# Evidence-based assessment/Anorexia nervosa (assessment portfolio)/extended version

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## What is a "portfolio"?

For background information on what assessment portfolios are, click the link in the heading above. Does this page feel like too much information? Click here for the condensed version.

## Preparation phase
### Diagnostic criteria for anorexia nervosa

   ICD-11 Criteria
   Anorexia Nervosa is characterized by significantly low body weight, which is less than minimal normal/expected weight for the individual’s height, sex, age and developmental stage (body mass index (BMI) less than 18.5 kg/m2 in adults and BMI-for-age under fifth percentile in children and adolescents) that is not due to another health condition or to the unavailability of food. Low body weight is accompanied by a persistent pattern of behaviors to prevent restoration of normal weight, which may include behaviors aimed at reducing energy intake (restricted eating), purging behaviors (e.g., self-induced vomiting, misuse of laxatives), and behaviors aimed at increasing energy expenditure (e.g., excessive exercise), typically associated with a fear of weight gain. Low body weight or shape is central to the person's self-evaluation or is inaccurately perceived to be normal or even excessive.
   Changes in DSM-5
   * The diagnostic criteria for anorexia nervosa changed slightly from DSM-IV to DSM-5. Summaries are available here and here.

### Base rates of anorexia nervosa in different populations and clinical settings

This section describes the demographic setting of the population(s) sampled, base rates of diagnosis such as prevalence rates, country/region sampled, and the diagnostic method that was used. Using this information, clinicians will be able to anchor the rate of adolescent depression that they are likely to see in their clinical practice.
* To see prevalence rates across multiple disorders, click here.
| Setting (Reference) | Base Rate | Demography | Diagnostic Method |
| Non-clinical: Population-based (NCS-R) | .9% Female, .3% Male | Nationally representative US sample of adults | World Health Organization-Clinical International Diagnostic Interview (WHO-CIDI) |
| Non-clinical: Population-based (NCS-A) | .3% Female, .3% Male | Nationally representative US sample of adolescents | WHO-CIDI |
| Non-clinical: US Population-based prevalence (Adolescent Brain Cognitive Development (ABCD) study | 0.1%, no gender differences | Nationally representative US sample of 9- and 10-year old children | DSM-5 using Kiddie Schedule for Affective Disorders and Schizophrenia (KSADS) |
| Non-clinical: Latinos in US | .12% Female, .03% Male | Latino Households in the US | WHO-CIDI |
| Non-clinical: African Americans and Caribbean Blacks in the US (NSAL) | .14% Female, .2% Male | National probability sample of adult and adolescent African Americans and Caribbean Blacks | WHO-CIDI |
| Non-clinical: National Latino and Asian American Study (NLAAS) | .12% Female, .05% Male | Asian American adults in US households | WHO-CIDI |
| Non-clinical; college students | .0% | US African American college females | Eating Disorder Diagnostic Questionnaire (EDD-Q) |
| Non-clinical; Adolescents | .8% | US Female Adolescents | Eating Disorder Diagnosis Interview (EDDI) |
| Non-clinical; student-athletes | .0% | US Division-I Varsity Student Athletes | Eating Disorder Inventory-2 (EDI-2) |
| Non-clinical; Military | 1.1% | Active duty females in US Army, Navy, Airforce, and Marines | EDI-2 |
| Non-clinical; Commonwealth of Virginia Mid-Atlantic Twin Registry (MATR) | 1.62% (narrow), 3.70% (broad) | US Caucasian female same-sex twins | Structured Clinical Interview for DSM Disorders (SCID) |
| Non-clinical; Health Omnibus Survey (HOS) | .46% (3 months; combined) | South Australian older adolescents and adults | Eating Disorder Examination (EDE) |
| Military | .04% (combined) | US Military | ICD codes from electronic records |
| Non-clinical; Military | .02% (7 years) Female, 0.0% (7 years) Males | US Military Academy cadets | Eating Attitudes Test- 26 items (EAT-26) |
| Non-clinical; Military | 1.1% (current & past) Female | US Navy female nurses | DSM-III |
| Non-clinical; Military | .04% Female, .005% Males | US veterans | ICD-9-CM |
| Non-clinical; Military | 2.5% Males | Active duty males in US Navy | N/A |
| Clinical; Collaborative Study on the Genetics of Alcoholism (COGA) | 1.41% (lifetime) Female, .00% (lifetime) Male | US alcohol-dependent adults from San Diego, St. Lois, Iowa City, Farmington, New York, & Indianapolis | SSAGA |
| Non-clinical; healthcare members | .0269% (current) | Healthcare provider records | |
| Non-clinical; high school students | . 00% (point), .45% (lifetime) Female .00% (point), .00% (lifetime) Males | US high school students in west central Oregon | DSM-III-R$_4$ |
| Clinical; substance users | .4% (lifetime), .3% (current) Female .4% (lifetime), .3% (current) Males | Canadian treatment-seeking substance users | DIS$_9$ |
| Europe ||||
| Non-clinical; adolescents | .3% Female | Adolescent females residing in Navarra, Spain | EAT-40$_3$ |
| Non-clinical; adolescents | .7% (lifetime) Female, .2% Male | Adolescents in secondary schools in Sør-Trøndelag, County in Norway | SEDs$_{10}$ |
| Non-clinical; adolescents | .7% (point; age 15), 1.8% (lifetime, age 15), .00% (point, age 18), 2.6% (lifetime, age 18), .9% (3 years) Female .00% (point & lifetime) Males | Adolescents in a comprehensive school in Ostrobothnia district in Finland | RAB-T$_{11}$ & RAB-R$_{12}$ |
| Australia ||||
| Non-clinical; adolescents | .00% (full), 1.8% (partial) Female | Adolescent females residing in Victoria, Australia | BET$_{13}$ |
| Central & South America ||||
| Non-clinical; college students | .00% Female | Mexican first & second year college females | EAT-40$_3$ |
| East Asia ||||
| Clinical; eating disorder patients | .53% Female | Adolescent and adult Japanese patients at a university hospital | DSM-III-R$_4$ |
| Non-clinical; Korean Epidemiologic Catchment Area (KECA) Study | .1% (lifetime), .1% (12 months) Female .2% (lifetime), .00% (12 months) Males | Korean adults | K-CIDI$_{15}$ 2.1 |
| Centers participating in the Collaborative Study on the Genetics of Alcoholism in San Diego; St. Louis; Iowa City; Farmington, CN; New York; & Indianapolis | 1.41% Females | Alcohol-dependent adults | Semi-Structured Assessment for the Genetics of Alcoholism; criteria based on DSM-III-R |

