Psychiatry and Clinical Neurosciences (1999), 53, 661–666
Regular Article
Prevalence and symptomatology of comorbid
obsessive–compulsive disorder among bulimic patients
HISATO MATSUNAGA, md, phd,1 NOBUO KIRIIKE, md, phd,1 AKIRA MIYATA, md,2
YOKO IWASAKI, md,1 TOKUZO MATSUI, md, phd,1 KAYO FUJIMOTO, md,1
SHINJI KASAI, md, phd1 AND WALTER H. KAYE md3
1
Department of Neuropsychiatry, Osaka City University Medical School, Osaka City, Osaka, 2Tsuda Hospital,
Sanda, Hyogo, Japan and 3Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center,
Pittsburgh, USA
Abstract
This study sought to assess the prevalence and symptomatology of comorbid obsessive–
compulsive disorder (OCD) among Japanese subjects who met the DSM-III-R criteria for
bulimia nervosa (BN). The Structured Clinical Interview for DSM-III-R Patient Version was
used to distinguish 26 BN patients with concurrent OCD from 52 BN patients without OCD.
Obsessive–compulsive symptoms in BN subjects with concurrent OCD were evaluated
using the Japanese version of the Yale-Brown Obsessive–Compulsive Scale. There were no differences in the prevalence of concurrent OCD between BN subjects with and without a lifetime
history of anorexia nervosa. Among BN subjects with concurrent OCD, symptoms related to
symmetry and order were most frequently identified, followed by contamination and aggressive obsessions, and checking and cleaning/washing compulsions. Bulimia nervosa subjects with
concurrent OCD were more likely than subjects without OCD to have more severe mood and
core eating disorder psychopathology. Comorbid OCD is a common phenomenon in Japanese
bulimics (33%) similar to that suggested in BN subjects in the Western countries. Obsessive–
compulsive symptoms related to symmetry and order were most frequently observed in BN
subjects with concurrent OCD, which was a similar finding to that reported among restricting
anorexic subjects.
Key words
bulimia nervosa, eating disorder, obsessive–compulsive disorder.
INTRODUCTION
A variety of psychopathological symptoms observed
among subjects with bulimia nervosa (BN) have
been extensively investigated in Japan.1–6 As reported
in Western countries, Japanese bulimics have been
similarly characterized as having features related
to impulsivity which may be expressive of some
diametrically opposite nature to restricting anorexics
who are traditionally characterized as rigid and
constrained.4–6
The essential features of BN are binge-eating and
inappropriate compensatory methods to prevent
Correspondence address: Hisato Matsunaga, md, phd, Department
of Neuropsychiatry, Osaka City University Medical School, 1-4-3
Asahi-machi, Abeno-ku, Osaka city, Osaka, 545-8585, Japan.
Received 2 April 1999; revised 24 July 1999; accepted 3 August
1999.
weight gain. Self-evaluation is excessively influenced
by body shape and weight.7 Bulimics usually exhibit
an obsessional preoccupation with body shape and
weight, along with frequent rumination about food.
Bulimics’ purgings have been considered to be an
anxiety-reducing behavior much as the performance
of compulsive behaviors is for patients with obsessive–compulsive disorder (OCD).8 Thus, the foodand weight-related thoughts associated with BN
have been described as obsessional in nature, and the
binge-eating/purging aspects as compulsive.9,10
These clinical characteristics among bulimic
subjects have stimulated investigators to study the
relationship between BN and OCD. Obsessive–
compulsive disorder has been found to occur in
3–43% of people who have BN.10–15 Thus, high frequencies of obsessional symptoms and higher than
expected rates of OCD have been described in
patients with BN, similar to those reported in patients
H. Matsunaga et al.
662
with restricting anorexia nervosa (AN).16–18 However,
few studies have assessed the prevalence of comorbid
OCD among Japanese women with BN. As for OCD
symptomatology, OCD symptoms have been characterized as consistent across culture among patients
with restricting AN,19 as well as among patients with
OCD.20,21 Thus, it can be hypothesized that OCD
symptomatology in bulimic subjects is free from
the influence of surrounding culture. One goal of this
study was to determine how OCD symptomatology in
Japanese bulimics might be characterized in comparison with those found in their Western counterparts.
