Dysthymia in anorexia nervosa and bulimia nervosa

© In e na ional Jou nal o Clinical and Heal h Psychology ISSN 1697-2600 2008, Vol. 8, Nº 1, pp. 65-75 Dys hymia in ano exia ne osa and bulimia ne osa Me cedes Bo da-Más1, Inmaculada To es-Pé ez, and Ca men del Río-Sánchez (Uni e sidad de Se illa, España) (Recei ed June 26, 2006 / Recibido 26 de junio 2006) (Accep ed Feb ua y 19, 2007 / Acep ado 19 de eb e o 2007) ABSTRACT. In his s udy ex pos ac o we ha e analyzed he p esence o dys hymia in 155 women. Nine y h ee me he DSM-IV diagnos ic c i e ia o some o he ea ing diso de (ED) ypes: 31 wi h es ic i e ano exia ne osa (AN ), 31 wi h pu ging/ bulimic ano exia ne osa (ANp) and 31 wi h pu ging bulimia ne osa (BNp); and 62 con o med he wo compa isons g oups: 31 women wi h high isk o ea ing diso de (symp oma ic compa a i e g oup: S-GC) and ano he 31 wi hou known pa hology (non symp oma ic compa a i e g oup: NS-CG). All o hem comple ed he Spanish e sion o he MCMI-II. The esul s indica ed ha ED pa ien s sco ed signi ican ly highe on possible dys hymic synd ome [Base Ra e (BR) sco es > 74], o hem, 50% wi h AN , 60% wi h ANp and 63.35% wi h BNp. Howe e , only 16.70% o women in high isk and 5.70% o non-pa hology women showed i . These indings suppo ha he dys hymic synd ome is equen in women wi h ED, and hose wi h pu ging beha iou show a sligh inc ease in he se e i y o such synd ome. KEYWORDS. Dys hymia. Ano exia ne osa. Bulimia ne osa. Como bidi y. Ex pos ac o s udy. RESUMEN. Es e es udio ex pos ac o analiza la p esencia de dis imia en 155 muje es. No en a y es pacien es cumplían los c i e ios diagnós icos pa a un as o no de la conduc a alimen a ia (TCA): 31 con ano exia ne iosa es ic i a (AN ), 31 con ano- 1Co espondence: Uni e sidad de Se illa. Facul ad de Psicología. Depa amen o de Pe sonalidad, E alua- ción y T a amien o Psicológico. C/ Camilo José Cela, s/n. 41018 Se illa (España). E-mail: [email p o ec ed] 66 BORDA-MAS e al. Dys hymia in ano exia ne osa and bulimia ne osa In J Clin Heal h Psychol, Vol. 8, Nº 1 exia ne iosa pu ga i a/bulímica (ANp) y 31 con bulimia ne iosa pu ga i a (BNp); y 62 muje es cons i uían los dos g upos compa a i os: 31 con al o iesgo de padece un TCA (g upo compa a i o sin omá ico: GC-S) y 31 sin pa ología conocida (g upo compa a i o no sin omá ico: GC-NS). Todas ellas cumplimen a on la e sión española del MCMI-II. En los esul ados encon amos di e encias signi ica i as en las medias ob enidas po los g upos con TCA espec o a los dos g upos compa a i os, y que p esen aban el posible sínd ome dis ímico [pun uaciones Tasa Base (TB) > 74] el 50% de las pacien es con AN , el 60% con ANp y el 63,30% de las pacien es con BNp. Sólo el 16,70% de las muje es de al o iesgo y el 5,70% de las muje es sin pa ología lo p esen aban. Es os hallazgos indican que el sínd ome dis ímico es ecuen e en las muje es con TCA, y en aquellas que p esen an conduc as pu ga i as aumen a le emen- e la se e idad del mismo. PALABRAS CLAVE. Dis imia, Ano exia ne iosa. Bulimia ne iosa. Como bilidad. Es udio ex pos ac o. Some in es iga ions ca ied ou wi h ea ing diso de pa ien s showed ha hey qui e o en ha e addi ional co-occu ing Axis I and Axis II diso de s. Fu he mo e, li le is known abou he speci ici y o hese associa ions (He zo g, Kelle , Sacks, Yeh, and La o i, 1992). The onse o ea ing diso de s ypically occu s du ing adolescence and psychia ic como bidi y appea s o be g ea e o e all among adolescen s han among adul s (Zaide , Johnson, and Cockell, 2000). A be e unde s anding and knowledge o he wide ange o pa hology associa ed o ea ing diso de s can p o ide clinical p ac i ione s wi h a mo e comple e iew o he pe sonali y ea u es co esponding o ea ing diso de pa ien s, and