0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Original Article |

Eating Disorders During Adolescence and the Risk for Physical and Mental Disorders During Early Adulthood FREE

Jeffrey G. Johnson, PhD; Patricia Cohen, PhD; Stephanie Kasen, PhD; Judith S. Brook, PhD
[+] Author Affiliations

From the Departments of Psychiatry, Columbia University and the New York State Psychiatric Institute (Drs Johnson, Cohen, and Kasen) and The Mount Sinai Medical Center (Dr Brook), New York, NY.


Arch Gen Psychiatry. 2002;59(6):545-552. doi:10.1001/archpsyc.59.6.545.
Text Size: A A A
Published online

Background  Data from a community-based longitudinal investigation were used to investigate whether adolescents with eating disorders are at an elevated risk for physical and mental disorders during early adulthood.

Methods  Psychosocial and psychiatric interviews were administered to a representative community sample of 717 adolescents and their mothers from 2 counties in the state of New York in 1983, 1985 to 1986, and 1991 to 1993. In 1983, the mean age of the youths was 13.8 years.

Results  Adolescents with eating disorders were at a substantially elevated risk for anxiety disorders, cardiovascular symptoms, chronic fatigue, chronic pain, depressive disorders, limitations in activities due to poor health, infectious diseases, insomnia, neurological symptoms, and suicide attempts during early adulthood after age, sex, socioeconomic status, co-occurring psychiatric disorders, adolescent health problems, body mass index, and worries about health during adulthood were controlled statistically. Problems with eating or weight during adolescence predicted poor health outcomes during adulthood, regardless of whether an eating disorder had been present. Only 22% of the adolescents with current eating disorders had received psychiatric treatment within the past year.

Conclusion  Eating disorders during adolescence may be associated with an elevated risk for a broad range of physical and mental health problems during early adulthood.

PATIENTS WITH severe eating disorders have elevated rates of physical illness,19 psychiatric disorder,1016 suicide,17 and mortality.1820 However, relatively little is known about the association between eating disorders and subsequent health problems among individuals in the general population.21 Nearly all of the population-based epidemiological studies of eating disorders and associated health problems have been cross-sectional investigations. Directional inferences cannot be made from cross-sectional data, and longitudinal research is needed to investigate whether individuals with eating disorders in the community are at an elevated risk for subsequent health problems. Because eating disorders often develop during adolescence,22 it is of particular interest to examine the long-term health outcomes associated with adolescent eating disorders.

Most of the information available regarding the course and sequelae of eating disorders has been provided by treatment outcome studies. Most of these studies have investigated the outcome of treatment for anorexia nervosa, although the outcome of adolescent-onset anorexia nervosa has not been extensively investigated.23 A few recent studies have examined outcomes associated with bulimia nervosa, but little information is available regarding the long-term outcome of patients with bulimia nervosa.24 Most treatment outcome studies have investigated the course of eating disorder symptoms, and relatively little information has been obtained regarding other outcomes, including physical and mental disorders.25 The available findings indicate that, while many patients who are treated for eating disorders have fair or satisfactory outcomes, patients with poor treatment outcomes are at risk for physical illnesses,2628 psychiatric disorders,2931 suicide attempts,28 and mortality.32,33

Yet, because participants in treatment outcome studies tend to have severe eating disorders and co-occurring health problems, the findings may not be applicable to adolescents with eating disorders in the community. Most eating disorders are not detected by primary care physicians,34 and most individuals with eating disorders in the community do not receive treatment.35 Although some epidemiological studies3537 have examined the course or development of eating disorders, to our knowledge, no population-based prospective longitudinal study has investigated the association between adolescent eating disorders and a broad range of physical and mental health problems during adulthood.

We report such epidemiological findings from the Children in the Community Study. Statistical procedures are used to control for age, sex, and parental income, which are associated with many physical and psychiatric symptoms. Preexisting health problems during adolescence are also controlled, permitting investigation of the hypothesis that adolescent eating disorders contribute to an increased risk for the development of mental and physical health problems.

PARTICIPANTS AND PROCEDURE

The participants in the present study were 717 youths (51% females) and their mothers, who completed research interviews conducted in 1983, 1985 to 1986, and 1991 to 1993.38 The participating families were a subset of 976 randomly sampled families from 2 upstate New York counties, with children ranging in age from 1 to 10 years, with whom maternal interviews had been conducted in 1975.39 During the 3 follow-up interviews, which were administered by extensively trained and supervised lay interviewers, the youths and their mothers were interviewed to assess Axis I and II psychiatric disorders and demographic and other psychosocial variables. The mean age of the youths was 13.8 (SD, 2.6; range, 9-19) years in 1983, 16.1 (SD, 2.7; range, 11-23) years in 1985 to 1986, and 22.0 (SD, 2.7; range, 17-28) years in 1991 to 1993. The families in this study generally represented families in the northeastern United States for socioeconomic status and most demographic variables (38%), but they reflected the sampled region, with high proportions of those taking the survey being Roman Catholic (54%) and white (91%). Study procedures were approved according to appropriate institutional guidelines. Written informed consent was obtained after the interview procedures were fully explained. Youths and their mothers were interviewed separately, and both interviewers were blind to the responses of the other informant. Additional information regarding the study methods is available from previous reports.38,39

