Perception of Family Functioning and Depressive

Symptomatology in Individuals With Anorexia Nervosa

or Bulimia Nervosa
Victor Fornari, Katarzyna Wlodarczyk-Bisaga, Michael Matthews, David Sandberg, Francine S. Mandel,
and Jack L. Katz
This study investigated the relationship between the
perception of family functioning and depressive symptomatology in individuals with eating disorders (EDs).
Subjects were evaluated by diagnostic clinical interview using DSM-III-R criteria for EDs, the Schedule for
Affective Disorders and Schizophrenia-Lifetime Version (SADS-L), and two self-report measures, the Beck
Depression Inventory (BDI) and the Family Assessment Device (FAD). A significant association was
found between self-reported depressive symptomatology and perceived poor family functioning. Subjects
with bulimia nervosa (BN) reported a significantly

more dysfunctional family background than subjects

with anorexia nervosa (AN). In our sample, the presence of self-reported depressive symptomatology was
a m o r e p o w e r f u l predictive variable for perceived
family dysfunction than the diagnosis of affective
disorder. Also, the diagnosis of BN was a more consistent predictor of dysfunctional family interaction than
the diagnosis of affective disorder. Depressive symptoms and EDs seem to play different roles in the way
in which they contribute to dysfunctional family pat-

NTEREST IN THE ROLE of family factors in

the development and maintenance of eating
disorders (EDs) dates back to the 1873 description
of anorexia nervosa (AN) by Lasegue. 1 More
systematic approaches to the investigation of family factors in the etiology of EDs were initiated by
Minuchin et al, 2 and by Selvini-Palazzoli and the
Milan school of family therapy? Several studies
identified prevailing styles of functioning in families with eating-disordered individuals and indicated that interactions in these families differ from
those in families without eating-disordered members. 4,5 Family interactions of subjects with anorectic and bulimic symptoms have been found to be
dichotomous in that subjects with AN describe their
families as cohesive and organized with a lower
tolerance of conflict,6,7 as opposed to subjects with
bulimia nervosa (BN), who report their families to
be significantly more conflicted and less cohesive. 8,9 However, it has also been suggested that
families of AN subjects are heterogenous, 1 and
that, for example, there is no single dominant
family pattern characteristic of AN. H Differences
described in the patterns of family functioning are
also possibly related to methodological limitations.

For example, there are theoretical differences in the

conceptualizations of family interactions, a2 and
findings are elicited by a wide variety of assessment measures (self-report and observational measures). 13
In recent years, there has also evolved a considerable interest in the comorbidity of ED and other
psychiatric conditions. Halmi et al. TMand Fornari et
al.15 found that subjects with AN and BN have high
rates of both depressive and anxiety disorders.
Similarly, high rates of personality disorder (PD)
have been reported in ED subjects. 16,17 While the
family interactions of individuals with ED and the
possible comorbidity of ED with other conditions
have generated considerable research interest, there
has been little research concerning the relationship
between the functioning of these families and the
presence of other symptomatic behaviors. Steiger
et al.18 found no association between the ED
severity and the reported family functioning, but
found a significant relationship between the severity of the PD and the degree of dysfunctional
family interactions. Waller 19 found that in ED
subjects also diagnosed with borderline personality
disorder (BPD), specific features of pathologic
family interactions were associated with particular
symptoms of BPD. Thienemann and Steiner2 reported that dysfunctional family interactions of ED
subjects were correlated with both the self-reported
level of depression and the clinical diagnosis of
major depressive disorder (MDD). Moreover, Miller
et al.21 found that families of patients with MDD
show severely impaired functioning, even more so
than families of subjects with alcoholism, schizo-

From the Departments of Psychiatry and Biostatisties, North

Shore University Hospital, Manhasset; and Division of Child
and Adolescent Psychiatry, Children's Hospital of Buffalo,
Buffalo, NY
Address reprint requests to Victor Fornari, MD, Division of
Child and Adolescent Psychiatry, North Shore University Hospital, 400 Community Dr, Manhasset, NY 11030.
Copyright 1999 by W.B. Saunders Company
0010-440X/99/4006-0005510. 00/0
434

terns.