his iew will consequen ly acili a e he de elopmen o mo e e ec i e he apeu ic s a egies (Pea ls ein, 2002; Río, To es, and Bo da, 2002). On he o he hand, esea ch on como bili y in dys hymia pa ien s has mainly ocused on i s s udy oge he wi h Axis II diso de s. High p e alence a es o pe sonali y diso de we e ound, anging om 15% o 85%. These a es we e highe han hose ound in majo dep ession pa ien s (Peppe e al., 1995). In he nine ies s udies al eady indica ed high p e alence a es o Axis I diso de s in pa ien s wi h ea ing diso de s (ED) anging om 80% o 97% (B aun, Sunday, and Halmi, 1994; B ewe on e al., 1995). Acco ding o da a, dep essi e diso de s appea as he mos diagnosed diso de s, ollowed by anxie y diso de s (B ewe on e al., 1995). Ne e heless, in spi e o he associa ion ound be ween ea ing diso de s and dep essi e diso de s, he na u e o such associa ion has no been clea ly de ined ye (T oop, Se pell, and T easu e, 2001). Among o he s aspec s, i has no been possible o empi ically de e mine whe he biological and cogni i e changes caused by malnu i ion enhance a endency o dep ession in people who ha e ea ing diso de s o whe he i is a di ec cause o dep ession (Coope , 1995; O’B ien and Vincen , 2003; Szmuckle , 1987). Specialized li e a u e has desc ibed he s ong ela ion be ween bo h diagnos ic ca ego ies. Fo example, low weigh can cause dep essed mood, while weigh loss is also a symp om o dep essi e diso de . Nega i e mood can lead people die ing o binge ea ing, and binge ea ing and also omi ing can esul in nega i e mood. BORDA-MAS e al. Dys hymia in ano exia ne osa and bulimia ne osa 67 In J Clin Heal h Psychol, Vol. 8, Nº 1 On he o he hand, he e is e idence ha women de elop an ea ing diso de be o e he onse o he dep essi e diso de . Thus, he e is wide consensus among esea che s conce ning he ac ha dep ession associa ed o ea ing diso de is a p ocess which de elops la e on (T oop e al., 2001). The e is g ea e han expec ed p e alence o dep essi e diso de s among pa ien s wi h ano exia ne osa (AN) and bulimia ne osa (BN). Howe e , i seems ha , dep essi e diso de s do no ha e he same p obabili y o de elopmen among all ypes o ea ing diso de s, bu hey a e impo an pa icula ly in he pu ging/bulimic a ia ions (BNp and ANp), his means pa ien s who a e mo e dis essed by he lack o con ol o e hei die and o e he seconda y e ec s o he ea ing diso de (O’Kea ney, Ge le , Con i, and Du , 1998). De ini ely, he ela ion be ween ea ing and dep essi e diso de s has been ex ensi ely s udied and has unde gone deep deba e especially h oughou he nine ies (Caspe , 1998; S obe and Ka z, 1987; Szmuckle , 1987). Howe e , he e a e ew in es iga ions which ha e speci ically s udied he dys himic diso de in pa ien s wi h ea ing diso de s. In es iga ions in his line ha e especially ocused on samples o adolescen pa icipan s wi hin he gene al popula ion. Zaide e al. (2000) ound a s ong associa ion be ween dys hymia and he p esence o ea ing diso de s, al hough hey also ound he p esence o majo dep ession diso de , dys hymia and panic diso de ; howe e , only dys hymia (no majo dep ession) was a s ong p edic o o ea ing diso de s. Pé ez, Joine , and Lewinsohn (2004) ha e ecen ly ound ha he p esence o dys hymia in adolescence can be a possible isk ac o in he de elopmen o bulimia ne osa. Recen ly, Ka lsson e al. (2007) ound ha cu en como bidi y wi h ED was a e in majo dep essi e diso de and accumula ed in subjec wi h dys hymia, sugges ing a speci ic associa ion be ween dys hymia wi h ea ing diso de s. As hese au ho s also indica e, when s udying adul popula ion, li e a u e shows ha he ela ion be ween bulimia o ano exia ne osa and dys hymia has no been ho oughly in es iga ed. We base ou s udy on he de ini ion