Because there are significant differences between
AN patients who binge and purge and normal-weight
bulimics, the conceptualization of BN in DSM-IV7
was changed from DSM-III-R.22 However, from the
serotonin (5-HT) dysregulation hypothesis in BN,
along with a phenomenological point of view, patients
with bulimic symptoms have similar degrees and
types of pathological features, regardless of weight,
which tend to be qualitatively distinct from and more
severe than that of non-bulimic anorexics,17 and little
influence of concurrent AN on the prevalence of
comorbid OCD among eating disordered subjects
has been suggested.13 Therefore, we evaluated OCD
symptoms among patients who met the DSM-III-R
criteria for both BN and OCD, regardless of weight,
assessing the influence of a lifetime comorbidity of
AN on prevalence of comorbid OCD, as well as OCD
symptomatology.
SUBJECTS AND METHODS
Subjects
The subjects were 78 female patients with BN diagnosed according to the DSM-III-R criteria.22 Of
these subjects, 48 (62%) patients concurrently met the
DSM-III-R criteria for AN at the time of this study
(BAN), and the remaining 30 patients (38%) met the
criteria for BN alone (NWB). According to the DSMIV criteria,7 all BAN subjects met the criteria for AN
binge-eating/purging type. Of the 30 patients with
NWB, 24 (80%) patients met the DSM-IV criteria for
BN purging type, and the others met the criteria for
BN non-purging type. Among subjects in the NWB
group, 12 (40%) patients had a past history of AN.
Each diagnosis was made by the senior psychiatrist
who had been trained to yield a reliable diagnosis for
eating disorders (ED), and had been engaged in the
treatment of ED for at least 5 years.
All participants were consecutively admitted to the
Department of Neuropsychiatry at the Osaka City
University Medical School Hospital between March
1994 and May 1997, and gave informed consent to
participate in this study. At the time of this study, 67
(86%) patients were outpatients and the remaining
11 patients (14%) were hospitalized. The subjects
were excluded from this study if the duration of current BN was less than 6 months at the date of these
assessments.
Assessment
Each subject was interviewed to provide information
regarding her demographic profile with family and
medical history, and the clinical features related to
ED. Global functioning was assessed using the DSMIII-R Axis V (Global Assessment of Functioning
Scale: GAFS)22 by one of the authors (HM) who was
trained to yield reliable GAFS scores. All subjects
were subsequently interviewed for the evaluation of
current comorbidity of OCD using the Japanese
version of the Structured Clinical Interview for DSMIII-R Patient Version (SCID-P).23 This was performed
on each subject individually by one of the authors
(YI) who had extensive experience in diagnostic
assessment with structured interviews and was blind
to any clinical information on the subject. On the
assessment of the inter-rater reliability based on a
joint interview design, a kappa coefficient derived for
current diagnosis of OCD was 0.72.
Obsessive–compulsive disorder symptoms in BN
patients who were diagnosed as having concurrent
OCD were assessed using the Japanese version24
of the Yale-Brown Obsessive–Compulsive Scale (YBOCS).25,26 The assessment was performed in a semistructured interview by one of the authors (HM
or AM) who had been trained under the supervision of
senior psychiatrists according to the instructions of the
developers of the interview.25 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 bodyrelated obsession-like symptoms or ritualized eating
behaviors were omitted from the Y-BOCS scoring. The
severity of OCD symptoms was assessed using the YBOCS 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 a 4-point scale representing ‘no symptoms’
(0) to ‘extreme symptoms’ (4). 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.24
In order to assess psychological and behavioral features related to ED, we administered the Eating Disorder Inventory (EDI)27 to all subjects on the same
Comorbid OCD among bulimic patients
day as the other assessments. The Manifest Anxiety
Scale (MAS)28 and the Zung’s Self-rating Depression
Scale (SDS)29 were also administered to all subjects
for assessment of anxiety and depressive symptoms,
respectively.
Data analysis
Mean group differences for parametric variables were
evaluated using Student’s t-tests. Non-parametric variables were compared using c2 tests with one degree of
freedom and Yate’s correction for discontinuity. The
significance level was considered to be P < 0.05.
