Download Prevalence of eating disorders among young Hungarian women

Theses of doctoral work
Prevalence of eating disorders among young Hungarian women.
Psycho-social background characteristics and comorbidity with
other mental problems
Irena Szumska
Semmelweis University
4th Interdisciplinary Doctoral School
Behavioural Sciences Programme
Supervisor and Programme Leader: Prof. Mária Kopp
Budapest, 2004
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INTRODUCTION
Research into eating disorders has drawn increasing attention in the last two
or three decades. There are two tendencies in the research: one is the ever
more precise description of various sub-types and associated comparative
studies, and the other is work towards integration, concentrating on
common elements of different eating disorders.
Eating disorders give rise to many physical complications, often only
appearing only later, and mortality is high, particularly in the case of
anorexia nervosa (AN). In both conditions, AN and bulimia nervosa (BN)
there is a high risk of becoming chronic, and both are associated with other
comorbid psychiatric disorders. Easting disorders are classed as multicausal diseases, and their causes involve socio-cultural and family
characteristics, individual psychological and biological predispositions.
There already exist therapeutic methods of proven effectiveness and new
procedures are constantly being devised. Preventive interventions and
programmes for eating disorders are not yet well enough developed, and
many questions have arisen in evaluating primary preventive interventions.
The review of the literature outlines the latest research and research trends,
and conveys out the scientific debates and uncertainties presented in the
literature.
Epidemiological studies, carried out mainly in Western countries, show a
rising prevalence and broadening spectrum of eating disorders. Different
studies indicate different prevalences of eating disorders. Two-stage studies
using strict diagnostic criteria show the one-year prevalence of AN among
young women to be 0.28% on average, and the lifetime prevalence of BN
to be around 1% (1). According to DSMIV (2), the prevalence of AN is
0.5-1%, and that of BN 1-3% among adolescents and young women.
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In Hungary, several studies have been carried out among student samples.
To date, one study has involved the average population, but not on a
representative sample.
Of the few surveys have been carried out in the Central-Eastern European
countries, most have been made on small, specific student samples, and no
representative survey has been produced in any Central-Eastern European
country.
OBJECTIVES
The purpose of our research was to survey the prevalence of eating
disorders among young (15-24 year-old) Hungarian women in a
representative sample, and to detect the psycho-social background factors
and comorbid mental problems associated with eating disorders in the study
sample. The two classic types of eating disorder, AN and BN, and their
sub-clinical forms were examined. The subclinical eating disorders studied
were confined to those which, although not completely fulfilling the AN
and BN criteria, lie very close to AN or BN. Since the study involved a
questionnaire, the diagnoses were only estimated or simulated.
Answers were sought to the following questions:
1. What is the prevalence of eating disorders among young Hungarian
women?
2. What are the psychosocial characteristics and comorbid problems
that distinguish the group bearing eating disorder characteristics
from their peers?
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SAMPLE
The study involved the analysis of 3615 women aged 15-24 using an
anonymous questionnaire. 2016 were students, and 1599 were no longer in
education. The questionnaire was broadly based, and included questions on
social-financial background, school and workplace circumstances, health,
health behaviour, eating behaviour and habits, physical and sexual abuse,
sexual behaviour, and psychological condition and characteristics.
The sampling method was multi-stage layered sampling. The students were
selected so that the types of establishment (grammar school, vocational
school, skills training school, college, university) were in proportions
corresponding to the national average. The student sample was selected
firstly in the regions of the country (the six regions designated by the
Statistics Hungary: Central Hungary, North Hungary, North Great Plain,
South Great Plain, South Transdanubia and North Transdanubia), in
proportion to the population of the regions, and in the second stage by
school and age within each region. The schools within each region were
selected at random from the list of all schools in the region, and in the next
stage an average of 10 persons were selected from each school year at
random, from the school register. They completed the questionnaires under
the supervision of a trained researcher. The non-student sample (workers,
unemployed people, people on maternity leave, housewives) was selected
in the first stage by region (the same regions as for students). Within
regions, selection was made by size of town or village, occupation type
(categories provided by Statistics Hungary) and age. The survey was
carried out by trained researchers. The overall refusal rate was 6%.
Permission for the study was granted by the Semmelweis University of
Medicine Research Ethics Committee, the Data Protection Ombudsman and
the Minorities Ombudsman.
This study only took into account questionnaires where the respondent
answered every question required to establish eating disorders. The sample
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for eating disorders thus consisted of 3385 persons, 94% of the original
sample (3615 persons).