## Prediction phase
### Psychometric properties of screening instruments for anorexia nervosa

The following section contains a list of screening and diagnostic instruments for anorexia nerova. The section includes administration information, psychometric data, and PDFs or links to the screenings.
* Screenings are used as part of the prediction phase of assessment; for more information on interpretation of this data, or how screenings fit in to the assessment process, click here.
* For a list of more broadly reaching screening instruments, click here.
| Measure | Format (Reporter) | Administration/ Completion Time | Inter-rater reliability | Test-retest reliability | Construct validity | Content validity | Highly recommended |
| Structured Clinical Interview Diagnosis for DSM-IV (SCID-IV) Module H SCID-IV (for purchase) Wiki Page | Interview (Patient) | | G | L | A | E | X |
| Eating Disorder Examination (EDE) OSF Wiki Page | Interview (Patient) | 45min-1.25hrs | E | A | A | E | X |
| EDE-Q (Eating Disorder Examination Questionnaire) OSF Wiki Page Assessment Center Online Version | Questionnaire (Patient) | 15-20 min | NA | L | U | E | |
| EDDS (Eating Disorder Diagnosis Scale) OSF Wiki Page | Questionnaire (Patient) | 10-15 min | NA | A | A | G | X |
Note: L = Less than adequate; A = Adequate; G = Good; E = Excellent; U = Unavailable; NA = Not applicable