RESULTS
There were no significant differences in demographic
and clinical features between BAN and NWB patients
except for body mass index (BMI). The mean BMI in
patients with BAN (15.1 ± 1.8 kg/m2) was significantly
lower than that in patients with NWB (21.4 ± 2.8; t =
11.75, d.f. = 76, P < 0.0001). With respect to psychometric test results, NWB patients had significantly higher
mean scores on the EDI subscales for drive for thinness (t = 2.77, d.f. = 76, P < 0.01) and body dissatisfaction (t = 2.16, d.f. = 76, P < 0.05) than BAN patients.
There were no other significant differences in psychometric test results between BAN and NWB patients.
Subsequently, we divided all participants into two
groups based on the presence or absence of a concurrent diagnosis of OCD evaluated by the SCID-P.
Twenty-six patients (33%) who met the criteria for
concurrent OCD (BN + OCD) were distinguished
from 52 patients (67%) without OCD (BN – OCD).
There were no differences between BAN and NWB
patients in the prevalence of current comorbidity of
OCD (17/48 (35%) vs 9/30 (30%), respectively). This
was similar in the NWB group where no differences
in terms of prevalence of concurrent OCD were
found between patients with and without a past
history of AN (33 vs 28%, respectively).
Y-BOCS assessments were completed only on BN +
OCD subjects. All BN + OCD patients had a score of
16 or higher with a mean total Y-BOCS score of 23.8
± 4.8 with obsession and compulsion subtotals of 12.1
± 2.9 and 11.7 ± 2.9, respectively. There were no differences in the Y-BOCS scores when 26 BN + OCD
patients were separated into 17 patients with BAN
and nine patients with NWB (24.5 ± 5.5 vs 23.6 ± 3.8,
respectively). Table 1 shows the specific categories of
the primary obsessions and compulsions in patients
with BN + OCD. Obsessions of symmetry or exactness were the most commonly identified, followed
by contamination, miscellaneous, and aggressive
663
Table 1. Obsessive and compulsive symptoms in bulimic
patients with obsessive–compulsive disorder
Obsession
Aggressive
Contamination
Sexual
Hoarding/saving
Religious
Need for symmetry, or exactness
Somatic
Miscellaneous
11 (42.3)
13 (50.0)
2 (7.7)
2 (7.7)
0 (0)
14 (53.8)
2 (7.7)
12 (46.2)
Compulsion
Cleaning/washing
Checking
Repeating rituals
Counting
Ordering/arranging
Hoarding/collecting
Miscellaneous
12 (46.2)
13 (50.0)
6 (23.1)
6 (23.1)
13 (50.0)
1 (3.8)
9 (34.6)
obsessions. Checking and ordering/arranging compulsions were the most common compulsions, followed
by cleaning/washing compulsions.
Table 2 compares demographic profiles and clinical
features between BN patients with and without concurrent OCD. There were no significant differences
between these groups in age at onset of BN, years
of education, BMI, lifetime incidence of suicidal
attempts and current frequencies of binge eating and
self-induced vomiting. Patients with BN + OCD were
significantly more likely than patients with BN – OCD
to have higher mean age (t = 3.13, d.f. = 76, P < 0.005)
and longer duration of illness (t = 2.30, d.f. = 76,
P < 0.05). Patients with BN + OCD also showed
significantly lower GAFS scores (t = 4.85, d.f. = 76,
P < 0.0001) and significantly greater numbers of hospitalizations (t = 2.98, d.f. = 76, P < 0.005) than patients
with BN – OCD.
Table 3 compares psychometric test results between
BN patients with and without concurrent OCD.
Patients with BN + OCD had significantly higher mean
scores on the MAS (t = 2.37, d.f. = 76, P < 0.05), SDS
(t = 2.63, d.f. = 76, P < 0.05) and on the EDI subscales
for drive for thinness (t = 2.35, d.f. = 76, P < 0.05), ineffectiveness (t = 2.37, d.f. = 76, P < 0.05), perfectionism
(t = 2.15, d.f. = 76, P < 0.05), and maturity fear (t = 2.24,
d.f. = 76, P < 0.05) than patients with BN – OCD.