o dys hymia p oposed by Millon (1987). Wi hin his heo y, he dys hymic synd ome is conside ed, as assesed by he MCMI-II (Base Ra e BR > 74), when a pe son has been a ec ed wi h eelings o dejec ion o guil , a lack o ini ia i e and apa hy in he beha io , low sel -es eem and, equen ly, exp essions o uselessness and sel -de alua i e commen s du ing a pe iod o wo o mo e yea s. Du ing he pe iods o dep ession, an indi idual c ies, ha e suicidal ideas, pessimis ic eelings conce ning he u u e, social wi hd awal, lack o appe i e o excessi e u ge o ea , ch onic i edness, poo concen a ion, an impo an loss o in e es in leisu e ac i i ies and a p og essi e lack o e icacy and he achie emen o ou ine and o dina y li e asks. To da e and acco ding o ou knowledge, no s udy which would speci ically in es iga e on dys hymic diso de in young people wi h ea ing diso de s has been published. We e e o s udies which also include compa a i e g oups wi h and wi hou known pa hology. In spi e o he ac ha MCMI-II (Millon, 1987) is an ins umen ha p o ides a eliable measu e o clinical psychopa hology, i has sca cely been used in ea ing diso de s. Ne e heless, we conside i o be a alid ins umen , due o i s u ili y in he de ec ion o possible clinical synd ome as e han he o he ins umen s. 68 BORDA-MAS e al. Dys hymia in ano exia ne osa and bulimia ne osa In J Clin Heal h Psychol, Vol. 8, Nº 1 The gene al objec i e o his ex pos ac o s udy (Mon e o and León, 2007) is o compa e he sco ings o he MCMI-II Dys hymia subscale (o dep essi e neu osis) (D) ob ained by a) pa ien s wi h ea ing diso de s: es ic i e AN, binge-ea ing/pu ging AN and pu ging BN, b) women wi h ypical ea ing diso de symp oma hology and, he e o e, in high isk o su e ing om ea ing diso de s, and c) women wi hou known pa hology. Me hod Pa icipan s A o al g oup o 155 women we e s udied, o which 93 women me he DSM-IV diagnos ic c i e ia o some o he ED ypes: 31 wi h ano exia ne osa es ic i e sub ype (AN ) wi h an a e age age o 22.23 yea s, 31 wi h AN pu ging sub ype (ANp) wi h an a e age age equal o 23.29 yea s and 31 wi h bulimia ne osa pu ging sub ype (BNp), wi h an a e age age o 23.16 yea s. They had all been e alua ed be o e being assigned o an homogeneous g oup o cogni i e-beha iou al ea men in ADANER, Ea ing Diso de s Associa ion in Se ille. The emaining 62 women con o med he wo compa a i e g oups: a) 31 women in high isk o de eloping ED (symp oma ic compa a i e g oup: S-CG), since hey showed ypical symp oma hology o he diso de (Ea ing A i udes Tes -EAT sco es g ea e o equal o 30 poin s and a Body Shape Ques ionnai e- BSQ o e 104); wi h an a e age age equal o 22.48 yea s. And b) 31 women who did no show known pa hology and wi hou any diso de in hei ea ing beha iou (non symp oma ic compa a i e g oup: NS-CG) wi h an a e age age o 22.61 yea s. Sociodemog aphic a iables we e con olled du ing he sample selec ion, so ha all g oups we e equi alen in a iables such as sex (cons an ), age (which anged om 18 o 31 yea s), educa ion, ma i al s a us and socioeconomic s a us (see Table1). TABLE 1. Demog aphic cha ac e is ics o he sample. Ins umen s and p ocedu es All pa ien s me DSM-IV diagnos ic c i e ia o diso de s analysed in his s udy. The assessmen was ca ied ou by a clinical psychologis wi h expe ience in ea ing AN (n = 31) ANp (n = 31) BNp (n = 31) S-CG (n = 31) NS-CG (n = 31) Age Mean (SD) 22.23 (3.48) Mean (SD) 23.29 (4.03) Mean (SD) 23.16 (3.45) Mean (SD) 22.48 (3.72) Mean (SD) 22.61 (3.44) Pe cen age (n) Pe cen age (n) Pe cen age (n) Pe cen age (n) Pe cen age (n) Ma ied 6.50 (2) 6.50 (2) 3.20 (1) 6.50 (2) 3.20 (1) Ma i al s a us Single 93.50 (29) 93.50 (29) 96.80 (30) 93.50 (29) 96.80 (30) High School 16.10 (5) 16.10 (5) 19.40 (6) 19.40 (6) 