Copyright 1999by W.B. Saunders Company

ComprehensivePsychiatry,Vol. 40, No. 6 (November/December), 1999: pp 434-441

PERCEPTION OF FAMILY FUNCTIONING AND DEPRESSION IN AN/BN

435

the presence and severity of depressive symptoms

in ED subjects are more powerful predictors of the
patterns of family dysfunction than the mere presence and severity of ED symptoms. Thus, the
potential correlation of both factors--ED symptoms with and without the comorbid depressive
symptoms--with perceived family interactions was
investigated. Additionally, the relationship between
different ED subgroups and perceived family interactions was investigated.

phrenia, bipolar disorder, and adjustment disorder.

These findings indicate that a diagnosis of MDD or
any other comorbid psychiatric condition (such as a
PD) in individuals with an ED might be a more
reliable predictor of the presence of pathological
family interactions than the ED subgroup or the
severity of ED symptoms.
In recent years, the McMaster model of Family
Functioning has been proposed as a reliable and
valid method for assessment of the transactional
and systemic properties of the family system. 22The
McMaster Family Assessment Device (FAD) was
developed23 to investigate six dimensions of family
functioning: style of resolving problems (problem
solving), clarity of information transmission (communication), differentiation of tasks (roles), experience of emotions (affective responsiveness), concern for each other (affective involvement), and
clarity of rules (behavior control). This instrument
is easy to administer and focuses on contemporary
rather than retrospective family interactions. It has
been shown to differentiate between families with
and without members suffering from psychiatric
disorders 24 and has been proven to be a reliable
instrument for the assessment of family interactions in subjects with MDD. 25The FAD has already
been used in the assessment of families with
eating-disordered individuals, and it differentiates
clinical ED groups from comparison subjects.~S,26It
is for these reasons that the FAD was selected to
assess family functioning in the study reported
here.
In this study, the hypothesis investigated is that

METHOD

Subjects
The subjects were 106 consecutive individuals who were
evaluated in the outpatient Eating Disorders Program at North
Shore University Hospital-New York University School of
Medicine during a 3-year period. The study was approved by the
hospital's Institutional Review Board, and all subjects participated on a voluntary basis.
Subjects were classified into one of four ED diagnostic
groups: AN, BN, AN/BN (if symptoms of both AN and BN were
present), and ED-NOS. The marital status of the sample was as
follows: 93% (94 subjects) were single, 4% (four) were married,
2% (two) were widowed, and 1% (one) was divorced. Further
descriptive data for the subjects are listed in Table 1.

Instruments
All subjects were interviewed during each of two 2-hour
clinical interviews (total of 4 hours of interview). One of the
authors (V.E) completed all interviews. DSM-III-R criteria for
AN and BN were used to establish both current and lifetime ED
diagnoses, and the Schedule for Affective Disorders and Schizophrenia-Lifetime Version (SADS-L) 27 was used to establish the
diagnosis of an affective disorder.
All subjects were asked to complete the FAD 22 and the Beck
Depression Inventory (BDI). 2s For the total sample, 100% (106)

Table 1. Descriptive Statistics for the 106 Subjects Across ED Diagnostic Groups
AN
Parameter
Sex
Female
Male
Age, yr (mean _+ SD)
Education
Graduate school
College degree
1-3 yr college
10-11 yr
7-9 yr
SES (mean _+ SD)*

No.

BN
%

No.

33
89
4
11
18.5 +_ 4.4

26

0
4
11
6
16
6
16
5
14
46.2 + 14.5

AN/BN
%

100
0
20.9 _+ 3.4
0

6
11
6

23
42
23

0
51.5 -+ 12.2

No.

ED-NOS
%

No.

