BRIEF REPORT

Clinical Normative Data for Eating Disorder Examination Questionnaire and Eating Disorder Inventory for DSM-5 Feeding and Eating Disorder Classifications: A Retrospective Study of Patients Formerly Diagnosed Via DSM-IV Nicola Brewin1*, Jonathan Baggott1, Pat Dugard2 & Jon Arcelus1,3 1

Leicestershire Eating Disorder Service, Bennion Centre, Glenfield Hospital, Leicester, UK University of Dundee, Department of Psychology, Dundee, UK 3 Loughborough University Centre for Research into Eating Disorders, School of Sport, Exercise and Health Science, Loughborough, UK 2

Abstract Normative data for measures of eating disorder (ED) psychopathology provide a fundamental description of a presentation and a means to establish clinically significant change following an intervention. Clinical norms for the ED population are lacking and out of date following the publication of Diagnostic and Statistical Manual of Mental Health Disorders (DSM) 5. This study aimed to show that scores from the Eating Disorder Examination Questionnaire (EDE-q) and the Eating Disorder Inventory (EDI) differ across ED diagnosis groups and provide norm data for DSM-5 ED diagnoses. Patients (n = 932) presenting to an out-patient service over 5 years were retrospectively re-diagnosed based on DSM-5 criteria. Statistical analysis showed a significant difference on most subscale scores of the EDE-q and the EDI across diagnosis. Means, standard deviations and percentile ranks are presented by diagnosis. The norms detailed contribute to improving the accuracy with which scores are interpreted when using DSM-5 and aid with the assessment of clinically significant change following treatment. Copyright © 2014 John Wiley & Sons, Ltd and Eating Disorders Association. Keywords eating disorders; norms; Eating Disorder Examination Questionnaire; eating disorder inventory; DSM-5 *Correspondence Nicola Brewin, Leicestershire Eating Disorder Service, Bennion Centre, Glenfield Hospital, Leicester LE3 9DZ, UK. Tel. +44 116 225 2576. Email: [email protected] Published online in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/erv.2301

Introduction The recent publication of the much anticipated Diagnostic and Statistical Manual of Mental Health Disorders (DSM) 5 (American Psychiatric Association, 2013) has bought changes to the Feeding and Eating Disorder section. Included in the changes is the broadening of the criteria for both anorexia nervosa (AN) and bulimia nervosa (BN), with the former having the amenorrhoea criterion removed and the latter now requiring a lower frequency threshold for binge eating and purging. Prior to DSM-5, around 50% of eating disorder (ED) cases were diagnosed as EDs not otherwise specified (EDNOS) (Fairburn et al., 2007; Ricca et al., 2001). The changes to AN and BN along with the introduction of binge eating disorder (BED) as a diagnosis in its own right should see a decrease in the proportion of patients being classified as EDNOS. Several studies have already detailed this change (e.g. Fairburn & Cooper, 2011; Keel, Brown, Holm-Denoma, & Bodell, 2011). The revised EDNOS section now named other specified feeding or eating disorder (OSFED) details several conditions considered to be of potential clinical relevance with the hope that additional research will determine if these conditions warrant formal recognition and thus reduce the OSFED category yet further. These conditions have been recognised by clinicians, and their validity and clinical utility have

been investigated by researchers prior to inclusion in DSM-5., e.g. purging disorder and night eating syndrome (Keel & StriegelMoore, 2009; Striegel-Moore, Franko, & Garcia, 2009). With the publication of DSM-5, the existing clinical norms of the main assessment questionnaires used in the field of EDs are no longer representative of the diagnostic groups, having been based on DSM-IV diagnosis criteria. The newly defined OSFED presentations lack normative data, and, with the call to research these conditions to establish clinical relevance, the availability of such data is essential. The gold standard of assessment in the field of EDs is considered to be the Eating Disorder Examination (EDE) (Fairburn & Cooper, 1993), a semi-structured interview which generates an ED diagnosis along with a global and four subscale scores. The EDE has several disadvantages such as the time required for the administration, the fact that it is time consuming, can only be administered to one person at a time by a trained person and that the subjectivity of the interviewer may affect scoring. These shortcomings were addressed by Fairburn and Beglin (1994) with the development of the self-report version of the EDE the Eating Disorder Examination Questionnaire (EDE-q). This measurement is widely used within the ED field as part of the clinical assessment and as a research tool (Fairburn & Beglin, 2008).

Eur. Eat. Disorders Rev. 22 (2014) 299–305 © 2014 John Wiley & Sons, Ltd and Eating Disorders Association.

