Comorbidity in Anorexic Adolescents: Assessment Through ASEBA System and Semistructured Interviews

  • Filippo Muratori
  • Valentina Viglione
  • Chiara Montalto
  • Sandra Maestro


A literature review on comorbidity in adolescent Anorexia Nervosa (AN) reveals a high rate of depressive and anxiety disorders broadly termed as internalizing conditions. The association between Axis II personality disorders (PD) and ED is also frequent with a prevalence of cluster C and B. Consequently, the accurate assessment of comorbidity is a key aspect in adolescent eating disorders to overcome the tendency to deny anorexic behavior as well as its comorbidity. The presence of comorbidity in ED is usually assessed with structured or semistructured clinical interviews, self-report questionnaires, and checklists. The assessment protocol used in the Eating Disorder Program at the Stella Maris Scientific Institute was elaborated by considering the type of patients and the clinical features of eating disorders at a young age: the Schedule for Affective Disorders and Schizophrenia for School Aged Children (K-SADS) for ED diagnosis and Axis I comorbidity; the Structured Clinical Interview for DSM-IV Axis II Disorders (SCID-II) for Axis II comorbidity; the Achenbach System of Empirically Based Assessment (ASEBA), especially the Child Behavior CheckList (CBCL) and Youth Self Report (YSR) for general psychopathology. In particular, a high percentage of our patients were found in the internalizing clinical range both at CBCL and YSR when using the ASEBA; these data were confirmed through Kiddie-SADS diagnosis with a prevalence of depressive disorders. High PD rates were found in our adolescent samples when using the SCID-II, similar to those of recent studies with a prevalence of cluster B and obsessive-compulsive personality disorder (OCPD). This accompanying comorbidity plays an important role in the outcome of ED and in the planning of therapeutic interventions.


Eating Disorder Anxiety Disorder Anorexia Nervosa Eating Disorder Personality Disorder 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