ASSESSMENT OF PSYCHIATRIC DISORDERS, TREATMENT, AND PHYSICAL HEALTH PROBLEMS

The parent and youth versions of the Diagnostic Interview Schedule for Children (DISC-I)40 were administered in 1983, 1985 to 1986, and 1991 to 1993 to assess anxiety (obsessive-compulsive disorder, overanxious disorder, panic disorder, separation anxiety disorder, and social phobia), disruptive (attention-deficit disorder, conduct disorder, and oppositional defiant disorder), eating (anorexia nervosa, binge-eating disorder, bulimia nervosa, and eating disorder not otherwise specified), depressive (dysthymic disorder and major depressive disorder), and substance use (alcohol and other drug abuse or dependence) disorders. The eating disorders module of the DISC-I assessed height, weight, and specific eating and weight problems. The height and weight data were used to compute the youths' body mass index (BMI) (calculated as weight in kilograms divided by the square of height in meters). Following the publication of DSM-IV, computerized diagnostic algorithms were developed to determine whether the diagnostic criteria for DSM-IV eating disorders were met. Eating disorder not otherwise specified was diagnosed, in accordance with DSM-IV guidelines, if there were clinically significant eating problems(eg, anorexia without amenorrhea or self-induced vomiting), but these symptoms did not meet the criteria for a specific eating disorder. Parents and youths were interviewed because research has demonstrated that the use of multiple informants tends to increase the reliability and validity of psychiatric diagnoses.41,42 Symptoms were considered present if reported by either informant. Diagnostic findings were not provided to either informant. Parental and youth reports of psychiatric symptoms were positively correlated in the entire sample (r = 0.38, P<.001) and in the subsample of youths with eating disorders(r = 0.40, P = .01). Previous research43 has indicated that the reliability and validity of the DISC-I as used in the present study are comparable to those of other structured interviews.43

Personality disorders were assessed with items from the Personality Diagnostic Questionnaire,44 the DISC-I, and other measures.38 Items were selected based on correspondence with DSM-III-R45 diagnostic criteria, combined using algorithms developed by a psychiatrist and 2 clinical psychologists,46 and subsequently modified to correspond with revisions in the DSM-IV22 diagnostic criteria. Adolescent personality disorder diagnoses were assigned only if youths met the DSM-IV diagnostic criteria in 1983 and 1985 to 1986 or if they met the DSM-IV diagnostic criteria at one assessment and were within one criterion of the diagnosis at the other assessment. Research4749 has supported the reliability and validity of the items and algorithms used to assess personality disorders.

The version of the DISC-I administered in the present study was expanded to assess the following physical health problems during adolescence and early adulthood: cardiovascular illness, chronic allergies, chronic fatigue, chronic orthopedic problems, chronic or frequent insomnia, chronic or frequent pain, chronic respiratory illnesses, limitations in activities due to poor health, migraine or other chronic headaches, neurological symptoms (eg, epilepsy), other chronic illnesses (eg, diabetes), worries about health problems, and fair or poor overall health. Susceptibility to infectious diseases (eg, influenza) was assessed during early adulthood with an item assessing whether the participant tended to become "sick more easily than other people." These health problems were considered present if reported by either informant. Parental and youth reports of physical health problems were positively correlated in the entire sample (r = 0.42, P<.01) and in the subsample of youths with eating disorders (r = 0.61, P<.01). Additional questions regarding psychiatric treatment were asked during the maternal interviews and during the youth interview in 1991 to 1993. The respondents were asked if the youth had received treatment from a mental health professional and if such treatment had been provided in the past year. Data were not obtained regarding specific treatment for eating disorders.

DATA ANALYSIS

Descriptive statistics were computed to determine the prevalence of all of the study variables. Analyses of contingency tables were conducted to investigate whether eating disorders, weight loss behaviors, and behaviors associated with weight gain during adolescence were associated with risk for the development of mental and physical health problems during early adulthood. Logistic regression analyses were conducted to investigate whether these associations were significant after age; sex; anxiety; depressive, disruptive, personality, and substance use disorders; corresponding health problems during adolescence; parental income; co-occurring problems with eating or weight; and worries about health during early adulthood were controlled statistically. To reduce the likelihood of type II errors, these covariates were controlled sequentially in a series of analyses, rather than simultaneously in a single analysis, and bivariate odds ratios (ORs) are reported. To reduce the likelihood of type I errors, α = .01 was used to determine whether the ORs were statistically significant.

Analyses of contingency tables and logistic regression analyses were conducted to investigate whether low body weight (defined as a BMI of ≤16.60, identifying individuals whose BMI was at least 2 SDs below the sample mean) or obesity (defined as a BMI of ≥28.25, identifying individuals whose BMI was at least 2 SDs above the sample mean) during adolescence was associated with an elevated risk for health problems during early adulthood.

DESCRIPTIVE STATISTICS

Thirty-six female subjects (10%) and 4 male subjects (1%) had eating disorders during early or middle adolescence (Table 1). Of the 40 adolescents with current eating disorders, 9(22%) had received treatment from a mental health professional during the past year. Of these 9 youths, 8 (89%) had co-occurring psychiatric disorders. In comparison, 17 (55%) of the 31 youths who were not treated by a mental health professional had co-occurring psychiatric disorders (χ2= 3.45, P = .06). Four individuals had eating disorders during adolescence and early adulthood. Youths with eating disorders had a mean of 6 problems with eating or weight during adolescence, regardless of treatment status.

Table Graphic Jump LocationTable 1. Eating and Weight Problems During Adolescence and Early Adulthood*

The BMI scores of adolescents with eating disorders were not significantly(t715 = 1.60, P = .12) different from those of adolescents without eating disorders. However, the adolescents who reported strict dieting (t715 = 6.38, P<.001), eating alone to conceal unusual eating behavior (t715 = 3.03, P = .004), frequent exercise to lose weight (t715 = 9.27, P<.001), fasting for at least 24 hours (t715 = 3.45, P = .001), recurrent fluctuations in weight (t715 = 4.36, P<.001), self-induced vomiting (t715 = 2.32, P = .02), and the use of medication to lose weight (t715 = 3.48, P = .001) had significantly higher BMI scores at a mean age of 16.1 years than those who did not have these eating or weight problems.

