Anorexia Nervosa and Anorexic-Like Syndromes

in a Population-Based Female Twin Sample

Ellen E. Walters, M.S., and Kenneth S. Kendler, M.D.

Objective: The authors explored the epidemiologic characteristics and risk factors of ano-
rexia nervosa and examined the relationship between narrowly defined anorexia nervosa and
anorexia-like syndromes. Method: Structured interviews were administered to a population-
based sample of2, 1 63 female twins. Anorexia nervosa was diagnosed by computer algorithm
(“computer narrow”) and by narrow and broad clinical definitions. Results: Lifetime preva-
lence estimates ofO.51 %, 1.62%, and 3.70% were obtained for the computer narrow, clinical
narrow, and clinical broad diagnoses, respectively. Dieting status, greater number ofyears of
parental education, low self-esteem, high levels of neuroticism, and maternal overprotective-
ness were significantly associated with anorexia nervosa. Both the pattern ofcomorbidity and
the relationship to epidemiologic risk factors suggested an etiologic continuity between nar-
rowly and broadly defined anorexic syndromes. Co-twins oftwins with anorexia nervosa were
at significantly higher risk for lifetime anorexia nervosa, bulimia nervosa, major depression,
and current low body mass index. Significant comorbidity was found between anorexia ner-
vosa and major depression, bulimia nervosa, generalized anxiety disorder, alcoholism, pho-
bias, and panic disorder. Conclusions: The authors’ analyses support the hypothesis ofa spec-
trum of anorexic-like syndromes in women. These syndromes are familial and share familial
etiologic factors with major depression and bulimia nervosa.
(Am J Psychiatry 1995; 152:64-71)

A lthough
explain
many theories
the etiology
have
of anorexia
been proposed
nervosa, rang-
to partial
In a general
syndromes
population
have been frequently
study in London,
noted
0.75%
(3, 5-7).
of the
ing from a fear of growing up, a reaction to a rigid fam- sample was diagnosed with anomexic-like partial syn-
ily life, to hypothalamic dysfunction, theme is a scarcity dromes. Another study (6) reported a partial syndrome
of empirical data that objectively address possible etio- prevalence of 3.43% in a population of 15-year-old
logic mechanisms of this disorder. One difficulty encoun- schoolgirls unselected for psychopathology. Twenty-
temed in studying anorexia nervosa in epidemiologic one of 60 patients referred to a pediatric eating dison-
samples is its rarity. Prevalence estimates in general dens clinic were diagnosed with a subclinical form of
population samples range from 0.10% to 1.0% (1-5) anorexia nervosa (7). Partial-syndrome anorexia nem-
and vary depending on the type and age of the popula- vosa is probably more common than anorexia nervosa
tion studied, method of ascertainment, and diagnostic itself (3, 5) and suggests that a continuum of pathology
criteria. For example, amenorrhea was a diagnostic cmi- may exist on which classic anorexia nervosa represents
tenon for anorexia nervosa in DSM-III-R, but not in the furthest extreme. One attempt to determine if the
DSM-III. partial syndrome is qualitatively different from ano-
In addition to classic anorexia nervosa, anorexia-like rexia nervosa found no demographic or psychological
features that distinguished individuals with the two
diagnoses (7).
Received Feb. 22, 1994; revision received June 10, 1994; accepted It is generally recognized that anorexia nervosa is a
July 14, 1994. From the Department of Psychiatry and the Depart- familial disorder. Several studies have reported a higher
ment of Human Genetics, Medical College ofVirginia/Vinginia Com-
risk for anorexia nervosa in female relatives of pro-
monwealth University, Richmond. Address reprint requests to Dr.
Kendlen, Department of Psychiatry, Medical College ofVirginia, Box bands with anorexia nervosa than in female relatives of
710, Richmond, VA 23298. control subjects (8, 9). Less work has been done to de-
Supported in part by NIMH grant MH-40828 and National Insti- termine what proportion of this familial component is
tute on Alcohol Abuse and Alcoholism grant AA-09095. The Virginia caused by genetic as compared to environmental fac-
Twin Registry, established and maintained by Drs. W. Nance and L.
tons. A review of case reports of twins (10) found con-
Corey, is supported by NIH grants HD-26746 from the National In-
stitute of Child Health and Human Development and NS-25630 from comdance rates of 52% in monozygotic and 1 1 % in
the National Institute of Neurological Disorders and Stroke. dizygotic twins. As case reports are probably biased to-