CRITE
RITERIA
RIA, VARIABLES EXAMINED
A section of the criteria was designed to match the diagnostic criteria for
eating disorders defined in DSM-IV. For amount of weight loss, the BNO10 body mass index criterion was applied.
Two scales were used as a basis for the criteria: the “Drive for Thinness”
scale from the Eating Disorder Inventory of Garner et al (3) and the Eating
Disorder Symptom Severity Scale devised by Yager et al (4), which
examines the frequency of eating disorder symptoms.
The estimated AN criteria were:
• BMI ≤ 17.5 kg/m2,
• amenorrhoea for at least 3 months,
• at least 14 points on the “Drive for Thinness” scale in the Eating
Disorder Inventory (EDI).
The estimated BN criteria:
• binging of frequency at least several times a week,
• minimum occurrence of at least one compensation behaviour (selfinduced vomiting, taking laxatives, diuretics, appetite reducers, dieting,
exercise) at least several times a week,
• at least 14 points on the “Drive for Thinness” scale in the EDI.
The subclinical AN criteria:
• irregular menstruation or amenorrhoea,
• at least 10 points on the EDI “Drive for Thinness” scale,
• BMI<19 kg/m2.
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The subclinical BN criteria:
• binging at least several times a week,
• minimum occurrence of at least one compensation behaviour (selfinduced vomiting, taking purgatives, diuretics, appetite inhibitors,
dieting, exercise) at least several times a month,
• at least 10 points on the EDI “Drive for Thinness” scale.
The following variables were examined to establish social and family
background characteristics: place of residence, parents’ educational level,
parents’ divorce or death, incidence of parents’ psychiatric disorders, and
the presence of alcohol problems in the family.
Examination of psychological characteristics involved application of
emotional and problem-solving ways of coping in difficult life situations
(Shortened Ways of Coping Inventory), hostility (Shortened Hostility
Inventory), and characteristic attitudes (Shortened Dysfunctional Attitude
Scale).
Examination of comorbid mental problems included the measurement of
alcohol consumption, drug use, depressive symptoms (Shortened Beck
Depression Inventory), suicidal thoughts, suicide attempts, and frequent
occurrence of unwarranted anxiety.
In addition, the occurrence of sexual and physical abuse in the last year was
measured.
STATISTI
STATISTIC
TICAL PROCEDURES
For comparison of groups, the odds ratio (OR) was estimated with a 95%
confidence interval (CI). Logistic regression analysis was used for
multivariable analysis.
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RESULTS
In the sample as a whole, AN prevalence was 0.03%, BN prevalence
0.41%, subclinical AN prevalence 1.09% and subclinical BN prevalence
1.48%.
The most common weight control method was dieting and exercise, and
purgative behaviour was rare. The student and non-student samples were
compared separately.
In the study of background characteristics and comorbid problems, the
eating disorder group was compared with the rest of the sample (non-eating
disorder group). A complementary comparison, involving all examined
variables, was made between the AN sub-group (AN and subclinical AN)
and the BN group (BN and subclinical BN). The following results were
obtained:
•
Eating disorders occurred more frequently among students than
non-students (OR: 2.1 CI: 1.4-3.3), and among urban dwellers.
•
In respect of family background factors, there were two differences
between the eating-disorder and non-eating-disorder groups.
Parents’ psychiatric disorders were significantly more frequent in
the eating-disorder group (only in the BN subgroup). The two
groups were also significantly distinguished by parents’ level of
education. Parents with higher education had a three times higher
chance of their daughters having an eating disorder than those with
low levels of education. (OR:3 CI: 1.8-4.9).
•
The two groups were significantly distinguished by psychological
characteristics. Emotional coping strategies in difficult life
situations are characteristic of the eating disorder group, which also
displays a higher frequency of high internal expectations (OR: 4.5
CI: 3-6.7) and high hostility (OR: 2.4 CI: 1.6-3.7).
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•
Of the comorbid mental problems, depressive symptoms (severity
in every category examined), suicide attempts (OR: 3.1 CI: 1.75.6), occurrence of suicidal thoughts (OR: 2.9 CI: 1.9-4.3)
and drug use (OR: 2.2 CI: 1.4-3.5) were significantly related to
eating disorders.
•
Physical (OR: 2.5 CI: 1.6-3.9) and sexual abuse (OR: 6.8 CI:
3.4-13.3) over the last year was significantly more frequent in the
eating-disorder group
•
No change in the results were found by examining the variables for
one group jointly by logistical regression, except drug use, whose
independent effect dropped out on control for the other comorbid
mental problems. In the AN and BN subgroups, the independent
relationship to eating disorder of characteristic application of the
same emotional ways of coping dropped out on control for the
other psychological characteristics.