HEALTH PROBLEMS ASSOCIATED WITH EATING DISORDERS DURING ADOLESCENCE

Eating disorders during adolescence were significantly associated with co-occurring chronic fatigue (OR, 3.81; 95% confidence interval [CI], 1.48-9.76), chronic or frequent insomnia (OR, 2.88; 95% CI, 1.44-5.76), chronic or frequent pain (OR, 3.26; 95% CI, 1.71-6.21), migraine or other chronic headaches (OR, 3.38; 95% CI, 1.72-6.64), and any chronic health problems (OR, 2.33; 95% CI, 1.22-4.44). Adolescent eating disorders were also associated with co-occurring anxiety (OR, 3.49; 95% CI, 1.73-7.04), depressive disorders (OR, 5.20; 95% CI, 2.44-11.08), disruptive disorders (OR, 3.78; 95% CI, 1.84-7.76), personality disorders (OR, 3.64; 95% CI, 1.73-7.66), substance use disorders (OR, 4.50;95% CI, 2.01-10.09), and suicide attempts (OR, 5.02; 95% CI, 1.92-13.14) during adolescence.

ADOLESCENT EATING DISORDERS AND PHYSICAL HEALTH OUTCOMES DURING EARLY ADULTHOOD

Eating disorders during adolescence were associated with an increased risk for cardiovascular symptoms, chronic fatigue, chronic or frequent insomnia, chronic or frequent pain, neurological symptoms, frequent sickness, many activities limited due to poor health, fair or poor overall health, and any chronic health problems during early adulthood (Table 2). These associations remained significant after age, sex, co-occurring psychiatric disorders, corresponding health problems during adolescence, parental income, BMI, and worries about health during early adulthood were controlled statistically. Eating disorders were not associated with risk for diabetes, which was present in 3 individuals.

Table Graphic Jump LocationTable 2. Eating Disorders During Adolescence and Chronic Health Problems During Early Adulthooda
ADOLESCENT EATING DISORDERS AND MENTAL HEALTH OUTCOMES DURING EARLY ADULTHOOD

Eating disorders during adolescence were associated with an increased risk for anxiety disorders, depressive disorders, and suicide attempts during early adulthood (Table 3). These associations remained significant after age, sex, co-occurring psychiatric disorders, corresponding psychiatric conditions during adolescence, parental income, BMI, and worries about health during early adulthood were controlled statistically. Twenty-five (62%) of the adolescents with eating disorders had 2 or more chronic physical health problems during early adulthood. In comparison, 22% of the adolescents without psychiatric disorders and 32% of the adolescents without eating disorders who had other psychiatric disorders had multiple chronic physical health problems during early adulthood (χ22 = 34.34, P<.001).

Table Graphic Jump LocationTable 3. Eating Disorders During Adolescence and Psychiatric Conditions During Early Adulthooda
ADOLESCENT WEIGHT LOSS BEHAVIORS AND HEALTH PROBLEMS DURING EARLY ADULTHOOD

Fasting, frequently exercising to lose weight, self-induced vomiting, and strict dieting during adolescence were associated with health problems during early adulthood after age, sex, co-occurring psychiatric disorders, corresponding health problems during adolescence, parental income, and worries about health during early adulthood were controlled statistically (Table 4). Several of the associations between weight loss behaviors and subsequent health problems remained significant after adolescent eating disorders, co-occurring eating or weight problems, and BMI were controlled statistically. Because all of the adolescents who reported self-induced vomiting met the criteria for bulimia nervosa or eating disorder not otherwise specified, co-occurring eating disorders could not be controlled in the analyses involving self-induced vomiting. The use of medications to lose weight was not significantly associated with any subsequent physical or mental health problems. A low body weight during adolescence was associated with an elevated risk for respiratory illnesses during adulthood(OR, 4.44; 95% CI, 2.07-9.62). This association remained significant after age, sex, co-occurring psychiatric disorders, corresponding health problems during adolescence, parental income, adolescent eating disorders, and worries about health during early adulthood were controlled statistically. A low body weight during adolescence was not independently associated with any other adult health problems after these covariates were controlled.

Table Graphic Jump LocationTable 4. Significant Associations Between Weight Loss Behaviors During Adolescence and Health Problems During Early Adulthooda
ADOLESCENT BEHAVIORS ASSOCIATED WITH WEIGHT PROBLEMS AND ADULT HEALTH PROBLEMS

Eating alone to conceal unusual eating behavior, eating a large amount of food, and frequent fluctuations in weight during adolescence were associated with early adulthood health problems after age, sex, co-occurring psychiatric disorders, corresponding health problems during adolescence, parental income, and worries about health during early adulthood were controlled statistically(Table 5). Several of the associations between these behaviors and subsequent health problems remained significant after adolescent eating disorders, co-occurring eating or weight problems, and BMI were controlled. Adolescent obesity was associated with an elevated risk for fair or poor health during adulthood (OR, 4.31; 95% CI, 1.39-13.33). This association remained significant after age, sex, co-occurring psychiatric disorders, corresponding health problems during adolescence, parental income, adolescent eating disorders, and worries about health during early adulthood were controlled. Adolescent obesity was not independently associated with any other adult health problems after these covariates were controlled.

