Kerstin Ekeroth - GUPEA (PDF)

Kerstin Ekeroth Psychological problems in adolescents and young women with eating disturbances ISSN 1101-718X ISRN GU/PSYK/AVH--154--SE ISBN 91-628-6550-1 Department of Psychology Göteborg University, 2005 Sweden Psychological problems in adolescents and young women with eating disturbances Kerstin Ekeroth  Department of Psychology Göteborg University, 2005 Sweden Psychological problems in adolescents and young women with eating disturbances Kerstin Ekeroth  Kerstin Ekeroth Printed in Sweden Grafikerna Livréna AB, Kungälv, 2005 ISSN 1101-718X ISRN GU/PSYK/AVH--154--SE ISBN 91-628-6550-1  DOCTORAL DISSERTATION AT GÖTEBORG UNIVERSITY, SWEDEN, 2005 Abstract Ekeroth, K. (2005). Psychological problems in adolescents and young women with eating disturbances. Department of Psychology, Göteborg University, Sweden This thesis investigated general psychopathology in adolescent and young adult female patients with eating disorders (ED) and in women from the general population with or without self-reported eating problems. First, an overview of different approaches for assessing and classifying psychopathology is presented. The thesis continues with a gene- ral description of eating disorders and co-morbidity in eating disorder patients. Since no appropriate standardized self-report measure of general psychopathology for adolescents was available in Sweden, study I provides normative data for the Youth Self- Report (YSR) when completed by Swedish adolescents and tests the impact of various demographical variables. In Study II, the YSR was used to assess general psychopatho- logy and competencies in female adolescent ED patients compared to matched controls. Results showed that girls with ED reported less competence and more problems com- pared to controls. Patients with bulimia nervosa (BN) scored higher than both patients with anorexia nervosa (AN) and those with an eating disorder not otherwise specified (EDNOS) on most problem scales, and AN-bingers/purgers scored higher than pure restrictors on externalizing behaviors. About twice as many patients with BN and the binging/purging type of AN scored in the clinical range on total problems compared to pure restricting AN patients and EDNOS patients. Study III compared young adult women with EDs with controls from the general population with and without self-re- ported eating problems on general psychopathology, using the Symptom Check-List-90 (SCL-90). Results showed that controls with self-reported eating problems reported as many emotional and behavior problems as patients with ED. In study IV, a three-year follow-up was obtained on young adult patients and controls concerning eating related problems and general psychopathology. Results showed that after three years, patients with ED did not differ significantly from controls, while the elevated problem scores in women with self-reported eating problems from the general population, remained. Findings are discussed in relation to diagnosis, prevention and treatment. Key words: Youth Self-Report, Symptom Check List-90, Eating Disorder Inventory-2, Adolescents, Young adults, General psychopathology, Self-reported eating problems, Eating Disorders Kerstin Ekeroth, Department of Psychology, Göteborg University, Box 500, SE 405 30 Göteborg, Sweden. Phone +46 31 773 4294, Fax: +46 31 773 46 28, E mail: [email protected]   Acknowledgments Writing a doctoral thesis is not a one man’s work. Many people have contrib- uted in different ways and in different areas. First and foremost, I would like to thank my outstanding supervisor and co-author, Professor Anders Broberg, for his scientific guidance and for his truly never-ending support. I would also like to thank Dr. Lauri Nevonen, co-author on study III and IV, for actually pushing me into the research world, and for his good advice, enthusiasm and encouragement, which has been so needed at times. Further, I want to thank Per Gustafsson, Kjell Hansson, Bruno Hägglöf, Tord Ivarsson, and Bo Larsson, co-authors on Study I. A special thanks also to Ingemar Engström and Bruno Hägglöf, co-authors on Study II, for their skillful help and comments. A big thank you must also go to all friends and colleagues at the Department of Psy- chology who have contributed with inspiration and encouragement, and very important non-academic, non-scientific chats, about everything and nothing. A special thanks also to my family, especially my mother and father who always support me in what I do. Without your emotional support and practical help, I would have ended this project before intended. You are fantastic. My dearest thank you goes to Emil for his love and encouragement and for making me laugh even when it was tough. I also want to thank Smilla, for always being happy to see me, and for telling me that life should really be a walk in the park. Last but not least, I want to thank the staff on the Anorexia and Bulimia Unit at Queen Silvia Children’s Hospital, and all participants who took their time, shared their feelings and thoughts, thereby making this thesis possible. A grant from Vårdalstiftelsen financially supported this research. Kerstin Ekeroth Göteborg, May 2005  List of publications This thesis is based on the following studies, which will be referred to by their Roman numerals: I. Broberg, A.G., Ekeroth, K., Gustafsson, P.A., Hansson, K., Hägglöf, B., Ivarsson, T., & Larsson, B. (2001). Self-reported competencies and prob- lems among Swedish adolescents; a normative study of the YSR. Euro- pean Child and Adolescent Psychiatry, 10, 186-193 II. Ekeroth, K., Engström, I., Hägglöf, B., & Broberg, A.G. (2003). Self- reported competence and problems among Swedish girls with eating dis- orders and a control sample, using the Youth Self-Report. Eating and Weight Disorders, 8, 274-281 III. Ekeroth, K., Broberg, A.G., & Nevonen, L. (2004). Eating disorders and general psychopathology: a comparison between young adult patients and normal controls with and without self-reported eating problems. Eu- ropean Eating Disorders Review, 12, 208-216 IV. Ekeroth, K., Broberg, A.G., & Nevonen, L. Eating related problems and general psychopathology