RESEARCH ARTICLE

Risk Factors and Antecedent Life Events in the Development of

Anorexia Nervosa: A Portuguese Case-Control Study
Brbara C. Machado1,2*, Snia F. Gonalves2, Carla Martins2, Hans W. Hoek3,4,5 & Paulo P. Machado2
1
CEDHCentre for Studies in Human Development, Faculty of Education and Psychology, Catholic University of Portugal, Porto, Portugal
2
Psychotherapy and Psychopathology Research UnitCIPsi, School of Psychology, University of Minho, Braga, Portugal
3
Parnassia Bavo Academy, Parnassia Psychiatric Institute, The Hague, The Netherlands
4
Department of Epidemiology, Columbia University, New York, NY, USA
5
Department of Psychiatry, University of Groningen, Groningen, The Netherlands

Abstract
Objective: The aetiology of anorexia nervosa (AN) is considered to be multifactorial. This study aims to identify potential risk factors for
AN and whether these factors are specic to AN or precede the development of psychiatric disorders in general and to identify specic life
events in the 12 months immediately preceding the onset of eating disorder (ED) symptoms.
Method: A case-control design was used to compare a group of women who meet Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition criteria for AN (N = 86) with healthy controls (N = 86) and with a group of controls with other psychiatric disorders
(N = 68), each group matched to the AN patients by age and parental socioeconomic status bands. Risk factors were assessed by
interviewing each person with the Oxford Risk Factor Interview.
Results: Women with AN reported signicantly higher rates of perfectionism, negative attitudes toward parents shape and weight,
signicant concern about feeling fat and a family history of AN or bulimia nervosa. Critical comments about weight, shape or eating
was the most notable event in the year preceding AN onset.
Discussion: Perfectionism and a family history of ED emerged as the most convergent ndings in the development of AN,
along with being critical toward parents shape and weight, and feeling fat. Critical comments about appearance and
eating seem to be an important precipitating factor in AN onset. Copyright 2014 John Wiley & Sons, Ltd and Eating
Disorders Association.
Keywords
anorexia nervosa; risk factors; perfectionism; family history of ED; replication

*Correspondence
Brbara C. Machado, PhD, Faculty of Education and Psychology, Catholic University of Portugal, Rua Diogo Botelho, 1327, 4169-005 Porto, Portugal.
Email: bcmachado@porto.ucp.pt

Published online in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/erv.2286

Introduction development of AN raises signicant challenges to the research

Anorexia nervosa (AN) is a psychiatric disorder characterized by
high morbidity and mortality rates. Although the disorder has been
identied and described for a long time, still little is known about its
aetiology (Attia and Walsh, 2007; Arcelus et al., 2011; Bulik et al.,
2007). Recent reviews and meta-analyses (Striegel-Moore and Bulik,
2007; Jacobi et al., 2004; Stice, 2002; Keel and Forney, 2013) have
listed a number of possible risk factors for the development of
AN, from genetic to psychosocial risk factors, but also stressed our
limited knowledge on the aetiology of AN. The most frequent
explanation is still sociocultural, in combination with a possible
genetic predisposition (e.g. Bulik et al., 2007; Collier and Treasure,
2004; Treasure et al., 2010), which emphasizes a multifactorial
aetiology involving a complex interaction between genes and
the environment.
The relatively low prevalence of AN in the general population
(Hoek and Hoeken, 2003) and the complexity of the relationship
between biological and psychosocial factors associated with the
on its risk factors. And, although prospective longitudinal studies
would be the most methodological sophisticated ones, most of the
time, they lack sufcient statistical power (Jacobi et al., 2004).
Moreover, they do not answer about the general or specic nature
of the risk factors found. For these reasons, cross-sectional
controlled designs are still an effective tool to establish potential
relations between risk factors and AN development, which can
be further tested in longitudinal studies.
Several reviews of existing research were published over the last
years. Stice (2002), in a meta-analytic review, concludes that
prevention programmes for eating disorders (ED) should address
eating pathology risk factors such as thin-ideal internalization,
body dissatisfaction and negative affect, as well as factors that
potentiate the effects of other risk factors, such as pressure to be
thin and perfectionism. Jacobi et al. (2004) highlighted the
common denominator factors that have been consistently reported
on both longitudinal and cross-sectional studies in predicting ED,
including gender, ethnicity, genetic factors, feeding, eating and