27
96
1
4
21.0 _+ 3.9

15

1
4
2
7
9
33
5
19
1
4
46.9 _+ 15.8

100
0
17.4 _+ 4.5

0
1
2
1
4
53.9 -+ 8.3

NS
.0051"
.002~t

7
14
7
29
NS

*Calculated using the Hollingshead (1975) Four Factor Index of Social Status. Median SES was 50 (social class I; interquartile range,
40-61 ).
t A N subjects were younger than AN/BN and BN subjects, and ED-NOS subjects were younger than BN subjects,
t A N subjects were significantly less educated than BN and AN/BN subjects, and ED-NOS subjects were significantly less educated
than BN subjects.

436

FORNARI ET AL

Table 2. FAD Subscale Scores for the Four ED Groups and Total ED Sample (mean _+ SD)
AN

BN

AN/BN

ED-NOS

Total

Problem-solving

Scale

2.28 _+ .58

2.68 _+ .65

2.55 _+ .67

2.32 _+ .50

2.45 _+ .63

NS

Communication

2.38 -+ .59

2.59 +_ .59

2.45 -+ .60

2.32 _+ .43

2.44 _+ .57

Roles

2.24 _+ .49

2.47 +_ .41

2.42 -+ .49

2.18 _+ .42

2.33 -+ .47

Affective responsiveness
Affective involvement

2.21 -+ .82
2.22 +- .52

2.67 _+ .69
2.42 _+ .51

2.44 -+ .75
2.42 -+ .66

2.13 _+ .55
2.00 +_ .47

2.37 -+ .76
2.29 -+ .56

Behavior control

2.14 -+ .36

2.12 _+ .44

2.16 -+ .47

1.97 +_ .39

2.12 -+ .41

General functioning

2.16 _+ .72

2.51 _+ .65

2.50 -+ .70

2.12 _+ .57

2.33 _+ .69

of the subjects completed the FAD and 87% (98) of the subjects
completed the BDI.
The FAD is a 60-item self-report instrument developed to
measure six dimensions of family functioning as outlined in the
McMaster Model of Family Functioning. 29 The FAD has been
found to have satisfactory psychometric properties in psychiatric and medical samples.22 Internal consistency for this questionnaire was reported to be highest for the affective responsiveness
scale (.83) and lowest for the roles scale (.72). The questionnaire
was also found to have good validity. The internal consistency of
the questionnaire assessed for our sample was found to be
satisfactory for all scales except behavioral control (.62), for
which the coefficient alpha was .79 to .91.
The BDI was developed to measure the depth of depression,
independently of the psychiatric diagnosis. It has content,
concurrent, and construct validity. 3 The BDI measures not only
depressive symptoms but also the cognitive functions and
distorted perceptions that are part of the depressive syndrome.
The SADS-L is a structured diagnostic research interview that
elicits symptoms to allow for a reliable diagnosis of affective
disorders and schizophrenia, both current and lifetime. The
diagnoses in the SADS-L are a subset of the Research Diagnostic Criteria, diagnoses which correspond to DSM-III-R criteria.

factors were as follows: AN diagnosis (yes/no), BN diagnosis

(yes/no), and both diagnoses (AN/BN). The diagnosis of
ED-NOS is represented as "no" on all previous categories (no
AN and no BN). The covariates were "depression" (in the first
model measured by the BDI and in the second model measured
by the diagnosis), age, SES, and educational level.

RESULTS

FAD Results
The FAD results were scored according to the
recommendation of the authors. 22Descriptive statistics are shown in Table 2. There were no significant
differences in the mean scores on the seven FAD
subscales among the four ED diagnostic subgroups.

Depressive Symptoms
The mean BDI score for the total sample was
21.48 _+ 13.57, which is indicative of moderate to
severe depression. Eleven percent of our sample
scored within the mild to moderate range (16 to
19), 20% within the moderate to severe range (20 to
29), and 30% within the severe range (30 to 63).
There was no difference in the mean BDI scores
for the four ED diagnostic groups (Table 3).
However, when categorized by severity groupings,
interesting differences appear. For example, 62% of
the ED-NOS group are in the normal (0 to 15)
range, whereas only 20% of the AN/BN group,
31% of the BN group, and 50% of the AN group are
in this category. Similar disparities are found for

