RESEARCH ARTICLE

Comorbid Psychiatric Disorders in Female Adolescents with First-

Onset Anorexia Nervosa
K. Bühren1*, R. Schwarte1, F. Fluck1, N. Timmesfeld2, M. Krei1, K. Egberts3, E. Pfeiffer4, C. Fleischhaker5,
C. Wewetzer6 & B. Herpertz-Dahlmann1
1
Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Clinics RWTH Aachen, Aachen, Germany
2
Department of Medical Statistics, University of Marburg, Marburg, Germany
3
Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University of Würzburg, Würzburg, Germany
4
Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Charité Universitätsmedizin Berlin, Berlin, Germany
5
Department of Child and Adolescent Psychiatry and Psychotherapy, University Clinics Freiburg, Freiburg, Germany
6
Department of Child and Adolescent Psychiatry and Psychotherapy, Kliniken der Stadt Köln, Köln, Germany

Abstract
Objective: Patients with anorexia nervosa (AN) exhibit high rates of psychiatric comorbidity. To disentangle the effects of duration of
illness on comorbid psychiatric symptoms, we investigated the rates of comorbid psychiatric disorders, suicidality and self-harm
behaviour in adolescent patients with a first onset of AN.
Methods: In adolescent females (n = 148) with a first onset of AN, body mass index, psychiatric comorbidity (according to DSM-IV),
depressive symptoms, suicidality and self-injurious behaviour were assessed.
Results: Seventy patients (47.3%) met the criteria for at least one comorbid psychiatric disorder. The binge-purging subtype was
associated with increased rates of psychiatric comorbidity, suicidality and self-injurious behaviour. The severity of eating disorder-
specific psychopathology influenced current psychiatric comorbidity and suicidal ideation.
Conclusion: Prevalence rates of comorbid psychiatric disorders and suicidal ideation are considerably lower among adolescents with AN
compared with adults. An early and careful assessment, along with adequate treatment of the eating disorder, might prevent the
development of severe psychiatric comorbidities. Copyright © 2013 John Wiley & Sons, Ltd and Eating Disorders Association.
Keywords
Anorexia nervosa; comorbidity; psychiatric; adolescent; suicidality

*Correspondence
Katharina Bühren, MD, Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Clinics RWTH Aachen, Neuenhofer Weg
21 ,52074 Aachen, Germany. Tel.: +49-241-8088737; Fax: +49-241-8082544
Email: kbuehren@ukaachen.de

Published online 12 September 2013 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/erv.2254

Introduction & Kessler, 2007; Swanson, Crow, Le Grange, Swendsen, &

Merikangas, 2011).
Anorexia nervosa (AN) often takes a chronic and disabling course Although the onset of AN typically occurs during adolescence,
fraught with high personal and societal tolls (Steinhausen, 2002; psychiatric comorbidities have mostly been examined only in
Wentz, Gillberg, Anckarsater, Gillberg, & Rastam, 2009). Indeed, adult samples. However, adult patients have often had a chronic
the morbidity and mortality rates are among the highest of eating disorder for many years. A long duration of illness
any mental disorder (Blinder, Cumella, & Sanathara, 2006; complicates efforts to identify whether psychiatric comorbidities
Smink, van Hoeken, & Hoek, 2012). Greater negative long-term
existed before, at or after the onset of the disorder. Significant
outcomes in AN seem to be associated with the psychiatric
evidence has suggested that prolonged starvation during brain
comorbidity of the eating disorder (Herpertz-Dahlmann et al.,
maturation might lead to brain dysfunctions (Kaye, Fudge, &
2001; Steinhausen, 2002). In clinical and epidemiological samples,
the lifetime prevalence rates of at least one comorbid according Paulus, 2009; McAdams & Krawczyk, 2011; Rothemund et al.,
to the Diagnostic and Statistical Manual of Mental Disorders 2011) and, accordingly, to increased vulnerability to psychiatric
(DSM-IV) axis-I disorder range from 49% to 97% (Blinder disorders (Mainz, Schulte-Ruther, Fink, Herpertz-Dahlmann, &
et al., 2006; McDermott, Forbes, Harris, McCormack, & Konrad, 2012). In addition, chronic AN disrupts educational
Gibbon, 2006). Mood, anxiety and obsessive–compulsive and vocational development, as well as social relationships,
disorders, as well as substance abuse and personality disorders, which might also contribute to psychiatric comorbidities such
are frequently diagnosed in AN patients (Hudson, Hiripi, Pope, as depression and anxiety.