•
No differences were found between the eating-disorder and noneating-disorder groups in the following variables. Family
background factors: parents regular alcohol consumption, parents’
divorce, parents’ death. Psychological variable: problem-centred
ways of coping. Comorbid problems: regular or high-quantity
alcohol consumption, frequent unwarranted anxiety.
•
Differences were found between the AN and BN subgroups in four
variables. In the BN subgroup, parents’ psychiatric problems and
the application of the “eating, drinking and smoking” way of
coping were significantly more frequent, and there was a tendency
– although not significant – to more frequent regular or highquantity alcohol consumption than in the AN subgroup. Wish to
conform to others was significantly more frequent in the AN than
the BN group.
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DISCUSSION AND CONCLUSIONS
CONCLUSIONS
This survey was the first representative survey of eating disorders in any
Central-Eastern European country. The overall eating disorder prevalence
was 3.01% among young women aged 15-24. We hope that our study,
owing to its representativeness, will contribute to exploding the myth that
eating disorders is a characteristic of women in Western societies.
The psychological characteristics which distinguished the eating-disorder
group from the non-eating-disorder group agree with data in the literature.
High hostility, which expresses a kind of social distrust, the frequent
application of emotional ways of coping, mainly in the BN subgroup, the
frequent occurrence of suicidal fantasies and attempts, and the more
frequent appearance of depressive syndrome – all reveal a kind of
emotional instability and unsatisfactory control of emotional life.
The examination of family background indicated a lower level of problems
than in other published studies, although the latter are not uniform in this
respect. The results of the study coincide with the literature in finding more
problematic family background characteristics among the BN than the AN
group. The preponderance of children of more highly educated parents in
the eating disorder group partly coincide with the figures in the literature
(for the AN group).
As regards comorbidity, the results for depression syndrome, suicide
attempts and suicidal thoughts were as expected from the figures in the
literature. The results for alcohol consumption and drug use partly coincide
with figures in the literature. Possible explanations for the differences are
discussed in the thesis.
The high occurrence of sexual or physical abuse in the eating disorder
group also coincides with figures in the literature.
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Most of the data from the examination of psycho-social background
characteristics coincide with figures in the literature, and for those variables
showing some departure, the figures in the literature are not uniform.
The launch of prevention programmes in the field of eating disorders is
very important. People in the eating-disorder group differed significantly
differed from their peers in several respects – in social and family
background indicators, which facilitates identification of the endangered
group. The results of the study and the literature highlight the importance of
school mental health work and the necessity for programmes which
promote the formation of satisfactory ways of coping and are directed at
raising self-esteem and setting realistic objectives.
References
1.Van Hoeken D, Lucas AR, Hoek HW.: Epidemiology. In: Neurobiology
in the treatment of eating disorders (Eds.: Hoek H, Treasure JL, Katzman
MA). New York, Wiley, 1998, 97-126.
2.American Psychiatric Association.: Diagnostic and statistical manual of
mental disorders. Fourth Edition. Washington, D.C. APA, 1994.
3.Garner DM. Eating Disorders Inventory-2. Odessa, Psychological
Assessment Resources, 1991.
4.Yager J, Landsverk J, Edelstein CE.: A 20-month follow-up study of 628
women with eating disorders. I. Course and severity. Am J Psychiatry
1987, 144:1172-1177.
LIST OF PUBLICATIONS
Szumska I, Túry F, Csoboth C, Réthelyi J, Purebl, G Hajnal Á.: The
prevalence of eating disorders and weight-control methods among young
women: A Hungarian representative study. European Eating Disorders
Review. (accepted for publication)
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Csoboth Cs, Szumska I, Purebl Gy.:Self-rated health and health damaging
behaviour among women in Hungary: the effect of off-spring family
characteristics. Social and Preventive Medicine (accepted for publication)
Rethelyi JM, Berghammer R, Ittzes A, Szumska I, Purebl G, Csoboth C.:
Comorbidity of pain problems and depressive symptoms in young women:
results from a cross-sectional survey among women aged 15-24 in
Hungary. European Journal of Pain 2004, 8(1):63-9.
Túry F, Szumska I.: Az evészavarok kognitív viselkedésterápiája. In:
Kognitív viselkedésterápia. (eds: Mórotz K., Perczel-Forintos D.).
Medicina Kiadó (megjelenés alatt)
Berghammer R, Szumska I.: Vizsgálati módszerek: teszt- és kérdőíves
módszerek. In: Orvosi pszichológia (eds: Kopp M, Berghammer R.).
