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SticeTelch00

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Psychological Assessment Copyright 2000 by the American Psychological Association, Inc.2000, Vol. 12, No. 2, 123-131 1040-3590/00/$5.00 DOI: 10.1037//1040-3590.12.2.123
Development and Validation of the Eating Disorder Diagnostic Scale:A Brief Self-Report Measure of Anorexia, Bulimia,and Binge-Eating Disorder
Eric Stice
University of Texas at Austin
Christy F. Telch
Stanford University
Shireen L. Rizvi
University of WashingtonThis article describes the development and validation of a brief self-report scale for diagnosing anorexianervosa, bulimia nervosa, and binge-eating disorder. Study 1 used a panel of eating-disorder experts andprovided evidence for the content validity of this scale. Study 2 used data from female participants withand without eating disorders (N = 367) and suggested that the diagnoses from this scale possessedtemporal reliability (mean K = .80) and criterion validity (with interview diagnoses; mean K = .83). Insupport of convergent validity, individuals with eating disorders identified by this scale showedelevations on validated measures of eating disturbances. The overall symptom composite also showedtest-retest reliability (r = ,87), internal consistency (mean a = .89), and convergent validity with extanteating-pathology scales. Results implied that this scale was reliable and valid in this investigation and thatit may be useful for clinical and research applications.It has been estimated that 10% of female individuals in westerncountries will suffer from a diagnosable eating disorder (AmericanPsychiatric Association [APA], 1994), making it one of the moreprevalent psychiatric problems faced by women. Anorexia nervosais characterized by (a) extreme emaciation; (b) intense fear ofgaining weight or becoming fat despite a low body weight; (c)disturbed perception of weight and shape, an undue influence ofweight or shape on self-evaluation, or a denial of the seriousnessof the low body weight; and (d) amenorrhea (APA, 1994). Thisdisorder has a lifetime prevalence of almost 1% among females, isrefractory to treatment, shows a chronic course, results in seriousmedical complications, and is associated with psychiatric comor-bidity such as mood, anxiety, and personality disorders (Wilson,Heffernan, & Black, 1996).Bulimia nervosa involves (a) recurrent episodes of uncontrolla-ble consumption of large amounts of food, (b) compensatoryEric Stice, Department of Psychology, University of Texas at Austin;Christy F. Telch, Depa~nent of Psychiatry and Behavioral Sciences,Stanford University; Shireen L. Rizvi, Department of Psychology, Univer-sity of Washington.This study was supported by Postdoctoral Fellowship MH19908, CareerAward MH01708, Exploratory Development Grant MH54641, and Re-search Grant MH50271 from the National Institute of Mental Health, aswell as by a grant from the McKnight Foundation. We thank Kim Frornme,Helen C. Kraemer, Heather Shaw, and Michael J. Telch for their thoughtfulinput regarding this article.Correspondence concerning this article should be addressed to EricStice, Department of Psychology, 330 Mezes Hall, University of Texasat Austin, Austin, Texas 78712. Electronic mall may be sent to stice@psy.utexas.edu.123behavior to prevent consequent weight gain (e.g., vomiting, laxa-tive abuse, diuretic abuse, or excessive exercise), and (c) undueinfluence of weight and shape on self-evaluation (APA, 1994). Thelifetime prevalence for bulimia nervosa is approximately 2% forfemales (Newman et ai., 1996; Whitaker et al., 1990). This disor-der is markedby a persistent course and is associated with highlevels of comorbid psychopathology, including affective disorders,anxiety disorders, and substance abuse (Garfinkel et al., 1995;Keller, Herzog, Lavori, Bradburn, & Mahoney, 1992).Binge-eating disorder involves (a) repeated episodes of uncon-trollable binge eating characterized by certain features (e.g., rapideating or eating alone because of embarrassment), (b) markeddistress regarding binge eating, and (c) the absence of compensa-tory behaviors (APA, 1994). The lifetime prevalence for binge-eating disorder is approximately 4% in the community (Spitzer etal., 1993), but it has been estimated that about 30% of individualspresenting for weight-control treatment meet criteria for this dis-order (Brody, Walsh, & Devlin, 1994). This disorder appears tohave a persistent course and is associated with obesity, weightcycling, health complications, and psychiatric comorbidity (Wil-son et al., 1996; Telch & Stice, 1998).Research on the etiology, prevention, and treatment of eatingdisorders has increased dramatically over the past 2 decades (Smo-lak, Levine, & Striegel-Moore, 1996), but progress has been lim-ited in part by the scarcity of validated measures of eating disor-ders. Although there are structured psychiatric interviews forarriving at
Diagnostic and Statistical Manual of Mental Disorders
(4th ed.;
DSM-1V,"
APA, 1994) diagnoses of anorexia nervosa,bulimia nervosa, and binge-eating disorder (e.g., the Eating Dis-order Examination [EDE; Fairburn & Cooper, 1993] and theStructured Clinical Interview for
DSM
[SCID; Spitzer, Williams,
 
