Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

At a glance: The STEP trials

A round-up of the STEP phase 3 clinical trials evaluating semaglutide for weight loss in people with overweight or obesity.
ADVANCED SEARCH
Log in
Top
Social Psychiatry and Psychiatric Epidemiology
Published in: Social Psychiatry and Psychiatric Epidemiology 7/2019

Open Access 01-07-2019 | Affective Disorder | Original Paper

Psychiatric comorbidity as a risk factor for the mortality of people with bulimia nervosa

Authors: Hubertus Himmerich, Matthew Hotopf, Hitesh Shetty, Ulrike Schmidt, Janet Treasure, Richard D. Hayes, Robert Stewart, Chin-Kuo Chang

Published in: Social Psychiatry and Psychiatric Epidemiology | Issue 7/2019

Login to get access

Abstract

Background

Bulimia nervosa (BN) is associated with increased mortality. Frequent comorbidities of BN include substance use disorders, affective disorders and personality disorders (PD). These comorbidities may add an additional risk for mortality.

Methods

We investigated the influence of these psychiatric comorbidities on all-cause mortality with demographic and socioeconomic factors considered as confounders over an observation period from January 2007 to March 2016 for 1501 people with BN using anonymised health records data from the South London and Maudsley NHS Foundation Trust (SLaM), retrieved through its Clinical Records Interactive Search (CRIS) data resource. Mortality was ascertained through monthly linkages to the nationwide tracing system administered by the Office for National Statistics (ONS). We used Cox proportional hazards regression to calculate hazard ratios (HRs) with 95% confidence intervals (CIs). Multivariable analyses were also performed to estimate effects when controlling for confounding of age, sex, ethnicity, borough, marital status and deprivation score.

Results

A total of 18 patients with BN died during the observation period. The standardised mortality ratio (SMR) for our study cohort (against the population of England and Wales in 2012 as a standard) was 2.52 (95% CI 1.49–3.97). Cox regressions revealed significant associations of mortality with older age and male gender. Comorbid PD (HR: 3.36; 95% CI 1.05–10.73) was significantly associated with all-cause mortality, even after controlling for demographic and socioeconomic covariates.