Eur. Eat. Disorders Rev. (2014) 2014 John Wiley & Sons, Ltd and Eating Disorders Association.
Risk Factors and Antecedent Life Events in Anorexia Nervosa
gastrointestinal problems in childhood, sexual and physical abuse,
negative self-evaluation, psychiatric disorders, heightened weight
and shape concerns, body dissatisfaction and dieting behaviour.
Striegel-Moore and Buliks (2007) review stresses the importance
of considering both biological and sociocultural factors to under-
stand the aetiology of ED. Most recently, Keel and Forneys
(2013) review of risk factors for ED concludes that the idealization
of thinness and resulting weight and shape concerns are psychoso-
cial risk factors for ED, and that personal characteristics such as
perfectionism and negative emotionality may inuence suscepti-
bility to the previously mentioned risk factors.
Bulik et al. (2006) in a prospective study accessed risk factors
before AN onset and concluded that neuroticism was associated
with subsequent development of AN, being the only signicant
prospective predictor of the disorder. More recently, Nicholls and
Viner (2009) conducted a prospective birth cohort study. From
the 22 suggested risk factors for AN assessed, the results conrmed
female sex, early feeding problems, childhood undereating, mater-
nal weight, psychological functioning and increased risk for AN
development. Stice et al. (2010) argued that several factors that
increase the risk of ED onset have been identied from prospective
studies, which include perceived pressure for thinness, thin-ideal
internalization, body dissatisfaction, self-reported dietary restraint,
negative affect and substance use.
Previous reviews also highlighted important limitations of
existing cross-sectional risk factor studies, namely, (i) most of the
research focuses on a limited number of potential risk factors; (ii)
most studies did not consider ED onset and did not control for
initial symptoms or risk factors precedence; and (iii) there are few
studies that used control groups with other psychiatric disorders
(cf., Fairburn et al., 1999; Fairburn et al., 1997; Jacobi et al., 2004).
Four studies assessed risk factors for AN using the Oxford Risk
Factors Interview (RFI; Fairburn et al., 1999; Karwautz et al.,
2001, 2011; Pike et al., 2008), and addressed several of the limita-
tions cited in the previous research by using an interview to establish
diagnosis and to establish precedence of the risk factor evaluated,
and by considering a wide array of potential risk factors. In addition,
Pike et al. (2008) used the RFI in a matched case-control study that
included a psychiatric and a non-psychiatric control group.
Fairburn et al. (1999) found that perfectionism and negative self-
evaluation has specic risk factors for AN development. Tempera-
mental traits, sexual abuse and parental pressure increased the risk
for developing AN in the work of Karwautz et al. (2001). Pike
et al. (2008) results showed that women with AN had signicantly
higher rates of negative affectivity, perfectionism, family discord
and higher parental demands. Finally, Karwautz et al. (2011) found
that disruptive events, interpersonal problems and dieting environ-
ment increased the risk for AN independent of genotype.
Most recently, Hartmann et al. (2012) conducted a study using
the RFI in a community-based case-control design with children
with and without loss of control (LOC) over eating; the authors
concluded that children with LOC eating had greater levels of
exposure to parental problems (such as underinvolvement,
arguments and depression of family members) and dieting-related
risk factors compared with children without LOC eating.
The current study contributes to the literature by expanding
our knowledge on the basis of risk factors. Addressing one of
the most important requisite to infer causalityreplication of
Eur. Eat. Disorders Rev. (2014) 2014 John Wiley & Sons, Ltd and Eating Disorders Association.
B. C. Machado et al.
resultswe designed this Portuguese AN-matched case-control
study by using the RFI. The study aimed (i) to identify potential
risk factors for AN in a wide array of possible risk factors,
and to determine whether these factors are specic to AN or
precede the development of psychiatric disorders in general and
(ii) to identify specic life events in the 12 months immediately
preceding ED symptoms to address shortcomings of earlier case-
control studies.
Method
Design
A matched case-control design was used to compare a group of
women who met Diagnostic and Statistical Manual of Mental Disor-
ders, Fourth Edition (DSM-IV; American Psychiatry Association,
2004) criteria for AN (N = 86) with healthy controls (N = 86) and
with a group of controls with other psychiatric disorders (N = 68),
each group was matched to the AN patients by gender, age and
parental socioeconomic status bands. After informed consent was
obtained, eligible individuals were invited to participate in the study.
Recruitment procedure
Participants with AN (N = 86) were recruited in specialized ED
treatment settings; psychiatric control group participants were
also recruited in treatment settings. Potential non-psychiatric
control group participants (healthy control group) were recruited
in schools and on a university campus.
Participants
Eighty-six women with a DSM-IV (2004) primary diagnosis of
AN (AN group; 67.4% (n = 58) restricting type and 32.6%
(n = 28) binge eating/purging type), 68 women with a current
Axis I DSM-IV psychiatric diagnoses other than an ED (PC
group) and 86 women with no psychiatric disorder diagnosis
(NC group) were recruited. Exclusion criteria for all three groups
were physical disorders likely to inuence eating habits or weight
(e.g. diabetes), psychosis or current pregnancy. Inclusion criteria
for the NC group were absence of past or present psychiatric
disorder, including ED. Inclusion criteria for the PC group
included a current DSM-IV Axis I psychiatric disorder diagnosis
and no previous or present history of ED symptoms. The PC
group participants had the following primary DSM-IV diagnoses:
anxiety disorder (n = 35; 51.4%) and depressive disorder (n = 32;
47.1%); one PC group member had a current diagnosis of
somatoform disorder.
The NC and PC participants were individually matched to the
participants with AN on the basis of current age (1 year) and pa-
rental socioeconomic status (within two parental socioeconomic
status bands). Matching for current age reduced the risk for age-
related recall bias, and matching for parental socioeconomic
status removed an important potential confounding variable
(Fairburn et al., 1997, 1999), such as having different family
experiences according to availability of funds or level of parents
education. The NC and PC participants were assigned an index