19.40 (6) P o essional T aining 16.10 (5) 19.40 (6) 19.40 (6) 19.40 (6) 16.10 (5) Academic le el Uni e si y Educa ion 67.70 (21) 64.50 (20) 61.30 (19) 61.30 (19) 64.50 (20) Low 22.60 (7) 16.10 (5) 29 (9) 29 (9) 25.80 (8) Medium 45.20 (14) 41.90 (13) 41.90 (13) 41.90 (13) 38.70 (12) S ocio-economic e el High 32.30 (10) 41.90 (13) 29 (9) 29 (9) 35.50 (11) Socio-economic le el BORDA-MAS e al. Dys hymia in ano exia ne osa and bulimia ne osa 69 In J Clin Heal h Psychol, Vol. 8, Nº 1 diso de s. All pa ien s had showed he de elopmen o an ea ing diso de du ing a pe iod o mo e han wo yea s. This was ca ied ou ollowing c i e ia on he diagnosis o dys hymic diso de , acco ding o he DSM-IV-TR and acco ding o Millon (1987). We adminis a ed o all women he ollowing es s: – Ea ing A i udes Tes (EAT-40) (Ga ne and Ga inkel, 1979); adap ed e sion by Cas o, To o, Salame o, and Guime á (1991) in which he au ho s ob ained a global coe icien o alidi y o 0.61 (p < 0.001). Fo a cu -o poin o 30 hey ob ained a sensibili y o 67.90% and a speci ici y o 85.90%. – Body Shape Ques ionnai e (BSQ) (Coope , Taylo , Coope , and Fai bu n, 1987); adap ed by Raich e al. (1996). The Spanish e sion has shown good in e nal consis ency (α o C onbach = .97) and concu en alidi y (Raich e al., 1996). A cu -o poin o 104 poin s was conside ed. – Millon Clinical Mul iaxial In en o y (MCMI-II) in a e sion adap ed o he Spanish popula ion (Á ila, 2002; Millon, 1987). In addi ion o he assessmen o di e en pe sonali y ea u es, acco ding o he DSM-III-R classi ica ion (clinical pa e ns and se ious pe sonali y pa hology in 13 scales); his ins umen assesses clinical synd omes (in 6 scales: anxie y (A), soma o o m (H), hypomania (N), dys hymia (D), alcohol abuse (B), d ugs abuse (T), and se ious synd omes in 3 scales: psycho ic hough (SS), majo dep ession (CC) and deli ious diso de (PP). All he scales in he in en o y e lec bo h “ ai s” and “s a es” o di e en deg ees. Only he dys hymia scale (D) was used o his s udy. The Spanish adap a ion o his es p o ides wi h eliabili y coe icien s in his scale, o .90 o he clinical sample and o .86 o he compa ison g oup. A cu -o sco e o BR highe o equal o 75 was conside ed in he MCMI-II, acco ding o au ho ecommenda ions (sco ings BR highe o equal o 75 which show p esence o his ype o pe sonali y, while BR highe o equal o 85 indica e he highes o ou s anding ype o pe sonali y) (Millon, 1987). Women om he wo non-clinical g oups who ob ained a sco e o 30 o highe in he EAT as well as a sco e o 105 o highe in he BSQ (a e age EAT = 40.87 and a e age BSQ= 132.48) we e pa o he symp oma ic compa a i e g oup. And hose who ob ained sco es lowe han 20 poin s (maximum sco e ob ained below 30) in he EAT and sco es unde 95 poin s (maximum sco e ob ained below 105) in he BSQ, con o med he non symp oma ic compa a i e g oup (a e age EAT = 8.42 and a e age BSQ = 61.26). Resul s ob ained by women wi h ea ing diso de s in hese wo es s we e no used o his s udy. All ins umen s we e adminis e ed acco ding o adminis a ion and co ec ion no ms ecommended by he co esponding au ho s. All women signed an In o med Consen P o ocol be o e hei pa icipa ion as ecommended by Río (2005). S a is ical p og am SPPS 12.0 S e sion was used o s a is ical analysis. We ca ied ou a desc ip i e analysis oge he wi h a compa ison o a e age sco es wi h one ac o ANOVA echnique and wi h he mul iple compa ison es (She é es ). The p esen a icle was edi ed acco ding o he no ms es ablished by Ramos- Ál a ez, Valdés-Con oy, and Ca ena (2006). 