64 AmJPsychiatry 152:1,January 1995

 ELLEN E. WALTERS AND KENNETh S. KENDLER

ward monozygotic and concordant pairs, such results ing similarity and frequency of contact (shown to be greater than
95 % accurate [1 8]), photographs, and, in cases of uncertainty, blood
are unlikely to be reliable. However, the presence of a
typing. This resulted in 590 monozygotic twins, 440 dizygotic twins,
genetic component is supported in two reports by Hol- and 3 pairs of unknown zygosity. No attempt was made to determine
land et al. (9, 1 1), which found a significantly greater the zygosity ofthe unmatched twins. The mean age of this sample was
number of concordant monozygotic twins than dizygo- 30.1 years (SD=7.6).
A blind review of interviews was conducted by an experienced psy-
tic twins. Unfortunately, these two studies contain
chiatnic diagnostician (K.S.K.) to assign twins a lifetime DSM-III-R,
some overlap in subjects and, thus, are not independent diagnosis of anorexia nenvosa, major depression, bulimia nenvosa,
replications of this finding. The larger of the two studies alcoholism, panic disorder, generalized anxiety disorder, and pho-
(9) reported a heritability estimate for anorexia nervosa bias. This review included examination of the SCID items as well as
additional comments recorded in the interview and clinical material
of at least 80%. All previous family and twin studies of
provided by the interviewers in a one- to two-page summary at the
anorexia nervosa ascertained probands through treat- end of the interview. These clinical diagnoses were made at three 1ev-
ment facilities. Since a family history of anorexia ner- els of certainty-definite, probable, and possible. For all diagnoses
vosa may increase the probability of treatment seeking, except anorexia nervosa and bulimia nenvosa the narrow clinical
definition (definite plus probable cases) was used. The broad clinical
results of these studies are potentially biased toward
definition (definite plus probable plus possible cases) was used for
showing excess familial aggregation. bulimia nenvosa since it has been shown in these data that a spectrum
Several studies have found significant comorbidity ofliability exists for bulimia nenvosa and bulimia-like syndromes (19).
between patients with anorexia nervosa and major de- Social class variables were collected as well as a series of personal-
ity and diet-related measures. Body mass index was calculated as
pression, which suggests that these two disorders share
weight in kilograms divided by height in meters squared from self-re-
common etiologic factors (12, 13). That these shared port estimates of weight and height. Self-esteem was measured by the
etiologic factors may be familial is suggested by reports Rosenberg Self-Esteem scale (20). Several measures were obtained
that first-degree relatives of patients with anorexia ner- from a previous questionnaire completed 1-3 years before interview.
vosa are at higher risk for major depression than rela- These variables included amount of exercise, dieting status, present
body image and ideal body image as assessed by body silhouettes
tives of control subjects (13). Studies disagree as to
(21 ), locus of control as assessed by a modified form of the Attribu-
whether the higher risk for affective illness is seen in tional Styles Questionnaire (22), extraversion and neuroticism from
relatives of all anorexia nervosa probands (14), on only the short version of the Eysenck Personality Questionnaire (23), and
relatives of probands with both anorexia nervosa and maternal and paternal cane and overprotectiveness as assessed by
selected items from the Parental Bonding Instrument (24). In sum-
major depression (8, 15). Of note, one study reported
many, the 1 7 risk factors examined were exercise, dieting status, pres-
no increased risk for anorexia nervosa in relatives of ent body image, ideal body image, parental education, parental occu-
patients with major depression (8). pation, college education, current income, current occupation,
This paper addresses the following issues related to self-esteem, locus of control, neuroticism, extraversion, maternal
anorexia nervosa in a population-based sample of fe- cane, paternal cane, maternal ovenprotectiveness, and paternal over-
protectiveness.
male twins: 1 ) estimating the lifetime prevalence of ano-
We examined three diagnostic approaches to anorexia nervosa.
rexia nervosa as defined by a spectrum of diagnoses The first was a strict computer algorithm based solely on responses
ranging from a broad syndrome through strict DSM- to the appropriate SCID items assessing DSM-III-R criteria. We
III-R criteria, 2) identifying epidemiologic risk factors termed this the “computer narrow” diagnosis. The second diagnosis,
termed “clinical narrow,” referred to a definite or probable clinical
for anorexia nervosa and determining if they differ sub-
diagnosis based on all available information. A “probable” clinical
stantially in type or effect among the spectrum of diag- diagnosis of anorexia nenvosa was given when the individual, al-
noses, 3) establishing the pattern of comorbidity of ano- though not meeting all criteria with certainty, clearly had a psychiat-
mexia nervosa with other major psychiatric disorders nc condition with anorexic-like features and this condition certainly
and determining if this pattern differs among the spec- more closely resembled classic anorexia nenvosa than any other dis-
order. The third diagnosis, termed “cljnical broad,” referred to defi-
trum of disorders, 4) examining whether anorexia ner-
nite, probable, or possible cases of anorexia nenvosa as diagnosed. A
vosa aggregates in families in a nonclinical population, “possible” clinical diagnosis of anorexia nervosa was applied, al-
and 5) determining patterns of familial coaggregation though all criteria for anorexia nenvosa were clearly not present,
of anorexia nervosa with major depression and bulimia when the twin probably had a psychiatric condition with anorexic-
like features that was outside the bounds of the normal range of
nervosa.
weight-related problems.
For some purposes, we refer to these three groups, which are sub-
sets of each other. All the computer narrow subjects were within the
METHOD group diagnosed as clinical narrow, and all the clinical narrow sub-
jects were within the group diagnosed as clinical broad. For other
analyses, it was necessary to define three related but mutually exclu-
Data for these analyses were collected from 2,163 Caucasian fe- sive groups of subjects with anorexia nervosa. These were as follows:
male same-sex twins ascertained through a population-based twin group I-subjects who met computer narrow criteria; group 2-sub-
registry in the Commonwealth ofVirginia. As detailed elsewhere (16), jects who met clinical narrow but not computer narrow criteria;
all twins who completed an earlier mailed questionnaire were eligible group 3-subjects who met clinical broad but not clinical narrow
for this study. A structured personal interview was conducted with criteria. Of note, group 3 was equivalent to those subjects diagnosed
both members of 1,033 twin pairs and an additional 97 individual as having anorexia nervosa at the possible level.
twins whose co-twin refused to participate. Ninety-three percent of Of those diagnosed with a lifetime history of some anorexic syn-
the subjects were interviewed face to face; 7% were interviewed by drome, 12.5% (N=10) had a body mass index at least 15% below
telephone. The interview detailed genetic and environmental risk fac- normal weight at the time of interview (group 1: none of 11; group
tons for common psychiatric disorders. These disorders were assessed 2: three of 24 [12.5%]; group 3: seven of 45 [1S.6%J). While no
by using adapted sections from the Structured Interview for DSM-III information was specifically obtained regarding current anorexia ncr-
(SCID) (details available from Dr. Kendler on request) (17). Zygosity vosa status, these results suggest that only a small minority of the
determinations were based on a series of standard questions concern- twins at interview continued to have prominent anorexic symptoms.