Eur. Eat. Disorders Rev. 22 (2014) 39–44 © 2013 John Wiley & Sons, Ltd and Eating Disorders Association. 39
Comorbidity in Adolescent Anorexia Nervosa K. Bühren et al.

To date, only three studies of AN in population-based adoles- on long-term outcome, which underscores the importance of
cent samples (Rastam, 1992; Swanson et al., 2011; Touchette understanding the interaction between the eating disorder and
et al., 2011) and a small number of studies in treatment-seeking comorbid disorders. Adolescent samples of patients with first
adolescents with AN (Fennig & Hadas, 2010; McDermott et al., onset of AN and with a short duration of illness are especially
2006; Ruuska, Kaltiala-Heino, Rantanen, & Koivisto, 2005; helpful for addressing this question because the effects of a
Salbach-Andrae et al., 2008) have been published. However, chronic illness are not yet present. The study aimed to assess the
most of these studies are biased by methodological flaws and prevalence of comorbid psychiatric disorders and suicide-related
small sample sizes. Several of these studies examined psychiatric behaviour in a large, well-characterised sample of inpatient and
symptoms but not comorbid diagnoses according to common day patient female adolescents with a first onset of AN. In light
classification systems. of previous studies, we assumed that psychiatric comorbidity in
Suicide is the major cause of high mortality in AN (Arcelus, adolescent AN patients is less common than in adult samples
Mitchell, Wales, & Nielsen, 2011). Approximately, one half of and that depressive and anxiety disorders are the most prevalent
adult patients report suicidal ideation, with up to 26% of comorbid disorders (Salbach-Andrae et al., 2008; Swanson et al.,
patients attempting suicide (Bulik et al., 2008; Forcano et al., 2011). Furthermore, we investigated whether binge-purging
2011). In adolescent patients, only three studies have directly behaviour and/or higher severity of the eating disorder have a
assessed the prevalence of suicidal ideation and the relationship significant impact on the risk to suffer from additional psychiatric
of suicidal ideation to comorbid psychiatric symptoms or disorders or suicidal ideation in adolescent patients with AN.
disorder-specific psychopathology. These studies reported a
strong association among depressive symptoms, the binge-purge Methods
subtype of AN and the duration of illness. An overview of studies
on psychiatric comorbidity and suicidality in adolescent AN is We performed a randomised, controlled and multicentre trial
given in Table 1. between 2007 and 2010 to compare day patient and inpatient
Comorbid psychiatric disorders and suicidal ideation are treatment settings in adolescent AN at five study sites within
common in patients with eating disorders and have a great impact different regions of Germany (four university clinics and one

Table 1 Overview of studies of psychiatric comorbidities and suicidality in adolescent anorexia nervosa patients

Author and Sucidality associated

date Study design Sample size Mean age Diagnosis assessment Comorbidity Suicidality with

Fennig & clinical (outpatient) 33 women 15.7 years SCID DSM-IV 51.5% comorbid suicidal thoughts : depression, longer
Hadas, 2010 (29 AN-R and lifetime diagnosis mood disorder 57% duration of illness
4 AN-BP) suicide attempts:
17%
McDermott clinical (outpatient) 49 AN 14.5 years CBCL (psychiatric 49% comorbid not assessed not assessed
et al., 2006 (women + men) symptoms) psychopathology
Rastam, 1992 population- 20 AN 15.9 years DSM-III-R 86% axis I diagnosis not assessed not assessed
based and (18 women, (clinical) other than AN
clinical and 2 men) current or depressed
32 AN 16.1 years diagnosis mood without
(31 women fulfilling DSM-criteria
and 1 man)
Ruuska clinical (outpatient) 34 AN women 16.2 years ICD-10 not assessed suicidal ideation: BP-subtype,
et al., 2005 (clinical) current 41.2% depression,
diagnosis suicide attempts : symptom
3.1% severity
Salbach-Andrae clinical 101 women 15.2 years CIDI-DIA-X 73.3% at least one not assessed not assessed
et al., 2008 (inpatient) (71 AN-R DSM-IV current comorbid axis
and 30 AN-BP) diagnosis I diagnosis
Touchette population- 28 women 15.7 years DISC-2 14.3% major not assessed not assessed
et al., 2011 based with subclin. AN DSM-IIIR depression
current diagnosis 10.7% separation
anxiety
Swanson population- 34 AN (women + men) 13–18 years CIDI DSM-IV 55.2% at least on suicidal ideation: all AN subtypes
et al., 2011 based lifetime comorbid DSM-IV 31.4%
diagnosis disorder sucidide attemps:
8.2%

