Assessment of Eating Disorders Review and Recommendations For Clinical Use

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Assessment of Eating Disorders: Review and Recommendations for Clinical Use

Drew A. Anderson, Jennifer D. Lundgren, Jennifer R. Shapiro and Carrie A. Paulosky
Behav Modif 2004; 28; 763
DOI: 10.1177/0145445503259851
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BEHAVIOR
10.1177/0145445503259851
Anderson et al.
MODIFICATION
/ ASSESSMENT/ OF
November
EATING2004
DISORDERS
Assessment of Eating Disorders

Review and Recommendations for Clinical Use
DREW A. ANDERSON
JENNIFER D. LUNDGREN
JENNIFER R. SHAPIRO
CARRIE A. PAULOSKY
University at Albany–SUNY
Practitioners have come under increasing pressure to provide objective data on assessment and
treatment outcome of clients. This article provides a brief summary of assessment of eating dis-
orders for the practicing clinician, with an emphasis on well-validated assessment instruments.
The critical domains that should be covered in a thorough assessment of eating disorders are
reviewed, as are some shortcomings in the current assessment literature, and also discussed is
which assessment instruments for the eating disorders are most useful in a clinical context. Using
well-validated, standardized assessment instruments in all phases of the treatment process is a
critical part of justifying a treatment plan and providing objective data on client progress and
outcome.
Keywords: assessment; anorexia; bulimia; clinical; review
Practitioners have come under increasing pressure to provide

objective data on assessment and treatment outcome of clients. This
article will provide a brief and hopefully useful summary of assess-
ment of eating disorders for the practicing clinician, with an emphasis
on well-validated assessment instruments. We first review the domains
that should be covered in a thorough assessment of eating disorders in
clinical practice, focusing on anorexia nervosa (AN) and bulimia
nervosa (BN). We then examine which assessment instruments are
actually used regularly in the treatment outcome literature. Finally, we
discuss some shortcomings in the current assessment literature and
some particularly useful assessment instruments for the eating disor-
ders in a clinical context.
BEHAVIOR MODIFICATION, Vol. 28 No. 6, November 2004 763-782
DOI: 10.1177/0145445503259851
© 2004 Sage Publications
763

764 BEHAVIOR MODIFICATION / November 2004
DOMAINS OF INTEREST
IN THE EATING DISORDERS
Knowing what domains to assess is an integral part of the assess-

ment process. Although eating disorders are often associated with
secondary psychopathology, and assessing this pathology is impor-
tant for treatment planning, in this section we limit our review to the
central domains of the eating disorders themselves. For a thorough
discussion of secondary psychopathology associated with eating dis-
orders, see Williamson (1990).
Several models have been proposed that identify the central symp-
toms associated with the eating disorders, including the Diagnostic
and Statistical Manual of Mental Disorders (4th ed.) (DSM-IV-TR)
diagnostic criteria (American Psychiatric Association, 1994), cogni-
tive models of the disorders (Fairburn, 1997; Vitousek & Orimoto,
1993; Williamson, 1990), and models derived from factor analytic
studies of symptom patterns (Byrne & McLean, 2002; Gleaves &
Eberenz, 1993; Gleaves, Williamson, & Barker, 1993; Tobin, Johnson,
Steinberg, Staats, & Dennis, 1991; Vanderheyden, Fekken, & Boland,
1988). Although there are some differences among these models, they
have several symptom domains in common which appear to be central
to the eating disorders.
BODY WEIGHT
Body weight is one of the primary features distinguishing persons

with AN from persons with BN (DSM-IV). In AN, low weight is diag-
nostic and weight gain is the primary goal in the early stages of treat-
ment. Conversely, patients with BN are typically normal-weight or
slightly overweight (although they fear weight gain).
BINGE EATING AND COMPENSATORY BEHAVIOR
Binge eating and compensatory behavior such as vomiting are the

most visible behavioral symptoms of the eating disorders. Although
more closely identified with BN, binge eating and compensatory
behavior are frequently seen in AN as well (DSM-IV), and reductions
in these symptoms are primary treatment goals when they are present.

