CALIFORNIA STATE UNIVERSITY, NORTHRIDGE

Reconceptualizing Eating Disorder Diagnosis:

A Hybrid Categorical-Dimensional Model

A graduate project submitted in partial fulfillment of the requirements

For the degree of Master of Science in Counseling,

Marriage and Family Therapy

By

Sara D. Klausner

December 2016
Copyright by Sara D. Klausner 2016

ii
The graduate project of Sara D. Klausner is approved:

_________________________________________ ______________
Angela Kahn, LMFT Date

_________________________________________ ______________
Diana Losey, M.S. Date

_________________________________________ ______________
Shari Tarver-Behring, Ph.D. Date

_________________________________________ ______________
Stan Charnofsky, Ed.D., Chair Date

California State University, Northridge

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 Acknowledgments

Completing this project has been a challenging, enjoyable, and emotional

experience. I have so much gratitude for those who assisted me with its realization. I

would first like to thank my hardworking committee. Dr. Stanley Charnofsky, after

having the privilege of taking your practicum class during my first year of the program,

my academic experience has now come full circle with your signature on my culminating

experience assignment. Your expansive resources of therapeutic empathy are inspiring.

Angela Kahn, I sincerely appreciate your insights, your strength, and your professional

contributions to improve the overall competency of our field. Diana Losey, your patience

and tenacity in systematically fine-tuning each of my chapters are nothing short of

admirable. Your guidance has been profoundly helpful.

Next I would like to thank two additional faculty members. Dr. Jessica ChenFeng,

you assisted me in conceptualizing my project from the start. Your warm and sensitive

nature was just what I needed to have my ideas be validated. I would also like to express

my sincere gratitude to Dr. Diane Gehart, whom I have considered a mentor and role

model throughout the graduate program. I have so much respect and appreciation for you.

Thank you for modeling what a strong, competent, assertive, and passionate female

faculty member and psychotherapist can be.

While not a formal member of my committee, Kelly McMichael, with your

intimate knowledge of eating disorder treatment, supportively and enthusiastically guided

me through this writing process in ways that proved extremely valuable. And finally, to

my partner, Chris, thank you for your sweetness and encouragement. You really helped

me see this through, my love.

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 Table of Contents
Signature Page ............................................................................................................................................................ iii
Acknowledgments .................................................................................................................................................... iv
Abstract ........................................................................................................................................................................ vii
Chapter I: Introduction ............................................................................................................................................ 1
Purpose of Project ................................................................................................................................................ 3
Terminology ........................................................................................................................................................... 4
Summary .................................................................................................................................................................. 7
Chapter II: Literature Review ............................................................................................................................... 8
Introduction ............................................................................................................................................................ 8
Eating Disorders ................................................................................................................................................... 8
Comorbid Psychopathology .......................................................................................................................... 13
Current Criteria for Eating Disorder Diagnoses ................................................................................... 18
Criticisms of Categorical Diagnosis ............................................................................................................ 20
Revelations of the DSM-5 ............................................................................................................................... 22
Progress toward Dimensional Diagnosis ................................................................................................ 26
Evolution of Eating Disorder Diagnosis ................................................................................................... 27
Criticisms of Eating Disorder Diagnosis .................................................................................................. 32
Alternative Categorical Diagnostic Models for Eating Disorders ................................................. 37
Staging Diagnostic Models for Eating Disorders .................................................................................. 41
Dimensional and Spectrum-Based Diagnostic Models of Eating Disorders ............................. 43
Proposed Categorical-Dimensional Diagnostic Model for Eating Disorders ........................... 58
Dimensions of Categorical-Dimensional Diagnostic Model for Eating Disorders ................. 62
Assessments ......................................................................................................................................................... 67
Conclusion ............................................................................................................................................................ 75
Chapter III: Project Audience and Implementation Factors ................................................................ 76
Introduction to Assessment System and Diagnostic Model ............................................................ 76
Development of Project .................................................................................................................................. 77
Intended Audience ............................................................................................................................................ 77
Personal Qualifications ................................................................................................................................... 78
Environment and Equipment ....................................................................................................................... 78
Formative Evaluation ...................................................................................................................................... 79
Project Outline .................................................................................................................................................... 79
Chapter IV: Conclusion ......................................................................................................................................... 81
Summary ............................................................................................................................................................... 81
Evaluation ............................................................................................................................................................. 82
Recommendations for Implementation ................................................................................................... 82
Limitations ........................................................................................................................................................... 83
Recommendations for Future Research .................................................................................................. 84
Conclusion ............................................................................................................................................................ 85
References .................................................................................................................................................................. 86
Appendix A: Supplemental Figures and Table for Chapter II ............................................................ 129

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Appendix B: Assessment and Diagnosis of Eating Disorders: Instruction Manual and Case
Study Example ........................................................................................................................................................ 139
Appendix C: Graphic Conceptualizations of Categorical-Dimensional Diagnostic Model for
Eating Disorders .................................................................................................................................................... 153
Appendix D: Psychometric Measures ........................................................................................................... 157

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 Abstract

Reconceptualizing Eating Disorder Diagnosis:

A Hybrid Categorical-Dimensional Model

By

Sara D. Klausner

Master of Science in Counseling,

Marriage and Family Therapy

The diagnostic system for psychiatric illnesses in the DSM has been widely

criticized for lack of empirical backing, ambiguous validity pertaining to its categories,

high rates of transdiagnostic comorbidity, and significant within-group heterogeneity.

Eating disorder diagnoses in particular have raised concerns with regard to having a poor

reflection of clinical reality, consistently observed diagnostic crossover, lack of support

for diagnostic subtypes, and overuse of the residual unspecified category. Since eating

disorders are a pervasive and debilitating condition, proper and thorough care is

necessary for clients to approach remission. Poor clinical utility from a deficient

nosological system hinders optimal client care and early intervention. The DSM currently

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recognizes anorexia nervosa, bulimia nervosa, and binge-eating disorder as three

categorical and unique diagnoses. Multiple alternative diagnostic models for eating

disorders have been proposed, including those of a categorical and dimensional nature,

but none has received sufficient support for implementation. This project proposes a

paradigm shift in eating disorder diagnosis with a hybrid categorical-dimensional model

comprised of Restrictive Profile, which emphasizes the features of anorexia nervosa,

restricting type (AN-R), and Impulsive Profile, which describes core symptoms of binge-

eating disorder (BED); anorexia nervosa, binge-eating/purging type (AN-BP); and

bulimia nervosa (BN). The integrative biopsychosocial classification system is comprised

of dominant eating disorder symptoms, co-occurring psychiatric illnesses, and

neurobiological mechanisms. The assessment procedure utilizes psychometric measures

and clinical observations to assess dimensions of eating disorder symptomatology, level

of impairment related to the eating disturbances, comorbid psychopathology, and

clinically significant personality traits for an inclusive and personalized diagnosis. This

project presents an extensive literature review to substantiate this proposal and explores

the diagnostic and assessment approaches in detail.

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 Chapter I

Introduction
Glaring concerns surrounding standardized eating disorder (ED) diagnosis have

spawned debates for decades (e.g., Fairburn & Cooper, 2011; Thomas et al., 2015). Strict

criteria set forth by the American Psychiatric Association (APA) in the Diagnostic and

Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) for the current three

recognized eating disorders (EDs), anorexia nervosa (AN), bulimia nervosa (BN) and

binge-eating disorder (BED), prevent many individuals from warranting a specified

diagnosis, thus creating issues pertaining to managed healthcare plan reimbursement and

receiving appropriate treatment (Dingemans & Van Furth, 2015). A preponderance of

individuals have notably fallen into the residual category of other specified feeding or

eating disorder (OSFED) or unspecified feeding or eating disorder (UFED), formerly

recognized as eating disorder, not otherwise specified (EDNOS), yielding significantly

limited clinical utility and access to efficient care (Dunn, Geller, Brown, & Bates, 2010).

Individuals with subclinical symptomatology are often overlooked, as they do not meet

criteria for a specified diagnosis (Fairburn & Cooper, 2011; Uher & Rutter, 2012). A

second significant criticism of the current ED categories in the DSM-5 is the prevalence

of diagnostic crossover. Since ED presentations notoriously fluctuate across the lifespan

in both nature and severity, individuals commonly receive multiple diagnoses as

symptom expression varies (Eddy et al., 2002; Fairburn & Cooper, 2011; Fairburn &

Harrison, 2003; Tozzi et al., 2005), raising questions surrounding the longitudinal

legitimacy of discrete ED diagnoses.

The current categorical classification system of the DSM as a whole, has faced

notable disapproval. It has been argued that the criteria-based disorder descriptions are, in

1
fact, arbitrary and a poor reflection of clinical reality (Blashfield, Sprock, & Fuller, 1990;

Westen, 2012). High rates of comorbidity among psychiatric illnesses suggest

questionable validity of a rigid categorical structure (Narrow et al., 2013). Extensive

within-group heterogeneity observed under diagnostic criteria sets allows for multiple

distinct presentations of the same illness (Clark, Watson, & Reynolds, 1995). Further, the

DSM has been largely criticized for the lack of empirical evidence substantiating its

diagnostic principles (Kozak & Cuthbert, 2016).

Recent empirical data support that the current categorical classification system of

psychiatric nosology should be directed toward more dimensional conceptualizations to

address existing diagnostic deficiencies (van Elburg & Treasure, 2013; Franko & Omori,

1999; Kozak & Cuthbert, 2016; Wildes & Marcus, 2013). A dimensional diagnostic

approach including multiple psychopathological features and severity scales could be

utilized to optimize client assessment and care (e.g., van Elburg & Treasure, 2013;

Widiger & Gore, 2014). The question remains, however, regarding precisely which

dimensions should be included in order to best improve formal diagnosis (Wildes &

Marcus, 2013). Diagnostic focus should be on the level of functional impairment and the

client’s specific presenting issues rather than on observing rigid categorical cutoffs that

preclude clients in need from receiving appropriate attention (Westen, 2012).

The APA has acknowledged the many shortcomings of categorical diagnosis and

conceded that movement toward dimensional conceptualizations of nosology has positive

implications for the field of mental health (APA, 2013). The release of the DSM-5

indicated small but significant steps toward dimensional diagnosis and a departure from

categorical criteria (APA, 2013; Gehart, 2014). In its introduction, the APA offered, “In

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short, we have come to recognize that the boundaries between disorders are more porous

than originally perceived” (APA, 2013, p. 6). This edition also demonstrated an emphasis

on researched-informed criteria. The DSM-5 includes standardized assessment

instruments in Section III to be utilized in routine clinical practice for assessment and

treatment purposes. These tests indicate progress toward grounding diagnoses in

empirically substantiated evidence and promoting observable tracking of client progress

(APA, 2013; Narrow et al., 2013).

Purpose of Project

This project recommends a paradigm shift in the nosology of EDs to optimize

client care and clinical utility, proposing a hybrid categorical-dimensional diagnostic

model that emphasizes two main subtypes of EDs: Restrictive Profile (RP) and Impulsive

Profile (IP). Each profile is comprised of primary ED symptoms (i.e., food restriction and

binge eating and/or purging) and related psychopathology. The project also proposes a

third category labeled Transdiagnostic Dimensions (TD), which contains a list of clinical

issues that are commonly observed in both subtypes and can be added to the client’s

diagnosis as appropriate for a personalized and detailed analysis. Both RP and IP are

thorough and multi-faceted in their construction, including dimensions of relevant

psychological features and neurobiological mechanisms in addition to ED disturbances.

This diagnostic approach yields clinical utility by addressing two fundamental diagnostic

concerns: (a) eliminating the residual category of unspecified EDs and (b) minimizing

diagnostic crossover throughout the client’s lifespan.

For purposes of assessment in this project, clients will be administered the

following psychometric measures: the Eating Disorder Inventory, Third Edition (EDI-3;

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Garner, 2004), Clinical Impairment Assessment (CIA; Bohn & Fairburn, 2008), Cross-

Cutting Symptom Measure (CCSM; APA, 2013), CCSM Level 2 measures as needed,

and Personality Inventory for DSM-5 (PID-5; APA, 2013). To arrive at the correct

diagnosis, the battery of assessments evaluates multiple dimensions of psychopathology,

including the type and frequency of ED behaviors, level of impairment due to eating

pathology, comorbid psychopathology (e.g., evidence of mood disturbances and

substance abuse), and clinically significant personality traits. Clinicians in both inpatient

and outpatient settings can utilize the assessment and diagnostic procedures to inform

evaluation and treatment planning for clients with EDs.

Benefits of the proposed assessment and diagnostic procedure include: (a)

acknowledging differences in treatment responses between RP and IP, (b) clustering

together commonly co-occurring psychological issues for a more comprehensive clinical

picture, (c) identifying within-group heterogeneity, (d) detecting subclinical presentations

of EDs for early intervention, and (e) allowing for observable and measurable progress

should the clinician choose to re-administer the assessments at later points in treatment.

Terminology

Below are brief definitions for key terms used in this project.

Alexithymia: “A deficit in affect regulation, specifically referring to difficulty identifying

feelings and distinguishing them from bodily sensations stemming from

emotional activation, difficulty in describing […] feelings to others, limited

imaginative processes […], and externally oriented cognitive style related to the

stimulus” (Pace, Cavanna, Guiducci, & Bizzi, 2015, p. 2)

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Binge eating: Eating a subjectively large volume of food in a discrete period of time

while experiencing a lack of control (APA, 2013); also referred to as “bingeing”

Categories: Discrete entities that are discontinuous with one another (Williamson et al.,

2005)

Cluster analysis: Statistical procedures used to determine the categorical nature of

entities, such that groups sharing similar features can be “clustered” together (e.g.,

ED symptom profiles; Williamson et al., 2005)

Compensatory behaviors: Inappropriate measures taken to prevent weight gain (e.g., self-

induced vomiting, laxative misuse, excessive exercise; APA, 2013); also referred

to as “purging”

Compulsivity: A neurobiological mechanism and personality trait that describes engaging

in behavior(s) repeatedly and/or ritualistically despite adverse consequences

(Robbins, Gillan, Smith, de Wit, & Ersche, 2012)

Diagnostic crossover: A phenomenon describing the longitudinal instability of diagnoses,

such that a client may meet criteria for multiple distinct disorders of a similar

nature (e.g., AN-BP and BN) across the lifespan (Castellini et al., 2011); also

referred to as “diagnostic migration”

Dimensions: Features of a diagnosis that reside on the same continuum, as opposed to

categories (Williamson et al., 2005)

Eating disorders: Psychiatric illnesses characterized by pathological eating disturbances,

fear of fatness, excessive preoccupation with body shape and weight, and undue

influence of body image perceptions on self-evaluation (Herpertz-Dahlmann,

2015)

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Endophenotype: Genetically influenced symptoms or neurobiological traits that may

predispose an individual to developing a psychiatric illness (Robbins et al., 2012;

Stice, Ng, & Shaw, 2010); also referred to as “intermediate phenotype”

Impulsivity: A neurobiological mechanism and personality trait that describes “the

tendency to act prematurely, without foresight, despite adverse consequences”

(Robbins et al., 2012, p. 82)

Latent structure analysis: Statistical procedures used to identify subtypes in multivariate

categorical data; “Latent class analysis attempts to determine the number and

composition of the unobserved latent classes that give rise to the observed data”

(Bulik, Sullivan, & Kendler, 2000, p. 887); “latent profile analysis” and “latent

class analysis” are two such procedures

Neuroprogression: A concept describing neurobiological mechanisms that influence the

prognosis and course of a psychiatric illness (Berk et al., 2010)

Phenotype: A set of symptoms or traits (e.g., ED diagnoses) that are a result of an

interaction between genetic influences and environmental factors (Robbins et al.,

2012; Stice, Ng, & Shaw, 2010)

Purging: See “compensatory behaviors”

Restriction: Intentionally avoiding adequate food intake in order to prevent weight gain

(APA, 2013)

Set-shifting: An executive function that describes the ability to move back and forth

among multiple cognitive tasks (Wildes & Marcus, 2013)

Taxometric analysis: Statistical procedures used for purposes of classification to

determine if entities (e.g., ED diagnoses) reside on the same continuum or if they

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 have discrete, discontinuous properties (Meehl, 1995; Williamson, Womble,

Smeets, Netemeyer, Thaw, Kutlesic, & Gleaves, 2002)

Taxonic: Of a discrete and categorical nature, as opposed to dimensional (Williamson,

Gleaves, & Stewart, 2005)

Transdiagnostic: Describes a feature or set of features that cuts across multiple diagnoses

(e.g., drive for thinness in EDs; Fairburn, 2008)

Summary

The current categorical classification system of the DSM as a whole has faced

notable disapproval. It has been argued that the criteria-based disorder descriptions are in

fact arbitrary and a poor reflection of clinical reality (Blashfield, Sprock, & Fuller, 1990;

Westen, 2012). Recent empirical data supports that the current categorical classification

system of psychiatric nosology should be directed toward more dimensional

conceptualizations to address existing diagnostic deficiencies (van Elburg & Treasure,

2013; Franko & Omori, 1999; Kozak & Cuthbert, 2016; Wildes & Marcus, 2013). As a

result, this project recommends a paradigm shift in the nosology of EDs to optimize

client care and clinical utility, proposing a hybrid categorical-dimensional diagnostic

model. In order to provide a foundation for this proposal, a review of relevant literature

has been conducted and will be discussed in the next chapter. EDs and concerns

pertaining to current diagnostic standards will be explored as support is gathered for the

proposed assessment system and diagnostic model. The definition and nature of EDs will

be presented, as well as the current diagnostic standards for each ED. The evidence base

regarding more effective diagnostic models will be examined, followed by a detailed

description of the proposed model and assessment and diagnostic procedure.

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 Chapter II

Literature Review
Introduction

This chapter is a review of extant literature relevant to the proposed methods of

assessment and diagnosis of eating disorders (EDs). The literature review discusses the

following: (a) features of EDs, including symptomatology, etiology and risk factors,

comorbid psychopathology, and current diagnostic criteria; (b) criticisms of traditional

categorical diagnosis; (c) innovative modifications presented in the DSM-5 and evident

progress toward dimensional diagnostic conceptualizations; (d) the evolution of and

concerns pertaining to ED diagnosis; (e) an overview of alternative classification models

using categorical and dimensional methods that have been proposed for general

psychiatric nosology and specifically EDs; (f) unique and overlapping features of ED

etiology, symptomatology, commonly co-occuring disorders, and empirically derived

neurobiological substrates as support for the hybrid categorical-dimensional profile

model; and (g) the psychometric tests recommended for use in the assessment system.

Eating Disorders

The third most common pervasive illness among adolescents, EDs are a chronic

and debilitating condition that affect multiple levels of human functioning (Fairburn,

2008). Typical onset occurs between 14 and 19 years of age. EDs are characterized by “a

fear of fatness and a pathologic preoccupation with weight and shape” (Herpertz-

Dahlmann, 2015, p. 178), and perceptions of body image typically have undue influence

on self-worth. Prevalence rates for anorexia nervosa (AN), bulimia nervosa (BN), and

binge-eating disorder (BED) are estimated at 0.9%, 1.5%, and 3.5% among women, and

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0.3%, 0.5%, and 2.0% among men, respectively (Hudson, Hiripi, Harrison, Pope, Jr., &

Kessler, 2007).

AN has the highest mortality rate of all psychiatric illnesses (Herpertz-Dahlmann,

2015). Approximately one-fifth of deaths related to AN are a result of suicide (Arcelus,

Mitchell, Wales, & Nielsen, 2011). Individuals with this diagnosis present with excessive

dissatisfaction with how they perceive their bodies and develop extreme aversions to

certain foods and gaining weight (Herpertz-Dahlmann, 2015). Clients may engage in

drastic measures to restrict food intake and vigorous exercise regimens to lower weight.

Anorexia symptoms may be erroneously glamorized as “egosyntonic,” despite their

profound impact on overall functioning and quality of interpersonal relationships. AN

may be further classified as restricting type (AN-R) or binge-eating/purging type (AN-

BP; APA, 2013).

BN has similar underlying pathology that leads to symptom manifestation,

including fat phobia and extreme means to control one’s weight (Herpertz-Dahlmann,

2015). Episodes of binge eating occur intermittently throughout sustained efforts at food

restriction, followed by compensatory measures (i.e., self-induced vomiting) to regulate

calories absorbed. Binges are typically characterized by a sense of losing control and

consuming a larger-than-typical quantity of food in one sitting (APA, 2013). Individuals

with BN do not present as emaciated like those with AN; typically weight is within

normal range (Fairburn & Harrison, 2003).

Clients diagnosed with BED engage in similar binge-eating behavior to those with

BN, but they do not engage in purging episodes (Herpertz-Dahlmann, 2015). Binge

eating is accompanied by a loss of control, which implies a degree of dissociation and

9
inability to regulate the volume of food intake during a discrete period of time. BED is

commonly associated with body dissatisfaction, despite lack of overt effort to control

weight gain (Goldschmidt et al., 2010).

Etiology and risk factors. The etiology of EDs is likely an interaction of both

biological and environmental factors (e.g., Culbert, Racine, & Klump, 2015; Garner and

Desai, 2000). Researchers have isolated susceptibility to social pressures (Stice, 2002),

genetic factors (Iranzo-Tatay et al., 2015), family-of-origin environment (Dring, 2015),

and trauma history (Woodside & Staab, 2006) as causes that inform ED development. A

combination of these domains leads to even higher risk (Culbert et al., 2015; Garner &

Desai, 2000; Strober & Peris, 2011).

Garner (1993) contends that EDs, specifically AN and BN, are “multidetermined

disorders” that have shared symptomatology resulting from complex and varied

developmental substrates. Physiological and psychological determinants, interwoven with

certain family environments and sociocultural contexts, appear to significantly influence

the expression of ED symptoms (Garner and Desai, 2000). A study on risk factors

identified the following elements precipitating EDs: ethnicity, gender, gastrointestinal

and eating issues in childhood, trauma history, general comorbid psychopathology, low

self-worth, and high concerns regarding shape and weight (Jacobi, Hayward, de Zwaan,

Kraemer, & Agras, 2004). Other risk factors include perfectionism, negative affect, and

high family standards, and family discord (Pike et al., 2008).

It appears that elevated risk for ED symptom expression is a result of the

relationship between certain sociocultural factors (e.g., thinness pressure, exposure to

media) and personality traits (e.g., rigidity, perfectionism, negative affect; Culbert et al.,

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2015). The primary age group of the prodromal eating disorder population is children and

adolescents, a population extremely vulnerable to the influence of societal discourses and

social media (Borzekowski, Schenk, Wilson, & Peebles, 2010). Individuals are readily

exposed to unrealistic beauty ideals and unhealthy approaches to obtain them. The

pressure for thinness potentiates the internalization of the thin-body ideal, body

dissatisfaction, and dietary restraint (e.g., Stice, 2002). In light of these known

vulnerabilities, Stice, Ng, and Shaw (2010) propose that early intervention programs

should target perceived idealization of thinness, negative affect, and discontentment with

body shape and weight for most desirable outcomes. In fact, some researchers argue that

“normal” eaters who engage in maladaptive dieting behaviors should be considered at

high risk for EDs and that interventions surrounding attitudes toward body image are

indicated at both micro (i.e., individual) and macro (i.e., societal) levels (Polivy &

Herman, 1987). An integrative biopsychosocial comprehension may be necessary in

order to be fully inclusive of ED risk factors, as environmental and psychological

contingencies interact with and inform genetic inclinations toward ED development

(Culbert et al., 2015).

Genetic predisposition. Genetic factors influence appetite control systems,

cognitive processing, and temperamental traits, which all contribute to ED diathesis

(Treasure & Kanakam, 2012). Research linking the genetic contribution to certain

personality traits such as neuroticism and perfectionism also suggests that hereditary

characteristics may be predisposing influences (Ferguson, Muñoz, Winegard, &

Winegard, 2012; Iranzo-Tatay et al., 2015). There appears to be a stronger hereditary

component for AN, with rates of 56% in monozygotic twins and 5% in dizygotic twins,

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and 35% and 30%, respectively, for BN (Treasure & Holland, 1988). The particular ED

symptoms that manifest during the course of the illness appear to be influenced by

genetic components (Bulik et al., 2000; Thornton, Mazzeo, & Bulik, 2011). In a twin

study conducted by Bulik, Sullivan, and Kendler (2000), monozygotic twins

demonstrated stronger associations in ED symptom expression than did dizygotic twins,

indicating that underlying mechanisms of EDs have some genetic implications. Stice et al.

(2010) contend that further exploration of genetic risk is needed and that research

investigating endophenotypes (i.e., symptoms) may be more fruitful than phenotypes (i.e.,

cluster of symptoms and characteristics). It is likely that an interaction of genetic etiology

and family environment may lead to greater vulnerability to ED development (Strober &

Peris, 2011).

Family environment. Certain family dynamics have been associated with ED

predisposition. Factors including parental attitudes toward body image and eating (Dring,

2015; Kluck, 2008), parental expectations of perfectionism and conformity (Dring, 2015),

insecure attachment (Abbate-Daga, Gramaglia, Amianto, Marzola, & Fassino, 2010;

Dring, 2015; Tasca & Balfour, 2014), poor family conflict resolution skills (Dring, 2015),

invalidating childhood environments (Ford, Waller, & Mountford, 2010), and overall

family dysfunction (Dring, 2015; Ford et al., 2010; Kluck, 2008; Kluck et al., 2014) are

signature features of the family environment that predicts ED development. A study

analyzing the relationship between parent and daughter personality profiles indicated

strong trait associations and ED risk (Amianto, Ercole, Marzola, Abbate-Daga, & Fassino,

2015). Individuals with AN tend to come from families with reported lower cohesion and

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higher conflict (Kang et al., 2014), while an interaction of family issues and sexual abuse

history likely influence the onset of BN (Hastings and Kern, 2003).