Statistical Methods
The distributions of age and socioeconomic status (SES) for
the four diagnostic groups were compared using the KruskalWallis test. The mean FAD scores for the four groups were
compared using analysis of variance. Post hoc comparisons
were made using Tukey's least-significant difference test. Pearson product-moment correlation coefficients were used to measure the relationship between FAD subscales and the severity of
depressive symptoms (as measured by the BDI).
Two sets of analysis of covariance (ANCOVA) models were
used to examine the family functioning scores. The grouping

Table 3. Distribution of Affective Disorders Across ED Categories

AN

BN

AN/BN

Affective
Disorder

No.

No.

Current MDD
Lifetime MDD

20
21

54
57

BDI score*
BDI category

20.35 14.94

12
46
19
73
21.73 ~ 12.29

0-15
16-19
20-29
30-63
* M e a n _+ SD.

17
5
3
9

50
15
9
26

8
4
6
8

31
15
23
31

No.

19
68
22
79
25.60 11.23
5
1
11
8

Total

ED-NOS
%

20
4
44
32

No.

3
2O
5
33
6.00 ~ 15.34
8
1
0
4

62
8
0
31

No.

54
51
67
63
21.48 _+ 13,57

.03
.02
NS

38
11
20
29

38
11
20
30

PERCEPTION OF FAMILY FUNCTIONING AND DEPRESSION IN AN/BN

the moderate to severe category (20 to 29) and

severe category (30 to 63), as 76% of the AN/BN
group are in this range, as compared with 31% of
the ED-NOS group, 54% of the BN group, and
35% of the AN group. There were no differences in
BDI scores when compared by age, SES, or
educational level.
Lifetime and current MDD was diagnosed using
the SADS-L. The distribution of affective disorder
diagnoses across the four ED diagnostic subgroups
is presented in Table 3. There was a significant
difference in the proportion of patients with MDD
in each of the four ED diagnostic groups. The
AN/BN group exhibited the highest rate of MDD
compared with the ED-NOS group (with the lowest
rate of MDD).

Predictors of Family Functioning With BDI Scores

as a Measure of Depression
There was a significant difference in the mean
problem-solving scores (P = .0004). A significant
difference was found between those who have
bulimic symptoms in comparison to those who do
not (P = .05). Additionally, there was a significant
relationship between depressive symptoms (BDI)
and problem-solving (P = .0001). Subjects with a
diagnosis of BN (which included subjects with BN
or AN/BN) scored higher on problem-solving (more
"unhealthy") than patients without a diagnosis of
BN. Subjects with higher BDI scores (more depressed) also had higher problem-solving scores
(more unhealthy).
There was a significant difference in the mean
scores on the communication subscale (P = .01).
The BDI score was significantly related to the
communication score (P = 0.0004). Subjects with
higher levels of self-reported depression (as measured by BDI) had higher scores on the communication subscale (more unhealthy).
There was a significant difference in the mean
scores on the affective responsiveness subscale
(P = .0002). The affective responsiveness subscale
score was significantly related to the BDI score
(P = .0001). Subjects with higher BDI scores (selfreported as more depressed) also had higher affective responsiveness subscale scores (more unhealthy).
There was a significant difference in the mean
scores on the roles subscale (P = .03). There was a
significant difference between subjects with bulimic symptoms in comparison to those without

437

Table 4. ANCOVA Results for FAD Scales Using BDI as a

Measure of Depression
Predictor
Outcome variable: problemsolving (P = .0004)
AN
BN
AN/BN
BDI
Age
SES
Education level
Outcome variable: communication (P - .01)
AN
BN
AN/BN
BDI
Age
SES
Education level
Outcome variable: affective
responsiveness (P = .0002)
AN
BN
AN/BN
BDI
Age
SES
Education level
Outcome variable: roles (P = .03)
AN
BN
AN/BN
BDI
Age
SES
Education level
Outcome variable: general functioning (P = .004)
AN
BN
AN/BN
BDI
Age
SES
Education Level
NOTE.