299

N. Brewin et al.

EDE-q and EDI Clinical Norms for DSM-5

The Eating Disorder Inventory (EDI) (Garner, Olmstead, & Polivy, 1983) is also a commonly used self-report questionnaire in EDs having been used in both research and clinical settings to assess symptoms and psychological features of EDs (Clausen, Rosenvinge, Friborg, & Rokkedal, 2011). For scores from such assessment tools to be meaningful, an empirical frame of reference is needed. Normative data provide that empirical context and represent the range of scores on a particular test that a population of functional (non-clinical)/ dysfunctional (clinical) individuals produce. Normative data which defines what is usual for a distinct population are of enormous importance as they provide a fundamental description of a phenomenon and permit the identification of variation in different populations and over time (O’Connor, 1990). As Welch, Birgegard, Parling and Ghaderi (2011) point out, normative data provides a framework in which psychological testing and evaluation can be interpreted. Norms provide researchers and clinicians with a realistic context in which they can compare and appraise an individual or group and aid them in development of a treatment plan when needed. However, these clinical and non-clinical norms are lacking for many commonly used measures (Jacobson & Traux, 1991). Norm scores provide a starting point for the interpretive process of what an individual’s scores mean by providing an index of the severity level of their ED psychopathology and identifying them as being in the clinical or non-clinical population. Along with this, they also provide a means to establish clinically significant change following an intervention rather than just relying on statistically significant change (Aardoom, Dingemans, Slof Op’t Landt, & Van Furth, 2012). Jacobson, Follette and Revenstorf (1984) define clinically significant change as ‘the extent to which therapy moves someone outside the range of the dysfunctional population or within the range of the functional population’. One suggested way to establish clinically significant change was proposed by Jacobson and Traux (1991). They suggested that the level of functioning following therapy would result in a score closer to the non-clinical norm than the clinical norm. For this to be established in the ED population norms for the commonly used questionnaires are required. Review of literature revealed only three studies publishing clinical norms for the EDE-q (Aardoom et al., 2012; Pennings & Wojciechowski, 2004; Welch et al., 2011). Welch et al. and Aardoom et al. report norms for all 4 diagnostic groups, AN, BN, EDNOS and BED. Neither paper included a breakdown of the sub-categories of the large EDNOS group. Pennings and Wojciechowski (2004) only report clinical norms for AN patients. All the norms are based on DSM-IV criteria. Reviews of literature have previously identified that many studies detail means for at least 3 of EDI subscale scores (Podar & Allik, 2009). The majority of these reported AN and BN norms will all have used DSM-IV or earlier as their diagnostic basis. This paper aims to show that EDE-q subscale scores and EDI subscale scores differ significantly among patients with different ED diagnoses, thereby justifying the provision of clinical normative scores for the EDE-q and EDI questionnaires across the range of ED diagnoses detailed in DSM-5, including the sub-conditions detailed in OSFED. 300

Method Sample The study used the available clinical database of the Leicestershire Adult Eating Disorder Service. This is an NHS service in the UK that offers assessment and treatment to patients, referred by primary care, of patients over the age of 18 with symptoms of an ED. The service covers a population of approximately 1 million. Patients are assessed using the Clinical Eating Disorders Rating Instrument (CEDRI) (Palmer, Christie, Cordle, Davies, & Kenrick, 1987) which is a semi-structured investigator-based interview that measures eating-related behaviours and attitudes in accordance with DSM-IV criteria. The tool has been shown to have good reliability and validity (Palmer, Robertson, Cain, & Black, 1996). As part of the clinical assessment, all new assessments are asked to complete a set of self-report questionnaires that provide a quantitative measure of current eating psychopathology as well as their wider psychological well-being. Completion of these questionnaires is not compulsory. Data from the assessments along with questionnaire responses are recorded on to a dedicated ED database. Process The records of all assessments completed between 2007 and 2011 inclusive were collected from the database (n = 932) along with related ED questionnaire data (EDEQ and EDI). EDNOS cases (n = 452) were re-diagnosed using the revised DSM-5 criteria for EDs based on information collected at assessment via the CEDRI. AN and BN cases were not re-diagnosed as the change in criteria would not affect these diagnoses. As the service was already diagnosing patients with the suggested criteria for BED in DSM-IV, patients fulfilling this diagnosis did not require re-diagnosis. A flow chart was developed based on the information available from the CEDRI and the new diagnosis criteria in DSM-5 to aid re-diagnosis. Patients were re-diagnosed under DSM-5 by following the flow chart by one of the authors (NB). A second author (JB) reviewed the process and re-diagnosed a selection of patients independently to aid the validity of the process. When disagreements occurred or diagnosis could not be reached via the flow chart, a consultation took place with a senior psychiatrist within the service, the patient notes were examined and a diagnosis agreed. Measures EDE-q The EDE-q is a self-report measure derived from the EDE (Fairburn & Cooper, 1993). The 28-item version (Fairburn & Beglin, 2008) is used in this study. The EDE-q focuses on the past 28 days and measures core elements of ED psychopathology. It provides four subscale scores, restraint, weight concern, eating concern and shape concern. A global score is also obtained. Items are scored on a 7-point Likert scale, and items for each sub-scale are summed and averaged to calculate the score. The global score is the average of all the sub-scale scores. A high score indicates greater level of ED psychopathology. The EDE-q has good reliability and internal consistency (Luce & Crowther, 1999; Peterson et al., 2007).