Table Graphic Jump LocationTable 5. Significant Associations Between Behaviors Associated With Weight Problems During Adolescence and Health Problems During Early Adulthooda

The present findings indicate that adolescents with eating disorders are at an elevated risk for a broad range of physical and mental health problems during early adulthood. Our findings are consistent with the findings of cross-sectional and treatment outcome studies2633,50,51 indicating that eating disorders tend to be associated with poor physical and mental health outcomes. However, to our knowledge, these are the first systematic findings from a community-based longitudinal investigation to demonstrate that adolescent eating disorders are associated with the risk for the development of physical and mental disorders after preexisting health problems are controlled statistically. Because most individuals with eating disorders are not appropriately diagnosed or treated,34,35 it seems that greater effort should be devoted to the recognition and treatment of eating disorders among adolescents in the community. The administration of screening questionnaires to patients with eating or weight problems may help primary care physicians, pediatricians, and other practitioners to increase the recognition of eating disorders.52 Referring adolescents with eating disorders to appropriate treatment specialists may help to prevent the development of potentially serious health problems.

The present findings also indicate that specific problems with eating or weight during adolescence are associated with an increased risk for physical and mental disorders during early adulthood. Our findings are of particular interest because they indicate that youths with eating or weight problems may be at an elevated risk for health problems during adulthood, even if their problems with eating or weight are not severe enough to warrant an eating disorder diagnosis. Because problems with eating and weight are so common among adolescents in the general population, it would seem important to develop and implement educational and public health interventions that inform parents and youths about the potentially harmful long-term consequences of eating and weight problems during adolescence.53

The present findings also indicate that problematic behaviors associated with eating and weight tend to be more strongly associated with risk for subsequent health problems than body weight itself. Particularly noteworthy are our findings indicating that self-induced vomiting is strongly associated with various adverse health outcomes. Future research should investigate the biological and psychological processes that may mediate the associations between specific problems with eating and weight and the development of physical and mental disorders. Numerous factors, including disruptions in hormonal, neurotransmitter, cytokine, peptide, immunologic, and metabolic functioning, may underlie these associations.50,51,5458 An increased understanding of the mechanisms that govern the association between eating or weight problems and adverse health outcomes may facilitate the development of more effective treatment interventions.

Although effective treatments are available for youths with eating disorders,2333 the present findings from this upstate New York sample are consistent with previous findings35 indicating that relatively few adolescents with eating disorders receive these kinds of specialized treatment services. Because eating and weight problems are associated with a wide range of adverse health outcomes, the present findings suggest that greater effort should be made to promote increased recognition and treatment of eating and weight problems by pediatricians, primary care physicians, and other health professionals. Our findings also suggest that specialized treatment programs should be made more widely available to adolescents with eating disorders.

Limitations of the present study merit consideration. There were not enough cases to permit analyses regarding associations between specific types of adolescent eating disorders and adult health problems. Therefore, we investigated associations between specific eating or weight problems and health problems during early adulthood. In this respect, the present findings provide a uniquely detailed and systematic contribution to the scientific literature. Health outcomes were assessed by interview and could not be independently verified. However, adolescent problems with eating or weight were associated with poor adult health outcomes after worries about health during early adulthood were controlled statistically. Because sufficiently detailed data regarding treatment were not available, treatment outcomes could not be systematically investigated. Few male subjects had eating disorders; however, many male subjects had eating or weight problems, and it was of interest to investigate the health problems that were associated with these problems. There were relatively few subjects with certain health outcomes, such as cardiovascular symptoms, chronic fatigue, and neurological symptoms. This would have been a concern if adolescent problems with eating or weight did not predict these health outcomes. However, problems with eating or weight during adolescence did predict several of the health outcomes that were low in prevalence.

The present study also has numerous methodological strengths, including the use of a large representative sample, the use of a longitudinal design, the systematic assessment of a wide range of psychiatric disorders and health problems from adolescence through early adulthood based on data that were obtained from the youths and their mothers, and the use of statistical procedures to control for the effects of age, sex, socioeconomic status, co-occurring psychiatric disorders, preexisting health problems, and worries about health during early adulthood. For these reasons, the present findings promise to increase our understanding of the association between eating disorders and health problems during early adulthood.

Submitted for publication February 28, 2001; final revision received August 16, 2001; accepted September 11, 2001.

This study was supported by grant MH-36971 from the National Institute of Mental Health, Rockville, Md (Dr Cohen); and grant DA-03188 from the National Institute on Drug Abuse, National Institutes of Health, Bethesda, Md (Dr Brook).

Corresponding author: Jeffrey G. Johnson, PhD, New York State Psychiatric Institute, 1051 Riverside Dr, Campus Box 60, New York, NY 10032 (e-mail: jjohnso@pi.cpmc.columbia.edu).