### Likelihood ratios and AUCs of screening instruments for anorexia nervosa

* For a list of the likelihood ratios for more broadly reaching screening instruments, click here.
| Screening Measure (Primary Reference) | AUC | DiLR+ (Score) | DiLR- (Score) | Clinical Generalizability |
| Biological & Physical Measures | Biological & Physical Measures | Biological & Physical Measures | Biological & Physical Measures | Biological & Physical Measures |
| Serum leptin level | 0.984 (N=139) | 14.72 (<2.31) | 0.10 (2.31+) | Adolescent and adult patients in the acute phase of AN according to the DSM-IV and no AN pretreatment versus healthy lean female volunteer university students. |
| Serum leptin standard deviation score (SDS) | 0.939 (N=139) | 5.89 (<-0.45) | 0.09 (-0.45+) | Adolescent and adult patients in the acute phase of AN according to the DSM-IV and no AN pretreatment versus healthy lean female volunteer university students. |
| Body Mass Index (BMI) | 0.936 (N=139) | 5.89 (<17.10) | 0.11 (17.10+) | Adolescent and adult patients in the acute phase of AN according to the DSM-IV and no AN pretreatment versus healthy lean female volunteer university students. |
| REDS-C$_1$ | REDS-C$_1$ | REDS-C$_1$ | REDS-C$_1$ | REDS-C$_1$ |
| REDS-C | 0.658 (N=333), 0.624 (N=236, > 13 years old), 0.772 (N=97, ≤ 13 years old) | -- | -- | Children and adolescents (8-18 years old) at a clinic being treated for eating and weight concerns. Eating disorders were not separated. |
| EDI$_2$ | EDI$_2$ | EDI$_2$ | EDI$_2$ | EDI$_2$ |
| EDI-2 | 0.556 (N=77) | -- | -- | Children and adolescents (10-18 years old) at a clinic being treated for eating and weight concerns. Eating disorders were not separated. |
| EDI-2 - Drive for Thinness Sub-scale | 0.97 (N=92) | 29.39 (14+) | 0.274 (DT≤14) | Italian individuals with a DSM-IV-TR eating disorder versus individuals at risk for eating disorders. Eating disorders were not separated. |
| EDI-3 - Drive for Thinness Subscale (Garner, 2004) Lehmann et al., 2013 | .903 (N=1298) | -- | -- | |
| EDI-3 - Eating Disorder Risk Composite(EDRC) (Garner, 2004) | 0.942 (N=92) | 52.08 (EDRC 75+, adults; 90+ adolescents) | 0.379 (EDRC≤75, adults; ≤90 adolescents) | Italian individuals with a DSM-IV-TR eating disorder versus individuals at risk for eating disorders. Eating disorders were not separated. |
| EDI-3 - Interoceptive Deficits Subscale(Garner, 2004) | .911 (N=2561) | 4.0 (9+) | -- | Danish females with a DSM-IV eating disorder diagnosis recruited from an eating disorder center versus non-clinical control individuals from the Danish Civil Registration system. |
| EDI-3 - Interoceptive Deficits Subscale (Garner, 2004) Lehmann et al., 2013 | .901 (N=1298) | -- | -- | Dutch patients recruited from eating disorder specialized clinics versus undergraduate female psychology students from a Dutch university. Eating disorders were not separated. |
| EDI-3 - Asceticism Subscale (Garner, 2004) | .886 (N=2561) | 6.5 (9+) | -- | Danish females with a DSM-IV eating disorder diagnosis recruited from an eating disorder center versus non-clinical control individuals from the Danish Civil Registration system. |
| EDI-3 - Asceticism Subscale (Garner, 2004) Lehmann et al., 2013 | .902 (N=1298) | -- | -- | Dutch patients recruited from eating disorder specialized clinics versus undergraduate female psychology students from a Dutch university. Eating disorders were not separated. |
| EDI-3 - Low Self-Esteem Subscale (Garner, 2004) | .884 (N=2561) | 5.8 (10+) | -- | Danish females with a DSM-IV eating disorder diagnosis recruited fm an eating disorder center versus non-clinical control individuals from the Danish Civil Registration system. |
| EDI-3 - Low Self-Esteem Subscale (Garner, 2004) Lehmann et al., 2013 | .906 (N=1298) | -- | -- | Dutch patients recruited from eating disorder specialized clinics versus undergraduate female psychology students from a Dutch university. Eating disorders were not separated. |
| EDI-3 - Personal Alienation Subscale (Garner, 2004) | .88 (N=2561) | -- | -- | Danish females with a DSM-IV eating disorder diagnosis recruited from an eating disorder center versus non-clinical control individuals from the Danish Civil Registration system. |
| EDI-3 - Personal Alienation Subscale (Garner, 2004) Lehmann et al., 2013 | .899 (N=1298) | -- | -- | Dutch patients recruited from eating disorder specialized clinics versus undergraduate female psychology students from a Dutch university. Eating disorders were not separated. |
| EDI-3 - Emotional Dysregulation Subscale (Garner, 2004) | .81 (N=2561) | -- | -- | Danish females with a DSM-IV eating disorder diagnosis recruited from an eating disorder center versus non-clinical control individuals from the Danish Civil Registration system. |