Am J Psychiatry 1 52:1, January 1995 65

ANOREXIC-LIKE SYNDROMES

TABLE 1. Prevalence of DSM-IIl-R Criteria for Lifetime Anorexia Nervosa in a Population-Based Sample of 2, 163 Female Twins

Diagn osis of Anorexia Nervosa

Clinical Clinical
Narrow Broad
Group Ia Group 2b Group 3C Definition’ Definitione
Variable (N=II) (N=24) (N=45) (N=35) (N=80)

N % N % N % N % N %
DSM-III-R criteria
1S%undenweight II 100.0 21 87.5 33 73.3 32 91.4 65 81.3
Fear of becoming fat I 1 100.0 23 95.8 44 97.8 34 97.1 78 97.5
Feel fat even though thin 11 100.0 22 91.7 33 73.3 33 94.3 66 82.5
Presence of amenorrhea1
Ever 11 100.0 6 26.1 8 20.5 17 50.0 25 34.2
Lasting3months 11 100.0 3 13.0 S 12.8 14 41.2 19 26.0

Mean SD Mean SD Mean SD Mean SD Mean SD

Underweight (%) 23 4 24 8 18 5 24 8 21 7
aSubjects whose diagnosis of anorexia nervosa was based on a computer algorithm of their responses to the appropriate SCID items.
bSubjects who met the clinical narrow definition (definite or probable diagnosis of anorexia nenvosa) but not the computer algorithm criteria.
cSubjects who had a diagnosis of possible anorexia nervosa.
dDefinite or probable anorexia nenvosa.
eDefinite, probable, on possible anorexia nervosa.
Data were not available for all subjects.