Trauma history. Various forms of trauma (e.g., sexual abuse, physical abuse,

neglect) are highly associated with EDs (Madowitz, Matheson, & Liang, 2015; Moulton,

Newman, Power, Swanson, & Day, 2015). Some researchers speculate that childhood

emotional abuse has the most salient etiological implications for ED development (Burns,

Fischer, Jackson, & Harding, 2012; Moulton et al., 2015). However, in a center treating

severe AN, rates of sexual and physical abuse history were present in 50% of AN-R cases

and 80% of AN-BP cases (Woodside & Staab, 2006). Trauma and PTSD symptoms may

have greater influence on development for BN than AN (Brewerton & Brady, 2014). A

study found that sexual abuse was more closely linked with the “dissocial/impulsive

group” of participants with bulimic tendencies than the “inhibited/compulsive group”

with anorexic tendencies (Steiger, Richardson, Schmitz, Israel, Bruce, & Gauvin, 2009).

A product of trauma exposure, experiential avoidance is often found in individuals with

EDs, a phenomenon strongly related to childhood sexual abuse (Skinner, Rojas, &

Veilleux, 2016). Trauma history is also linked to alexithymia (Behar & Arancibia, 2014),

which may predict perfectionism, a known risk factor for EDs (Ruggiero, Scarone,

Marsero, Bertelli, & Sassaroli, 2011). In fact, higher levels of alexithymia predict less

favorable outcomes for illness prognosis (Pinna, Sanna, & Carpiniello, 2014).

Comorbid Psychopathology

EDs are routinely observed with co-occurring mental health diagnoses. In an 18-

year longitudinal study of adolescent-onset AN, one in four participants denied having

formal paid employment, citing consequences from an ED or related pathology (Wentz,

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Gillberg, Anckarsäter, Gillberg, & Råstam, 2009). Results from a study analyzing a large

clinical database of participants with EDs (n = 7156) indicated that 71% were diagnosed

with one or more additional psychiatric illnesses (Ulfvebrand, Birgegård, Norring,

Högdahl, & Von Hausswolff-Juhlin, 2015). Another study investigating the comorbid

psychopathology of women with AN and BN (n = 229) concluded that the majority of

participants were diagnosed with a co-occurring psychiatric illness (Herzog, Keller,

Sacks, Yeh, & Lavori, 1992). The most common comorbid disorder was major

depression. Additional illnesses observed included substance use and personality

disorders. Individuals with mixed features of AN and BN (i.e., AN-BP) and BN

demonstrated greater tendency toward kleptomania than those with AN. AN-BP had the

highest rate of comorbidity overall. AN can present with depressive and anxious

symptoms, irritability, impaired concentration, low or absent libido, and obsessive

features (Fairburn & Harrison, 2003). BN commonly co-occurs with depression (Fairburn

& Harrison, 2003), bipolar disorder (Lunde, Fasmer, Akiskal, Akiskal, & Oedegaard,

2009), substance use (Dansky, Brewerton, & Kilpatrick, 2000), and self-harm (Paul,

Shroeter, Dahme, & Nutzinger, 2002). In one study, psychiatric comorbidity for BED

(i.e., impulsivity, body dissatisfaction, and history of sexual abuse) and BN (i.e., NSSI)

predicted client prognosis (Bulik et al., 2008). While individuals with ED have more

comorbid psychopathology than the general population, higher levels of comorbidity

have been found among individuals with BN and BED than those with AN-R (Hudson et

al., 2007; Kessler et al., 2013; Ulfvebrand et al., 2015).

Depression and anxiety disorders. In one epidemiological study, 50% of

individuals with BN presented with a mood disorder and 66% with an anxiety disorder,

14
including specific phobias and social phobia (Swanson, Crow, Le Grange, Swendsen, &

Merikangas, 2011). Approximately 25% of individuals with AN have a co-occurring

anxiety disorder, including social phobia, other specified phobias, and separation anxiety

disorders (Salbach-Andrae, Lenz, Simmendinger, Klinkowski, Lehmkuhl, & Pfeiffer,

2008). Two studies concluded that most females with AN with a comorbid anxiety

disorder developed the anxiety disorder before developing AN (Deep, Nagy, Weltzin,

Rao, & Kaye, 1995; Bulik, Sullivan, Fear, & Joyce, 1997), suggesting that anxiety

symptoms emerge from a neurobiological substrate relevant to AN development (Lutter,

Croghan, & Cui, 2016). It should be noted that starvation often precipitates affective and

anxiety disturbances, so clinicians should be cautious to examine the onset of the ED and

mood-related pathology (Herpertz-Dahlmann, 2015). Woodside and Staab (2006) agree

that an accurate diagnosis of depression in AN and BN is “extremely difficult” due to the

physiological and psychological effects of maladaptive eating patterns. AN presentations

of depression routinely include flat affect, hopelessness, and loss of energy, appetite, and

libido, while BN presentations typically involve labile mood and suicidal ideation. BED

also commonly co-occurs with mood disorders, particularly depression, and anxiety

(Becker & Grilo, 2015; Grilo, White, & Masheb, 2009) and presents with somatic issues,

perceived ineffectiveness, and low self-esteem (Glasofer et al., 2007).

Obsessive-compulsive disorder (OCD). OCD is another comorbid illness

typically associated with AN, which is also linked to perfectionism, scrupulosity, and

rigidity (Herpertz-Dahlmann, 2015). Clinicians are cautioned to preclude ED-specific

OCD traits (e.g., food ritualization, repetitive weighing) from OCD diagnosis and that a

notation of obsessive-compulsive personality disorder (OCPD) may at times be more

15
appropriate (Woodside & Staab, 2006). It is widely conjectured that OCD and EDs have

shared etiological implications (Altman & Shankman, 2009).

Substance use. EDs and substance use disorders co-occur frequently and may

share causal aspects (Cohen & Gordon, 2009). Approximately one-fourth of individuals

with AN engage in substance abuse (Herpertz-Dahlmann, 2015). AN-BP is twice as

likely to present with substance use as AN-R, indicating that chemical dependency has a

stronger association with bulimic psychopathology (Root et al., 2010). AN-BP tends

toward greater use of stimulants, diet pills, and polysubstance use compared to AN-R

(Root et al., 2010). Also, AN-BP and BN demonstrate higher use of alcohol than AN-R.

A study revealed lifetime prevalence rates of alcohol abuse as 17% in AN-R and 46% in

BN (Bulik et al., 2004).

Consistent with its impulsive nature, BN is more commonly associated with

substance use disorders than AN (Claes et al., 2006; Cohen & Gordon, 2009; Milos,

Spindler, & Schnyder, 2004; Westen & Harnden-Fischer, 2001; Wonderlich et al., 2005).

Cohen and Gordon (2009) highlight the “strong link” between BN and alcohol use

disorder. BED also commonly co-occurs with substance use disorders (Becker & Grilo,

2015); binge-eating behaviors tend to predict binge-drinking (Field et al., 2012) and drug

abuse (Becker & Grilo, 2015). One study found that higher rates of bingeing and purging

predicted higher rates of substance use, and participants with AN-BP and BN

demonstrated greater use of alcohol and other substances than those with AN-R (Fouladi

et al., 2015). Milos et al. (2004) offer an explanation for the relationship between

impulsivity and substance use: “Indeed, the psychopathology of patients with substance-

related disorders is often characterized by a lack of control over their own lives,

16
insecurity, and confusion and apprehension in recognizing and accurately responding to

emotional states” (pp. 182-183).

Suicidality and self-harm. Suicidality is a serious and unfortunate feature of AN,

with suicidal ideation occurring in approximately half of adolescent clients, and suicide

attempts reported in 3% to 7% of cases (Fennig & Hadas, 2010). Most at risk are those

with depressed affect, AN-BP, and longer duration of the disorder. In one study, more

than half of participants with BN reported previous suicidal ideation, and more than a

third reported a previous suicide attempt (Swanson et al., 2011). Another study found that

BN was more closely linked with suicidality than AN (Bodell, Joiner, & Keel, 2013),

which may be due to the impulsive nature of BN. Non-suicidal self-injury (NSSI) is a

common comorbid feature of EDs (Solano, Fernández-Aranda, Aitken, López, & Vallejo,

2005; Svirko & Hawton, 2007), but was found to be most closely linked to urgency (i.e.,

an impulsive attribute; Black & Mildred, 2014). The preferred methods of NSSI tend to

be cutting and scratching, and many clients engage in multiple methods.

Personality disorders. A study found that 69% of participants with EDs also

presented with at least one personality disorder (Braun, Sunday, & Halmi, 1994).

Individuals with AN-R often feature Cluster-C traits (i.e., avoidant and obsessive-

compulsive personality pathology; Westen & Harnden-Fischer, 2001), while individuals

with BN are more likely to present with attributes from Cluster B (e.g., borderline

personality traits; Turner et al., 2014; Westen & Harnden-Fischer, 2001). This finding

was consistent with another study that demonstrated a significant relationship between

BN and Cluster-B characteristics (Milos et al., 2004). Avoidant personality disorder

(APD) is characterized by social withdrawal, feelings of inadequacy, reluctance toward

17
novelty and risk-taking, and extreme preoccupation with criticisms from others (APA,

2013). Borderline personality disorder (BPD) demonstrates a pattern of traits involving

interpersonal intensity and instability, impulsivity, emotional lability, irresponsibility and

risk taking, and proclivities toward NSSI and suicidal ideation (APA, 2013). Pervasive

interpersonal insecurity incites “frantic efforts” to avoid real or perceived abandonment,

which may be executed by means of manipulation. Preliminary research for BED shows

co-occurrence with Cluster-A, Cluster-B, and Cluster-C traits (Davis et al., 2008; Smink,

Van Hoeken, & Hoek, 2013), with BPD features more prominent among individuals with

a comorbid substance use or mood disorder (Davis et al., 2008). A related study found

elevated Cluster-B personality traits in individuals with BED, indicating higher levels of

impulsivity (Peterson, Miller, Crow, Thuras, & Mitchell, 2005).

Current Criteria for Eating Disorder Diagnoses

The current diagnostic criteria for AN, BN, and BED are described below.

Anorexia nervosa. AN is recognized by persistent efforts to restrict food intake,

resulting in “significantly low body weight” (APA, 2013, p. 338). The weight is

abnormally low when considering sex, age, stage of development, and physical health.

Individuals with AN also present with “intense fear of gaining weight or becoming fat”

(APA, 2013, p. 338) and engage in behavior to avoid gaining weight. The final critical

standard for this diagnosis is “disturbance in the way in which one’s body weight or

shape is experienced, undue influence of body weight or shape on self-evaluation, or

persistent lack of recognition of the seriousness of the current low body weight” (APA,

2013, p. 339). Two subtypes of AN are indicated, AN-R and AN-BP. Clients with AN-R

do not binge or engage in compensatory behaviors other than intake circumscription and

18
excessive exercise to maintain low weight, while clients with AN-BP engage in behaviors

to regulate episodes of binge eating, such as diuretics, vomiting, and laxatives (APA,

2013).

Bulimia nervosa. BN is characterized by recurrent episodes of binge eating (i.e.,

“lack of control” while consuming larger-than-average food quantities in a finite duration

of time) and compensatory behaviors to avoid weight gain (APA, 2013). Additional

criteria include over-evaluation of self due to perceived body shape and weight and that

the episodes of binge eating and purging do not occur within the context of AN.

Binge-eating disorder. For clients to meet criteria for a diagnosis of BED, they

must present with recurrent episodes of binge eating in the absence of compensatory

behaviors (APA, 2013). The binge eating does not occur within the context of AN or BN.

Clients experience clinical levels of distress in regard to the eating disturbances and

experience three or more of the following: rapid food consumption, physiological

discomfort from volume of food intake, eating alone due to embarrassment of volume of

food, eating in the absence of hunger, and consequential adverse emotions following

binge-eating episodes (e.g., disgust, depressed affect, guilt).

Unspecified eating disorder. Should a client fail to meet criteria for one of the

three specified disorders above but still experiences “clinically significant distress or

impairment,” a diagnosis of other specified feeding or eating disorder (OSFED) may be

provided (APA, 2013). Typical candidates for this diagnosis include those not meeting

the frequency of bingeing and purging episodes for BN or the weight threshold for AN. A

diagnosis of unspecified feeding or eating disorder (UFED) may be provided should the

19
clinician choose not to specify why the client fails to meet criteria for a specific ED

diagnosis.

After having delineated the criteria for the ED diagnostic categories, current

standards of DSM nosology on a broader scale and relevant limitations will be

subsequently reviewed.

Criticisms of Categorical Diagnosis

According to Widiger and Samuel (2005), The DSM “routinely fails in the goal of

guiding the clinician to the presence of one specific disorder, despite the best efforts of

the leading clinicians and researchers who have authored the manual” (p. 494). The

traditional classification system of the DSM has been criticized for its lack of empirical

validation and poor reflection of clinical reality. In fact, the categories themselves have

been considered an “inappropriate assumption” (Blashfield, Sprock, & Fuller, 1990;

Carson, 1991). Further concerns involve high rates of comorbidity and “boundary

disputes” (Widiger & Samuel, 2005) and what Westen (2012) refers to as “the arbitrary

nature of criteria for severity, duration, and number of symptoms met” (p. 16).

When considering the history of mental illness organization, the DSM-III became

the cornerstone of psychiatric nosology that subsequent iterations became based upon.

“The DSM-III categories prematurely became reified and seen as real disease entities

[…] with ensuing assumptions that they involve a unitary pathophysiology and

psychopathology” (Kozak & Cuthbert, 2016, p. 287). A fundamental diagnostic concern

for psychiatric illnesses is that new editions of the DSM are essentially refined and

modified versions of their predecessor, rather than based on research of broader,

innovative diagnostic classification systems (Fairburn & Cooper, 2011). One of the most

20
central concerns with the current diagnostic approach is the pervasive comorbid

psychopathology that cuts across multiple categories, prompting questions regarding

categorical validity (Narrow et al., 2013). These symptoms also risk being entirely

overlooked due to the categorical nature of reporting diagnoses (Wilk et al., 2006).

Within-group heterogeneity (i.e., distinct presentations of the same diagnosis) is another

concern of categorical constructs (Clark, Watson, & Reynolds, 1995). These varied

presentations may at times fall short of meeting all criteria for a given diagnosis, yielding

an unspecified illness description. Individuals sharing a diagnosis may present with

considerably different symptomatology, and individuals with different diagnoses may

present with similar symptomatology (Kozak & Cuthbert, 2016). Another deficient

feature of categorical diagnosis is the neglect to indicate symptom severity (Kozak &

Cuthbert, 2016). Diagnostic specifiers may indicate additional relevant information about

a client’s presentation but fail to capture a quantitative measure of acuteness. Just a few

symptoms from multiple diagnoses may cause clients to experience significant functional

impairment, even though they have not met criteria for a named illness (Regier et al.,

2009).

There are important implications for research as well. Although the DSM-III

conceded that disorders do not demonstrate “sharp boundaries” (APA, 1980), studies

have operationalized disorders based on fundamental categorical characteristics, thereby

missing an opportunity to investigate shared symptom dimensions or etiology (Kozak &

Cuthbert, 2016). Some researchers argue that adhering to strictly categorical nosology in

fact hinders identifying etiology and treatments for mental illnesses (Narrow et al., 2013).

DSM criteria focus on clinical observation and client report of behavioral and cognitive

21
functioning without consideration of the neurobiological processes at play (McHugh,

2005). There is also a paucity of empirical backing for treatment plans and interventions

utilized when treating those with psychiatric illnesses (Westen, Novotny, & Thompson-

Brenner, 2004). Another treatment-related issue is that multiple diagnoses appear to

respond to similar interventions (e.g., SSRIs), again raising questions surrounding

categorical validity (Regier, Narrow, Kuhl, & Kupfer, 2009).

Above all, reorchestrating diagnostic structure requires an emphasis on clinical

utility, which First, Pincus, Levine, Williams, Ustun, and Peele (2004) define as “the

extent to which DSM assists clinical decision makers in fulfilling the various clinical

functions of a psychiatric classification system” (p. 947). They further delineate that the

DSM should assist clinicians with conceptualizing nosological criteria; communicating

with mental health providers, managed health care personnel, and clients; utilizing

diagnoses in routine clinical practice; treatment planning; and anticipating potential

clinical management needs. Improved clinical utility can be marked by improved use of

diagnosis, more favorable clinical outcomes, and enhanced decision-making in clinical

practice. Kendler (1990) advocates for scientifically informed nosology with an advisory

model, in which empirical evidence objectively informs diagnostic classification and can

be integrated with relevant nonempirical matters.

Revelations of the DSM-5

In response to extensive criticism pertaining to categorical nosology (e.g., Kozak

& Cuthbert, 2016; Regier. Narrow, Kuhl, & Kupfer, 2009; Westen, 2012), the publication

of the DSM-5 allowed for discussion about progressive attitudes and research in the field

of mental health (APA, 2013). While categorical guiding criteria for diagnosis may allow

22
for some clarity and simplicity, the rich complexity and varied presentations of disorders

fail to be wholly captured by this model. The task force behind the latest iteration of the

DSM arrived at the conclusion that “a too-rigid categorical system does not capture

clinical experience or important scientific observations” (APA, 2013, p. 5). It was

determined that symptoms relegated to specific disorders are in fact shared by other

diagnoses, and the firm boundaries differentiating these classifications necessitates a

degree of fluidity among them in order to better reflect clinical reality. Most disorders

can be positioned across a spectrum of diagnoses with related symptoms, as well as

genetic, environmental, and neurobiological implications (APA, 2013). It was then

suggested that dimensional measures cutting across various diagnoses could serve as a

more accurate diagnostic approach rather than maintaining rigid, compartmentalized

criteria. The DSM-5 was reorganized with the intent to structure diagnostic classes “to

stimulate new clinical perspectives and to encourage researchers to identify the

psychological and physiological cross-cutting factors that are not bound by strict

categorical designations” (p. 10). These cross-cutting features allow for more accurate

and efficient diagnosis and treatment (Regier, 2007).

The difficulties encountered in both research and clinical practice stemming from

the rigid diagnostic categories of previous DSM editions resulted in high incidence of

comorbidity and “not otherwise specified” diagnoses (APA, 2013). EDs in particular

were often diagnosed as unspecified due to overly limiting guidelines. Studies of

comorbid psychopathology yielded important information regarding the high rate of

shared symptoms across multiple disorders, as well as genetic and environmental risk

factors (e.g., Herzog et al., 1992; Ulfvebrand et al., 2015). The apparently inherent

23
heterogeneity to psychiatric disorders no longer allows for compartmentalized diagnostic

approaches, even when accompanied by multiple options for subtypes (APA, 2013). “The

once plausible goal of identifying homogeneous populations for treatment and research

resulted in narrow diagnostic categories that did not capture clinical reality, symptom

heterogeneity within disorders, and significant sharing of symptoms across multiple

disorders” (APA, 2013, p. 12).

Part of the DSM-5 task force, a diagnostic spectra study group was assigned to

identify specific “scientific validators” to restructure diagnostic classifications and

regroup related disorders (APA, 2013). Disorders were then arranged based on the

following 11 domains: “shared neural substrates, family traits, genetic risk factors,

specific environmental risk factors, biomarkers, temperamental antecedents,

abnormalities of emotional or cognitive processing, symptom similarity, course of illness,

high comorbidity, and shared treatment response” (p. 12). Diagnoses were also regrouped

under considerations of “internalizing and externalizing factors” (p. 13), to further

consider cross-cutting dimensions. The internalizing group is comprised of depressive,

anxious, and somatic symptomatology, and the externalizing group represents disorders

involving dysregulated impulse control, conduct, and substance abuse. These related

diagnoses allow for additional research to be oriented toward determining shared

neurobiological substrates and relevant underlying psychological mechanisms. This

restructuring and reordering of diagnostic classifications serves as a meaningful transition

to the future standardization of more dimensional diagnostic approaches that will likely

replace categorical approaches utilized thus far (APA, 2013; Gehart, 2014).

24
 In an effort to integrate more empiricism into the DSM, several psychometric

measures were introduced for use in clinical practice (APA, 2013). Of these measures,

the Cross-Cutting Symptom Measure (CCSM) evaluates the cross-cutting dimensions

described above. This test “represent[s] a first step in moving psychiatric diagnosis away

from solely categorical descriptions toward assessments that recognize different levels of

symptom frequency and intensity” (Narrow et al., 2013, p. 80). The measure minimizes

risk of overlooking symptoms, as multiple domains of psychopathology are assessed

(Narrow et al., 2013). Over time, results may indicate common presentations of comorbid

features and inspire further research to explore certain clusters of symptoms. This

research may indeed lead to reductions in residual category diagnosis. The standardized

measurement of cross-cutting symptoms also benefits broader research efforts, allowing

for further insight into incidence rates, course, underlying mechanisms, treatment, and

treatment outcomes for disorders and clusters of symptoms, which may “contribute to the

development of new disorder boundaries, and eventually new conceptualizations of

mental disorders” (Narrow et al., 2013, p. 81). Standard utilization of this measure in

clinical practice will also improve care by providing clients the opportunity to have more

understanding of symptomatological presentations and collaboration with their clinician

in treatment decisions (Valenstein et al., 2009).

The modifications made in the DSM-5 demonstrated some favorable outcomes. In

a study evaluating responses to the changes, participants from six distinct mental health

professions reported that the criteria was “easy to use” and “useful,” as compared with

the DSM-IV (Moscicki et al., 2013). The proposed assessment measures (e.g., the

CCSM) were also positively received. Yet despite the intelligent changes made, concerns

25
remain surrounding the categorical nosological system as a whole (e.g., McHugh, 2005;

Westen, 2012; Widiger & Samuel).

Progress toward Dimensional Diagnosis

With the multiple issues cited with regard to the extant categorical diagnostic

model of the DSM, more dimensional approaches have received much attention and

praise (Widiger & Gore, 2014). Dimensional diagnosis can increase “diagnostic

precision,” explain and identify comorbid psychopathology, and improve clinical utility

by avoiding strict threshold criteria (Helzer, Kraemer, Krueger, Wittchen, Sirovatka, &

Regier, 2008). Support for progress from strictly categorical to more dimensional

nosology has already been demonstrated in the DSM-5. Shifts toward dimensional

constructs within certain diagnoses suggest a departure from compartmentalized

diagnoses and advancement toward classifying symptomatology along a clinical scale

(Gehart, 2014). Some of the disorders that now contain dimensional components include

substance use disorders, autism spectrum disorder, oppositional defiant disorder,

schizophrenia, and intellectual disability (APA, 2013; Gehart, 2014). The DSM-5 also

integrated cross-diagnostic specifiers to assist in more detailed and personalized

diagnosis (e.g., “with catatonia,” “with anxious distress,” “with mixed features;” APA,

2013).

Personality disorders. More evidence of devaluing purely categorical constructs

is illustrated in the proposed dimensional approach to diagnosing personality disorders

(Gore & Widiger, 2013; Keeley, Flanagan, & McCluskey, 2014; Watson, Stasik, Ro, &

Clark, 2013; Widiger, 2011; Zachar & First, 2015). In need of further empirical

validation, this system is placed in Section III of the DSM-5 but presents a hopeful

26
prospect for continued movement toward dimensional conceptualization. In conjunction

with the proposed criteria, the Personality Inventory for DSM-5 (PID-5) was introduced

to assess relevant personality trait dimensions (Krueger, Derringer, Markon, Watson, &

Skodol, 2013).

Severity dimension for eating disorders. The APA acknowledged the need for

dimensional evaluation for ED diagnosis in the DSM-5, as evidenced by the inclusion of

a severity dimension (APA, 2013; Pike, 2013; Wildes & Marcus, 2013). Severity for AN

is determined by body mass index, for BN by frequency of inappropriate compensatory

behaviors, and for BED by frequency of binge-eating episodes (APA, 2013). This

addition represents a small but significant step toward dimensional diagnosis for EDs.

“The DSM-5 remains a work in progress,” (Gehart, 2014, p. 71). As empirical

evidence continues to evolve and influence descriptive clinical psychiatry, the

community of mental health practitioners is likely to see more and more changes in years

to come.

Evolution of Eating Disorder Diagnosis

In order to discuss further modifications to ED diagnoses, it is necessary to

understand their evolution throughout historical advancements in psychiatry. The focus

of EDs was primarily on AN until “bulimia,” later renamed BN, was added as a diagnosis

in the DSM-III (APA, 1980). The diagnostic criteria for EDs remained largely unchanged

since 1980, as the modifications to the DSM-IIIR, put forth in the DSM-IV, were

intended to be conservative (Wilson & Walsh, 1991). Until the release of the DSM-5,

little significant change to the two identified EDs occurred, necessitating extensive

27
review for this diagnostic class. According to Fairburn and Cooper (2011), “Anorexia

nervosa and bulimia nervosa are simply two presentations among many” (p. 8).