| EDI-3 - Emotional Dysregulation Subscale (Garner, 2004) Lehmann et al., 2013 | .779 (N=1298) | -- | -- | Dutch patients recruited from eating disorder specialized clinics versus undergraduate female psychology students from a Dutch university. Eating disorders were not separated. |
| EDI-3 - Interpersonal Alienation Subscale(Garner, 2004) | .79 (N=2561) | -- | -- | Danish females with a DSM-IV eating disorder diagnosis recruited from an eating disorder center versus non-clinical control individuals from the Danish Civil Registration system. |
| EDI-3 - Interpersonal Alienation Subscale (Garner, 2004) Lehmann et al., 2013 | .743 (N=1298) | -- | -- | Dutch patients recruited from eating disorder specialized clinics versus undergraduate female psychology students from a Dutch university. Eating disorders were not separated. |
| EDI-3 - Perfectionism Subscale (Garner, 2004) | .79 (N=2561) | -- | -- | Danish females with a DSM-IV eating disorder diagnosis recruited from an eating disorder center versus non-clinical control individuals from the Danish Civil Registration system. |
| EDI-3 - Perfectionism Subscale (Garner, 2004) Lehmann et al., 2013 | .768 (N=1298) | -- | -- | Dutch patients recruited from eating disorder specialized clinics versus undergraduate female psychology students from a Dutch university. Eating disorders were not separated. |
| EDI-3 - Maturity Fears Subscale (Garner, 2004) | .77 (N=2561) | -- | -- | Danish females with a DSM-IV eating disorder diagnosis recruited from an eating disorder center versus non-clinical control individuals from the Danish Civil Registration system. |
| EDI-3 - Maturity Fears Subscale (Garner, 2004) Lehmann et al., 2013 | .678 (N=1298) | -- | -- | Dutch patients recruited from eating disorder specialized clinics versus undergraduate female psychology students from a Dutch university. Eating disorders were not separated. |
| EDI-3 - Bulimia Subscale (Garner, 2004) | .76 (N=2561) | -- | -- | Danish females with a DSM-IV eating disorder diagnosis recruited from an eating disorder center versus non-clinical control individuals from the Danish Civil Registration system. |
| EDI-3 - Bulimia Subscale (Garner, 2004) Lehmann et al., 2013 | .776 (N=1298) | -- | -- | Dutch patients recruited from eating disorder specialized clinics versus undergraduate female psychology students from a Dutch university. Eating disorders were not separated. |
| EDI-3 - Interpersonal Insecurity Subscale(Garner, 2004) | .76 (N=2561) | -- | -- | Danish females with a DSM-IV eating disorder diagnosis recruited from an eating disorder center versus non-clinical control individuals from the Danish Civil Registration system. |
| EDI-3 - Interpersonal Insecurity Subscale (Garner, 2004) Lehmann et al., 2013 | .697 (N=1298) | -- | -- | Dutch patients recruited from eating disorder specialized clinics versus undergraduate female psychology students from a Dutch university. Eating disorders were not separated. |
| EDI-3 - Body Dissatisfaction Subscale (Garner, 2004) | .722 (N=2561) | 1.7 (15+) | -- | Danish females with a DSM-IV eating disorder diagnosis recruited from an eating disorder center versus non-clinical control individuals from the Danish Civil Registration system. |
| EDI-3 - Body Dissatisfaction Subscale (Garner, 2004) Lehmann et al., 2013 | .849 (N=1298) | -- | -- | Dutch patients recruited from eating disorder specialized clinics versus undergraduate female psychology students from a Dutch university. Eating disorders were not separated. |
| EAT$_3$ | EAT$_3$ | EAT$_3$ | EAT$_3$ | EAT$_3$ |
| EAT-26 | .90 (N=129) | 12.83 (20+) | .24 (<20) | Low-moderate: College women with no eating disorder versus college women with a DSM-IV eating disorder. Eating disorders were not separated. |
| EDE-Q$_4$ | EDE-Q$_4$ | EDE-Q$_4$ | EDE-Q$_4$ | EDE-Q$_4$ |
| EDE-Q | .96 (N=1170) | -- | -- | Moderate: Dutch treatment-seeking females meeting DSM-IV criteria for an eating disorder versus female adult general population sample recruited through advertisements and personal contacts. Eating disorders were not separated. |
| EDE-Q | -- | 6.57 (2.3+) | 0.09 (<2.3) | Moderate: “Clinically significant eating disorder” from a community sample versus female adultsindividuals without “clinically significant eating disorder” from same sample. Eating disorders were not separated. |
| EDE-Q | 0.89 (N=2465) | -- | -- | Norwegian adult females with an eating disorder recruited from eating disorder specialist centers versus controls determined using the DSM-IV. |
| EDQ-O$_5$ | EDQ-O$_5$ | EDQ-O$_5$ | EDQ-O$_5$ | EDQ-O$_5$ |
| EDQ-Q | 0.72 (N=134) | 1.00 (all criteria met) | 0.92 (≥1 criteria not met) | Dutch adults recruited from an eating disorder specialist center determined using the DSM-IV-TR. |