DISCUSSION
This study showed that 33% of people with BN diagnosed by the DSM-III-R concurrently met the criteria
H. Matsunaga et al.
664
Table 2. Comparison of demographic profiles and clinical features between bulimic patients with and without obsessive–
compulsive disorder
Analysis (t-test)
BN + OCD (n = 26)
BN - OCD (n = 52)
t (d.f. = 76)
P
25.6 ± 3.9
20.0 ± 3.7
5.5 ± 3.5
13.4 ± 2.4
41.0 ± 10.4
24(1)/2
17.5 ± 4.0
7.1 ± 3.1
7.1 ± 3.1
1.8 ± 1.8
12 (46%)
22.8 ± 3.7
19.1 ± 2.8
3.7 ± 2.8
13.3 ± 2.1
53.1 ± 10.7
45(2)/7
17.5 ± 3.7
6.4 ± 4.4
6.8 ± 4.6
0.6 ± 1.4
16 (31%)
3.13
1.22
2.30
0.17
4.85
–
0.08
0.73
0.29
2.98
1.18‡
0.003
0.23
0.02
0.87
< 0.0001
–
0.94
0.47
0.77
0.004
0.28‡
Age (years)
Age at onset (years)
Duration of illness (years)†
Education (years)
GAFS score
Single (divorced)/married
Body mass index (kg/m2)
Current frequency of binge eating (/W)
Current frequency of vomiting (/W)
Number of admissions
Incidence of suicidal attempts
Values are expressed as mean ± SD. †Age at onset and duration of illness refer to BN; ‡Chi-squared tests with Yates correlation for 2 ¥ 2 tables.
BN, bulimia nervosa; OCD, obsessive–compulsive disorders; GAFS score, Global Assessment of Functioning Scale score.
Table 3.
Comparison of psychometric test results
Analysis (t-test)
Manifest Anxiety Scale
Zung’s Self-rating Depression Scale
Eating Disorder Inventory
Drive for thinness
Bulimia
Body dissatisfaction
Ineffectiveness
Perfectionism
Interpersonal distrust
Interoceptive awareness
Maturity fear
BN + OCD (n = 26)
BN - OCD (n = 52)
t (d.f. = 76)
P
30.5 ± 6.7
60.7 ± 6.2
26.3 ± 7.3
54.6 ± 10.2
2.37
2.63
0.02
0.01
14.0 ± 6.2
11.6 ± 7.4
16.3 ± 6.8
19.0 ± 6.7
8.2 ± 4.1
9.4 ± 4.4
16.9 ± 6.5
11.3 ± 5.6
10.4 ± 5.4
11.3 ± 5.3
14.3 ± 5.8
14.6 ± 7.5
6.1 ± 3.9
8.0 ± 4.9
13.7 ± 5.4
8.3 ± 5.0
2.35
0.19
1.29
2.37
2.15
1.16
1.95
2.24
0.02
0.84
0.20
0.02
0.04
0.25
0.06
0.03
Values are expressed as mean ± SD. BN, bulimia nervosa; OCD, obsessive–compulsive disorder.
for OCD, even after excluding the OCD-like symptoms typical of ED. Importantly, the coexistence of
AN had little effect on the comorbidity of current
OCD in bulimics. Other studies reported similar rates
for the lifetime prevalence of OCD between BN
patients with and without a past history of AN, which
was consistent with the finding observed among subjects with NWB in this study.12,14 In addition, some
studies found restricting AN, AN and BN, and BN
patients to have similar rates of current,13 and lifetime
OCD.12,14 However, Hudson et al. found that the lifetime prevalence of OCD in patients with restricting
AN was about three-fold that of BN subjects, and the
lifetime diagnosis of OCD in anorexic subjects with
BN fell halfway between that of restricting AN and
BN subjects.11
In this study, patients in the BN + OCD group had a
score of 23.8 ± 4.8 on the Y-BOCS, which is almost
similar in magnitude to the score reported by
Goodman et al. for 81 OCD patients (25.1 ± 6),26 and
that reported by us for 75 Japanese patients with OCD
(27.1 ± 5).21 This result suggests that BN subjects with
OCD have substantial impairment from primary OCD
symptoms. In terms of target symptoms categorized
Comorbid OCD among bulimic patients
using the symptom checklist of the Y-BOCS,
obsessions of symmetry or exactness were the most
commonly identified, followed by contamination
obsessions and aggressive obsessions. Checking and
ordering/arranging compulsions were the most common compulsions, followed by cleaning/washing compulsions. Other studies have had similar findings in
people with AN and in those with BN. Thiel et al. found
an obsessive need for symmetry and a compulsion for
order to be common symptoms in ED patients with
OCD in Germany.30 Previous studies on restricting
AN subjects have found that symptoms of symmetry,
exactness, ordering, and arranging were the most
common symptoms in ill16,18 and recovered subjects,31
as well as in a Japanese population.19 Taken together,
these data suggest that commonalities may exist in the
kinds of OCD symptoms experienced by women with
ED, regardless of type of ED, or whether subjects are
ill or recovered, and independent of culture.