The DSM-5 Eating Disorders Work Group (EDWG) was confronted with the

daunting task of scrutinizing and modifying the diagnostic criteria for EDs based on

available empirical data (Call, Walsh, & Attia, 2013; Striegel-Moore, Wonderlich, Walsh,

& Mitchell, 2011; Walsh, 2009). A main issue the EDWG wished to address was the

extensively used residual category of unspecified EDs. The diagnosis EDNOS from

previous editions of the DSM was widely utilized when individuals failed to meet the

stringent criteria for a specific ED (APA, 1994; 2000; Fairburn & Cooper, 2011; Walsh,

2009; Walsh & Sysko, 2009). Under the guiding criteria of the DSM-IV, about 50%

(Fairburn, Cooper, Bohn, O’Connor, Doll, & Palmer, 2007; Fairburn & Cooper, 2011) to

70% (Ricca et al., 2001) of ED cases fell into the EDNOS diagnostic category. An

extremely heterogeneous class, those diagnosed with EDNOS had varied presentations of

particular ED symptoms but still demonstrated significant impairment due to their undue

influence of body shape and size on self-evaluation and desperate measures to regulate

weight (Fairburn et al., 2007; Mitchell et al., 2007; Fairburn & Cooper, 2011).

Parallel research developed within the World Health Organization during

preparation for the launch of the International Classification of Diseases and Related

Health Problems, 10th Revision (ICD-10; Al-Adawi et al., 2013; World Health

Organization, 1992). With a central focus to enhance clinical utility, the Eating Disorders

Consultation Group (EDCG) reviewed the diagnostic categories for EDs and presented

several recommendations, including minimizing the residual category of unspecified EDs

by relaxing criteria (e.g., cutoff requirements) for AN, BN, and BED, decreasing or

28
omitting the frequency criterion for BN and BED, and describing bingeing as “subjective”

episodes.

Changes to eating disorder criteria in the DSM-5. The DSM-5 EDWG

conducted exhaustive reviews of existing literature and meta-analysis to determine the

validity of the diagnostic parameters for AN, BN, and BED (Striegel-Moore, Wonderlich,

Walsh, & Mitchell, 2011). The recommended modifications principally intended to

reduce the overuse of the residual diagnostic category following research publications

indicating the clinical significance of EDNOS. A meta-analytic research endeavor

determined that clients with EDNOS experienced similar severity of psychopathology as

those with AN, BN, and BED (Thomas & Vartanian, 2013). One area of focus was the

quantitative guiding criteria for EDs (i.e., weight criterion for AN, frequency of bingeing

and purging for BN, and frequency of bingeing for BED). The EDWG recommended that

the guidelines for low weight cutoff be excluded from the DSM-5, as research suggested

that higher-weight individuals with AN presented with clinically similar psychopathology

severity (Santonastaso, Bosello, Schiavone, Tenconi, Degortes, & Favaro, 2009). The

EDWG also suggested a decrease in frequency of bingeing and compensatory behavior

episodes for BN (i.e., from twice per week to once per week) following the completion of

a meta-analysis that revealed no significant differences in ED disturbances between the

former and proposed rates (Striegel-Moore et al., 2011). No meaningful distinctions were

observed between individuals who engaged in binge-eating episodes once per week

versus twice or more per week (Rockert, Kaplan, & Olmsted, 2007). These findings

indicate that low-frequency BN merits clinical attention. Finally, a similar reduction in

frequency was recommended for BED criteria from bingeing twice to once per week,

29
which was consistent with empirical findings as well as conveniently identical to the

suggested frequency criterion for BN (Striegel-Moore et al., 2011).

The criteria for AN were somewhat relaxed overall (Herpertz-Dahlmann, 2015).

AN’s signature defining characteristic is low weight status, but instead of DSM-IV’s

articulation of low weight as less than 85% of normalcy, it is now considered weight less

than “minimally normal” in adults or “minimally expected” in children and adolescents

(APA, 2013; Call, Walsh, & Attia, 2013). Under current guidelines, clients no longer

need to explicitly express fat phobia and instead may demonstrate behaviors that maintain

low weight (APA, 2013). Developmental status, age, gender, and physiological

functioning must be surveyed when considering the classification of abnormally low

weight (Herpertz-Dahlmann, 2015). A study revealed that individuals who presented with

cognitive features of AN, including preoccupation with body shape and weight, did not

meet the low weight requirement for full diagnosis (Bulik et al., 2000). These participants

may not have yet engaged in extreme compensatory or restricting measures to control

food intake, but were still at high risk for EDs. For AN, the stipulation of “amenorrhea”

was removed in order to allow for males, prepubescent females, and females using

contraceptives to be eligible for the diagnosis. According to Uher and Rutter (2012), it

was found that up to 25% of women who met all other criteria for AN menstruated. The

two subtypes of AN in the DSM-IV remain in the DSM-5, AN-R and AN-BP, but a

three-month duration was specified for these subtypes, rather than simply considering the

“current episode” (Herpertz-Dahlmann, 2015). This time duration is consistent with that

used for binge eating in the context of BN and BED. Other changes involved altering

certain terminology relating to the diagnoses’ descriptors to alleviate stigma associated

30
with AN that suggested clients’ unwillingness to recover (Herpertz-Dahlmann, 2015). For

example, “denial of the seriousness of low body weight” was adjusted to “persistent

behavior that interferes with weight gain, even though at a significantly low weight”

(APA, 2013, p. 338).

BN’s criteria remained mostly consistent with that from the previous DSM,

except for the stipulation of bingeing and purging episodes occurring once per week for

three months rather than twice per week for three months (Herpertz-Dahlmann, 2015).

The subtypes BN-purging type (BN-P) and non-purging type (BN-NP) were removed

from the criteria in the DSM-5 (APA, 2013; Call et al., 2013; Jordan et al., 2014) after

studies revealed their questionable validity (Mitchell, 1992; van Hoeken, Veling, Sinke,

Mitchell, & Hoek, 2009).

BED earned its place in the DSM-5 as a formal diagnosis after its proposal for

further study in the DSM-IV was empirically substantiated (APA, 2013; Herpertz-

Dahlmann, 2015). Empirically validated studies substantiated the clinical need for this

diagnosis (Wonderlich, Gordon, Mitchell, Crosby, & Engel, 2009).

Results of changed criteria. Under the new guidelines, prevalence rates of

unspecified ED diagnoses declined as more individuals qualified for specified diagnoses.

Studies concluded decreases from 55% to 38% (Birgegård, Norring, & Clinton, 2012),

52.7% to 25.1% (Fairburn & Cooper, 2011), and 46% to 29% (Mancuso, Newton,

Bosanac, Rossell, Nesci, & Castle, 2015), in their respective samples. AN diagnoses

increased from 35% to 47% (Mancuso, Newton, Bosanac, Rossell, Nesci, & Castle,

2015). The introduction of criteria for BED yielded a rate of 5%. According to Flament et

al. (2015), the prevalence of ED diagnoses increased from 1.8% under DSM-IV criteria

31
to 3.7% under DSM-5 criteria, and the prevalence of unspecified ED diagnoses decreased

from 5.1% to 3.4%. There may have been cause for concern that lowering the diagnostic

thresholds for AN and BN would result in cases presenting as less clinically distinct or

with attenuated severity, but the opposite appears to be true (Birgegård et al., 2012;

Flament et al., 2015). Although the significant reduction in unspecified ED cases

indicates remarkable progress in refining diagnostic approaches, the current prevalence

rates are still far too high for a residual diagnostic category (Birgegård et al., 2012; Uher

& Rutter, 2012).

Criticisms of Eating Disorder Diagnosis

For several reasons, “the existing scheme for classifying eating disorders is a

historical accident that is a poor reflection of clinical reality” (Fairburn & Bohn, 2005, p.

699). First, utilizing a categorical model to classify ED diagnoses is met with limitations

inherent to DSM publication. The criteria continue to evolve, albeit slightly, inhibiting

prolonged publication of confirmed categories (Williamson, Gleaves, & Stewart, 2005).

Second, the categories themselves have progressively shifted over the last several

editions of the DSM (APA, 1980, 1987, 1994, 2013). Since each iteration of the DSM is

comprised of modified information of its predecessor, there have been no major shifts in

ED diagnostic conceptualization, even though data supporting existing criteria are mixed

(Fairburn & Cooper, 2011). Finally, most ED clinical trials prior to the release of the

DSM-5 utilized broader diagnostic criteria for purposes of operationalization to more

accurately reflect clinical reality, indicating defective nosological standards (Uher &

Rutter, 2012). Additionally, valid prognostic value of the current ED diagnoses remains

ambiguous (Birgegård et al., 2012).

32
 Despite the modifications to ED diagnoses effective in the DSM-5, multiple

diagnostic concerns remain. Inter-rater reliability of ED diagnoses has found to be

moderate in some cases (Thomas et al., 2015) and poor in others (Thomas et al., 2014).

The residual category of unspecified EDs still sustains a large quantity of cases (Fairburn

& Cooper, 2011; Thomas et al., 2015). Consistent diagnostic crossover reveals poor

longitudinal stability across ED diagnoses (e.g., Castellini et al., 2011; Eddy et al., 2002).

With regard to ED subtyping, data provide little evidence supporting their utility (Peat et

al., 2009). Finally, empirical substantiation also conflicts surrounding quantitative cutoff

criteria (Santonastaso et al., 2009; Striegel-Moore et al., 2011).

Unspecified eating disorders. Under the diagnostic specifications of the DSM-

IV, the “majority” of individuals with EDs were classified as having EDNOS (Uher &

Rutter, 2012). Although the changes in ED diagnostic criteria from the DSM-IV to the

DSM-5 allowed a lower incidence of unspecified disorders relative to specific EDs,

unspecified EDs may still be the most prevalent ED diagnosis, particularly among

community samples and adolescents (Birgegård et al., 2012). Up to 38% of ED cases still

reside within the unspecified ED range (Birgegård et al., 2012). This residual category,

divided into OSFED and UFED in the DSM-5, has highly varied presentations, prognosis,

and treatment responses (Eddy, Doyle, Hoste, Herzog, & Le Grange, 2008) with serious

physiological sequelae (Peebles, Hardy, Wilson, & Lock, 2010). Many unspecified cases

are simply a phase during the transition to recovery or another ED diagnosis (Fairburn et

al., 2007). With no clear guidelines for treatment, this category risks being disregarded

and misconstrued as less severe than its specified counterparts, despite evidence of poor

prognosis (Schmidt et al., 2008). Wade and O’Shea (2015) compared a group of

33
adolescent females with UFED to adolescent females with AN or atypical AN and found

that they had unremarkable differences in scores measuring global ED severity. The

UFED group also presented with clinically significant distress and impairment as

compared with the control group. Due to the inherent heterogeneity of this residual

category, it is often neglected in research efforts, particularly pertaining to treatment

efficacy (Andersen, Bowers, & Watson, 2001; Fairburn & Bohn, 2005). The high

prevalence of unspecified ED cases, despite the modifications put forth in the DSM-5,

may be due to the varied symptomatological presentations of EDs, including mixed

features of both AN and BN (Fairburn & Bohn, 2005). Clients with these mixed

presentations do not benefit from the relaxed thresholds in the changed criteria for AN

and BN. A solution proposed to mediate issues surrounding unspecified ED cases is to

create a “mixed eating disorder” diagnosis to catch remaining cases not eligible for

classification under AN, BN, or BED.

Diagnostic crossover. “Eating disorder diagnoses are snapshots in the course of

an eating disorder” (Fairburn & Cooper, 2011, p. 9). The categorical diagnoses of EDs

sustain little longitudinal stability, as symptom expression changes significantly over the

course of the illness (e.g., Castellini et al., 2011; Fairburn & Harrison, 2003). Diagnostic

crossover or migration describes the phenomenon of meeting criteria for distinct

disorders of a given diagnostic class across the lifespan. “Most individuals with an eating

disorder sequentially receive several diagnoses instead of a single diagnosis that would

describe the individual’s problems at various developmental stages” (Uher & Rutter,

2012, p. 80). In a six-year longitudinal study (n = 793), a “large majority” of individuals

with AN, BN, and EDNOS were found to experience diagnostic crossover (Castellini et

34
al., 2011). Co-occuring depressive symptoms and substance use tend to predict increased

diagnostic crossover. Another study determined that while the general diagnosis of ED

retained longitudinal stability, only one-third of participants maintained their original

diagnoses after 30 months, suggesting shared biological and psychological etiology and

illness-maintenance factors for EDs (Milos et al., 2005). AN, BN, and BED, are

considered to belong on a spectrum, and clients with any of these illnesses tend to present

symptoms belonging to two or more of these diagnoses over their lifetimes (Fairburn &

Harrison, 2003). In fact, those who meet criteria consistently for AN and maintain a

clinically low body mass index (BMI) throughout their lives are a small minority of cases

(Fairburn & Cooper, 2011). Most individuals with AN-R eventually succumb to bingeing

and purging behaviors (Eddy et al., 2002). AN-R commonly transitions through AN-BP

to BN (Eddy et al., 2002; Milos, Spindler, Schnyder, & Fairburn, 2005; Monteleone, Di

Genio, Monteleone, Di Filippo, & Maj, 2011; Strober, Freeman, & Morrell, 1997; Tozzi

et al., 2005); the reverse direction of crossover is less common (Castellini et al., 2011;

Eddy et al., 2002). Approximately half of cases of AN eventually morph to BN (Bulik,

Sullivan, Fear, & Pickering, 1997; Keel et al., 2005). In a National Comorbidity Survey

Replication study, AN was found to have lower 12-month persistence and a significantly

shorter lifetime duration than BN or BED (Hudson et al., 2007), suggesting that

participants with AN migrated to another ED diagnosis. Additionally, individuals with

BN often develop BED or an unspecified ED (Fichter, Quadflieg, & Hedlund, 2008).

Researchers have attempted alternative diagnostic measures in order to reduce the

prevalence of ED diagnostic instability. Empirically derived classification in one study

identified bingeing only, bingeing and purging, and low BMI as three classes that

35
maintained more longitudinal stability than the DSM-IV criteria for EDs (Peterson et al.,

2011). Classifying individuals who engage in bingeing and purging, regardless of BMI,

allowed for more diagnostic consistency over time. These outcomes support the

dimensional conceptualization of ED symptoms and that numerical cutoffs within

diagnostic criteria should be based on clinical utility or omitted entirely. The researchers

advocate for future studies to determine the influence of other factors on the enduring

accuracy of ED diagnosis, including physiological indicators, comorbidity, and

personality traits. Fairburn and Cooper (2011) contend that EDs are one diagnosis with a

spectrum of presentations. Uher and Rutter (2012) propose a category of “combined

eating disorder” comprised of cases with mixed AN and BN features to attenuate the high

degree of diagnostic migration among EDs. Others advocate for a hybrid diagnostic

model that is both categorical and dimensional in nature to reduce diagnostic instability

(Castellini et al., 2011).

Eating disorder subtypes. “The historical aspiration of achieving diagnostic

homogeneity by progressive subtyping within disorder categories is no longer sensible”

(APA, 2013, p. 12). ED subtypes demonstrate poor predictive validity and frequently

present as developmental junctures within the overarching context of ED

psychopathology (Eddy et al., 2002). Evidence supporting clinically significant

distinctions among ED subtypes is lacking (Wonderlich, Koiner Jr., Keel, Williamson, &

Crosby, 2007). As stated previously, individuals who present exclusively with restrictive

behaviors commonly develop bingeing and purging behaviors over time (Eddy et al.,

2002; Eddy, Dorer, Franko, Tahilani, Thimpson-Brenner, & Herzog, 2008; Strober et al.,

1997), and AN-BP often migrates to BN (Eddy et al., 2002), indicating poor predictive

36
validity for AN-R and AN-BP (Peat et al., 2009). Additionally, researchers discovered

that AN-R and AN-BP show qualitative differences using taxometric analysis and that

AN-BP is likely continuous with BN (Gleaves et al., 2000; Williamson et al., 2002).

Similar research using latent class analysis also substantiates AN-BP and BN existing on

the same continuum (Wade, Crosby, & Martin, 2006).

Cutoff criteria. “Whether a patient with bulimic symptoms has binged and

purged twice a week every week for an arbitrarily specified period of time is far less

useful to know than that the patient is binging and purging frequently […] and that binge

episodes seem to be preceded by feelings of rejection or abandonment” (Westen, 2012, p.

16). Cutoff criteria excludes individuals from meeting diagnostic criteria for EDs, often

resulting in an unspecified diagnosis (Wade & O’Shea, 2015). Research indicates no

significant differences in terms of impairment or genetic factors between specified and

subthreshold EDs, whose distinctions are contingent on boundary specifications

(Fairweather-Schmidt & Wade, 2014). Some researchers advocate for the removal of all

cutoff criteria entirely (Westen, 2012; Ortigo, Bradley, & Westen, 2010). There is

precedent for excluding numeric thresholds; the ICD-10 operates on hallmark qualities of

disorders and omits numerical criteria of frequency and duration (Uher & Rutter, 2012).

In light of the diagnostic concerns described, multiple alternative diagnostic

models for EDs have been proposed and will be discussed in subsequent sections.

Alternative Categorical Diagnostic Models for Eating Disorders

There remains some support for categorical conceptualizations of EDs. “A

categorical diagnostic system with operationalized diagnostic criteria [has] allowed the

field of psychiatry to have a common clinical and research language” (Narrow et al.,

37
2013, p. 71). Clear-cut criteria afford a degree of simplicity (Kozak & Cuthbert, 2016). A

twin study revealed three classes resembling AN, BN, and BED after interviewing 2,163

Caucasian female twins and conducting latent class analysis on nine distinct ED

symptoms (Bulik et al., 2000). In taxometric analysis studies, BN has been found to be

categorically distinct from AN (Gleaves et al., 2000; Williamson et al., 2002). Studies

also reveal that EDs with binge-eating symptoms (e.g., AN-BP) likely reside in their own

category, separate from AN-R (Gleaves, Brown, & Warren, 2004; Gordon, Holm-

Denoma, Smith, Fink, & Joiner, Jr., 2007). Further, and more generally, radical shifts

from current methods of nosology may be too substantial and thus challenging to

integrate for the mental health professional community (Kendler, 1990). “Rapid change

tends to undermine confidence in the diagnostic system itself,” states Kendler (1990, p.

972). Proposed alternative categorical approaches include more conservative options that

simply modify existing diagnostic criteria and more radical alternatives that suggest

broadening specifications to minimize diagnostic crossover and improve clinical utility

(Walsh & Sysko, 2009).

Broad categories model. Walsh and Sysko (2009) proposed an alternative ED

diagnostic scheme during the development of the DSM-5 called Broad Categories for the

Diagnosis of Eating Disorders (see Figure A1). This model was created with the intent to

preserve the existing diagnostic categories of previous DSM editions while reducing the

preponderance of unspecified ED diagnoses. The model focuses on three prototypal

classes, anorexia nervosa and behaviorally similar disorders (AN-BSD), bulimia nervosa

and behaviorally similar disorders (BN-BSD), and binge eating disorder and behaviorally

similar disorders (BED-BSD), which are arranged in a hierarchical manner based on

38
clinical severity. A residual category of EDNOS remains for those not eligible for

specified classification. Based on extensive literature review, the researchers determined

that “the overwhelming majority of adults” would be reassigned to a category, thus

significantly diminishing the prevalence of EDNOS cases.

Multiple research efforts have empirically substantiated the broad diagnostic

category proposal compared to maintaining more rigid standards (Bulik, Sullivan, &

Kendler, 1998; Mitchell et al., 2007; Williamson et al., 2005). Sysko and Walsh (2011)

concluded that the more flexible parameters of this model could nearly render the

residual category of EDNOS unnecessary. These studies, however, fail to integrate

clinical validators of mortality, treatment response, course of illness, or outcomes,

making it difficult to ascertain how clients would respond to treatment based on their

respective categories (Walsh & Sysko, 2009). Also, while some support for the

hierarchical arrangement of the categories was found based on course of illness and

treatment responses and outcomes, no available studies have specifically evaluated the

recommended descending order of severity.

Another concern of this model is “overdiagnosis,” (i.e., assigning individuals to a

diagnostic category despite lack of clinical necessity; Walsh & Sysko, 2009). Due to the

more relaxed prototypal criteria put forth by the broad categories method, clinical

judgment would be imperative to accurately discern whether or not clients merit an ED

diagnosis. In the absence of specific guiding criteria (e.g., frequency of bingeing and

purging episodes for BN), clinicians would need to effectively judge clinical distress and

functional impairment based on client presentation and report. The developers of this

model suggest adding a criterion indicating psychosocial impairment for additional

39
diagnostic assistance and to avoid overdiagnosis. Additionally, this diagnostic format

does not address the issue of diagnostic crossover, the poor clinical utility of maintaining

an unspecified category even if a small minority of cases, and how to precisely articulate

recovery. Despite these limitations, however, the broad categories model is a step toward

less stringent diagnostic criteria so that more clients can have access to appropriate care

(Walsh & Sysko, 2009).

Single-category model. Fairburn and Bohn (2005) argue that partitioning EDs

into mutually exclusive diagnoses “detracts attention from the most striking characteristic

of the eating disorders; namely, that far more unites the various forms of eating disorder

than separates them” (p. 697). Several researchers advocate for conceptualizing EDs as a

single diagnostic category (Beumont, Garner, & Touyz, 1994; Fairburn, 2008; Fairburn

& Bohn, 2005; Fairburn, Cooper, & Shafran, 2003). Beaumont, Garner, and Touyz

(1994) discourage further modification of existing DSM categories and contend that

“there is no rigid separation between anorexic and bulimic patients except in respect to

the presence or absence of emaciation” (p. 358). They argue that the fundamental

characteristic of all EDs is the extreme drive for thinness, which is fueled by an extreme

preoccupation with body image and control over weight and shape. A transdiagnostic

model, termed simply “eating disorder,” operates under the notion that all ED diagnoses

share the central underlying psychopathological mechanism of overevaluation of self due

to shape and weight and exercising extreme control over eating (Fairburn, 2008; Fairburn

& Bohn, 2005; Fairburn, Cooper, & Shafran, 2003; Fairburn & Harrison, 2003).

Additional shared features across EDs include food restriction, bingeing, various

40
compensatory behaviors (e.g., laxative misuse, vomiting, excessive exercise), and body

checking (Fairburn, 2008; Fairburn & Bohn, 2005; Fairburn, Cooper, & Shafran, 2003).

Research testing the validity of a transdiagnostic treatment modality yielded

results that the heterogeneous sample (i.e., individuals diagnosed with an ED with a BMI

of 17.5 or more) responded well to the treatment, independent of specific ED diagnosis

(Fairburn et al., 2009). These outcomes question the clinical utility of maintaining

compartmentalized distinctions between ED diagnostic categories. The researchers

advocate for additional studies to evaluate broader, more comprehensive samples of

individuals with varied ED presentations in order to determine treatment efficacy and

prognosis. A noteworthy limitation regarding the transdiagnostic treatment study,

however, is that participants with AN were omitted from evaluation, leaving AN

outcomes unknown. Further, critics of the single-category theory contend that it may be

an oversimplification, as individuals with AN and BN are shown to vary in prognosis and

treatment response (Herzog et al., 1999; Treasure & Schmidt, 2002).

Staging Diagnostic Models for Eating Disorders

A general criticism pertaining to extant diagnostic approaches relates to missed

opportunities for early intervention (Treasure, Stein, & Maguire, 2014). Once a mental

illness meets criteria for diagnosis, the psychopathology has been established and

symptoms expressed. A staging model follows the course of an illness from the high-risk

and premorbid stages through early symptom onset and eventual complete

psychopathological manifestation (Maguire, le Grange, Surgenor, Marks, Lacey, &

Touyz, 2008; Scott et al., 2013; Treasure et al., 2014). The illness is tracked using

41
neuroprogression, which follows neurobiological mechanisms that inform the trajectory

of a mental illness (Berk et al., 2010).

Staging has been recommended for application to ED conceptualization (e.g.,

Maguire et al., 2008; Treasure et al., 2014). Focusing on severity of symptoms, staging

allows for early intervention and case management to assist with AN’s related

psychological and medical complications (see Figure A2; Maguire et al., 2008). Evidence

supporting this scheme is associated with the following features of EDs: the presence of

prodromal characteristics and longitudinal course, apparent neurobiological progression,

success with early intervention, response to specific interventions unique to the stage of

illness, and distinctions of later-stage development when treatment resistance increases

(Treasure et al., 2014).

Spiral model. Another longitudinal conceptualization, the spiral model maps the

course of EDs from dietary restriction to full onset of AN or BN (Heatherton & Polivy,

1992). The developers of this model propose that after repeated failures at dieting, self-

esteem is compromised to a severe degree, leading to chronic negative affect and

maladaptive coping skills. Individuals with BN criticize themselves for bingeing episodes,

and individuals with AN-R view themselves as failures for not attaining an unrealistically

low goal weight, which perpetuates illness maintenance and severity. This model fails to

explain, however, which dieting individuals are more vulnerable to ED development and

has yet to be formally substantiated in replicable research.

These diagnostic models may demonstrate some benefits but fail to address most

of the inadequacies of a categorical system. “The predominant current approach to

studying psychopathology proceeds from a diagnostic system based on relatively

42
informal clinical intuition about the clustering of presenting symptoms – as opposed to

dimensional structures built from empirically demonstrated correlations and factor

analyses” (Kozak & Cuthbert, 2016, p. 288). Multiple dimensional classification systems

for psychiatric illnesses have been proposed, including the Research Domain Criteria

(RDoC) and the prototype model. These conceptualizations and their applications for

EDs will be reviewed before exploring ED-specific dimensional templates.

