Surgenor and Maguire Journal of Eating Disorders 2013, 1:29

http://www.jeatdisord.com/content/1/1/29

REVIEW Open Access

Assessment of anorexia nervosa: an overview of

universal issues and contextual challenges
Lois J Surgenor1* and Sarah Maguire2

Abstract
Aim: Anorexia Nervosa (AN) is a complex and clinically challenging syndrome. Intended for specialist audiences,
this narrative review aims to summarise the available literature related to assessment in the adult patient context,
synthesising both research evidence and clinical consensus guidelines.
Method: We provide a review of the available literature on specialist assessment of AN focusing on common
trajectories into assessment, obstacles accessing assessment, common presenting issues and barriers to the
assessment process, the necessary scope of assessment, and tools and techniques. It describes the further step of
synthesising assessment information in ways that can inform resultant care plans.
Results: In addition to assessment of core behaviours and diagnostic skills, considerations for the expert assessor
include the functions of primary care, systemic and personal barriers, knowledge of current assessment tools and
research pertaining to comorbid pathology in AN, assessing severity of illness, role of family at assessment, as well
as medical, nutritional and compulsory elements of assessment.
Conclusion: Comprehensive assessment of AN in the current healthcare context still remains largely the remit of
the specialist ED clinician. Assessment should remain an on-going process, paying particular attention to available
empirical evidence, thereby reducing the gap between research and practice.
Keywords: Anorexia nervosa, Assessment, Eating disorders

Introduction Assessment and a resulting early diagnosis become a

Most health workers recognise that anorexia nervosa vital task for the health system and current research
(AN) is a serious disorder that results in significant dis- continues to suggest that, although primary care is the
ability and impaired quality of life. Unfortunately for some, context of most presentation [4] areas with specialist
this disorder becomes a chronic or life-shortening illness. services have more than double the number of diagnos-
It is well-established that AN has the highest mortality able eating disorder (ED) cases, suggesting a sizeable
rate of all psychiatric disorders [1]; compared with their proportion of diagnoses do not occur until the specialist
peers without the illness the risk of premature death is ap- service level [5]. What this means for both settings is
proximately ten-fold in a person with AN [2]. Health con- worth discussion, but regardless, assessment skills and
sequences are widespread, both in terms of direct physical knowledge of the evidence base pertaining to diagnoses
and mental health effects and economic costs to society remain an important part of the skill set of the specialist
overall; a recent Australian analysis placed the total yearly clinician.
direct health system costs of AN at $59.8 million [3]. This Regardless of the setting and complexity, there are
means that although AN and AN-like conditions are rela- descriptions of ‘ideal practice’ in the assessment of the
tively rare, severe and enduring forms of AN have impair- disorder and associated health difficulties. However,
ment outcomes comparable to people with moderately assessment approaches do vary, along with models of
severe depression and schizophrenia [3]. service delivery, admission thresholds and the resources
available in specialist settings [5]. Such factors will influ-
* Correspondence: [email protected] ence the composition of a multidisciplinary assessment
1
Department of Psychological Medicine, University of Otago at Christchurch,
4 Oxford Terrace, Christchurch 8140, New Zealand team. There are suggestions about what constitutes an
Full list of author information is available at the end of the article

© 2013 Surgenor and Maguire; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the
Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work is properly cited.
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‘ideal’ assessment team, but rarely will services have all symptoms are most important in assessing medical
recommended components, and multiple tasks may fall to acuity or how severe the condition has become.
‘mini teams’ [6]. There is however areas of general consen- Systemic issues also contribute to rates of diagnosis
sus about many necessary and desirable tasks of assess- and their accuracy. GP education about risk factors and
ment and given the above constraints it often falls to the early warning signs as well as screening instruments like
specialist clinician working in relative isolation to be well the SCOFF [10] can assist detection and management,
versed in all factors pertinent to a comprehensive assess- particularly where GPs are expected to coordinate and
ment. Focusing primarily on adult populations, this paper manage concurrent medical and psychiatric conditions.
aims to reduce the gap between research and practice Close and regular liaison with ED specialists may
(as it relates to assessment of AN) by firstly providing a encourage more regular enquiry about eating difficulties
comprehensive review of the current literature relating in those who frequently present with emotional and/or
to assessment pathways, barriers to assessment, diag- physical problems. GPs are referral “gatekeepers” (whether
nostic issues, instruments for assessment of illness and intended or otherwise), and ED clinicians have a role in
severity, role of the family at assessment, comorbid pre- supporting and educating their colleagues about frontline
sentations relevant to assessment, medical, nutritional assessment practices and referral thresholds. In the
and compulsory assessment practises. Secondly, it dis- regions where there are specialist services, GPs are likely
cusses the process of synthesising information gathered to have greater awareness of eating disorders and in turn
at assessment for the purposes of formulation and refer to specialist services more frequently [6]. In any
ultimately to direct treatment. event, presentation to primary care or emergency services
should always be used as an opportunity to introduce, or
Pathways to assessment re-engage with an ED clinician or ED service if one is
Links with primary care providers available.
Given the scarcity of specialist ED services, most people
with AN will not be seen by a specialist service in the Facilitating assessment following referral
first instance, and for a significant number, specialist Early identification and treatment of AN is consistently
assessment may not occur at any stage. Half of those argued as a means to reduce the duration of AN [11,12].
with an ED are first diagnosed by their primary care A systematic review of treatment seeking has recently
physician, although of concern a sizeable minority may estimated that the median delay from onset to treatment
go through life without any help whether this is for AN for AN is 15 years [13]. Identifying the barriers between
or other emotional problems [4]. General practitioners these two time points becomes pivotal, and will likely
(GPs) and other primary health care providers are best vary. A significant minority of people referred for ED
placed to be the health practitioners first involved in problems fail to attend an initial assessment [14], and
conducting preliminary assessments, providing initial further significant attrition occurs between assessment
triage, and thereafter sharing case management with and providing and/or completing treatment. The following
other clinicians [7]. This is partly because people with sections discuss common obstacles and possible solutions.
eating disorders attend GPs and other medical speciality
services more frequently than their peer group, albeit System and resource barriers
often for conditions seemingly unrelated to the disorder. There are extensive system factors contributing to delays
The presence of an ED also increases the rate of presen- in accessing assessment. The shortage of services often
tations to Emergency Departments [4]. In terms of ac- results in prolonged waiting lists for assessment, mean-
curacy of diagnosis, AN is the ED most often accurately ing that by the time of assessment, patients may be
diagnosed by primary care physicians [8]. Atypical cases, demotivated or otherwise less likely to engage in what is
or those who do not present with all diagnostic criteria, offered. Tatham et al. [15] trialled an active ‘opt in’
can be misdiagnosed [9] or considered ‘less serious’ waitlist management strategy for an ED clinic, whereby
despite clearly having a clinically significant disorder that following initial assessment patients were required to
squarely sits within the AN spectrum. actively select to remain on the waitlist for treatment.
A number of obstacles arise for primary care health While ‘opting in’ letters may reduce the waiting time for
professionals in their attempt to detect AN and refer on an assessment [16], this triage approach is not without
to ED services. Setting obstacles include the limited con- significant risk. Specifically, those most in need of
sultation time available and relatively limited exposure assessment may be the least able or willing to ‘opt in’.
to AN. Clinical obstacles include patient minimisation of Long assessment waiting lists are likely to pose a barrier
behavioural and psychological symptoms, the diversity of to engaging in any subsequent assessment - just as these
symptom expression, and well-hidden symptoms [7]. do in many other health settings. It has been reported by
Further, there may be difficulty in determining which patients that this can send a distorted message that the
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disorder is not serious enough. World-wide, services are engagement in behaviours directed towards weight gain.
caught in the ethical dilemma of setting priorities for how Engaging in conversations that highlight this variability
scarce resources should be allocated and prioritised. As at the beginning of a therapeutic interaction is likely to
these decisions have major clinical implications, resource build alliance. As noted by [18], assessing what makes
priority-setting should be reviewed at regular intervals. people want to recover, and what recovery represents to
Suggested strategies that have been shown to increase the them, is important, and this is something highly valued
likelihood of a valid referral resulting in an assessment in- by patients themselves.
clude direct phone contact with the patient [14] accurate Of note, there is controversy regarding the ability of
written knowledge services and, where appropriate, steps clinicians to accurately assess motivation, and whether
to engage significant others (for example, family) in the this predicts anything about the likelihood of engage-
assessment process [11]. ment or even treatment outcome. Waller [19] provides a
compelling overview of the complexities involved, includ-
Barriers of ambivalence and motivation ing clinician overreliance on verbal expressions of change.