Anderson et al. / ASSESSMENT OF EATING DISORDERS 765
OVERCONCERN WITH SHAPE AND WEIGHT
An extreme concern with shape and weight, sometimes character-

ized as a fear of fatness or drive for thinness, appears to be central to
both AN and BN. This overconcern is thought to drive much of the
behavior seen in anorexia and bulimia (Fairburn, 1997; Holmgren et
al., 1983; Vitousek & Orimoto, 1993), and a reduction in shape and
weight concern is critical for treatment success (Fairburn, 1997;
Fairburn, Marcus, & Wilson, 1993). Overconcern with shape and
weight is tied closely to cultural norms concerning the body, which
vary across time and culture (Heinberg, 1996). Therefore, clinicians
should consider cultural factors when assessing weight and shape
concerns.
DIETARY RESTRAINT
Dietary restraint, conceptualized as the intent to limit caloric

intake, whether or not the individual is actually successful (Lowe,
1993), plays a critical role in the eating disorders. In AN, successful
caloric restriction leads to weight loss, which is the hallmark of the
disorder. In BN, the relationship is more complex. Dietary restraint
has been hypothesized to lead to binge eating through a variety of
physiological and psychological mechanisms (Fairburn, 1997;
Heatherton & Baumeister, 1991; Lowe, 1993; Polivy & Herman,
1993; Vitousek & Orimoto, 1993), and a decrease in dietary restraint is
thought to be the central mechanism underlying cognitive-behavioral
treatment of bulimia (Craighead & Agras, 1991). Although not all
researchers have found a direct relationship between restraint and
binge eating (e.g., Byrne & McLean, 2002), reductions in dietary
restraint are critical to successful treatment of AN and BN.
BODY IMAGE DISTURBANCE
There is some disagreement about the exact nature of the concept of

body image disturbance (e.g., Cash & Deagle, 1997; Thompson,
Altabe, Johnson, & Stormer, 1994) and how to assess it (Cash &
Deagle, 1997; Thompson, 1995). In particular, researchers have dis-
tinguished between attitudinal (i.e., dissatisfaction with one’s body or

body parts) and perceptual (i.e., inability to accurately gauge body

size) aspects of body image (Cash & Deagle, 1997). However, most
models of the eating disorders consider some aspect of body image
disturbance to be central to the eating disorders, and several studies
have shown that body image concerns are important in the develop-
ment and treatment of eating disorders (Kearney-Cooke & Striegel-
Moore, 1997; Rosen, 1996, 1997). Treatment of body image concerns
are often underemphasized in eating disorder treatment programs
(Rosen, 1997), but improvements in body image are essential for suc-
cessful treatment of AN and BN. Because attitudinal components of
body image appear to be more relevant for clinical practice (Cash &
Deagle, 1997), the present review will concentrate on this aspect of
body image.
AFFECTIVE DISTURBANCE
Negative affect, especially depression, often develops as a conse-

quence of eating pathology (P. J. Cooper & Fairburn, 1986). In fact,
eating disorders and affective disorders co-occur to such a degree
(Troop, Serpell, & Treasure, 2001) that some researchers in the 1980s
hypothesized that bulimia was merely a subtype of depression (P. J.
Cooper & Fairburn, 1986; Hinz & Williamson, 1987; Levy, Dixon, &
Stern, 1989). Although this theory has not received empirical support,
negative affect (especially depression) remains a major area of con-
cern in the eating disorders. Depression does not merely co-occur
with eating disorders, however; depression exacerbates the eating dis-
orders and can interfere with treatment, and greater pretreatment levels
of depression have been found to predict greater posttreatment eating
disorder psychopathology and body dissatisfaction (Bossert, Schmölz,
Wiegand, Junker, & Krieg, 1992).
SHORTCOMINGS IN THE ASSESSMENT

OF EATING DISORDERS
The clinical assessment of eating disorders can be problematic.