AN-R = restrictive subtype of AN, AN-BP = binge-purging subtype of AN, SCID = Structural Clinical Interview for Axis I DSM-IV disorders, CBCL = Child Behaviour Check-
list, CIDI = Composite International Diagnostic Interview, CIDI-DIA-X = German version of the CIDI and DISC-2 = Diagnostic Interview Schedule for Children–Version 2

40 Eur. Eat. Disorders Rev. 22 (2014) 39–44 © 2013 John Wiley & Sons, Ltd and Eating Disorders Association.
K. Bühren et al. Comorbidity in Adolescent Anorexia Nervosa

department at a major general hospital). In addition to general according to DSM-IV criteria; this instrument is based on semi-
child and adolescent psychiatry, each centre also offered specialised structured interviews of the patient and her caregivers (Kaufman
treatment for adolescent AN patients. et al., 1997), and allows the therapist to diagnose psychiatric
disorders that had an onset prior to the actual eating disorder, as
Participants well as current psychiatric comorbidities. Eating disorder-specific
The sample consisted of 172 female adolescent patients consecu- psychopathology was assessed using the Eating Disorder Inventory
tively admitted to inpatient or day patient treatments. All patients (EDI-2; Rathner & Waldherr, 1997). This widely used self-report
met DSM-IV (American Psychiatric Association, 1994) diagnostic questionnaire has good psychometric properties and is recom-
criteria for first onset of AN. Although three of them had not yet mended for children and adolescents from the age of 11 years.
met the weight criterion, each had lost a significant amount of
weight in a very short time. The patients were assessed within Statistical analysis
1 week of hospital admission. A total of 86% of patients For descriptive statistics of continuous variables such as clinical
(n = 148) completed the entire diagnostic battery, including the parameters, means and standard deviations were calculated.
assessment of comorbid psychiatric disorders. For the nominal variables, the exact numbers and proportions
Exclusion criteria included any history of organic brain disease, are provided. Comparisons between groups were performed
schizophrenia, bipolar disorder, severe self-injury or severe using the Wilcoxon rank-sum test for continuous variables
substance abuse. However, no patients were excluded due to any and with Fisher’s exact test for nominal variables. Associations
of these criteria. between the two continuous variables were examined through
All local ethics committees approved the study, and all partici- linear regression. All p-values were two-sided, p-values less
pants and their caregivers gave written informed consent. than 5% were considered statistically significant. Statistical
analyses were performed with the R statistical software package
Clinical parameters (www.r-project.org) version 2.15.0.
Age, weight, height, body mass index (BMI), duration of illness
(the elapsed time between initiation of weight loss or insufficient Results
age-appropriate weight gain and admission) and overall weight
loss (the weight difference in kilograms between the beginning Demographic data
of the illness and the time of admission) were recorded for each Detailed clinical data of the 148 female AN patients are described
patient at the time of admission. in Table 2.