Dimensional and Spectrum-Based Diagnostic Models of Eating Disorders

“The failings of a categorical diagnosis suggest, but do not require, that a

dimensional model of classification would provide a more valid description of

psychopathology” (Widiger & Samuel, 2005, p. 496). Widiger and Gore (2014) offer

explicit support for transitioning categorical nosology toward dimensional constructs.

They contend that dimensional symptom assessment and treatment are already seen in

routine clinical practice. Clinicians use categorical diagnoses to inform treatment

planning but commonly address salient symptomatology that may not adhere to the

determined diagnosis (Mojtabai & Olfson, 2010). Dimensional features could address

multiple categorical issues, such as high comorbidity, inflexible criteria, and identifying

antecedent conditions (Widiger & Samuel, 2005). In the World Psychiatric Association

(WPA)-World Health Organization (WHO) Global Survey, psychiatrists (n = 4,887) in

44 countries were asked to characterize their perceptions of nosological systems (Reed,

Correia, Esparza, Saxena, & Maj, 2011). The highest-rated purposes of psychiatric

classification were to facilitate treatment planning and management, and simplify

communication between clinicians. The majority of participants reported preferring the

43
integration of dimensional assessment into diagnostic categories in order to make

diagnosis more personalized and a more precise characterization of clinical issues.

Strict categorical criteria for EDs risk overlooking those who experience

significant impairment and distress but may not meet all diagnostic criteria (Schmidt et

al., 2008; Wade & O’Shea, 2015). Considering EDs as flexible “clinical entities” and

investigating the underlying psychological mechanisms leading to the manifestation of

symptoms yields a more realistic and comprehensive diagnostic approach, which in turn

may facilitate improved treatment strategies (Garner & Garfinkel, 1988). Multiple studies

have analyzed the validity of proposed dimensional models of ED diagnosis by

evaluating symptomatology and identifying relevant psychological features across ED

presentations (e.g., Franko & Omori, 1999; Stice, Killen, Hayward, & Taylor, 1998; Stice,

Ziemba, Margolis, & Flick, 1996; Tylka & Subich, 1999). These research efforts

concluded that there is empirical evidence substantiating a dimensional classification

system. Elucidating specific dimensions that explain variations in symptom expression

would allow for more useful and accurate classification, as well as clarification of

etiological distinctions, prognosis, and treatment outcomes for all EDs (Lavender et al.,

2013). Wildes and Marcus (2013) reviewed three types of dimensional diagnostic models

for EDs, each with its own strengths and liabilities. These models focus on dimensions of

ED symptomatology, comorbid psychopathology, and neurobiological mechanisms

underlying ED behaviors and cognitions and will be explored subsequently.

Dimensional and spectrum models based on eating disorder symptomatology.

The multiple symptoms that comprise ED psychopathology have the capacity to vary in

terms of severity (Wildes & Marcus, 2013). Clients may experience changes in intensity

44
for existing impediments and not others, as well as develop new disturbances in addition

to or in place of others, resulting in the emergence of diagnostic crossover and ambiguous

definitions of remission under purely categorical systems. Some researchers thus suggest

grouping individuals with EDs according to their “symptom profiles” to decrease

unspecified cases and improve clinical utility (Dunn et al., 2010).

Prototype diagnosis. Westen (2012) discusses an alternative diagnostic approach

based on clinical prototypes, which integrates both categorical and dimensional

components (Ortigo et al., 2010). In this format, clinicians rate clients on an ordinal scale

of 1, “little or no match,” to 5, “very good match,” indicating how closely the client’s

symptom presentation matches a paragraph description of a given mental illness.

Prototype diagnosis has been suggested for use with EDs. To assess the model’s

favorability, ED-treating clinicians were presented with current (i.e., categorical) and

prototype diagnostic options for use with their clients and largely reported preferring the

latter (Ortigo et al., 2010; Westen, 2012). The prototype conceptualization of EDs used in

this study was comprised of two disorders, AN, with a primary feature of self-starvation,

and BN, with a primary feature of bingeing and purging (see Figure A3). The clinicians’

responses favoring the prototype template indicate promising evidence for openness to

alternative nosological organization. Prototype diagnosis has also been applied to

adolescent psychiatric disorders (Haggerty et al., 2016), mood and anxiety disorders

(DeFife, Peart, Bradley, Ressler, Drill, & Westen, 2013), and personality disorders

(Westen, DeFife, Bradley, & Hilsenroth, 2010; Westen, Shedler, & Bradley, 2006). The

ICD-10 mirrors the model’s prototypic design with a narrative-based template describing

each diagnosis and its signature features (Uher & Rutter, 2012; WHO, 1992). With

45
respect to limitations of this model, Westen (2012) acknowledges the risk of

confirmatory bias and erroneously assigning a particular prototype to a client that may

not be substantiated. Similarly, a degree of subjectivity is inherent to the clinical

observations necessary for this design, yielding concerns of inter-rater reliability.

Three-dimensional conceptualizations of eating disorders. Williamson, Gleaves,

and Stewart (2005) propose a model based on three dimensions of EDs: binge eating, fear

of fatness/compensatory behaviors, and extreme drive for thinness (see Figure A4). These

dimensions emerged from a factor analysis study investigating the latent structure of ED

features (Williamson et al., 2002). BN is placed high on the fear of fatness/compensatory

behaviors and binge-eating dimensions and relatively low on drive for thinness. AN is

placed high on the fear of fatness/compensatory behaviors and drive for thinness

dimensions and low on binge-eating. BED is placed midway on the fear of

fatness/compensatory behaviors dimension, low on drive for thinness, and high on binge-

eating.

Other researchers also identified three-dimensional constructs of EDs that appear

to differ in severity but not in kind. Advocates for a single-category ED construct,

Beumont et al. (1994) proposed a diagram illustrating that all EDs can be identified by

the following three dimensions: low to high weight, absence of binge eating to multiple

episodes of binge eating, and absence of purging to multiple episodes of purging (see

Figure A5). Also, Holm-Denoma, Richey, and Joiner, Jr. (2010) isolated dietary restraint,

drive for thinness, and body dissatisfaction as three key diagnostic facets. Another study

determined that body thinness, body perfectionism, and body awareness were salient

across participants (n = 5,193) with heterogeneous ED presentations, lending toward a

46
dimensional system (Olatunji , Kim, & Wall, 2015). Three-dimensional models for EDs

are offered tentatively, however, as replication is required in order to substantiate their

validity (Williamson et al., 2005).

The eating disorder continuum. A general ED severity spectrum has been

proposed and endorsed by multiple researchers (e.g., Hay & Fairburn, 1998; Mintz,

O’Halloran, Mulholland, & Schneider, 1997; Scarano & Kalodner-Martin, 1994; Tylka &

Subich, 1999). The model places asymptomatic individuals at one extreme end and

individuals with ED at the opposite end, with moderate presentations of ED-like

symptoms in the center (Mintz et al., 1997). Tylka and Subich (1999) evaluated the

construct validity of the continuum in one study investigating relationships between

personality traits, body dissatisfaction, dieting locus of control across women with EDs,

and another study investigating common psychological features of EDs as indicated by

the Eating Disorder Inventory, Revised (EDI-2; Garner, 1991). The researchers

discovered evidence supporting the continuum model, as neuroticism, eight of nine EDI-

2 subscales, and internal dieting locus of control demonstrated a linear progression

correlated with severity of ED disturbance (Tylka & Subich, 1999). Another study found

DSM-IV subtypes BN-P and BN-NP residing on a continuum with BED, with BN-P

being associated with the most severe comorbid psychopathology, social adjustment, and

ED symptoms (Hay & Fairburn, 1998). BN-NP showed moderate severity, and BED had

least severity.

Tylka and Subich (2003) also performed taxometric analysis to find evidence

substantiating a dimensional (i.e., continuous) conceptualization of ED. They

investigated common sociocultural (e.g., perceived pressure for thinness) and

47
psychological (e.g., neuroticism) factors of EDs and found that these domains function

along a continuum. The researchers advocate for attending to individuals at varying

placements on the spectrum, as interventions targeting those presenting mildly disordered

eating behaviors may intercept the development of an ED. This study was limited by its

largely homogeneous sample of university-affiliated sorority members. Future research is

encouraged to determine ED cognitive symptoms that can be evaluated within the context

of a continuum model.

The continuity hypothesis for BN. Research has supported the continuous nature

of BN, termed the “continuity hypothesis” (Franko & Omori, 1999; Lowe et al., 1996;

Stice, Killen, Hayward, & Taylor, 1998; Stice, Ziemba, Margolis, & Flick, 1996). This

model suggests that BN is placed at an extreme end of a continuum of eating and body

image disturbances (Pike & Rodin, 1991). Stice et al. (1996) investigated the relationship

of the continuity hypothesis and the “dual pathway model” (Stice, 1994), an etiological

explanation for BN linking negative affect and dietary restraint to the onset of symptom

expression (see Figure A6). The study found support for the continuity hypothesis, as

multiple sociocultural factors driving pressure for thinness, ideal-body internalization,

food restriction, and negative affect differentiated individuals with BN, subclinical BN,

and the control group (Stice et al., 1996). In a similar study, negative affect,

dysfunctional thinking, and problematic eating attitudes had a positive relationship with

ED severity, further substantiating BN’s locality on a continuum (Franko & Omori, 1999).

Stice and Agras (1999) performed cluster analysis and discovered two subtypes of BN,

pure dietary and mixed dietary-depressive. Both groups presented with common BN

features, but the mixed dietary-depressive subtype reported increased food and body

48
image obsessions; comorbid psychopathology including mood, anxiety, and personality

disorders; and less favorable treatment outcomes. These findings suggest that the

combination of dietary restriction and negative affect lend toward increased illness

severity. Lowe et al. (1996) evaluated individuals with BN, dieters, restrained eaters, and

unrestrained eaters with regard to ED symptomatology, comorbid psychopathology, and

bingeing and found progressive linear trends for two of the three dimensions. The

researchers concede, however, that a clear causal relationship between dieting and BN

cannot be concluded due to the cross-sectional nature of the study. This limitation was

also cited in Stice et al.’s (1996) study.

Dimensional models based on comorbidity. As discussed, comorbidity rates are

consistently high across presentations of EDs (e.g., Bulik et al., 2000; Lavender et al.,

2013; Wonderlich & Mitchell, 1997). Considering co-occurring psychopathology

provides valuable insight regarding the underlying mechanisms of ED symptom

expression and within-group heterogeneity (Wildes & Marcus, 2013b). Several

diagnostic constructs for EDs based on comorbidity research have been proposed (Wildes

& Marcus, 2013). These models have considered levels of impulsivity, the presence of

BPD traits, the presence of OCD pathology, dietary and dietary-negative-affect, and

personality profiles comprised of overcontrolled or undercontrolled features. Meaningful

classifications informed by personality traits will be explored in further detail.

Personality traits. Isolating patterns of personality attributes and their

associations with EDs has been of particular empirical interest (e.g., Goldner,

Srikameswaran, Schroeder, Livesley, & Birmingham, 1999; Westen & Harnden-Fischer,

2001). Preliminary features of personality disorders have been shown to inform the

49
etiology of EDs and the particular symptoms developed (Wonderlich & Mitchell, 1992).

Clients with EDs can be classified based on their individual personality features and the

severity of associated psychopathology (Pryor & Wiederman, 1996). Clusters of

personality traits commonly linked to EDs have emerged, including emotionally

dysregulated and impulsive, emotionally constricted and compulsive, and normative (e.g.,

Holliday, Landau, Collier, & Treasure, 2006; Wonderlich et al., 2005). The three ED

classes that emerged in Bulik et al.’s (2000) twin study presented with similar

constellations of personality features despite differences in ED symptom expression. The

researchers propose that certain configurations of personality traits may account for

predisposition to ED development, and the specific manifestation of ED symptoms may

be explained by genetic and/or environmental factors. Another study revealed three

classes of individuals with EDs based on personality features: an overcontrolled and

inhibited group resembling AN, an undercontrolled and dysregulated group resembling

BN, and a resilient group with lower psychopathology (Turner et al., 2014). Individuals

with AN seem to present with rigidity, tendency toward overcontrol, compulsivity, and

perfectionism (Strober, 1980) and can be further described as anxious, avoidant, and

insecure (Strober, 1983). Conversely, individuals with BN and AN-BP often present with

impulsivity, poor distress tolerance, and labile affect (Bulik, Beidel, Duchmann, Weltzin,

& Kaye, 1992; Robbins et al., 2012; Root et al., 2010).

Goldner et al. (1999) assessed 18 personality disorder characteristics in

individuals with EDs using factor analysis and cluster analysis, revealing three groups of

participants. All three clusters scored higher than the general population on the dimension

of neuroticism. Cluster 1 demonstrated compulsivity, restricted affect, and interpersonal

50
issues; 78% of this group were diagnosed with AN-R. Cluster 2 demonstrated

neuroticism, impulsivity, and features of BPD and resembled qualities of BN. The third

group was characterized by mild personality psychopathology and did not meet criteria

for a personality disorder. However, this cluster scored significantly higher than the

general population on the following dimensions: affective instability, anxiousness,

identity problems, and narcissism.

In another study focused on personality profiles, psychiatrists and psychologists

evaluated individuals with AN and BN using dimensional and categorical personality

measures (Westen & Harnden-Fischer, 2001). Participants were clustered into three

significantly distinct groups: high-functioning and perfectionist, overcontrolled and

constricted, and undercontrolled and emotionally dysregulated. The emerged subgroups

had predictive validity for general psychopathology, personality-specific

psychopathology, overall functioning, and etiology. The overcontrolled and

undercontrolled profiles resembled AN and BN, respectively. Overcontrolled individuals

were characterized by overall restriction across multiple facets, including food, needs,

pleasure, emotions, relationships, introspection, self-awareness, sexuality, and deep

understanding for others. This group is further described as dysphoric and feeling empty,

depressive, anxious, inferior, anhedonic, avoidant, and ashamed. Conversely, the

undercontrolled group presented as impulsive (e.g., engaging in bingeing and

compensatory behaviors to alleviate distress), labile, reward-seeking, and erratic and

desperate within the context of relationships.

In similar research, Wildes and Marcus (2013a) systematically reviewed 23

research studies identifying comorbid psychopathology in EDs. Despite the diverse

51
samples and constructs utilized in each study, three main categories emerged:

“undercontrolled,” “overcontrolled,” and “low psychopathology.” The “undercontrolled”

class is characterized by impulsivity and risky behaviors, while the “overcontrolled” class

is characterized by compulsivity, inhibition, rigidity, and avoidance. The final group with

“low psychopathology” presents with low to no comorbid psychopathology. Utilizing

these three categories indicates efficacy in clinical outcome prediction (Wildes et al.,

2011) and alignment with ED risk factors (Westen & Harnden-Fischer, 2001).

While the comorbid classification system holds promise for ED diagnosis and

treatment, determining precisely which dimensions are most relevant to categorizing the

three groups remains uncertain (Wildes & Marcus, 2013b). Investigating ED symptoms

and related co-occurring psychopathology requires further research but is an auspicious

direction for identifying shared underlying mechanisms across multiple disorders and

developing specific treatments targeting those transdiagnostic properties (Lavender et al.,

2013).

Dimensional and spectrum models based on neuroscience. An ongoing

criticism of both categorical and dimensional approaches to nosology is a lack of

empirical substantiation (e.g., McHugh, 2005). Some researchers support integrating

neurocognitive endophenotypes into the psychiatric classification system in order to have

more biological evidence supporting descriptions of mental illness (Robbins, Gillan,

Smith, de Wit, & Ersche, 2012). They contend that certain endophenotypes are shared

across multiple diagnoses and thus may provide elucidation surrounding typically co-

occurring disorders. In line with RDoC (e.g., Garvey et al., 2010; Kozak & Cuthbert,

52
2016), current empirical efforts seek to uncover neurobiological dimensions to inform

future methods of psychiatric nosology.

Research Domain Criteria. A comprehensive dimensional conceptualization of

psychiatric illness based on the latest findings in neuroscience, the National Institute of

Mental Health’s RDoC is described as “an integrative psychobiological approach to

construct elaboration” (Kozak & Cuthbert, 2016, p. 296). The model is based on the

following five domains: negative valence systems, positive valence systems, cognitive

systems, systems for social processes, and arousal and regulatory systems (see Figure A7),

which are comprised of functional and behavioral constructs that determine human

functioning. These domains are evaluated across eight units of analysis, including genes,

molecules, cells, circuits, physiology, behavior, self-report, and paradigms (Insel et al.,

2010). The RDoC approach has been considered within the context of EDs (van Elburg

& Treasure, 2013; Lutter, Croghan, & Cui, 2016; Tanofsky-Kraff, Engel, Yanovski, Pine,

& Nelson, 2013). Advocates for this application argue, “So far within the eating disorder

field there has been minimal adoption of a dimensional, transdiagnostic approach to

defining biological mechanisms or traits other than in the field of neurocognitive research”

(van Elburg & Treasure, 2013, p. 556). Researchers have examined the application of

RDoC with children who present with subclinical or premorbid ED symptoms with

favorable outcomes (Tanofsky-Kraff et al., 2013).

Fully conceptualizing EDs within the RDoC framework presents with certain

difficulties, however, as molecular and cellular units of analysis for EDs are not indicated

and ED behavioral symptoms are not easily transcribed to this model (van Elburg &

Treasure, 2013). For example, food can behave as a reward, placing it in the positive

53
valence system, except in cases of AN, when food is generally feared, placing it in the

negative valence system. Also, since ED behaviors are a result of a multifaceted

interaction among cognitive, physiological, emotional, and behavioral processes, they

may be more aptly placed in regulatory systems. Critics of RDoC contend that the

neuroscience conceptualizations informing the classification system are underdeveloped,

and mental illnesses cannot be diagnosed based on neural activity without also

considering social and cognitive functioning (Paris & Kirmayer, 2016). They further

argue that the importance of psychosocial factors is minimized for diagnosis and

treatment planning, and the focus on science eliminates the integration of client

experiences and clinical observations into the assessment process. RDoC is still in

preliminary development, but this model provides an encouraging avenue to explore the

neurobiological underpinnings of EDs and their associations with behavioral and

cognitive functioning across ED presentations and comorbid disorders (Lavender, Crosby,

& Wonderlich, 2013).

Impulsivity and compulsivity. Analysis of the neurobiological constructs of

impulsivity and compulsivity appears to have value for classifying multiple psychiatric

disorders, including EDs (Robbins et al., 2012). Impulsivity and compulsivity are

considered to be transdiagnostic constructs, cutting across multiple mental illnesses.

Oldham, Hollander, and Skodol (1996) contend that these characteristics are aspects of a

dimensional model for nosology conceptualization that accounts for the “biopsychosocial

forces” behind certain illnesses. More specifically, “[EDs] might appropriately be

labelled ‘impulsive-compulsive disorders’ on the bases of these predisposing traits”

(Robbins et al., 2012, p. 82). Impulsivity can be described as a tendency toward “actions

54
which are poorly conceived, prematurely expressed, unduly risky or inappropriate to the

situation and that often result in undesirable consequences” (Daruna & Barnes, 1993).

Conversely, compulsivity is characterized by “actions inappropriate to the situation

which persist, have no obvious relationship to the overall goal and often result in

undesirable consequences” (Robbins et al., 2012, p. 83). Both of these neurobiological

processes are thought to be dysfunctional inhibition responses, or what is referred to as

“top-down” cognitive regulation (Brooks, Rask-Andersen, Benedict, and Schiöth, 2012;

Dalley, Everitt, & Robbins, 2011).

Compulsivity is a trait observed in various psychiatric illnesses, including OCD

and EDs (Robbins et al., 2012). Since these disorders are also known to commonly co-

occur, this shared feature may explain neurobiological substrates accounting for their

development. AN’s “compulsive rejection of food” is a clear demonstration of the illness’

compulsive substructure. Contrarily, individuals with BN tend toward impulsive

behaviors, particularly bingeing and purging. One study determined that individuals with

BED experience a greater reward from food than the general population, which is likely

associated with impulsivity (Schag et al., 2013). Bingeing is associated with less

“effortful control,” as evidenced by responses to both self-report and observed behavioral

measures (Claes, Mitchell, & Vandereycken, 2012). Lack of control is likely linked to

impulsivity and overreactivity to emotions and prospective rewards. Robbins et al. (2012)

recommend future studies analyzing genetic indicators for impulsivity and compulsivity

for further clarification of their implications and etiology. They also recognize that

impulsivity and compulsivity may themselves not be unitary dimensions and could

possibly be further deconstructed, which stimulates additional research directions.

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 Impulse-control spectrum model. Recent findings in neuroscience support the

conceptualization of an ED diagnostic spectrum. Brooks, Rask-Andersen, Benedict, and

Schiöth (2012) propose an impulse-control spectrum model of ED diagnosis, mediated by

temperamental dominance (i.e., persistent tendency toward restriction or impulsivity; see

Figure A8). This model is largely based on genetic data (Brooks et al., 2012) and

neurobiological data indicating that dysfunctional striatal dopaminergic circuitry

combines with different levels of cognitive control by the PFC, leading to symptoms

associated with AN, BN, and BED (Kaye et al., 2011). Elevated PFC responses to food

stimuli are associated with intake restriction, rigidity, perfectionism, and obsessive

thinking, which are signature features of AN presentations. On the other extreme of the

spectrum, characteristics resembling BN, including impulsivity, loss of control,

interpersonal difficulties, substance abuse, and risky behaviors, are related to increases in

mesolimbic rewards in response to food stimuli. This framework accounts for diagnostic

migration and symptom fluctuation across restriction and impulsivity, with

temperamental dominance being the grounding feature associated with the more

prevalent disposition. An important limitation to note about this spectrum model is that it

precludes EDs with mixed symptomatology (i.e., features of both restriction and

impulsivity).

Other neurobiological conceptualizations. Studies rooted in neurobiology

typically evaluate neural pathways underlying cognitive and behavioral functioning

(Sanislow et al., 2010) and address that psychopathological disorders are inherently

multifactorial and often yield significant within-group heterogeneity with regard to

clinical presentation (APA, 2013; Garner, 1993). Several neurobiological features have

56
been observed across ED presentations. Symptoms that appear to be transdiagnostic in

nature (e.g., bingeing, purging, overevaluation of self due to perceived body image)

suggest the presence of underlying neurobiological mechanisms that may explain shared

symptomatology (Wildes & Marcus, 2013b). An overactive amygdala, for example, is a

probable cause of transdiagnostic anxiety symptoms (Joos et al., 2011). Additionally,

alexithymia, or difficulty with emotional identification and expression, is a common

feature of all EDs and likely a result of dysfunctional neural circuitry connecting the

prefrontal cortex (PFC) to the mesolimbic regions, leading to a compromised sense of

emotional self (Oldershaw, Hambrook, Tchanturia, Treasure, & Schmidt, 2010). Another

unifying feature across EDs is dysfunctional neural activation regulation upon exposure

to a food stimulus in areas of the brain responsible for interoceptive awareness and

somatosensory perception, leading to distorted body image (Pietrini, Castellini, Ricca,

Polito, Pupi, & Faravelli, 2011).

Strober (2004) proposes that individuals with AN suffer from poor emotional

regulation due to dysfunctional neural systems associated with fear-based learning. They

often seem to have a distinct appetite-regulating mechanism resulting from reward,

sensory, and interoceptive processes (Kaye, Wagner, Fudge, & Paulus, 2011). Variations

in serotonin output and their implications for diverse presentations of EDs have also been

examined (Kaye, 2008). Frank and Kaye (2012) offer that the PFC is likely a factor in

anorexic restriction of food intake through elevated anxiety and fear responses, which

then inform decision-making. Individuals with BN experience reward desensitization in

response to overeating, as evidenced by a study evaluating brain taste reward responses

57
(Bohon & Stice, 2011). This maladaptive functioning resembles that of substance abuse

reward processes.

Specific literary foundation for this project’s proposed diagnostic model will be

discussed next.

Proposed Categorical-Dimensional Diagnostic Model for Eating Disorders

“The controversy about the relative merits of categorical versus dimensional

models has raged for many years” (Williamson, Gleaves, & Stewart, 2005, p. 1). In

reality, psychiatric illnesses may be best defined with both categorical and dimensional

components (e.g., Holm-Denoma, et al., 2010; Muthén, 2006; Westen, 2012). Wildes and

Marcus (2013b) identify a need for unifying the above classification factors (i.e., ED

symptoms, comorbidity, and neuroscience) for increased clinical utility. Isolating

underlying neurobiological mechanisms to determine their implications for the

expression of ED symptomatology and comorbid psychopathology would yield a

comprehensive and useful means of psychiatric nosology. The multiple dimensions of

diagnostic information would provide context with regard to ED etiology, risk factors,

prognosis, course, and treatment approaches.