Although detailed critiques of the assessment literature can be found
elsewhere (e.g., Anderson & Maloney, 2001), this article reviews one

of the more critical shortcomings in the eating disorders field that is

important for practitioners.
ASSESSING CRITICAL DOMAINS OF THE EATING DISORDERS
As mentioned above, researchers have delineated a number of

domains that are critical to the development and maintenance of eat-
ing disorders. However, outcome studies do not assess these areas
equally well. For example, in a recent review, Anderson and Maloney
(2001) found that although most controlled treatment outcome studies
of cognitive-behavioral therapy (CBT) for BN provided data on binge
eating, purgative behavior, and concern for shape and weight, rela-
tively few provided data on restraint and self-esteem. In fact, only
19% of the studies reviewed provided outcome data on all five of the
components of this model. This is problematic because restraint and
self-esteem are essential components of the CBT model of BN (Byrne
& McLean, 2002; Fairburn, 1997). Similarly, in a review of the litera-
ture, Rosen (1996) found that only one third of studies of CBT for BN
assessed body image disturbance, another key component of the eat-
ing disorders. Because of these gaps in assessment, we have corre-
sponding gaps in our knowledge of the effectiveness of treatment of
the eating disorders. Anderson and Maloney (2001) provide some rec-
ommendations to improve these shortcomings, including using more
assessment instruments and measuring both cognitive restraint and
caloric restriction when assessing dietary restraint. These recommen-
dations apply for those in clinical practice as well; to thoroughly
assess client outcome, practitioners should be sure to assess all of the
core domains of the eating disorders discussed above.
The binge eating dilemma. The assessment of binge eating is a par-

ticularly problematic topic in the eating disorders literature. First,
there is disagreement about the definition of the term “binge.”
According to the DSM-IV-TR, a binge episode must involve eating an
amount of food that is definitely larger than most people would con-
sider normal under the circumstances and be accompanied by a sense
of lack of control over eating during the episode. A binge episode that
fully meets DSM-IV-TR criteria has also been called an objective

bulimic episode (OBE; Fairburn & Cooper, 1993). However,

laypersons, including those who binge eat, rely more on feelings of
loss of control and violation of dietary standards rather than the
amount of food eaten to define an eating episode as binge (Beglin &
Fairburn, 1992; Johnson, Boutelle, Torgrud, Davig, & Turner, 2000;
Telch, Pratt, & Niego, 1998). Any self-reported binge episode that
does not fully meet DSM-IV-TR criteria has been termed a subjective
bulimic episode (SBE; Fairburn & Cooper, 1993).
This distinction has practical implications in diagnosis and evalua-
tion of treatment outcome. Self-report questionnaires typically ask
simply how often the respondent engages in “binge eating.” If the
respondent reports all binge episodes (both SBEs and OBEs) as
“binge,” this may result in an overestimation of true binge frequency.
Similarly, even if the clinician obtains detailed reports of “binge epi-
sodes” via interview or food records, they are still dependent on cli-
ents’ providing accurate reports of food intake. However, large errors
in food estimation, particularly overestimation, are extremely com-
mon (Anderson, Williamson, Johnson, & Grieve, 1999; Hadigan,
LaChaussee, Walsh, & Kissileff, 1992; Schoeller, 1995). If individu-
als overestimate when reporting food intake, then they may overesti-
mate the number of their OBEs by reporting their intake appear as
larger than it actually is.
This issue is further complicated by studies that suggest that the
current DSM-IV-TR requirement that a binge consists of a large
amount of food is unnecessary (Niego, Pratt, & Agras, 1997; Pratt,
Niego, & Agras, 1998). However, a recent study found that eliminat-
ing this diagnostic requirement had little effect on the base rate of BN
(Thaw, Williamson, & Martin, 2001).
In sum, the assessment of binge eating remains one of the most dif-
ficult aspects of the assessment of eating disorders. This is particularly
troubling because binge eating is one of the essential aspects of the
eating disorders. Some of the difficulty lies in the definition of a binge
episode itself; the definition and essential components of a binge epi-
sode are still unclear. The measurement of binge eating is also prob-
lematic, however, because it is extremely difficult to obtain an accu-
rate estimation of food intake. The use of test meals may be useful in
this context (see below).