DeZwaan  MMitchell  J Medical complications of anorexia nervosa and bulimia nervosa. Kaplan  ASGarfinkel  PEeds.Medical Issues and Eating Disorders. New York, NY Brunner/Mazel1993;60- 100
Palmer  EPGuay  AT Reversible myopathy secondary to abuse of ipecac in patients with major eating disorders. N Engl J Med. 1985;3131457- 1459
Link to Article
Johnson  JGSpitzer  RLWilliams  JBW Health problems, impairment, and co-occurring illnesses associated with eating disorders among female primary care and obstetric-gynecology patients. Psychol Med. 2001;311455- 1466
Link to Article
Mallick  MJ Health hazards of obesity and weight control in children: a review of the literature. Am J Public Health. 1983;7378- 82
Link to Article
Devlin  MJWalsh  TBKral  JGHeymsfield  SBPi-Sunyer  FXDantzic  S Metabolic abnormalities in bulimia nervosa. Arch Gen Psychiatry. 1990;47144- 148
Link to Article
Kaplan  AS Biomedical variables in the eating disorders. Can J Psychiatry. 1990;35745- 753
Kaye  WHGwirtsman  HEGeorge  DT The effects of binging and vomiting on hormonal secretion. Biol Psychiatry. 1989;25768- 780
Link to Article
Spitzer  RLDevlin  MWalsh  TBHasin  DWing  RMarcus  MStunkard  AWadden  TYanovski  SAgras  SMitchell  JNonas  C Binge eating disorder: a multisite field trial of the diagnostic criteria. Int J Eat Disord. 1992;3191- 203
Link to Article
Yanovski  SZ Biological correlates of binge eating. Addict Behav. 1995;20705- 712
Link to Article
Bulik  CMSullivan  PFFear  JLJoyce  PR Eating disorders and antecedent anxiety disorders: a controlled study. Acta Psychiatr Scand. 1997;96101- 107
Link to Article
Braun  DLSunday  RHalmi  KA Psychiatric comorbidity in patients with eating disorders. Psychol Med. 1994;24859- 867
Link to Article
Brewerton  TDLydiard  BRHerzog  DBBrotman  AWO'Neil  PMBalenger  JC Comorbidity of Axis I psychiatric disorders in bulimia nervosa. J Clin Psychiatry. 1995;5677- 80
Grilo  CMLevy  KNBecker  DFEdell  WSMcGlashan  TH Comorbidity of DSM-III-R Axis I and Axis II disorders among female inpatients with eating disorders. Psychiatr Serv. 1996;47426- 429
Striegel-Moore  RHGarvin  VDohm  FARosenheck  RA Eating disorders in a national sample of hospitalized female and male veterans: detection rates and psychiatric comorbidity. Int J Eat Disord. 1999;25405- 414
Link to Article
Yanovski  SZNelson  JEDubbert  BKSpitzer  RL Association of binge eating disorder and psychiatric comorbidity in obese subjects. Am J Psychiatry. 1993;1501472- 1479
Wonderlich  SAMitchell  JE Eating disorders and comorbidity: empirical, conceptual, and clinical implications. Psychopharmacol Bull. 1997;33381- 390
Favaro  ASantonastaso  P Suicidality in eating disorders: clinical and psychological correlates. Acta Psychiatr Scand. 1997;95508- 514
Link to Article
Bulik  CMSullivan  PFJoyce  PR Temperament, character, and suicide attempts in anorexia nervosa, bulimia nervosa, and major depression. Acta Psychiatr Scand. 1999;10027- 32
Link to Article
Grilo  CMDevlin  MJCachelin  FMYanovski  SZ Report of the National Institutes of Health (NIH) Workshop on the Development of Research Priorities in Eating Disorders. Psychopharmacol Bull. 1997;33321- 333
Moller-Madsen  SNystrup  JNielsen  S Mortality in anorexia nervosa in Denmark during the period 1970-1987. Acta Psychiatr Scand. 1996;94454- 459
Link to Article
Pike  KM Long-term course of anorexia nervosa: response, relapse, remission, and recovery. Clin Psychol Rev. 1998;18447- 475
Link to Article
American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.  Washington, DC American Psychiatric Association1994;
Hsu  LKG Outcome of early onset anorexia nervosa: what do we know? J Youth Adolescence. 1996;25563- 568
Link to Article
Keel  PKMitchell  JEMiller  KBDavis  TLCrow  SJ Long-term outcome of bulimia nervosa. Arch Gen Psychiatry. 1999;5663- 69
Link to Article
Steiner  HLock  J Anorexia nervosa and bulimia nervosa in children and adolescents: a review of the past 10 years. J Am Acad Child Adolesc Psychiatry. 1998;37352- 359
Link to Article
Crisp  AHCallender  JSHallek  CHsu  LKG Long-term mortality in anorexia nervosa: a 20-year follow-up of the St. George's and Aberdeen cohorts. Br J Psychiatry. 1992;161104- 107
Link to Article
Neumarker  KJ Mortality and sudden death in anorexia nervosa. Int J Eat Disord. 1997;21205- 212
Link to Article
Fichter  MMQuadflieg  N Six-year course and outcome of anorexia nervosa. Int J Eat Disord. 1999;26359- 385
Link to Article
Pla  CToro  J Anorexia nervosa in a Spanish adolescent sample: an 8-year longitudinal study. Acta Psychiatr Scand. 1999;100441- 446
Link to Article
Sunday  SRReeman  IREckert  EHalmi  KA Ten-year outcome in adolescent-onset anorexia nervosa. J Youth Adolescence. 1996;25533- 544
Link to Article
Herpertz-Dahlman  BMWewetzer  CSchulz  ERemschmidt  H Course and outcome in adolescent anorexia nervosa. Int J Eat Disord. 1996;19335- 345
Link to Article