in eating disorder patients and normal controls with and without self-reported eating problems. A three-year follow-up. Manu- script submitted for publication  Contents ABBREVIATIONS ......................................................................................8 INTRODUCTION .....................................................................................9 Health and ill-health ...........................................................................9 APPROACHES FOR CLASSIFYING PSYCHOLOGICAL DISTURBANCES .....................................................................................11 Theoretical approach .........................................................................11 Phenomenological/Descriptive approach ...........................................12 Different dimensional methods ..........................................................14 Swedish studies of psychological ill-health in adolescents ..............15 Achenbach System of Empirically Based Assessment (ASEBA) .............16 Multi-informant assessment ................................................................17 EATING DISORDERS .............................................................................18 Diagnostic criteria according to DSM-IV .........................................19 Prevalence and incidence ....................................................................21 Treatment and outcome ......................................................................22 Continuity/Discontinuity hypothesis .................................................24 Co-morbidity and general psychopathology .......................................25 Neurobiological aspects on psychopathology and eating disorders ..30 Competence .........................................................................................32 Concluding remarks ............................................................................33 EMPIRICAL STUDIES ............................................................................34 General aim .........................................................................................34 Study I and II .......................................................................................34 Study III and IV ...................................................................................44 GENERAL DISCUSSION ........................................................................52 CONCLUSIONS ......................................................................................58 REFERENCES ..........................................................................................59 APPENDIX ...............................................................................................75  Introduction 8 Abbreviations AN Anorexia Nervosa AN-b/p Anorexia Nervosa - binging/purging type AN-r Anorexia Nervosa - restricting type ASEBA Achenbach System of Empirically Based Assessment ASR Adult Self-Report BN Bulimia Nervosa CBCL Child Behavior Check List CBT Cognitive-Behavioral Therapy EDI-2 Eating Disorder Inventory-2 EDNOS Eating Disorder Not Otherwise Specified IPT Interpersonal Psychotherapy OCD Obsessive-Compulsive Disorder SCL-90 Symptom Check List-90 SES Socio-economic Status TRF Teacher Report Form YSR Youth Self-Report  Health and ill-health 9 Introduction Experts warn about the growing number of obese children and adolescents in western countries, and at the same time more attention is directed to the problem of eating disorders especially among female adolescents and young adults. Young people are exposed to an enormous quantity of unhealthy food and snacks, but to fewer “natural” opportunities for exercise (like walking or biking to school). Combining this reality with the picture portrayed in media, that being thin and fit is the way to a happy life and a good career, makes for a truly contradictory message. Feelings of dissatisfaction, frustration and des- peration stemming from this “mission impossible”, is common among young females. Fortunately, even though a large number of adolescents and young adults are dissatisfied with their bodies and try out various methods for con- trolling weight, far from all are affected by an eating disorder. Why is that and what differentiates clinical eating disorders from non-clinical eating problems? Are individuals with eating problems also affected by other emotional and be- havioral problems? Health and ill-health Many definitions of what constitutes health, both mental and physical, have been suggested. However, since both types of health are strongly related, they probably should be understood from the same dimensional constructs (Brülde, 1998). According to the World Health Organization, the definition of health is “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity”. The word “complete” makes the definition seem much like a Platonian ideal, probably not reachable by many people. From this point of view health is valued as a final or intrinsic goal, good to have in itself, and not merely as a means for a good life (Brülde, 1998). A more func- tional perspective on health is proposed by Nordenfelt (1995), claiming that a person is healthy if she is in a physical or mental state that enables her to fulfill all her vital goals considering standard conditions. Pörn (1995) defines health as a person’s ability to act in accordance with her life plan, and the balance be- tween a person’s ability and her plans. Brülde (1998) suggests a heterogeneous, multi-factorial definition of health made up of several factors or dimensions.  