Psychiatric assessment Psychiatric comorbidity

The expert form of the structured interview for anorexic and Seventy-eight of the 148 patients (52.7%) did not met DSM-IV
bulimic disorders (SIAB-EX) was administered to diagnose AN criteria for any lifetime psychiatric comorbidity. However, the
subtype and to obtain additional information on core eating remaining 70 (47.3%) patients met criteria for at least one
disorder behaviours. The SIAB-EX is a detailed semi-standardised additional lifetime psychiatric disorder. Fifty-two (35.1%)
expert interview with good validity and reliability assessing the patients had one additional disorder, 13 (8.8%) patients had
prevalence and severity of specific eating disorder-related symp- two, four (2.7%) patients had three and one (0.7%) patient
toms (according to DSM-IV) in patients from the age of 12 years had four psychiatric comorbidities. The most frequently ob-
(Fichter & Quadflieg, 2001). This interview also enables the served comorbid disorders were affective disorders and anxiety
differentiation between the two subtypes of AN according to disorders (mostly social phobia and obsessive–compulsive disor-
the DSM-IV (restrictive vs binge-purging subtype). Additionally, der). For more details, see Table 3.
this interview affords information on the prevalence and severity Compared with patients with the binge-purging subtype, the
of suicidal ideation, suicide attempts and self-injurious behav- patients with the restrictive subtype of AN showed less current
iour (SIB). Suicidal ideation was defined in this study as frequent psychiatric comorbidities (64.3% vs 35.8%, p = 0.01) and a lower
thoughts and plans to kill one´s self within the previous total score on the BDI (p = 0.0003) (Figures 1 and 2). The average
3 months. SIB was defined as self-harming behaviour, either total score on the BDI-II was 19.51 ± 10.65, which indicates the
with or without suicidal intent that had a non-fatal outcome presence of mild–moderate depressive symptoms(Beck, Steer, &
(Madge et al., 2008). Suicidal ideation and SIB were considered
to be present if the patient received a score of at least 2 on a
ranking scale from 0 to 4 on the corresponding items of the Table 2 Clinical data for anorexia nervosa patients (n = 148)
SIAB-EX.
Depressive symptoms were assessed using the Beck Depression mean (sd) or n (%)
Inventory (German version, BDI-II) (Hautzinger, Kühner, &
age [years] 15.2 (1.5)
Keller, 2006), which has good validity and reliability in adoles- 2
BMI [kg/m ] 15.0 (1.3)
cents (Dolle et al., 2012). The presence of additional psychiatric
duration of illness [weeks] 46.7 (31.2)
disorders was assessed using the Kiddie-Schedule for Affective restrictive subtype of AN 120 (81.1)
Disorders and Schizophrenia (Kiddie-SADS; Delmo, Weiffenbach, binge-purging subtype of AN 28 (18.9)
Gabriel, & Poustka, 2000), which is designed to generate valid
and reliable psychiatric diagnoses in children and adolescents BMI = body mass index

Eur. Eat. Disorders Rev. 22 (2014) 39–44 © 2013 John Wiley & Sons, Ltd and Eating Disorders Association. 41
Comorbidity in Adolescent Anorexia Nervosa K. Bühren et al.

Table 3 Current and premorbid psychiatric disorders according to DSM-IV

(‘premorbid’ defines the time before onset of the eating disorder)

Current n (%) Premorbid n (%)

affective disorders 51 (34.5) 9 (6.1)

major depressive disorder 47 (31.8) 9 (6.1)
dysthymia 7 (4.7) 0
anxiety disorders 16 (10.8) 12 (8.1)
social phobia 10 (6.8) 0
generalized anxiety disorder 1 (0.7) 0
obsessive-compulsive disorder 5 (3.4) 6 (4.1)
specific phobia 1 (0.7) 2 (1.4)
childhood anxiety disorder 0 5 (3.5)
others 2 (1.4) 2 (1.4)
attention hyperactive deficit disorder 2 (1.4) 0
adjustment disorder 0 1 (0.7)
acute alcohol intoxication 0 1 (0.7)
no diagnosis 78 (58.8) 124 (83.8)
Figure 2 Association between BDI (Beck Depression Inventory 2) total score,
suicidality and anorexia nervosa subtype in adolescent patients with AN

behaviour (p = 0.01) (Figure 1). There was also a strong relation-

ship between suicidal ideation and the severity of depressive symp-
toms, as indicated by the BDI total score (p = 0.0002) (Figure 2).
Suicidal ideation was also significantly correlated with the severity
of eating disorder-specific psychopathology (p < 0.0001).