RECOMMENDED MEASURES FOR

THE ASSESSMENT OF EATING DISORDER
SYMPTOMS IN CLINICAL CONTEXT
Although more comprehensive reviews of assessment instruments

exist (Allison, 1995; Williamson, 1990), the following instruments
were chosen as some of the most effective and well-validated in the
eating disorders literature that are also practical for use in clinical
practice.
SCREENING MEASURES
When screening for the presence of eating disorders, it is not neces-

sary to determine an exact diagnosis or obtain detailed patterns of
problematic symptoms. Rather, the purpose of screening is to identify
individuals who are likely to have significant levels of eating pathol-
ogy and need further assessment. Screening measures are usually
brief, self-report inventories with a simple cutoff score to indicate
clinical levels of psychopathology. The most useful and psychometri-
cally sound instruments are reviewed below.
Eating Attitudes Test (EAT). The EAT (Garner & Garfinkel, 1979)
is a 40-item self-report inventory originally designed to measure
symptoms of AN. A modified version, the EAT-26, was developed
after factor analysis found 14 items of the original EAT unnecessary
(Garner, Olmstead, Bohr, & Garfinkel, 1982). The EAT and EAT-26
are highly correlated (r = .98) (Garner et al., 1982).
Test-retest reliability (Carter & Moss, 1984) and internal consis-
tency (Garner & Garfinkel, 1979) of the EAT are good, and it has been
shown to have good concurrent validity with a number of other eating
disorder measures (Williamson, Anderson, Jackman, & Jackson,
1995).
Although the EAT was designed to identify individuals with AN-
like symptoms, it is best conceptualized as a measure of general eating
disorder pathology. Although it cannot yield a specific eating disorder
diagnosis (Garner, 1997), the EAT has been found to have good
discriminant validity. It can differentiate persons with AN, BN, and

binge eating disorder (BED) from controls and persons with AN and
BN from those with BED, although it cannot differentiate persons
with AN from those with BN (Williamson, Prather, McKenzie, &
Blouin, 1990). Norms are available for individuals diagnosed with
AN, BN, and BED, as well as obese controls, female controls, and
male controls (Williamson et al., 1995). Cutoff scores of 30 on the
EAT and 20 on the EAT-26 have been suggested to identify persons
with problematic attitudes and behavior toward eating (Garner et al.,
1982).
The EAT and EAT-26 are simple to administer and score and rela-
tively quick to complete, which is perhaps why they are the most com-
monly used self-report inventories in eating disorder treatment studies
(Williamson, Anderson, & Gleaves, 1996). In a clinical context, they
may be used as screening measures to identify those clients likely to
have significant eating concerns. They may also be given repeatedly
throughout treatment as global measures of treatment progress (Garner,
1997).
Bulimia Test–Revised (BULIT-R). The BULIT-R (Thelen, Farmer,

Wonderlich, & Smith, 1991) is a 28-item questionnaire designed to
measure the DSM-III-R symptoms of BN (American Psychiatric
Association, 1987).
Although most psychometric research has been conducted on an
earlier form of the BULIT-R (BULIT; Smith & Thelen, 1984), the
BULIT and BULIT-R are highly correlated (r = .99) (Thelen et al.,
1991). The BULIT has been found to be reliable, there is evidence for
its validity (Thelen et al., 1991; Williamson et al., 1995) and it can dis-
criminate individuals with BN from those with AN and controls
(Thelen et al., 1991; Welch, Thompson, & Hall, 1993). A cutoff of 104
was originally recommended to differentiate individuals with BN
from controls, although lower cutoff scores can be used to minimize
false negatives (Thelen et al., 1991; Welch et al., 1993).
In sum, the BULIT-R is a brief, easy to score, well-validated mea-
sure of the symptoms of bulimia. In clinical practice, it can be
extremely useful as a screening measure for persons suspected of BN,
and it can be used to track progress throughout treatment as well.

DIAGNOSTIC MEASURES
Because it allows for more detailed questioning, the clinical inter-

view remains the assessment tool of choice when diagnosing the eat-
ing disorders. Two semistructured interviews are reviewed below. For
those wanting to use a less structured interview format, Crowther and
Sherwood (1997) provide detailed suggestions for diagnostic
interviewing.
Eating Disorder Examination (EDE). The EDE (Z. Cooper & Fair-
burn, 1987; Fairburn & Cooper, 1993), currently in its 12th edition, is
a semistructured interview designed to assess psychopathology asso-
ciated with AN and BN. The 12th edition assesses two behavioral
indices, overeating and methods of extreme weight control, as well as
four subscales (restraint, eating concern, shape concern, and weight
concern). The EDE is an investigator-based interview, in which the
interviewer, not the participant, rates the severity of symptoms. This is
particularly important in rating episodes of binge eating, because the
term “binge” appears to be defined differently by laypersons and pro-
fessionals (see above).
Interrater reliability for individual items and the subscales is good
(Z. Cooper & Fairburn, 1987; Wilson & Smith, 1989), as is test-retest
reliability (Rizvi, Peterson, Crow, & Agras, 2000) and internal consis-
tency (Z. Cooper, Cooper, & Fairburn, 1989). The EDE has been
shown to discriminate between individuals with eating disorders and
controls (Z. Cooper et al., 1989) as well as between persons with BN
and restrained eaters (Rosen, Vara, Wendt, & Leitenberg, 1990; Wil-
son & Smith, 1989).
Because of the EDE’s strong psychometric properties and its
investigator-based format, it has been called the “method of choice”
for assessing the specific psychopathology of the eating disorders
(Fairburn & Beglin, 1994) and is commonly used in treatment out-
come studies. It assesses several of the central domains of interest in
the eating disorders, including binge eating, purgative behavior,
restraint, and body image concerns. However, it requires training and
may take more than an hour to complete, which make it less suitable
for some purposes (Wilson, 1993), such as screening or routine clini-

cal use. Moreover, studies have found discrepancies between the EDE
and other measures on rates of binge eating, purgative behavior, and
shape and weight concerns (see Anderson & Maloney, 2001, for a
review). Despite these shortcomings, the EDE is strongly recom-
mended as an assessment tool where the clinician has the time and
resources to permit its use.
The Interview for the Diagnosis of Eating Disorders–IV (IDED-

IV). The IDED-IV (Kutlesic, Williamson, Gleaves, Barbin, &
Murphy-Eberenz, 1998) is a semistructured interview that was devel-
oped for the purpose of differential diagnosis using DSM-IV criteria,
including AN and BN as well as BED and other subthreshold syn-
dromes currently categorized under Eating Disorder Not Otherwise
Specified (EDNOS).
The IDED-IV has good reliability and validity, and does discrimi-
nate between eating disorder diagnoses (Kutlesic et al., 1998). A par-
ticular strength of the IDED-IV is that patient responses are rated on
severity scales that are related directly to current DSM-IV criteria. In
each case, a score of 3 or above on a 1-5 scale is equal to the opera-
tional definition of that particular diagnostic symptom. Following the
interview, the rater completes a diagnostic checklist using the severity
ratings that leads directly to differential diagnosis according to DSM-
IV criteria. Because it is very user-friendly and leads directly to diag-
nosis using current criteria, the IDED-IV is a viable alternative to the
EDE in clinical practice.
MEASURES FOR TREATMENT PLANNING AND EVALUATION
There are a number of assessment instruments that may potentially

be used in treatment planning and evaluation of the eating disorders,
and the use of multiple measures for this purpose is the rule rather than
the exception. The most important point to keep in mind in treatment
planning and evaluation is to assess all core components of the eating
disorders. The measures listed below are some of the best for assess-
ing these core components most efficiently.
Self-monitoring. Self-monitoring of food intake is a useful method

of obtaining information about eating behavior. Typically, informa-

tion is collected on variables such as temporal eating patterns, type

and amounts of food eaten, frequency and topography of binge epi-
sodes and purgative behavior, and mood before and after the meal
(Crowther & Sherwood, 1997; Williamson, 1990). Self-monitoring is
an essential component of CBT for the eating disorders (Garner,
Vitousek, & Pike, 1997; Wilson, Fairburn, & Agras, 1997) and can be
used throughout treatment to monitor change in symptoms.
Self-monitoring can provide a great deal of data, and self-reported
binge/purge episodes are commonly collected in clinical practice.
However, there is some controversy over the reliability and validity of
self-reported binge/purge episodes and food intake. For example,
Anderson and Maloney (2001) found that BN treatment studies that
used self-monitoring as an outcome measure were less likely to show
decreases in binge eating and purgative behavior following treatment
than those that used the EDE, and one outcome study that used both
methods found large discrepancies between self-report and the EDE
(Walsh et al., 1997). As noted above, large errors in food estimation
are also extremely common, and some individuals deliberately mini-
mize or deny eating pathology on self-report forms (Crowther &
Sherwood, 1997). A final concern with self-monitoring is that there is
no standard format for self-monitoring; these procedures vary from
professional to professional, which potentially limits their reliability.
Despite these shortcomings, however, self-monitoring can be a useful
tool in assessing dietary restraint, binge eating, and purgative behav-
ior if viewed with appropriate caution and should be routinely
collected during treatment.
EDE. The EDE (see the Diagnostic Measures section above for a
thorough review) is also one of the best measures available for treat-
ment planning and evaluation. It was developed, in part, for use as a
measure of treatment outcome and it has been used widely in the eat-
ing disorder treatment literature. Although it has some disadvantages
for use in clinical practice (see above), it can be an extremely useful
tool for evaluating outcome if time and training permit its use.
Multifactorial Assessment of Eating Disorder Symptoms (MAEDS).

The MAEDS (Anderson, Williamson, Duchmann, Gleaves, & Barbin,
1999) is a 56-item self-report measure designed to measure six symp-

tom clusters that may be directly manipulated in treatment and are

thought to be important for treatment outcome of the eating disorders:
depression, binge eating, purgative behavior, fear of fatness, restric-
tive eating, and avoidance of forbidden foods.
The test-retest reliability and internal consistency reliability of the
MAEDS are good (Anderson, Williamson, Duchmann, et al., 1999),
and a recent study of the criterion validity of the MAEDS found that
subscale score patterns matched well with the symptom profiles gen-
erated from a diagnostic interview (Martin, Williamson, & Thaw,
2000).
The MAEDS was designed specifically for use as a treatment out-
come measure. It is brief and easy to administer, and its multifactorial
design allows for a detailed analysis of symptom domains. Thus,
changes in specific symptoms can be tracked throughout treatment.
The MAEDS is a new measure and it has yet to be widely adopted in
the literature, but it shows promise as a simple, easy to use outcome
measure suitable for clinical practice.
Eating Disorders Inventory–2 (EDI-2). The EDI-2 (Garner, 1991)

is a 91-item self-report measure that assesses symptom domains asso-
ciated with AN and BN. The EDI-2 was developed from an earlier ver-
sion of the measure (EDI; Garner, Olmstead, & Polivy, 1983), which
had eight scales (Drive for Thinness, Bulimia, Body Dissatisfaction,
Ineffectiveness, Perfectionism, Interpersonal Distrust, Interoceptive
Awareness, and Maturity Fears); the EDI-2 kept the original eight
scales and added three more (Asceticism, Impulse Regulation, and
Social Insecurity).
Most of the psychometric information on the EDI was conducted
using the original version of the EDI. Test-retest reliability of the orig-
inal EDI subscales has been shown to be adequate (Crowther, Lilly,
Crawford, & Shepard, 1992; Wear & Pratz, 1987). The internal con-
sistency of the EDI-2 is higher for the original scales than for the new
scales (Eberenz & Gleaves, 1994).
The EDI has been shown to discriminate between individuals with
AN and controls (Garner et al., 1983) and BN and controls (Schoemaker,
Verbraak, Breteler, & van der Staak, 1997), and EDI scores are associ-
ated with problematic eating behavior (Bourne, Bryant, Griffiths,

Touyz, & Beumont, 1998). Although the Drive for Thinness, Bulimia,
and Body Dissatisfaction scales are most strongly correlated with
eating-related pathology (Garner et al., 1983; Hurley, Palmer, &
Stretch, 1990), scores on a number of the scales have been shown to
improve with treatment (e.g., Bizeul, Sadowsky, & Rigaud, 2001;
Thiel, Zueger, Jacoby, & Schuessler, 1998).
The EDI-2 is one of the most frequently used self-report assess-
ment measures (Williamson et al., 1996) and it assesses many of the
central domains of the eating disorders, including binge eating and
purging and body image disturbance. Although the scales do not
strictly adhere to DSM-IV-TR criteria for the eating disorders, it is rel-
atively brief, is responsive to treatment, and assesses a number of the
essential eating disorder domains.
Body Shape Questionnaire (BSQ). The BSQ is a 34-item self-

report measure designed to assess negative feelings about one’s body
size and shape (P. J. Cooper, Taylor, Cooper, & Fairburn, 1987). Higher
scores are reflective of more body dysphoria, an aspect of body image
disturbance; a score of 110 or above is indicative of clinically signifi-
cant body dysphoria (P. J. Cooper et al., 1987). Although short forms
of the measure have been developed (Evans & Dolan, 1993), includ-
ing one specifically developed for use in an AN population (Dowson
& Henderson, 2001), the original version remains most widely used in
the literature. The BSQ has been shown to have good reliability and
validity, and has been shown to discriminate between persons with
BN and controls as well as persons in body image therapy and controls
(P. J. Cooper et al., 1987; Rosen, Jones, Ramirez, & Waxman, 1996).
Although other commonly used assessment measures also provide
some information about weight and shape concerns (e.g., the EDE and
EDI-2, see above), and related constructs such as fear of fatness (e.g.,
the MAEDS), the BSQ is a brief and easy-to-score instrument that can
be used throughout the treatment process.
The Restraint Scale (RS) and the Three Factor Eating Question-
naire Cognitive Restraint Scale (TFEQ-R). The RS (Herman &
Polivy, 1980) and the TFEQ-R (Stunkard & Messick, 1985) are per-
haps the most widely used measures of dietary restraint in the litera-

ture. Although there has been some debate over the best way to mea-
sure dietary restraint via self-report (Gorman & Allison, 1995;
Heatherton, Herman, Polivy, King, & McGree, 1988; Lowe, 1993),
both the RS and TFEQ-R are brief self-report inventories with ade-
quate psychometrics (Allison, Kalinsky, & Gorman, 1992; Gorman &
Allison, 1995). The two instruments measure slightly different com-
ponents of restraint; the RS measures the consequences of chronic
unsuccessful dieting (Gorman & Allison, 1995; Heatherton et al.,
1988; Laessle, Tuschl, Kotthaus, & Pirke, 1989b), whereas the TFEQ-
R measures more successful caloric restriction, although individuals
scoring high on this scale may not actually be in a hypocaloric state
(Heatherton et al., 1988; Laessle, Tuschl, Kotthaus, & Pirke, 1989a,
1989b; Tuschl, Platte, Laessle, Stichler, & Pirke, 1990). Although
other scales also measure some features of restraint (e.g., the EDE,
EDI-2, and MAEDS), both the RS and TFEQ-R are brief alternatives
to those other scales that can be used throughout treatment.
Test meals. Test meals are an often-overlooked tool for the assess-
ment of eating disordered behavior (Andersen, 1995; Anderson &
Maloney, 2001; Anderson, Williamson, Johnson, & Grieve, 2001). A
test meal allows an assessor to obtain direct information on food con-
sumption, which bypasses some of the problems inherent in self-
report of eating. Test meals are particularly useful for individuals who
minimize or deny eating pathology on other assessment measures.
Test meals can be used in a number of ways in treatment planning
and evaluation. For example, a meal consisting of standard servings
from each of the food groups could be administered. The amount of
each food and overall calories consumed could be calculated. The
same meal could be administered periodically throughout treatment,
and change in the amount of food and calories consumed could be
used as an index of treatment progress. Used in this way, test meals
eliminate the inaccuracy associated with self-reported food intake and
provide a useful index of dietary restraint (Anderson & Maloney,
2001; Williamson, 1990). A hierarchy of feared food can also be con-
structed and utilized as part of an exposure-type intervention (e.g.,
Leitenberg, Rosen, Gross, Nudelman, & Vara, 1988; Williamson,
1990). In this context, progress along the hierarchy can also be
utilized as an index of treatment progress.

In summary, test meals can provide direct information about eating

behavior and progress in treatment over and above the information
gathered via interview, questionnaire, or self-monitoring. However,
they can be somewhat difficult to conduct (e.g., having to prepare
food), and they must be used cautiously because there is little informa-
tion about their reliability, validity, or generalizability at the present
time.
Beck Depression Inventory–II (BDI-II). Because depression is

extremely common in persons with eating disorders, practitioners
should assess depressive symptomatology regularly throughout treat-
ment. Although a number of measures exist for the assessment of
depressive symptoms, including the MAEDS (see above), the newest
revision of the Beck Depression Inventory (BDI-II; Beck, Steer, &
Brown, 1996) is one of the most widely used self-report measures in
the field, with good psychometrics (Dozois & Dobson, 2002).
DISCUSSION
This review has hopefully highlighted some of the problems in the

clinical assessment of the eating disorders and provided practitioners
with guidelines for the use of existing assessment instruments through-
out treatment. Increasingly, practitioners are being called upon by
health maintenance organizations and insurers to justify their treat-
ments and provide objective data on client progress and outcome.
Using well-validated, standardized assessment instruments in all
phases of the treatment process is a critical part of collecting this data.
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Drew A. Anderson, Ph.D., is an assistant professor in the Department of Psychology at

the University at Albany, State University of New York. His research interests span a
range of eating-related issues, from anorexia nervosa to obesity. He has a particular
interest in the assessment of eating disorders and related problems.
Jennifer D. Lundgren, M.A., is a fourth-year doctoral student in clinical psychology at

the University at Albany, State University of New York. Her research interests include
body image and behavioral treatments for weight loss. She is currently developing a
mindfulness-based behavioral weight loss treatment program, which combines tradi-
tional behavior modification, nutrition, and physical activity components with mindful-
ness training.
Jennifer R. Shapiro, M.A., is a doctoral student in clinical psychology at the University at

Albany, State University of New York. Her research interests include stress-induced eat-
ing, eating disorders, body image, and obesity.
Carrie A. Paulosky, B.A., is a clinical psychology graduate student at the University at

Albany, State University of New York. Her research interests include body image, treat-
ment and prevention of obesity, and eating disorders.


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Assessment of Eating Disorders: Review and Recommendations for Clinical Use

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Citations (this article cites 33 articles hosted on the

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Assessment of Eating Disorders

Keywords: assessment; anorexia; bulimia; clinical; review

Practitioners have come under increasing pressure to provide

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Knowing what domains to assess is an integral part of the assess-

Body weight is one of the primary features distinguishing persons

BINGE EATING AND COMPENSATORY BEHAVIOR

Binge eating and compensatory behavior such as vomiting are the

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OVERCONCERN WITH SHAPE AND WEIGHT

An extreme concern with shape and weight, sometimes character-

Dietary restraint, conceptualized as the intent to limit caloric

BODY IMAGE DISTURBANCE

There is some disagreement about the exact nature of the concept of

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body parts) and perceptual (i.e., inability to accurately gauge body

Negative affect, especially depression, often develops as a conse-

SHORTCOMINGS IN THE ASSESSMENT

The clinical assessment of eating disorders can be problematic.

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of the more critical shortcomings in the eating disorders field that is

ASSESSING CRITICAL DOMAINS OF THE EATING DISORDERS

As mentioned above, researchers have delineated a number of

The binge eating dilemma. The assessment of binge eating is a par-

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bulimic episode (OBE; Fairburn & Cooper, 1993). However,

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RECOMMENDED MEASURES FOR

Although more comprehensive reviews of assessment instruments

When screening for the presence of eating disorders, it is not neces-

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Bulimia Test–Revised (BULIT-R). The BULIT-R (Thelen, Farmer,

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Because it allows for more detailed questioning, the clinical inter-

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The Interview for the Diagnosis of Eating Disorders–IV (IDED-

MEASURES FOR TREATMENT PLANNING AND EVALUATION

There are a number of assessment instruments that may potentially

Self-monitoring. Self-monitoring of food intake is a useful method

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tion is collected on variables such as temporal eating patterns, type

Multifactorial Assessment of Eating Disorder Symptoms (MAEDS).

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tom clusters that may be directly manipulated in treatment and are

Eating Disorders Inventory–2 (EDI-2). The EDI-2 (Garner, 1991)

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Body Shape Questionnaire (BSQ). The BSQ is a 34-item self-

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In summary, test meals can provide direct information about eating

Beck Depression Inventory–II (BDI-II). Because depression is

This review has hopefully highlighted some of the problems in the

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Heinberg, L. J. (1996). Theories of body image disturbance: Perceptual, developmental, and

Downloaded from http://bmo.sagepub.com at SUNY ALBANY LIBRARY on May 31, 2007