.7 30.3 43.6*

(13.75) (18.13) ( 18.1 2) (11.81) (6.61) (6.37)

(10.64) (5.67)

(6.29) (6.29) (8.07) (7.78) (5.03) (4.4) (7.29) (4.6)

*Distribution significantly different from standardization sample (p < 0.01).

Table 5 . Frequency distribution for BDI depression severity classification and means and standard deviations for SCL 90 dimensions and Global Symptom Index, and deviation score (2) from psychiatric outpatient sample

BDI Minimal Mild to moderate Moderate to severe Severe

SCL dimension

Somatization Obsessive compulsive Interpersonal sensitivity Depression Anxiety Hostility Phobic anxiety Paranoid ideation Psychoticism Global Symptom Index

Score

(0-9) (10-18) (19-20) ( > 30)

Mean

1.36 1.71 2.10 2.14 1.48 1.46 0.84 1.47 1.31 1.26

No. %

18 11.0 43 26.2 52 31.7 51 31.1

SD Z

0.89 0.94 0.98 0.26 0.98 0.92 0.99 0.48 1.00 0.20 0.97 0.37 0.94 0.31 0.94 0.44 0.86 0.05 0.68 0.50

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deviations of the sample for the SCL 90 subscales and General Symptom Index. It is not possible to calculate percentiles from the SCL 90 normative data and severity classifications are not provided in the manual, consequentially deviation scores from the means for the psychiatric outpatient normative group (Derogatis, 1979) are included as a comparison. Sixty-three per cent of this sample report depression to a moderate or severe level with almost one-third falling in the severe depression classification of BDI scores. The sample’s self- report of general psychological symptoms is in line with the SCL 90 psychiatric outpatient normative data and overall represents a generally elevated level of symptom reporting. Notably, relative to other psychiatric outpatients the sample’s symptom profile peaks on the somatization and interpersonal sensitivity dimensions.

DISCUSSION

The descriptive features of this sample of patients presenting to a speciality eating disorder service highlights the demographic and behavioural diversity, and range of significant psychological dysfunction present in eating disordered populations. All our presenters have disturbances in their attempts to control their weight with the majority identifying their behaviour rather than their weight as the primary problem. Their accounts of these behavioural disturbances describe a broader range of perceived problems associated with attempts to control weight than provided by samples defined by the DSM criteria for AN or BN.

Our sample is almost split evenly between those who report overeating regularly (54 per cent) and those whose overeating is infrequent (46 per cent). As the self-report of overeating used here is likely to be inclusive of both objective and subjective ‘large amounts of food’, it is probable that a smaller proportion of our sample regularly engage in objective bulimic episodes. However, many of the presenters report loss of control over their eating and strong distress associated with their eating. In view of the role that these psychological factors play in attempts to compensate for perceived overeating, and in maintaining the cognitive focus on inappropriate weight control, the nature of subjective ‘bulimic’ episodes should not be overlooked in attempts to refine the assessment of binge eating (Wilson, 1992). Perceived loss of control, or fear of loss of control, and restrictive eating interact in the mechanisms of attempts at weight control (Polivy and Herman, 1993) and in our sample are the aspects which are most common.

At most about 60 per cent of the sample regularly attempt in some way to compensate for perceived dietary failures. Vomiting and laxative use predominate in these attempts with many of the laxative users employing vomiting as well. Because of their physical complications the prominence of

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these compensatory methods in our sample have clear implications for the general clinical management of eating disorders.

The changes in the frequency distribution of BMIs between presentation weight and lowest and highest previous adult weights confirm the clinical impression of the frequent occurrence of extreme weight fluctuations in eating disordered individuals. While only 8.7 per cent of the sample currently have a BMI below or equal to 17.5,33 per cent were below that weight at some time in the past. At the same time, half reported previously being overweight and for 20 per cent the degree of their obesity was extreme. Given the strong positive correlations between current, lowest and highest BMIs, the findings suggest that many of the presenters have a history of considerable weight change in adulthood.

The inference from the behavioural descriptions and current weight is that our sample contains a high proportion of sub-clinical or ENOS cases. Using equivalents of the DSM-111-R criteria based on the self-report data less than 50 per cent of the sample could be classified as BN and only 9 per cent as AN cases. Despite this, the psychological disturbances reported are remarkably similar to those seen in defined AN and BN groups. Putative underlying features such as body dissatisfaction, drive for thinness, interoceptive awareness and a sense of ineffectiveness are similarly distributed in our sample and the combined AN and BN sample of Garner (1991). These data suggest that many of the presenters may have, at some time in the past, met the criteria for BN or AN, or may go on to become cases, and are consistent with the few follow-up studies of subclinical eating disordered groups which show high rates of ‘conversion’ to full criteria cases (Herzog et al., 1993; Yager et al., 1987).