df =

SE
Estimate Estimate

.35
-.12
-.30
.02
.001
-.0007
.13

.17
.16
.26
.004
.002
.005
.08

2.38 NS
3.95 .05
1.41 NS
16.33 .0001
0.29 NS
0.02 NS
2.67 NS

.34
.11
-.39
.02
.002
-.002
.10

.16
.16
.25
.004
.002
.005
.08

1.31 NS
0.37 NS
2.45 NS
13.36 .0004
0.76 NS
0.14 NS
1.79 NS

.50
.07
-.47
.02
.002
-.009
.07

.20
.19
.31
.005
.002
.006
.09

3.04 NS
1.00 NS
3.31 NS
18.88 .0001
0.52 NS
2.49 NS
0.51 NS

.13
-.18
-.12
.006
-.001
.008
.02

.13
.13
.21
.004
.002
.004
.06

0.42 NS
4.50 .04
0.36 NS
2.35 NS
0.79 NS
4.90 .03
0.10 NS

.22
-.17
-.21
.02
.001
-.008
.10

.19
.19
.30
.005
.002
.005
.09

0.61 NS
3.04 NS
0.52 NS
10.92 .001
0.25 NS
2.12 NS
1.10 NS

1.87.

bulimic symptoms (P = .04). Additionally, there

was a significant relationship between the roles
score and SES (P = .03). Subjects with BN scored
higher on the roles subscale (more unhealthy) than
patients without BN. Subjects with higher SES
scores (more affluent) also had higher roles scores
(more unhealthy).
There was no difference in the mean scores for

438

the two remaining subscales, affective involvement

and behavioral control, when controlling for the
diagnosis of AN, BN, and AN/BN, BDI score, age,
SES, and educational level.
Finally, there was a significant difference in the
mean general functioning subscale scores
(P = .004). The BDI score was significantly related
to the score on the general functioning subscale
(P = .0014). Subjects with higher BDI scores (more
depressed) also scored higher on the general functioning subscale (more unhealthy).

Predictors of Family Functioning With SADS-L

Diagnoses as a Measure of Depression
ANCOVA models similar to those already mentioned were analyzed using the diagnosis rather
than the BDI as a measure of depression. Due to the
nature of the diagnosis of lifetime versus current
MDD, separate models were examined for lifetime
and current MDD. The results of these analyses
were not significantly different. Therefore, only the
analysis using current MDD will be described.
There was a significant difference in the measures on the problem-solving subscale (P = .01).
There was a significant difference in the mean
problem-solving scores for those with a diagnosis
of BN as compared with those without (P = .005).
Additionally, there was a significant difference in
the mean scores for those with current MDD in
comparison to those without current MDD
(P = .05). Subjects with a diagnosis of BN scored
higher on problem-solving (less healthy) than patients without a diagnosis of BN. Similarly, patients
with current MDD had higher problem-solving
scores than those without current MDD (Table 5).
There was a significant difference in the mean
scores on the roles subscale (P = .04). Patients
with BN had a significantly higher mean score than
those without BN (P = .006). Additionally, patients with a higher SES had higher roles scores
(e = .05).
There was a significant difference in the mean
scores on the general functioning subscale
(P = .03). There was a significant difference in the
mean general functioning scores for subjects with
BN versus those without BN (P = .01). Subjects
with BN scored higher on general functioning than
those without BN.
There was no relationship between the scores on
all other subscales, i.e., communication, affective
responsiveness, affective involvement, and behav-

FORNARI ET AL

Table 5. ANCOVA Results for FAD Scales Using Diagnosis of

Current MDD as a Measure of Depression
SE
Estimate Estimate

Predictor
Outcome variable: problemsolving (overall P = .01)
AN
BN
AN/BN
Current MDD
Age
SES
Education level
Outcome variable: roles (P = .04)
AN
BN
AN/BN
Current MDD
Age
SES
Education level
Outcome variable: general functioning (P = .03)
AN
BN
AN/BN
Current MDD
Age
SES
Education level