There are multiple psychological reasons why people Interestingly, similar critical analyses are now being ex-
with AN may be reluctant to present for assessment or tended to motivational enhancement techniques, noting
are guarded during an assessment. The disorder itself, at that in regard to AN, the evidence is mixed at best [20].
best, presents genuine ambiguity for many who suffer Rieger et al. [21] specifically suggests motivation is not
from it. As one woman described it, “I want to get rid of only required to alter the behavioural aspects of the illness
the disorder but not the body shape (of AN)…I want the (namely how much weight are patients are prepared to
best of both worlds” [17], page 29. AN has been demon- gain each week until they reach a healthy weight, and
strated to serve more pivotal functions of affect numbing how motivated they feel to be at a normal weight) but
or identity and the individual may see no reason to alter also feeling of self-efficacy about achieving this. Some
it at all or, as is most common, the patient may move patients will state that they are very motivated to be at a
between wanting to address it and not seeing it as a normal weight and would be prepared to gain up to a
problem. This ambivalence is complex and may shift kilo a week to do so, but when asked how confident they
even in the preliminary assessment interview. The inter- are that they can actually do this, the answer is quite
view may be infused with ‘bargaining points’ or requests different.
for ‘conditional’ or no treatment at all. With these dynam-
ics at play, careful clinical skills are required. It is import- Clinicians as barriers
ant that such bargaining is not seen as ‘manipulation’ with People presenting for assessment are often fearful of be-
the negative connotations of that concept. Rather, it ing judged or criticised. These fears are not unfounded
represents a genuine struggle with symptoms that are as it has been repeatedly demonstrated that attitudes of
both controlling and out of control, and at times deeply health professionals, including mental health specialists
confusing for the person. It can be very validating to the towards EDs, are not always positive [22], and are no
client, and move the process of assessment along more empathic than those of non-professionals [23].
smoothly, to express understanding for the two seem- Negative professional attitudes may arise through lack of
ingly opposite positions that can be held within the one training or experience [24], inadequate resources and
person, and to not dismiss or invalidate the part of the work pressure, and genuinely held stereotypes about AN
client that wants to retain the illness. Family and carers being a personal choice. These factors can contribute to
may be equally conflicted about the need for treatment, AN being seen as a disorder with relatively low prestige
with parents sometimes caught between loyalty for their by health care professionals [25]. Training and support
offspring and wanting to heed professional advice. strategies may go some way to counter these effects. As
Assessment of family functioning is discussed later in clinical experience decreases the likelihood of negative
this paper. reactions, services significantly benefit from retaining
Although overlapping with ambivalence, motivation is highly skilled staff.
a wider construct involving cognitive, behavioural, and
biological systems. Appraising motivation for treatment Early drop-out
and ability to change is an important component of any Failure to engage, or drop out once treatment begins has a
initial assessment: it often contributes to case formula- negative association with prognosis [26,27] and increases
tion, decisions made at the conclusion of assessment, the likelihood of intensive treatment utilisation in later
and subsequent treatment planning. Yet assessment of stages of illness [28]. Specialist services have lower treat-
this is far from straight forward. Motivation may be ment drop out and allow greater continuity of care with
symptom-specific: there may be high engagement in the same service, yet studies suggest that amongst those
strategies to control physical side effects, but minimal with EDs who actually attend assessment, approximately
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one-in-five drop out before treatment can start [29]. Reli- or both of the essential symptoms. Other clinicians may
able predictors (clinical or otherwise) of drop-out from misconstrue this as ‘denial’ and engage in confrontational
services are scarce [17,26,30], meaning that future assess- discussions with patients, which may be unhelpful.
ment interviews should be seen as an opportunity to ex- At very low weights, the effects of starvation will
plore the factors involved from the patient’s perspective. always distort the expression of distress, and patients in
Hudson et al. [31] found life-time treatment for AN to be general are not necessarily aware of why they behave in
33.8%, and thus much lower than other DSM-IV eating certain ways or why they may pursue certain goals. It
disorders (BN 43.2%; BED 43.6). Reducing drop-out before may be useful to assess certain symptoms from the per-
and after assessment is an obvious means to increase spective of what it would be like not to have them. For
treatment take-up. example, assessing body dissatisfaction/drive for thinness
not from the standpoint of how the person with AN
Diagnostic issues at assessment feels about their body at its current weight, but rather
AN is a syndrome involving considerable symptom vari- how they would feel about their body, and how intense
ability between and within cases over time. Cross-over their drive to lose weight would be if they imagined their
between AN subtypes is common, suggesting that those weight being within a normal weight range, holds some
with AN-Restricting Type and AN-Binge-Eating/Purging utility [36].
Type may be phases of the same condition rather than
distinct groups [32]. Diagnostic weight cut-offs are de- Culture and ethnicity
bated [9] and the severity of psychological versus physical AN may present differently in people with a non-Western
symptomatology may not always highly correlate, albeit background (see Soh et al. [37] for a review), and there are
these will be highly intertwined at extremely low weights significant body composition differences across ethnicities.
due to the behavioural, psychological, and cognitive effects For example, Asian women show higher levels of body fat
of starvation [33]. The following sections discuss key for the same BMI than their Western peers [38]. There is
issues regarding diagnostic variability. more mixed evidence that cultural issues influence psy-
chological symptom variability. While a commonly cited
Revised diagnostic criteria difference is that fear of fatness is less evident in patients
The American Psychiatric Association diagnostic criteria from a non-Western background, many studies do not
(DSM-5) [34] have recently been reviewed. Hebebrand show this [39]. Likewise, levels of body image disturbance
et al. [9] comprehensively discusses the rationale behind amongst clinical groups from different cultures have been
revised criteria, highlighting the reframing of psychological found to be largely identical despite genuine cultural dif-
symptoms so that some pejorative attitudes are removed ferences in body image concern in those who do not have
and other criteria are redefined to reflect the evidence. For an ED [40]. Studies that have historically highlighted
example, eliminating the term ‘refusal’ (to maintain body symptom variability across cultures have commonly exam-
weight), and replacing this with more objective terms de- ined ethnic minorities residing in Western countries:
scribing food restriction. The removal of the diagnostic when an ethnic group is studied in their country of origin,
criteria of amenorrhea in post-menarcheal females is well many of the proposed differences in clinical presentation
overdue given the mounting evidence that this is of ques- cannot be found. Likewise, struggles with psychological
tionable utility. Similar changes are proposed for ICD-11 control reported in AN appear universal, but importantly
[35]. Clinicians involved in the assessment of AN should it is deviation from the cultural norm (whatever the cul-
become familiar with current and future diagnostic de- ture) that seems to distinguish women with EDs from
bates in order to reduce the risk of adopting a rigid or their peer group [41]. In short, rather than ethnicity
outdated approach to formulating core psychopathology explaining any noted symptom variations, the pertinent
of AN and the expressions of this. assessment issues may relate to understanding the current
cultural norms and their dissonance with the culture of
Effect of symptoms their ethnic background.