Eur. Eat. Disorders Rev. 22 (2014) 299–305 © 2014 John Wiley & Sons, Ltd and Eating Disorders Association.

N. Brewin et al.

EDE-q and EDI Clinical Norms for DSM-5

EDI THE EDI is a 64-item self-report questionnaire developed in 1983 (Garner et al., 1983). It is designed to assess psychological and behavioural traits present in both AN and BN. It contains three subscales measuring ED symptoms, i.e. drive for thinness (DT), bulimia (B), body dissatisfaction (BD) and five more subscales measuring more general psychological features related to EDs, i.e. ineffectiveness (I), perfectionism (P), interpersonal distrust (ID), interoceptive awareness (IA) and maturity fears (MF). Each question is scored on a 6-point scale. It has good reliability and validity (Eberenz & Gleaves, 1994; Espelage et al., 2003; Schoemaker, Van Strien, & Van der Staak, 1994).

Results Of the 932 patients assessed, 726 completed and returned either the EDI or the EDE-q or both. Demographic details of these patients are detailed in Table 1. The diagnostic category of unspecified feeding or eating disorder (UFED) (n = 51) contained a mixture of ED symptoms. The majority of cases (88%) broadly fell into patients who presented with mild to persistent ED cognitions, a healthy BMI, some level of restriction but with no significant weight loss. A variety of compensatory behaviours were exhibited but very few binged. The remaining 12% were a wide selection of presentations including selective eating with a high BMI and very mild ED cognitions with some ED behaviours (e.g. binging or SIV) and BMIs at the lower end of healthy. The very small diagnostic categories of avoidant/restrictive food intake disorder (ARFID) and purging disorder are omitted from the significance testing as such small group sizes make the test less robust. A MANOVA revealed that there was a significant difference in EDE-q sub-scale scores across patients with different diagnoses (F(20, 2282) = 6.628, p < 0.001, Wilks’ Lambda = 0.829). Robust MANOVA, which does not rely on the rather restrictive assumptions of MANOVA, confirmed this finding (p < 0.01). Follow-up post hoc analysis using ANOVAs of each subscale reported significant differences in restraint (F(5, 69) = 9.368, p < 0.001), weight concern (F(5,691) = 4.102, p = 0.001), eating concern (F(5,691) = 3.631, p = 0.003) and shape concern (F(5,691) = 3.879, p = 0.002) across the different diagnoses. All sub-scales still displayed significant differences when Bonferroni correction was applied.

Statistical analysis Norms are presented using descriptive statistics. The EDE-q was scored as directed by Fairburn and Beglin (2008), and the EDI was scored as instructed by Garner et al. (1983). Multivariate analysis of variance (MANOVA) tests were conducted to detect for any differences between EDE-q scores and EDI scores among patients with different diagnoses. Robust MANOVAs were also conducted due to the unequal covariance matrices and the asymmetric distribution of the data. Statistical analysis was conducted in SPSS 21; robust MANOVAs were performed in the free software R as this functionality is not available on SPSS. As this study uses anonymised data collected as part of the clinical assessment, NHS ethics approval was not required (National Research Ethics Service, 2010), but the study was granted Hospital Research and Development (R&D) approval.

Table 1 Demographic characteristics of the clinical population, by diagnosis, used to generate normative data Mean (SD) All ED

N Age (years) BMI Ethnicity White Mixed White Asian Black Other Unknown Occupational status Paid employment Unemployed Homemaker Student Sick/disabled Other

AN

726 244 27.7 (9.3) 26.1 (9.2) 21.2 (7.2) 15.6 (1.9) Percentage (%) 92.6 95.9 0.9 0.8 3.9 1.7 0.9 0.8 0.8 0.9 0.8 42.1 10.7 6.3 31.3 2.3 7.3

32.4 16.8 3.7 35.2 3.7 8.2

BN

BED

234 28.1 (8.5) 24.1 (5.8)

38 37.9 (9.7) 37.9 (9.8)

88.9 1.7 5.2 1.7 0.8 1.7

97.4

47 6.4 8.1 30.8 1.3 6.4

52.6 10.5 10.5 13.2 5.3 7.9

ARFID

6 27.3 (11.9) 16.5 (2.6) 100

2.6

OSFED

UFED

Atypical AN

BN low freq/ltd duration

Purging disorder

84 27.6 (9.6) 19.9 (1.9)

63 27.4 (8.4) 27.4 (7.6)

5 25 (8.4) 23.8 (7.4)

52 26.9 (8.9) 22.9 (5.9)

89.3 1.2 5.9 1.2 2.4

92.1

100

94.3

7.9

3.8

1.9 66.6 16.7 16.7

48.7 4.8 8.3 29.8 2.4 6

44.5 11.1 6.3 33.3

40

40

4.8

20

40.5 11.5 5.8 28.8 1.9 11.5

ED = eating disordered, AN = anorexia nervosa, BN = bulimia nervosa, BED = binge eating disorder, ARFID = avoidant/restrictive food intake disorder, OSFED = other spec2 ified feeding or eating disorder, UFED = unspecified feeding or eating disorder, BMI = body mass index (kg/m )

Eur. Eat. Disorders Rev. 22 (2014) 299–305 © 2014 John Wiley & Sons, Ltd and Eating Disorders Association.

