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Demographic Information

This section describes the demographic setting of the population(s) sampled, base rates of diagnosis, country/region sampled and the diagnostic method that was used. Using this information, clinicians will be able to anchor the rate of anorexia nervosa that they are likely to see in their clinical practice.

Setting	Reference	Base Rate (Female)	Basic Rate (Male)	Demography	Diagnostic Method
Non-clinical: Population Based (NCS-R)	Hudson, Hiripi, Pope, & Kessler, 2007	.9%	.3%	Nationally representative US sample of adults	WHO-CIDI
Non-clinical: Population Based (NCS-A)	Swanson, Crow, Le Grange, Swendson, & Merikangas, 2011	.3%	.3%	Nationally representative US sample of adolescents	WHO-CIDI
Non-clinical: Latinos in US	Alegria et al., 2007	.12%	.03%	Latino Households in US	WHO-CIDI
Non-clinical: African Americans and Caribbean Blacks in the US (NSAL)	Taylor, Caldwell, Baser, Faison, & Jackson, 2007	.14%	.2%	National probability sample of adult and adolescent African Americans and Caribbean Blacks	WHO-CIDI
Military	Antczak & Brininger, 2008	.04% (combined)	.04% (combined)	US Military	ICD codes from electronic records
Centers participating in the Collaborative Study on the Genetics of Alcoholism in San Diego; St. Louis; Iowa City; Farmington, CN; New York; & Indianapolis	Schuckit et al., 1996	1.41%	N/A	Alcohol-dependent adults	Semi-Structured Assessment for the Genetics of Alcoholism; criteria based on DSM-III-R

Diagnosis

Recommended Screening Measures:

1. Structured Clinical Interview for DSM Diagnoses Anorexia Nervosa module (SCID): See Appendix A
2. Eating Disorder Examination (EDE): See Appendix B
3. Eating Disorder Examination Questionnaire (EDE-Q): See Appendix C
4. Eating Attitudes Test (EAT-26): See Appendix

Diagnostic Criteria

Diagnostic efficiency information for all included measures is based on criteria from DSM-IV or earlier. As of the compilation of this portfolio, diagnostic efficiency information for these measures based on DSM-5 criteria is unavailable. Once sufficient time for implementation of DSM-5 has passed, measures should be re-evaluated for efficiency with new data. The Feeding and Eating Disorders section of the DSM has undergone notable revision with the shift from DSM-IV to DSM-5, with a primary goal of reducing the large number of Eating Disorder Not Otherwise Specified (EDNOS) diagnoses due to many individuals not fully meeting criteria for Anorexia Nervosa or Bulimia Nervosa as delineated by DSM-IV. Base rates of Feeding and Eating Disorders are likely to shift once DSM-5 criteria have been fully incorporated into clinical practice and research.

Anorexia Nervosa diagnostic criteria have changed as follows:

• The requirement for amenorrhea was eliminated in DSM-5
• Criterion A (low body weight) wording was edited for clarification
• Criterion B (fear of weight gain) expanded to include both expressed fear of weight gain and persistent behavior interfering with weight gain

Areas Under the Curve (AUCs) and Likelihood Ratios for Potential Screening Measures for Anorexia Nervosa in Adult Females

Screening Measure (Primary Reference)	AUC	LR+ (Score)	LR- (Score)	Citation	Clinical Generalizability
EDE-Q (Fairburn & Beglin, 1994)	.96 (N=1170)	--	--	(Aardoom, Dingemans, Slof Op't Landt, & Van Furth, 2012)	Moderate: Dutch treatment-seeking females meeting DSM-IV criteria for an eating disorder versus female general population sample recruited through advertisements and personal contacts. Eating disorders were not separated
EDE-Q (Fairburn & Beglin, 1994)	--	6.57 (2.3+)	0.09 (<2.3)	(Mond, Hay, Rodgers, Owen, & Beumont, 2004)	Moderate: “Clinically significant eating disorder” from a community sample versus individuals without “clinically significant eating disorder” from same sample. Eating disorders were not separated.
EAT-26 (Garner, Olmsted, Bohr, & Garfinkel, 1982)	.90 (N=129)	12.83 (20+)	.24 (<20)	(Mintz & O'Halloran, 2000)	Low-moderate: College women with no eating disorder versus college women with a DSM-IV eating disorder. Eating disorders were not separated.

Note: “LR+” refers to the change in likelihood ratio associated with a positive test score, and “LR-” is the likelihood ratio for a low score. Likelihood ratios of 1 indicate that the test result did not change impressions at all. LRs larger than 10 or smaller than .10 are frequently clinically decisive; 5 or .20 are helpful, and between 2.0 and .5 are small enough that they rarely result in clinically meaningful changes of formulation (Sackett et al., 2000).

Search terms: [Anorexia Nervosa OR eating disorder] AND [measure OR assessment] AND [sensitivity OR specificity OR ROC OR AUC] in Google Scholar

Treatment

Treatment of AN typically consists of restoring the individual to a healthy weight and addressing thoughts and behaviors which are related to the eating disorder. It may involve re-nutrition, psychotherapy, nutritional counseling, and medication.

Literature reviews of existing research indicate that evidence supporting AN treatment is lacking. A systematic review of AN treatment efficacy studies by Bulik et al. (2007) found that evidence supporting medications, medications and behavioral interventions, and behavioral interventions alone in adults is weak. There is moderately strong evidence suggesting that behavioral interventions may be helpful for adolescents. In particular, adolescents may benefit from family therapy. Clinical trials investigating AN treatment suffer from high rates of attrition, as key features of AN (e.g., denial, fear of weight gain) may contribute to low motivation for remaining in treatment.

More severe cases of AN may be treated in inpatient settings, which are equipped to manage the re-nutrition process and provide medical monitoring. Partial hospitalization and intensive outpatient programs may provide intermediate levels of treatment intensity to assist individuals in the transition from intensive care to outpatient care after weight restoration.

Process and Outcome Measures

Clinically Significant Change Benchmarks with Common Instruments

Benchmarks Based on Published Norms

Measure	A Cut Score	B Cut Score	C Cut Score	95% Critical Change (Unstandardized Scores)	90% Critical Change (Unstandardized Scores)	SE-difference Critical Change (Unstandardized Scores)
EDE-Q (Mond et al., 2004 norms) 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 (Mond et al., 2004 norms) 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 (Mintz & O'Halloran, 2000 norms) 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

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 (Gusella, Butler, Nichols, & Bird, 2003). See Appendix E