.24
-.30
-.21
-.25
.0005
-.003
.11

.17
.16
.26
.12
.002
.005
.08

0.97
7.88
0.60
1.24
0.04
0.40
1.72

NS
.005
NS
.05
NS
NS
NS

.11
-.23
-.15
-.005
-.0009
-.007
.03

.13
.12
.20
.10
.002
.004
.06

0.04
7.36
0.49
0.23
0.51
4.25
0.26

NS
.006
NS
NS
NS
.05
NS

.15
-.32
-.15
-.21
.0003
-.009
.06

.19
.17
.29
.14
.002
.005
.09

0.22
6.25
0.24
0.79
0.01
2.79
0.48

NS
.01
NS
NS
NS
NS
NS

NOTE. dr= 1.94.

ioral control, and the variables of a diagnosis of

AN, BN, or AN/BN, SADS-L diagnosis of MDD,
age, SES, and educational level.

DISCUSSION
Our findings suggest higher rates of major depression in ED subjects than reported by Halmi et al., le
who found 29% of their ED sample to have major
depression. However, a higher rate of affective
disorder than the rate in our current sample was
reported by some members of our group in 1992.13
In that report, 72% of subjects with both AN/BN
evaluated in an ED program qualified for the
diagnosis of current affective disorder, 54% of AN
subjects, and 29% of BN subjects. In our sample,
the relationship between ED diagnoses and affective disorder rates seemed similar, as subjects with
AN/BN were found to have the highest rates of
MDD (current 68% and lifetime 79%), followed by
BN subjects (current 54% and lifetime 57%) and
AN subjects (current 46% and lifetime 73%).
Interestingly, the rates of depressive symptoms
measured by self-report (BDI) were very similar in

PERCEPTION OF FAMILY FUNCTIONING AND DEPRESSION IN AN/BN

that 76% of AN/BN subjects scored within the

moderate to severe and severe range, and 54% of
BN subjects and 35% of AN subjects. Thus,
regardless of the measure (self-report v structured
interview), depressive symptoms and disorders
occurred at high prevalence in individuals with ED,
as previous research has suggested, and they represent a major variable that could affect perception
and functioning (including familial interactions) in
these individuals.
For this sample of outpatient ED subjects, there
was no significant relationship between the ED
diagnostic subgroup and perceived family interaction when univariate analysis was applied. Our
results are consistent with previous studies in
which the FAD was used. 18,2,26Even though FAD
results do not differentiate between families with
BN and AN individuals, this instrument was found
to reliably differentiate between the responses of
ED subjects and controls) 8,26 The failure of the
FAD to find a dichotomy between the anorectic and
bulimic patients indicates that, in our sample,
subjects perceived their family interactions as similarly pathological. Perhaps the high rates of affective disorders in our sample had an effect on this
lack of anorexic versus bulimic differences, so that
similarly depressed subjects reported their familial
interactions as similar. However, the family interactions of ED subgroups might contain commonalities instead of a clear-cut dichotomy as suggested
by Steiger et al) 6 Limitations of the instrument
should also be considered, as it may not be
sensitive to the trends that can be detected using
other methods (such as observational measures).
In this study, the relationship between family
functioning and depressive symptomatology, measured both by self-report questionnaire and by
diagnostic psychiatric interview in the sample of
ED subjects, was investigated. High scores on the
BDI in our subjects were associated with selfreported pathological family functioning on five
dimensions: the family style for problem resolution
(problem-solving), transmission of information
(communication), differentiation of tasks (roles),
experience of emotions (affective responsiveness),
and general functioning, a measure of overall
health/pathology. Our results are consistent with
those of Thienemann and Steiner, is who, in a recent
study of subjects with ED and MDD, also found
that self-reported depressive symptoms were significantly associated with a negative report of family