Medicina Kiadó ( megjelenés alatt)
Szumska I, Túry F, Jakabfi P.: Az evészavarok prevenciója. Kérdések és
ellentmondások. Lege Artis Medicinae 2003, 13(1): 24-28.
Szumska I, Túry F, Jakabfi P.: Új modellek az evészavarok prevenciójában.
Mentálhigiéné és Pszichoszomatika 2003, 3:5-9.
Szumska I, Túry F, Hajnal Á, Csoboth Cs, Purebl Gy, Réthelyi J.:
Evészavarok prevalenciája fiatal nők hazai reprezentatív mintájában.
Psychiatria Hungarica 2001, 16 (4):374-383.
Szumska I.: Kutatás a magatartástudományban. In Magatartástudomány
(ed. Buda B.). Budapest, 2001, 701-715 old.
Other publications
Szumska I, Purebl Gy, Gál K.: A klinikai pszichológus feladatai a
pulmonológiai ellátásban. In: A klinikai pszichológia és mentálhigiéné
protokollja (ed: Bogdy E.). Animula, Budapest, 1998, 195-201 old.
Lukács J, Mohácsi E, Batiz A, SzumskaI., Kaszab Zs.: Tapasztalataink
súlyos asthma bronchiálés betegek komplex terápiás módszerével.
Rehabilitáció 1994/2.
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Citable lectures
Szumska I.: Evészavarok prevalencia vizsgálatában nyert adatok 15-24
éves magyar nők körében: a pszichoszociális mutatók összehasonlítása
nyugati vizsgálatok eredményeivel. Semmelweis Egyetem 4. sz.
Interdiszciplináris Doktori Iskolájának hetedik önálló tudományos ülése,
Budapest, 2003.
Szumska I, Túry F, Csoboth Cs.:The Prevalence of Eating Disorders in a
Hungarian Representative Sample of Young Women. Kongress
Essstörungen.10.
Internationale
Wissenschaftliche
Tagung
Jubiläumskongress, Alpbach, 2002.
Szumska I, Túry F.: Kérdések és ellentmondások. Evészavarok
prevenciója. MPT V Nemzeti Kongresszus, Budapest, 2002.
Szumska I.: Az evészavarok prevalenciája és pszichoszociális vonatkozásai
fiatal magyar nők körében, Semmelweis Egyetem 4. sz. Interdiszciplináris
Doktori Iskolájának hatodik önálló tudományos ülése, Budapest, 2002.
Szumska I, Hajnal Á.: Falásrohamok összefüggései magatartási és szociális
jellemzőkkel fiatal magyar nők körében. MPT IX Vándorgyűlése. Miskolc
2001.
Hajnal Á, Szumska I, Csoboth Cs.: A szülői és gyermeki
magatartásproblémák összefonódása egy felmérés tükrében. MPT IX
Vándorgyűlése, Miskolc, 2001.
Szumska I.: Az evészavarok prevalenciája és pszichoszociális vonatkozásai
15-24 éves fiatal magyar nők körében, Pszichiáter Professzorok és
Tanítványaik Klubja. Veszprém 2001.
Hajnal Á, Csoboth Cs, Szumska I.: What does it mean, if young women
appraise their mothers as depressed? IV European Conference and the XV
Hungarian National Conference on Family Therapy. Budapest 2001.
Szumska I: A fiatal lányok és nők táplálkozási zavar tüneteinek
gyakorisága. MPT Vándorgyűlés, Győr, 2000.
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Szumska I: A pánik és agorofóbia kognitív-viselkedésterápiás kezelése. A
Magyar Pszich. Társaság Országos Tudományos Nagygyűlése, Budapest,
2000.
Purebl Gy, Szumska I.: Asthmás betegek adjuváns pszichológiai
kezelésének alapelvei. MPT IV. Nemzeti Kongresszus, Budapest, 1998.
Fóris N, Szumska I.: 17-25 éves fiatalok egészségszokásai és pszichés
jellemzői. A Magyar Pszich. Társaság XII Országos Tudományos
Nagygyűlése. Budapest 1996.
Kaszab Zs, Szumska, I, Lukács J, Mohácsi E,: Felnőtt asthmás betegek
önsegítő csoportja. Magyar Pszich. Társaság XI. Országos Tudományos
Nagygyűlés, Debrecen1994.
Kaszab Zs, Szumska I.: Complex Therapy of Adult Astmatic Patient. 3-th
International Congress of Behavioural Medicine, Amsterdam, 1994 .
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