This project proposes an integrative biopsychosocial dimensional diagnostic

model with categorical features based on ED symptomatology, clinical impairment,

comorbid psychopathology, and underlying neurobiological mechanisms. The

conceptualization is comprised of two patterns of ED, Restrictive Profile (RP) and

Impulsive Profile (IP), and a Transdiagnostic Dimensions (TD) category containing

features commonly observed across ED presentations. RP and IP resemble the

internalizing and externalizing factors, respectively, described in the DSM-5 (APA, 2013;

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Adambegan, Wagner, Nader, Fernández-Aranda, Treasure, & Karwautz, 2012; Mitchell,

Wolf, Reardon, & Miller, 2014; Muratori, Viglione, Maestro, & Picchi, 2004).

This project intends to be a departure from the categorical definitions of AN, BN,

and BED. However, it is recognized that too sharp of a paradigm shift may deter the

model’s implementation. In response to this concern, a more transitional spectrum model

is also suggested, placing AN-R at one extreme end (i.e., Restrictive), Normalcy in the

center, BED moderately on the Impulsive side, AN-BP intermediately on the Impulsive

side, and BN at the other extreme end of Impulsive.

Profile features of eating disorders. Under the proposed model, EDs can be

simplified into two profiles: RP with restrictive and compulsive tendencies (e.g., AN-R),

and IP with impulsive tendencies (e.g., AN-BP, BED, BN; e.g., Claes, Nederkoorn,

Vandereycken, Guerrieri, & Vertommen, 2006; Wildes & Marcus, 2013). It has been

suggested that EDs belong to a spectrum of restriction versus impulsivity, where AN-R

and BN are at opposite ends (Brooks et al., 2012; McElroy, Phillips, & Keck, 1994).

Evidence supports a “longitudinal distinction” for AN-R and BN, supporting the

categorical component of this model (Eddy et al., 2008). In one study, participants with

restricting anorexia reported less impulsivity than those with purging anorexia (AN-P),

BN, and those in the control group (Claes et al., 2006). AN-P, BN, and the control group

were rated as significantly more impulsive than AN-R in terms of lack of self-control and

motor impulsivity. AN-P, BN, and the control group also reported more fun-seeking

behaviors than AN-R, with AN-R reporting higher levels of inhibition than the other

groups. These findings were consistent with Sohlberg’s (1991) indications that AN-R

presents as more controlled and less impulsive than BN. In the context of neuroscience,

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individuals with AN seem to be able to demonstrate excessive self-control and food

restriction due to amplified dorsal cognitive circuit functioning, while individuals with

BN demonstrate greater impulsivity and decreased control over certain behaviors (e.g.,

bingeing and purging; Kaye et al., 2011). In a study assessing dominant ED traits using

the EDI, perfectionism and body dissatisfaction predicted restrictive tendencies, and

bulimic symptoms predicted impulsivity (Izydorczyk, 2014). Low interoceptive

awareness was predictive of both restrictive and impulsive inclinations but had “greater

predictive power” in anorexic tendencies toward restriction.

Treatment efficacy varies across the two profiles discussed (Fairburn & Harrison,

2003; Treasure & Schmidt, 2002). Though it may take years before resigning to seek

professional help, individuals with BN are typically more open to seek treatment than

those with AN due to shame surrounding their eating pathology (Fairburn & Harrison,

2003). Psychotherapeutic interventions with BN and BED populations have proven far

more successful than for those with AN (Treasure & Schmidt, 2002). Additionally,

pharmacological interventions (e.g., SSRIs) have been proven useful for treatment of BN

and BED but less so for AN (Krüger & Kennedy, 2000; Tortorella, Fabrazzo, Monteleone,

Steardo, & Monteleone, 2014; Treasure & Schmidt, 2002). As Claes et al. (2006) contend,

“These findings suggest the likely utility for both research and clinical practice of

considering ED symptoms in their characterological context” (p. 413). Further descriptors

are reviewed below.

Restrictive profile. Individuals with compulsive and restrictive traits tend to be

hypervigilant and avoid harm, discomfort, or negative affect (Hollander, 1998). AN tends

to present with more obsessive and compulsive features (Dawe & Loxton, 2004;

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Herpertz-Dahlmann, 2015). Individuals with AN present with particular difficulty with

social processing (Cardi, Matteo, Corfield, & Treasure, 2013). They appear to have

attentional bias toward criticism but away from expressions of positive affect. Further,

they tend toward restricted emotional expressions but report higher levels of anger than

the general population (Claes et al., 2012). AN also features asceticism (Beumont, 2002;

Garner, 1991; 2004), self-punishment (Beumont, 2002), perfectionism (Culbert et al.,

2015; Herpertz-Dahlmann, 2015; Iranzo-Tatay et al., 2015; Pike et al., 2008), and

competitiveness (Beumont, 2002). Finally, those with AN, especially AN-R, are less

inclined to be motivated for instant rewards (Steinglass, Figner, Berkowitz, Simpson,

Weber, & Walsh, 2012).

Impulsive profile. Those with impulsive traits seek pleasure and rewards and may

demonstrate antisocial behaviors (Hollander, 1998). BED and BN are of a more

impulsive nature (Dawe & Loxton, 2004; Robbins et al., 2012; Schag et al., 2013). AN-

BP also displays impulsive features (Eddy et al., 2002). Individuals with BN demonstrate

fewer deficits in emotional identification than those with AN (Kenyon et al., 2012). With

respect to neurobiological reward systems, individuals with BN experience rewards in

response to novelty (Miettunen & Raevuori, 2012). Children with subclinical

presentations of BN and BED were observed to have a more intense psychophysiological

pleasure response to anticipating food reward (Soussignan, Schaal, Boulanger, Gaillet, &

Jiang, 2012). BED and BN show further evidence of nosological proximity. When

considering diagnostic crossover, the separation between BED and BN remains

ambiguous, as the two disorders may be transitional manifestations of the same illness

(Castellini et al., 2011; Fichter et al., 2008). In fact, one study revealed that individuals

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with BED are typically older than those with BN and report history of compensatory

behaviors (Mond, Peterson, & Hay, 2010). Additionally, a 12-year longitudinal study

revealed that the course, outcome, and mortality rates were statistically similar for BED

and BN with comorbidity as the greatest outcome predictor (Fichter et al., 2008). This

study further substantiated diagnostic migration between BN and BED. While current

BED criteria omit a stipulation for body image concerns, clients often report these

disturbances (Goldschmidt et al., 2010). Individuals with BED are also shown to be more

motivated by rewards, demonstrate greater impulsivity, and present with addictive

features (Davis et al., 2008), similar to those with BN.

Dimensions of Categorical-Dimensional Diagnostic Model for Eating Disorders

The profiles described above will include multiple critical dimensions designed to

capture a comprehensive and useful clinical picture, including ED pathology, level of

functional impairment, associated comorbidity, and neurobiological mechanisms.

Eating disorder symptomatology. Core trends of ED psychopathology are

central to these profiles, with RP and IP grounded in dominant tendencies toward food

restriction or bingeing and purging. AN-R’s predominantly restrictive nature adheres to

RP, while the bingeing and/or purging behaviors of AN-BP, BN, and BED are affiliated

with IP. While AN-BP has restrictive features, it is speculated that it is a transitory state

anticipating BN (Eddy et al., 2002; Tozzi et al., 2005; Milos et al., 2005), and rarely do

impulsive tendencies migrate to purely restrictive (Castellini et al., 2011; Eddy et al.,

2002). Additionally, studies have revealed that AN-BP and BN likely reside on the same

continuum (Gleaves et al., 2000; Wade et al., 2006) and that AN-BP, BN, and BED may

comprise a class separate from AN-R (Gleaves et al., 2004; Gordon, Holm-Denoma,

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Smith, Fink, & Joiner, Jr., 2007; Williamson et al., 2002). “AN, restricting type appears

to comprise its own continuous entity,” according to Gordon et al. (2007, p. S38).

Level of impairment. The degree of impaired functioning is extremely relevant

in assessing psychopathological severity associated with EDs (Bohn, Doll, Cooper,

O’Connor, Palmer, & Fairburn, 2008). This dimension also mirrors the severity scales

introduced in the DSM-5 (APA, 2013).

Comorbid disorders. Individuals with restrictive ED features (i.e., AN-R) tend to

present with anxiety disorders (Fairburn & Harrison, 2003), OCD (Herpertz-Dahlmann,

2015; Woodside & Staab, 2006), and depressive symptoms (Fairburn & Harrison, 2003).

BN and BED tend to co-occur with depression (Fairburn & Harrison, 2003), bipolar

disorder (Lunde et al., 2009), anxiety disorders (Swanson et al., 2011), NSSI (Paul et al.,

2002), and substance use (Becker & Grilo, 2015; Claes et al., 2006; Cohen & Gordon,

2009; Dansky et al., 2000; Claes et al., 2006). The comorbid cluster of illnesses for AN-

BP more closely resembles that of BN, rather than AN-R (Herpertz-Dahlmann, 2015).

Also, as indicated above, BN and BED tend to carry more comorbidity than AN-R

(Hudson et al., 2006; Kessler et al., 2013; Ulfvebrand et al., 2015), which suggests

further distinctions between impulsive and restrictive classes.

Personality traits. As discussed, multiple research efforts have concluded that

ED diagnoses can be meaningfully grouped into personality clusters. Upon reviewing

multiple studies examining the relationships among comorbid psychopathology and ED

symptoms (see Table A1), significant trends emerged. Most research efforts identified

three clusters of participants, which were generally classified as resilient and higher-

functioning, overcontrolled and restrictive, and undercontrolled and impulsive (Claes et

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al., 2006; Eddy, Novotny, & Westen, 2004; Goldner et al., 1999; Peñas-Lledó et al.,

2010; Steiger et al., 2009; 2010; Strober, 1983; Thompson-Brenner & Westen, 2004;

Thompson-Brenner, Eddy, Satir, Boisseau, & Westen, 2008; Turner et al., 2014; Westen

& Harnden-Fischer, 2001; Wildes & Marcus, 2013). In these studies, the overcontrolled

group correlated with anorexic pathology, and the undercontrolled group correlated with

bulimic pathology. Wildes and Marcus (2013) conducted an extensive review of 23

related studies and concluded that despite the diverse samples of participants analyzed,

the three stated clusters remained largely consistent. According to Steiger et al. (2009),

“Evident correspondences across studies suggest that the tendency for participants with

eating disorders to cluster into impulsive, relatively intact, and compulsive groups is quite

a replicable one” (p. 431).

A representative example of these studies, Claes et al. (2006) revealed an

undercontrolled/dysregulated group, which demonstrated bulimic symptoms with higher

levels of neuroticism and lower levels of conscientiousness and agreeableness compared

to the overcontrolled/constricted group, which demonstrated anorexic symptoms. A select

number of studies investigated specific correlations of certain traits among these clusters.

Eddy et al. (2004) explored how sexuality relates to personality types and ED features

and found an overcontrolled and constricted group with “childlike and prim/proper”

sexual features and an undercontrolled and emotionally dysregulated group presenting

with impulsivity, flirtatiousness, and promiscuity. Another study examined social

avoidance, distress, and novelty seeking (Peñas-Lledó et al., 2010). Novelty seeking was

linked with bulimic symptoms; the high novelty-seeking group was “the most impaired”

in terms of purging.

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 Individuals with AN-R are more often characterized by features of avoidant and

obsessive-compulsive personality pathology than those with AN-BP or BN (e.g., social

isolation, interpersonal alienation, sensitivity to negative evaluation, harm avoidance;

Claes et al., 2006; Westen & Harnden-Fischer, 2001). BN diagnosis typically co-occurs

with BPD and associated traits (e.g., impulsivity, interpersonal difficulties, risky

behaviors and promiscuity, labile affect; Claes et al., 2006; Westen & Harnden-Fischer,

2001). As BED became a formal diagnosis in the most recent edition of the DSM (APA,

2013), limited research is available associating this illness with personality disorders.

However, preliminary findings indicate that BED tends to co-occur mostly with Cluster-

B and Cluster-C traits (Smink et al., 2013) with more common correlations with BPD

features (Davis et al., 2008; Peterson et al., 2005). In summary, RP mostly features

characteristics from Cluster-C personality disorders, and IP is more commonly associated

with Cluster-B traits.

Neurobiological mechanisms. Individuals with AN tend to have cognitive

inflexibility, problem-solving deficiencies, and impairment in set-shifting (Danner et al.,

2012; Fox, 1981; Friederich & Herzog, 2011). Cognitive rigidity likely contributes to and

maintains the behavioral rigidity characteristic of those with restrictive proclivity (Lutter

et al., 2016). AN also commonly presents with obsessive and compulsive features, which

alludes to shared neurobiological substrates for AN and OCD (Robbins et al., 2012).

While observed in both impulsive and restrictive types of EDs, alexithymia and its

underlying neurobiological features (e.g., impairment in comprehension of facial cues)

are more often described for individuals with AN (Kessler, Schwarze, Filipic, Traue, &

von Weitersheim, 2006; Kucharska-Pietura, Nikolaou, Masiak, & Treasure, 2004), as the

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shared phenomenon appears to manifest differently in AN compared with BN and BED

(Behar & Arancibia, 2014). Those with AN show restricted affect, avoidance of

confrontation or harm, and are unable to describe their emotions. Individuals with BN

have difficulty separating physiology and emotion, responding to stressors by bingeing

and purging rather than acknowledging internal cues and expressing them. In a brain

study, alexithymia was associated with the grey matter of the parietal lobe in individuals

with BN, which accounts for difficulty describing emotions (D’Agata et al., 2015). No

such association was found for AN, supporting distinct presentations of the same

mechanism in AN and BN. BED has similar associations with alexithymia to BN and

also presents with difficulty describing emotions related to suicidality (Behar &

Arancibia, 2014). Another neurobiological descriptor, BN and BED are characterized by

reward- and novelty-seeking tendencies, while AN-R indicates low reward responses to

novel stimuli (Brooks et al., 2012; Kaye et al., 2011; Schag et al., 2013). Steiger et al.

(2009) found evidence that the “inhibited/compulsive” (i.e., restrictive) group of

participants were more likely to carry the triallelic 5HTTLPR gain-of-function LA allele,

a feature linked to trait compulsivity, than the “dissocial/impulsive” group.

Transdiagnostic dimensions. Multiple features are common to all ED

presentations (e.g., Fairburn, 2008; Fairburn & Bohn, 2005). The Transdiagnostic

Dimensions category is reserved for traits that routinely co-occur with both RP and IP.

These include ED-related psychological features, other signature psychological features

of EDs, and shared comorbid psychopathology. General ED psychological characteristics

including drive for thinness (e.g., Beumont et al., 1994; Garner, 1991; 2004),

internalization of thin-ideal (Stice, 2002; Stice et al., 1996), and body dissatisfaction (e.g.,

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Fichter et al., 2008; Garner et al., 1983; Izydorczyk, 2014; Stice, 2002). Related

psychological characteristics across both profiles include neuroticism (Ferguson et al.,

2012), alexithymia (Behar & Arancibia, 2014; Oldershaw et al., 2010; Ruggiero et al.,

2011), low self-esteem (Garner, 2004; Glasofer et al., 2007; Heatherton & Polivy, 1992),

maturity fears (Garner, 1991; 2004; Garner et al., 1983), and low interoceptive awareness

(e.g., Garner, 2004; Izydorczyk, 2014; Kaye et al., 2011; Pietrini et al., 2011). Repetitive

thoughts and behaviors (Herpertz-Dahlmann, 2015; Woodside & Staab, 2006) and

intimacy avoidance (Garner, 2004) may be observed in both RP and IP but are more

typically observed in RP presentations. Non-purging compensatory measures (i.e.,

excessive exercise) are observed in both profile types (Herpertz-Dahlmann, 2015).

Common comorbid features include negative affectivity (Stice, 1994; Woodside & Staab,

1994), depression (Woodside & Staab, 2006), and anxiety (Grilo et al., 2007; Salbach-

Andrae et al., 2008; Swanson et al., 2011). Both AN and BN demonstrate impaired

attentional processes (Bosanac et al., 2007).

Assessments

The correct diagnostic profile with relevant and appropriate dimensions can be

articulated based on psychometric data and clinical observations. This project proposes

administering a battery of multiple standardized measures to gather specific information

regarding the client’s comprehensive symptomatological presentation, so that issues of

concern can be expressly identified and targeted for treatment. The resulting information

can thus be transcribed to the dimensional profile model described above.

There are profound benefits to integrating standardized assessment procedures

into clinical practice. “Traditionally, mental health clinicians have excelled at focusing on

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the whole person but have sometimes failed to routinely and systematically assess core

symptoms of their patients’ psychiatric illnesses or functional capacities” (Valenstein et

al., 2009, p. 1374). Sessions can be more structured, collecting more reliable data with

the use of standardized questions (Valenstein et al., 2009). Comorbid psychopathology

and suicidal ideation are less likely to be missed if the clinician is accustomed to

consistent assessment protocols. It is also important to consider that certain comorbid

symptoms (e.g., substance use) may affect treatment responses and require additional

resources adjunct to treatment, making them particularly important to evaluate. Regularly

checking for these critical symptoms, especially suicidality, improve the safety of clients

and may reduce clinician liability. Further, administering the same assessments at various

points in treatment yields valuable information about symptom course and progress, as

well as a consistent method to gauge overall functioning. As clients engage in self-report

measures, they can be more involved in treatment decisions and more informed about

their illnesses (Moscicki et al., 2013; Valenstein et al., 2009). Treatment planning can

also be more easily explained and justified based on observable data (Narrow et al., 2013).

The tests for the proposed assessment procedure include the Eating Disorder

Inventory, Third Edition (EDI-3; Garner, 2004), the Clinical Impairment Assessment

(CIA; Bohn & Fairburn, 2008), the Cross-Cutting Symptom Measure (CCSM; APA,

2013), Level 2 forms of the CCSM as indicated, and the Personality Inventory for DSM-5

(PID-5; Krueger et al., 2013). For auxiliary observation and explanation, a clinical

interview supplements the measure outcomes.

Eating Disorder Inventory, third edition. “The EDI was developed on the

premise […] that eating disorders are multidetermined and multidimensional” (Garner,

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2004, p. 5). The original version of the EDI is a 64-item self-report questionnaire with

good convergent and discriminant validity consisting of the following eight subscales:

drive for thinness, bulimia, body dissatisfaction, ineffectiveness, perfectionism,

interpersonal distrust, interoceptive awareness, and maturity fears (Garner, Olmstead, &

Polivy, 1983). Its successor, the EDI-2, grew to 91 items, eight confirmed subscales, and

three provisional subscales (Garner, 1991). The most recent version, the EDI-3 retains 91

items with 12 subscales (Garner, 2004). Cumella (2006) contends that “the EDI-3 is a

significant contribution to the assessment of eating disorders and a substantial advance

over the EDI-2” (p. 117). It provides helpful information to inform diagnosis, treatment,

and outcomes. Clausen, Rosenvinge, Friborg, and Rokkedal (2011) tested the validity of

the measure and concluded that it holds good discriminant validity, sensitivity, and

specificity. The EDI-3’s subscales are defined as follows.

Drive for thinness. A “cardinal” trait of EDs, drive for thinness describes extreme

preoccupation with being thin and engaging in extraordinary measures to achieve a

certain body type (Garner et al., 1983; Garner, 1991; 2004).

Bulimia. The bulimia domain evaluates for ideation of and engagement in binge-

eating episodes and tendencies toward compensatory behaviors (Garner et al., 1983;

Garner, 1991; 2004).

Body dissatisfaction. Items assessing for body dissatisfaction measure an

individual’s general discontentment with perceived body image and size of particular

body parts (e.g., hips; Garner et al., 1983; Garner, 1991; 2004).

Low self-esteem. The low self-esteem domain evaluates negative self-concept,

including items measuring insecurity, ineffectiveness, inadequacy, and low self-worth

69
(Garner, 2004). This construct was originally labeled ineffectiveness (Garner, 1983;

1991) but was subsequently modified to be more broad (Garner, 2004).

Personal alienation. Similar to low self-esteem, personal alienation refers to

feelings of emptiness, loneliness, and lack of understanding of self (Garner, 2004).

Interpersonal insecurity. Introduced in the EDI-2 as social insecurity (Garner,

1991), this construct assesses for interpersonal issues, including social withdrawal and

difficulty expressing self to others (Garner, 2004).

Interpersonal alienation. This subscale measures maladaptive qualities of

relationships (e.g., lack of trust, disappointment, and feeling trapped) and insecure

attachment (Garner, 2004).

Interoceptive deficits. Interoceptive deficits are a phenomenon that describe

difficulty interpreting and expressing emotion (Garner, 2004). This quality is related to

alexithymia and is common to all EDs (e.g., Behar & Arancibia, 2014).

Emotional dysregulation. This domain assesses for impulsivity, lability, and

tendency toward self-harm (Garner, 2004). Two items assess for related substance abuse

comorbidity (Garner, 2004), which is another common manifestation of impulsive

behavior (e.g., Milos et al., 2004). Results of this subscale may reveal BPD traits (Garner,

2004).

Perfectionism. One of the original scales of the EDI, perfectionism reflects

personal ambitions and values of extraordinary achievement (Garner et al., 1983; Garner,

1991; 2004). Though observed in both AN and BN (Slade, 1982), perfectionism is more

often characteristic of anorexic presentations (Culbert et al., 2015; Herpertz-Dahlmann,

2015) and is grounded in the sociocultural drive for success (Garner, 1983).

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 Ascetism. Ascetism was initially presented as a provisional subscale in the EDI-2

(Garner, 1991) and measures spiritual notions of discipline, restraint, self-sacrifice, and

exercising control over physiological functions (Garner, 2004).

Maturity fears. The final domain of the EDI-3, maturity fears illustrate

motivation “to retreat to the security of childhood” (Garner, 1991; 2004). By means of

starvation, individuals can maintain a prepubescent exterior and attempt to avoid

responsibilities and conflicts associated with adulthood.

While an excellent instrument to assess ED symptomatology, “the EDI should not

be considered to represent an exhaustive sampling of psychopathological characteristics

of AN. Other personality features such as obsessionality, rigidity, compliance, depression,

introversion, interpersonal sensitivity, poor ego strength, excessive control, and others

have been identified” (Garner et al., 1983, p. 32). The developers of the EDI

acknowledge that for purposes of holistic assessment, further testing, clinical observation,

and client report are warranted. This sentiment is echoed in a study analyzing

relationships between the EDI subscales and psychiatric comorbidity, which found

several meaningful correlates but did not detect all comorbid presentations of EDs (Milos

et al., 2004).

Clinical Impairment Assessment. “The assessment of psychopathology requires

not only an evaluation of the nature and severity of particular features, but also an

assessment of the impact of these features on the person’s psychosocial and physical

functioning” (Bohn et al., 2008, p. 1105). EDs present with significant clinical

impairment, including low self-worth, interpersonal difficulties, and cognitive and

affective complications (Fairburn, 2008). The CIA was developed to address the dearth of

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ED-related impairment measures (Bohn et al., 2008). The 16-item self-report

questionnaire yields a global impairment score as well as three subscale scores: personal,

social, and cognitive. In evaluating the efficacy of this measure, favorable internal

consistency, construct validity, discriminant validity, sensitivity to change, and test-retest

reliability were demonstrated. The test asks questions assessing functioning over the past

28 days with responses in Likert-scale format (Bohn & Fairburn, 2008). Its developers

advise that it be completed following a test assessing ED symptomatology, so that ED

disturbances are salient and accessible to the client. The results of this assessment reveal

a quantitative impairment score that serves as a severity indicator for this project’s

proposed diagnostic protocol.

Cross-Cutting Symptom Measure. The DSM-5 Diagnostic Spectrum Study

Group recommended developing a psychometric measure evaluating cross-cutting

symptoms for use in clinical practice (APA, 2013; Narrow et al., 2013). The CCSM for

adults contains items assessing for depression, anger, mania, anxiety, somatic symptoms,

suicidal ideation, psychosis, sleep problems, memory, repetitive thoughts and behaviors,

dissociation, personality functioning, and substance use in the Level 1 form (APA, 2013).

All but five of these domains include a Level 2 instrument should a client endorse items

requiring further evaluation; suicidal ideation, psychosis, memory, dissociation, and

personality functioning do not currently have a follow-up measure for adults. In field

trials for the CCSM, the test demonstrated “good or excellent” test-retest reliability

(Narrow et al., 2013). The measure was also positively received by both clinicans and

clients when used before the clinical interview; clients “saw these instruments as a useful

72
means of communicating their reasons for coming in for clinical evaluation or treatment”

(Moscicki et al., 2013, p. 957).

In addition to the adult self-report measure, a pediatric self-report measure for

ages 11 to 17 and a pediatric measure for ages six to 17 to be completed by the parent or

guardian are available (APA, 2013). The pediatric versions assess for somatic symptoms,

sleep problems, inattention, depression, anger, irritability, mania, anxiety, psychosis,

repetitive thoughts and behaviors, substance use, and suicidal ideation and attempts. The

self-rated child version provides no Level 2 form for inattention, psychosis, or suicidality,

and the parent-or-guardian-rated child version provides no Level 2 form for psychosis,

repetitive thoughts and behaviors, or suicidality.

There are no known studies at this time utilizing the CCSM to evaluate EDs.

While this multidimensional assessment accounts for several major clinical issues, a

conspicuous omission is the absence of an ED domain. Considering the prevalence

(Hudson et al., 2007) and mortality rates (Arcelus et al., 2011; Fennig & Hadas, 2010;

Herpertz-Dahlmann, 2015) of EDs described earlier in this chapter and the high rates of

comorbidity associated with EDs (e.g., Ulfvebrand et al., 2015), including items to assess

for ED symptoms is highly recommended for future versions of this measure.