### Interpreting anorexia nervosa screening measure scores

* For information on interpreting screening measure scores, click here.
* Also see the page on likelihood ratios in diagnostic testing for more information.

## Prescription phase
### Gold standard diagnostic interviews

* For a list of broad reaching diagnostic interviews sortable by disorder with PDFs (if applicable), click here.

### Recommended diagnostic interviews for anorexia nervosa

Diagnostic instruments for anorexia nervosa :
| Measure | Format (Reporter) | Age Range | Administration/ Completion Time | Interrater Reliability | Test-Retest Reliability | Construct Validity | Content Validity | Highly Recommended |
| Development and Well-Being Assessment (DAWBA) | Structured; child/adolescent and parent versions | 11-18 | 10-20 minutes for the eating disorder module | | | | | |
| Children's Eating Disorder Examination- Child (ChEDE) | Semistructured; child version | 8-16 | 45-75 minutes; mean 1 hour | E | | | | |
| Eating Disorder Examination (EDE) | Semistructured; adolescent version | 16+ | 45-75 minutes | E | A | A | E | X |
| Pica, ARFID, and Rumination Disorder Interview | Semistructured; multi-informant and different versions | 2-22 | Mean of 39 minutes | G (ARFID diagnosis) | | | | |
Note: L = Less than adequate; A = Adequate; G = Good; E = Excellent; U = Unavailable; NA = Not applicable

### Severity interviews for anorexia nervosa

| Measure | Format (Reporter) | Age Range | Administration/ Completion Time | Free and Accessible Measures |
| Placeholder example (CDRS-R) | Structured Interview | 6-12 | 15-20 minutes | Link to purchase CDRS-R PDF (excerpt) |
Note: L = Less than adequate; A = Adequate; G = Good; E = Excellent; U = Unavailable; NA = Not applicable

## Process phase

The following section contains a brief overview of treatment options for anorexia nervosa and a list of process and outcome measures for anorexia nervosa. The section includes benchmarks based on published norms for several outcome and severity measures, as well as information about commonly used process measures. Process and outcome measures are used as part of the process phase of assessment. For more information on the differences between process and outcome measures, see the page on the process phase of assessment.