70 BORDA-MAS e al. Dys hymia in ano exia ne osa and bulimia ne osa In J Clin Heal h Psychol, Vol. 8, Nº 1 Resul s Women wi h ANp as well as hose wi h BNp ob ained a e age sco es which indica ed he p esence o dys hymic synd ome (BR > 74) (78.17 and 74.53, espec i ely). Ne e heless, al hough he p esence o he synd ome is no obse ed in AN women, hey do show signi ican clinical symp oma hology co esponding o he diso de , since hei sco e (70.90) is wi hin he ange o an expec ed median in all pa ien s (BR > 60). Bo h compa a i e g oups, he symp oma ic and he non-symp oma ic, showed an a e- age sco e (43.97 and 25.31, espec i ely) which co esponds o he sco e ob ained by people who do no epo clinical diso de s (BR > 35) (Á ila, 2002) (see Figu e 1). FIGURE 1: Mean sco es o MCMI-II in dys hymia (D) scale. 70.9 78.17 74.53 43.97 25.31 0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 AN ANp BNp S-CG NS-CG AN ANp BNp S-CG NS-CG BR 75 BR 60 No es. AN : ano exia ne osa es ic i e sub ype. ANp: ano exia ne osa pu ging sub ype BNp: bulimia ne osa pu ging sub ype. S-CG: symp oma ic compa a i e g oup NS-CG: non symp oma ic compa a i e g oup. BR = Base Ra e Compa a i ely, we obse e ha women wi h ea ing diso de s show signi ican ly highe clinical dep essi e symp oma hology compa ed o he g oups wi h no ea ing pa hology (see Figu e 1 and Table 2). BORDA-MAS e al. Dys hymia in ano exia ne osa and bulimia ne osa 71 In J Clin Heal h Psychol, Vol. 8, Nº 1 TABLE 2. Mean compa ison o MCMI-II dys hymia (D) scale. Compa isons (Sche é es ) F= 31,143 gl = 4 p AN – S- CG AN – NS-CG ANp – S-CG ANp – NS-CG BNp – S-CG BNp – NS-CG S-CG – NS-CG .000 ** .001 ** .000 ** .000 ** .000 ** .000 ** .042 * * p < .05 ** p < .01 No es. AN : ano exia ne osa es ic i e sub ype. ANp: ano exia ne osa pu ging sub ype; BNp: bulimia ne osa pu ging sub ype. S-CG: symp oma ic compa a i e g oup. NS-CG: non symp oma ic compa a i e g oup. I we ocus on he g oup o pa icipan s who show he diagnosis o dys hymic synd ome (BR > o = 75) (see Figu e 2), we obse e e y simila sco es. Ne e heless, when conside ed as a g oup, women in he ED g oup, ob ain sco es which no only show he p esence o he dys hymic synd ome bu also i s se e i y and signi icance (BR > o = 85). FIGURE 2. Mean sco es o women who ha e possible dys hymic synd ome (BR > 74). 89.8 90.83 91.52 81.5 89.6 75 80 85 90 95 100 AN ANp BNp S-CG NS-CG AN ANp BNp S-CG NS-CG No es. AN : ano exia ne osa es ic i e sub ype. ANp: ano exia ne osa pu ging sub ype. BNp: bulimia ne osa pu ging sub ype. S-CG: symp oma ic compa a i e g oup. NS-CG: non symp oma ic compa a i e g oup. BR=Base Ra e 72 BORDA-MAS e al. Dys hymia in ano exia ne osa and bulimia ne osa In J Clin Heal h Psychol, Vol. 8, Nº 1 Rega ding he pe cen age o women wi h ea ing diso de s who show dys hymic synd ome (BR > o = 75) (see Figu e 3), ou esul s indica e ha women wi h BNp a e hose who epo he dys hymic synd ome wi h g ea e equency 63.3% (n = 19), ollowed, in 60% wi h ANp (n = 18). Finally, 50% showed AN (n = 15). These da a aim owa d a g ea e p obabili y o de elop dys hymia among he bulimic a ian (BNp and ANp) o ea ing diso de s. Ne e heless, hese di e ences a e no s a is ically signi ican . Due o his eason, da a should be conside ed cau iously. FIGURE 3. Pe cen ages o women wi h possible dys hymic synd ome (BR > 74). 50 60 63.3 16.7 5.7 0 10 20 30 40 50 60 70 80 90 100 AN (n = 15) ANp (n = 18) BNp (n = 19) S-CG (n = 5) NS-CG (n = 2) No es. AN : ano exia ne osa es ic i e sub ype. ANp: ano exia ne osa pu ging sub ype. BNp: bulimia ne osa pu ging sub ype. S-CG: symp oma ic compa a i e g oup. NS-CG: non symp oma ic compa a i e g oup. Finally, pa icipan s wi h ypical ea ing diso de symp oma hology as o a i udes and beha iou ela ed o ood, weigh and exe cise, e idenced he dys hymic synd ome in a no ably lowe p opo ion han in he ea ing diso de g oups (16.70%; n = 5), bu in a g ea e p opo ion han pa icipan s wi hou ea ing