A polychotomous logistic regression analysis was performed for RESULTS

each variable to determine if any of the proposed social class and
personality risk factors were significantly related to anorexia nenvosa
after the effects of age and zygosity were controlled. Individuals were The computer narrow, clinical narrow, and clinical
assigned to a severity scale of 0-3 where 0 referred to those in group broad definitions identified 1 1 , 35, and 80 subjects with
1, 1 to group 2, 2 to group 3, and 3 to unaffected individuals. These lifetime anorexia nervosa, yielding prevalences of
four categories were meant to define four levels of decreasing classic
0.51%, 1.62%, and 3.70%, respectively. Since the
anorexia-like syndromes with the first category being those most se-
verely affected and the fourth being those who were unaffected. The computer narrow, clinical narrow, and clinical broad
assumption that the magnitude of effect of the risk factor was the groups are subsets of one another, the sample sizes for
same for each type of anorexia nervosa, but that the baseline level of groups 1, 2, and 3 are 1 1, 24, and 45, respectively. The
risk was greaten for
more narrowly defined anorexia nenvosa types
mean age (in years) at interview of the computer nan-
(proportional odds assumption), was tested. A nonsignificant result
of the proportional odds test was consistent with the hypothesis that
row, clinical narrow, and clinical broad groups was
the three levels of anorexia-like syndromes define a spectrum of con- 28.5 (SD=S.3), 29.2 (SD=5.8), and 28.3 (SD=6.2), respec-
ditions that differ quantitatively but not qualitatively with respect to tively. The age at onset was 18.7 (SD=3.6), .0.1 (SD=
the risk factor under examination. In addition, logistic regressions 5.4), and 18.8 (SD=S.3). These ages were not statisti-
were performed to determine if the proposed risk factor could signifi-
cally different across definitions.
candy discriminate among the three anorexia nervosa groups. The
standard errors of these analyses were adjusted upward to correct for The endorsement of specific DSM-III-R anorexia ner-
the correlated responses of twin pairs. The connection factor was a vosa criteria for the three syndromic definitions are
function of the proportion of the sample who were complete twin given in table 1 By definition,. all computer narrow sub-
pairs and the magnitude of the correlation of the dependent variable
jects met all criteria. Over 90% of the clinical narrow
in those twin pairs (25). These analyses are considered exploratory,
and, thus, no connections have been made for multiple tests. Readers
subjects met all the criteria except amenorrhea, which
should be aware in interpreting these results of the possibility of some lasted for 3 or more months in only 41.2% (N=14) of
positive findings occurring by chance alone (type I error). the subjects. In clinical broad subjects, over 80% of
Odds ratios and 95% confidence intervals were obtained to quan- subjects met all criteria except amenorrhea for 3
tify the comorbidity present between anorexia nervosa and the other
months, which was endorsed by only 26.0% (N=19) of
diagnosed disorders. For this analysis, groups I , 2, and 3 were com-
pared. A chi-square test of homogeneity was performed to determine the sample. As we did not inquire about contraceptive
if the odds ratios for comonbidity differed among these three classes use during anorexia nervosa episodes, it is possible we
of anorexia-like syndromes. underestimated the true rate of amenorrhea, because in
In addition, odds ratios were calculated from 2x2 contingency ta-
a proportion of our sample it could have been masked
bles to determine the risk for anorexia nervosa in the co-twin of a twin
with anorexia nervosa. Cox proportional hazard models (26) were fit
by the use of birth control pills. Of note, over 95% of
to test if such a co-twin was at a higher risk for major depression on all the subjects endorsed the fear of becoming fat de-
bulimia nervosa. spite being substantially underweight. Table I also lists
We approximated the DSM-IV subdivision of anorexia nenvosa the mean percent underweight at the time of anorexia
into restricting and binge-eating types by defining the latter as those
nervosa for those in each anorexia nervosa class; the
who reported bulimic symptoms with an age at onset identical to that
of anorexia nervosa. Analyses were performed to examine differences
proportion exceeded 15% for all three groups.
in comorbidity and proposed risk factors between the two types. For the computer narrow, clinical narrow, and clini-