age corresponding to the index age of the AN case to which they
were matched. Both control groups were questioned about their
life until the age of onset of disturbed eating (index age) of
their particular matched participant with AN. Index age was
B. C. Machado et al.
conservatively dened as the age at onset when at least one of the
following symptomatic behaviours rst began (Fairburn et al.,
1997, 1999; Pike et al., 2008): sustained dieting, sustained overeat-
ing, sustained purging (as determined at the Oxford RFI), rather
than the age at which the participants rst met all of the criteria
for an ED diagnosis. The assessment of risk factors focused on
the period prior to the index age, thereby ensuring that the risk
factor preceded the onset of clinically signicant eating pathology
(Pike et al., 2008). Adjusting case-control comparisons for age
at onset (i.e. index age) minimized differences between AN partic-
ipants and each control group in the time the participants were
exposed to the risk factor (Fairburn et al., 1999).
This study was reviewed and approved by the Institutional
Review Board and conformed with both Portuguese and European
regulations on conducting research with human participants and on
the management of personal data. All participants gave written
informed consent, and in the case of minors, parental consent for
participation in the research was obtained.
Assessment
Diagnostic assessment
Current and lifetime psychiatric disorders were assessed with
the Structured Clinical Interview for DSM-IV Axis I Disorders
(SCID-IV; First et al., 1995). ED diagnosis and psychopathology
were assessed with the diagnostic items of the Eating Disorder
Examination (EDE; Fairburn and Cooper, 1993). The Eating
Disorder Examination Questionnaire (EDE-Q; Fairburn and Beglin,
1994) was used as the primary instrument to screen potential
healthy controls.
Risk factor assessment
Exposure to putative risk factors for ED was assessed with the
Oxford RFI for Eating Disorders (RFI; Fairburn et al., 1997).
The interviews focused on the period before onset of the ED
(retrospective reporting), with age of onset being dened as the
age at which the rst signicant and persistent eating pathology
behaviours began (Fairburn et al., 1997). The presence of seven
risk factors was assessed before and after onset, as the authors
believe they may have a hereditary component (e.g. family history
of psychiatric disorders, such as ED, depression, manic, and
obsessive-compulsive disorders and substance abuse; we also
consider parental overweight and obesity). The RFI was investiga-
tor-based and used behavioural denitions of key concepts to
minimize problems related to retrospective data (Fairburn et al.,
1999). A large number of putative risk factors were assessed
(Tables 2 and 3). They were categorized into one of the three
domains: personal vulnerability domain, environmental domain
and dieting vulnerability domain. Within each domain, we
organized risk factors into several subdomains to reect types of
exposure. Additional risk factors were also evaluated (e.g. menar-
che age). Degree of exposure to a potential risk factor was rated on
a ve-point rating scale ranging from 0 = no exposure to 4 = high
severity, long duration or high frequency of exposure. A score of 3
or 4 was considered to indicate signicant severity, duration or
frequency of exposure.
Eur. Eat. Disorders Rev. (2014) 2014 John Wiley & Sons, Ltd and Eating Disorders Association.
Risk Factors and Antecedent Life Events in Anorexia Nervosa
Socioeconomic status
An adaptation of the Graffar schedule (Graffar, 1956) was used
in which scores range from 5 to 25, with higher scores indicating
lower socioeconomic level. This schedule takes into account the
years of formal education and profession of the parents, sources
of income, and type of housing and neighbourhood to assign
the family to one of the ve socioeconomic status categories.
Assessment of antecedent life events
The RFI also assesses 15 specic events that might have
occurred in the 12-month period preceding the index age.
Procedure
Participants in the AN group had been previously diagnosed by
clinicians, and they were interviewed using the EDE diagnostic
items (Fairburn et al., 1997). The PC group participants had a
previous psychiatric diagnosis by a clinician, but case status
was established and conrmed using the Structured Clinical
Interview for DSM-IV (SCID-I; First et al., 1995). Participants
in the NC group were screened using EDE-Q (Fairburn and
Beglin, 1994). They were included in the study if they had (i) a
score <4 on all the 4 EDE-Q subscales and (ii) reported the
absence of dysfunctional eating behaviours (i.e. binge eating
episodes and inappropriate weight control methods). They were
also interviewed with the SCID-I (First et al., 1995) to rule out
any DSM-IV diagnosis. Participants in both control groups were
interviewed with EDE diagnostic items (Fairburn et al., 1997) to
rule out ED pathology.
All participants of the study were interviewed using the Oxford
RFI (Fairburn et al., 1997). All interviews were performed face-
to-face and were carried out by clinical psychologists trained in
the use of the standardized interview procedure of the EDE,
SCID-I and RFI. Risk factor interviews were conducted by an
assessor who was aware of the case status of the participant. In
order to address this limitation and minimize the risk of biased
assessment, interviewer bias was discussed during training and
supervision, as suggested by Fairburn et al. (1999).
Data analysis
Comparisons between AN and control groups (PC and NC) were
carried out using a conditional logistic regression analysis (Egret
version 2.0.3) appropriate for a case-control design with individ-
ual matching. Firstly, we analysed some relevant statistical
assumptions previous to the regression analysis: (i) we studied
the variability of each risk factor in the three different participants
groups excluding the risk factors that did not show variability
between the groups; (ii) we assess the relative signicance of
different types of exposure in each subdomain and domain
individual putative risk factors and case status were rst assessed
by univariate analysis with each risk factor being considered as a
single indicator variable and coded 0 for absence and 1 for pres-
ence (we only considered risk factors for the regression analysis
when they showed statistical signicant values between the groups
at p < .05); (iii) then, and despite having p < .05 results, we
studied the cases in which cells presented a percentage superior
to 20% when the minimum expected was less than 5; (iv) the
multicolinieraty assumption was also investigated, excluding all
Risk Factors and Antecedent Life Events in Anorexia Nervosa B. C. Machado et al.