A high incidence of depression is frequently reported in groups of BN patients (Strober and Katz, 1988) but the level of self-reported depression in our sample illustrates the degree to which emotional distress, self-disgust, and negative evaluation is common in people with recognized disturbances of eating and weight management. The data also indicate elevated psychopathology on a range of dimensions and a profile of disturbances suggestive of strong general negative emotionality. The prevalence of raised general negative affect is in line with theories which propose a link between affect regulation and disordered attempts at weight control (Heatherington and Baumeister, 1991; Johnson and Connors, 1987). Of particular interest are the peaks of our sample’s SCL 90 profile on the somatization and interpersonal sensitivity dimensions. The apparent characteristic importance of these two aspects of psychological dysfunction for these individuals emphasizes the role of mechanisms related to the representation of psychological distress in physical/bodily terms (somatization), and also the part played by the person’s preoccupation with presentation of the physical self and the self in general in the social realm (interpersonal

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sensitivity). These findings may also indicate areas of psychopathology persisting through the course of the disorder and, more speculatively, areas of developmental disruption for individuals who go on to become eating disordered (Leon et al., 1993).

In terms of treatment research, our data reinforce observations of the diversity of problems that will be encountered by practitioners treating eating disordered patients. While this may seem self-evident, the prominent, indeed almost exclusive, methodology of treatment research in eating disorders remains treatment comparison studies for groups defined by the DSM-111-R diagnostic criteria for BN, or, less frequently, AN. The heterogeneity of demographic, experiential, behavioural and psychological characteristics of our presenting sample together with the strong representation of sub-clinical cases are strong arguments for diversifying treatment research options. Such options might include: treatment matching studies; studies looking at the effects of treatment sequencing; outcome predictor studies; or evaluations of the more comprehensive treatment models (e.g. Agras, 1993).

The overwhelming occurrence of restraint in the sample, together with the data on the changes in BMIs, underlines our impression that treatment must target the on-going mismanagement of weight by eating disordered individuals. As part of doing so, treatments need to offer alternative and healthy weight management techniques in combination with acceptance of a normal and stable weight which may not comply with cultural stereotypes. The degree and commonality of psychological dysfunction in the area of somatization and interpersonal sensitivity suggest that, in addition to nutritional education and counselling, psychological therapies will be required for the majority of patients to help them obtain and maintain appropriate goals with respect to weight management.

Other implications for treatment can be drawn from the characteristics of this sample. The data, indicating a high level of interpersonal sensitivity as a common feature of presenters, support the application of psychological therapies which focus on interpersonal dysfunctions as central to the restoration of more adaptive behaviour. In addition, the age characteristics of this sample present a challenge to structured psychological approaches to treatment. The most advocated psychological intervention, CBT, has so far not considered the psychological effects of a prolonged history of failed attempts at weight control nor the resultant developmental changes in self-esteem and self- evaluation of such individuals.

The behavioural variability within this sample has implications for current diagnostic approaches to eating disorders. It questions whether a categorical system based on behavioural thresholds will provide a comprehensive way of classifying eating disordered patients. As others (Beumont et al., 1993; Garner et al., 1993) have argued, rather than continue to subtype and redefine cutoffs it may be time to apply alternative methods to the

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task of dividing up the cake. In addition, the present data show that the current nosology of eating disorders imposes frequent limitation on clinicians’ ability to appreciate the problems of many people who seek help for an eating disorder and to make treatment suggestions which are empirically based.

A self-selected sample like the one described here is unlikely to be completely representative of the population of eating disordered individuals. The small number of individuals in the sample with very low BMIs at presentation can partly be explained by the alternative referral route for the more seriously underweight, i.e. directly to inpatient treatment. Limitations to the validity of the self-report assessment method can also be noted. For example, the results obtained from our measure of restrained eating are likely to be optimistic compared to actual dietary restraint as our scale was based only on the frequency of missed meals and snacks. The selective reduction of high energy foods would not be detected by such a measure. Similarly, the self-report of alcohol consumption used here was non-comprehensive and its narrowness probably accounts for the relatively low frequency of alcohol abuse noted in our sample.

Despite the study’s limitations it clearly covers a broader range of dysfunctional behaviour associated with weight control, and indicates that the whole cake for eating disorders is one that is more heterogeneous than implied by the current diagnostic criteria of AN or BN. The data presented argue for a correspondingly broader approach to conceptual and treatment research in order to understand and assist all those suffering from disturbances of eating and weight control.

ACKNOWLEDGEMENTS

We wish to thank Ms. Kaarin Anstey for statistical consultation, and Professor Peter Beumont for comments and advice on a draft of this paper.

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Richard O’Kearney, BA, MPsychol, MAPS (Departmental Clinical Psychologist) Former address: Department of Psychiatry, Royal Prince Alfred Hospital, Camperdown, NSW 2050, Australia. Present address: Department of Psychology, University of Queensland, St. Lucia QLD. 4072, Australia.

Robert Gertler, MBBS, FRANZCP (Clinical Senior Lecturer) Department of Psychiatry, Royal Prince Alfred Hospital, Camperdown, NSW 2050, Australia.

Janet Conti, BSc, PostgradDip (Nutrition and Dietetics), MDAA (Specialist Dietitian in Eating Disorders)

Marian Duff, BSc, PostgradDip (Nutrition and Dietetics), MDAA (Dietitian) Department of dietetics, Royal Prince Alfred Hospital, Camperdown, NSW 2050, Australia.

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