Some features of AN can be difficult to assess meaning-
fully in that they decrease in ‘severity’ as illness severity Gender
increases. For example, fear of fatness can decrease as Although representing around one in ten people with AN
the individual’s weight drops and they are no longer [42], males with this condition are much less likely to be
confronted with fat on their own body. Similarly, drive recognised. Amongst those who do present for assess-
for thinness and body image dissatisfaction can also ment, medical complications are more likely apparent
decrease as weight decreases. To generalist clinicians, than with their female counterparts [43]. There are mixed
this could result in a failure to diagnose individuals with views about whether males present for assessment much
potentially severe AN, as they appear to lack either one earlier (see Carlat et al. [44]) or later (see Siegel et al. [43])
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than their female counterparts. Psychological symptoms Disorder Examination (EDE) [56] are often referred to as
are largely identical, although there is some limited evi- “gold standards” (APA, 2006, p.46). These are more
dence that males may have less severe scores on diagnostic time-consuming, involve training and are more likely
tools and symptom rating scales [45] and are more likely suitable for research purposes rather than clinical set-
present with particular weight control strategies (for tings, although they do possess the advantage of being
example, excessive exercise [46]) and dissatisfaction with validated to render an ED diagnosis.
muscle size and shape. Too few studies have been Irrespective of the measure used, scores are affected
conducted to examine whether the natural course of the by a number of clinical, demographic and psychometric
illness differs by gender. Some studies report a more issues. Denial may occur in interviews due to embarrass-
benign outcome in men at one year (e.g. Strober et al. ment and reluctance to disclose, whereas the risk with
[47]), while a recent long term follow-up study found no self-report measures is that patients may inaccurately es-
gender differences in 10-year survival rates [48]. Causal timate the seriousness of core symptoms [57,58], or sim-
models particularly relevant to males are still largely ply disagree that symptoms are problematic [59]. In very
speculative, although sexual orientation issues feature severe cases, administration of psychometric tests (AN-
prominently in males [49]. However it may be that gay related or otherwise) is clearly inappropriate. Wider
men may be more willing to seek help for psychological psychometric limitations arise from differences in inter-
problems. At this stage therefore, the assessment of national norms and few national clinical norms [54], and
males presenting with AN largely should follow the the utility of measures differ between adults and adoles-
same assessment considerations as females. cents [60]. Furthermore, different formats of the same
measure (e.g. EDE and EDE-Q) have only modest agree-
Assessment screening and severity tools ment ratings, with rates of agreement being dependent
Screening tools on the type of symptom being assessed [58]. In terms of
A large number of standardised self-report and interview- AN, no measure reliably distinguishes between AN and
based measures are available to clinicians. There is long- EDNOS-AN [61].
standing debate about the superiority of interviews as A positive diagnosis can be made in most cases with-
opposed to self-report measures (whether paper and out the need for a battery of psychometric tests. The
pencil or computerised), and ultimately the selection of more useful place of standardised psychometric tools is
any measure will depend on the purpose and context of to screen, assess symptom change and research. In the
assessment, along with constraints on time, availability end, standardised psychometric tools cannot replace the
of training and clinical factors. These issues are now advantages of a thorough clinical interview. As noted by
discussed. Nordbø et al. [62], “an assessment tool should never be
Self-report questionnaires are easy and quick to ad- regarded as a substitute for treating the patients indi-
minister, although they differ in their utility. Shorter vidually or replace the need for an individual exploration
measures such as the Eating Attitudes Test (EAT-12; in each single patient” (page 660). This is further
EAT-26) [50] and SCOFF [10] are useful in primary care discussed in the final section of this paper.
situations where an ED may be suspected (NICE Guide-
lines; Allen et al., 2011), and identifying the need for sec- What constitutes severity?
ond screening steps is a focus. However these are less The use of the concept of illness severity is common in
useful in specialist settings where the more relevant task ED settings, and there are solid grounds for this. For ex-
is to gather systematic information about severity and ample, severity markers can help aid treatment deci-
the extent of psychopathology. Here, longer self-report sions, potentially aid prognosis, and promote more
measures (for example, Eating Disorder Inventory (EDI-3) uniform international understandings about clinical pre-
[51], Eating Disorder Examination Questionnaire (EDE-Q) sentations [63]. However, empirically supported defini-
[52], and Yale-Brown-Cornell Eating Disorders Scale tions of severity are largely lacking. Clinicians commonly
(YBC-EDS, [53]) tend to assess two factors - a combin- default to one or more symptom markers or treatment
ation of risk factors and psychological disturbances as- intensity markers such as BMI [64] or multiple severity
sociated with AN [54]. Detailed information about indices based on different symptoms (not all of which
psychological symptoms can be elicited from these, are AN symptoms [65]), hospitalisation [66] or length of
which in turn adds to any clinical formulations. As illness [67]. In an attempt to address problems with all
standardised measures, they can be useful in assessing of the above strategies, a more recent approach has been
symptom change. the development of empirically derived tools to stage
Semi-structured or structured clinical interviews such AN severity [36,68]. Early indicators suggest that such
as the Structured Clinical Interview for DSM-IV Axis I measures involve multiple symptom dimensions, and
Disorders Clinical Version (SCID-CV) [55], and Eating neatly capture both clinical reality and patient subjective
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reality [36]. One of these instruments [67], the CASIAN, Mood disorders
largely assess the behavioural features of the ED so as to While major depression features prominently, depressive
minimise the factors of denial and the often perverse re- symptoms may also result from severe malnutrition,
duction in psychological distress discussed above, as the which almost certainly elevate these rates. Generally,
illness progresses (i.e. drive for thinness and body dissatis- however, there is robust evidence for elevated rates of
faction can decrease with severity). Longitudinal data is major depression in all AN populations, irrespective of
still needed to determine how staging instruments could whether these are clinic or community samples. Godart
usefully aid assessment, treatment pathway decisions and et al. [72] found life-time prevalence rates ranging from
the prediction of prognosis. 9.5% - 71.3%, with the variability in findings likely due to
methodological differences across studies. The overall
lifetime prevalence for eating disorders patients is esti-
Family involvement and family assessment
mated at 40%. There is debate about the most common
Where possible, it is highly desirable to have carers or
sequencing of these comorbidities with some suggesting
family involved in the assessment process given they pro-
that the mood disorder more often precedes the ED
vide much of the on-going care and share the extensive
(Cooper et al., 2002) and others highlighting past
burden of the disorder. For younger patients still living at
problems of over-diagnosing depression when instead
home, family members may need to be directly involved
symptoms may be secondary to malnutrition [57]. The
as treatment agents [69] as long as they are appropriately
consensus is that the relationship is complex. Scores on
supported and advised, noting that family members can
depression screening measures can be significantly ele-
become entangled with behaviours that maintain the
vated by an ED [73] resulting in a need to set higher
disorder [70]. For adolescents, the assessment phase may
cut-off scores in order to be meaningful. Vigilance for
more directly involve assessment of family functioning.
mood symptoms should also be ongoing given that im-
The inevitable distress about having a family member with
provements in AN can be experienced as depressogenic,
AN may need addressing in its own right and assessment
with some sufferers construing the relinquishing of
of family functioning is core where family therapy treat-
symptoms as a sign of losing control or giving in (to
ment models are to be employed. There is no clearly
treatment) [74].
superior way to assess family functioning: approaches are
Bipolar disorder co-morbidity in AN is rare [75].
likely to reflect the model of family therapy employed and
Affective disorders along this spectrum are more likely
there are several variants of this. Family therapy models
to be associated with forms of disordered eating in-
have been met with enthusiasm although a recent
volving bingeing or over-eating. How EDs and bipolar
Cochrane Collaboration review suggests a need to temper
disorders overlap requires further study.
this enthusiasm due to a range of methodological short-
comings in the small number of published treatment trials
Assessment of self-harm and suicide risk
[71]. Such moderation should equally apply to assessment
A recent meta-analysis observed a decreased risk of
processes meaning that rigid approaches to assess families
completed suicide in AN [76] over recent decades, with
should be avoided.
a standardised mortality ratio (SMR) of 31. This SMR
still represents an elevated risk when compared with
Co-morbidity other EDs and the general population. The extent to
Given psychiatric co-morbidity is common in people with which AN directly contributes to this risk as opposed to
AN, consideration of these associated problems should be the combined effects of AN and co-morbidity to this risk
routine. Those presenting for assessment may have higher is still debated [77].
rates of co-morbidity than AN community samples due to Information gathering about risk comprises a two
the additional burden and distress of these comorbid con- stepped approach. First, standard suicide self-harm risk
ditions. Indeed, these conditions may be the precipitant assessment considerations apply. Thus, just with non-ED
for presentation rather than AN itself. If psychiatric co- populations, the presence of depression increases the
morbidity is recognised, conclusions about the actual risk of suicidal behaviours and completed suicide and a
presence of a primary anxiety (or mood disorder) is often sizeable proportion of these people will have had contact
best delayed until the symptom contribution of AN can be with their GP in the week or months before death. Other
clarified, especially in the case of severe AN. Co-morbidity risk factors include a history of mental disorder, more se-
may impact on treatment engagement, in both directions, vere psychopathology overall, Axis 2 psychopathology, his-
with co-morbidity prompting assessment or in other cir- tory of self-harm/suicide attempts, and substance misuse
cumstances reducing engagement. The following sections (see Hawton et al. [78]). It follows that assessment of these
discuss common forms of co-morbidity and implications standard risk factors should always occur when engaging
for assessment. with a person presenting with AN.