the predictors that showed results highly correlated between them Risk factors in AN versus non-psychiatric disorder
(values .10 or variance ination factor <4); (v) we then control group
organized all the domains and subdomains taking into account Table 2 presents the distribution of putative risk factors in the AN
the maximum number of predictors by participants according versus NC, and AN versus PC groups and the results of matched
to Stevens (1946) guidelines; (iv) nally, we look for potential univariate conditional regression analyses, and Table 3 presents
outliers that would need to be excluded from the nal analysis the overall level of exposure in each subdomain for these groups.
(ZResidual outside the range 3/+3 or Cooks < 1). Both tables summarize the results of comparisons of AN group
At the end, for the prediction of case status, that is, comparisons with the matched NC and PC groups.
between AN and control groups (PC and NC), we used the condi- In comparison to the NC group, participants with AN reported
tional logistic regression analysis. More specically, a nal logistic signicantly greater levels of exposure to all except 1 of the 16
regression equation retained the signicant risk factors that resulted subdomains (i.e. behavioural problems; see Table 3). A greater
from the conditional logistic regression analysis. Because of the degree of exposure within each subdomain/domain was associated
number of comparisons performed, statistical signicance for with a greater risk of developing AN.
the risk factor subdomain and domain analysis was set at 1% level Concerning the individual risk factors, in comparison to the
(p .01). The same set of analyses was used to assess the antecedent NC group, the AN participants reported signicantly greater levels
life events. of exposure in regard to perfectionism, self-consciousness about
appearance, unresolved/unaddressed family disagreements,
Results teasing, parental comments about eating, negative attitudes
Participants demographics toward parents shape and weight, feeling fat with signicant con-
cern, teased by peers about shape, weight, eating and appearance,
Participants with AN had a mean age of 20.02 4.49 years; the mean and a family history of AN or bulimia nervosa (BN) (all p 0.01;
age of onset of the rst ED symptom was 15.16 2.30. Mean body 3.06 OR 36.66; see Table 2).
mass index was 15.10 1.61 for AN participants, 20.77 2.56 for
non-psychiatric control participants and 21.04 2.56 for psychiatric AN versus psychiatric control group
control participants. AN parental socioeconomic distribution was as
In comparison to the PC group, participants with AN reported sig-
follows: high, 31 (36%); middle, 30 (34.9%); and low, 25 (29%).
nicantly greater levels of exposure to all except 2 of the 16
Results were similar after participants from both control groups
subdomains (i.e. fatherdaughter relationship and sexual, physical
were individually matched to AN participants on the basis of age
and psychological abuse; see Table 3). A greater degree of exposure
and parental socioeconomic status (Table 1).
within each subdomain/domain was again associated with a greater
risk of developing AN. The AN group reported signicantly greater
Table 1 Sociodemographic characteristics comparison of anorexia nervosa levels of exposure than the PC group to four risk factors: perfection-
group (AN) matched for age and parental socioeconomic status to non- ism, negative attitudes toward parents shape and weight, signicant
psychiatric (NC) and other psychiatric disorder (PC) control groups concern about feeling fat and a family history of AN or BN (all
p 0.01; 2.87 OR 36.28; see Table 2).
AN (n = 86) versus AN (n = 68) versus
NC (n = 86) PC (n = 68) Antecedent life events
AN NC AN PC
Table 4 summarizes the results of comparisons of the AN group
with both matched no psychiatric disorder and other psychiatric
M (SD) M (SD) M (SD) M (SD) disorder control groups regarding specic life events in the 12-
Index age 15.16 (2.30) _ 14.76 (2.13) _ month period immediately preceding rst ED symptoms. The
(years) AN group reported signicantly greater levels of exposure when
Current age 20.02 (4.49) 20.08 (4.24) 19.74 (4.76) 19.79 (4.74) compared with the NC group (at p < 0.001) to critical comments
(years) about weight, shape or eating (OR = 17.75). No signicant differ-
Current body 15.10 (1.61) 20.77 (2.56) 15.16 (1.55) 21.04 (2.56) ences were found between the AN and PC group (at p < 0.01).
mass index
2
(kg/m ) Discussion
N (%) N (%) N (%) N (%)
Education Perfectionism, feeling fat, negative attitudes regarding parents
9th grade 43 (50) 25 (29.1) 37 (54.4) 28 (41.1) shape and weight, and a family history of ED (either AN or BN)
12th grade 33 (38.4) 47 (54.7) 22 (32.4) 29 (42.6) were associated with the highest risk for AN. On the other hand,
College/ 10 (11.7) 14 (16.3) 9 (13.2) 11 (16.2) unresolved/unaddressed family disagreements, teasing (in general
university and specically related to shape, weight, eating and/or appear-
Parental socioeconomic status
ance), parental comments about eating and the participants
High (I or II) 31 (36) 30 (34.9) 24 (35.3) 20 (29.4)
self-consciousness about appearance emerged as risk factors for
Middle (III) 30 (34.9) 33 (38.4) 22 (32.4) 17 (25)
Low (IV or V) 25 (29) 23 (26.8) 22 (32.3) 31 (45.6)
general psychopathology.
In line with previous research (Fairburn et al., 1999; Karwautz
M = mean; SD = standard deviation. et al., 2001; Pike et al., 2008), circumstances associated with fam-