439

functioning independently of the diagnosis. In their

sample, a negative report of the family-environment characteristics was associated more with the
depressive cognition as measured by the BDI, than
with the diagnosis of depression. Thus, not surprisingly, subjects with high BDI scores perceive
family functioning as pathological in most areas. A
diagnosis of BN was also significantly related to
the negative family interaction concerning problemsolving and roles (associated with task differentiation). This finding is similar to the results of
previous studies in which families of bulimic
individuals were described as highly conflicted and
disorganized. 31,32
In our sample of ED outpatients, when family
functioning was analyzed with the diagnosis of
MDD as the measure of depression, three aspects of
family functioning (problem-solving, roles, and
general functioning) were significantly different.
The variable which consistently contributed to this
finding was the diagnosis of BN. This again
corresponds with the findings that families of
subjects with BN are more disorganized and have
higher levels of conflict and hostility than families
of subjects without BN. 9 Our ED subjects with a
diagnosis of MDD, similar to the subjects with
MDD described by Keitner et al., 34 reported a
pathological style of family problem-solving. However, our subjects failed to report significant family
dysfunction in other dimensions as described by
Miller et al) 9 for a sample of subjects with MDD
only. It was expected that the presence of MDD and
the stress associated with this illness would contribute to the reported dysfunctional family patterns.
However, in our sample, the diagnosis of BN was a
more consistent predictor of family dysfunction
than comorbidity with MDD. Thus, the stress
associated with BN has an impact on the perception
of family dysfunctional interaction, even more so
than affective disorder, even though dysphoric
mood is an integral part of the clinical picture of
BN as well as MDD.
Interestingly, in our sample, there was a significant association between the SES and family
interaction concerning the differentiation of tasks
(roles) when depressive symptoms were measured
by self-report and diagnostic interview: the more
affluent the subject, the more pathological the
perception of family functioning reported in this
dimension. It is not clear what this finding means,

440

FORNARI ET AL

since there were no differences in SES in our

subjects across different ED subgroups.
When investigating the familial interactions in
our sample of ED subjects, we found that when the
ED diagnosis was the only variable considered,
there were no differences between diagnostic subgroups. This is surprising, given the previous
research in this area. However, when other factors
were considered such as the presence of depressive
symptoms, SES, age, and educational level, both
self-reported depressive symptoms and the diagnosis of BN were the most consistent predictors of
pathological family functioning. Only when all of
these factors were included did the impact of ED
diagnostic subgroup on familial interactions emerge
for BN. We are not clear as to why BN was the only
diagnostic category for which there was any association.
There are also several methodological considerations in our study that are worthy of discussion.
We included all diagnostic subgroups of patients
with ED (e.g., AN, BN, AN/BN, and ED-NOS) as
recommended by Kog et al. 34 It can also be argued
that since we included subjects age 9.7 to 29.9
years, the perception of family functioning would
be affected by the age of the particular subject.
However, Kog and Vandereycken4 found that clinical symptomatology, not age, showed a significant
effect on family measures. Furthermore, the marital
status could be considered a possible confounder of
the report on the family of origin. This confounding
effect in our sample is likely of marginal power,
since only seven of 106 subjects had a marital

status other than single. Another important issue

relates to the fact that we based the assessment of
family functioning on the perceptions of individuals with an ED and did not include other family
members' perceptions. However, Waller et al. 26
found that patients' perceptions of their family
functioning should be considered the most valid, as
their perceptions proved to be the best predictor of
the presence of an ED in the family when the
responses of all family members were compared.
Our results indicate that in our eating-disordered
individuals, the presence of self-reported depressive symptoms is the best predictor of perceived
familial dysfunctional patterns, even better than the
diagnosis of MDD, and the diagnosis of BN is also
a better predictor of perceived pathological family
interaction than the diagnosis of MDD. Both eating
and affective symptoms constitute major stressors
for both the afflicted individual and the family, and
we would thus expect them to have a significant
negative impact on family functioning. In interpreting our findings on the interaction between the
perception of familial functioning, ED, depressive
symptoms, and depressive disorder, we would like
to stress that different factors appear to play
different roles in the familial interaction. However,
at present, we cannot determine whether it is the
ED per se or the depressive symptomatology that is
the more important covariant of dysfunctional
family patterns. Further studies with a prospective
design are needed to shed light on the causal
relationship between family functioning and specific forms of psychopathology.

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