### Process measures

Body weight is commonly monitored by clinicians throughout the AN treatment process as helping individuals regain and maintain a healthy weight is a primary treatment goal for AN. Many treatment centers have policies prohibiting patients from seeing their weight.
Motivational Stages of Change may be used to monitor individuals’ readiness to take action against eating disorder behaviors. It has demonstrated predictive validity in a sample of female adolescents attending eating disorder treatment groups. See Appendix E.

### Outcome and severity measures

This table includes clinically significant benchmarks for anorexia nervosa specific outcome measures
* Information on how to interpret this table can be found here.
* Additionally, these vignettes might be helpful resources for understanding appropriate adaptation of outcome measures in practice.
* For clinically significant change benchmarks for the CBCL, YSR, and TRF total, externalizing, internalizing, and attention benchmarks, see here.
Clinically significant change benchmarks with common instruments for anorexia nervosa :
| Benchmarks Based on Published Norms ||||||||
| Measure | Subscale | Cut-off scores | Cut-off scores | Cut-off scores | Critical Change (unstandardized scores) | Critical Change (unstandardized scores) | Critical Change (unstandardized scores) |
| Measure | Subscale | A | B | C | 95% | 90% | SE$_{difference}$ |
| EDE-Q | Global | 1.4 | 3.2 | 2.3 | .7 | .6 | .3 |
| EDE-Q | Restraint | (-.3) | 3.6 | 1.8 | 1.5 | 1.2 | .8 |
| EDE-Q | Eating Concern | .1 | 2.0 | 1.2 | 1.1 | .9 | .6 |
| EDE-Q | Weight Concern | 1.5 | 3.9 | 2.6 | 1.0 | .9 | .5 |
| EDE-Q | Shape Concern | 2.1 | 4.8 | 3.2 | .9 | .7 | .4 |
| EDE | Global | 1.7 | 2.3 | 1.9 | 1.9 | 1.6 | 1.0 |
| EDE | Restraint | .3 | 3.3 | 1.9 | 1.8 | 1.5 | .9 |
| EDE | Eating Concern | (-.5) | .9 | .5 | .8 | .7 | .4 |
| EDE | Weight Concern | 2.0 | 2.8 | 2.4 | 1.3 | 1.1 | .7 |
| EDE | Shape Concern | 2.0 | 3.2 | 2.6 | 1.2 | 1.0 | .6 |
| EAT-26 | Total | 6.5 | 19.6 | 15.0 | 7.9 | 6.7 | 4.0 |
Note: “A” = Away from the clinical range, “B” = Back into the nonclinical range, “C” = Closer to the nonclinical than clinical mean.
Search terms: [Anorexia Nervosa OR eating disorder] AND [validity OR clinical significance] in Google Scholar

### Treatment

* Please refer to the page on anorexia nervosa for more information on available treatment or go to the Effective Child Therapy page for Eating & Body Image Problems for a curated resource on effective treatments for anorexia nervosa.

## External resources

* ICD-10 diagnostic criteria
* Find-a-Therapist
** This is a curated list of find-a-therapist websites where you can find a provider
* NIMH: Eating Disorders--About More Than Food and Eating Disorders
** These NIMH website posts provide more information on anorexia nervosa
* John's Hopkins Resource (guide about anorexia nervosa, treatment, and more)
* OMIM (Online Mendelian Inheritance in Man)
** Anorexia nervosa
* Effective Child Therapy page for anorexia nervosa
** Effective Child Therapy is website sponsored by Division 53 of the American Psychological Association (APA), or The Society of Clinical Child and Adolescent Psychology (SCCAP), in collaboration with the Association for Behavioral and Cognitive Therapies (ABCT). Use for information on symptoms and available treatments.