Herzog  DBGreenwood  DNDorer  DJFlores  ATEkeblad  ERRichards  ABlais  MAKeller  MB Mortality in eating disorders: a descriptive study. Int J Eat Disord. 2000;2820- 26
Link to Article
Theander  S Outcome and prognosis in anorexia nervosa and bulimia: some results of previous investigations, compared with those of a Swedish long-term study. J Psychiatr Res. 1985;19493- 508
Link to Article
Spitzer  RLWilliams  JBWKroenke  KLinzer  MdeGruy  FHahn  SRBrody  DJohnson  JG Utility of a new procedure for diagnosing mental disorders in primary care: the PRIME-MD 1000 Study. JAMA. 1994;2721749- 1756
Link to Article
Whitaker  AJohnson  JShaffer  DRapoport  JLKalikow  KWalsh  BTDavies  MBraiman  SDolinsky  A Uncommon troubles in young people: prevalence estimates of selected psychiatric disorders in a nonreferred adolescent population. Arch Gen Psychiatry. 1990;47487- 496
Link to Article
Marchi  MCohen  P Early childhood eating behaviors and adolescent eating disorders. J Am Acad Child Adolesc Psychiatry. 1990;29112- 117
Link to Article
Hsu  LKG Epidemiology of the eating disorders. Psychiatr Clin North Am. 1996;19681- 700
Link to Article
Cohen  PCohen  J Life Values and Adolescent Mental Health.  Mahwah, NJ Lawrence A Erlbaum Associates1996;
Kogan  LSSmith  JJenkins  S Ecological validity of indicator data as predictors of survey findings. J Soc Serv Res. 1977;1117- 132
Link to Article
Costello  EJEdelbrock  CSDuncan  MKKalas  R Testing of the NIMH Diagnostic Interview Schedule for Children (DISC) in a Clinical Population: Final Report to the Center for Epidemiological Studies, NIMH.  Pittsburgh, Pa University of Pittsburgh1984;
Bird  HRGould  MStaghezza  B Aggregating data from multiple informants in child psychiatry epidemiological research. J Am Acad Child Adolesc Psychiatry. 1992;3178- 85
Link to Article
Piacentini  JCohen  PCohen  J Combining discrepant diagnostic information from multiple sources: are complex algorithms better than simple ones? J Abnorm Psychol. 1992;2051- 63
Link to Article
Cohen  PO'Connor  PLewis  SAMalachowski  B A comparison of the agreement between DISC and K-SADS-P interviews of an epidemiological sample of children. J Am Acad Child Adolesc Psychiatry. 1987;26662- 667
Link to Article
Hyler  SEReider  RWilliams  JBWSpitzer  RLHendler  JLyons  M The Personality Diagnostic Questionnaire: development and preliminary results. J Personal Disord. 1988;2229- 237
Link to Article
American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition.  Washington, DC American Psychiatric Association1987;
Bernstein  DPCohen  PVelez  CNSchwab-Stone  MSiever  LJShinsato  L Prevalence and stability of the DSM-III-R personality disorders in a community-based survey of adolescents. Am J Psychiatry. 1993;1501237- 1243
Johnson  JGCohen  PSkodol  AOldham  JMKasen  SBrook  J Personality disorders in adolescence and risk of major mental disorders and suicidality during adulthood. Arch Gen Psychiatry. 1999;56805- 811
Link to Article
Johnson  JGCohen  PSmailes  EKasen  SOldham  JMSkodol  AE Adolescent personality disorders associated with violence and criminal behavior during adolescence and early adulthood. Am J Psychiatry. 2000;1571406- 1412
Link to Article
Johnson  JGCohen  PKasen  SSkodol  ABrook  J Age-related change in personality disorder symptom levels between early adolescence and adulthood: a community-based longitudinal investigation. Acta Psychiatr Scand. 2000;102265- 275
Link to Article
Spitzer  RLKroenke  KWilliams  JBW Validation and utility of a self-report version of PRIME-MD: the PHQ Primary Care Study. JAMA. 1999;2821737- 1744
Link to Article
Brewerton  TDGeorge  MS Is migraine related to the eating disorders? Int J Eat Disord. 1993;1475- 79
Link to Article
Koo-Loeb  JHCostello  NLight  KCGirdler  SS Women with eating disorder tendencies display altered cardiovascular, neuroendocrine, and psychosocial profiles. Psychosom Med. 2000;62539- 548
Link to Article
Steiner-Adair  CPurcell  A Approaches to mainstreaming eating disorders prevention. Eat Disord. 1996;4294- 309
Link to Article
Lydiard  RBBrewerton  TDFossey  MDLaraia  MTStuart  GBeinfeld  MCBallenger  JC CSF cholecystokinin octapeptide in patients with bulimia nervosa and in normal comparison subjects. Am J Psychiatry. 1993;1501099- 1101
Brewerton  TDMueller  EALesem  MDBrandt  HAQuearry  BGeorge  DTMurphy  DLJimerson  DC Neuroendocrine responses to m-chlorophenylpiperazine and L-tryptophan in bulimia. Arch Gen Psychiatry. 1992;49852- 861
Link to Article
Brewerton  TDLydiard  RBLaraia  MTShook  JEBallenger  JC CSF β-endorphin and dynorphin in bulimia nervosa. Am J Psychiatry. 1992;1491086- 1090
Jimerson  DCLesem  MDKaye  WHBrewerton  TD Low serotonin and dopamine metabolite concentrations in cerebrospinal fluid from bulimic patients with frequent binge episodes. Arch Gen Psychiatry. 1992;49132- 138
Link to Article
Raymond  NCDysken  MBettin  KEckert  EDCrow  SJMarkus  KPomeroy  C Cytokine production in patients with anorexia nervosa, bulimia nervosa, and obesity. Int J Eat Disord. 2000;28293- 302
Link to Article