On the basis of an adaptation of the Graffar schedule. ily context, factors related to the role of parents or signicant

Eur. Eat. Disorders Rev. (2014) 2014 John Wiley & Sons, Ltd and Eating Disorders Association.
B. C. Machado et al. Risk Factors and Antecedent Life Events in Anorexia Nervosa

Table 2 Distribution of putative risk factors in the anorexia nervosa group (AN) matched for age and parental socioeconomic status to non-psychiatric (NC) and other
psychiatric disorder (PC) control groups using univariate conditional regression analyses

AN (n = 86) versus NC (n = 86) AN (n = 68) versus PC (n = 68)

Group, n (%) Group, n (%)

Risk factors AN NC p Odds ratio 95% CI AN PC p Odds ratio 95% CI

Personal vulnerability domain

Subdomain 1childhood characteristics
Negative self-evaluation 37 (43) 19 (22.1) .247 1.82 (.665.03) _ _ _ _ _
Shyness 39 (45.3) 23 (26.7) .862 .92 (.372.29) _ _ _ _ _
Perfectionism 59 (68.6) 33(38.4) .006 3.06 (1.376.86) 45 (66.2) 30 (44.1) .010 2.87 (1.286.42)
Self-consciousness about appearance 21 (24.4) 2 (2.3) .009 8.13 (1.6839.42) 14 (20.6) 5 (7.4) .058 3.26 (.9611.11)
Height 20 (23.3) 7 (8.1) .287 .56 (.191.63) 18 (26.5) 8 (11.8) .033 .23 (.6.89)
Subdomain 2premorbid psychiatric disorder _ _ _ _ _ _ _ _ _
Subdomain 3behavioural problems _ _ _ _ _ _ _ _ _
Subdomain 4family/parental psychiatric disorder (ever)
Depression 44 (51.2) 32 (37.2) .147 1.61 (.853.08) _ _ _ _ _
Obsessive-compulsive disorder 11 (12.8) 2 (2.3) .046 4.73 (1.0321.81) 10 (14.7) 1 (1.5) .028 10 (1.2878.12)
Parental alcoholism 11 (12.8) 4 (4.7) .090 .32 (.091.19) _ _ _ _ _
Environmental domain
Subdomain 1parental problems
Family dynamic/context
Low parental contact 30 (34.9) 14 (16.3) .052 3.26 (.9910.71) _ _ _ _ _
Separation from parents 18 (20.9) 10 (11.6) .986 1.01 (.254.05) 14 (20.6) 25 (36.8) .042 .37 (.15.96)
Family isolated 31 (36) 16 (18.6) .017 4.49 (1.3115.38) _ _ _ _ _
Parental arguments 29 (33.7) 18 (20.9) .348 2.23 (.4211.96) _ _ _ _ _
Parental arguments (subject involved) 17 (19.8) 9 (10.5) .380 .42 (.062.89) 12 (17.6) 23 (33.8) .124 .46 (1.207.12)
Arguments within the home 30 (34.9) 17 (19.8) .709 1.30 (.335.05) _ _ _ _ _
Unresolved/unaddressed family disagreements 45 (52.3) 9 (10.5) <.001 11.98 (3.4541.66) 35 (51.5) 23 (33.8) .018 2.92 (.171.24)
Negative self-evaluation compared with siblings 22 (25.6) 8 (9.3) .284 2.72 (.4416.93) 18 (26.5) 10 (14.7) .469 1.46 (.534.04)
Siblings rivalry 15 (17.4) 5 (5.8) .472 2.22 (.2519.55) 11 (16.2) 5 (7.4) .277 2.29 (.5110.17)
Family tension during meals 26 (30.2) 10 (11.6) .759 .72 (.095.90) _ _ _ _ _
Family tension during meals (related to food/eating) 12 (14) 2 (2.3) .230 .18 (.012.98) _ _ _ _ _
Parental relationship
Parental criticism 27 (31.4) 14 (16.3) .338 1.48 (.663.32) _ _ _ _ _
Parental underinvolvement 54 (62.8) (37 )43 .160 .60 (.301.22) _ _ _ _ _
Parental minimal affection 44 (51.2) 28 (32.6) .220 1.72 (.724.06) _ _ _ _ _
Excessive parental control _ _ _ _ _ 27 (39.7) 37 (54.4) .082 1.91 (.923.96)
Motherdaughter relationship
Maternal underinvolvement 24 (27.9) 15 (17.4) .249 .57 (.221.49) _ _ _ _ _
Maternal overinvolvement 9 (10.5) 1 (1.2) .062 .13 (.011.11) _ _ _ _ _
Maternal minimal affection 20 (23.3) 12 (14) .777 1.14 (.472.75) _ _ _ _ _
Maternal high expectations 42 (48.8) 31 (36) .535 1.26 (.612.61) 35 (51.5) 25 (36.8) .074 2 (.944.27)
Maternal criticism 21 (24.4) 9 (10.5) .168 2.06 (.745.75) _ _ _ _ _
Fatherdaughter relationship
Paternal underinvolvement 47 (54.7) 31 (36) .100 .58 (.311.11) _ _ _ _ _
Paternal minimal affection 38 (44.2) 27 (31.4) .351 1.43 (.683.01) _ _ _ _ _
Paternal high expectations _ _ _ _ _ 36 (52.9) 27 (39.7) .163 1.56 (.832.93)
Subdomain 2disruptive events
Parental death 2 (2.9) _ _ _ _ 2 (2.9) 9 (13.2) .101 .12 (.011.52)
Change of parent gure _ _ _ _ _ 5 (7.4) 24 (35.3) .008 .24 (.08.69)
Frequent house moves _ _ _ _ _ 42 (61.8) 52 (76.5) .335 .62 (.241.63)
Severe personal health problems 12 (14) 1 (1.2) .016 15.24 (1.65140.57) _ _ _ _ _
(weight/appearance changed)
Teasing (not about shape, weight, 52 (60.5) 25 (29.1) .003 3.30 (1.487.33) 39 (57.4) 28 (41.2) .019 2.91 (1.187.13)
eating or appearance)
Threatening teasing 19 (22.1) 8 (9.3) .238 .44 (.111.72) _ _ _ _ _
Subdomain 3family/parental psychiatric disorder
Family alcoholism 24 (27.9) 14 (16.3) .056 2.25 (.995.17) _ _ _ _ _
Parental alcoholism _ _ _ _ _ 9 (13.2) 18 (26.5) .058 2.5 (.976.44)

