Psychiatric comorbidity and inpatient treatment history in bulimic subjects Anja Spindler, Ph.D.*, Gabriella Milos, M.D. Psychiatric Outpatient Department of the University Hospital Zurich, Zurich, Switzerland Received 28 January 2003; accepted 9 July 2003 Abstract Bulimia nervosa (BN) is often associated with other forms of psychopathology. There is a need to clarify which specific factors of psychopathology are linked with the referral to psychiatric or psychotherapeutic inpatient treatment. This study examined which factors of psychopathology are linked with the referral of BN patients to inpatient treatment while controlling for history of suicide attempts and history of underweight. 126 females with a current diagnosis of BN purging type were assessed with the Structured Clinical Interview for DSM-IV and interviewed about their history of treatment for the BN, history of weight, and history of suicide attempts. Logistic regressions were conducted to examine whether psychiatric comorbidity, suicide attempts, and underweight were associated with inpatient treatment history. Axis I comorbidity in general, but no specific axis I disorder, was associated with inpatient history. Axes II comorbidity, especially Cluster B disorders and to a lesser degree depressive/negativistic personality disorders, was associated with a history of inpatient treatment. History of suicide attempts was also linked with inpatient experience, but history of underweight was not. The results showed that BN patients with specific types of comorbidity are more likely to be hospitalized than others. © 2004 Elsevier Inc. All rights reserved. Keywords: Inpatient treatment experience; Psychiatric comorbidity; Suicide attempts; Underweight; Bulimia nervosa 1. Introduction Bulimia nervosa (BN) is the most prevalent of eating disorders, affecting between 1% and 3% of adolescent and young adult women [1]. Clinical experience and research indicates that BN patients often present a complex psycho- pathological picture with high levels of psychiatric comor- bidity both on axes I and II [2,3]. When determining what type of treatment to offer, clinicians consider how the dis- order has affected the patient’s social integration and ability to work, previous failed attempts of therapy, and the sever- ity of the patient’s disorder, of which one aspect is presence and type of comorbidity. Thus, persons attending more intense treatment settings, such as psychiatric or psycho- therapeutic inpatient treatment facilities, tend to have higher levels of psychopathology. To this end, it has been shown that eating disorder inpatients have higher levels of anxiety, depression, and somatization [4], and higher rates of per- sonality disorders [5,6] than outpatients. The existing re- search investigating differences of psychopathology be- tween inpatient and noninpatient eating disorder samples has not employed systematic assessments of psychiatric comorbidity. In addition, while findings of differences in levels of psychopathology have been reported, the signifi- cance of the type of comorbidity for referral of BN patients to inpatient treatment has not previously been systemati- cally examined. Identifying the specific psychopathological characteristics that are associated with psychiatric or psy- chotherapeutic inpatient treatment would help to better un- derstand referral processes, and help in tailoring appropriate treatment programs or support existing standards of care in the treatment of BN. This study was designed to examine which specific types of psychopathology are found in BN subjects with inpatient experience as compared to BN subjects without such expe- rience. Assessing the whole range of axes I and II comor- bidity made it possible to examine specific types of comor- bidity for links with inpatient experience while controlling for other forms of psychopathology. Deliberate self-harm- ing behavior, such as suicide attempts [7] and severe un- derweight [8], are considered indications for hospitalization of eating disorder patients. Because suicidality or starvation behavior may be confounded with axes I or II comorbidity, * Corresponding author. Tel.: +41-1-225-5280; fax: +41-1-225-4530. E-mail address: anja.spindler@psy.usz.ch (A. Spindler). General Hospital Psychiatry 26 (2004) 18 –23 0163-8343/04/$ – see front matter © 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.genhosppsych.2003.07.001