Conclusions

These results highlight increased mortality in patients with BN and the importance of recognising and treating PDs in patients with BN.
Appendix
Available only for authorised users
Literature
1.
American Psychiatric Association (1980) Diagnostic diagnostic and statistical manual of mental disorders and statistical manual of mental disorders, 3rd edn. APA Publishing, Washington, DC
2.
3.
American Psychiatric Association (2013) Diagnostic and statistical manual of mental disorders, 5th edn. APA Publishing, ArlingtonCrossRef
4.
World Health Organization (1992) Manual of the international statistical classification of diseases and related health problems 10th revision (ICD-10). WHO, Geneva
5.
Zerwas S, Larsen JT, Petersen L et al (2015) The incidence of eating disorders in a Danish register study: associations with suicide risk and mortality. J Psychiatr Res 65:16–22CrossRefPubMedPubMedCentral
6.
Keski-Rahkonen A, Mustelin L (2016) Epidemiology of eating disorders in Europe: prevalence, incidence, comorbidity, course, consequences, and risk factors. Curr Opin Psychiatry 29:340–345CrossRefPubMed
7.
Miniati M, Benvenuti A, Bologna E et al (2018) Mood spectrum comorbidity in patients with anorexia and bulimia nervosa. Eat Weight Disord 23:305–311CrossRefPubMed
8.
Ulfvebrand S, Birgegård A, Norring C et al (2015) Psychiatric comorbidity in women and men with eating disorders results from a large clinical database. Psychiatry Res 230:294–299CrossRefPubMed
9.
Dansky BS, Brewerton TD, Kilpatrick DG (2000) Comorbidity of bulimia nervosa and alcohol use disorders: results from the National Women’s Study. Int J Eat Disord 27:180–190CrossRefPubMed
10.
Fouladi F, Mitchell JE, Crosby RD et al (2015) Prevalence of alcohol and other substance use in patients with eating disorders. Eur Eat Disord Rev 23:531–536CrossRefPubMed
11.
Wade T, Bulik CM, Prescott CA, Kendler KS (2004) Sex influences on shared risk factors for bulimia nervosa and other psychiatric disorders. Arch Gen Psychiatry 61:251–256CrossRefPubMed
12.
Martinussen M, Friborg O, Schmierer P et al (2017) The comorbidity of personality disorders in eating disorders: a meta-analysis. Eat Weight Disord 22:201–209CrossRefPubMed
13.
Sansone RA, Levitt JL, Sansone LA (2006) The prevalence of personality disorders in those with eating disorders. In: Sansone RA, Levitt JL (eds) Personality disorders and eating disorders: exploring the frontier. Routledge, New York, pp 23–39
14.
Herzog DB, Nussbaum KM, Marmor AK (1996) Comorbidity and outcome in eating disorders. Psychiatr Clin North Am 19:843–859CrossRefPubMed
15.
Del Pino-Gutiérrez A, Jiménez-Murcia S, Fernández-Aranda F et al (2017) The relevance of personality traits in impulsivity-related disorders: from substance use disorders and gambling disorder to bulimia nervosa. J Behav Addict 6:396–405CrossRefPubMedPubMedCentral
16.
Lilenfeld LR, Kaye WH, Greeno CG et al (1997) Psychiatric disorders in women with bulimia nervosa and their first-degree relatives: effects of comorbid substance dependence. Int J Eat Disord 22:253–264CrossRefPubMed
17.
Vitousek K, Manke F (1994) Personality variables and disorders in anorexia nervosa and bulimia nervosa. J Abnorm Psychol 103:137–147CrossRefPubMed
18.
Hadad NA, Knackstedt LA (2014) Addicted to palatable foods: comparing the neurobiology of bulimia nervosa to that of drug addiction. Psychopharmacology 231:1897–1912CrossRefPubMedPubMedCentral
19.
Pearson CM, Lavender JM, Cao L et al (2017) Associations of borderline personality disorder traits with stressful events and emotional reactivity in women with bulimia nervosa. J Abnorm Psychol 126:531–539CrossRefPubMedPubMedCentral
20.
Fichter MM, Quadflieg N (2016) Mortality in eating disorders—results of a large prospective clinical longitudinal study. Int J Eat Disord 49:391–401CrossRefPubMed
21.
Hoang U, Goldacre M, James A (2014) Mortality following hospital discharge with a diagnosis of eating disorder: national record linkage study, England, 2001–2009. Int J Eat Disord 47:507–515CrossRefPubMed
22.
23.
24.
Arcelus J, Mitchell AJ, Wales J, Nielsen S (2011) Mortality rates in patients with anorexia nervosa and other eating disorders. A meta-analysis of 36 studies. Arch Gen Psychiatry 68:724–731CrossRefPubMed
25.
26.
Forcano L, Fernández-Aranda F, Alvarez-Moya E et al (2009) Suicide attempts in bulimia nervosa: personality and psychopathological correlates. Eur Psychiatry 24:91–97CrossRefPubMed
27.
Pisetsky EM, Thornton LM, Lichtenstein P et al (2013) Suicide attempts in women with eating disorders. J Abnorm Psychol 122:1042–1056CrossRefPubMed
28.
Tachi T, Murakami K, Murotsu K, Washizuka T (2001) Affective states associated with bingeing and purging behaviours in Japanese patients with bulimia nervosa. Br J Med Psychol 74(Pt 4):487–496CrossRefPubMed
29.
Whitfield JB, Heath AC, Madden PAF (2018) Effects of high alcohol intake, alcohol-related symptoms and smoking on mortality. Addiction 113:158–166CrossRefPubMed
30.
31.
Degenhardt L, Bucello C, Mathers B et al (2011) Mortality among regular or dependent users of heroin and other opioids: a systematic review and meta-analysis of cohort studies. Addiction 106:32–51CrossRefPubMed
32.
Cailhol L, Pelletier É, Rochette L et al (2017) Prevalence, mortality, and health care use among patients with cluster b personality disorders clinically diagnosed in Quebec: a provincial cohort study, 2001–2012. Can J Psychiatry 62:336–342CrossRefPubMedPubMedCentral
33.
Ho CSH, Jin A, Nyunt MS et al (2016) Mortality rates in major and subthreshold depression: 10-year follow-up of a Singaporean population cohort of older adults. Postgrad Med 128:642–647CrossRefPubMed
34.
Mitchell JE, Specker SM, de Zwaan M (1991) Comorbidity and medical complications of bulimia nervosa. J Clin Psychiatry 52 Suppl:13–20PubMed
35.
O’Brien KM, Vincent NK (2003) Psychiatric comorbidity in anorexia and bulimia nervosa: nature, prevalence, and causal relationships. Clin Psychol Rev 23:57–74CrossRefPubMed
36.
Duncan AE, Neuman RJ, Kramer J et al (2005) Are there subgroups of bulimia nervosa based on comorbid psychiatric disorders? Int J Eat Disord 37:19–25CrossRefPubMed
37.
Keel PK, Dorer DJ, Eddy KT et al (2003) Predictors of mortality in eating disorders. Arch Gen Psychiatry 60:179–183CrossRefPubMed
38.
Keel PK, Mitchell JE, Miller KB et al (1999) Long-term outcome of bulimia nervosa. Arch Gen Psychiatry 56:63–69CrossRefPubMed
39.
Kjær JNR, Biskin R, Vestergaard C et al (2018) All-cause mortality of hospital-treated borderline personality disorder: a nationwide cohort study. J Pers Disord 11:1–13CrossRef
40.
Patten SB, Williams JV, Bulloch AG (2019) Major depressive episodes and mortality in the Canadian household population. J Affect Disord 242:165–171CrossRefPubMed
41.
Miloyan B, Bulley A, Bandeen-Roche K et al (2016) Anxiety disorders and all-cause mortality: systematic review and meta-analysis. Soc Psychiatry Psychiatr Epidemiol 51:1467–1475CrossRefPubMedPubMedCentral
42.
Suokas JT, Suvisaari JM, Gissler M (2013) Mortality in eating disorders: a follow-up study of adult eating disorder patients treated in tertiary care, 1995–2010. Psychiatry Res 210:1101–1106CrossRefPubMed
43.
Pan YJ, Yeh LL, Chen YC et al (2016) Hospital treatment, mortality and heathcare costs in relation to socioeconomic status among people with bipolar affective disorder. BJPsych Open 2:10–17CrossRefPubMedPubMedCentral
44.
Perera G, Broadbent M, Callard F et al (2016) Cohort profile of the South London and Maudsley NHS Foundation Trust Biomedical Research Centre (SLaM BRC) Case Register: current status and recent enhancement of an electronic mental health record-derived data resource. BMJ Open 6:e008721CrossRefPubMedPubMedCentral
45.
Stewart R, Soremekun M, Perera G et al (2009) The South London and Maudsley NHS Foundation Trust Biomedical Research Centre (SLAM BRC) case register: development and descriptive data. BMC Psychiatry 9:51CrossRefPubMedPubMedCentral
46.
Chang CK, Hayes RD, Broadbent MT et al (2014) A cohort study on mental disorders, stage of cancer at diagnosis and subsequent survival. BMJ Open 4:e004295CrossRefPubMedPubMedCentral
47.
Su YP, Chang CK, Hayes RD et al (2014) Mini-mental state examination as a predictor of mortality among older people referred to secondary mental healthcare. PLoS One 9:e105312CrossRefPubMedPubMedCentral
48.
Hayes RD, Downs J, Chang CK et al (2015) The effect of clozapine on premature mortality: an assessment of clinical monitoring and other potential confounders. Schizophr Bull 41:644–655CrossRefPubMed
49.
Ackard DM, Richter S, Egan A, Cronemeyer C (2014) Poor outcome and death among youth, young adults, and midlife adults with eating disorders: an investigation of risk factors by age at assessment. Int J Eat Disord 47:825–835CrossRefPubMed
50.
Waldron I (1993) Recent trends in mortality ratios for adults in developed countries. Soc Sci Med 36:451–462CrossRefPubMed
51.
Gjonça A, Tomassini C, Toson B, Smallwood S (2005) Sex differences in mortality, a comparison of the United Kingdom and other developed countries. Health Stat Q 26:6–16
52.
Christensen K, Kristiansen M, Hagen-Larsen H et al (2000) X-linked genetic factors regulate hematopoietic stem-cell kinetics in females. Blood 95:2449–2450PubMed
53.
Waldron I (1995) Contributions of biological and behavioural factors to changing sex differences in ischaemic heart disease mortality. In: Lopez AD, Caselli G, Volkonen T (eds) Adult mortality in developed countries: from description to explanation. Clarendon Press, Oxford, pp 161–178
54.
Fernández-Aranda F, Aitken A, Badía A et al (2004) Personality and psychopathological traits of males with an eating disorder. Eur Eat Disord Rev 12:367–374CrossRef
55.
Gueguen J, Godart N, Chambry J et al (2012) Severe anorexia nervosa in men: comparison with severe AN in women and analysis of mortality. Int J Eat Disord 45:537–545CrossRefPubMed
56.
Mitchison D, Mond J (2015) Epidemiology of eating disorders,eating disordered behaviour, and body image disturbance in males: A narrative review. J Eat Disord 3:20CrossRefPubMedPubMedCentral
57.
Núñez-Navarro A, Agüera Z, Krug I et al (2012) Do men with eating disorders differ from women in clinics, psychopathology and personality? Eur Eat Disord Rev 20:23–31CrossRefPubMed
58.
Griffiths S, Mond JM, Li Z et al (2015) Self-stigma of seeking treatment and being male predict an increased likelihood of having an undiagnosed eating disorder. Int J Eat Disord 48:775–778CrossRefPubMed
59.
Strother E, Lemberg R, Stanford SC, Turberville D (2012) Eating disorders in men: underdiagnosed, undertreated, and misunderstood. Eat Disord 20:346–355CrossRefPubMedPubMedCentral
60.
Weltzin TE, Weisensel N, Franczyk D et al (2005) Eating disorders in men: update. J Men Health Gend 2:186–193CrossRef
61.
Agüera Z, Sánchez I, Granero R et al (2017) Short-term treatment outcomes and dropout risk in men and women with eating disorders. Eur Eat Disord Rev 25:293–301CrossRefPubMed
62.
Fichter MM, Quadflieg N, Hedlund S (2008) Long-term course of binge eating disorder and bulimia nervosa: relevance for nosology and diagnostic criteria. Int J Eat Disord 41:577–586CrossRefPubMed
63.
64.
Conason AH, Brunstein Klomek A, Sher L (2006) Recognizing alcohol and drug abuse in patients with eating disorders. QJM 99:335–339CrossRefPubMed
65.
Franko DL, Keshaviah A, Eddy KT et al (2013) A longitudinal investigation of mortality in anorexia nervosa and bulimia nervosa. Am J Psychiatry 170:917–925CrossRefPubMedPubMedCentral
66.
Brewster DH, Nowell SL, Clark DN (2015) Risk of oesophageal cancer among patients previously hospitalised with eating disorder. Cancer Epidemiol 39:313–320CrossRefPubMedPubMedCentral
67.
Ekselius L, Lindström E, von Knorring L et al (1994) SCID II interviews and the SCID Screen questionnaire as diagnostic tools for personality disorders in DSM-III-R. Acta Psychiatr Scand 90:120–123CrossRefPubMed
68.
Andresen-Streichert H, Müller A, Glahn A et al (2018) Alcohol biomarkers in clinical and forensic contexts. Dtsch Arztebl Int 115:309–315PubMedPubMedCentral
69.
Szegedi A, Müller MJ, Himmerich H et al (2000) Carbohydrate-deficient transferrin (CDT) and HDL cholesterol (HDL) are highly correlated in male alcohol dependent patients. Alcohol Clin Exp Res 24:497–500CrossRefPubMed
70.
71.
Crow SJ, Salisbury JJ, Crosby RD et al (1997) Serum electrolytes as markers of vomiting in bulimia nervosa. Int J Eat Disord 21:95–98CrossRefPubMed
72.
Franke S, Halfter SM, Himmerich H (2010) Diagnosis and therapy of bulimia nervosa. MMW Fortschr Med 152:80–82PubMed
73.
Chen EY, Matthews L, Allen C et al (2008) Dialectical behavior therapy for clients with binge-eating disorder or bulimia nervosa and borderline personality disorder. Int J Eat Disord 41:505–512CrossRefPubMed
74.
Kröger C, Schweiger U, Sipos V et al (2010) Dialectical behaviour therapy and an added cognitive behavioural treatment module for eating disorders in women with borderline personality disorder and anorexia nervosa or bulimia nervosa who failed to respond to previous treatments. An open trial with a 15-month follow-up. J Behav Ther Exp Psychiatry 41:381–388CrossRefPubMed
Metadata
Title
Psychiatric comorbidity as a risk factor for the mortality of people with bulimia nervosa
Authors
Hubertus Himmerich
Matthew Hotopf
Hitesh Shetty
Ulrike Schmidt
Janet Treasure
Richard D. Hayes
Robert Stewart
Chin-Kuo Chang
Publication date
01-07-2019
Publisher
Springer Berlin Heidelberg
Published in
Social Psychiatry and Psychiatric Epidemiology / Issue 7/2019
Print ISSN: 0933-7954
Electronic ISSN: 1433-9285
DOI
https://doi.org/10.1007/s00127-019-01667-0

Other articles of this Issue 7/2019

Social Psychiatry and Psychiatric Epidemiology 7/2019 Go to the issue

Original Paper

Psychological well-being and mortality: longitudinal findings from Lithuanian middle-aged and older adults study

Original Paper

Five-year rehospitalization experience of a state-wide cohort of persons with schizophrenia

Original Paper

Association between body weight status and suicidal ideation among Chinese adolescents: the moderating role of the child’s sex

Original Paper

Incident depression and mortality among people with different types of dementia: results from a longitudinal cohort study

Review

The association of time since spousal loss and depression in widowhood: a systematic review and meta-analysis

Original Paper

Trauma exposure, depression, suicidal ideation, and alcohol use in people with severe mental disorder in Ethiopia