Figures

Tables

Table Graphic Jump LocationTable 1. Eating and Weight Problems During Adolescence and Early Adulthood*
Table Graphic Jump LocationTable 2. Eating Disorders During Adolescence and Chronic Health Problems During Early Adulthooda
Table Graphic Jump LocationTable 3. Eating Disorders During Adolescence and Psychiatric Conditions During Early Adulthooda
Table Graphic Jump LocationTable 4. Significant Associations Between Weight Loss Behaviors During Adolescence and Health Problems During Early Adulthooda
Table Graphic Jump LocationTable 5. Significant Associations Between Behaviors Associated With Weight Problems During Adolescence and Health Problems During Early Adulthooda

References

DeZwaan  MMitchell  J Medical complications of anorexia nervosa and bulimia nervosa. Kaplan  ASGarfinkel  PEeds.Medical Issues and Eating Disorders. New York, NY Brunner/Mazel1993;60- 100
Palmer  EPGuay  AT Reversible myopathy secondary to abuse of ipecac in patients with major eating disorders. N Engl J Med. 1985;3131457- 1459
Link to Article
Johnson  JGSpitzer  RLWilliams  JBW Health problems, impairment, and co-occurring illnesses associated with eating disorders among female primary care and obstetric-gynecology patients. Psychol Med. 2001;311455- 1466
Link to Article
Mallick  MJ Health hazards of obesity and weight control in children: a review of the literature. Am J Public Health. 1983;7378- 82
Link to Article
Devlin  MJWalsh  TBKral  JGHeymsfield  SBPi-Sunyer  FXDantzic  S Metabolic abnormalities in bulimia nervosa. Arch Gen Psychiatry. 1990;47144- 148
Link to Article
Kaplan  AS Biomedical variables in the eating disorders. Can J Psychiatry. 1990;35745- 753
Kaye  WHGwirtsman  HEGeorge  DT The effects of binging and vomiting on hormonal secretion. Biol Psychiatry. 1989;25768- 780
Link to Article
Spitzer  RLDevlin  MWalsh  TBHasin  DWing  RMarcus  MStunkard  AWadden  TYanovski  SAgras  SMitchell  JNonas  C Binge eating disorder: a multisite field trial of the diagnostic criteria. Int J Eat Disord. 1992;3191- 203
Link to Article
Yanovski  SZ Biological correlates of binge eating. Addict Behav. 1995;20705- 712
Link to Article
Bulik  CMSullivan  PFFear  JLJoyce  PR Eating disorders and antecedent anxiety disorders: a controlled study. Acta Psychiatr Scand. 1997;96101- 107
Link to Article
Braun  DLSunday  RHalmi  KA Psychiatric comorbidity in patients with eating disorders. Psychol Med. 1994;24859- 867
Link to Article
Brewerton  TDLydiard  BRHerzog  DBBrotman  AWO'Neil  PMBalenger  JC Comorbidity of Axis I psychiatric disorders in bulimia nervosa. J Clin Psychiatry. 1995;5677- 80
Grilo  CMLevy  KNBecker  DFEdell  WSMcGlashan  TH Comorbidity of DSM-III-R Axis I and Axis II disorders among female inpatients with eating disorders. Psychiatr Serv. 1996;47426- 429
Striegel-Moore  RHGarvin  VDohm  FARosenheck  RA Eating disorders in a national sample of hospitalized female and male veterans: detection rates and psychiatric comorbidity. Int J Eat Disord. 1999;25405- 414
Link to Article
Yanovski  SZNelson  JEDubbert  BKSpitzer  RL Association of binge eating disorder and psychiatric comorbidity in obese subjects. Am J Psychiatry. 1993;1501472- 1479
Wonderlich  SAMitchell  JE Eating disorders and comorbidity: empirical, conceptual, and clinical implications. Psychopharmacol Bull. 1997;33381- 390
Favaro  ASantonastaso  P Suicidality in eating disorders: clinical and psychological correlates. Acta Psychiatr Scand. 1997;95508- 514
Link to Article
Bulik  CMSullivan  PFJoyce  PR Temperament, character, and suicide attempts in anorexia nervosa, bulimia nervosa, and major depression. Acta Psychiatr Scand. 1999;10027- 32
Link to Article
Grilo  CMDevlin  MJCachelin  FMYanovski  SZ Report of the National Institutes of Health (NIH) Workshop on the Development of Research Priorities in Eating Disorders. Psychopharmacol Bull. 1997;33321- 333
Moller-Madsen  SNystrup  JNielsen  S Mortality in anorexia nervosa in Denmark during the period 1970-1987. Acta Psychiatr Scand. 1996;94454- 459
Link to Article
Pike  KM Long-term course of anorexia nervosa: response, relapse, remission, and recovery. Clin Psychol Rev. 1998;18447- 475
Link to Article
American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.  Washington, DC American Psychiatric Association1994;
Hsu  LKG Outcome of early onset anorexia nervosa: what do we know? J Youth Adolescence. 1996;25563- 568
Link to Article
Keel  PKMitchell  JEMiller  KBDavis  TLCrow  SJ Long-term outcome of bulimia nervosa. Arch Gen Psychiatry. 1999;5663- 69
Link to Article
Steiner  HLock  J Anorexia nervosa and bulimia nervosa in children and adolescents: a review of the past 10 years. J Am Acad Child Adolesc Psychiatry. 1998;37352- 359
Link to Article
Crisp  AHCallender  JSHallek  CHsu  LKG Long-term mortality in anorexia nervosa: a 20-year follow-up of the St. George's and Aberdeen cohorts. Br J Psychiatry. 1992;161104- 107
Link to Article
Neumarker  KJ Mortality and sudden death in anorexia nervosa. Int J Eat Disord. 1997;21205- 212
Link to Article
Fichter  MMQuadflieg  N Six-year course and outcome of anorexia nervosa. Int J Eat Disord. 1999;26359- 385
Link to Article
Pla  CToro  J Anorexia nervosa in a Spanish adolescent sample: an 8-year longitudinal study. Acta Psychiatr Scand. 1999;100441- 446
Link to Article
Sunday  SRReeman  IREckert  EHalmi  KA Ten-year outcome in adolescent-onset anorexia nervosa. J Youth Adolescence. 1996;25533- 544