Anorexia Nervosa


Achenbach System of Empirically Based Assessment


Beck Anxiety Inventory


Beck Depression Inventory


Body Mass Index


Child Behavior CheckList


Children’s Depression Inventory


Children’s Depression Rating Scale Revised


Diagnostic Interview for Children and Adolescents


Diagnostic and Statistical Manual of Mental Disorders


Eating Attitude Test


Eating Disorders


Eating Disorder Inventory




Hamilton Depression Rating Scale




Schedule for Affective Disorders and Schizophrenia for School Aged Children


Multidimensional Anxiety Scale for Children


Obsessive Compulsive Disorder


Obsessive-Compulsive Personality Disorder


Pediatric Anxiety Rating Scale


Personality Disorders


Structured Clinical Interview for Axis I


Structured Clinical Interview for Axis II


Structured Interview for Anorexic and Bulimic Disorders-Expert Form


State-Trait Anxiety Inventory


Total Problem


Yale-Brown Obsessive Compulsive Scale


Youth Self-Report


  1. Achenbach TM. Manual for the Child behaviour Checklist/4–18 and 1991 profile. Burlington, University of Vermont department of Psychiatry; 1991a.Google Scholar
  2. Achenbach TM. Manual for the Youth self-Report and 1991 profile. Burlington, University of Vermont Department of Psychiatry; 1991b.Google Scholar
  3. Alessi NE, Krahn D, Brehm D, Wittekindt J. J Am Acad Child Adolesc Psychiat. 1989;28:380–4.CrossRefGoogle Scholar
  4. Ambrosini PJ. J Am Acad Child Adolesc Psychiat. 2000;39:49–56.CrossRefGoogle Scholar
  5. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th ed.Washington, DC: APA; 1994.Google Scholar
  6. Beck AT, Epstein N, Brown G, Steer RA. J Consult Clin Psychol. 1988;56:893–7.PubMedCrossRefGoogle Scholar
  7. Beck AT, Steer RA, Ball R, Ranieri W. J Pers Assess. 1996;67:588–97.PubMedCrossRefGoogle Scholar
  8. Braun DL, Sunday SR, Halmi KA. Psychol Med. 1994;24:859–67.PubMedCrossRefGoogle Scholar
  9. Bulik C, Thornton L, Pinheiro A, Plotnicov K, Klump K, Brandt H, Crawford S, Fichter M. et al. Psychosom Med. 2008;70:378–83.PubMedCrossRefGoogle Scholar
  10. Chambers WJ, Puig-Antich J, Hirsch M, Paez P, Ambrosini PJ, Tabrizi MA. Arch Gen Psychiat. 1985;42:696–702.PubMedCrossRefGoogle Scholar
  11. Chen EY, McCloskey MS, Keenan KE. Int J Eating Disord. 2009;42:275–83.CrossRefGoogle Scholar
  12. Claes L, Vandereychen W, Luyten P, Soenens B, Pieters G, Vertommen H. J Pers Disord. 2006;20:401–16.PubMedCrossRefGoogle Scholar
  13. Cooper PJ, Watkins B, Bryant-Waugh R, Lask B. Psychol Med. 2002;32:873–80.PubMedCrossRefGoogle Scholar
  14. Cotrufo P, Barretta V, Monteleone P. Acta Psychiat Scand. 1998;98:112–5.PubMedCrossRefGoogle Scholar
  15. Couturier J. Canadian J CME. 2004; February: 81–4.Google Scholar
  16. Fosson A, Knibbs J, Bryant-Waugh R, Lask B. Arch Dis Childhood. 1987;62:114–8.CrossRefGoogle Scholar
  17. Franko DL, Keel PK. Clin Psychol Rev. 2006;26:769–82.PubMedCrossRefGoogle Scholar
  18. Geist R, Davis R, Heinmaa M. Can J Psychiat. 1998;43:507–12.Google Scholar
  19. Godart NT, Flament MF, Lecrubier Y, Jeammet P. Eur Psychiat. 2000;15:38–45.CrossRefGoogle Scholar
  20. Godart NT, Perdereau F, Rein Z, Berthoz S, Wallier J, Jeammet Ph, Flament MF. J Affect Disord. 2007;97:37–49.PubMedCrossRefGoogle Scholar
  21. Goodman WK, Price LH, Rasmussen SA, Mazure C, Fleischman RL, Hill KL, Heninger GR, Charney DS. Arch Gen Psychiat. 1989;46:1006–11.PubMedCrossRefGoogle Scholar
  22. Grilo CM, Levy KN, Becker DF, Edell WS, McGlashan TH. Psychiat Serv. 1996;47:426–9.Google Scholar
  23. Halmi KA, Eckert E, Marchi P, Sampugnano V, Apple R, Cohen J. Arch Gen Psychiat. 1991;48:712–8.PubMedCrossRefGoogle Scholar
  24. Heebink DM, Sunday S, Halmi KA. J Am Acad Child Adolesc Psychiat. 1995;34:378–82.CrossRefGoogle Scholar
  25. Herpertz-Dahlmann B. Child Adolesc Psychiatric Clin N Am. 2008;18:31–47.CrossRefGoogle Scholar
  26. Herzog DB, Keller MB, Lavori PW, Kenny GM, Sacks NR. J Clin Psychiat. 1992a;53:147–52.Google Scholar