66 AmJPsychiatry 152:1,January 1995

 ELLEN E. WALTERS AND KENNETh S. KENDLER

TABLE 2. Odds Ratios f or Prey alence of Psychiatric Com orbidity in Subjects With Lifetime An orexia N ervosa From a Population-Ba sed Sample
of 2,163 Female Twins

Diagnosis of Anorexia Nenvosa

Group v’ (N=11) Group2t’(N=24) Group 3’ (N=45)

95% 95% 95%

Odds Confidence X2 Odds Confidence X2 Odds Confidence x2 x2
Disorder Ratio Interval (df=I) Ratio Interval (df=1) Ratio Interval (df=1) (df=1)”

Majordepression 4.0 1.2-13.8 5.71* 2.7 1.2-6.1 6.33* 2.6 1.4-4.7 10.90*** 0.39
Bulimia nervosa 11.8 3.4-41.0 24.2Sf 12.4 5.3-29.1 54.18t 9.3 4.8-18.1 63.07t 0.32
Alcoholism 1.9 0.5-7.3 0.96 3.7 1.6-8.3 10.99*** 2.3 1.2-4.4 6.94** 1.01
Panic disorder 2.7 0.3-21.5 0.97 1.2 0.2-8.8 0.03 3.4 1.3-8.8 7.03** 1.06
Generalized anxiety
disorder 6.1 1.6-23.4 9.1S** 1.5 0.3-6.4 0.29 1.2 0.4-3.8 0.07 3.31
Phobias 2.9 0.9-9.6 3.39 4.0 1.8-9.3 12.63*** 2.5 1.4-4.6 10.13** 0.83
aSubjects whose diagnosis of anorexia nervosa was based on a computer algorithm of their responses to the appropriate SCID items.
bSubjects who met the clinical narrow definition (definite or probable diagnosis of anorexia nervosa) but not the computer algorithm criteria.
cSubjects who had a diagnosis of possible anorexia nervosa.
dChisquare for homogeneity.
*p<O.Os. **p<O.Ol. ***p<O.OOI. tp<0.000I.