Introduction 10 According to his definition, a person’s health is composed of her clinical sta- tus, functional health (performance, abilities, competencies), and physical and psychological well-being. This definition views health both as a means (clinical status and functional health) and as a goal (well-being). Even if many people agree that health is not equal to the absence of clinical ill-health, this is not always regarded in health research. Many studies and in- struments claiming to measure health status, in fact rather measure ill-health or disturbances (Antonovsky, 1991; Seedhouse, 1987). Even if we cannot meas- ure or state a bad clinical status, neither physical nor mental, we cannot con- clude that the person is healthy or is feeling well. A person’s health is definitely influenced by her clinical status, but this is only one dimension or aspect of the health construct. According to Antonovsky (1991) it is important to study both what is necessary for developing good health and to study the develop- ment of psychopathology. Since those constructs are not each other’s oppo- sites, different criteria and perspectives are needed (Antonovsky, 1991). Psy- chological disturbance is however one important aspect of health. According to DSM-IV (1994) a mental disorder is “a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is as- sociated with present distress or disability or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom” (American Psychiatric Association, 1994, pp xxi-xxii). Achenbach (1995) broadly defines psychopathology to encompass persistent behavior, thoughts, and emotions that are likely to impede the accomplishment of developmental tasks necessary for long-term adaptation. This thesis investigates general psychopathology in adolescent girls and young women with eating disturbances, i.e. we do not claim to assess health. The thesis begins with a description of common approaches for measuring and clas- sifying psychological disturbance, and continues with a description of eating disorder diagnoses and related co-morbidity. The thesis is based on four stud- ies, where the first (study I), is a standardization of an instrument for measur- ing competence and general psychopathology in adolescents, which is there- after used for assessing competence and psychopathology in teenage girls with eating disorders (study II). Study III continues with an assessment of general psychopathology in young adult women with ED and women from the general population with and without self-reported eating problems. Finally, study IV investigates eating related problems and general psychopathology from a lon- gitudinal perspective.  Health and ill-health 11 Approaches for classifying psychological disturbances The debate on how to assess and classify psychopathology has confounded psychologists and psychiatrists for decades, and there has been a polarization between various standpoints (Jensen, Brooks-Gunn, & Graber, 1999). There are two main approaches for classification of psychological disorders, one theo- retical and one phenomenological/descriptive. The theoretical approach tries to understand the underlying causes for a disorder, while the descriptive ap- proach aims to describe the phenomena as they appear and are experienced. The phenomenological/descriptive approach can utilize clinical (categorical) or empirical dimensional methods. Theoretical approach Theoretical approaches for classification have emanated from different tradi- tions, but all agree to the assumptions about how intrapsychological events and personality processes are believed to cause psychological disorders. The foremost advocate for this approach was Sigmund Freud. Freud’s psychoana- lytic theory was primarily based on his clinical work with adults and he did not include observations of normal children as an empirical base for his theory of early development. Anna Freud brought further the theoretical assumptions on how children develop psychopathology. Among other things, she constructed a special developmental profile grounded in psychoanalytically based observa- tions of children (Freud, 1965). The only systematic effort to classify develop- mental psychopathology came in 1966 from the Group for the Advancement of Psychiatry (GAP; 1966). This effort resulted in eight categories based on psy- choanalytic terms and presumptions. Supporters of the theoretical approaches claim that by paying attention to the underlying personality processes, from where the disorders are thought to emerge, we will have better opportunities to formulate treatment and interventions. Theoretical approaches are helpful for the clinician when trying to understand and help patients. Disadvantages and constraints with this method for classification are that the theories are based on presumptions and hypotheses not shared by all (Volkmar, 1991), and that  Approaches for classifying psychological disturbances 12 the subjective interpretations make it difficult for clinicians to agree about the diagnosis of a disorder (Weiner, 1992). Phenomenological/Descriptive approach Clinical/Categorical approach The clinical approach to classification is based on observations looking for similarities between various symptoms and manifestations shown in different disorders. Repeated patterns of symptomathology are thought of as a group constituting or representing a syndrome or a diagnosis. Theoretical specula- tions about causes of the disorder are secondary to the process of establishing a syndrome and its manifestations clinically (Weiner, 1992). American Psy- chiatric Association’s (1994) Diagnostic and Statistical Manual of Mental Dis- orders (DSM) and the schema developed by the World Health Organization (WHO) International Classification of Diseases (ICD; 1992) are examples of classification based on clinical observations as those mentioned above. When it comes to the validity for children and adolescents, all upgradings have con- tained additions and changes as knowledge has expanded and inadequacies have been observed. Before the 1968 version of the DSM (DSM II) there were only two categories of psychopathology for children and adolescents; Adjust- ment Reaction of Childhood and Schizophrenic Reaction, Childhood Type. In later versions, categories have been added and specified, but critics claim that those categories have not been derived from empirical studies, neither have they been calibrated from one version to another (Achenbach, 1995). The ap- proach is based on the assumption that a disorder is either present or absent. Either you fulfill the criteria for a conduct disorder or you do not. Today, both DSM and ICD have been tested in empirical field trials, but those studies have presupposed what was