124 STICE, TELCH, AND RIZVIGibbon, & First, 1990]), no parallel self-report questionnaire mea-sure exists. Available self-report questionnaires, such as the Bu-limia Test--Revised (Thelen, Farmer, Wonderlich, & Smith,1991), Questionnaire on Eating and Weight Patterns (Spitzer et al.,1992), Eating Disorder Examination---Questionnaire (Fairburn &Beglin, 1994), and Questionnaire for Eating Disorder Diagnoses(Mintz, O'HaUoran, Mulholland, & Schneider, 1997), do not yield
DSM-IV
diagnoses for all three eating disorders. Moreover, thereliability and validity of measures from extant self-report ques-tionnaires have not been well established. For example, we wereunable to locate any published studies that report the test-retestreliability for
DSM-IV
eating-disorder diagnoses generated bythese self-report questionnaires. Similarly, there appear to be nopublished studies that report the agreement between
DSM-IV
eating-disorder diagnoses ascertained through validated structuredinterviews and those generated by these self-report questionnaires.A brief self-report questionnaire would be very useful for etio-logic research, in that it is time consuming and expensive toconduct lengthy structured psychiatric interviews with large num-bers of participants. Such a questionnaire might also be usefulwhen researchers need relatively frequent measurement of eatingpathology (e.g., prevention programs or treatment studies), as itwould minimize the response burden for participants. Finally, sucha measure might prove useful in clinical settings (e.g., primary careoffices) where a brief questionnaire is desired to identify individ-uals with eating pathology.Accordingly, we sought to develop a brief self-report scale thatwould provide diagnoses of anorexia nervosa, bulimia nervosa,and binge-eating disorder, and to generate evidence of the reliabil-ity and validity of this new diagnostic instrument. Study 1 de-scribes the processes by which we generated items and examinedthe content validity of this new scale. Study 2 assesses the test-retest reliability, criterion validity, and convergent validity of thisdiagnostic scale. As some researchers may be interested in usingan overall eating-disorder symptom composite for etiologic, pre-vention, or treatment studies (because of the low base rate of thesedisorders), a tertiary aim was to explore the psychometric proper-ties of such a symptom composite derived from this diagnosticscale. In particular, the test-retest reliability, internal consistency,and convergent validity of the overall symptom composite wereexamined.Study 1
Overview
The purpose of Study 1 was to (a) generate a set of items toassess the
DSM-IV
diagnostic criteria for anorexia nervosa,bulimia nervosa, and binge-eating disorder for an Eating Dis-order Diagnostic Scale (EDDS), (b) document that all relevantsymptoms were included and that no irrelevant ones wereincluded, and (c) refine item content and instructions. Follow-ing recommendations regarding content validation (Haynes,Richard, & Kubany, 1995), we used a multistep process toaccomplish these aims.
MethodStep 1
Items were derived from multiple sources to enhance the content validityof the scale. Items assessing
DSM-IV
diagnostic criteria for anorexianervosa, bulimia nervosa, and binge-eating disorder were adapted fromvalidated smactured psychiatric interviews, which assessed these disorders:the EDE (Fairburn & Cooper, 1993) and the eating-disorder module of theSCID (Spitzer et al., 1990). We used the version of the EDE that assessesdiagnostic criteria for anorexia nervosa, bulimia nervosa, and binge-eatingdisorder. We also consulted the
DSM-1V
APA, 1994) regarding diagnosticcriteria for these three eating disorders in an effort to ensure that allrelevant symptoms were represented on the scale. Items were worded tocapture diagnostic criteria for these disorders, including the necessary timewindows for various behaviors.
Step 2
To document that all of the diagnostic criteria for the three eatingdisorders were included and that no irrelevant information was included inthe EDDS, a panel of eating-disorders researchers from around the countryevaluated a preliminary version of this questionnaire. Twenty-six eating-disorder experts, identified through a literature search, were mailed thepreliminary draft of the EDDS, a list of the diagnostic criteria taken directlyfrom the
DSM-IV,
and a cover letter with instructions. Experts were askedto (a) check that all of the
DSM-IV
diagnostic criteria were assessed onEDDS, (b) cross out any EDDS items that did not reflect a
DSM-IV
symptom, (c) suggest refinements to the wording of items or instructions,and (d) write down any additional items that should be included. Of the 26participants who were mailed this information, 14 (54%) returned com-pleted packets. Four of the 14 experts noted that one diagnostic criteria wasnot reflected on the EDDS (fasting) and made suggestions regardingwording of this item. Experts agreed that all remaining diagnostic criteriawere included and that no irrelevant items were included. Experts alsoprovided several useful suggestions that clarified the wording of items andinstructions. These responses were used to guide a revision of the prelim-inary EDDS.