Personality Inventory for DSM-5 (PID-5). “In light of proposals of more

dimensional taxonomies of other psychological disorders […], the progression toward

dimensional frameworks of [personality disorder] classification might contribute to a

larger paradigm shift spanning the field as a whole” (Al-Dajani, Gralnick, & Bagby, 2016,

p. 75). The proposed dimensional diagnostic model for personality disorders in the DSM-

5 is based on five central domains of personality functioning: negative affectivity,

73
detachment, antagonism, disinhibition, and psychoticism (APA, 2013). The PID-5 is a

220-item measure that assesses for psychopathology using a self-report measure with

statements associated with 25 personality traits that make up the five domains (APA,

2013). An abbreviated form of the test is also available, known as the Personality

Inventory for DSM-5 – Brief Form (PID-5-BF), which is comprised of 25 items (APA,

2013). Pediatric versions of both the PID-5 and PID-5-BF are also available for children

ages 11 to 17. Mental health professionals have reported favorable opinions regarding the

PID-5 and its associated trait-based diagnostic constructs (Moscicki et al., 2013). The

PID-5 demonstrates good convergent and construct validity (Al-Dajani, Gralnick, &

Bagby, 2016) and coordinates well with the proposed nosological system.

Several of the personality traits in the PID-5 are features of the ED personality

profiles described above (e.g., anxiousness, emotional lability, impulsivity, intimacy

avoidance, restricted affectivity, rigid perfectionism, and risk-taking). No published

research has yet evaluated EDs using the PID-5.

Clinical interview. A follow-up clinical interview to supplement and interpret

psychometric data is a necessary aspect of diagnosis and assessment (e.g., Jensen-Doss &

Hawley, 2010; Valenstein et al., 2009). According to Garner et al. (1983), “Psychological

tests should be an adjunct, not a replacement, for clinical judgments” (p. 32). Dialogue

with the client serves as an opportunity to clarify confusing or conflicting outcomes in

any of the assessment measures and gather information surrounding potential etiological,

familial, sociocultural, and other related environmental factors. Additionally, further

assessment of symptom severity and functional impairment can be performed at this time.

74
Conclusion

In summary, multiple deficiencies have been cited with regard to ED diagnosis

and the current nosological system in general. To address these concerns, many unique

diagnostic models have been submitted to encompass all psychiatric disorders and to

specifically classify EDs. In light of the researchers’ efforts discussed above it appears

that incorporating aspects of both categorical and dimensional constructs may be the most

inclusive and meaningful choice for diagnosing EDs, establishing a foundation for this

project. The proposed categorical-dimensional hybrid diagnostic model for EDs

harmonizes aspects of ED symptomatology, comorbid psychopathology, and

neurobiological mechanisms to yield an integrative biopsychosocial conceptualization.

The proposed assessment and diagnostic system will be explored in further detail in the

subsequent chapters.

75
 Chapter III

Project Audience and Implementation Factors

Introduction to Assessment System and Diagnostic Model

This project proposes a paradigm shift in assessing and diagnosing eating

disorders (EDs). With the pervasive and debilitating nature of this illness (Fairburn,

2008), targeted and efficient diagnosis and treatment is vital to client recovery. Multiple

significant concerns have emerged surrounding categorical ED diagnosis, including

within-group heterogeneity (Wildes & Marcus, 2013), diagnostic crossover (Castellini et

al., 2011), overuse of the unspecified residual category (Fairburn & Cooper, 2011),

empirically unsubstantiated subtyping (Peat, Mitchell, Hoek, & Wonderlich, 2009), poor

guidance for subclinical presentations (Schmidt et al., 2008), and questionable criteria

validity (Fairburn & Cooper, 2011). In light of these issues, an integrative

biopsychosocial diagnostic model is suggested. In the proposed model, clients are

administered a battery of psychometric measures to evaluate ED symptomatology; level

of impairment; and co-occurring psychopathology, including clinically significant

personality traits. Clients will then be diagnosed according to a hybrid categorical-

dimensional system, which emphasizes two main subtypes of EDs: Restrictive Profile

(RP) and Impulsive Profile (IP). Each profile is comprised of primary ED symptoms (i.e.,

food restriction for RP and bingeing or purging for IP) and related psychological features.

A third category called Transdiagnostic Dimensions (TD) contains a list of clinical issues

that commonly occur with either profile type, which can be assigned to the client as

indicated by the assessment results.

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Development of Project

The concept for this project was largely inspired by my own personal struggles

with an ED. Although I was fortunate enough to receive quality care and progress

successfully toward recovery, I recognized the deficiencies of ED diagnoses and how

they fail to capture an accurate clinical picture. During my treatment process, I witnessed

peers unable to receive insurance reimbursement for services when they did not “meet

criteria” for a certain diagnosis. I also saw how many clients’ symptomatological features

overlapped, despite the range of diverse diagnoses, and began to question the value of

compartmentalized diagnostic standards in general. It occurred to me that a more fluid,

dimensional approach to diagnosis may be an improved reflection of clinical reality and

could assist clinicians in guiding treatment planning.

While participating in the marriage and family therapy graduate program, it was

my experience that a dearth of information surrounding ED diagnosis and treatment was

offered. I began to research ED diagnosis and discovered a multitude of concerns cited by

researchers surrounding its shortcomings. With assistance from ED specialist mental

health professionals and an extensive review of literature, I found evidence supporting a

categorical diagnostic model comprised of multiple salient dimensions characteristic of

EDs and co-occurring psychopathology.

Intended Audience

This project targets individuals suffering with premorbid and clinical

presentations of ED symptoms. Clients in inpatient, residential, and outpatient settings

can benefit from the proposed assessment and diagnostic procedures. Individuals in the

77
beginning stages of or at risk for ED development can be more readily identified and thus

be eligible for early intervention.

Personal Qualifications

The assessment and diagnostic system can be useful for all mental health

professionals but is particularly designed for implementation by specialists working in

both inpatient and outpatient ED treatment facilities. These clinicians should possess a

graduate degree and a clinical license whose scope of practice authorizes the diagnosis

and treatment of clients with EDs. Such practitioners include marriage and family

therapists, clinical psychologists, and licensed clinical social workers. Trainees and

interns under licensed supervision may also be permitted to administer the psychometric

instruments and apply the diagnostic model, providing that their supervisor is competent

in ED diagnosis and treatment.

Environment and Equipment

The following standardized measures are required: Eating Disorder Inventory,

Third Edition; Clinical Impairment Assessment; Cross-Cutting Symptom Measure; and

the Personality Inventory for DSM-5. Upon review of the Cross-Cutting Symptom

Measure results, Level 2 forms will be administered as indicated. The assessments should

be administered in a quiet room with adequate lighting, a writing surface, and a writing

utensil. Once all measures are scored, a clinical interview will be conducted later the

same day of testing or during the client’s subsequent therapy session.

78
Formative Evaluation

This project necessitates evaluation to provide feedback on its efficacy. The

members of my graduate project committee have contributed commentary regarding its

constructs. I have also sought the opinions of ED specialists in the mental health field for

additional guidance.

Project Outline

I. Appendix B: Assessment and Diagnosis of Eating Disorders

a. Instruction manual
i. Assessment procedure
1. Subject eligibility
2. Psychometric measures
3. Administration environment
4. Administration instructions
5. Clinical interview
ii. Diagnostic procedure
1. EDI-3 subscales
2. CIA severity indicator
3. CCSM subscales for adults
4. CCSM subscales for adolescents
5. PID-5 subscales
iii. Dimension and assessment compatibility tables
iv. Psychometric measures
v. Clinical interview
vi. Continued client care
b. Categorical-Dimensional Diagnostic Model for Eating Disorders
i. Diagnostic criteria
ii. Dimensional specifiers
1. Restrictive Profile
2. Impulsive Profile
3. Transdiagnostic Dimensions
c. Case Study Example
i. Background and phone screening
ii. Psychometric measure results
iii. Clinical interview
iv. Diagnosis
II. Appendix C: Graphic Conceptualizations of Categorical-Dimensional
Diagnostic Model for Eating Disorders
a. Categorical-Dimensional Diagnostic Model for Eating Disorders
b. Spectrum conceptualization of eating disorder diagnostic model (with
DSM-5 diagnoses)

79
 c. Venn diagram conceptualization of eating disorder diagnostic model
d. Venn diagram conceptualization of eating disorder diagnostic model (with
dimensional specifiers)
III. Appendix D: Psychometric Measures
a. EDI-3 (sample subscale descriptions and score report)
b. CIA
c. CCSM for adults
d. CCSM Level 2 forms for adults
i. Depression
ii. Anxiety
iii. Repetitive Thoughts and Behaviors
iv. Substance Use
e. CCSM for adolescents
f. CCSM Level 2 forms for adolescents
i. Depression
ii. Anxiety
iii. Repetitive Thoughts and Behaviors
iv. Substance Use
g. PID-5 for adults
h. PID-5 for adolescents

80
 Chapter IV

Conclusion
Summary

The purpose of this project is to propose an alternative categorical-dimensional

diagnostic approach for eating disorders (EDs). In light of the significant impairments ED

symptomatology can cause (Fairburn, 2008), it is paramount that clients are properly

diagnosed to be eligible for targeted treatment. Extensive literature has cited deficiencies

in the current categorical nosology of the DSM (e.g., Kozak & Cuthbert, 2016; Widiger

& Samuel, 2005) and EDs in particular (e.g., Fairburn & Bohn, 2005). Modest progress

has been made toward dimensional diagnostic approaches that serves as a bridge to a

future with more personalized diagnoses that better reflect clinical reality and provide

improved utility in treatment planning (APA, 2013). The integrative biopsychosocial ED

model introduced in this project is an inclusive and detailed option designed to accurately

capture client presentations. Individuals with EDs are assessed using psychometric data

and clinical observation and given a diagnosis of Restrictive Profile (RP) or Impulsive

Profile (IP) with symptomatology specific to their presentations. The recommended

assessment system utilized in conjunction with the diagnostic model emphasizes the

importance of incorporating empirical evidence and measurable data into routine clinical

practice. The psychometric measures suggested include the Eating Disorder Inventory,

Third Edition (EDI-3), Clinical Impairment Assessment (CIA), Cross-Cutting Symptom

Measure (CCSM), CCSM Level 2 forms, and Personality Inventory for DSM-5 (PID-5)

to assess ED symptomatology, level of impairment, comorbidity, and pathological

personality features. A clinical interview concludes the assessment process in order to

81
clarify conflicting test results, gather etiological information, and make appropriate

referrals.

Evaluation

Upon review by ED outpatient specialists, this project received positive feedback.

While these opinions are tentative in the absence of empirical validation, they provide a

hopeful prospect for the assessment and diagnostic procedure’s successful

implementation. Encouraging remarks focused on the choice of standardized instruments

and the multi-faceted dimensional criteria integrated in the model. Further lauded was the

absence of quantitative threshold criteria, so that individuals vulnerable to ED

development may be recognized. A licensed marriage and family therapist with 15 years

of professional experience in residential and outpatient ED treatment provided her

opinion of the categorical-dimensional diagnostic model:

“I find [the model] to be a very accurate categorical description/profile of

people suffering with eating disorders. I find this to be much more
comprehensive and inclusive than the most commonly used diagnostic
tools in this field. I really appreciate the inclusion of the transdiagnostic
dimensions, as these things are often overlooked once a person is given a
diagnosis, which I have found problematic in both the treatment approach
used in treatment centers as well as in private practice. Too often these
things go missed or unaddressed, at the detriment of the client. This offers
a much more inclusive and comprehensive treatment approach that would
be beneficial in the patient’s work toward recovery (K. M. McMichael,
personal communication, September 20, 2016).”

Recommendations for Implementation

It is recommended that mental health practitioners who specialize in ED treatment

implement this assessment and diagnostic procedure in both inpatient and outpatient

settings. The assessment measures should be administered within the context of treatment

for an ED (i.e., the client must remain in the clinician’s care after assessment and

82
diagnosis). It would be ideally incorporated into the standardized intake process in order

to obtain baseline data and determine a preliminary diagnosis on which to base treatment

planning. Those who implement the assessment and diagnostic procedures must be

sensitive to the potential medical complications that can arise from EDs and should be

prepared to make appropriate referrals to general physicians and psychiatrists as

necessary. Ideally, every client with an ED should have a treating medical professional in

addition to a mental health practitioner, and the clinical team should communicate

frequently. The diagnostic model is designed to be a primed platform from which to

establish therapeutic objectives and consider appropriate interventions. The psychometric

measures are also an excellent indicator of client progress if readministered at 4-week

intervals in inpatient and residential facilities and 12-week intervals in outpatient

facilities, as well as at the conclusion of treatment.

Limitations

It has been argued that both categorical and dimensional models of ED are

insufficient (Williamson et al., 2005), which is why a hybrid model of these two designs

is offered here. Still, important limitations must be acknowledged with regard to this

conceptualization. Diagnostic crossover may still be a factor, as individuals belonging to

RP have the propensity to develop bingeing and purging symptoms characteristic of IP

(Castellini et al., 2011). Findings have suggested that even when considering categorical

and dimensional features of EDs, “a remarkable shift” of symptomatology may occur.

Further, the proposed model is likely to be more complicated in nature compared to

traditional categorical designs due to the number of presented clinical dimensions.

Information described in the literature review appears to provide extremely promising

83
support for this classification system, but empirical evidence is required to justify its

validity and clinical utility.

Recommendations for Future Research

The proposed diagnostic model requires empirical evidence to substantiate its

validity. It is recommended that it be tested with multiple populations of individuals with

EDs to determine the efficacy of the proposed ED profiles and their respective

dimensions. Further research can explore precisely which dimensions are necessary and

most useful to isolate the proper diagnosis. The assessment system itself can also benefit

from future research, as the recommended battery of psychometric measures has not yet

been documented for implementation with ED treatment specifically.

This model can also be expanded by offering etiological components. Clients with

EDs routinely report history of traumatic experiences (Madowitz, Matheson, & Liang,

2015). These individuals also tend to come from certain family environments that

demonstrate a breeding ground for psychological precursors to ED development (Dring,

2015). It is suggested then that two additional assessment measures be included for a

more comprehensive assessment strategy: the Trauma Symptom Inventory, Revised

(Briere, 2010) and Family Assessment Measure, Third Edition (Skinner, Steinhauer, &

Santa-Barbara, 1995). Specific associations with trauma history and family dynamics can

be explored to gain insight and inform intervention choices. For example, if the client’s

family members are formally assessed and involved in the treatment process, systemic

therapeutic approaches could be integrated for more sustainable change.

84
Conclusion

My personal experiences of recovery from an ED have incited a great passion for

working with individuals who struggle with distorted perceptions of self and eating

disturbances. I am also extremely interested in research-informed diagnosis and treatment

and aspire to have my own future clinical work reflect these elevated and evidence-based

practices. Although multiple alternative diagnostic models for EDs have been proposed,

it seems that none so far involves both psychological and neurobiological features. As the

field of mental health continues to advance, I am eager to witness how modern science

can further influence the evolution of nosology and psychotherapy standards.

I would also like to emphasize the sensitive and critical nature of at-risk and

prodromal populations and how important it is to identify subclinical presentations of

EDs, particularly in consideration of the prevalence of social media and largely

unattainable societal perceptions of beauty. It is imperative that at-risk individuals get

properly assessed and receive appropriate treatment. In line with this sentiment, I

advocate for ED assessment items to be added to the CCSM for both adults and

adolescents so that this measure can yield an even more thorough symptom screening.

My intention is to continue working on this project’s foundation as I move on

toward doctoral studies in clinical psychology. The next directions for my research

involve proposing an integrative psychotherapy treatment modality that would

synergistically collaborate with the diagnostic model.

85
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 Appendix A

Supplemental Figures and Table for Chapter II

Figure A1. Broad Categories for the Diagnosis of Eating Disorders (Walsh & Sysko,
2009).

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130
131
Figure A2. A staging model conceptualization of eating disorder development (Treasure,
Stein, & Maguire, 2015).

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Figure A3. Prototype diagnosis for anorexia nervosa and bulimia nervosa (Westen, 2012).

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Figure A4. A three-dimensional conceptualization of eating disorders based on binge
eating, fear of fatness/concern with body size and shape (FF/CB), and drive for thinness
(DFT; Williamson et al., 2005). Anorexia nervosa, restricting type (AN-R), anorexia
nervosa, binge-eating/purging type (AN-BP), bulimia nervosa (BN), and binge eating
disorder (BED) are placed in respective locations according to their respective constructs.

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Figure A5. A three-dimensional conceptualization of eating disorders based on weight,
binge-eating episodes, and purging episodes (Beumont et al., 1994).

Figure A6. The “dual pathway model” for bulimia nervosa, which suggests that onset for
the illness results from dietary restraint and negative affect (Stice et al., 1996).

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Figure A7. The Research Domain Criteria Matrix from the National Institute of Mental
Health. Psychiatric illnesses are analyzed across five domains and eight units of analysis
for a comprehensive and scientific diagnostic procedure.

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Figure A8. A spectrum-based impulse-control diagnostic model for eating disorders
mediated by temperamental dominance (Brooks et al., 2012).

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Table A1. Overview of studies analyzing relationship between ED presentations and
comorbid psychopathology profiles. Identified clusters of participants based on
symptomatology are described for each study.

Number
of
Study n Characteristics of Groups
Groups
Identified
Claes et al. 1) Resilient/high-functioning; 2) Overcontrolled/
(2006) 335 3 constricted; 3) Undercontrolled/emotionally
dysregulated
Eddy et al. 1) Constricted/overcontrolled;
(2004) 234 2 2) Undercontrolled/emotionally dysregulated

Goldner et al. 1) Mild personality pathology;

(1999) 136 3 2) Rigid/compulsive;
3) Severe/impulsive
Peñas-Lledó 1) Social avoidance and distress (SAD)-low
et al. (2010) 825 3 novelty seeking (NS);
2) SAD-mid NS; 3) SAD-high NS
Steiger et al. 1) Low psychopathology;
(2009) 185 3 2) Inhibited/compulsive;
3) Dissocial/impulsive
Steiger et al. 1) Low psychopathology;
(2010) 185 3 2) Inhibited/compulsive;
3) Dissocial/impulsive
Strober 1) Low psychopathology;
(1983) 130 3 2) Rigid/socially avoidant;
3) Impulsive/emotionally dysphoric
Thompson- 1) High-functioning; 2) Constricted;
Brenner & 3) Dysregulated
145 3
Westen
(2004)
Thompson- 1) High-functioning/perfectionistic;
Brenner et al. 120 3 2) Avoidant/depressed;
(2008) 3) Emotionally dysregulated
Turner et al. 1) Resilient; 2) Overcontrolled/inhibited;
(2014) 145 3 3) Undercontrolled/dysregulated

Westen & 1) High-functioning/perfectionistic;

Harnden- 2) Constricted/overcontrolled;
103 3
Fischer 3) Emotionally dysregulated/undercontrolled
(2001)
Wildes & 1) Low (comorbid) psychopathology;
5030
Marcus 3 2) Overcontrolled; 3) Undercontrolled
(review)
(2013)

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 Appendix B

Assessment and Diagnosis of Eating Disorders:

Instruction Manual and Case Study Example

Assessment and Diagnosis of Eating Disorders:

Instruction Manual

Assessment Procedure

Subject Eligibility: Subjects who participate in this assessment procedure

should be at least 11 years of age with suspected pathological eating
disturbances.

Psychometric Measures:

1. Eating Disorder Inventory, Third Edition (EDI-3)

2. Clinical Impairment Assessment (CIA)
3. Cross-Cutting Symptom Measure (CCSM)*
4. Cross-Cutting Symptom Measure Level 2 forms*
5. Personality Inventory for DSM-5 (PID-5)*

*Please note that the CCSM, CCSM Level 2 forms, and PID-5 are available in
both adult versions for ages 18+ and adolescent versions for ages 11 to 17.
Administer the appropriate version for the client’s age level.

Administration Environment: The psychometric measures should be

administered in a quiet room with adequate light. The client should be provided
with a writing surface (e.g., desk, clipboard) and a writing utensil.

Administration Instructions: All measures must be taken during the initial client
evaluation. Administer the following psychometric measures in a packet in the
following order: (1) EDI-3, (2) CIA, (3) CCSM, and (4) PID-5. Advise the client to
endorse all items on each questionnaire. Instruct the client to choose the BEST
answer for each item. It is important that the clinician not assist the client in
interpreting any items. Read the test-taking instructions aloud for all four
assessments and have the client follow along. Ask the client if he or she has any
questions before beginning. Remind the client to complete ALL items on each
measure. The time limit for completing these tests is 1.5 hours.

Collect all measures once completed. Score the CCSM only. Determine if
Depression, Anxiety, Repetitive Thoughts and Behaviors, and Substance Use
domains require further assessment with CCSM Level 2 forms. If none of these
domains require further assessment, proceed to score all measures.

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If one or more domains from the CCSM require further assessment, administer
the CCSM Level 2 form(s) as indicated. Advise the client to endorse all items on
the questionnaire. Instruct the client to choose the BEST answer for each item.
Do not assist the client in interpreting any items. Read the test-taking instructions
aloud for the CCSM Level 2 form(s) and have the client follow along. Ask the
client if he or she has any questions before beginning. There is no time limit for
completing the Level 2 form(s).

Score all psychometric measures.

Clinical Interview: The post-measure clinical interview can be conducted upon

scoring all measures, which may be the same day the client completes the tests
or during the subsequent evaluation. Pre-measure clinical interviews are not
recommended for this procedure.

Diagnostic Procedure

Using information from the psychometric measures and the clinical interview, a
hybrid categorical-dimensional diagnosis can be determined. The client will be
diagnosed within Restrictive Profile or Impulsive Profile, primarily based on
eating disorder symptomatology. The psychometric measures provide
supplemental information regarding the dimensions of Comorbid
Psychopathology and Neurobiological Mechanisms relevant to the client’s profile
type. Eating Disorder Symptomatology, Comorbid Psychopathology, and
Neurobiological Mechanisms dimensions from the Transdiagnostic Dimensions
category can also be included in the diagnosis as appropriate.

EDI-3: The EDI-3 results indicate the presence of eating disorder behaviors
under Eating Disorder Symptomatology. If the client endorses items indicating
clinically significant food restriction with no accompanying compensatory
measures except exercise, the client should receive a diagnosis of Restrictive
Profile. If the client endorses items indicating bingeing and/or compensatory
measures (e.g., purging), the client should receive a diagnosis of Impulsive
Profile. The EDI-3’s subscales yield further information regarding other Eating
Disorder Symptomatology dimensions (e.g., cognitions).

The EDI-3 yields the following six composite scores:

1. Eating Concerns Composite (ECC)

2. Ineffectiveness Composite (IC)
3. Interpersonal Problems Composite (IPC)
4. Affective Problems Composite (APC)
5. Overcontrol Composite (OC)
6. Global Psychological Maladjustment (GPM)

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OC typically informs Restrictive Profile. ECC, IC, IPC, APC, and GPM scores are
Transdiagnostic Dimensions and can thus be used to inform the diagnosis of
either Restrictive Profile or Impulsive Profile.

The EDI-3 subscales are as follows:

1. Drive for Thinness (DT) 8. Interoceptive Deficits (ID)

2. Bulimia (B) 9. Emotional Dysregulation
3. Body Dissatisfaction (BD) (ED)
4. Low Self-Esteem (LSE) 10. Perfectionism (P)
5. Personal Alienation (PA) 11. Ascetism (A)
6. Interpersonal Insecurity (II) 12. Maturity Fears (MF)
7. Interpersonal Alienation
(IA)

DT, B, and BD are Eating Disorder Specific Scales, and LSE, PA, II, IA, ID, ED,
P, A, and MF are Psychological Trait Scales. Subscales PA, IA, ID, P, and A
typically co-occur with Restrictive Profile. Subscales B, II, and ED typically co-
occur with Impulsive Profile. Subscales DT, BD, LSE, and are Transdiagnostic
Dimensions and can thus be assigned to either Restrictive Profile or Impulsive
Profile.

CIA: The CIA yields a quantitative score indicating the level of impairment the
client experiences due to the eating disturbances. This score serves as a severity
indicator for the diagnosis. The developers of the CIA state that an overall score
of 16 or higher is indicative of clinically significant impairment. The CIA’s three
subscales (i.e., Personal, Social, Cognitive) yield more specific impairment
information, but the purpose of this measure is to determine a global severity
indicator.

CCSM: The CCSM for adults yields information for Comorbid Psychopathology
dimensions. The CCSM contains the following subscales:

1. Depression 8. Sleep Problems

2. Anger 9. Memory
3. Mania 10. Repetitive Thoughts and
4. Anxiety Behaviors
5. Somatic Symptoms 11. Dissociation
6. Suicidal Ideation 12. Personality Functioning
7. Psychosis 13. Substance Use

While the CCSM for adults assesses all of the above domains, the subscales of
particular interest for this diagnostic procedure are Depression, Anxiety, Suicidal
Ideation, Repetitive Thoughts and Behaviors, Personality Functioning, and
Substance Use. Restrictive Profile typically co-occurs with Repetitive Thoughts
and Behaviors. Impulsive Profile typically co-occurs with Suicidal Ideation and

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Substance Use. Subscales Depression, Anxiety, and Personality Functioning are
Transdiagnostic Dimensions and can thus be assigned to either Restrictive
Profile or Impulsive Profile.

Of the subscales relevant to this diagnostic procedure, Depression, Anxiety,

Repetitive Thoughts and Behaviors, and Substance Use have adult CCSM Level
2 forms available for further assessment and to determine Comorbid
Psychopathology distress severity.

The CCSM for adolescents ages 11 to 17 contains the following subscales:

1. Somatic Symptoms 8. Anxiety

2. Sleep Problems 9. Psychosis
3. Inattention 10. Repetitive Thoughts and
4. Depression Behaviors
5. Anger 11. Substance Use
6. Irritability 12. Suicidal Ideation/Suicide
7. Mania Attempts

While the CCSM for adolescents assesses all of the above domains, the
subscales of particular interest for this diagnostic procedure are Inattention,
Depression, Anxiety, Repetitive Thoughts and Behaviors, Substance Use, and
Suicidal Ideation/Suicide Attempts. Restrictive Profile typically co-occurs with
Repetitive Thoughts and Behaviors. Impulsive Profile typically co-occurs with
Substance Use and Suicidal Ideation/Suicide Attempts. Subscales Inattention,
Depression, and Anxiety are Transdiagnostic Dimensions and can thus be
assigned to either Restrictive Profile or Impulsive Profile.

Of the subscales relevant to this diagnostic procedure, Depression, Anxiety,

Repetitive Thoughts and Behaviors, and Substance Use have pediatric versions
of CCSM Level 2 forms available for further assessment and to determine
Comorbid Psychopathology distress severity.

PID-5: The PID-5 also yields information for Comorbid Psychopathology

dimensions but is specifically designed to assess clinically significant personality
traits, regardless of whether or not the client meets criteria for a full threshold
personality disorder. The PID-5 versions for both adults and adolescents have
the following personality trait domains:

1. Negative Affect
2. Detachment
3. Antagonism
4. Disinhibition
5. Psychoticism

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These domains are composite scores reflecting results of the following
personality trait facets:

1. Anhedonia 14. Irresponsibility

2. Anxiousness 15. Manipulativeness
3. Attention Seeking 16. Perceptual Dysregulation
4. Callousness 17. Perseveration
5. Deceitfulness 18. Restricted Affectivity
6. Depressivity 19. Rigid Perfectionism
7. Distractibility 20. Risk Taking
8. Eccentricity 21. Separation Insecurity
9. Emotional Lability 22. Submissiveness
10. Grandiosity 23. Suspiciousness
11. Hostility 24. Unusual Beliefs and
12. Impulsivity Experiences
13. Intimacy Avoidance 25. Withdrawal

While the PID-5 assesses all of the above domains, the personality trait facets of
particular interest for this diagnostic procedure are subscales Anhedonia,
Anxiousness, Attention Seeking, Depressivity, Distractibility, Emotional Lability,
Impulsivity, Intimacy Avoidance, Irresponsibility, Manipulativeness,
Perseveration, Restricted Affectivity, Rigid Perfectionism, Risk Taking,
Separation Insecurity, and Withdrawal. Restrictive Profile typically co-occurs with
Anhedonia, Perseveration, Restricted Affectivity, Rigid Perfectionism, and
Withdrawal. Impulsive Profile typically co-occurs with Attention Seeking,
Emotional Lability, Impulsivity, Irresponsibility, Manipulativeness, Risk Taking,
and Separation Insecurity. Subscales Anxiousness, Depressivity, Distractibility,
and Intimacy Avoidance are Transdiagnostic Dimensions and can thus be
assigned to either Restrictive Profile or Impulsive Profile.

Dimension and Assessment Compatibility Tables

Most dimensions of Restrictive Profile, Impulsive Profile, and Transdiagnostic

Dimensions are direct reflections of subscales from the psychometric measures.
Others, however, can be informed by one or more subscales assessing similar
features (e.g., Restrictive Profile’s Comorbid Psychopathology dimension
Competitiveness can be informed by results on EDI-3 subscale Perfectionism
and PID-5 subscale Perseverance). As stated above, the clinical interview is a
critical supplemental tool to assist in interpreting test results and identifying all
client symptoms, especially for those dimensions that do not specifically coincide
with coordinating subscales. Three tables follow delineating the relationships
between all diagnostic dimensions and their corresponding subscales.

143
 Restrictive Profile Psychometric
Subscale(s)
Dimension Measure
Eating Disorder Symptomatology

Restricted Food Intake EDI-3 See Symptom Checklist

Comorbid Psychopathology

Anhedonia PID-5 Anhedonia

Ascetism EDI-3 Ascetism

Interpersonal Alienation, Low Self-Esteem;
Avoidant Personality
EDI-3; PID-5 Anhedonia, Anxiousness, Intimacy Avoidance,
Disorder
Withdrawal
Competitiveness EDI-3; PID-5 Perfectionism
Perfectionism, Ascetism; Perseveration,
Excessive Control EDI-3; PID-5
Restrictive Affectivity, Rigid Perfectionism
Harm Avoidance PID-5 Anxiousness, Risk Taking (low score)

Interpersonal Alienation EDI-3 Interpersonal Alienation

Obsessive-Compulsive
CCSM Repetitive Thoughts And Behaviors
Disorder
Perfectionism EDI-3; PID-5 Perfectionism; Rigid Perfectionism

Perseveration PID-5 Perseveration

Personal Alienation EDI-3 Personal Alienation

Repetitive Thoughts And
CCSM Repetitive Thoughts And Behaviors
Behaviors
Restricted Affectivity PID-5 Restricted Affectivity

Restricted Libido EDI-3; PID-5 Interpersonal Alienation; Intimacy Avoidance

Restricted Sexuality EDI-3; PID-5 Interpersonal Alienation; Intimacy Avoidance

Rigidity EDI-3; PID-5 Perfectionism, Ascetism; Rigid Perfectionism

Social Interpersonal Alienation; Anxiousness, Intimacy
EDI-3; PID-5
Isolation/Withdrawal Avoidance, Withdrawal
Neurobiological Mechanisms

Cognitive Inflexibility EDI-3 Perfectionism, Ascetism

Compulsivity CCSM Repetitive Thoughts And Behaviors

Impaired Concentration PID-5 Distractibility

Impaired Set-Shifting PID-5 Distractibility

144
 Impulsive Profile Psychometric
Subscale(s)
Dimension Measure
Eating Disorder Symptomatology

Binge Eating EDI-3 Bulimia, see Symptom Checklist

Compensatory Behaviors EDI-3 Bulimia, see Symptom Checklist

Comorbid Psychopathology

Attention Seeking PID-5 Attention Seeking

Interpersonal Insecurity, Emotional Dysregulation,
Borderline Personality EDI-3; Low Self-Esteem; Anxiousness, Depressivity,
Disorder PID-5 Emotional Lability, Hostility, Impulsivity, Risk
Taking, Separation Insecurity
Emotional Dysregulation; Anxiousness,
Emotional Dysregulation EDI-3; PID-5
Depressivity, Emotional Lability
Interpersonal Alienation, Interpersonal Insecurity;
Interpersonal Difficulties EDI-3
Separation Insecurity
Interpersonal Insecurity EDI-3; PID-5 Interpersonal Insecurity

Irresponsibility PID-5 Irresponsibility

Manipulativeness PID-5 Manipulativeness

Attention Seeking, Impulsivity, Manipulativeness,
Non-Suicidal Self-Injury PID-5
Risk Taking
Interpersonal Insecurity; Attention Seeking,
Promiscuity EDI-3; PID-5 Impulsivity, Intimacy Avoidance, Irresponsibility,
Risk Taking, Separation Insecurity
Risk Taking PID-5 Risk Taking

Separation Insecurity PID-5 Separation Insecurity

Substance Use CCSM Substance Use

Suicidal Ideation CCSM Suicidal Ideation

Neurobiological Mechanisms

Impulsivity PID-5 Impulsivity

Novelty Seeking PID-5 Impulsivity, Risk Taking

Reward Seeking PID-5 Impulsivity, Risk Taking

145
 Transdiagnostic Psychometric
Subscale(s)
Dimension Measure
Eating Disorder Symptomatology

Body Dissatisfaction EDI-3 Body Dissatisfaction

Drive For Thinness EDI-3 Drive For Thinness

Excessive Exercise EDI-3 See Symptom Checklist

Internalization Of Thin
EDI-3 Drive For Thinness, Body Dissatisfaction
Ideal
Comorbid Psychopathology

Alexithymia EDI-3 Interoceptive Deficits, Personal Alienation

Anxiety CCSM Anxiety

Anxiousness PID-5 Anxiousness

Depression CCSM Depression

Depressivity PID-5 Depressivity

Distractibility PID-5 Distractibility

Interoceptive Deficits EDI-3 Interoceptive Deficits

Intimacy Avoidance PID-5 Intimacy Avoidance

Low Self-Esteem EDI-3 Low Self-Esteem

Maturity Fears EDI-3 Maturity Fears

Anxiousness, Depressivity, Emotional lability,

Neuroticism PID-5
Hostility

Personality Functioning CCSM Personality Functioning

Neurobiological Mechanisms

Attentional Impairment PID-5 Distractibility

146
 Psychometric Measures

Included in Appendix D are the self-report questionnaires necessary for the

assessment and diagnostic procedure delineated in the instruction manual in
Appendix B. The measures are accompanied by administration and scoring
instructions.

Clinical Interview

The clinical interview should be conducted following the completion and scoring
of all psychometric measures. This session serves as an opportunity to:

1. Clarify conflicting test results

2. Assess for suicidality
3. Identify collateral supports and referral sources as needed (e.g.,
physician, psychiatrist, registered dietician)*
4. Obtain broad information surrounding etiological and risk factors for
both clinical and subclinical presentations (e.g., trauma history, family
dynamics)
5. Discuss relevant test results as appropriate

*IMPORTANT: If any Neurological Mechanisms within the diagnostic model are

indicated by the measure outcomes or clinical observation, it is imperative that
the client be referred to an appropriate medical professional for further
evaluation.

Continued Client Care

The clinician should now have arrived at a preliminary diagnosis informed by

results from the psychometric measures and clinical interview. The relevant
eating disorder profile has been identified and personalized with corresponding
dimensional features specific to the client. At this time, treatment planning with
the client is recommended in order to establish a therapeutic framework and
objectives.

As with any formal diagnosis, clinical observation is considered paramount.

Information gathered in subsequent therapy sessions may either corroborate or
conflict with the data derived from the psychometric measures and initial clinical
interview. The clinician is therefore encouraged to modify the client’s diagnosis
based on ongoing clinical observations. The psychometric measures can also be
readministered every four weeks in residential and inpatient settings or every 12
weeks in outpatient settings in order to record clinical progress.

147
 Categorical-Dimensional Diagnostic Model for Eating Disorders

EATING DISORDERS

Diagnostic Criteria:
1. There is a disturbance in eating behaviors that cause clinically significant
distress or impairment.
2. Body shape and weight have undue influence on self-worth. There may be
significant disturbance and/or distortions with the perception of body
image.
3. The eating disturbances are not due to another medical disorder.

Clients who meet the above criteria are classified by the nature of
longitudinally predominant eating disorder behaviors. While no specific length of
time is indicated for the disturbances to persist, clients must experience clinically
significant distress or impairment directly related to the eating disturbances, such
that social or professional functioning has been affected. Those who restrict food
intake in the absence of binge eating or compensatory behaviors (with the
exception of excessive exercise) are diagnosed within Restrictive Profile. Those
who engage in binge eating and/or compensatory behaviors are diagnosed within
Impulsive Profile. Binge eating is defined as an episode of eating in which an
individual experiences a lack of control and consumes a subjectively larger than
typical amount of food. Compensatory behaviors are extreme measures taken to
prevent weight gain (e.g., self-induced vomiting, laxative misuse). Clients must
meet the first criterion in Restrictive Profile or one or both of the first two criteria
in Impulsive Profile to merit the respective diagnosis.
A personalized diagnosis is further comprised of eating disorder
psychological traits, comorbid psychopathology and personality features, and
neurobiological mechanisms that correspond with the client’s profile type. Clients
within Restrictive Profile are typically characterized by compulsivity, avoidant
personality traits, overcontrol, rigidity, and cognitive inflexibility. Clients within
Impulsive Profile are typically characterized by impulsivity, emotional
dysregulation, interpersonal difficulties, risk taking, and reward seeking.
Dimensions from the Transdiagnostic Dimensions category are routinely
observed in both Restrictive Profile and Impulsive Profile and can thus be added
to the client’s diagnosis per clinical observation.
A severity indicator is determined by the level of impairment the client
experiences from the eating disturbances and associated psychopathology. The
level of clinical impairment is more significant than the number of dimensions
applicable to a client’s presentation (e.g., a client may meet six dimensional
criteria yet experience less impairment compared to a client who meets two
dimensional criteria). The Clinical Impairment Assessment (CIA; Bohn &
Fairburn, 2008) is recommended to obtain a quantifiable severity value. This
measure indicates that a score of 16 or higher demonstrates clinically significant
impairment and that higher scores suggest more severe disturbances in
functioning.

148
 Profile Types

Restrictive Profile Impulsive Profile

Eating Disorder Symptomatology Eating Disorder Symptomatology

1. Restricted Food Intake 1. Binge Eating
2. Compensatory Behaviors
Comorbid Psychopathology
1. Anhedonia Comorbid Psychopathology
2. Ascetism 1. Attention Seeking
3. Avoidant Personality Disorder 2. Borderline Personality
4. Competitiveness Disorder
5. Excessive Control 3. Emotional Dysregulation
6. Harm Avoidance 4. Interpersonal Difficulties
7. Interpersonal Alienation 5. Interpersonal Insecurity
8. Obsessive-Compulsive 6. Irresponsibility
Disorder 7. Manipulativeness
9. Perfectionism 8. Non-Suicidal Self-Injury
10. Perseveration 9. Promiscuity
11. Personal Alienation 10. Risk Taking
12. Repetitive Thoughts and 11. Separation Insecurity
Behaviors 12. Substance Use
13. Restricted Affectivity 13. Suicidal Ideation
14. Restricted Libido
15. Restricted Sexuality Neurobiological Mechanisms
16. Rigidity 1. Impulsivity
17. Social Isolation/Withdrawal 2. Novelty Seeking
3. Reward Seeking
Neurobiological Mechanisms
1. Cognitive Inflexibility
2. Compulsivity
3. Impaired Concentration
4. Impaired Set-Shifting

149
 Transdiagnostic Dimensions

Eating Disorder Symptomatology

1. Body Dissatisfaction
2. Drive for Thinness
3. Excessive Exercise
4. Internalization of Thin Ideal

Comorbid Psychopathology
1. Alexithymia
2. Anxiety
3. Anxiousness
4. Depression
5. Depressivity
6. Distractibility
7. Interoceptive Deficits
8. Intimacy Avoidance
9. Low Self-Esteem
10. Maturity Fears
11. Neuroticism
12. Personality Functioning

Neurobiological Mechanisms
13. Attentional Impairment

150
 Case Study Example

Background and Phone Screening

Annette is a 24-year-old single Caucasian female presenting for outpatient

psychotherapy. She works full-time as an assistant manager of a retail store and
lives alone in an apartment. Her presenting concerns are related to her report
that she “just can’t stop eating sometimes.” She also reported when scheduling
her first appointment that her mood has been significantly affected by her eating
behaviors and consequent weight gain.

Psychometric Measure Results

On the Eating Disorder Inventory, Third Edition (EDI-3), Annette’s scores

were of clinical interest in the following subscales: Bulimia, Drive for Thinness,
Body Dissatisfaction, Low Self-Esteem, and Emotional Dysregulation. The next
measure, the Clinical Impairment Assessment (CIA), yielded a score of 30,
indicating clinically significant impairment related to Annette’s reported eating
disturbances. On the adult version of the Cross-Cutting Symptom Measure
(CCSM), Annette endorsed enough items on the Anxiety and Depression
domains to merit administration of Cross-Cutting Symptom Measure Level 2
forms for further information. On the Anxiety Level 2 form, Annette scored 56.3T,
which falls in the upper tier of mild anxiety. Annette scored 61.6T on the
Depression measure, placing her at the lower tier of moderate depression. On
the final instrument, the Personality Inventory for DSM-5 (PID-5), Annette’s item
endorsements yielded clinical interest for the following domains: Emotional
Lability, Impulsivity, Interpersonal Insecurity, and Separation Insecurity.

Clinical Interview

Mary contacted Annette to schedule a second visit for the clinical interview
to discuss the assessment results. When prompted, Annette further described
her eating behaviors. She reported beginning to engage in binge-eating episodes
approximately five months ago, at which time episodes occurred once weekly
and have now progressed to four to six times weekly. Annette denied engaging in
compensatory behaviors. Annette stated how these binges interfere with her
daily life and cause significant shame, often leading her to cancel social plans.
While speaking, Annette presented with some anxious symptomatology (e.g.,
fidgeting, nervousness) and depressive symptomatology (e.g., tearfulness).
Annette stated that sometimes she experiences “mood swings” and that she has
“a hard time calming down.” Mary noted that Annette’s endorsements on the PID-
5 yielded clinical interest for Interpersonal Insecurity, but her endorsements on
the EDI-3 were unremarkable for the subscale by the same name. Mary thus
sought clarification and probed about Annette’s relationship history in order to
investigate Interpersonal Insecurity and other potentially pathological personality
traits indicated on the PID-5. Annette reported experiencing anxiety toward the

151
end of social engagements, when she is aware that she will soon leave her
friends. She also reported extreme difficulty being alone, except during bingeing
episodes, during which she prefers isolation.

Diagnosis

After further reviewing Annette’s assessment outcomes and information

obtained during the clinical interview, Mary determined a preliminary diagnosis
for her client, using features from Impulsive Profile and Transdiagnostic
Dimensions. The diagnosis is Eating Disorder, Impulsive Profile with moderate
impairment and the following symptoms: binge eating, body dissatisfaction, drive
for thinness, internalization of thin ideal, anxiety, depression, emotional
dysregulation, interpersonal insecurity, low self-esteem, separation insecurity,
and impulsivity.

Eating Disorder, Impulsive Profile

Severity
30 (moderate impairment)

Eating Disorder Symptomatology

Binge Eating
Body Dissatisfaction
Drive for Thinness
Internalization of Thin Ideal

Comorbid Psychopathology
Anxiety
Depression
Emotional Dysregulation
Interpersonal Insecurity
Low Self-Esteem
Separation Insecurity

Neurobiological Mechanisms
Impulsivity

152
 Appendix C

Graphic Conceptualizations of
Categorical-Dimensional Diagnostic Model for Eating Disorders

Categorical-Dimensional Diagnostic Model for Eating Disorders

Restrictive Profile Impulsive Profile

Eating Disorder Comorbid Eating Disorder Comorbid
Symptomatology Psychopathology Symptomatology Psychopathology
Restricted Food Intake Anhedonia Binge Eating Attention Seeking
Asceticism Compensatory Behaviors Borderline Personality Disorder
Neurobiological Avoidant Personality Disorder Emotional Dysregulation
Mechanisms Neurobiological
Competitiveness Interpersonal Difficulties
Cognitive Inflexibility Mechanisms
Excessive Control Interpersonal Insecurity
Compulsivity Impulsivity
Harm Avoidance Irresponsibility
Impaired Concentration Novelty Seeking
Interpersonal Alienation Manipulativeness
Impaired Set-Shifting Reward Seeking
Obsessive-Compulsive Disorder Non-Suicidal Self-Injury
Perfectionism Promiscuity
Perseveration Risk Taking
Personal Alienation Separation Insecurity
Repetitive Thoughts and Behaviors Substance Use
Restricted Affectivity Suicidal Ideation
Restricted Libido
Restricted Sexuality
Rigidity
Social Isolation/Withdrawal

Restrictive Normalcy Impulsive

Transdiagnostic Dimensions
Comorbid
Eating Disorder Psychopathology
Symptomatology
Alexithymia
Body Dissatisfaction
Anxiety
Drive for Thinness
Anxiousness
Excessive Exercise
Depression
Internalization of Thin Ideal
Depressivity
Neurobiological Mechanisms Distractibility
Attentional Impairment Interoceptive Deficits
Intimacy Avoidance
Low Self-Esteem
Maturity Fears
Neuroticism
Personality Functioning

This diagram shows the complete hybrid categorical-dimensional diagnostic model for
eating disorders. The spectrum of severity extends from extreme Restrictive to extreme
Impulsive with Normalcy in the center. The categories Restrictive Profile, Impulsive
Profile, and Transdiagnostic Dimensions contain respective specifiers that can be applied
to a client’s diagnosis for a more specific and comprehensive clinical picture. These
dimensions are classified as Eating Disorder Symptomatology, Comorbid
Psychopathology, and Neurobiological Mechanisms.

153
Spectrum Conceptualization of Eating Disorder Diagnostic Model
(with DSM-5 Diagnoses)

Restrictive Normalcy Impulsive

AN-R BED AN-BP BN

This diagram is a spectrum conceptualization of the hybrid categorical-

dimensional diagnostic model for eating disorders. Indicated along the
continuum are the currently recognized eating disorder diagnoses:
anorexia nervosa, restricting type (AN-R); binge eating disorder (BED);
anorexia nervosa, binge-eating/purging type (AN-BP); and bulimia nervosa
(BN). With the predominant nature of AN-R’s restrictive tendencies, it is
placed at the far end of the Restrictive side. BN is placed at the opposite
end on the Impulsive side and is thus classified as the most impulsive of
the four diagnoses. AN-BP is characterized by both restrictive and
impulsive behaviors and thus has an attenuated placement on the
Impulsive side. BED has impulsive binge-eating behaviors in the absence
of compensatory or purging behaviors, thus placed closer to Normalcy
than AN-BP.

154
Venn Diagram Conceptualization of Eating Disorder Diagnostic Model

Restrictive Profile Transdiagnostic Impulsive Profile

Dimensions

This diagram shows a Venn conceptualization of the categorical-dimensional

diagnostic model for eating disorders. While Restrictive Profile and Impulsive
Profile reside at opposite ends of the diagnostic continuum, they share the
Transdiagnostic Dimensions category.

155
Venn Diagram Conceptualization of Eating Disorder Diagnostic Model
(with Dimensional Specifiers)

Restrictive Profile Transdiagnostic Dimensions Impulsive Profile

Eating Disorder Symptomatology Eating Disorder Eating Disorder

Restricted Food Intake Symptomatology Symptomatology
Body Dissatisfaction Binge eating
Comorbid Psychopathology Drive for Thinness Compensatory Behaviors
Anhedonia
Ascetism Excessive Exercise
Comorbid
Avoidant Personality Disorder Internalization of Thin Ideal Psychopathology
Competitiveness
Attention Seeking
Excessive Control
Comorbid Psychopathology Borderline Personality Disorder
Harm Avoidance
Emotional Dysregulation
Interpersonal Alienation Alexithymia
Interpersonal Difficulties
Obsessive-Compulsive Disorder Anxiety Interpersonal Insecurity
Perfectionism
Anxiousness Irresponsibility
Perseveration
Manipulativeness
Personal Alienation Depression Non-Suicidal Self-Injury
Repetitive Thoughts and Behaviors
Depressivity Promiscuity
Restricted Affectivity
Distractibility Risk Taking
Restricted Libido
Separation Insecurity
Restricted Sexuality Interoceptive Deficits Substance Use
Rigidity
Intimacy Avoidance Suicidal Ideation
Social Isolation/Withdrawal
Low Self-Esteem
Neurobiological Mechanisms
Neurobiological Mechanisms Maturity Fears
Impulsivity
Cognitive Inflexibility Neuroticism
Novelty Seeking
Compulsivity Personality Functioning
Reward Seeking
Impaired Concentration
Neurobiological
Impaired Set-shifting Mechanisms
Attentional impairment
Low interoceptive awareness

This diagram shows a Venn conceptualization of the categorical-dimensional

diagnostic model for eating disorders with dimensional specifiers. This format
indicates that Restrictive Profile and Impulsive Profile reside at opposite ends of
the diagnostic continuum, yet they can share the dimensional specifiers of
Transdiagnostic Dimensions, according to the client’s symptomatological
presentation.

156
 Appendix D

Psychometric Measures

Table of Contents

Eating Disorder Inventory, Third Edition
(Sample Subscale Descriptions and Score Report) ................................................................ 158

Clinical Impairment Assessment .................................................................................................... 169

Cross-Cutting Symptom Measure (Adults) ................................................................................ 171
Cross-Cutting Symptom Measure Level 2 Forms (Adults) .................................................. 173
Depression .......................................................................................................................................................... 173
Anxiety ................................................................................................................................................................. 175
Repetitive Thoughts and Behaviors ........................................................................................................ 177
Substance Use ................................................................................................................................................... 179
Cross-Cutting Symptom Measure (Adolescents) ..................................................................... 181
Cross-Cutting Symptom Measure Level 2 Forms (Adolescents) ...................................... 183
Depression .......................................................................................................................................................... 183
Anxiety ................................................................................................................................................................. 185
Repetitive Thoughts and Behaviors ........................................................................................................ 187
Substance Use ................................................................................................................................................... 189
Personality Inventory for DSM-5 (Adults) ................................................................................. 191
Personality Inventory for DSM-5 (Adolescents) ..................................................................... 199

157
The EDI-3 is available for purchase online from Psychological Assessment
Resources (PAR), which provides clinicians access to standardized assessment
instruments. The test is comprised of an Item Booklet and a Symptom Checklist.
The client utilizes a separate answer sheet to record responses. Below are
sample descriptions of the EDI-3 subscales and a sample score report.