(Continues)

Eur. Eat. Disorders Rev. (2014) 2014 John Wiley & Sons, Ltd and Eating Disorders Association.
Risk Factors and Antecedent Life Events in Anorexia Nervosa B. C. Machado et al.

Table 2 (Continued)

AN (n = 86) versus NC (n = 86) AN (n = 68) versus PC (n = 68)

Group, n (%) Group, n (%)

Risk factors AN NC p Odds ratio 95% CI AN PC p Odds ratio 95% CI

Subdomain 4teasing and bullying _ _ _ _ _ _ _ _ _ _

Subdomain 5sexual, physical and psychological abuse
Sexual abuse 17 (19.8) 5 (5.8) .051 4.77 (.9922.94) _ _ _ _ _
Physical abuse 13 (15.1) 3 (3.5) .154 6.70 (.4991.80) _ _ _ _ _
Repeated and/or severe sexual or physical abuse 17 (19.8) 4 (4.7) .635 .62 (.094.49) 13 (19.1) 21 (30.9) .174 .62 (.311.24)
Psychological maltreatment 15 (17.4) 4 (4.7) .129 2.89 (.7311.28) _ _ _ _ _
Dieting vulnerability domain
Subdomain 1dieting risk
Family weight and eating concerns
Family member dieting for any reason _ _ _ _ _ 16 (23.5) 9 (13.2) .207 1.92 (.705.31)
Family member dieting for shape or weight 35 (40.7) 21 (24.4) .627 1.32 (.434.11) _ _ _ _ _
Parents dieting for shape or weight 19 (22.1) 4 (4.7) .640 .68 (.143.39) _ _ _ _ _
Critical comments by family about shape or weight 46 (53.5) 32 (37.2) .809 1.15 (.373.60) 41 (60.3) 31 (45.6) .955 1.02 (.472.22)
Parents underweight 10 (11.6) 1 (1.2) .176 .19 (.022.10) _ _ _ _ _
Family shape or weight concern 30 (34.9) 21 (24.4) .996 .99 (.313.24) 26 (38.2) 14 (20.6) .483 1.55 (.455.33)
Parents shape or weight concern 13 (15.1) 5 (5.8) .902 1.11 (.216.01) 11 (16.2) 4 (5.9) .333 .42 (.072.41)
Family history of eating disorders 14 (16.3) 6 (7) .578 1.49 (.366.13) 12 (17.6) 1 (1.5) .042 9.70 (1.0886.94)
Family overeating 16 (18.6) 8 (9.3) .059 3.93 (.9516.24) _ _ _ _ _
Family excessive preoccupation with appearance 14 (16.3) 7 (8.1) .246 2.38 (.5510.34) 12 (17.6) 2 (2.9) .292 2.41 (.4712.40)
Parents repeated comments about eating 48 (55.8) 26 (30.2) .012 .29 (.11.76) 41 (60.3) 25 (36.8) .128 .52 (.231.20)
Parents risk occupations (working with 20 (23.3) 11 (12.8) .462 1.49 (.514.36) _ _ _ _ _
food/food-related job)
Participants weight and eating concerns
Negative attitude towards parents shape and weight 15 (17.4) 1 (1.2) .006 36.66 (2.87468.52) 12 (17.6) 1 (1.5) .004 36.28 (3.0630.81)
Encouraged to diet by family member 15 (17.4) 6 (7) .774 1.23 (.295.22) _ _ _ _ _
Childhood underweight 11 (12.8) 19 (22.1) .938 1.05 (.303.63) _ _ _ _ _
Adolescent overweight 20 (23.3) 7 (8.1) .121 8.56 (.57128.78) 16 (23.5) 8 (11.8) .392 .57 (.162.05)
Negative consequences by childhood overweight 12 (14) 3 (3.5) .416 .40 (.053.60) _ _ _ _
Negative consequences by adolescent overweight 16 (18.6) 4 (4.7) .698 .57 (.049.32) _ _ _ _ _
Concern about feeling big 24 (27.9) 8 (9.3) .128 .28 (.051.45) _ _ _ _ _
Concern about feeling fat 47 (54.7) 17 (19.8) .008 .16 (.04.62) 38 (55.9) 15 (22.1) .005 .22 (.08.64)
Concern about sister being slimmer 14 (16.3) 4 (4.7) .418 4.10 (.14124.40) 12 (17.6) 3 (4.4) .573 .33 (.0115.70)
Concern about sister being more attractive 12 (14) 4 (4.7) .376 .21 (.016.50) 12 (17.6) 3 (4.4) .923 .82 (.0240.91)
Others weight and eating related behaviours
Teasing about shape, weight, eating or appearance 41 (47.7) 15 (17.4) <.001 .26 (.12.56) 30 (44.1) 19 (27.9) .040 .42 (.18.96)
Repeated comments by others about eating 15 (17.4) 6 (7) .320 1.68 (.614.64) _ _ _ _ _
Parents and participants obesity before index age
Parental obesity 38 (44.2) 26 (30.2) .618 1.30 (.473.59) _ _ _ _ _
Maternal overweight 27 (31.4) 17(19.8) .630 1.32 (.434.07) _ _ _ _ _
Childhood overweight 22 (25.6) 9 (10.5) .017 3.14 (1.259.34) 18 (26.5) 8 (11.8) .048 2.43 (1.015.86)
Subdomain 2obesity risk
Parental obesity (ever) 44 (51.2) 27 (31.4) .035 2.22 (1.064.64) _ _ _ _ _
Maternal overweight (ever) _ _ _ _ _ 25 (36.8) 17 (25) .222 1.64 (.743.61)
Childhood overweight 22 (25.6) 9 (10.5) .092 2.55 (.867.56) 18 (26.5) 8 (11.8) .168 2.02 (.745.47)
Adolescent overweight 20 (23.3) 7 (8.1) .154 2.20 (.746.53) 16 (23.5) 8 (11.8) .560 1.34 (.503.54)
Subdomain 3family/parental eating disorders
Family history of anorexia nervosa 23 (26.7) 8 (9.3) .008 3.14 (1.347.36) 21 (30.9) 3 (4.4) .002 10 (2.3442.78)
or bulimia nervosa (ever)
Additional risk factors
Age at menarche12 years 19 (27.9) _ 19 (27.9) 30 (44.1) .256 .61 (.261.42)
Negative feelings about menstruation 24 (27.9) 12 (14) .041 2.45 (1.045.77) 20 (29.4) 4 (5.9) .022 6.28 (1.3030.25)
Antecedent life events 81 (94.2) 61 (70.9) .036 4.54 (1.1018.70) 63 (92.6) 56 (82.4) .234 3.43 (.4526.14)
More than one antecedent life event 65 (75.6) 39 (45.3) .068 .42 (.161.07) 52 (76.5) 44 (64.7) .817 1.13 (.393.03)
Importance of religion in childhood 9 (10.5) 17 (19.8) .198 .49 (.161.45) 7 (10.3) 26 (38.2) .020 .32 (.12.83)

2
The signicance of the exposure (likelihood ratio statistic, ) and odds ratios with their signicance levels and 95% condence intervals (CI) are given for each factor. All exposures,
except those labelled ever, predate the onset of the eating disorder; _ indicates that risk factor data failed to meet relevant statistical assumptions for the analysis; bold for p .01 values.

Eur. Eat. Disorders Rev. (2014) 2014 John Wiley & Sons, Ltd and Eating Disorders Association.
B. C. Machado et al. Risk Factors and Antecedent Life Events in Anorexia Nervosa

Table 3 Overall level of exposure in each risk factor subdomain in the three groups

Anorexia nervosa subjects versus Anorexia nervosa subjects versus

non-psychiatric control group psychiatric control group
2 2
Domain/subdomains df p df p

Personal vulnerability domain

Subdomain 1childhood characteristics 34.32 5 <.001 17.89 3 <.001
Subdomain 2premorbid psychiatric disorder _ _ _ _ _ _
Subdomain 3behavioural problems 2.10 1 ns _ _ _
Subdomain 4family/parental psychiatric disorder (ever) 12.38 3 <.01 8.55 1 <.01
Environmental domain
Subdomain 1parental problems
Family dynamic/context 58.59 11 <.001 17.17 5 <.01
Parental relationship 10.56 3 <.05 3.18 1 <.10
Motherdaughter relationship 14.52 5 <.05 3.40 1 <.10
Fatherdaughter relationship 6.09 2 <.05 1.99 1 ns
Subdomain 2disruptive events 28.82 3 <.001 23.60 4 <.001
Subdomain 3family/parental psychiatric disorder 3.95 1 <.05 3.98 1 <.05
Subdomain 4teasing and bullying _ _ _ _ _ _
Subdomain 5sexual, physical and psychological abuse 16.98 4 <.01 1.90 1 ns
Dieting vulnerability domain
Subdomain 1dieting risk
Family weight and eating concerns 30.82 11 <.01 23.33 7 <.01
Participants weight and eating concerns 48.78 10 <.001 31.69 6 <.001
Others weight and eating related behaviours 18.35 3 <.001 4.61 1 <.05
Parents and participants obesity before index age 10.12 3 <.05 4.30 1 <.05
Subdomain 2obesity risk 15.98 3 <.01 6.38 3 <.10
Subdomain 3Family/parental eating disorders 8.15 1 <.01 17.09 1 <.001
Additional risk factors 28.80 4 <.001 25.77 5 <.001

2
The signicance of the exposure (likelihood ratio statistic, ) is given for each subdomain. All exposures, except those labelled ever, predate the onset of the eating disorder;
_ indicates that risk factor data failed to meet relevant statistical assumptions for the analysis; bold for p .01 values.