Step 3
The revised draft of EDDS was pilot tested with patients from aneating-disorders clinic, undergraduate students, and high school students(N = 15). These participants were asked to comment on the clarity of thequestions and instructions. This feedback was used to guide a final revisionof the preliminary EDDS, which primarily centered on clarifying theinstructions.
Results
The above item-generation and refinement procedures resultedin a 22-item version of the EDDS. Items used a combination ofLiken, yes-no, frequency, and write-in response formats to assessall of the
DSM-IV
diagnostic symptoms for anorexia nervosa,bulimia nervosa, and binge-eating disorder. In an effort to mini-mize the effects of idiosyncratic conceptions of what constitutes a"binge," we did not use this term in the scale. The EDDS isincluded in the Appendixes, along with the scoring algorithm'.Study 2
Overview
The purpose of Study 2 was to examine the test-retest reliabil-ity, criterion validity, and convergent validity of the EDDS eating-disorder diagnoses, as well as the test-retest reliability, internalconsistency, and convergent validity of the EDDS symptomcomposite.
 
EATING DISORDER DIAGNOSTIC SCALE
125
MethodParticipants
An effort was made to recruit a heterogeneous sample that was diversein age, socioeconomic status, and geographic location to maximize thegeneralizability of the findings. Participants were 367 females between theages of 13 and 65 recruited from the metropolitan areas of San Francisco,New York, Minneapolis-St. Paul, and Austin. Participants were recruitedfrom several ongoing projects, including (a) a randomized clinical trial forthe treatment of anorexia nervosa (n = 12), (b) a randomized clinical trialfor the treatment of bulimia nervosa (n = 3), (c) a randomized clinical trialfor the treatment of binge-eating disorder (n = 17), (d) a multisite study onthe longitudinal course of threshold and subthreshold eating disorders in anon-treatment seeking sample (n = 185), (e) a multisite study on affect(n = 38), (f) a longitudinal study of the risk factors for eating disorders(n = 109), and (g) an inpatient psychiatric treatment unit (n = 3).Participants from the first six sources were recruited directly from thecommunity through advertisements placed in local media, fliers distributedat universities and medical clinics, and direct mailings to eligible femalesbetween the ages of 13 and 65 to participate in these research studies. The 3patients recruited from the inpatient treatment unit were approached di-rectly because a chart review suggested that they had a diagnosis ofanorexia nervosa. Data for this study were collected at: (a) various assess-ment points in the three randomized clinical trials and the longitudinalcourse study, (b) at the baseline assessment of the affect study and thelongitudinal risk factor study, and (c) within the first month of treatment forthe 3 anorexic individuals from the inpatient treatment unit.Participants ranged in age from 13 to 61 (M = 29.7,
SD
= 13.2). Thesample was composed of participants who were 2% Asian or PacificIslander, 2% Black, 6% Hispanic, 1% Native American, 80% Caucasian,and 9% who specified "other" or mixed-racial heritage. Educational at-tainment ranged from some high school (22%) to graduate or professionaldegree (17%), with a mode of some college education (29%).
MeasuresStructured Psychiatric Interview.
The EDE (Fairburn & Cooper, 1993)was the primary "gold standard" against which our new self-report diag-nostic scale was compared for validation purposes. The EDE is a structuredpsychiatric interview that assesses diagnostic criteria for
DSM-IV
eatingdisorders. We used the version that assesses diagnostic criteria for anorexianervosa, bulimia nervosa, and binge-eating disorder. The EDE also con-tains four subscales that measure dietary restraint, eating concern, weightconcern, and shape concern. Using community and clinical samples, stud-ies by Cooper, Cooper, and Fairburn (1989), Fairburn and Cooper (1993),Rizvi, Peterson, Crow, and Agras (1999), Williamson, Anderson, Jackman,and Jackson (1995), and Wilson and Smith (1989) reported internal con-sistency coefficients for the EDE scales ranging from .76 to .90, test-retestreliability correlations for diagnostic items ranging from .83 to .97, andinterrater reliability kappas ranging from .83 to .99.To assess the interrater reliability of the EDE in this study, a subset(25%) of EDE interviews were audiotaped and rated by a second inter-viewer who was unaware of the original diagnosis, resulting in acceptableinterrater agreement (kappas ranged from .92 to 1.00). The EDE wasadministered to 346 of the 367 participants to ascertain eating-disorderdiagnosis.The SCID (Spitzer et al., 1990) served as the "gold standard" againstwhich our self-report diagnostic scale was compared for a subset ofparticipants (the 3 anorexia nervosa patients from the inpatient unit and 18participants from the affect study) where we could not administer the moredetailed EDE. The SCID is a standardized interview that assesses psychi-atric status for major Axis I psychiatric disorders. Research has providedevidence of the reliability diagnoses of the SCID, with interrater reliabilityagreement kappas ranging from .70 to 1.00 and test-retest reliability of theeating-disorders sections ranging from .82 to .90 in community and clinicalsamples (Pike, Loeb, & Walsh, 1995; Segal, Hersen, & Van Hasselt, 1994;Stukenberg, Dura, & Kiecolt-Glaser, 1990).Responses to the EDE and SCID interviews were used to group partic-ipants into four diagnostic categories:
DSM-IVanorexia
nervosa (n = 15),
DSM-IV
bulimia nervosa (n = 31),
DSM-IV
binge-eating disorder (n =48), and noneating disordered controls (n = 273).