to be proven, namely that psychiatric dichotomies do exist (Achenbach, 1995) The clinical syndromes have not been derived from empirical studies; on the contrary the empirical investigation has been the sec- ond procedure in the process. The categorical method of classification also has reliability problems concerning overlapping syndromes that contain common or similar symptoms, which make it difficult for clinicians to agree about the actual disorder. A problem concerning validity is that the categorical models of classification do not take into consideration that the same disorder can mani- fest itself differently at different occasions and under different circumstances. A methodological problem following from the clinical approach concerns treating continuous variables as categorical and thereby reducing them, even  Phenomenological/Discriptive approach 13 though they would better be described as continuous. Dichotomizing an in- herently continuous variable leads to a substantial loss in power. Some psycho- pathological problems/aspects are not well described as either present or ab- sent, but can manifest themselves in various degrees and in different ways, not least due to the development in childhood and adolescence. By treating them as dichotomous, we risk ignoring important information about the syndrome. Following from the above is the problem about what to do with the false-posi- tive (individuals that score high on a screening or symptom instrument but not meet the criteria for a formal diagnosis), and subthreshold cases (Helmchen, & Linden, 2000; Jensen et al., 1999). However, despite its limitations, the clini- cal/categorical approach is most advantageous in facilitating decision-making in clinical practice. Also, new empirical research adds valuable knowledge, con- tinually improving comprehension of the categories and diagnoses. Empirical/dimensional approach The dimensional approach for classifying psychopathology has been derived from experimental trials or procedures (Weiner, 1992). Data about behavioral and emotional problems have been collected from big representative samples and have been analyzed, using multivariate statistical methods, to identify syn- dromes of co-occurring problems. Also, by analyzing separate groups with dif- ferent characteristics, such as sex and age, one is allowed to take into account the variations in problems and symptoms. Comparisons between groups can then be made to reveal similarities and differences in problem patterns, which are related to different characteristics (Achenbach, 1995). One apparent prob- lem with this approach is that you cannot derive anything beyond what is in the data. Odd and rare symptoms might never be clustered and thereby not included in the instrument, leading to loss of important aspects of psychopa- thology. One empirically derived procedure for collecting data about psychopathol- ogy in children and adolescents is behavior-rating scales. They are typically composed of standardized instructions and answers, and individual scores are added to give quantitative indications on how the individual functions in some areas. The questionnaires contain items concerning problems and/or compe- tencies. Standard scores are calculated from normative samples and scale scores are tested for validity and reliability. The advantage of using rating scales is that quantitative scores often are more reliable methods for measuring children’s psychological adjustment than projective tests or subjective judgments. It is  Approaches for classifying psychological disturbances 14 also easier to say something about the child’s deviant behavior when he or she is compared to a normative sample. Many questions covering a wide spectrum of relevant behaviors can point towards problems other than those that were the reason for referral. Moreover, it is an effective and economical procedure for collecting data, which gives the researcher or clinician an opportunity to spend more resources on other important sources of information that are not covered by the questionnaire (McConaughy, 1993). Taken together, all of the approaches have contributed to the understanding of developmental psychopathology. Different approaches and methods for clas- sification are needed in different situations and since none of them are superior in all contexts, they should rather be seen as complementary to each other. Different dimensional methods Children and adolescents have not always been seen as reliable and important sources of information about their own emotions and behaviors. During the last decades there has been an increasing development and refinement of be- havioral rating scales, including children and adolescents’ self-reports (Hart, & Lahey, 1999). Reliability and validity tests have been of great concern, which has increased the utility and usefulness of the instruments in both research and clinical practice. Measurement of behavioral and emotional problems can be made using both broad generic rating scales and more narrow scales deve- loped for assessing specific symptoms or syndromes (Hart, & Lahey, 1999). Examples of instruments developed for specific internalizing symptoms are the Beck Depression Inventory (BDI) (Beck et al., 1981) and its downward exten- sion Children’s Depression Inventory (CDI) (Kovacs, 1992), the Depression Self-Rating Scale (DSRS) (Birleson, 1981), the Revised Children’s Manifest Anxiety Scale (RCMAS) (Reynolds, & Richmond, 1978), and the State-Trait Anxiety Inventory for Children (STAIC) (Spielberger, Edwards, Montuori, & Lushene, 1973). For externalizing type of behavior (especially attention deficit, hyperactivity, and oppositional defiant behavior) most existing instruments are parent and teacher reports. One example of self-reports covering externalizing behavior is the Self-Report Delinquency (SRD; Hinshaw, & Nigg, 1999). Examples of well-developed broad or generic instruments offering self- reports are the Behavior Assessment System of Children (BASC; Hart, & La- hey, 1999), the Strength and Difficulties Questionnaire (SDQ; Goodman, Meltzer, & Bailey, 1998), and the Achenbach System of Empirically Based