Discussion
Our study revealed a lifetime prevalence of at least one mental
disorder in half of the adolescent patients with a first onset of
AN. This result is in line with other clinical and population-based
studies in adolescents (Fennig & Hadas, 2010; McDermott et al.,
2006; Salbach-Andrae et al., 2008; Swanson et al., 2011), although
these studies did not restrict their samples to first onset of AN. As
in other studies, the most frequent comorbid diagnosis observed
Figure 1 Association between subtype of anorexia nervosa (AN), the presence in our sample was an affective disorder (major depression or
of at least one current psychiatric comorbidity and suicidal ideation in adoles- dysthymia), followed by anxiety disorders (more precisely, social
cent patients with AN (n = 148 adolescent patients with first-onset AN) phobia and obsessive–compulsive disorders) (Fennig & Hadas,
2010; Salbach-Andrae et al., 2008). However, the prevalence of
comorbid anxiety disorders was comparatively low in our sample.
Brown, 1996). Furthermore, our analyses revealed a trend Several authors showed that the binge-purging subtype of AN is
towards a significant association between current depressive highly associated with comorbid anxiety disorders (Salbach-
symptoms and weight loss (p = 0.07). Andrae et al., 2008; Swanson et al., 2011). In contrast to other
There was no association between a current diagnosis of at least studies (McDermott et al., 2006; Salbach-Andrae et al., 2008),
one comorbid psychiatric disorder and BMI-SDS at admission the percentage of patients with the binge-purging subtype was
(p = 0.39), BMI (p = 0.49), duration of illness (p = 0.64), weight loss relatively low (18.9%) in our sample.
(p = 0.86) or premorbid psychiatric disorders (p = 0.06). However, The development of these additional psychiatric disorders
the severity of the eating disorder-specific psychopathology was remains ambiguous. On the one hand, they could have occurred
significantly correlated to a current diagnosis of at least one comor- prior to the onset of the eating disorder. It is well known that
bid psychiatric disorder (p < 0.0001). anxiety and depressive disorders often precede eating disorders
(Kaye, Bulik, Thornton, Barbarich, & Masters, 2004), and
Suicidal and self-injurious behaviour negative affect has been a relatively consistent predictor of eating
Seventeen of 148 (11.5%) patients reported suicidal ideation, disorder symptoms (Stice, Ng, & Shaw, 2010). In our study,
and 6 of 148 (4.1%) reported having engaged in self-harming 16.2% of the patients had a pre-existing psychiatric disorder other
behaviour. Compared with the restrictive subtype of AN, a than an eating disorder (mostly depressive and anxiety disorders).
greater number of patients diagnosed with the binge-purging However, pre-existing psychiatric disorders were not associated
subtype showed suicidal ideation (p = 0.0008) and self-harming with any current eating disorder symptoms or anthropometric

42 Eur. Eat. Disorders Rev. 22 (2014) 39–44 © 2013 John Wiley & Sons, Ltd and Eating Disorders Association.
K. Bühren et al. Comorbidity in Adolescent Anorexia Nervosa