Yale-Brown-Cornell Eating Disorder Scale.
The Yale-Brown-Cornell Eating Disorder Scale (YBC-EDS; Mazure, Halmi, Sunday, Ro-mano, & Einhorn, 1994) is an 84-item structured interview that assessesobsessions and rituals relating to food, eating, weight, and shape issues.Research has supported the reliability of the YBC-EDS measures, withinternal consistency coefficients ranging from .82 to .90 and interrateragreement kappas ranging from .80 to 1.00 in clinical samples (Mazure etal., 1994; Sunday, Halmi, & Einhorn, 1995). All participants completed theYBC-EDS except the 38 participants from the affect study, 109 participantsfrom the longitudinal risk factor study, and the 3 anorexic participants fromthe inpatient treatment unit.
Three-Factor Eating Questionnaire.
The Three-Factor Eating Ques-tionnaire (TFEQ; Stunkard & Messick, 1985) is a 54-item questionnairewith three subscales measuring cognitive (dietary) restraint, perceivedhunger, and emotionally based disinhibition of eating. The reliability andvalidity of the TFEQ subscales has been supported by research indicatingthat the internal consistency coefficients ranged between .85 and .93, andthat the subscales correlated with dietary intake and discriminated betweendieters and nondieters in both community and clinical samples (French,Jeffery, & Wing, 1994; Laessle, Tuschl, Kotthaus, & Pirke, 1989; Stunkard& Messick, 1985). The 38 participants from the affect study, 109 partici-pants from the longitudinal risk-factor study, and the 3 anorexic partici-pants from the inpatient unit did not complete the TFEQ.
Eating Disorder Diagnostic Scale.
Items assessing the
DSM-IV
diag-nostic criteria for anorexia nervosa, bulimia nervosa, and binge-eatingdisorder were developed and revised following the procedures described inStudy 1. Responses to the EDDS were used to group participants into fourdiagnostic categories:
DSM-IV
anorexia nervosa (n = 18),
DSM-IV
bu-limia nervosa (n = 39),
DSM-IV
binge-eating disorder (n = 57), andnoneating disordered (n = 253). As noted above, because some researchersmay desire a broadband measure of eating pathology, an overall symptomcomposite was formed by standardizing all items (to control for the effectsof the different response formats) and then summing across all items(except the height and birth control pill items). Thus, the symptom com-posite reflected each participant's overall level of eating pathology.
Procedures
At baseline, all participants completed the EDDS prior to partaking inthe structured diagnostic interview (either the EDE or the SCID). Thisorder was chosen because concepts such as "binge eating episodes" aredefined in the interview, and we wanted to minimize the possibility thatcompleting the interview would influence how participants responded tothe EDDS. All interviews were conducted by clinical assessors with eithera bachelor's, master's, or doctorate in psychology. Clinical assessorsattended 16 hr of training, wherein structured interview skills were taught,diagnostic criteria for eating disorders were reviewed, simulated interviewswere observed, and interviews were role played. Assessors had to demon-strate an interrater agreement (K > .80) with experts with tape-recordedinterviews before they were allowed to collect data. After the interview,clinical assessors measured height and weight. Participants from the firstfour eating-disorder studies then completed the TFEQ and the YBC-EDS.A randomly selected subset of participants (N = 55) from the longitudinalcourse of eating disorders study was asked to complete the EDDS 1 weekafter coming into the laboratory for their structured interview to providedata on the test-retest reliability of this scale. Participants were compen-sated for completing these measures (compensation ranged from $15 to$50, depending on the study).

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