  27. Herzog DB, Keller MB, Sacks NR, Yeh CJ, Lavori PW. J Am Acad Child Adolesc Psychiat. 1992b; 31:810–8.CrossRefGoogle Scholar
  28. Holliday J, Uher R, Landau S, Collier D, Treasure J. J Pers Disord. 2006;20:417–26.PubMedCrossRefGoogle Scholar
  29. Kaye WH, Bulik CM, Thornton L, Barbarich N, Masters K. Am J Psychiat. 2004;161:2215–21.PubMedCrossRefGoogle Scholar
  30. Kennedy SH, Kaplan AS, Garfinkel PE, Rockett W, Toner B, Abbey SE. J Psychosomatic Res. 1994;38:773–82.CrossRefGoogle Scholar
  31. Kovacs M. Psychopharmacol Bull. 1985;21:995–8.PubMedGoogle Scholar
  32. Krol NP. J Am Acad Child Adolesc Psychiat. 1990;29:986–7.CrossRefGoogle Scholar
  33. Levy AB, Dixon KN. Int J Eating Disord. 1985;4:389–405.CrossRefGoogle Scholar
  34. Lewinsohn P, Striegel-Moore R, Seeley J. J Am Acad Child Adolesc Psychiat. 2000;39:1284–92.CrossRefGoogle Scholar
  35. Lilenfeld LR, Kaye WH, Greeno CG, Merikangas KR, Plotnicov K, Pollice C. Arch Gen Psychiat. 1998;55:603–10.PubMedCrossRefGoogle Scholar
  36. March JS, Sullivan K, Parker J. J Anxiety Disord. 1999;13:349–58.PubMedCrossRefGoogle Scholar
  37. Milos G, Spindler A, Schnyder U. Can J Psychiat. 2004;49:179–84.Google Scholar
  38. Mouren-Simeoni MC, Fontanon M, Bouvard MP, Dugas M. Revue Can. de Psychaitrie. 1993; 38:51–5.Google Scholar
  39. Muratori F, Viglione V, Maestro S, Picchi L. Psychopathology. 2004;37:92–7.PubMedCrossRefGoogle Scholar
  40. North C, Gowers S. Int J Eating Disord. 1999;26:386–91.CrossRefGoogle Scholar
  41. Overholser JC, Brinkman DC, Lehnert KL, Ricciardi AM. J Clin Child Adolesc Psychol. 1995;24:443–52.CrossRefGoogle Scholar
  42. Piran N, Lerner P, Garfinkel PE, Kennedy SH, Brouillette C. Int J Eat Disord. 1988;7:589–99.CrossRefGoogle Scholar
  43. Presnell K, Stice E, Seidel A, Madeley MC. Clin Psychol Psychother. 2009;16:357–65.PubMedCrossRefGoogle Scholar
  44. Rastam M. J Am Acad Child Adolesc Psychiat. 1992;31:819–29.CrossRefGoogle Scholar
  45. Reich W. J Am Acad Child Adolesc Psychiat. 2000;39:59–66.CrossRefGoogle Scholar
  46. Saccomani L, Savoini M, Cirrincione M, Verzellino F, Ravera G. J Psychosomatic Res. 1998; 44:565–71.CrossRefGoogle Scholar
  47. Salbach-Andrae H, Lenz K, Simmendinger N, Klinkowski N, Lehmkuhl U, Pfeiffer E. Child Psychiat Hum Dev. 2008;39:261–72.CrossRefGoogle Scholar
  48. Skodol AE, Rosnick L, Kellman D, Oldham JM, Hyler SE. Am J Psychiat. 1988;145:1297–9.PubMedGoogle Scholar
  49. Smith C, Steiner H. J Am Acad Child Adolesc Psychiat. 1992;31:841–3.CrossRefGoogle Scholar
  50. Smith C, Feldman S, Nasserbakht A, Steiner H. J Am Acad Child Adolesc Psychiat. 1993;32:1237–45.CrossRefGoogle Scholar
  51. Spielberger CD, Gorsuch, RL, Lushene RE. Manual for the state-trait anxiety inventory. Palo Alto, CA: Consulting Psychologists Press; 1970.Google Scholar
  52. Thompson-Brenner H, Eddy KT, Satir DA, Boisseau C, Westen D. J Child Psychol Psychiat. 2008;49:170–80.PubMedCrossRefGoogle Scholar
  53. Thornton C, Russell J. Int J Eat Disord. 1997;21:83–7.PubMedCrossRefGoogle Scholar
  54. The Research Units on Pediatric Psychopharmacology anxiety study group. J Am Acad Child Adolesc Psychiat. 2002;41:1061–9.CrossRefGoogle Scholar
  55. Viglione V, Muratori F, Maestro S, Brunori E, Picchi L. Psychopathology. 2006;39:255–60.PubMedCrossRefGoogle Scholar
  56. Williams JB. Arch Gen Psychiat. 1988;45:742–7.PubMedCrossRefGoogle Scholar
  57. Williams JBW, Gibbon M, First MB, Spitzer RL, Davis M, Borus J, Howes MJ, Kane J, Pope HG, Rounsaville B, Wittchen H. Arch Gen Psychiat. 1992;49:630–6.PubMedCrossRefGoogle Scholar
  58. Wonderlich SA, Swift WJ, Slomik HB, Goodman S. Int J Eat Disord. 1990;9:607–16.CrossRefGoogle Scholar
  59. Zaider TI, Johnson JG, Cockell S. Int J Eating Dis. 2000;28:58–67.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  • Filippo Muratori
    • 1
  • Valentina Viglione
  • Chiara Montalto
  • Sandra Maestro
  1. 1.Division of Child Neuropsichiatry, Stella Maris Scientific InstituteUniversity of Pisa, IRCCS Stella MarisCalambroneItaly

Personalised recommendations