others were associated with increasing vulnerability for dieting,
and factors associated with the experience of disruptive events
emerged as risk factors for general psychopathology but not as
specic risk factors for AN. Our results support the nonspecic
nature of family factors in the aetiology of AN because they may
increase the risk for psychopathology development in general.
However, a family history of ED emerged as a specic risk factor,
which suggests a possible genetic vulnerability associated with
these disorders (Striegel-Moore and Bulik, 2007).
Our ndings further support the centrality of perfectionism as
a specic risk factor for AN, and are consistent with previous
research (Fairburn et al., 1999; Pike et al., 2008; Wade et al.,
2008). Perfectionism may play an important role in the develop-
ment of AN, especially when associated with shape and weight
concern (e.g. feeling fat and being critical of ones parents weight)
and a family history of ED (which might suggest a genetic vulnera-
bility). The results found in our study emphasize the role of
perfectionism as a more global characteristic of the individuals
functioning that should be considered along with a biological pre-
disposition for ED which, in turn, can be increased by a more
idiosyncratic concern about owns and parents shape and weight.
We believe that this spectrum of risk must be taken into account
when dening community high-risk groups beneting from
prevention programmes. We also consider that this idiosyncratic
concern about shape and weight is a relevant result in a society that
is focused on counteracting the adverse effects of the rapid growth
of obesity in children and adolescents. Public policies should be
aware about the emphasis given to shape and weight issues in pre-
vention campaigns for obesity considering the fact that feeling fat
with signicant concern is also a risk factor for AN development.
Our results did not support the relationship between negative
self-evaluation and AN like Fairburn et al. (1999) study did. Most
recently, Nicholls and Viners (2009) longitudinal study also showed
no association between low self-esteem and AN development;
instead, the authors found that high self-esteem seemed to be a
protective factor against AN. The relationship between negative
self-evaluation, low self-esteem and ED seems to be most relevant
in the development of BN.
Lastly, no specic life event emerged as a specic proximal
trigger for AN, contrary to previous research (Pike et al., 2008),
which had identied critical comments about weight, shape and/
or eating as such. Although the AN group showed greater expo-
sure to critical comments in the 12 months preceding the devel-
opment of the disorder when compared with the NC group, this
was not signicantly different from what the PC group reported
(at p < .01).
The current study has several limitations. The most important
one is inherent in retrospective case-control designs, namely,
potential biases associated with recall. Although we made every
effort to maximize accuracy of recall, bias is unavoidable. We
did not involve other informants such as relatives or signicant
others, and the methodology concerning family issues used was

Eur. Eat. Disorders Rev. (2014) 2014 John Wiley & Sons, Ltd and Eating Disorders Association.
 Table 4 Life events occurring within the year before onset of disordered eating in women with anorexia nervosa (AN) matched for age and parental socioeconomic status to non-psychiatric (NC) and other
psychiatric disorder (PC) control groups using univariate conditional regression analyses

AN (n = 86) versus NC (n = 86) AN (n = 68) versus PC (n = 68)

Group, n (%) Group, n (%)

Risk factors AN NC p Odds ratio 95% CI AN PC p Odds ratio 95% CI

Risk Factors and Antecedent Life Events in Anorexia Nervosa

Life events 81 (94.2) 61 (70.9) .116 3.61 (.7317.95) 63 (92.6) 56 (82.4) .176 3.54 (.5722.06)
One or more life events 65 (75.6) 39 (45.3) .202 2.45 (.629.72) 52 (76.5) 44 (64.7) .403 1.61 (.534.89)
Major house relocation 15 (17.4) 8 (9.3) .202 2.34 (.638.59) 12 (17.6) 16 (23.5) _ _ _
Relocation to a different country 2 (2.3) 2 (2.3) _ _ _ 1 (1.5) 0 _ _ _
Signicant episode of physical illness 15 (17.4) 7 (8.1) _ _ _ 14 (20.6) 13 (19.1) _ _ _
Pregnancy 1 (1.2) 1 (1.2) _ _ _ 0 1 (1.5) _ _ _
Bereavement (close relative/friend/partner) 19 (22.1) 16 (18.6) _ _ _ 14 (20.6) 20 (29.4) _ _ _
Major episode of illness (close relative/friend/partner) 23 (26.7) 24 (27.9) .303 2.53 (.4314.78) 18 (26.5) 23 (33.8) _ _ _
Change in family structure (member leaving or joining) 11 (12.8) 8 (9.3) _ _ _ 9 (13.2) 12 (17.6) _ _ _
Beginning of relationship boyfriend/partner 27 (31.4) 10 (11.6) .060 3.93 (.9416.42) 19 (27.9) 8 (11.8) .053 2.86 (.988.33)
End of relationship boyfriend/partner 16 (18.6) 7 (8.1) .707 1.33 (.315.76) 12 (17.6) 6 (8.8) _ _ _
Sexual abuse 4 (4.7) 0 _ _ _ 2 (2.9) 1 (1.5) _ _ _
Physical abuse 7 (8.1) 1 (1.2) _ _ _ 6 (8.8) 3 (4.4) _ _ _
Major stress from school or work 31 (36) 11 (12.8) .08 3.59 (.8615.05) 24 (35.3) 20 (29.4) _ _ _
Major stress from other source 38 (44.2) 13 (15.1) .182 2.55 (.6410.12) 30 (44.1) 23 (33.8) _ _ _
Critical comments about weight, shape or eating 42 (48.8) 11 (12.8) <.001 17.75 (3.4391.77) 35 (51.5) 18 (26.5) .024 2.58 (1.325.88)
Anything else signicant 18 (20.9) 9 (10.5) .873 1.11 (.314.04) 16 (23.5) 10 (14.7) _ _ _

2
The signicance of the exposure (likelihood ratio statistic, ) and odds ratios with their signicance levels and 95% condence intervals (CI) are given for each factor. All exposures, except those labelled ever,
predate the onset of the eating disorder; _ indicates that risk factor data failed to meet relevant statistical assumptions for the analysis; bold for p .01 values.

