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

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## What is a "portfolio"?

For background information on what assessment portfolios are, click the link in the heading above. Want even 'more' information about this topic? There's an extended version of this page here.

## 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.
| Demography | Setting (Reference) | Base Rate | Diagnostic Method |
| Nationally representative US sample of adults | Non-clinical: Population-based (NCS-R) | .9% Female, .3% Male | World Health Organization-Clinical International Diagnostic Interview (WHO-CIDI) |
| Nationally representative US sample of adolescents | Non-clinical: Population-based (NCS-A) | .3% Female, .3% Male | WHO-CIDI |
| Nationally representative US sample of 9- and 10-year old children | Non-clinical: US Population-based prevalence (Adolescent Brain Cognitive Development (ABCD) study | 0.1%, no sex differences | DSM-5 using Kiddie Schedule for Affective Disorders and Schizophrenia (KSADS) |
| Latino Households in the US | Non-clinical: Latinos in US | .12% Female, .03% Male | WHO-CIDI |
| National probability sample of adult and adolescent African Americans and Caribbean Black people | Non-clinical: African Americans and Caribbean Black people in the US (NSAL) | .14% Female, .2% Male | WHO-CIDI |
| Asian American adults in US households | Non-clinical: National Latino and Asian American Study (NLAAS) | .12% Female, .05% Male | WHO-CIDI |
| US African American college females | Non-clinical; college students | .0% | Eating Disorder Diagnostic Questionnaire (EDD-Q) |
| US Female Adolescents | Non-clinical; Adolescents | .8% | Eating Disorder Diagnosis Interview (EDDI) |
| US Division-I Varsity Student Athletes | Non-clinical; student-athletes | .0% | Eating Disorder Inventory-2 (EDI-2) |
| Active duty females in US Army, Navy, Airforce, and Marines | Non-clinical; Military | 1.1% | EDI-2 |
| US Caucasian female same-sex twins | Non-clinical; Commonwealth of Virginia Mid-Atlantic Twin Registry (MATR) | 1.62% (narrow), 3.70% (broad) | Structured Clinical Interview for DSM Disorders (SCID) |
| South Australian older adolescents and adults | Non-clinical; Health Omnibus Survey (HOS) | .46% (3 months; combined) | Eating Disorder Examination (EDE) |
| US Military | Military | .04% (combined) | ICD codes from electronic records |
| US Military Academy cadets | Non-clinical; Military | .02% (7 years) Female, 0.0% (7 years) Males | Eating Attitudes Test- 26 items (EAT-26) |
| US Navy female nurses | Non-clinical; Military | 1.1% (current & past) Female | DSM-III |
| US veterans | Non-clinical; Military | .04% Female, .005% Males | ICD-9-CM |
| Active duty males in US Navy | Non-clinical; Military | 2.5% Males | N/A |
| US alcohol-dependent adults from San Diego, St. Lois, Iowa City, Farmington, New York, & Indianapolis | Clinical; Collaborative Study on the Genetics of Alcoholism (COGA) | 1.41% (lifetime) Female, .00% (lifetime) Male | SSAGA |
| Healthcare provider records | Non-clinical; healthcare members | .0269% (current) | |
| US high school students in west central Oregon | Non-clinical; high school students | . 00% (point), .45% (lifetime) Female .00% (point), .00% (lifetime) Males | DSM-III-R$_4$ |
| Canadian treatment-seeking substance users | Clinical; substance users | .4% (lifetime), .3% (current) Female .4% (lifetime), .3% (current) Males | DIS$_9$ |
| | Europe | Europe | Europe |
| Adolescent females residing in Navarra, Spain | Non-clinical; adolescents | .3% Female | EAT-40$_3$ |
| Adolescents in secondary schools in Sør-Trøndelag, County in Norway | Non-clinical; adolescents | .7% (lifetime) Female, .2% Male | SEDs$_{10}$ |
| Adolescents in a comprehensive school in Ostrobothnia district in Finland | 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 | RAB-T$_{11}$ & RAB-R$_{12}$ |
| | Australia | Australia | Australia |
| Adolescent females residing in Victoria, Australia | Non-clinical; adolescents | .00% (full), 1.8% (partial) Female | BET$_{13}$ |
| | Central & South America | Central & South America | Central & South America |
| Mexican first & second year college females | Non-clinical; college students | .00% Female | EAT-40$_3$ |
| | East Asia | East Asia | East Asia |
| Adolescent and adult Japanese patients at a university hospital | Clinical; eating disorder patients | .53% Female | DSM-III-R$_4$ |
| Korean adults | Non-clinical; Korean Epidemiologic Catchment Area (KECA) Study | .1% (lifetime), .1% (12 months) Female .2% (lifetime), .00% (12 months) Males | K-CIDI$_{15}$ 2.1 |
| Alcohol-dependent adults | 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 | 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 eating disorders, including anorexia nervosa. The Eating Disorder Diagnosis Scale (EDDS) outputs diagnostic categories of various eating disorders based on the DSM. 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) | Age Range | Administration/ Completion Time | Where to Access |
| Eating Disorder Examination Questionnaire (EDE-Q) | Questionnaire (Patient) | 14+ | 15-20 min | PDF Assessment Center Online Version |
| Eating Disorder Diagnosis Scale (EDDS) | Questionnaire (Patient) | 13 - 65 | 10-15 min | PDF |
| Eating Attitudes Test- 26(EAT-26; Adult version) Child Eating Attitudes Test - 26 (ChEAT-26; child version) | Questionnaire (Patient) | 13+ (adult version) 8 -13 (child version) | 5-10 min | PDFs Adult Version Online Form Child Version PDF |
Note: Reliability and validity are included in the extended version. This table includes measures with Good or Excellent ratings.

### 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 | Where to access |
| 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 female volunteer university students who have no eating disorder diagnoses and are not overweight | None |
| 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 female volunteer university students who have no eating disorder diagnoses and are not overweight | None |
| 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. | PDFs Adult Version Online Form Child Version PDF |
| EDE-Q | .96(N=1170) | 6.57 (2.3+) | 0.09 (<2.3) | 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. Moderate: “Clinically significant eating disorder” from a community sample versus female adults individuals without “clinically significant eating disorder” from same sample. Eating disorders were not separated. | PDF |

### 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 | Where to access |
| Eating Disorder Examination (EDE) | Semistructured (child and adult) | 8-16 (child version) 16+ (adult version) | 45-75 minutes | PDFs Child version PDF Adult version PDF |
| Structured Clinical Interview for DSM-5-Clinician Version (SCID-5-CV) | Semistructured Interview (Adult ) | 16+ | Varies | Website to purchase |
| Development and Well-Being Assessment (DAWBA) | Structured (child/adolescent and parent) | 11-18 | 10-20 minutes for the eating disorder module | English PDF Additional languages |
Note: Reliability and validity are included in the extended version. This table includes measures with Good or Excellent ratings.

## 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. It is worth noting, however, in inpatient or other acute care settings, weight restoration is the primary goal of treatment for anorexia nervosa, making body weight the most closely monitored process indicator. 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.