cal broad definitions, no significant differences were tiveness was significantly associated with group 1 (x2=
found for diagnosis on the basis of the method of in- 5.6, df=1, p=O.O2).
terview (telephone or in person) or interview status of Odds ratios to assess cornorbidity are listed in table
the co-twin. All tests of equal environment (frequency 2. Significant comonbidity was seen with major depres-
of contact and childhood similarity) were nonsignifi- sion and bulimia nervosa for all three groups of ano-
cant except for childhood similarity in the clinical nar- mexia nervosa subjects. Group 1 also had a significant
now definition (x2=S.7 df=1, p=O.O2). For this group, association with generalized anxiety disorder, group 2
greater childhood similarity was associated with higher with alcoholism and phobias, and group 3 with alco-
concordance for anorexia nervosa symptoms. holism, phobias, and panic disorder. Chi-squane tests
Under the proportional odds model, five of the 17 of homogeneity were nonsignificant across the three
risk factors examined were significantly associated with groups.
an anorexic syndrome: dieting status (X2=6.S df=1, p= The co-twin of a twin with anorexia nervosa had
0.01), a greater number of years of parental education an odds ratio for anorexia nervosa of 50.4 (p<0.OOS,
(x2=6.2 df=1, p=O.Ol), low self-esteem (x2=l2.l df=1, Fisher’s exact test) when the computer narrow defini-
p<O.OO1), high level of neumoticism (x2=l2.S df=1, p< tion was used, 8.9 (p<0.OOS, Fisher’s exact test) when
0.001), and maternal overprotectiveness (X2=6.l df=1, the clinical narrow definition was used, and 5.3 (p<
p=O.Ol). 0.001, Fisher’s exact test) when the clinical broad defi-
The assumption of proportional odds was rejected nition was used.
only for the risk factor dieting status. However, it No monozygotic twin pairs and only one dizygotic
should be noted that even this result may be question- twin pair was concordant (dizygotic pnobandwise con-
able since it was not possible to estimate the effect of cordance=40.O%) for the computer narrow definition
dieting status in the computer narrow group because of of anorexia nervosa. No monozygotic twin pairs and
singularity in the information matrix. two dizygotic twin pairs were concordant (dizygotic
To determine whether the risk factors had a similar probandwise concordance=25.0% ) for the clinical nan-
impact on each of the three groups with an anorexic- now group. Two pairs of monozygotic twins and four
like syndrome, the sample was restricted to only those pairs of dizygotic twins were concordant for the clinical
with a diagnosed syndrome and a three-level polychot- broad group (probandwise concordance rates of 9.5%
omous logistic regression was fit. Of the 1 7 risk factors, and 22.2%, respectively).
dieting status (x28.8 df=1, p<O.Ol), parental occupa- The relationship between a twin’s anorexia nervosa
tion (x2=6.O df=1, p=O.Ol), and college education (x2= diagnosis and her co-twin’s body mass index score was
7.8, df=1, p<O.Ol) significantly discriminated among examined. The co-twin of a twin diagnosed with ano-
the three levels of anorexia nervosa (groups 1-3). On rexia nervosa had a body mass index score that aver-
examining these risk factors more closely, college edu- aged 1.1-1.8 units less than the co-twin of a twin with-
cation had a significantly greater impact for groups 1 out anorexia nervosa, the reduction in body mass index
(2=4#{149}, df=1, p=O.O3) and 2 (x2=3.9 df=1, p=O.OS) being greater for co-twins of more severely affected
than for group 3, while parental occupation indicated a twins. This change in body mass index score was sig-
significantly greater risk for group 2 (x2=S.7 df=1, p= nificant (p=O.O3) for the clinical broad (beta=1.1)
0.02) than for group 3. Also of particular note, dieting group. A similar analysis with weight in pounds as the
appeared to be more closely associated with group 3 dependent variable resulted in a reduction that ranged
than group 2 (nonsignificant), and paternal overprotec- from 6.3 to 11.1 pounds.

Am] Psychiatry 152:1,January 1995 67

ANOREXIC-LIKE SYNDROMES

TABLE 3. Risks for Major Depression and Bulimia in Co-Twins of Twins With Lifetime Anorexia Nervosa From a Population-Based Sample of
2,163 Female Twins
Relative Risk of Relative Risk of
Major Depression in Co-Twin Bulimia in Co-Twin

Estimate Estimate
Controlled for Controlled for
Uncontrolled Comonbidity Uncontrolled Comorbidity
Definition of Anorexia in Proband Estimate With Anorexia Estimate With Anorexia

Computer narrow (computer algorithm of responses to SCID) (N=I 1) 2.0 1 .8 1 .5 1.4

Clinical narrow (definite on probable anorexia) (N=35) 2.3** 2.0* 4.6** 2.6*
Clinical broad (definite, probable, on possible anorexia) (N=80) 2.2* * 1.9* * 2.4* 1.3
*p<0.00I. **p<o.000l.