diso de (5.70%, n = 2) (See Figu e 3). Discussion Ou esul s a e consis en wi h he indings desc ibed in specialized li e a u e, in he sense ha a high p esence o dep essi e diso de s was ound in women who de eloped ea ing diso de s. Acco ding o ou knowledge, he e is li le esea ch on he dys hymic synd ome which could be compa ed wi h ou s udy. Caspe (1998) collec ed he p e alence BORDA-MAS e al. Dys hymia in ano exia ne osa and bulimia ne osa 73 In J Clin Heal h Psychol, Vol. 8, Nº 1 ound in se e al in es iga ions ca ied ou on dep ession in AN and in BN including hose ela ed o dys hymia. In gene al, hey ound ha hese a es anged om 19% o 93% in he case o AN, and om 6% o 95% in he case o BN. Conside ing hese da a, we can indica e ha ou indings a e, in bo h cases, wi hin he pe cen age and a es obse ed o hese diso de s. Ou esul s show ha women, who epo some ype o ea ing diso de , show he dys hymic synd ome in a signi ican ly g ea e p opo ion, when compa ed o he wo compa a i e g oups. Likewise, acco ding o wha was expec ed, we ound highe equencies among women wi h pu ging beha iou (ANp and BNp) compa ed o hose who p esen es ic i e beha iou (AN ), al hough we should poin ou ha hese di e ences a e no signi ican . Ne e heless, hese da a would be in line wi h he app oach ca ied ou by O’Kea ney e al. (1998) as he e is highe p obabili y ha bulimic a ian pa ien s also su e om dys hymia, due o he ac ha hese pa ien s show g ea e anxie y caused by he lack o con ol o e hei die and he seconda y e ec s p oduced by he ea ing diso de . As we ound in ou s udy, he p esence o ea ing symp oma hology which means a g ea e isk o de eloping an ea ing diso de , is associa ed o a highe p obabili y o de eloping dys hymia, while his p obabili y dec eases signi ican ly in he g oup o women wi hou pa hology. Howe e , based on he design o ou in es iga ion, we canno s a e ha dys hymia is a p edic ing ac o o a isk ac o in he de elopmen o ea ing diso de s o in BN as claimed by Zaide e al. (2000) and Pé ez e al. (2004). Ne e heless, since hese au ho s s udied adolescen s, ou esul s would suppo his hypo hesis, as i is obse ed, dys hymia is mo e equen among women wi h isk o de elopmen o an ea ing diso de han in hose who show no pa hology. I is e iden ha hese esul s should be conside ed wi h cau ion, due o he size o ou sample. I would be necessa y o ca y ou his ype o s udy inc easing he numbe o people in each g oup. On he o he hand, ega ding he hypo hesis men ioned in he li e a u e which claims ha he onse o dep essi e diso de s is seconda y o ea ing diso de s, we ha e o men ion ce ain di icul ies conce ning he in e p e a ion o such hypo hesis. Among hese di icul ies is he common symp oma hology in dys hymia and ea ing diso de s especially when he ea ing diso de shows an e olu ion o a leas wo yea s (c i e ia o dys hymia). Howe e , he e a e ob iously di e en ial symp oms o each diso de . When s udying and compa ing a g oup o women ha show anomalous beha iou and a i udes conce ning ood, weigh and exe cise which a e ypical in ea ing diso de s (bu which do no mee diagnos ic c i e ia acco ding o DSM-IV), his means, women who e idence symp oms o ea ing pa hology, al hough hey ha e no de eloped he comple e ea ing diso de synd ome, we can obse e ha he dys hymic diso de s a s o appea wi h g ea e equency in hese women (compa ed o women wi hou any ea ing pa hology). The e o e, keeping in mind he necessa y c i e ia o wo yea s du a ion o he dep essi e symp oma hology in dys hymia, would dep essi e symp oma hology be p io o ha co esponding o he onse o ea ing diso de s in hese women? O on he con a y, do bo h diso de s de elop simul aneously? This is a ques ion ha would ha e o be cla i ied by ca ying ou longi udinal s udies.