Eur. Eat. Disorders Rev. (2014) 2014 John Wiley & Sons, Ltd and Eating Disorders Association.
B. C. Machado et al.
B. C. Machado et al. Risk Factors and Antecedent Life Events in Anorexia Nervosa

based on family history reported by the participants who were of a family history of ED. These characteristics should be considered
being evaluated (in contrast to a family study design; cf. Jacobi to target high-risk groups and improve the effectiveness of tailored
et al., 2004). We were also aware about the fact that some of the prevention programmes.
participants of the control group could already have a psychiatric
disorder in the period before the age of onset of the ED case. We Acknowledgements
try to overcome these limitations having all the interviews being
made by clinical psychologists with current clinical practice in This research was partially supported by a Portuguese Fundao
the evaluation and intervention on mental disorders. para a Cincia e a Tecnologia/Foundation for Science and Technol-
However, the convergence of our ndings with those previous ogy research grant to the last author (PTDC/PSI-PCL/099981/
reports on the centrality of perfectionism as a specic risk factor 2008), and a doctoral grant to the rst author (FCTSFRH/BD/
for AN (Fairburn et al., 1999; Pike et al., 2008; Wade et al., 2008) 22038/2005). The authors acknowledge Christopher G. Fairburn,
moves the eld forward, and highlights a potential risk factor to MD, of the Department of Psychiatry at Oxford University (UK)
be considered in developmental models of the disorder, especially for providing initial consultation and training and Helen A. Doll,
in the presence of concern about shape and weight and the presence PhD, for helping in the initial data analysis.

REFERENCES
American Psychiatry Association (2004). Diagnostic and Statistical Manual
of Mental Disorders, (4th edition-TR). Washington, DC.: Author.
Arcelus, J., Mitchell, A. J., Wales, J. & Nielson, S. (2011). Mortality
rates in patients with anorexia nervosa and other eating disor-
ders: A meta-analysis of 36 studies. Archives of General Psychiatry,
68(7), 724731.
Attia, E. & Walsh, B. T. (2007). Anorexia nervosa. American Journal
of Psychiatry, 164(12), 18051810.
Bulik, C. M., Landt, M. C., van Furth, E. F. & Sullivan, P. F. (2007). The
genetics of anorexia nervosa. Annual Review of Nutrition, 27, 263275.
Bulik, C. M., Sullivan, P. F., Tozzi, F., Furberg, H., Lichtenstein, P. & Pedersen,
N. L. (2006). Prevalence, heritability, and prospective risk factors for
anorexia nervosa. Archives of General Psychiatry, 63, 305312.
Collier, D. A. & Treasure, J. L. (2004). The aetiology of eating disor-
ders. British Journal of Psychiatry, 185, 363365.
Fairburn, C. G. & Beglin, S. J. (1994). Assessment of eating disorders:
Interview or self-report questionnaire? International Journal of
Eating Disorders, 4, 363370.
Fairburn, C. G. & Cooper, Z. (1993). The eating disorder examina-
tion (12th edition). In C. G. Fairburn & G. T. Wilson (Eds.).
Binge eating: Nature, assessment and treatment (317360).
New York: Guilford Press.
Fairburn, C. G., Cooper, Z., Doll, H. A. & Welch, S. L. (1999). Risk
factors for anorexia nervosa: Three integrated case-control com-
parisons. Archives of General Psychiatry, 56, 468476.
Fairburn, C. G., Welch, S. L., Doll, H. A., Davies, B. A. & OConnor,
M. E. (1997). Risk factors for bulimia nervosa: A community
based case-control study. Archives of General Psychiatry, 54,
509517.
First, M. B., Sptizer, R. L., Williams, J. B. & Gibbon, M. (1995).
Structured Clinical Interview for DSM-IV (SCID). Washington,
DC.: American Psychiatric Association.
Graffar, M. (1956). Une mthode de classication sociale
dchantillons de population. Courrier, 6, 445459.
Hartmann, A. S., Czaja, J., Rief, W. & Hilbert, A. (2012). Psychosocial
risk factors of loss of control eating in primary school children:
A retrospective case-control study. International Journal of Eating
Disorders, 45, 751758.
Hoek, H. W. & Hoeken, D. V. (2003). Review of the prevalence and
incidence of eating disorders. International Journal of Eating Dis-
orders, 34, 383396.
Jacobi, C., Hayward, C., de Zwaan, M., Kraemer, H. C. & Agras, W.
S. (2004). Coming to terms with risk factors for eating disorders:
Application of risk terminology and suggestions for a general tax-
onomy. Psychological Bulletin, 130(1), 1965.
Karwautz, A., Rabe-Heskeht, S., Hu, X., Zaho, J., Sham, P., Collier,
D. A.et al. (2001). Individual-specic risk factors for anorexia
nervosa: A pilot study using discordant sister-pair design. Psycho-
logical Medicine, 31, 317329.
Karwautz, A. F., Wagner, G., Waldherr, K., Nader, I. W., Fernandez-
Aranda, F., Estivill, X., Holliday, J., Collier, D. A. & Treasure, J. L.
(2011). Gene-environment interaction in anorexia nervosa:
Relevance of non-shared environment and the serotonin trans-
porter gene. Molecular Psychiatry, 16, 590592.
Keel, P. K. & Forney, K. J. (2013). Psychosocial risk factors for eating
disorders. International Journal of Eating Disorders, 46, 433439.
Nicholls, D. E. & Viner, R. M. (2009). Childhood risk factors for life-
time anorexia nervosa by age 30 years in a national birth cohort.
Journal of American Academy of Child and Adolescent Psychiatry,
48(8), 791799
Pike, K. M., Hilbert, A., Wiley, D. E., Fairburn, C. G., Dohm, F. A.,
Walsh, B. T.et al. (2008). Toward an understanding of risk fac-
tors for anorexia nervosa: A case-control study. Psychological
Medicine, 38, 14431453.
Stevens, S. S. (1946). On the theory of scales of measurement. Sci-
ence, 103(2684), 677680.
Stice, E. (2002). Risk and maintenance factors for eating pathology: A
meta-analytic review. Psychological Bulletin, 128(5), 825848.
Stice, E., Ng, J. & Shaw, H. (2010). Risk factors and prodromal
eating :pathology. Journal of Child Psychology and Psychiatry,
51(4), 518525.
Striegel-Moore, R. H. & Bulik, C. M. (2007). Risk factors for eating
disorders. American Psychologist, 62(3), 181198.
Treasure J., Claudino, A. M. & Zucker, N. (2010). Eating disorders.
The Lancet, 375, 583593.
Wade, T. D., Tiggemann, M., Bulik, C. M., Fairburn, C. G., FMedSci,
Wray, N. R. et al. (2008). Shared temperament risk factors for
anorexia nervosa: A twin study. Psychosomatic Medicine, 70,
239244.

Eur. Eat. Disorders Rev. (2014) 2014 John Wiley & Sons, Ltd and Eating Disorders Association.