data. On the other hand, comorbid mental disorders in patients the rates found in other studies of adolescents and adults with
with AN may emerge as consequences of acute starvation (Pollice, eating disorders, although we did not exclude any patient from
Kaye, Greeno, & Weltzin, 1997). our study because of the severity of their self-harming behaviour
Compared with adult patients, the adolescent patients in our (Peebles et al., 2011; Ruuska et al., 2005).
study reported lower rates of current psychiatric comorbidity There might be different explanations for this finding. Firstly,
(73% vs 41%) (Herzog, Keller, Sacks, Yeh, & Lavori, 1992). suicidal ideation and suicide mostly occur in patients who have
The presence of current comorbid psychiatric disorders was experienced a chronic course of AN (Guillaume et al., 2011;
not related to premorbid psychiatric disorders or the duration Ruuska et al., 2005). Secondly, binge-purging behaviour is associ-
of illness but to the severity of the eating disorder measured at ated with higher suicidality and SIB rates (Fennig & Hadas, 2010;
admission. Adolescence is a period characterised by developing Peebles et al., 2011; Wentz, Gillberg, Anckarsater, Gillberg, &
independence from parents and a turn to peers for support Rastam, 2012). Higher impulsivity and novelty-seeking and low
and companionship. It is also marked by first intimate experi- self-directedness in patients with binge-purging behaviour might
ences and first vocational aims. These important milestones are account for these discrepancies (Stein, Lilenfeld, Wildman, &
interrupted by a chronic psychiatric disorder and are likely Marcus, 2004). In our sample, only 18.9% of the patients
associated with academic failure and poor social relationships, showed binge-purging behaviour. However, their risk of suicidal
which may result in increased comorbid psychopathologies such ideation was more than four times higher, and the risk of SIB
as depression and anxiety. Two studies on the long-term was eight times higher, compared with patients with the restric-
outcome of AN corroborated the important implications of tive subtype. Thirdly, suicidality and SIB rates were also higher
eating disorder symptoms for the development of social life. in studies that assessed these symptoms by means of self-rating
Patients with a poor long-term outcome for their eating disorder scales compared with those using structured diagnostic inter-
were found to have poor psychosocial functioning and higher views, as in our study.
rates of psychiatric comorbidity (Strober, Freeman, & Morrell, However, it is interesting that our results concerning suicidality
1997; Wentz et al., 2009). and deliberate self-harm approximate the results of epidemiolog-
Furthermore, several years of chronic starvation might lead to neu- ical studies of European adolescents (Kokkevi, Rotsika, Arapaki, &
ronal dysfunction in adults, which is most likely mediated by altered Richardson, 2012) and of a recent population-based study of
neurotransmitter metabolism and endocrine changes (McAdams & German adolescents (Fischer et al., 2012).
Krawczyk, 2011; Neufang et al., 2009; Rothemund et al., 2011). One limitation of this study is that we only studied patients
Prolonged hormonal deficiencies might lead to insufficient matura- having moderate–severe AN in need of hospital treatment. Such
tion in brain regions responsible for mood regulation, most likely a sampling could produce an increased rate of comorbid psychiat-
resulting in ‘biological scars’ that can enhance one’s vulnerability to ric symptoms. However, our study has considerable methodolog-
mood and anxiety disorders (Mainz et al., 2012). ical strengths. Our sample is very large despite the low prevalence
Additionally, the higher number of patients with the binge- of AN. Because we only included first onset of AN patients, we
purging subtype of AN observed in most adult samples might managed to assess a homogeneous sample of patients with a
account for higher rates of psychiatric comorbidity and a greater relatively short duration of illness. This approach provided an
clinical severity compared with adolescent samples (McDermott opportunity to minimise the consequences of a lengthy illness
et al., 2006; Swanson et al., 2011). In our study, patients with the on psychiatric comorbidity. In addition, the patients were care-
binge-purging subtype of AN displayed comorbidity rates that fully assessed using well-validated multimodal assessment instru-
were twice as high as those patients with the restrictive subtype. ments (both interview and self-reporting).
Different personality traits, such as lower self-directedness
and irritable mood in patients with the binge-purging subtype, Conclusions
might influence comorbidity rates (Abbate-Daga et al., 2011;
Hoffman et al., 2012). At least one comorbid psychiatric disorder is prevalent in half of
Suicidal behaviour is common in patients with eating the patients with a first onset of AN, and patients diagnosed with
disorders. The two existing studies of adolescents found suicidal the binge-purging subtype were at a greater risk of having a
ideation in 41% to 57% and suicidal attempts in 3% to 17% of comorbid psychiatric disorder. A careful assessment of other
these patients (Fennig & Hadas, 2010; Ruuska et al., 2005). In mental disorders in addition to the eating disorder is necessary at
our sample, we found a lower proportion of suicidal behaviour admission and during treatment. However, prevalence rates
(11.5%) and no suicide attempts, but we also examined a consid- are significantly lower among adolescents than among adult
erably shorter time span (ever vs during the last 3 months). How- patients with a more chronic course of the eating disorder. More-
ever, suicidality was significantly associated with the presence of over, rates of suicidal and self-harming behaviour are still low in
depressive symptoms, consistent with studies in adults with AN, adolescents and are comparable to those of population-based
revealing that psychiatric comorbidity in general and especially samples, whereas adult patients show significantly increased rates.
depressive disorders typically characterise patients with a history These findings suggest that a chronic eating disorder with its neu-
of suicide attempts (Bulik et al., 2008; Forcano et al., 2011). robiological, social and vocational consequences might account
Self-injurious behaviour is associated with a range of psychiat- for a more severe comorbid psychopathology. Thus, the early
ric problems and an increased risk for suicide (Andover & Gibb, diagnosis and treatment of eating disorders might also prevent sui-
2010; Peebles, Wilson, & Lock, 2011). In the present sample, we cidal behaviours and reduce the likelihood of developing a comor-
found a prevalence rate of 4.1%, which is considerably lower than bid mental illness, thus improving the long-term outcome of AN.

Eur. Eat. Disorders Rev. 22 (2014) 39–44 © 2013 John Wiley & Sons, Ltd and Eating Disorders Association. 43
Comorbidity in Adolescent Anorexia Nervosa K. Bühren et al.

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