Table 3 presents the risks for major depression and early teens and early twenties (1 ). The mean age at onset
bulimia nervosa in the co-twin of a twin with one of the in our general population sample was higher than that
definitions of anorexia nenvosa. Co-twins of twins di- seen in many clinical samples. This may be because
agnosed with clinical narrow and clinical broad ano- women with early onset anorexia nervosa are more likely
rexia nervosa were at significantly higher risk for both to present for treatment.
major depression and bulimia nervosa. Co-twins of
twins diagnosed with computer narrow anorexia nem- Epidemiologic Risk Factors for Anorexia Nervosa
vosa also had a higher risk, although it was nonsignifi-
cant. Higher risk for major depression and bulimia ner- In this sample, a greater number of years of parental
vosa in co-twins could be due to comorbidity between education was significantly associated with a diagnosis
these disorders and anorexia nervosa in the proband of anorexia nenvosa, while parental occupation and col-
twins. Therefore, table 3 also presents these risks calcu- lege education significantly discriminated among the
lated after comonbidity in the proband was controlled. three anorexia nervosa groups. These findings suggest
Although slightly lower than the uncontrolled esti- a greater prevalence of anorexic symptoms among
mates, all the risks for co-twins of twins diagnosed with higher socioeconomic classes in a general population
the clinical narrow and clinical broad definitions me- sample. Our results cannot be due to social class pre-
mained significant except for bulimia nervosa in the dicting treatment seeking rather than the true risk of
clinical broad group. illness as we interviewed a general population sample.
Analyses of restricting and binge-eating types me- These findings have been replicated in some studies (1)
vealed no significant differences in patterns of comor- but not in others (27, 28). Such discrepancies could be
bidity. One finding of note was a substantial but non- caused by undendiagnosis of the disorder in lower social
significant higher risk for major depression in the classes on greater availability of medical resources to
restricting than in the binge-eating type. None of the 17 diagnose and treat such disorders in upper social
proposed risk factors significantly predicted type of classes. In addition, the results of one study (27) were
anorexia nervosa. However, because of small sample based solely on current social class of the adult patients.
size, these analyses were of low statistical power. Social class information for the childhood subjects
could not be obtained. However, it may be that it is the
social class during adolescent development that is a risk
DISCUSSION factor for anorexia nervosa, not the adult status. Fur-
then work in epidemiologic samples needs to be done to
Lifetime Prevalence ofAnorexia Nervosa clarify these relationships.
Our study found a significant association between
Consistent with previous epidemiologic surveys (1, 3, anorexia nenvosa and low self-esteem. However, we
4), we found that classic, narrowly defined anorexia nen- also found significant comorbidity between anorexia
vosa was a relatively rare syndrome in women, with a nervosa and major depression. Since low self-esteem is
lifetime prevalence of approximately one-half of one pen- a symptom of depression, the association of anorexia
cent. However, also in accord with previous work (5-7), nervosa and self-esteem may be secondary to the asso-
we found a substantial number of women who reported ciation of anorexia nervosa and major depression. To
anonexic-like syndromes. Using a clinical narrow defini- test this, we compared the self-esteem scones of those
tion, we found that over 1 % ofwomen had this anorexia- with anorexia nenvosa who had a history of major de-
like syndrome but did not meet full criteria for classic pnession to those with anorexia nervosa and no major
anorexia nervosa. Using broad criteria, we found that depression history. Both groups had significantly lower
over 3% of women reported an anonexic-like episode at self-esteem than the general population, but were not
one on more times in their lives. Although age at onset significantly different from one another. These findings
has been reported from 7 to 85 years, the majority of suggest that low self-esteem may be an epidemiologic
subjects presenting for clinical treatment have onset in the risk factor for anorexia nervosa and not simply a con-