Bastiani et al. reported that OCD patients were
significantly more likely than restricting AN patients
with OCD to have checking compulsions.18 Among
patients with OCD, checking compulsions have been
suggested to be one of the most common compulsions
across culture.21,32,33 This type of compulsion has been
indicated to be closely associated with aggressive
obsessions among patients with OCD.34 When comparing the OCD symptomatology in BN patients with
concurrent OCD in the present study with that
reported in patients with restricting AN,16,18,19,31 our
patients had a wider variety of OCD symptoms, especially those with a tendency to have elevated prevalence of the combination of aggressive obsessions
and checking compulsions similar to that reported
in patients with OCD.21,32,33 Thiel et al. found an
increased prevalence of both aggressive obsessions
and checking compulsions among patients with ED.30
However, it is difficult to consider their result as a
reflection on the specific characteristics of OCD
symptomatology among bulimic patients, because
they included restricting AN patients in their study.
Even though we found no differences in the prevalence of each OCD symptom between bulimic subjects with and without concurrent AN, small sample
size in each group limited us to discuss the effect
of coexisting AN on OCD symptomatology in BN
patients. Therefore, it remains to be elicited in further
studies as to whether the increased prevalence of
aggressive obsessions and checking compulsions may
be reflective of differential OCD symptomatology in
bulimics from that in restricting anorexics, or may be
reflective of cultural effects in Japanese subjects.
Finally, this study revealed that patients with
BN + OCD showed significantly lower GAFS scores
than patients with BN – OCD despite finding no
665
differences in severity of core BN symptoms, such as
binge/purge behaviors. They also tended to have
more severe psychopathology in terms of negative
affect and core ED symptoms. Thiel et al. found a
significantly higher degree of disturbed attitudes
and behavior concerning eating in ED patients with
OCD than those patients without OCD.30 Thus, while
these findings raise the possibility that comorbid
OCD may exert some influence on a variety of psychopathology in bulimic patients, it is unclear whether
these findings are attributable to comorbid OCD or
the higher rates of other comorbid symptoms.11–14
Further follow-up studies are required to clarify this
issue.
Rubenstein et al. suggested that in bulimics,
measures of obsessionality and compulsivity showed
significant decreases following inpatient treatment,
while one of two depression scores did not, which
might be indicative of a stronger relationship between
OCD and BN than that postulated between BN
and the affective disorders.8 On the other hand, Brewerton suggested that a variety of psychobiological
stressors, such as dieting, binge-eating, purging and
drug abuse, as well as psychosocial–interpersonal
stressors, may perturb and interact an already vulnerable 5-HT system in ED subjects.17 It may be that
bulimic patients with OCD have a more severe degree
of 5-HT dysregulation.17 Considering this hypothesis, it
can be speculated that comorbidity of OCD, along
with a higher degree of psychopathology, such as negative affect, are indicative of the greater disturbance
of 5-HT functioning among patients with BN +
OCD compared with patients with BN – OCD. This
speculation should be elucidated in further studies.
In conclusion, comorbid OCD is a common finding
in subjects who met the DSM-III-R criteria for BN
regardless of weight. Bulimic subjects with concurrent
OCD were more likely than subjects without OCD to
have more severe mood and core ED psychopathology. Patients with BN, like people with restricting AN,
tended to have OCD symptoms related to symmetry
and exactness. However, compared with restricting
AN subjects, more aggressive obsessions and checking
compulsions were found among BN subjects, which
may indicate differential OCD symptomatology
between these subtypes of ED.
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