301

N. Brewin et al.

EDE-q and EDI Clinical Norms for DSM-5

A MANOVA conducted on the EDI data showed significant differences in EDI sub-scale scores across patients with different diagnoses (F(40, 3001) = 15.473, p < 0.001, Wilks’ Lambda = 0.442). Once again, this finding was confirmed using a robust MANOVA (p = 0.01). Follow-up post hoc analysis using ANOVAs of each sub-scale revealed significant differences, once Bonferroni correction was

applied, in drive for thinness (F(5,695) = 3.817, p = 0.002), bulimia (F(5,695) = 105.484, p < 0.001), body dissatisfaction (F(5,695) = 11.597, p < 0.001), perfectionism (F(5,695) = 4.297, p = 0.001) and maturity fears (F(5,695) = 3.274, p = 0.006) across the different diagnoses. As most of the sub-scales on the EDE-q and the EDI showed significant differences across diagnosis, means and standard

Table 2 Means, standard deviations (SD) and ranges for EDE-q and EDI sub-scales from the clinical sample as a whole and by diagnosis Mean (SD) and range All ED

EDE-q N Restraint

Weight concern

Eating concern

Shape concern

Global score

EDI N Drive for Thinness Bulimia

Body dissatisfaction Ineffectiveness

Perfectionisim

Interpersonal Distrust Interoceptive Awareness Maturity fears

AN

BN

BED

ARFID

OSFED

UFED

Atypical AN

BN low freq/ltd duration

Purging disorder

708 3.93 (1.65) 0–6 4.49 (1.37) 0–6 3.85 (1.37) 0–6 4.83 (1.23) 0–6 4.25 (1.20) 0–6

238 4.04 (1.64) 0–6 4.21 (1.46) 0–6 3.74 (1.39) 0–6 4.58 (1.32) 0–6 4.11 (1.27) 0–6

227 3.94 (1.51) 0–6 4.76 (1.26) 0–6 4.16 (1.23) 0–6 5.05 (1.15) 0–6 4.45 (1.11) 0–6

38 2.60 (1.64) 0–6 4.63 (0.98) 2–6 4.11 (1.24) 0.6–6 4.95 (0.67) 3.25–6 4.07 (0.82) 1.51–6

6 0.4 (0.64) 0–1.8 2.7 (1.09) 0.8–4 1.1 (0.9) 0–2.4 2.98 (1.13) 0.5–3.62 1.79 (0.59) 0.93–2.78

82 4.52 (1.37) 0–6 4.52 (1.39) 0–6 3.67 (1.39) 0–6 4.95 (1.56) 0–6 4.42 (1.14) 0–5.95

61 3.51 (1.77) 0–6 4.48 (1.33) 0–6 3.74 (1.43) 0–6 4.89 (1.14) 0–6 4.15 (1.18) 0–5.86

5 3.6 (2.17) 0–6 3.52 (1.91) 1–6 2.6 (0.8) 1.6–4 4.25 (1.49) 2.5–6 3.49 (1.52) 1.42–5.35

51 4.52 (1.45) 0–6 4.68 (1.31) 0.4–6 3.63 (1.34) 0–5.8 4.96 (1.30) 0.25–6 4.40 (1.13) 0.16–5.75

712 14.40 (5.60) 0–24 6.91 (6.22) 0–21 18.51 (7.77) 0–27 14.20 (8.09) 0–30 7.25 (5.06) 0–18 6.83 (4.73) 0–21 12.20 (7.02) 0–30 5.84 (5.58) 0–24

237 13.75 (5.94) 0–24 3.33 (4.63) 0–19 16.03 (7.74) 0–27 15.49 (8.24) 0–30 7.95 (5.15) 0–18 7.03 (4.94) 0–21 12.59 (7.35) 0–30 6.86 (5.87) 0–24

230 15.57 (5.11) 0–21 11.93 (5.28) 0–21 19.31 (7.59) 0–27 14.12 (8.11) 0–30 7.54 (5.01) 0–18 7.16 (5.03) 0–21 13.25 (7.06) 0–30 5.34 (5.53) 0–24

38 12.82 (5.28) 1–21 11.52 (4.60) 4–21 24 (4.45) 11–27 13.26 (8.18) 0–29 5.79 (4.80) 0–18 5.84 (3.55) 0–12 11.55 (6.33) 1–25 3.61 (3.01) 0–11

6 1 (1.15) 0–3 0 (0)

82 15.21 (4.97) 1–21 2.76 (3.12) 0–15 18.67 (8.31) 0–27 13.32 (7.36) 0–29 7.09 (5.02) 0–17 7.13 (4.61) 0–18 11.41 (6.89) 1–29 5.85 (5.58) 0–23

63 14.11 (5.12) 2–21 8.33 (4.96) 1–21 21.14 (6.78) 2–27 12.65 (7.89) 0–30 6.53 (4.74) 0–17 6.14 (3.96) 0–14 10.25 (6.33) 0–25 5.48 (5.54) 0–23

5 11 (5.54) 3–17 2.8 (1.72) 0–5 18.6 (6.18) 12–26 8.8 (5.41) 2–18 9.6 (5.53) 3–18 8 (2.45) 5–12 11.2 (5.53) 5–19 2.4 (1.50) 0–4

51 14.23 (5.19) 0–21 3.57 (4.03) 0–21 19.78 (6.80) 3–27 14.11 (7.75) 0–30 4.88 (4.26) 0–18 5.75 (4.12) 0–18 1.37 (5.34) 1–26 6.10 (5.23) 0–22

11 (3.31) 6–15 6.33 (4.07) 1–13 5.5 (5.06) 0–14 4.17 (3.24) 1–9 7.83 (8.01) 0–24 2.83 (3.89) 0–11

EDE-q = Eating Disorder Examination questionnaire, EDI = Eating Disorder Inventory, ED = eating disordered, AN = anorexia nervosa, BN = bulimia nervosa, BED = binge eating disorder, ARFID = avoidant/restrictive food intake disorder, OSFED = other specified feeding or eating disorder, UFED = unspecified feeding or eating disorder.

302

Eur. Eat. Disorders Rev. 22 (2014) 299–305 © 2014 John Wiley & Sons, Ltd and Eating Disorders Association.

N. Brewin et al.

EDE-q and EDI Clinical Norms for DSM-5

deviations for the EDE-q and EDI scores are presented here for the sample as a whole and by diagnosis (Table 2). Percentile ranks for EDE-q global score and the 3 ED sub-scales of the EDI are detailed in Tables 3 and 4.

showed a significant difference across the six diagnostic groups used in the statistical analysis. With confirmation that different ED diagnoses report different EDE-q and EDI scores, the norms for each diagnosis are described. This differentiation of norms allows for increased accuracy in the interpretation of scores from these widely used measures of ED psychopathology. Assessment of more targeted treatments, through evaluation of clinically significant change, for specific sub-groups of patients will be more meaningful with the availability of current diagnosis specific norm

Discussion As far as we are aware, this is the first study to present normative data for the EDE-q and EDI based on DSM-5 diagnostic criteria. The subscale scores of both self-report questionnaire measures

Table 3 Percentile ranks for the EDE-q global score for all diagnoses All ED

Percentile rank 5 10 15 20 30 40 50 60 70 80 85 90 95 100

AN

1.81 2.63 3.08 3.38 3.89 4.18 4.55 4.8 5.04 5.26 5.40 5.55 5.70 6.00

BN

1.50 2.39 2.82 3.04 3.59 3.96 4.41 4.68 4.95 5.26 5.41 5.52 5.70 6.00

BED

2.39 3.09 3.48 3.76 4.14 4.50 4.69 4.91 5.11 5.34 5.42 5.62 5.75 6.00

ARFID

3.05 3.22 3.27 3.32 3.73 3.99 4.02 4.30 4.54 4.64 4.68 4.86 5.28 6.00

OSFED

UFED

Atypical AN

BN low freq/ltd duration

Purging disorder

2.27 2.70 3.17 3.60 4.11 4.47 4.73 4.90 5.15 5.34 5.44 5.61 5.71 5.95

2.37 2.79 3.26 3.35 3.61 4.01 4.34 4.53 4.79 5.30 5.35 5.53 5.66 5.86

1.55 1.68 1.81 1.94 2.42 3.11 3.80 4.20 4.60 4.91 5.02 5.13 5.24 5.35

1.04 1.14 1.25 1.35 1.50 1.65 1.75 1.85 2.03 2.20 2.35 2.49 2.64 2.78

2.72 3.15 3.28 3.66 4.04 4.36 4.85 4.98 5.13 5.20 5.28 5.40 5.58 5.75

EDE-q = Eating Disorder Examination questionnaire, ED = eating disordered, AN = anorexia nervosa, BN = bulimia nervosa, BED = binge eating disorder, ARFID = avoidant/ restrictive food intake disorder, OSFED = other specified feeding or eating disorder, UFED = unspecified feeding or eating disorder.

Table 4 Percentile ranks for the three eating disorder subscales of the EDI for all diagnoses All ED

AN

BN

BED

ARFID

OSFED Atypical AN

DT B BD DT Percentile ranks 5 2 0 4 10 5 0 7 15 8 0 9 20 10 1 11 30 13 2 14 40 15 3 17 50 16 5 20 60 17 8 23 70 18 11 25 80 19 13 27 85 20 15 27 90 20 17 27 95 21 18 27 100 24 21 27

B

BD DT

1 0 3 4.6 0 5 6 0 8 8 0 9 12 0 11 14 1 13 15 1 15 16 2 18 18 3 21 19 6 24.8 20 7 26 20 11 27 21 15 27 24 19 27

5 7 11 12 14 16 17 18 19 20 20 21 21 21

B

BD

DT

B

3 5 6 7 9 11 12.5 14 15 17 17.7 19 20 21

5 7.9 10 12 15 18 21 24 26 27 27 27 27 27

2.7 5.8 7 8 11 12 14 15.2 16.9 17.6 18 18 19.2 21

4 5 5.6 6.4 9 11 12 13 14 15 17 18 18 21

BN low freq/ltd duration

Purging disorder

BD DT B BD

DT

BD

DT

B

BD

DT

B

BD

DT

14.7 16 19.7 21 24 25 27 27 27 27 27 27 27 27

5.1 0 4 8.1 0 7 9.2 0 9 11 0 10.2 14 1 13.3 15.4 1 17 17 2 21.5 18 3 25 18 3 26 19 34.8 27 19.9 4.9 27 20 4.7 27 20.9 8.9 27 21 15 27

5 6.2 7.3 9 11.6 15 16 17 18 18 19 19 20 21

2 2.2 3 3.4 5 6 8 9 11 12 12 15.8 18 21

7 9.8 14.3 16 20.6 22 24 24.2 27 27 27 27 27 27

3.6 4.2 4.8 5.4 7.4 10.2 13 14.2 15.4 16.2 16.4 16.6 16.8 17

0.4 0.8 1.2 1.6 2.2 2.6 3 3.4 3.8 4.2 4.4 4.6 4.8 5

12.2 12.4 12.6 12.8 13.6 14.8 16 20 24 26 26 26 26 26

2.5 0 7.5 6 0 9 10 0 11.5 11 0 13 14 0 16 15 2 21 15 3 22 16 3 24 16 4 24 18 6 27 19 6.5 27 20 9 27 21 10.5 27 21 21 27

0 0 0 0 0 0 0.5 1 1.5 2 2.3 2.5 2.8 3

0 0 0 0 0 0 0 0 0 0 0 0 0 0

6.3 6.5 6.8 7 9.5 12 12.5 13 13 13 13.5 14 14.5 15

B

UFED

B

BD

EDI = Eating Disorder Inventory, DT = Drive for thinness, B = Bulimia, BD = Body dissatisfaction, ED = eating disordered, AN = anorexia nervosa, BN = bulimia nervosa, BED = binge eating disorder, ARFID = avoidant/restrictive food intake disorder, OSFED = other specified feeding or eating disorder, UFED = unspecified feeding or eating disorder.

Eur. Eat. Disorders Rev. 22 (2014) 299–305 © 2014 John Wiley & Sons, Ltd and Eating Disorders Association.

303

N. Brewin et al.

EDE-q and EDI Clinical Norms for DSM-5

data. In spite of this, it is important to highlight that in order to reach an ED diagnosis it is necessary to complete a clinical assessment by an experienced clinician. Questionnaire results alone are not sufficient to reach a diagnosis. Questionnaire results and normative data may be an aid to primary care professionals when deciding whether a referral to a specialist service is necessary. However, questionnaire results alone will not enable a clinical diagnosis to be reached unless the professional has specialist expertise in the field. Questionnaire results do not provide a substitution for a specialised clinical assessment interview. When the DSM-5 norms collected here for the EDE-q global score are compared to those collected by Aardoom et al., they are very similar, with the exception of BED, the score for the BED diagnosis being higher in the current study. Welch et al. also reported a lower norm for BED and AN based on DSM-IV diagnoses. Both these studies quote norms for EDNOS but do not break that down any further. Changes to the binge frequency criteria for BED in DSM-5, allowing more people to obtain this diagnosis, may account for the now higher EDE-q global score. More studies to look into this are required especially due to the relatively small number of BED patients used in the present study. As OSFED is a new diagnosis in DSM-5, this is the first study that provides normative data of the most used questionnaires in the ED field. This is important as OSFED can become the new EDNOS where clinical significance of the disorder and the need for treatment are unclear. It can become the catch-all DSM-5 diagnosis for patients with significant features of EDs that do not meet the criteria for any other diagnosis. Having normative and clinical data of these measurements can provide clinicians with a way to measure the need for treatment and the outcome of their intervention. Using the redefined diagnostic categories of DSM-5 within the clinical setting presented a few issues operationally. Most notably was the lack of any definition for significant weight loss. To be included in the OSFED category of Atypical AN, a patient needs to display significant weight loss but still have a weight within or above the normal range along with all other criteria for AN. With no guidance to what a significant amount of weight loss was this is often left to clinical judgement and in the case of this study usually involved a consultation with the authors and a senior consultant. In clinical practice, this may mean that a patient

REFERENCES

would be classified as Atypical AN in one unit but UFED in another. This issue was also highlighted by Birgegard, Norring and Clinton (2012). The category of UFED in this study seemed to capture a large proportion of the same type of presentation. That being patients who had a healthy BMI but exhibited ED cognitions, restrictive eating, some compensatory behaviours but with no significant weight loss reported. This would suggest that there is a potential for further sub-categories with in OSFED to capture these people who appear similar in presentation. Research into those conditions detailed in the OSFED sub-categories will benefit to aid the development of future diagnostic criteria. The findings are presented with the acknowledgement that norms for not all sub-conditions detailed in OSFED are provided. During the 5-year period looked at in the study, no cases on Night Eating Syndrome or BED of low frequency/limited duration were diagnosed. This would indicate a low prevalence of these conditions within the geographical area covered by the study or that individuals with those symptoms are not referred via their primary care doctors to specialist services due to the misunderstanding of these conditions. Studies looking over greater numbers of eating disordered patients and/or longer periods of time may yield more data for these conditions. Similarly, ARFID and purging disorder although detailed in the study did only have small sample sizes and were excluded from statistical analysis. We wish to highlight that the data presented in this paper is representative insofar as it represents those patients who have attended a specialist ED service for help. There is a plethora of evidence that the majority of those suffering with EDs are not in active treatment in specialist services (Hoek & van Hoeken 2003; Turnbull, Ward, Treasure, Jick, & Derby 1996; NICE guidelines 2004). Therefore, although we believe that this data is useful for helping target specialist treatments and furthering our knowledge, it does not encompass all those who suffer with EDs.

Acknowledgements The authors would like to thank Rebecca Scotcher, Jackie Wales and Debbie Whight for their assistance with this article.

Journal of Psychopathology and Behavioral Assessment, 33, 101–110.

tion. In C. G. Fairburn, & G. T. Wilson (Eds.), Binge Eating:

Aardoom, J. J., Dingemans, A. E., Slof Op’t Landt, M. C. T., & Van

Eberenz, K. P., & Gleaves, D. H. (1994). An examination of the inter-

Furth, E. F. (2012). Norms and discriminative validity of the

nal consistency and factor structure of the eating disorder

Eating Disorders Examination Questionnaire (EDE-Q). Eating

inventory-2 in a clinical example. International Journal of Eating

Behaviors, 13, 305–309.

Fairburn, C. G., & Cooper, Z. (1993). The Eating Disorder Examina-

Disorders, 16, 371–379.

Nature, assessment and treatment (12th edn). New York: Guilford Press, pp. 317–360. Fairburn, C. G., & Cooper, Z. (2011). Eating disorders, DSM-5 and clinical reality. The British Journal of Psychiatry, 198, 8–10.

APA. (2013). Diagnostic and Statistical Manual of Mental Disorders

Espelage, D. L., Mazzeo, S. E., Aggen, S. H., Quittner, A. L.,

Fairburn, C. G., Cooper, Z., Bohn, K., O’Connor, M., Doll, H. A., &

DSM-5 (5th edn). Washington, DC: American Psychiatric

Sherman, R., & Thompson, R. (2003). Examining the construct

Palmer, R. L. (2007). The severity and status of eating disorder

Association.

validity of the eating disorders inventory. Psychological Assessment,

NOS: implications for DSM-V. Behaviour Research and Therapy,

15, 71–80.

45, 1705–15.

Birgegard, A., Norring, C., & Clinton, D. (2012). DSM-IV Versus DSM-5: Implementation of proposed DSM-5 criteria in a large

Fairburn, C. G., & Beglin, S. J. (1994). Assessment of eating disor-

Garner, D. M., Olmstead, M. P., & Polivy, J. (1983). Development

naturalistic database. International Journal of Eating Disorders,

ders: interview or self-report questionnaire? International Journal

and validation of a multidimensional eating disorder inventory

45, 353–361.

of Eating Disorders, 16, 363–370.

for anorexia nervosa and bulimia. International Journal of Eating

Clausen, L., Rosenvinge, J. H., Friborg, O., & Rokkedal, K.

Fairburn, C. G., & Beglin, S. J. (2008). Eating disorder examination

(2011). Validating the eating disorder inventory-3 (EDI-3):

questionnaire (EDE-Q 6.0). In C. G. Fairburn (Ed.), Cognitive

Hoek, H. W., & van Hoeken, D. (2003). Review of the prevalence

A

behaviour therapy and eating disorders. New York, Guilford

and incidence of eating disorders. International Journal of Eating

Press, pp. 309–313.

Disorders, 34, 383–396.

comparison

between

561

female

eating

disorder

patients and 878 females from the general population.

304

Disorders, 2, 15–34.

Eur. Eat. Disorders Rev. 22 (2014) 299–305 © 2014 John Wiley & Sons, Ltd and Eating Disorders Association.

N. Brewin et al.

EDE-q and EDI Clinical Norms for DSM-5

Jacobson, N. S., Follette, W. C., & Revenstorf, D. (1984). Psychother-

O’Connor, P. J. (1990). Normative data; their definition, interpreta-

Ricca, V., Mannucci, E., Mezzani, B., Di Bernardo, M.,

apy outcome research: Methods for reporting variability and

tion and importance for primary care physicians. Family

Zucchi, T., Paionni, A., et al. (2001). Psychopathological

evaluating clinical significance. Behavior Therapy, 15, 336–352.

Medicine, 22, 307–311.

and clinical features of outpatients with an eating disorder

Jacobson, N. S., & Traux, P. (1991). Clinical Significance: A statistical

Palmer, R. L., Christie, M., Cordle, C., Davies, D., & Kenrick, J.

approach to defining meaningful change in psychotherapy re-

(1987). The clinical eating disorders rating instrument (CEDRI);

search. Journal of Consulting and Clinical Psychology, 59, 12–19. Keel, P. K., Brown, T. A., Holm-Denoma, J., & Bodell, L. P. (2011).

a preliminary description. International Journal of Eating

not otherwise specified. Eating and Weight Disorders, 6, 157–65. Schoemaker, C., Van Strien, T., & Van der Staak, C. (1994). Validation of the eating disorders inventory in a nonclinical

Disorders, 6, 9–16.

Comparison of DSM-IV Versus Proposed DSM-5 Diagnostic

Palmer, R., Robertson, D., Cain, M., & Black, S. (1996). The clinical

population using transformed responses and untransformed

Criteria for Eating Disorders: Reduction of Eating Disorder Not

eating disorders rating instrument (CEDRI); a validation study.

responses. International Journal of Eating Disorders, 15,

Otherwise Specified and Validity. International Journal of Eating

European Eating Disorders Review, 4, 149–156.

Disorders, 44, 553–560.

387–393.

Pennings, C. & Wojciechowski, F. L. (2004). Kort Instrumenteel De

Keel, P. K., & Striegel-Moore, R. H. (2009). The validity and clinical

Eating

Disorder

Examination

Questionnaire

(EDE-Q):

utility of purging disorder. International Journal of Eating Disor-

Nederlandse normscores voor anorexiapatienten en een niet-

ders, 42, 706–719.

eetstoornis controlegroep. Gedragstherapie, 37, 293–301.

Luce, K. H., & Crowther, J. H. (1999). The reliability of the Eating

Peterson, C. B., Crosby, R. D., Wonderlich, S. A., Joiner, T., Crow,

Striegel-Moore, R. H., Franko, D. L., & Garcia, J. (2009). The validity and clinical utility of night eating syndrome. International Journal of Eating Disorders, 42, 720–738. Turnbull, S., Ward, A., Treasure, J., Jick, H., & Derby, L. (1996). The demand for eating disorder care. An epidemiological study using

Version

S. J., Mitchell, J. E., et al. (2007). Psychometric properties of the

the general practice database. The British Journal of Psychiatry,

(EDE-Q). International Journal of Eating Disorders, 25, 349–351.

eating disorder examination-questionnaire: factor structure

169, 705–712.

National Institute of Health and Care Excellence (NICE). (2004).

and internal consistency. International Journal of Eating

Disorder

Examination-Self-Report

Questionnaire

Eating Disorders: NICE guideline. [CG9]. London: National Institute of Health and Care Excellence. National Research Ethics Service (NRES). (2010). NRES guidance on research database applications. [1.1]. www.nres.nhs.uk.

Disorders, 40, 386–389. Podar, I., & Allik, J. (2009). A Cross-cultural Comparison of the Eat-

Welch, E., Birgegard, A., Parling, T., & Ghaderi, A. (2011). Eating disorder examination questionnaire and clinical impairment assessment questionnaire: General population and clinical norms

ing Disorder Inventory. International Journal of Eating Disorders,

for young adult women in Sweden. Behaviour Research and

42, 346–355.

Therapy, 49, 85–91.

Eur. Eat. Disorders Rev. 22 (2014) 299–305 © 2014 John Wiley & Sons, Ltd and Eating Disorders Association.

305

Clinical normative data for eating disorder examination questionnaire and eating disorder inventory for DSM-5 feeding and eating disorder classifications: a retrospective study of patients formerly diagnosed via DSM-IV.

Normative data for measures of eating disorder (ED) psychopathology provide a fundamental description of a presentation and a means to establish clini...
108KB Sizes 0 Downloads 4 Views