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Second, the presence of particular AN symptoms or a scope of intrusive thoughts, the scope of avoidance, and
history of AN may produce additional risks. These in- any other symptoms of fear may help clarify how these
clude the presence of binge-purge patterns [79], markers features are directly part of AN or more correctly attrib-
of chronicity including illness duration and very low uted to another primary anxiety disorder. Importantly,
weight [80], and high anxiety in AN-R [79]. Rates of anxiety symptoms may not be reported due to the success
completed suicides in people with AN are debated [2], of avoidance or engaging in subtle “safety behaviours” that
with one study reporting suicide as the second most keep symptoms at bay. In such cases, anxiety symptoms
frequent cause of death in a retrospective study of those may only emerge once there are treatment demands for
treated in an ED service [81]. The most consistent find- change. As a result, the absence of anxiety symptoms on
ing is approximately 20% of deaths in AN are attribut- initial assessment should not be taken as evidence of the
able to suicide [82]. It is self-evident that assessment of absence of anxiety.
suicidal ideation and behaviours is important, especially Obsessions and compulsions particularly increase with
in those presenting with co-morbidity. starvation, and sometimes to an intensity that is compar-
Unusual forms of self-harm have been reported that are able to people with OCD. Conclusions about the presence
directly linked with efforts to maintain AN. For example, of a primary anxiety disorder should wait until the effects
ingesting large quantities of salt [83], scratching [84] and of starvation have abated.
blood-letting [85]. How these phenomena fall under the
umbrella of wider deliberate self-harm (DSH) phenomena
Substance abuse and dependence
is unclear as DSH has multiple intended functions [86].
Reported rates of substance abuse in AN vary widely
If present, such behaviours are unlikely to come to light
and are significantly associated with AN subtype (binge/
in outpatient assessment settings. Although the con-
purge), with rates as high as 35% in those who cross over
scientious clinician will assess for them, these may only
to Bulimia Nervosa (BN) after weight restoration [94]. In
be revealed following close monitoring, as occurs in
general, the presence of any bulimic symptomatology
inpatient settings.
significantly increases the likelihood of co-morbidity in-
volving a variety of substances, both illicit and legal
Anxiety disorders
[95,96]. The sequencing of co-morbid alcohol problems
There is extensive overlap between anxiety and AN symp-
and AN shows no distinctive pattern [97]. However the
toms, with AN exacerbating concurrent anxiety disorders
concurrent presence of alcohol misuse and AN should
in addition to extensive anxiety symptoms forming part of
prompt enquiry into wider psychopathology given the
the AN syndrome [87]. This makes assessment of anxiety
increased odds of this in this subpopulation [98] and the
a necessary component of any formulation, irrespective of
known increased mortality [2].
any suspected Axis 1 anxiety disorder. This is because
Other substance abuse and dependence problems in-
common anxiety treatment techniques inevitably will
clude the use of diet pills, laxatives, diuretics and other
be part of treatment. Assessment questions include the
illicit stimulants for appetite suppression and increased
extent of pre-morbid anxiety, the presence of genuine
metabolic effects [99]. Opioid and sedative use is also
co-morbidity and the degree to which anxiety symptoms
significantly elevated. In short, the assessment of sub-
are actually part of AN. These issues are addressed
stance misuse should cast a wide net, seeking informa-
in turn.
tion about illicit and over-the-counter drugs, including
Reported lifetime prevalence rates of anxiety disorders
common substances containing high levels of caffeine.
vary considerably ranging from 23%-75% (see Swinbourne
The assessment should also include patient understand-
and Touyz [88] for a review). Generally the anxiety dis-
ings about how these substances maintain AN symptoms
order is more likely to precede the onset of AN rather
(for example, warding off normal signals of hunger) or
than the other way around [89], although this may depend
manage other psychological symptoms or distress.
on the anxiety disorder in question [90]. Of the anxiety
disorders, obsessive-compulsive disorder (OCD) is the
most researched condition [91], although social phobia, Nutritional, weight, and eating behaviour assessment
other phobic states and Generalised Anxiety Disorder Obtaining a weight and nutritional history is a critical
(GAD) and anxiety-based problems such as clinical perfec- component of assessment, although this can be far from
tionism [92] have all received attention. straight-forward. Being asked to be weighed is one of the
Teasing out the functional relationship between wider most anxiety-provoking demands for someone with AN,
anxiety phenomena and/or the presence of a primary anx- even when many know their weight due to excessive
iety disorder can be challenging, and even after weight- self-monitoring. In the situation of outright refusal to be
restoration anxiety symptoms tend to persist [93]. Detailed weighed, this can be a temporary impasse if the anxiety
functional analysis of behavioural and cognitive rituals, the about this is explored. Clinicians who allow the continued
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avoidance of assessing weight may find themselves and phosphate, and glucose and liver functioning [105].
inadvertently colluding with the disorder. Assessment and monitoring for phosphate depletion is
Body mass index (BMI) is the most common metric particularly important. Hypophosphatemia is well known
used, with extreme levels (BMI ≤ 13) consistently showing to be associated with catastrophic consequences in the
a risk of a poorer outcome and elevated medical risks context of refeeding particularly for the severely under-
[81,100]. Centile charts are recommended for patients weight person.
who are younger than 18 years of age [101]. Percentage of Of concern, complications that are not reversible can
body fat is another useful indicator of risk as this also has occur in those who have yet to develop a chronic problem,
been associated with outcome [102]. and these include altered linear growth, osteoporosis, and
Apart from ascertaining current weight, there are several structural or functional brain changes [106]. It is import-
aspects of weight history that are clinically important. ant to recognise that patients may initially appear asymp-
These include obtaining information about highest and tomatic due to slow adaptation to starvation over time.
lowest-ever weight (BMI), means of weight control, and if More detailed medical assessments may be indicated for
amenorrhea is present, weight at which menses were lost those presenting with severe AN, as it is a mistake to con-
or in the case of primary amenorrhea consideration of the sider mild AN as a benign condition. Even those with mild
effect of delayed puberty. A history of a very low BMI at AN may experience prolonged periods of debilitating
any point in the illness trajectory is a risk factor for pre- symptoms [11].
mature death [2]. BMI alone is problematic in younger A full medical history and physical examination is es-
populations for whom BMI-for-age is argued as more sential to highlight immediate medical problems such as
appropriate [103]. Patient perception of their ‘ideal’ hypotension, hypothermia, bradycardia, skin conditions,
weight, and how they determined this, can provide use- and intercellular changes such as dehydration. Enquiry
ful clinical information about maintaining factors, and should extend to other gastrointestinal problems such
how AN is serving to manage psychological difficulties. as diarrhoea, constipation and abdominal cramping. A
Commonly, a particular weight may be fixated upon small number of patients may have had extensive previ-
with an expectation that achieving this will bring a sense ous medical work-up in an attempt to locate a medical
of well-being and success. Inevitably such rewards are not condition that could explain symptoms that are more
forthcoming often resulting in a decision to work towards correctly caused by AN. Likewise, although rare, other
a lower weight - as if the original goal was miscalculated. non-psychiatric causes of significant weight loss (for ex-
A food and fluid diary may help assess aspects of nutri- ample, medical conditions resulting in mal-absorbing
tional pathology, or at least start the discussion about consequences) should be considered early in the assess-
nutritional intake. Shame, embarrassment, and anxiety ment process.
about increasing nutritional intake, are amongst the fac- A medical review should include considering the pres-
tors that affect the accuracy of food diaries and other ence of other conditions that may have serious conse-
forms of self-recording. Additional enquiry should be quences while occurring in the context of AN (e.g.
made about avoided foods, behaviours and rituals around diabetes) or other causes of weight loss unrelated to AN
eating, evidence of self-imposed caloric limits, and the full (e.g. primary gastrointestinal disorders), along with a
repertoire of compensatory behaviours. review of medications that may compromise or contrib-
ute to medical risks occurring (for example, medications
Medical assessment that prolong QT intervals). Since cardiac abnormalities
The main causes of increased mortality in AN are those have been estimated to occur in up to 86% of patients
directly related to the disease [82]. Fortunately advances in [107], and cardiovascular causes are a major cause of
assessment and careful treatment of AN-related medical death [108], cardiac investigations (ECG) should check
abnormalities have helped reduce the rates of mortality for a range of cardiomyopathies, of which there are
[104] compared with earlier practices. Multiple organ many [109]. Studies suggest that is unclear when QT
systems should be reviewed at assessment and abnormal prolongation first occurs in the natural history of AN
medical findings can provide compelling objective evi- and when the period of greatest risk of cardiac abnor-
dence to ambivalent attendees who may contest the need malities may occur [107]. Endocrine screens are useful,
for treatment. The types of medical complications present- particularly checking thyroid functions and other hormo-
ing are influenced by age, clinical history, and weight his- nal disturbances.
tory. The extent of medical and physical investigations Other checks may need to include bone density scans
undertaken will depend on these factors although there is assessing for osteoporosis and spontaneous or low impact
some consensus on commonly recommended laboratory fractures, particularly if pain is a presenting complaint.
investigations. These include a full blood count, urea and When symptoms of self-induced vomiting are present, the
electrolytes, biochemistry including calcium, magnesium, risk of dental complications is high even after a relatively
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short history of vomiting [110] and dental reviews are judgement to weigh up both converging and conflicting
recommended. Common gastrointestinal disturbances in- data. A case formulation approach is also conducive to
clude gastric pain, prolonged gastric emptying and consti- building a therapeutic alliance which is vital in psycho-
pation [108], all of which can perpetuate the desire to therapeutic treatments both generally and specifically in
continue restricting. regarding to AN [119].
The presence of medical complications may or may not The formulation may include tentative hypotheses
lead to hospital admission. As noted earlier, significant about predisposing, precipitating and maintaining factors.
contextual factors, availability and regional treatment phil- Families commonly ask about causal factors fearing that
osophies influence admission decisions [111] both within assessment findings will implicate them in some way.
and between countries. When acute medical presentations Pressed for answers from distressed families (and patients
occur, particular care is needed to avoid the refeeding syn- themselves), clinicians may be tempted to be drawn on
drome and other treatment-related complications. Medical predisposing factors. However causes of AN are far from
symptoms may be alarming and prompt consideration of understood. Tentative hypotheses are best, and better
urgent steps, but cautious use of otherwise considered framed as general risk factors in the interim. Given the
routine interventions (for example, intravenous fluids) is typically prolonged time between onset and assessment
required in order to avoid catastrophic consequences combined with difficulties establishing age of onset, articu-
[112]. A small number of patients will require an explicit lating more immediate precipitating factors is equally
medical admission. fraught. It will be more possible to draw conclusions about
maintaining factors due to the extensive knowledge about
Compulsory assessments reinforcement schedules and behavioural traps in the lived
On occasions, preliminary assessments occur under experience of AN.
duress after formal steps have been taken to initiate the In a large multidisciplinary team, varying perspectives
assessment. Engagement of a reluctant patient who may and formulations may emerge and this can be clinically
require persuasion, formal or otherwise, to accept ur- useful. However such differences should never divert from
gent investigations or treatment requires skill and tact. the importance of all team members uniting behind any
The legal options and legislative pathways for compul- arising triage or treatment plan. The end result of the case
sory assessment vary across countries, but the principles formulation should be a set of working hypotheses articu-
are relatively universal and well discussed in the litera- lated into a coordinated care plan followed by all team
ture [113,114]. Legal coercion is required relatively members. This care plan should be both detailed and
infrequently [115]. Importantly, patient perceptions of broad covering immediate treatment needs and priorities
coercion, with or without the use of formal compulsion, for further investigation.
occur along a continuum [116] with many later describ-
ing formal treatment orders as helpful. Much can be Conclusion
done to mitigate distress when a compassionate and This overview in limited in its ability to fully discuss all
trusting approach is taken [117]. Decision-making must relevant factors in assessment; a decision was made to
consider patient capacity to make decisions, the urgency include issues that would be pertinent to a wide audience.
of presenting symptoms and the outcomes where com- Likewise, the scope of this overview precludes discussion
pulsory steps have been previously utilised to detain the of the steps instigating treatment following from assess-
patient. ment, although it follows that management of acute phys-
ical and psychiatric problems naturally take priority.
Synthesis and formulation of assessment information Experienced clinicians know that the process of assess-
A comprehensive assessment interview is likely to take ment is an on-going one, encompassing a need to repeat
several hours, and where clinically indicated, may re- and monitor medical investigations and revise psycho-
quire several appointments. Once sufficient and neces- logical formulations as more information comes to light,
sary information has been gathered, the next step is to symptoms worsen or improve and priorities shift. A pre-
synthesise this with other findings from other standard liminary assessment should never attempt to reach firm
assessment steps such as history taking and mental opinions about cause although formulations relating to
status examination. factors maintaining the disorder may be more apparent.
A case formulation approach is recommended to In conclusion, assessments require a systematic, rigor-
develop “a more complete picture of the patient than ous, and empathic approach that strikes an important
can be associated with a diagnosis” [[118], page 1] in- balance between carefully listening to patient needs and
corporating all presenting issues, past treatment out- dilemmas, while remaining firm and focused about the
comes and patient perspectives. It involves assimilating need for treatment. Even difficult assessment interviews
information from multiple sources and using clinical conducted under duress should leave the patient with a
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sense of dignity and that they have been heard. The as- 3. Butterfly Foundation: Paying the Price: The economic and social impact of
sessment interaction should be seen as an important eating disorders. Butterfly Foundation: Melbourne; 2012. Available from:
www.thebutterflyfoundation.org.au.
therapeutic interaction to begin building a therapeutic 4. Dooley-Hash S, Lipson SK, Walton MA, Cunningham RM: Increased
alliance, balancing both an atmosphere of acceptance emergency department use by adolescents and young adults with
[120] yet firmness without being over-confident or eating disorders. Int J Eat Disord 2012, 45:883–890.
5. Simon J, Schmidt U, Pilling S: The health service use and cost of eating
paternalistic. The most important assessment tool is the disorders. Psychol Med 2005, 35:1543–1551.
clinician and the knowledge and stance they take into 6. House J, Schmidt U, Craig M, Landau S, Simic M, Nicholls D, Hugo P,
the interpersonal interaction. An assessment will always Berelowitz M, Eisler I: Comparison of specialist and nonspecialist care
pathways for adolescents with anorexia nervosa and related eating
be a deeply complex interpersonal interaction requiring disorders. In J Eat Disord 2012, 45:949–956.
a careful clinical interview, and one based on a sound 7. Marks P, Beumont P, Birmingham CL: GPs managing patients with eating
understanding of the symptoms and issues faced by the disorders. a tiered approach. Aust Fam Physician 2003, 32:509–514.
8. Allen KL, Fursland A, Watson H, Byrne SM: Eating disorder diagnoses in
patient. general practice settings: comparison with structured clinical interview
On-going efforts are required to address substantive and self-report questionnaires. J Ment Health 2011, 20:270–280.
knowledge gaps and to encourage the uptake of evidenced- 9. Hebebrand J, Bulik CM: Critical appraisal of the provisional DSM-5 criteria
for anorexia nervosa and an alternative proposal. Int J Eat Disord 2011,
based approaches where such evidence is assessed as 44:665–678.
strong. As noted recently, “the bond that tethers our patient 10. Hill LS, Reid F, Morgan JF, Lacey JH: SCOFF, the development of an eating
to our treatment is a fragile one” [[121], page 178]. At times disorder screening questionnaire. Int J Eat Disord 2010, 43:344–351.
11. Treasure J, Russell G: The case for early intervention in anorexia nervosa:
this could be rephrased to say that the bond that tethers
theoretical exploration of maintaining factors. Br J Psychiatry 2011, 199:5–7.
assessing clinicians to the evidence is equally fragile. There 12. Von Holle A, Pinheiro AP, Thornton LM, Klump KL, Berrettini WH, Brandt H,
is a universal problem transferring research evidence into Crawford S, Crow S, Fichter MM, Halmi KA, Johnson C, Kaplan AS, Keel P, La
Via M, Mitchell J, Strober M, Woodside DB, Kaye WH, Bulik CM: Temporal
clinical practice, and this overview aims to reduce that
patterns of recovery across eating disorder subtypes. Aust NZ J Psychiatry
‘leakage’ [122] between research and practice. 2008, 42:108–117.
While not above criticism themselves, a number of 13. Hart LM, Granillo MT, Jorm AF, Paxton SJ: Unmet need for treatment in the
practice guidelines are available that outline in some de- eating disorders: a systematic review of eating disorder specific treatment
seeking among community cases. Clin Psychol Rev 2011, 31:727–735.
tail the required and desired assessment investigations, 14. Waller G, Schmidt U, Treasure J, Murray K, Aleyna J, Emanuelli F, Crockett J,
and at least draw clinicians’ attention to the quality and Yeomans M: Problems across care pathways in specialist adult eating
limitations of evidence. These include the Australasian disorder services. Psychiatr Bull 2009, 33:26–29.
15. Tatham M, Stringer H, Perera S, Waller G: "Do you still want to be seen?":
[123] (currently undergoing review), North American the pros and cons of active waiting list management. Int J Eat Disord
[124], and the British [101] guidelines. The latter of 2012, 45:57–62.
these (and the most recently published) appeared just 16. Carmen D, Shah S, Gilbert S, Russell F: Improving attendance at an eating
disorder clinic by means of an "opt in" letter. Clin Psych Forum 2007,
under a decade ago, but a recent review of the literature 173:22–25.
indicates that these guidelines are as relevant today as 17. Surgenor LJ, Plumridge EW, Horn J: 'Knowing one's self' anorexic:
they were in 2004, (http://www.nice.org.uk/nicemedia/ implications for therapeutic practice. Int J Eat Disord 2003, 33:22–32.
18. Nordbo RH, Gulliksen KS, Espeset EM, Skarderud F, Geller J, Holte A:
live/10932/55781/55781.pdf, downloaded 17 Sept 2012). Expanding the concept of motivation to change: the content of patients'
wish to recover from anorexia nervosa. Int J Eat Disord 2008, 41:635–642.
19. Waller G: The myths of motivation: time for a fresh look at some
Competing interests
received wisdom in the eating disorders? Int J Eat Disord 2012, 45:1–16.
Both authors declare that they have no competing interest.
20. Knowles L, Anokhina A, Serpell L: Motivational interventions in the eating
disorders: What is the evidence? Int J Eat Disord 2012, 46:97–107.
Authors’ contributions 21. Rieger E, Touyz SW, Beumont PJV: The anorexia nervosa stages of change
LS carried out the literature review and drafted the early version. SM revised questionnaire (ANSOCQ): Information regarding its psychometric
initial manuscript drafts and critically commented on the intellectual content. properties. Int J Eat Disord 2002, 32:24–38.
Both authors read and approved the final manuscript. 22. Morgan JF, Jones WR, Saeidi S: Knowledge and attitudes of psychiatrists
towards eating disorders. Eur Eat Disord Rev 2012, 21:84–88.
Author details 23. Stewart MC, Schiavo RS, Herzog DB, Franko DL: Stereotypes, prejudice and
1
Department of Psychological Medicine, University of Otago at Christchurch, discrimination of women with anorexia nervosa. Eur Eat Disord Rev 2008,
4 Oxford Terrace, Christchurch 8140, New Zealand. 2Centre for Eating and 16:311–318.
Dieting Disorders, University of Sydney, 92-94 Parramatta Road, Camberdown, 24. Reid M, Williams S, Burr J: Perspectives on eating disorders and service
New South Wales 2050, Australia. provision: A qualitative study of healthcare professionals. Eur Eat Disord
Rev 2010, 18:390–398.
Received: 2 December 2012 Accepted: 3 June 2013 25. Album D, Westin S: Do diseases have a prestige hierarchy? A survey
Published: 9 August 2013 among physicians and medical students. Soc Sci Med 2008, 66:182–188.
26. Sly R: What's in a name? Classifying 'the dropout' from treatment for
anorexia nervosa. Eur Eat Disord Rev 2009, 17:405–407.
References 27. Strober M, Freeman R, Morrell W: The long-term course of severe anorexia
1. Harris EC, Barraclough B: Excess mortality of mental disorder. nervosa in adolescents: survival analysis of recovery, relapse, and
Br J Psychiatry 1998, 173:11–53. outcome predictors over 10–15 years in a prospective study. Int J Eat
2. Button EJ, Chadalavada B, Palmer RL: Mortality and predictors of death in Disord 1997, 22:339–360.
a cohort of patients presenting to an eating disorders service. Int J Eat 28. Baran SA, Weltzin TE, Kaye WH: Low discharge weight and outcome in
Disord 2010, 43:387–392. anorexia nervosa. Am J Psychiatry 1995, 152:1070–1072.
Surgenor and Maguire Journal of Eating Disorders 2013, 1:29 Page 11 of 12
http://www.jeatdisord.com/content/1/1/29

29. Watkins CE Jr: The supervision of psychotherapy supervisor trainees. 54. Clausen L, Rosenvinge JH, Friborg O, Rokkedal K: Validating the Eating
Am J Psychother 1994, 48:417–431. Disorder Inventory-3 (EDI-3): A Comparison Between 561 Female Eating
30. Wallier J, Vibert S, Berthoz S, Huas C, Hubert T, Godart N: Dropout from Disorders Patients and 878 Females from the General Population.
inpatient treatment for anorexia nervosa: critical review of the literature. J Psychopath Behav Assess 2011, 33:101–110.
Int J Eat Disord 2009, 42:636–647. 55. First MB, Spitzer RL, Gibbon M, Williams JBW: Structured Clinical Interview for
31. Hudson JI, Hiripi E, Pope HG Jr, Kessler RC: The prevalence and correlates DSM-IV Axis I Disorders, Clinical Version (SCID-CV). Washington, DC: American
of eating disorders in the National Comorbidity Survey Replication. Psychiatric Press Inc.; 1996.
Biol Psychiatry 2007, 61:348–358. 56. Fairburn CG, Cooper Z: The eating disorders examination. In Binge Eating:
32. Eddy KT, Dorer DJ, Franko DL, Tahilani K, Thompson-Brenner H, Herzog DB: Nature, Assessment and Treatment. Edited by Fairburn CG, Wilson GT. New
Diagnostic crossover in anorexia nervosa and bulimia nervosa: York: Guildford Press; 1993:317–360.
implications for DSM-V. Am J Psychiatry 2008, 165:245–250. 57. Mattar L, Huas C, Duclos J, Apfel A, Godart N: Relationship between
33. Keys A, Brozek J, Henschel A, Mickelsen O, Taylor HL: The biology of human malnutrition and depression or anxiety in Anorexia Nervosa: a critical
starvation. Minneapolis: University of Minnesota Press; 1950. review of the literature. J Affect Disord 2011, 132:311–318.
34. American Psychiatric Association: Diagnostic and Statistical Manual of Mental 58. Wolk SL, Loeb KL, Walsh BT: Assessment of patients with anorexia
Disorders (DSM-5). American Psychiatric Publishing: Washington, DC; 2013. nervosa: interview versus self-report. Int J Eat Disord 2005, 37:92–99.
ISBN 5. 59. Allen S, Dalton WT: Treatment of eating disorders in primary care: a
35. Uher R, Rutter M: Classification of feeding and eating disorders: review of systematic review. J Health Psychol 2011, 16:1165–1176.
evidence and proposals for ICD-11. World Psychiatry 2012, 11:80–92. 60. Binford RB, Le Grange D, Jellar CC: Eating Disorders Examination versus
36. Maguire S, Touyz S, Surgenor L, Crosby RD, Engel SG, Lacey H, Heywood- Eating Disorders Examination-Questionnaire in adolescents with full and
Everett S, Grange DL: The clinician administered staging instrument for partial-syndrome bulimia nervosa and anorexia nervosa. Int J Eat Disord
anorexia nervosa: development and psychometric properties. Int J Eat 2005, 37:44–49.
Disord 2012, 45:390–399. 61. Le Grange D, Crosby RD, Engel SG, Cao L, Ndungu A, Crow SJ, Peterson CB,
37. Soh N, Touyz S, Surgenor LJ: Eating and body image disturbances across Mitchell JE, Wonderlich SA: DSM-IV-defined anorexia nervosa versus
cultures. Eur Eat Disord Rev 2006, 14:54–65. subthreshold anorexia nervosa (EDNOS-AN). Eur Eat Disord Rev 2013,
38. Wang J, Thornton JC, Russell M, Burastero S, Heymsfield S, Pierson RN Jr: 21:1–7.
Asians have lower body mass index (BMI) but higher percent body fat 62. Nordbo RH, Espeset EM, Gulliksen KS, Skarderud F, Geller J, Holte A: Reluctance
than do whites: comparisons of anthropometric measurements. to recover in anorexia nervosa. Eur Eat Disord Rev 2012, 20:60–67.
Am J Clin Nutr 1994, 60:23–28. 63. Maguire S, Le Grange D, Surgenor LJ, Marks P, Lacey H, Touyz S: Staging
39. Ung EK, Lee S, Kua EH: Anorexia nervosa and bulimia–a Singapore anorexia nervosa: conceptualising illness severity. Early Intervent Psych
perspective. Singapore Med J 1997, 38:332–335. 2008, 2:3–10.
40. Soh NL, Touyz S, Dobbins T, Surgenor L, Clarke S, Kohn M, Lee EL, Leow V, 64. Touyz S, Thornton C, Rieger E, George L, Beumont P: The incorporation of the
Rieger E, Ung KE, Walter G: Body image disturbance in young North stage of change model in the day hospital treatment of patients with
European and East Asian women with and without eating disorders in anorexia nervosa. Eur Child Adolesc Psychiatry 2003, 12(Suppl 1):I65–I71.
Australia and in Singapore. Eur Eat Disord Rev 2008, 16:287–296. 65. Loeb KL, Jones J, Roberto CA, Sonia Gugga S, Marcus SM, Attia E, Timothy
41. Soh N, Surgenor LJ, Touyz S, Walter G: Eating disorders across two Walsh B: Adolescent-adult discrepancies on the eating disorder
cultures: does the expression of psychological control vary? Aust NZ J examination: a function of developmental stage or severity of illness? Int
Psychiatry 2007, 41:351–358. J Eat Disord 2011, 44:567–572.
42. Rhys Jones W, Morgan JF: Eating disorders in men: a review of the 66. Milos G, Spindler A, Schnyder U, Martz J, Hoek HW, Willi J: Incidence of
literature. J Public Ment Health 2010, 9:23–31. severe anorexia nervosa in Switzerland: 40 years of development. Int J
43. Siegel JH, Hardoff D, Golden NH, Shenker IR: Medical complications in male Eat Disord 2004, 35:250–258.
adolescents with anorexia nervosa. J Adolesc Health 1995, 16:448–453. 67. Treasure J, Tchanturia K, Harrison A, Davies H, Roberts M, Oldershaw A, Stahl
44. Carlat DJ, Camargo CA Jr, Herzog DB: Eating disorders in males: a report D, Morris R, Schmidt U: Cognitive flexibility and clinical severity in eating
on 135 patients. Am J Psychiatry 1997, 154:1127–1132. disorders. Plos One (Electronic Resource) 2001, 6:e20462.
45. Nunez-Navarro A, Aguera Z, Krug I, Jimenez-Murcia S, Sanchez I, Araguz N, 68. Bauer S, Winn S, Schmidt U, Kordy H: Construction, scoring, and validation
Gorwood P, Granero R, Penelo E, Karwautz A, Moragas L, Saldana S, Treasure of the short evaluation of eating disorders (SEED). Eur Eat Disord Rev
J, Menchon JM, Fernandez-Aranda F: Do men with eating disorders differ 2005, 13:191–200.
from women in clinics, psychopathology and personality? Eur Eat Disord 69. Treasure J, Sepulveda AR, MacDonald P, Whitaker W, Lopez C, Zabala M,
Rev 2012, 20:23–31. Kyriacou O, Todd G: The assessment of the family of people with eating
46. Marks LI: Deconstructing locus of control: Implications for practitioners. disorders. Eur Eat Disord Rev 2008, 16:247–255.
J Counsel Devel 1998, 76:251–260. 70. Schmidt U, Treasure J: Anorexia nervosa: valued and visible. A cognitive-
47. Strober M, Freeman R, Lampert C, Diamond J, Teplinsky C, DeAntonio M: interpersonal maintenance model and its implications for research and
Are there gender differences in core symptoms, temperament, and practice. Br J Clin Psychol 2006, 45:343–366.
short-term prospective outcome in anorexia nervosa? Int J Eat Disord 71. Fisher CA, Hetrick SE, Rushford N: Family therapy for anorexia nervosa.
2006, 39:570–575. Cochrane Database Syst Rev 2010: . Issue 4: Art. No: CD004780.
48. Gueguen J, Godart N, Chambry J, Brun-Eberentz A, Foulon C, Divac Phd SM, 72. Godart NT, Perdereau F, Rein Z, Berthoz S, Wallier J, Jeammet P, Flament
Guelfi JD, Rouillon F, Falissard B, Huas C: Severe anorexia nervosa in men: MF: Comorbidity studies of eating disorders and mood disorders. Critical
comparison with severe AN in women and analysis of mortality. review of the literature. J Affect Disord 2007, 97:37–49.
Int J Eat Disord 2012, 45:537–545. 73. Kennedy SH, Kaplan AS, Garfinkel PE, Rockert W, Toner B, Abbey SE:
49. Keel PK, Brown TA: The impact of relationships on the association Depression in anorexia nervosa and bulimia nervosa: discriminating
between sexual orientation and disordered eating in men. depressive symptoms and episodes. J Psychosom Res 1994, 38:773–782.
Int J Eat Disord 2012, 45:792–799. 74. Mischoulon D, Eddy KT, Keshaviah A, Dinescu D, Ross SL, Kass AE, Franko DL,
50. Garner DM, Olmsted MP, Bohr Y, Garfinkel PE: The eating attitudes test: Herzog DB: Depression and Eating Disorders. J Affect Disord 2011, 130:470–477.
Psychometric features and clinical correlates. Psychol Med 1982, 12:871–878. 75. McElroy SL, Frye MA, Hellemann G, Altshuler L, Leverich GS, Suppes T, Keck PE,
51. Garner DM: Eating disorder inventory-3. Lutz, Florida: Psychological Nolen WA, Kupka R, Post RM: Prevalence and correlates of eating disorders
Assessment Resources, Inc.; 2004. in 875 patients with bipolar disorder. J Affect Disord 2011, 128:191–198.
52. Beglin S, Fairburn CG: Eating Disorder Examination Questionnaire (EDQ-Q 76. Preti A, Rocchi MB, Sisti D, Camboni MV, Miotto P: A comprehensive meta-
6.0). In Cognitive behaviour therapy and eating disorders. Edited by Fairburn analysis of the risk of suicide in eating disorders. Acta Psychiatr Scand
CG. New York: Guildford Press; 2008:265–308. 2011, 124:6–17.
53. Sunday SR, Halmi KA, Einhorn A: The Yale-Brown-Cornell Eating Disorder 77. Bodell LP, Joiner TE, Keel PK: Comorbidity-independent risk for suicidality
Scale: a new scale to assess eating disorder symptomatology. Int J Eat increases with bulimia nervosa but not with anorexia nervosa. J Psychiatr
Disord 1995, 18:237–245. Res 2013, 47:617–621.
Surgenor and Maguire Journal of Eating Disorders 2013, 1:29 Page 12 of 12
http://www.jeatdisord.com/content/1/1/29

78. Hawton K, Casanas ICC, Haw C, Saunders K: Risk factors for suicide in 102. Bodell LP, Mayer LE: Percent body fat is a risk factor for relapse in
individuals with depression: A systematic review. J Affect Disord 2013, anorexia nervosa: a replication study. Int J Eat Disord 2011, 44:118–123.
147:17–28. 103. Flegal KM, Wei R, Ogden C: Weight-for-stature compared with body mass
79. Forcano L, Alvarez E, Santamaria JJ, Jimenez-Murcia S, Granero R, Penelo E, index-for-age growth charts for the United States from the Centers for
Alonso P, Sanchez I, Menchon JM, Ulman F, Bulik CM, Fernandez-Aranda F: Disease Control and Prevention. Am J Clin Nutr 2002, 75:761–766.
Suicide attempts in anorexia nervosa subtypes. Compr Psychiatry 2011, 104. Lindblad F, Lindberg L, Hjern A: Improved survival in adolescent patients
52:352–358. with anorexia nervosa: a comparison of two Swedish national cohorts of
80. Favaro A, Santonastaso P: Suicidality in eating disorders: clinical and female inpatients. Am J Psychiatry 2006, 163:1433–1435.
psychological correlates. Acta Psychiatr Scand 1997, 95:508–514. 105. Nicholls D, Hudson L, Mahomed F: Managing anorexia nervosa. Arch Dis
81. Rosling AM, Sparen P, Norring C, von Knorring AL: Mortality of eating Child 2011, 96:977–982.
disorders: a follow-up study of treatment in a specialist unit 1974–2000. 106. Katzman DK: Medical complications in adolescents with anorexia
Int J Eat Disord 2011, 44:304–310. nervosa: a review of the literature. Int J Eat Disord 2005,
82. Papadopoulos FC, Ekbom A, Brandt L, Ekselius L: Excess mortality, causes 37(Suppl):S52–S59. discussion S87-9.
of death and prognostic factors in anorexia nervosa. Br J Psychiatry 2009, 107. Lesinskiene S, Barkus A, Ranceva N, Dembinskas A: A meta-analysis of heart
194:10–17. rate and QT interval alteration in anorexia nervosa. World J Biol Psychia
83. Morgan JF, Ahene P, Lacey JH: Salinophagia in anorexia nervosa: case 2008, 9:86–91.
reports. Int J Eat Disord 2010, 43:190–192. 108. Zipfel S, Sammet I, Rapps N, Herzog W, Herpertz S, Martens U:
84. Morgan JF, Lacey JH: Scratching and fasting: a study of pruritus and Gastrointestinal disturbances in eating disorders: clinical and
anorexia nervosa. Br J Dermatol 1999, 140:453–456. neurobiological aspects. Auton Neurosci 2006, 129:99–106.
85. Morgan JF, Lacey JH: Blood-letting in anorexia nervosa: a case study. Int J 109. Casiero D, Frishman WH: Cardiovascular complications of eating
Eat Disord 2000, 27:483–485. disorders. Cardiol Rev 2006, 14:227–231.
86. Skegg K: Self-harm. Lancet 2005, 366:1471–1483. 110. Montecchi PP, Custureri V, Polimeni A, Cordaro M, Costa L, Marinucci S,
87. Steinglass JE, Sysko R, Glasofer D, Albano AM, Simpson HB, Walsh BT: Montecchi F: Oral manifestations in a group of young patients with
Rationale for the application of exposure and response prevention to anorexia nervosa. Eat Weight Disord 2003, 8:164–167.
the treatment of anorexia nervosa. Int J Eat Disord 2011, 44:134–141. 111. Sylvester CJ, Forman SF: Clinical practice guidelines for treating restrictive
88. Swinbourne JM, Touyz SW: The co-morbidity of eating disorders and eating disorder patients during medical hospitalization. Curr Opin Pediatr
anxiety disorders: a review. Eur Eat Disord Rev 2007, 15:253–274. 2008, 20:390–397.
89. Touyz S, Swinbourne J, Hunt C, Abbott M, Russell J, St Clare T: The 112. Mascolo M, Trent S, Colwell C, Mehler PS: What the emergency
comorbidity between eating disorders and anxiety disorders: prevalence department needs to know when caring for your patients with eating
in an eating disorder sample and anxiety disorder sample. Aust NZ J disorders. Int J Eat Disord 2012, 45:977–981. Early view - Online Only.
Psychiatry 2012, 46:118–131. 113. Ayton A, Keen C, Lask B: Pros and cons of using the Mental Health Act for
90. Pallister E, Waller G: Anxiety in the eating disorders: understanding the severe eating disorders in adolescents. Eur Eat Disord Rev 2009, 17:14–23.
overlap. Clin Psychol Rev 2008, 28:366–386. 114. Carney T, Tait D, Touyz S, Ingvarson M, Saunders D, Wakefield A: Managing
91. Godart NT, Flament MF, Perdereau F, Jeammet P: Comorbidity between anorexia nervosa: Clinical, legal, and social perspectives on involuntary
eating disorders and anxiety disorders: a review. Int J Eat Disord 2002, treatment. New York: Nova; 2006.
32:253–270. 115. Carney T, Tait D, Touyz S: Coercion is coercion? Reflections on trends in
92. Fairburn CG, Cooper Z, Shafran R: Cognitive behaviour therapy for eating the use of compulsion in treating anorexia nervosa. Australas Psychiatry
disorders: a "transdiagnostic" theory and treatment. Behav Res Ther 2003, 2007, 15:390–395.
41:509–528. 116. Guarda AS, Pinto AM, Coughlin JW, Hussain S, Haug NA, Heinberg LJ:
Perceived coercion and change in perceived need for admission in patients
93. Yackobovitch-Gavan M, Golan M, Valevski A, Kreitler S, Bachar E, Lieblich A,
hospitalized for eating disorders. Am J Psychiatry 2007, 164:108–114.
Mitrani E, Weizman A, Stein D: An integrative quantitative model of
117. Tan JO, Stewart A, Fitzpatrick R, Hope T: Attitudes of patients with
factors influencing the course of anorexia nervosa over time. Int J Eat
anorexia nervosa to compulsory treatment and coercion. Int J Law
Disord 2009, 42:306–317.
Psychiatry 2010, 33:13–19.
94. Krug I, Pinheiro AP, Bulik C, Jimenez-Murcia S, Granero R, Penelo E, Masuet
118. Gody A, Haynes SN: Clinical case formulation: Introduction to a special
C, Aguera Z, Fernandez-Aranda F: Lifetime substance abuse, family history
section. Eur J Psychol Assess 2011, 27:1–3.
of alcohol abuse/dependence and novelty seeking in eating disorders:
119. Swain-Campbell NR, Surgenor LJ, Snell DL: An analysis of consumer
comparison study of eating disorder subgroups. Psychiatry Clin Neurosci
perspectives following contact with an eating-disorders service. Aust NZ
2009, 63:82–87.
J Psychiatry 2001, 35:99–103.
95. Herzog DB, Franko DL, Dorer DJ, Keel PK, Jackson S, Manzo MP: Drug abuse
120. Holte A, Gulliksen KS, Espeset EM, Nordbo RH, Skarderud F, Geller J:
in women with eating disorders. Int J Eat Disord 2006, 39:364–368.
Preferred therapist characteristics in treatment of anorexia nervosa: The
96. O'Brien KM, Vincent NK: Psychiatric comorbidity in anorexia and bulimia
patient's perspective. Int J Eat Disord 2012, 45:932–941. Early View.
nervosa: nature, prevalence, and causal relationships. Clin Psychol Rev
121. Strober M, Johnson C: The need for complex ideas in anorexia nervosa:
2003, 23:57–74.
why biology, environment, and psyche all matter, why therapists make
97. Baker JH, Thornton LM, Strober M, Brandt H, Crawford S, Fichter MM, Halmi
mistakes, and why clinical benchmarks are needed for managing weight
KA, Johnson C, Jones I, Kaplan AS, Klump KL, Mitchell JE, Treasure J,
correction. Int J Eat Disord 2012, 45:155–178.
Woodside DB, Berrettini WH, Kaye WH, Bulik CM: Temporal sequence of
122. Mickan S, Burls A, Glasziou P: Patterns of 'leakage' in the utilisation of
comorbid alcohol use disorder and anorexia nervosa. Addict Behav 2013,
clinical guidelines: a systematic review. Postgrad Med J 2011, 87:670–679.
38:1704–1709.
123. Royal Australian and New Zealand College of Psychiatrists Clinical Practice
98. Bulik CM, Klump KL, Thornton L, Kaplan AS, Devlin B, Fichter MM, Halmi KA,
Guidelines Team for Anorexia Nervosa: Australian and New Zealand
Strober M, Woodside DB, Crow S, Mitchell JE, Rotondo A, Mauri M, Cassano
clinical practice guidelines for the treatment of anorexia nervosa.
GB, Keel PK, Berrettini WH, Kaye WH: Alcohol use disorder comorbidity in Aust NZ J Psychiatry 2004, 38:659–670.
eating disorders: a multicenter study. J Clin Psychiatry 2004, 65:1000–1006.
124. American Psychiatric Association: Practice guidelines for the treatment of
99. Root TL, Pisetsky EM, Thornton L, Lichtenstein P, Pedersen NL, Bulik CM: patients. Am J Psychiatry 2000, 157:1–39.
Patterns of co-morbidity of eating disorders and substance use in
Swedish females. Psychol Med 2010, 40:105–115.
doi:10.1186/2050-2974-1-29
100. Pinter O, Probst M, Vandereycken W, Pieters G, Goris M: The predictive
Cite this article as: Surgenor and Maguire: Assessment of anorexia
value of body mass index for the weight evolution in anorexia nervosa. nervosa: an overview of universal issues and contextual challenges.
Eat Weight Disord 2004, 9:232–235. Journal of Eating Disorders 2013 1:29.
101. National Institute for Clinical Excellence: Eating disorders: Core interventions in
the treatment and management of anorexia nervosa, bulimia nervosa, and
related eating disorders. London: National Institute for Clinical Excellence; 2004.