68 Am J Psychiatry 152:1, January 1995

 V

ELLEN E. WALTERS AND KENNETH S. KENDLER

sequence of comorbid depression. These results par- among the three groups with respect to risk factors.
tially replicate the findings of a study (29) that exam- Only three of the proposed risk factors (dieting status,
med subjects with anorexia and bulirnia nenvosa. Both parental occupation, and college education) signifi-
the depressed and nondepressed eating disorder groups cantly discriminated among the three groups and a pro-
had lower self-esteem than the general population. portional odds model fits the continuum of anorexic-
However, the depressed and nondepressed groups were like diagnoses. This implies that there exists an etiologic
also statistically different from each other. continuity of impact for the risk factors across the defi-
The literature on the relationship between body im- nitions of anorexia nervosa, i.e., that there is a spectrum
age and anorexia nervosa suggests that body size dis- of anonexic-like behaviors, with no sharp qualitative
tortion and body image dissatisfaction are important difference between those with anorexia nervosa and
aspects of the disorder (30, 31). Although our study those with an anorexic-like syndrome.
found no significant associations between anorexia Analyses were performed to test for possible bias in
nervosa and body image or ideal body image as meas- interview methods and assumptions. The only signifi-
ured by a silhouette scale, it is possible that this was cant result, childhood similarity in the clinical narrow
because few of the twins with a history of anorexia group, suggests the possibility of some childhood envi-
nervosa were actively symptomatic at the time of as- ronmental effects in the etiology of anorexia nervosa.
sessment. Since recovery may be related to improve- Those twins who were treated more similarly as chil-
ment in body image perception (32, 33), individuals dren were more likely to be concordant for lifetime his-
who have recovered from anorexia nervosa may no tory of clinical narrow anorexia nervosa as adults.
longer be distinguishable from the normal population However, this association was not strong and six tests
on such measures. of significance for equal environment were made,
The results of several studies suggest that a complex which increased the probability of a test being signifi-
relationship exists among body image, overestimation cant by chance alone. If this effect is meal, it could inflate
of body size, self-esteem, neuroticism, and locus of the estimate of heritability. It is hoped that future twin
control (31, 32). While the exact mechanism that leads studies of anorexia nervosa will be able to address the
an individual with a sense of high external control to strength of this possible association.
overestimate her body size is unclear, it has been pro-
posed that self-worth is manifested in perceived body Pattern of Comorbidity in Anorexia Nervosa
shape (33). Our study found significantly higher levels
of neuroticism among those with anorexia nervosa but Significant comorbidity was found between anorexia
no significant difference in locus of control. Perhaps nenvosa and a mange of other psychiatric disorders. The
locus of control is abnormal only during the state of strongest of these relationships was between anorexia
anorexia nervosa, while neunoticism is a stable trait and bulimia nervosa, which suggests shared etiologic
marker for vulnerability. factors in these two eating disorders. This possibility is
The significance of maternal and paternal overpro- supported by the fact that after bulimia nervosa in the
tectiveness as risk factors in our sample supports the twin was controlled, the co-twin of a twin affected with
thesis presented by both Bruch (33) and Palazzoli (34) clinical narrow anorexia nervosa was still 2.6 times as
that the typical person with anorexia nervosa comes likely to have bulimia nervosa than the co-twin of an
from an inward family and is often overprotected and unaffected twin. Thus, while some of the familial rela-
highly controlled. Enmeshment, overprotectiveness, tionship between anorexia and bulimia nervosa is due
and rigidity have also been listed when describing fea- to comorbidity of the disorders, a common set of famil-
tunes of families with anorexic members (35). These me- ial factors appears to influence the risk for both kinds
sults should be considered as preliminary, however, be- of eating disorder. A previous study examining the ge-
cause they could result from retrospective recall bias. netic epidemiology of bulimia nervosa in this same sam-
Although one study (36) found significant differences in pIe of female twins (19) found high neunoticism and
family pathology between families of patients with ano- low self-esteem to be also significantly related to bu-
rexia nervosa and families of control subjects, no sig- limia nervosa. These findings, which are consistent with
nificant difference was found on a control subscale. In other published reports, reinforce the existence of a set
addition, a review by Yager (37) highlights the anecdo- of common predisposing factors for bulimia and ano-
tal nature of common perceptions of the role of the fam- rexia nervosa. Bulimia nervosa was not found to be as-
ily in the development of anorexia nervosa and the van- sociated with social class or maternal overprotective-
ability among studies as to the proposed role. ness, but there was an association with paternal care.
Several analyses presented here were made to deter- These differences in risk factors suggest that while bu-
mine if any qualitative difference exists among those limia and anorexia nervosa have some etiologic factors
with anorexia nervosa that met computer narrow crite- in common, the development of one or the other may
na, those with clinical narrow anorexia that did not be due to complex interrelationships among personality
meet strict DSM-III-R criteria, and those with clinical traits, personality-like constructs, familial environ-
broad anorexia that did not meet criteria for either of ment, and genetic predisposition. The pattern of co-
the more severe definitions. Within the power of our morbidity was very similar across the range of ano-
sample, few significant differences appeared to exist rexic-like syndromes (i.e., all tests of homogeneity were

Am J Psychiatry 152:1, January 1995 69

V

ANOREXIC-LIKE SYNDROMES

nonsignificant), which provides further evidence for a

population, however, inhibits the ability to discriminate
spectrum concept of anorexia nervosa. whether the familial component is environmental or ge-
netic. The small amount of available information is
Familial Aggregation ofAnorexia Nervosa more consistent with a familial environmental explana-
tion, but we would hesitate to base any firm conclu-
For all three definitions of anorexia nenvosa, the co- sions on these data. It may be necessary to conduct hi-
twin of a twin with anorexia nervosa was at signifi- tune twin studies on representative samples of treated
cantly higher risk for anorexia nenvosa. However, be- cases of anorexia nervosa to ensure the power required
cause of the very low prevalence of anorexia nervosa to fully examine this issue.
in the general population, the number of concordant
twins in this sample was very small, and the dizygotic
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