Link to Article
Herpertz-Dahlman  BMWewetzer  CSchulz  ERemschmidt  H Course and outcome in adolescent anorexia nervosa. Int J Eat Disord. 1996;19335- 345
Link to Article
Herzog  DBGreenwood  DNDorer  DJFlores  ATEkeblad  ERRichards  ABlais  MAKeller  MB Mortality in eating disorders: a descriptive study. Int J Eat Disord. 2000;2820- 26
Link to Article
Theander  S Outcome and prognosis in anorexia nervosa and bulimia: some results of previous investigations, compared with those of a Swedish long-term study. J Psychiatr Res. 1985;19493- 508
Link to Article
Spitzer  RLWilliams  JBWKroenke  KLinzer  MdeGruy  FHahn  SRBrody  DJohnson  JG Utility of a new procedure for diagnosing mental disorders in primary care: the PRIME-MD 1000 Study. JAMA. 1994;2721749- 1756
Link to Article
Whitaker  AJohnson  JShaffer  DRapoport  JLKalikow  KWalsh  BTDavies  MBraiman  SDolinsky  A Uncommon troubles in young people: prevalence estimates of selected psychiatric disorders in a nonreferred adolescent population. Arch Gen Psychiatry. 1990;47487- 496
Link to Article
Marchi  MCohen  P Early childhood eating behaviors and adolescent eating disorders. J Am Acad Child Adolesc Psychiatry. 1990;29112- 117
Link to Article
Hsu  LKG Epidemiology of the eating disorders. Psychiatr Clin North Am. 1996;19681- 700
Link to Article
Cohen  PCohen  J Life Values and Adolescent Mental Health.  Mahwah, NJ Lawrence A Erlbaum Associates1996;
Kogan  LSSmith  JJenkins  S Ecological validity of indicator data as predictors of survey findings. J Soc Serv Res. 1977;1117- 132
Link to Article
Costello  EJEdelbrock  CSDuncan  MKKalas  R Testing of the NIMH Diagnostic Interview Schedule for Children (DISC) in a Clinical Population: Final Report to the Center for Epidemiological Studies, NIMH.  Pittsburgh, Pa University of Pittsburgh1984;
Bird  HRGould  MStaghezza  B Aggregating data from multiple informants in child psychiatry epidemiological research. J Am Acad Child Adolesc Psychiatry. 1992;3178- 85
Link to Article
Piacentini  JCohen  PCohen  J Combining discrepant diagnostic information from multiple sources: are complex algorithms better than simple ones? J Abnorm Psychol. 1992;2051- 63
Link to Article
Cohen  PO'Connor  PLewis  SAMalachowski  B A comparison of the agreement between DISC and K-SADS-P interviews of an epidemiological sample of children. J Am Acad Child Adolesc Psychiatry. 1987;26662- 667
Link to Article
Hyler  SEReider  RWilliams  JBWSpitzer  RLHendler  JLyons  M The Personality Diagnostic Questionnaire: development and preliminary results. J Personal Disord. 1988;2229- 237
Link to Article
American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition.  Washington, DC American Psychiatric Association1987;
Bernstein  DPCohen  PVelez  CNSchwab-Stone  MSiever  LJShinsato  L Prevalence and stability of the DSM-III-R personality disorders in a community-based survey of adolescents. Am J Psychiatry. 1993;1501237- 1243
Johnson  JGCohen  PSkodol  AOldham  JMKasen  SBrook  J Personality disorders in adolescence and risk of major mental disorders and suicidality during adulthood. Arch Gen Psychiatry. 1999;56805- 811
Link to Article
Johnson  JGCohen  PSmailes  EKasen  SOldham  JMSkodol  AE Adolescent personality disorders associated with violence and criminal behavior during adolescence and early adulthood. Am J Psychiatry. 2000;1571406- 1412
Link to Article
Johnson  JGCohen  PKasen  SSkodol  ABrook  J Age-related change in personality disorder symptom levels between early adolescence and adulthood: a community-based longitudinal investigation. Acta Psychiatr Scand. 2000;102265- 275
Link to Article
Spitzer  RLKroenke  KWilliams  JBW Validation and utility of a self-report version of PRIME-MD: the PHQ Primary Care Study. JAMA. 1999;2821737- 1744
Link to Article
Brewerton  TDGeorge  MS Is migraine related to the eating disorders? Int J Eat Disord. 1993;1475- 79
Link to Article
Koo-Loeb  JHCostello  NLight  KCGirdler  SS Women with eating disorder tendencies display altered cardiovascular, neuroendocrine, and psychosocial profiles. Psychosom Med. 2000;62539- 548
Link to Article
Steiner-Adair  CPurcell  A Approaches to mainstreaming eating disorders prevention. Eat Disord. 1996;4294- 309
Link to Article
Lydiard  RBBrewerton  TDFossey  MDLaraia  MTStuart  GBeinfeld  MCBallenger  JC CSF cholecystokinin octapeptide in patients with bulimia nervosa and in normal comparison subjects. Am J Psychiatry. 1993;1501099- 1101
Brewerton  TDMueller  EALesem  MDBrandt  HAQuearry  BGeorge  DTMurphy  DLJimerson  DC Neuroendocrine responses to m-chlorophenylpiperazine and L-tryptophan in bulimia. Arch Gen Psychiatry. 1992;49852- 861
Link to Article
Brewerton  TDLydiard  RBLaraia  MTShook  JEBallenger  JC CSF β-endorphin and dynorphin in bulimia nervosa. Am J Psychiatry. 1992;1491086- 1090
Jimerson  DCLesem  MDKaye  WHBrewerton  TD Low serotonin and dopamine metabolite concentrations in cerebrospinal fluid from bulimic patients with frequent binge episodes. Arch Gen Psychiatry. 1992;49132- 138
Link to Article
Raymond  NCDysken  MBettin  KEckert  EDCrow  SJMarkus  KPomeroy  C Cytokine production in patients with anorexia nervosa, bulimia nervosa, and obesity. Int J Eat Disord. 2000;28293- 302
Link to Article

Correspondence

CME
Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Web of Science® Times Cited: 81

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles