Psychological Medicine, 1999, 29, 407–414.
# 1999 Cambridge University Press
Printed in the United Kingdom
Clinical characteristics in patients with anorexia
nervosa and obsessive–compulsive disorder
H. M A T S U N A GA," N. K I R I I K E, Y. I W A S A K I, A. M I Y A TA, S. Y A M A G A M I
   W. H. K A Y E
From the Department of Neuropsychiatry, Osaka City University Medical School, Osaka, Japan ; and
Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
ABSTRACT
Background. The purpose of this study was to assess clinical characteristics, including co-morbid
personality disorders in patients with both anorexia nervosa (AN) and obsessive–compulsive
disorder (OCD) in comparison with age- and sex-matched patients with OCD.
Methods. Fifty-three female patients with AN were divided into two groups based on the presence
or absence of a current diagnosis of OCD, as assessed by the Structured Clinical Interview for
DSM-III-R Patient version (SCID-P). Twenty-one women (40 %) who met the DSM-III-R criteria
for both AN and OCD were compared with 23 female patients with OCD, using the Yale-Brown
Obsessive Compulsive Scale (Y-BOCS) and the SCID Axis II disorders.
Results. There were no significant differences on the mean Y-BOCS severity scores between these
groups. However, AN patients with OCD were significantly more likely than OCD patients to have
obsessions with need for symmetry or exactness and ordering\arranging compulsions, whereas both
aggressive obsessions and checking compulsions tended to be more frequently identified in OCD
patients compared with AN patients with OCD. AN patients with OCD were significantly more
likely than OCD patients to meet the criteria for obsessive–compulsive personality disorder
(OCPD).
Conclusions. These results suggest that there are some differential characteristics of the OCD
symptomatology between these disorders, although many patients with AN manifest significant
impairment from primary OCD symptoms with similar magnitude in severity to that found in OCD
patients.
INTRODUCTION
Anorexia nervosa (AN) has been characterized
by a distorted attitude towards weight and
shape, a set of behaviours calculated to produce
weight loss, and amenorrhoea among young
females. Most AN patients have a marked
diminution of food intake in an obsessive pursuit
of thinness, along with an obvious body preoccupation and an incessant rumination about
food. In addition, they are often engaged in
compulsive calorie counting and excessive exercising. The personality of the anorexic has been
" Address for correspondence : Dr Hisato Matsunaga, Department
of Neuropsychiatry, Osaka City University Medical School, 1-4-3
Asahi-machi Abeno-ku, Osaka City, Osaka, 545-8585, Japan.
characterized as stereotypically rigid, ritualistic,
perfectionistic and meticulous. These clinical
characteristics commonly observed among anorexic patients have stimulated many investigators
to study the relationship between AN and
obsessive–compulsive disorder (OCD) (Holden,
1990 ; Hsu et al. 1993). The description of AN as
basically a manifestation of OCD was first made
by Palmer & Jones (1939), and supported by
recent investigators, such as Rothenberg (1986)
who proposed evidence for this hypothesis in a
review of 11 reported series of patients with AN,
and called eating disorders (ED) ‘ a modern
obsessive–compulsive syndrome ’.
While accepting that obsessional traits and
symptoms are a prominent feature in AN,
Garfinkel & Garner (1982) emphasized the role
407
408
H. Matsunaga and others
of severe starvation and weight loss in the
genesis of these traits, and mentioned the
possibility of these obsessional traits and symptoms existing as a secondary phenomena. It has
also been discussed as to whether OCD-like
symptoms related to core AN pathology fully
meet the criteria of OCD (Holden, 1990 ; Kaye,
1993). Most patients with AN do not regard
their obsessive-like symptoms including recurrent, persistent and intrusive thoughts about
their body image and desire for thinness as
senseless, and often they do not attempt to
ignore or suppress these thoughts (Kaye, 1993).
Similarly, core symptoms of AN have been
characterized as ego-syntonic ; those of OCD as
ego-dystonic (Garfinkel & Garner, 1982 ;
Holden, 1990 ; Kaye et al. 1992 ; Kaye, 1993).
AN patients with these symptoms were also
suggested to be different from those with OCD
in that their compulsion-like behaviours, such as
persistent exercising and ritualized eating behaviours, might not be designed to neutralize or
prevent discomfort (Kaye, 1993). Thus, the issue
of whether core anorexics symptoms are a
variant of OCD remains controversial.
On the other hand, some studies on the axis I
co-morbidity have suggested that 11 % to 69 %
of AN patients have a current or lifetime OCD,
even after excluding food and body-related
obsession-like symptoms or ritualized eating
behaviours (Solyom et al. 1982 ; Hudson et al.
1983 ; Halmi et al. 1991 ; Kaye et al. 1992 ; Hsu
et al. 1993 ; Kaye, 1993 ; Braun et al. 1994). And
studies on OCD have suggested that about 10 %
of the female patients with OCD had a history
of ED (Piggot et al. 1991, 1994 ; Fahy et al.
1993). These studies indicate a close relationship
between these disorders, and suggest that considerable numbers of patients with AN have
OCD symptoms severe enough to qualify for a
diagnosis of OCD. However, there have been
few studies investigating the clinical characteristics related to primary OCD symptoms in
AN patients, especially in the systematical
comparison with those in OCD patients. To our
knowledge, there is only one study, which was
conducted by Bastiani et al. (1996).
The objectives for this study are : (1) to assess
the prevalence of co-morbidity of OCD among
Japanese patients with AN, distinguishing AN
patients with OCD (ANjOCD) from those
patients without OCD (ANkOCD) ; (2) to
evaluate the characteristics of OCD symptomatology using the Yale-Brown Obsessive–Compulsive Scale (Y-BOCS) (Goodman et al.
1989 a, b) in ANjOCD in comparison with
age- and gender-matched patients with OCD
(PtjOCD) ; and (3) to compare clinical variables including co-morbidity of personality
disorders between ANjOCD and PtjOCD.
METHOD
Subjects
The subjects were 53 female patients with
anorexia nervosa (AN) and 23 age-matched
female patients with obsessive–compulsive disorder (PtjOCD) diagnosed according to the
DSM-III-R criteria (American Psychiatric Association, 1987). All anorexic patients also met
the DSM-IV criteria for restricting AN, and all
PtjOCD met this criteria for OCD (American
Psychiatric Association, 1994). All subjects were
out-patients between the age of 18 and 33 years,
and consecutively admitted to the Department
of Neuropsychiatry at the Osaka City University
Medical School Hospital between January, 1994
and March, 1997. After complete description of
the study, written informed consent was obtained from each subject. AN subjects had not
had an episode of binge eating, and had been
symptomatic for at least 6 months (mean
symptom duration of 3n9 years (range : 0n8–7n8
years)). Similarly, all PtjOCD had been symptomatic for at least 1 year (mean symptom
duration of 5n3 years (range : 1n0–9n0 years)). All
PtjOCD did not have a current diagnosis of
any eating disorders (ED), but two (8n7 %) of
them had a past history of AN.
Assessment procedures
Each subject provided information regarding
her demographic profile, family and medical
history, and the clinical features related to her
disorder. Global functioning was assessed using
the DSM-III-R Axis V (Global Assessment of
Functioning Scale : GAFS). The Manifest Anxiety Scale (MAS) (Taylor, 1953) and the Zung’s
Self-rating Depression Scale (SDS) (Zung, 1965)
were administered to all subjects for assessment
of anxiety and depressive symptoms, respectively. Personality disorder (PD) assessment was
concurrently performed on each subject, using
the Japanese version of the Structured Clinical
Anorexia nervosa and obsessive–compulsive disorder
Interview for DSM-III-R Personality Disorders
(SCID-II) (Spitzer et al. 1987). The acceptable
reliabilities for each PD diagnosis obtained by
the SCID-II Japanese version were previously
described for patients with eating disorders
(kappa value of 0n56–0n83 ; Matsunaga et al.
1998 a), and for patients with OCD (kappa value
of 0n55–1n0 ; Matsunaga et al. 1998 b).
After these assessments, all AN subjects were
interviewed for the evaluation of current and
lifetime co-morbidity of OCD using the Japanese
version of the Structured Clinical Interview for
DSM-III-R Patient version (SCID-P) (Spitzer et
al. 1987). This assessment was performed on
each subject in a face-to-face interview by one of
the authors who has extensive experience in
diagnostic assessment with structured interviews, and was blind to any clinical information
on each participant. In the assessment of the
inter-rater reliability based on a joint interview
design, kappa coefficients derived for current
and lifetime OCD were 0n72 and 0n81, respectively. After this evaluation, we divided these AN
patients into two groups based on the presence
or absence of a current diagnosis of OCD.
Twenty-one AN patients (39n6 %) who met the
criteria for current OCD (ANjOCD) were
distinguished from 32 AN patients (60n4 %)
without current OCD (ANkOCD). Among
ANkOCD, only two patients (6n3 %) had a past
history of OCD.
Subsequently, we compared OCD symptoms
between ANjOCD and PtjOCD, using the
Yale-Brown Obsessive–Compulsive Scale (YBOCS ; Goodman et al. 1989 a, b) in a Japanese
version (Nakajima et al. 1995). This assessment
was performed in a semi-structured interview by
one of the authors who had been trained under
the supervision of senior psychiatrists, according
to the instructions of the developers (Goodman,
1989 a, b). In the identification of current OCD
symptoms in each patient, up to three primary
obsessions and compulsions were listed using
the Y-BOCS symptom checklist. Food and
body-related obsession-like symptoms, or ritualized eating behaviours in AN patients were
omitted from Y-BOCS scoring. The severity of
OCD symptoms was assessed using the Y-BOCS
severity rating scale. The severity section of the
Y-BOCS is composed of 10 items, with five
items for obsessions and five for compulsions,
each of which is rated on 0–4 point scales
409
representing ‘ no symptoms ’ to ‘ extreme symptoms ’. The 10 items of the Japanese version of
the Y-BOCS have already been verified collectively to constitute a reliable instrument for
assessing OCD symptom severity (Nakajima et
al. 1995). The inter-rater reliability assessed
by Pearson’s product moment correlation coefficients (r l 0n874–0n997, P 0n01), intraclass
correlation coefficients (ICCs) (r l 0n793–0n963,
P 0n0001) and internal consistency measured
by Cronbach’s α coefficient (α l 0n889) were as
good as those reported by the developers
(Goodman et al. 1989 a).
Statistical analysis
Two-tailed group t tests were used in the
comparison of clinical features and psychometric
test results between ANjOCD and ANkOCD,
or between ANjOCD and PtjOCD. The
probabilities of co-occurrence of ANjOCD,
ANkOCD and PD subtypes were analysed
using chi-square tests and Yate’s correlation
for 2i2 tables, or Fischer’s exact test where
appropriate. This analysis was also used in a
frequency comparison of OCD target symptoms
and PD subtypes between ANjOCD and
PtjOCD. The significance level was set at
P 0n05.
RESULTS
There were no significant differences between
ANjOCD and ANkOCD on the mean age,
age of onset, duration of illness, years of
education, or percentage of standard body
weight (% SBW). ANjOCD had significantly
lower GAFS scores (t l 4n88, df l 51,
P 0n0001) and significantly greater numbers
of hospitalizations (t l 3n30, df l 51, P 0n005)
than ANkOCD. With regard to psychometric
test results, ANjOCD had significantly higher
mean scores on the MAS (t l 2n54, df l 51,
P 0n05) and the SDS (t l 2n81, df l 51,
P 0n01) than ANkOCD. Overall, 27 (50n9 %)
of all AN subjects met the criteria for at least
one PD. ANjOCD were significantly more
likely than ANkOCD to have any PD (71n4 %
v. 37n5 %, χ# l 4n58, df l 1, P 0n05). In the
prevalence of each PD, obsessive–compulsive
personality disorder (OCPD) was more frequently diagnosed in ANjOCD than
ANkOCD (38n1 % v. 9n4 %, χ# l 4n76, df l 1,
410
H. Matsunaga and others
P 0n05). However, there were no significant
differences between these groups in the prevalence of any other PD.
Table 1. Comparison of demographic profiles
and clinical features between AN patients with
OCD and patients with OCD
ANjOCD"
OCD#
Analysis
(N l 21)
(N l 23)
Meanp.. Meanp.. t(df l 42)
P
Age (years)
Age of onset
(years)
Duration of
illness (years)
Education
(years)
GAFS score$
Single\married
(numbers)
Percentage of
SBW%
Numbers of
admissions
23n7p3n6
19n7p2n8
25n7p4n5
20n2p4n8
1n62
0n40
0n11
0n69
3n8p2n3
5n3p2n6
2n07
0n04
13n5p2n3
13n4p1n8
0n07
0n95
46n2p8n2
19\2
54n6p9n3
15\8
3n16
—
0n003
0n07*
66n9p8n1
92n2p8n1
9n50
0n0001
1n9p2n5
0n2p0n5
3n08
0n004
" Patients with anorexia nervosa and obsessive–compulsive
disorder.
# Patients with obsessive–compulsive disorder.
$ Global Assessment of Functioning Scale (Axis V).
% Percentage of Standard Body Weight.
Group means of parametric variables were compared using
two-tailed t tests.
* Fisher’s exact test.
Table 1 shows the comparison of demographic
profiles and clinical features between ANjOCD
and PtjOCD. There were no significant differences between these groups for the mean age,
age of onset and years of education. PtjOCD
were more likely than ANjOCD to have longer
duration of illness (t l 2n07, df l 42, P 0n05).
ANjOCD had significantly lower GAFS scores
(t l 3n16, df l 42, P 0n005) and % SBW (t l
9n50, df l 42, P 0n0001), and significantly
greater numbers of hospitalizations (t l 3n08,
df l 42, P 0n005) than PtjOCD.
Table 2 shows the specific categories of
primary obsessions and compulsions in these
groups. All subjects in both groups presented a
mixture of obsessions and compulsions. When
comparing the distribution of each obsessive or
compulsive symptom between these groups,
ANjOCD were significantly more likely than
PtjOCD to have obsessions with need for
symmetry or exactness ( χ# l 4n42, df l 1,
P 0n05) and ordering\arranging compulsions
( χ# l 5n76, df l 1, P 0n05). Both aggressive
obsessions ( χ# l 1n99, df l 1, NS) and checking
compulsions ( χ# l 3n28, df l 1, NS) tended to
be more distributed in the PtjOCD group
compared with the ANjOCD group.
With respect to the severity scores of the YBOCS, all subjects in both groups reached the
Table 2. Comparison of obsessive and compulsive symptoms between AN patients with OCD and
patients with OCD
Analysis
ANjOCD
(N l 21)
OCD
(N l 23)
χ# (df l 1)
P
Obsession
Aggressive
Contamination
Sexual
Hoarding\saving
Religious
Need for symmetry,
or exactness
Somatic
Miscellaneous
4 (19n0)
13 (61n9)
1 (4n8)
0 (0)
0 (0)
14 (66n7)
10 (43n5)
16 (69n6)
1 (4n3)
2 (8n7)
1 (4n3)
7 (30n4)
1n99
0n05
0n00
0n43
0n00
4n42
0n16
0n83
0n999
0n51
0n999
0n04
3 (14n3)
10 (47n6)
1 (4n3)
11 (47n8)
0n03
0n00
0n86
0n999
Compulsion
Cleaning\washing
Checking
Repeating rituals
Counting
Ordering\arranging
Hoarding\collecting
Miscellaneous
12 (57n1)
7 (33n3)
4 (19n0)
4 (19n0)
13 (61n9)
0 (0)
6 (28n6)
13 (56n5)
15 (65n2)
7 (30n4)
6 (26n1)
5 (21n7)
1 (4n3)
8 (34n8)
0n00
3n28
0n27
0n04
5n76
0n00
0n01
0n999
0n07
0n60
0n84
0n02
0n999
0n91
Values were expressed as numbers (%) ; comparisons are made using χ# tests with 1 df and Yate’s correlation for discontinuity. Fisher’s exact
test was used for factors with expected cell frequencies of 5.
411
Anorexia nervosa and obsessive–compulsive disorder
Table 3. Comparison of co-morbid DSM-III-R personality disorders
Analysis
ANjOCD
(N l 21)
OCD
(N l 23)
χ# (df l 1)
P
Cluster A
Paranoid
Schizoid
Schizotypal
1 (4n8)
0 (0)
0 (0)
2 (8n7)
1 (4n3)
2 (8n7)
0n00
0n00
0n43
0n999
0n999
0n51
Cluster B
Antisocial
Borderline
Histrionic
Narcissistic
0 (0)
2 (9n5)
0 (0)
1 (4n8)
0 (0)
4 (17n4)
0 (0)
1 (4n3)
—
0n10
—
0n00
—
0n75
—
0n999
Cluster C
Avoidant
Dependent
Obsessive–compulsive
Passive–aggressive
Self-defeating
8 (38n1)
4 (19n0)
8 (38n1)
0 (0)
2 (9n5)
5 (21n7)
4 (17n4)
2 (8n7)
0 (0)
0 (0)
0n73
0n00
3n86
—
0n63
0n39
0n999
0n05
—
0n43
15 (71n4)
12 (52n2)
1n0
Any
0n32
Values are expressed as numbers (%) ; comparisons are made using χ# tests with 1 df and Yate’s correlation for discontinuity. Fisher’s exact
test was used for factors with expected cell frequencies of 5.
minimum score of 16 or higher for clinically
significant OCD symptoms. PtjOCD tended to
have higher mean scores compared with ANj
OCD on total (p..) (24n3p3n1 v. 22n7p3n1,
t l 1n72, df l 42, NS) and on obsession
(12n3p1n7 v. 11n3p2n1, t l 1n68, df l 42, NS)
and compulsion (12n0p1n5 v. 11n3p1n1, t l 1n68,
df l 42, NS) subtotals, but not significantly.
Also, there were no significant differences
between these groups in the mean scores both on
MAS (ANjOCD, 27n9p6n5 ; PtjOCD, 26n5p
5n7) and SDS (ANjOCD, 58n1p7n4 ; PtjOCD,
53n8p9n0).
The prevalence of personality disorders (PD)
in each group is shown in Table 3. Overall, 15
(71n4 %) of ANjOCD and 12 (52n2 %) of
PtjOCD met the criteria for at least one PD.
Among the three clusters of PD, the anxious–
fearful (cluster C) PD, especially avoidant PD,
were most frequently diagnosed in both groups.
In the ANjOCD group, OCPD was also the
most prevalent PD, followed by dependent PD.
In the PtjOCD group, on the other hand,
borderline PD and dependent PD were the next
most frequently diagnosed, followed by paranoid PD, schizotypal PD and OCPD. ANj
OCD were significantly more likely than Ptj
OCD to meet the criteria for OCPD ( χ# l 3n86,
df l 1, P 0n05). However, there were no other
differences between these groups in the prevalence of PD.
DISCUSSION
In this study, 40 % of our AN subjects met the
criteria for current OCD, even after excluding
the core obsessional symptoms typical of AN.
We found no significant differences in the mean
total, or obsession or compulsion subtotal scores
on the Y-BOCS between ANjOCD and Ptj
OCD. There are a few studies that have
systematically examined whether AN patients
have primary obsessions or compulsions, when
the core symptoms of AN are excluded. Kaye et
al. (1992) reported that 19 unmedicated AN
patients had significantly elevated scores on the
Y-BOCS (meanp.. l 22p5) compared with
matched healthy volunteer women, after excluding core anorexic symptoms, such as disturbances of body image, feeding, and exercise.
Thiel et al. (1995) found that 37 % of their 93
patients with AN or bulimia nervosa (BN) met
the DSM-III-R criteria for OCD on the basis of
symptoms not related to dieting and body image.
Bastiani et al. (1996), who performed a systematic comparison of OCD symptomatology
of 18 female patients with AN and 16 female
patients with OCD using the Y-BOCS, suggested
that AN patients had similar functional impairment from primary OCD symptoms as
indicated by their total Y-BOCS (meanp
.. l 19p9) to that of OCD patients (meanp
.. l 22p6). These findings support our re-
412
H. Matsunaga and others
sults, suggesting that patients with active AN
often manifest significant impairment from
primary obsessive or compulsive symptoms with
similar magnitude in severity to that of OCD
patients.
With regard to OCD symptomatology among
patients with OCD, checking compulsions usually accompanied by pathological doubting, and
washing compulsions usually accompanied by
contamination fears have been reported to be
the most common symptoms in the Western
world (Rasmussen & Elsen, 1992 ; Foa & Kozak,
1995 ; Tallis 1995), as well as in Japan (Honjo et
al. 1989 ; Matsunaga et al. 1998 b). Thus, OCD
symptoms among OCD subjects are considered
to be similar across culture (Greenberg &
Witztum, 1994). This is consistent with our
PtjOCD in spite of age- and gender-limitations
in this study. Leckman et al. (1997) examined
the correlational relationships of the OCD
symptoms in the Y-BOCS symptom checklist
using a principal-components factor analysis,
suggesting the existence of four factors ; (1)
obsessions (aggressive, somatic, sexual and
religious) and checking ; (2) symmetry and
ordering ; (3) cleanliness and washing ; and (4)
hoarding. When their set of four symptom
dimensions is applied to the OCD symptoms of
our ANjOCD, ‘ symmetry and ordering ’ is the
most common dimension, followed by ‘ cleanliness and washing ’ dimension. On the other
hand ‘ obsessions and checking ’ dimension,
along with ‘ cleanliness and washing ’ dimension,
are most commonly identified in PtjOCD.
Thus, the OCD symptoms in ANjOCD were
more likely to concentrate on two of the four
dimensions, such as ‘ symmetry and ordering ’
and ‘ cleanliness and washing ’, compared with
PtjOCD exhibiting a wider variety of symptoms, except for the ‘ hoarding ’ dimension. The
elevated frequencies of ‘ symmetry and ordering ’
and ‘ cleanliness and washing ’ in our ANjOCD
are supported by previous studies (Rothenberg,
1986 ; Kaye et al. 1992). Bastiani et al. (1996)
characterized OCD symptomatology in their
anorexic patients as having a tendency to
endorse mostly symptoms related to ‘ symmetry
and order ’, comparing OCD patients who
endorsed a wide variety of obsessions and
compulsions. Taken together, the OCD symptomatology of AN patients, which can be
characterized differentially from that of OCD
patients, are rather stable cross culturally, as
reported in patients with OCD.
When taking into account a significantly
elevated prevalence of obsessive–compulsive
personality disorder (OCPD) in ANjOCD than
PtjOCD in this study, there may be an essential
difference between AN and OCD in the association with OCPD. A close association between
obsessional personality and AN has been well
described, even in the recovered anorexics
(Strober, 1980 ; Holden, 1990 ; Srinivasagam
et al. 1995 ; Pollice et al. 1997). Studies on
co-morbid personality disorders (PD) among
AN patients revealed that OCPD is one of the
most common PD, with a reported prevalence
ranging from 17 % to 60 % (Gartner et al. 1989 ;
Wonderlich et al. 1990 ; Braun et al. 1994).
Although compulsiveness is considered to be
more common in Japanese compared with
Westerners (Derkesen, 1995), co-morbidity of
OCPD in AN patients in Japan was identified as
being essentially the same as that reported in the
Western world (Matsunaga et al. 1998 a). An
elevated obsessional personality is suggested to
have a causal significance on developing OCD
symptoms in AN patients (Strober, 1980 ; Kaye,
1993). And recent studies indicated the possibility that obsessive traits of temperament and
personality, which is expressive of OCPD and an
obsessive concern with symmetry, exactness and
perfectionism, might be related to an underlying
biological diathesis that places someone at
risk for developing AN (Kaye, 1993, 1997 ;
Srinivasagam et al. 1995).
On the other hand, although the majority of
OCD patients are suggested to meet criteria for
at least one PD, relatively lower rates of comorbid OCPD (6–28 %) have been identified
(Baer et al. 1990, 1992 ; Black et al. 1993 ;
Matsunaga et al. 1998 b). A somewhat lower
prevalence of OCPD in our OCD patients
(8n7 %) may be due to the gender limitation in
this study ; men have been reported to be more
likely than women to meet criteria for OCPD
(Golomb et al. 1995). Thus, OCPD has been
considered to be less frequently occurring in
OCD patients than that expected from psychodynamically orientated theories of OCD, and
may not be a necessary condition for the
development of OCD (Piggott et al. 1994). And
a research in this area suggests the relationship
between OCD and OCPD may best be under-
Anorexia nervosa and obsessive–compulsive disorder
stood as independent, yet an interrelated phenomena (Pollack, 1987). Taken together, in contrast to an association with OCPD in OCD
patients, OCPD in AN patients may have a
causal significance on a development of their
OCD symptoms. And a more close linkage with
OCPD, as well as a significantly elevated
prevalence of an obsessive concern with symmetry and exactness, and an ordering or arranging compulsion in AN patients, compared
with OCD patients, can be characterized as
transcultural phenomena which may represent
their vulnerability for developing AN. However,
in this cross-sectional study, we could not assess
the causality relationship between AN and OCD.
Another limitation of this study was the number
of subjects, as the chi-square test has been
found to be affected by sample size (Marsh
et al. 1988). Therefore, further follow-up studies
are required to clarify the essential relationship
between these disorders.
Finally, our ANjOCD showed significantly
lower GAFS scores, greater numbers of hospitalizations, greater severity of depressive or anxious
status than ANkOCD, in spite of no differences
between these groups in the duration of illness,
% SBW, or the prevalence of any PD except for
OCPD. Taking into account a close linkage
between OCD and OCPD in AN patients, these
findings raise the possibility that a difficulty of
social adaptation and a general psychopathology, such as depressive or anxious status in
AN patients, may be further strengthened by the
co-morbid OCD and\or OCPD rather than AN
per se. Our ANjOCD were also significantly
more likely than PtjOCD to have a greater
degree of social maladaptation as assessed by
the GAFS, in spite of no significant differences
in the severity of OCD symptoms between these
groups. Among studies on OCD, OCPD has
been suggested neither to be closely related to
OCD severity, nor to be identified as a predictor
of poorer outcome (Baer et al. 1992 ; Pigott et al.
1994). Taken together, as one of the differential
characteristics of AN from OCD, it can be
hypothesized that co-morbidity of OCD and\or
OCPD in AN patients may exaggerate the
severity of various clinical features, such as
generalized psychosocial problems. However,
these days concomitant OCD has been suggested
not to be an indicator of a significantly poorer
prognosis for AN. (Thiel et al. 1998). Therefore,
413
this hypothesis should be assured in further
research on this issue, including longitudinal
follow-up studies.
In conclusion, considerable numbers of AN
patients manifest significant impairment from
primary OCD symptoms, like patients with
OCD. And the OCD symptomatology in AN
patients may be rather stable cross-culturally, as
reported in OCD patients. However, there are
some differential characteristics of OCD symptomatology, and an association with OCPD
between AN and OCD. Especially, a close
linkage between OCD and OCPD in AN patients
may represent a causal significance of OCPD on
their OCD symptoms. In this study, we could
not assess the causality relationship between AN
and OCD. Further follow-up studies are needed
to clarify the essential relationship between these
disorders.
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