158
 Eating Disorder Inventory-3 (EDI-3) Scale Descriptions
David M. Garner, Ph.D.
© Psychological Assessment Resources (PAR)1

The EDI-3 consists of 91 items organized onto 12 primary scales, consisting of 3 eating-disorder-
specific scales and 9 general psychological scales that are highly relevant to, but not specific to,
eating disorders. It also yields six composites: one that is eating-disorder specific (i.e., Eating
Disorder Risk) and five that are general integrative psychological constructs (i.e., Ineffectiveness,
Interpersonal Problems, Affective Problems, Overcontrol, General Psychological Maladjustment).

EATING DISORDER INVENTORY-3 Scale Descriptions

EATING DISORDER INVENTORY-3 Scale Descriptions

Eating Disorder Specific Scales

Drive For Thinness The "Drive for Thinness" construct has been described as one of the cardinal
(DT) features of eating disorders and has been considered an essential criterion for
a diagnosis according to many classification schemes. The 7 items on this
scale assess an extreme desire to be thinner, concern with dieting,
preoccupation with weight and an intense fear of weight gain. Prospective
studies have indicated that the DT scale is a good predictor of binge-eating

SAMPLE
and the development of formal eating disorders
Bulimia The Bulimia construct assesses the tendency to think about and to engage in
(B) bouts of uncontrollable overeating (binge-eating). The 8 items on this scale
assess concerns about overeating and eating in response to being upset. The
presence of binge eating is one of the defining features of bulimia nervosa and
differentiates the bingeing/purging and restrictor subtypes of anorexia
nervosa. Research has shown that binge eating is common in individuals who
do not meet all of the criteria to qualify for a formal diagnosis of an eating
disorder; however, in most cases, severe binge eating is associated with
marked psychological distress.
Body Dissatisfaction (BD) The Body Dissatisfaction scale consists of 10 items that assess
discontentment with the overall shape and with the size of those regions of the
body of extraordinary concern to those with eating disorders (i.e., stomach,
hips, thighs, buttocks). One item on BD scale measures the feeling of bloating
after eating a normal meal, a common feature of those who are dissatisfied
with their body weight. Given the fact that body dissatisfaction is endemic to
young women in Western culture, it is does not cause disorder alone;
however, it may considered a major risk factor responsible for initiating and
then sustaining extreme weight controlling behaviors seen in eating disorders.

Psychological Trait Scales

Low Self-Esteem The Low Self-Esteem (LSE) construct measures the basic concept of negative
(LSE) self-evaluation. The LSE scale targets affect-laden self-schemas with 5 of the
6 items assessing feelings of insecurity, inadequacy, ineffectiveness, and lack
of personal worth. Additional content measures self-perception of being
unable to achieve personal standards. Most theories consider low self-esteem
to play a major role in the development and maintenance of eating disorders.
Personal Alienation The Personal Alienation (PA) construct is conceptually related to low self-
(PA) esteem; however, goes further to reflect a pervasive sense of emotional
emptiness, aloneness and poor sense of self-understanding. The 7 PA items
include content reflecting feelings of being separated from, losing out or not
being given due credit from others. PA items also measure the wish to be
someone else and a general sense of being out of control of things in one’s

1
PAR owns the copyright for the EDI (EDI, EDI-2, EDI-3, EDI-RF) and the manuals, tests and scoring
sheets can be ordered from PAR at www.parinc.com. The EDI is strictly protected under copyright laws.

159
 life.
Interpersonal Insecurity The Interpersonal Insecurity (II) scale consists of 7 items assessing discomfort
(II) apprehension, and reticence in social situations. The II scale focuses
particularly on difficulties expressing personal thoughts and feelings with
others. Item content on the II scale also assess the tendency to withdrawal
and isolate from others.
Interpersonal Alienation The Interpersonal Alienation (IA) scale includes 7 items that evaluate
(IA) disappointment, distance, estrangement, and lack of trust in relationships.
Item content also measures the tendency to feel trapped in relationships as
well as the sense that there is a lack of understanding and love from others. A
high score on the IA scale indicates a basic impairment of attachment in
relationships.
Interoceptive Deficits The Interoceptive Deficits (ID) scale consists of 9 items that measure
(ID) confusion related to accurately recognizing and responding to emotional
states. There is a “fear of affect” item cluster indicating distress when
emotions are too strong or out of control that contrasts with an “affective
confusion” item cluster indicating difficulty in accurately recognize emotional
states. Confusion and mistrust related to affective and bodily functioning have
been repeatedly described as an important characteristic of those who
develop eating disorders.
Emotional Disregulation The Impulse Disregulation (ID) scale consists of 8 items assessing a tendency
(ED) toward mood instability, impulsivity, recklessness, anger, and self-
destructiveness. There are 2 items indicating potential problems with
substance abuse; one for alcohol and one for drugs. The tendency toward
poor impulse regulation and mood intolerance has been identified as a poor
prognostic signs in eating disorders. Items on the Impulse Disregulation scale

SAMPLE
overlap with the "borderline" attributes characteristic of a subgroup of eating
disorder patients considered particularly resistant to treatment.
Perfectionism The Perfectionism (P) scale consists of 6 items evaluating the extent to which
(P) a person places a premium on achieving a high goals and standard of
personal achievement. Item content on the Perfectionism scale falls into two
clusters: 3 items measure “personal perfectionistic standards” reflecting
demanding personal standards for performance and 3 items assessing
“parental perfectionistic standards” indicating pressures from parents and
teachers. Research has shown that perfectionism may be at the heart of
relentless efforts at weight control as well as unrealistic strivings in other
areas. It has been identified as a key feature in the development and
maintenance of eating disorders.
Ascetism The Asceticism (A) scale consists of 7 items assessing the tendency to seek
(A) virtue through the pursuit of spiritual ideals such as self-discipline, self-denial,
self-restraint, self-sacrifice and control of bodily urges. A 3-item “suffering”
cluster relates to the concept that self-denial makes a person stronger; a
“weakness” cluster measures the tendency to view pleasure, relaxing and
human weakness as shameful. The ascetic motive for weight loss was
common in early writings on anorexia nervosa and is still an important theme
in some cases.
Maturity Fears The Maturity Fears (MF) scale consists of 8 items assessing the desire to
(MF) retreat to the security of childhood. This construct has been described as a
central maintaining feature in a subgroup of adolescent patients whose dieting
and weight loss is functional in that it provides a means to return to a produces
a pre-pubertal appearance and hormonal status that allows them to retreat
from turmoil, conflicts and developmental expectations associated with
adulthood. The fears of development may stimulate fears and expectations
related to role-changes for which the adolescent, the parents or both feel ill
prepared. Two items on this scale as the respondent retrospectively on
childhood; therefore, these items are not suited to younger children who are
still in childhood.

Composite Scales
Eating Concerns Composite The Eating Concerns Composite (ECC) is comprised of the summed T-scores
(ECC) on the DT, B and BD scales. It provides a global measure of eating concerns

160
 with equal weighting for each of the contributing scales. The ECC can be
used for screening purposes or to obtain one score reflecting level of eating
concerns.
Ineffectiveness Composite The Ineffectiveness Composite (IC) consists of the summed T-scores for the
(IC) Low Self-Esteem (LSE) scale and the Personal Alienation (PA) scales. These
scales are highly correlated (.80 or above) for both clinical and non-clinical
samples and their combination generally improves reliability (alpha). The IC
includes all of the items from the original EDI-2 Ineffectiveness scale and adds
three highly correlated items from the EDI-2 Social Insecurity scale. High
scores on this composite reflect both low self-evaluation and the sense of
emotional emptiness that reflects a basic deficit in personal identity.
Interpersonal Problems Composite The Interpersonal Problems Composite (IPC) consists of summed T-scores for
(IPC) the Interpersonal Insecurity (II) and the Interpersonal Alienation (IA) scales.
These scales are correlated, but only moderately. All of the items from the
EDI-2 Interpersonal Distrust scale load on either the II or the IA scale and it is
one of the EDI-2 scales most predictive of poor treatment response. An
elevated IPC indicates an individual's beliefs that social relationships are
tense, insecure, disappointing, unrewarding, and generally of poor quality.
Many eating disorder patients have been described as experiencing social
self-doubt and insecurity along with an overall distrust of relationships. It
indicates severe damage in the ability to form attachments and this has

SAMPLE
ominous implications for the therapeutic relationship. Interpersonal problems
play a role in maintaining eating disorder symptoms in many and are an
important target of treatment.
Affective Problems Composite The Affective Problems Composite (APC) consists of the summed T-scores
(APC) for the Interoceptive Deficits (ID) and the Impulse Disregulation (ID) scales.
These two scales are moderately correlated. The EDC reflects severe
disturbances in the way that they interpret and respond to emotional cues.
The subgroup of eating disorder patients who have both a poor understanding
of their emotional state and also tend to respond with impulsivity, anger, mood
swings and substance abuse can pose serious management problems.
Difficulties in both identifying and tolerating mood-states can be an important
factor in maintaining an eating disorder is a key focal point in therapy
Overcontrol Composite The Overcontrol Composite (OC) consists of the summed T-scores for the
(OC) Perfectionism (P) and the Asceticism (A) scales. These scales are moderately
correlated; however, a higher-order factor analysis of the all of the EDI-3
psychological scales indicates that these two scales form a distinct factor.
Together they reflect pursuit of perfection through self-denial and suffering.
Perfectionism in the presence of extreme self-sacrifice and control of bodily
urges has historical roots in among religious ascetics who advocated the
pursuit of spiritual and virtuous aims often to the detriment of the body. It can
have different meanings in an eating disorder; however, it usually denotes
self-defining constructs resistant to change because of their association with
virtue.
Global Psychological Maladjustment Global Psychological Maladjustment (GPM) consists of the summed T-scores
GPM of all 9 of the psychological scales of the EDI-3. Some factor analytic
research on the EDI in non-clinical samples has suggested that there are two
major factors; one related to eating concerns and the other reflecting global
psychological maladjustment. However, It can be argued that combining all
psychological subscales into one composite score is misguided since it
defeats the purpose of a multi-dimensional assessment; however, it may have
empirical value by predicting treatment outcome, suggesting test-taking
response set, or indicating particularly high levels of psychopathology.

161
 EDI-3
Score Report
by
David M. Garner, PhD
and PAR Staff

Client Information
Name: Sample Client Test Date: 10/20/2004

Client ID: SAM 1 Age: 21

Gender: Female Marital Status: Married

Normative Group: AN-B/P U.S. Clinical Sample 18 and Over

E
Present Weight: 94 pounds

Height: 5 feet 1 inches

BMI: 17.8
PL
M
Highest past adult weight: 125 pounds

How long ago? 15 months

SA

How long at this weight? 24 months

Lowest past adult weight: 103 pounds

How long ago? 6 months

How long at this weight? 8 months

Ideal Weight: 112 pounds

Age at which weight problems (if any) began: 18 years old

PAR Psychological Assessment Resources, Inc./16204 N. Florida Ave. Lutz, FL 33549/1.800.331.8378/www.parinc.com

Copyright ©1984, 1988, 1990, 2004 by Psychlogical Assessment Resources, Inc.. All rights reserved. May not be reproduced in
whole or in any part in any form or by any means without written permission of Psychological Assessment Resources, Inc.

Version: 3.00.016

162
 Client: Sample Client Test Date: 10/20/2004
ID#: SAM 1 Page 2 of 7

EDI-3 Validity Scales

Scale Classification
Inconsistency (IN) Typical

Infrequency (IF) Typical

Negative Impression (NI) Typical

EDI-3 Eating Disorder Risk Scales and Composite Scores

Raw T Qualitative
Scale score score %ile classification
14 40 16 Low Clinical

E
Drive for Thinness (DT)
Bulimia (B) 15 52 57 Typical Clinical

Body Dissatisfaction (BD)

PL 19 41 21 Low Clinical

Eating Disorder Risk Composite (EDRC) 133 42 19 Low Clinical

EDI-3 Psychological Scale Scores

M

Raw T Qualitative
Scale score score %ile classification
SA

Low Self-Esteem (LSE) 13 50 48 Typical Clinical

Personal Alienation (PA) 17 55 69 Elevated Clinical

Interpersonal Insecurity (II) 13 52 59 Typical Clinical

Interpersonal Alienation (IA) 13 55 68 Elevated Clinical

Interoceptive Deficits (ID) 16 49 47 Typical Clinical

Emotional Dysregulation (ED) 13 58 80 Elevated Clinical

Perfectionism (P) 15 52 56 Typical Clinical

Asceticism (A) 18 59 81 Elevated Clinical

Maturity Fears (MF) 17 59 81 Elevated Clinical

163
 Client: Sample Client Test Date: 10/20/2004
ID#: SAM 1 Page 3 of 7

EDI-3 Psychological Composite Scores

Raw T Qualitative
Scale score score %ile classification
Ineffectiveness Composite (IC) 105 52 56 Typical Clinical

Interpersonal Problems Composite (IPC) 107 53 62 Typical Clinical

Affective Problems Composite (APC) 107 53 66 Typical Clinical

Overcontrol Composite (OC) 111 56 71 Elevated Clinical

Global Psychological Maladjustment 489 55 70 Elevated Clinical
Composite (GPMC)

E
PL
M
SA

164
 Client: Sample Client Test Date: 10/20/2004
ID#: SAM 1 Page 4 of 7

EDI-3 T-Score Profile

T score T score
≥ 99 ≥ 99

90 90

80 80

70 70
SA
A
60 ED 60

165
OC
PA IA
B
M MF
IPC

APC
GPMC
50 II P IC 50
LSE
ID

40 EDRC 40
BD
DT
PL
30 30

20
E 20

≤ 10 ≤ 10
Scale DT B BD EDRC LSE PA II IA ID ED P A MF IC IPC APC OC GPMC
T Score 40 52 41 42 50 55 52 55 49 58 52 59 59 52 53 53 56 55

Client profile Adult Typical Clinical range Adult Female controls

 Client: Sample Client Test Date: 10/20/2004
ID#: SAM 1 Page 5 of 7

EDI-3 Percentile Profile

%ile %ile
≥ 99 ≥ 99

90 90

ED A
80 80
MF

OC
PA IA
70 70
GPMC
IPC
SA
APC
60 B 60
II
P IC
M

166
50 50

LSE ID

40 40

30 30
PL
20 20
BD
EDRC

10
DT
E 10

≤1 ≤1
Scale DT B BD EDRC LSE PA II IA ID ED P A MF IC IPC APC OC GPMC
%ile 16 57 21 19 48 69 59 68 47 80 56 81 81 56 62 66 71 70

Client profile Adult Female controls

Note. Adult Combined Clinical Group: Low Clinical range = 1st - 24th %ile; Typical Clinical range = 25th - 66th %ile; Elevated Clinical range = 67th - 99th %ile.
Client: Sample Client Test Date: 10/20/2004
ID#: SAM 1 Page 6 of 7

EDI-2 Raw Scores

Scale Raw score

Drive for Thinness (DT) 7

Bulimia (B) 5

Body Dissatisfaction (BD) 8

Ineffectiveness (I) 12

Perfectionism (P) 9

Interpersonal Distrust (ID) 6

E
Interoceptive Awareness (IA) 9

Maturity Fears (MF)

PL 9

Asceticism (A) 12

Impulse Regulation (IR) 7

Social Insecurity (SI) 10

M
SA

167
Client: Sample Client Test Date: 10/20/2004
ID#: SAM 1 Page 7 of 7

Item Responses
Item# Response Item# Response Item# Response
1. S 31. S 61. O
2. U 32. O 62. O
3. O 33. O 63. O
4. U 34. S 64. U
5. O 35. S 65. S
6. O 36. O 66. O
7. S 37. S 67. S
8. S 38. S 68. U
9. S 39. S 69. O
10. S 40. S 70. S
11. O 41. U 71. S
12. R 42. S 72. S

E
13. O 43. U 73. R
14. U 44. O 74. O
15. S 45. S 75. U
16.
17.
U
S
PL 46.
47.
S
O
76.
77.
R
O
18. O 48. O 78. U
19. S 49. U 79. O
20. S 50. S 80. N
M
21. O 51. O 81. O
22. S 52. U 82. U
23. S 53. S 83. U
24. U 54. S 84. O
SA

25. S 55. R 85. O

26. S 56. O 86. O
27. U 57. R 87. S
28. O 58. R 88. O
29. U 59. S 89. S
30. S 60. O 90 S
91. S

Note: Bold denotes an item score of 4.

168
THE CLINICAL IMPAIRMENT ASSESSMENT
QUESTIONNAIRE (CIA)
Kristin Bohn and Christopher G Fairburn
Nature and Use of the CIA
The Clinical Impairment Assessment questionnaire (CIA) is a 16-item self-report
measure of the severity of psychosocial impairment due to eating disorder features (Bohn
and Fairburn, 2008). It focuses on the past 28 days. The 16 items cover impairment in
domains of life that are typically affected by eating disorder psychopathology: mood and
self-perception, cognitive functioning, interpersonal functioning and work performance.
The purpose of the CIA is to provide a simple single index of the severity of psychosocial
impairment secondary to eating disorder features.
The CIA is designed to be completed immediately after filling in a measure of current
eating disorder features that covers the same time frame (e.g., the Eating Disorder
Examination questionnaire, EDE-Q; Fairburn and Beglin, 1994). This ensures that
patients have their eating disorder features “at the front of their mind” when filling in the
CIA.
The CIA is intended to assist in the clinical assessment of patients both before and after
treatment. It is also suitable for use in epidemiological studies.
Scoring of the CIA
Each item is rated on a Likert scale with the response options being ‘Not at all’, ‘A little’,
‘Quite a bit’, and ‘A lot’. These responses are scored 0, 1, 2 and 3 respectively with a
higher rating indicating a higher level of impairment. Since it is the purpose of the CIA to
measure the overall severity of secondary psychosocial impairment, a global CIA
impairment score is calculated. To obtain the global CIA impairment score the ratings on
all items are added together with prorating of missing ratings, so long as at least 12 of the
16 items have been rated. The resulting score ranges from 0 to 48 with a higher score
being indicative of a higher level of secondary psychosocial impairment. A ROC analysis
showed that a global impairment score of 16 was the best cut-point for predicting eating
disorder case status (Bohn et al., in preparation).

169
INSTRUCTIONS

Please place an 'X' in the column which best describes how your eating habits,
exercising or feelings about your eating, shape or weight have affected your
life over the past four weeks (28 days). Thank you.

Not at all

A little

Quite a bit

A lot
Over the past 28 days, to what extent have your
…eating habits
…exercising
or feelings about your eating, shape or weight …

1 ... made it difficult to concentrate?

2 ... made you feel critical of yourself?
3 ... stopped you going out with others?
4 ... affected your work performance (if applicable)?
5 ... made you forgetful?
6 ... affected your ability to make everyday decisions?
7 ... interfered with meals with family or friends?
8 ... made you upset?
9 ... made you feel ashamed of yourself?
10 ... made it difficult to eat out with others?
11 ... made you feel guilty?
12 ... interfered with you doing things you used to enjoy?
13 ... made you absent-minded?
14 ... made you feel a failure?
15 ... interfered with your relationships with others?
16 ... made you worry?

170
 DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure—Adult
Name: ___________________________ Age: ____ Sex: Male Female Date:________

If this questionnaire is completed by an informant, what is your relationship with the individual? ___________________
In a typical week, approximately how much time do you spend with the individual? ____________________ hours/week

Instructions: The questions below ask about things that might have bothered you. For each question, circle the number that best
describes how much (or how often) you have been bothered by each problem during the past TWO (2) WEEKS.
None Slight Mild Moderate Severe Highest
Not at Rare, less Several More than Nearly Domain
During the past TWO (2) WEEKS, how much (or how often) have you been
all than a day days half the every Score
bothered by the following problems? or two days day (clinician)
I. 1. Little interest or pleasure in doing things? 0 1 2 3 4
2. Feeling down, depressed, or hopeless? 0 1 2 3 4
II. 3. Feeling more irritated, grouchy, or angry than usual? 0 1 2 3 4
III. 4. Sleeping less than usual, but still have a lot of energy? 0 1 2 3 4
5. Starting lots more projects than usual or doing more risky things than 0 1 2 3 4
usual?
IV. 6. Feeling nervous, anxious, frightened, worried, or on edge? 0 1 2 3 4
7. Feeling panic or being frightened? 0 1 2 3 4
8. Avoiding situations that make you anxious? 0 1 2 3 4
V. 9. Unexplained aches and pains (e.g., head, back, joints, abdomen, legs)? 0 1 2 3 4
10. Feeling that your illnesses are not being taken seriously enough? 0 1 2 3 4
VI. 11. Thoughts of actually hurting yourself? 0 1 2 3 4
VII. 12. Hearing things other people couldn’t hear, such as voices even when no 0 1 2 3 4
one was around?
13. Feeling that someone could hear your thoughts, or that you could hear 0 1 2 3 4
what another person was thinking?
VIII. 14. Problems with sleep that affected your sleep quality over all? 0 1 2 3 4
IX. 15. Problems with memory (e.g., learning new information) or with location 0 1 2 3 4
(e.g., finding your way home)?
X. 16. Unpleasant thoughts, urges, or images that repeatedly enter your mind? 0 1 2 3 4
17. Feeling driven to perform certain behaviors or mental acts over and over 0 1 2 3 4
again?
XI. 18. Feeling detached or distant from yourself, your body, your physical 0 1 2 3 4
surroundings, or your memories?
XII. 19. Not knowing who you really are or what you want out of life? 0 1 2 3 4
20. Not feeling close to other people or enjoying your relationships with them? 0 1 2 3 4
XIII. 21. Drinking at least 4 drinks of any kind of alcohol in a single day? 0 1 2 3 4
22. Smoking any cigarettes, a cigar, or pipe, or using snuff or chewing tobacco? 0 1 2 3 4
23. Using any of the following medicines ON YOUR OWN, that is, without a 0 1 2 3 4
doctor’s prescription, in greater amounts or longer than prescribed [e.g.,
painkillers (like Vicodin), stimulants (like Ritalin or Adderall), sedatives or
tranquilizers (like sleeping pills or Valium), or drugs like marijuana, cocaine
or crack, club drugs (like ecstasy), hallucinogens (like LSD), heroin,
inhalants or solvents (like glue), or methamphetamine (like speed)]?

Copyright © 2013 American Psychiatric Association. All Rights Reserved.

This material can be reproduced without permission by researchers and by clinicians for use with their patients.

171
Instructions to Clinicians
The DSM-5 Level 1 Cross-Cutting Symptom Measure is a self- or informant-rated measure that assesses mental health
domains that are important across psychiatric diagnoses. It is intended to help clinicians identify additional areas of inquiry
that may have significant impact on the individual’s treatment and prognosis. In addition, the measure may be used to track
changes in the individual’s symptom presentation over time.

This adult version of the measure consists of 23 questions that assess 13 psychiatric domains, including depression, anger,
mania, anxiety, somatic symptoms, suicidal ideation, psychosis, sleep problems, memory, repetitive thoughts and behaviors,
dissociation, personality functioning, and substance use. Each item inquires about how much (or how often) the individual has
been bothered by the specific symptom during the past 2 weeks. If the individual is of impaired capacity and unable to
complete the form (e.g., an individual with dementia), a knowledgeable adult informant may complete the measure. The
measure was found to be clinically useful and to have good test-retest reliability in the DSM-5 Field Trials that were conducted
in adult clinical samples across the United States and in Canada.

Scoring and Interpretation

Each item on the measure is rated on a 5-point scale (0=none or not at all; 1=slight or rare, less than a day or two; 2=mild or
several days; 3=moderate or more than half the days; and 4=severe or nearly every day). The score on each item within a
domain should be reviewed. Because additional inquiry is based on the highest score on any item within a domain, the
clinician is asked to indicate that score in the “Highest Domain Score” column. A rating of mild (i.e., 2) or greater on any item
within a domain (except for substance use, suicidal ideation, and psychosis) may serve as a guide for additional inquiry and
follow up to determine if a more detailed assessment for that domain is necessary. For substance use, suicidal ideation, and
psychosis, a rating of slight (i.e., 1) or greater on any item within the domain may serve as a guide for additional inquiry and
follow-up to determine if a more detailed assessment is needed. The DSM-5 Level 2 Cross-Cutting Symptom Measures may be
used to provide more detailed information on the symptoms associated with some of the Level 1 domains (see Table 1 below).

Frequency of Use
To track change in the individual’s symptom presentation over time, the measure may be completed at regular intervals as
clinically indicated, depending on the stability of the individual’s symptoms and treatment status. For individuals with
impaired capacity, it is preferable that the same knowledgeable informant completes the measures at follow-up
appointments. Consistently high scores on a particular domain may indicate significant and problematic symptoms for the
individual that might warrant further assessment, treatment, and follow-up. Clinical judgment should guide decision making.

Table 1: Adult DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure: domains, thresholds for further inquiry, and
associated Level 2 measures for adults ages 18 and over
Domain Domain Name Threshold to guide DSM-5 Level 2 Cross-Cutting Symptom Measure available online
further inquiry
I. Depression Mild or greater LEVEL 2—Depression—Adult (PROMIS Emotional Distress—Depression—Short
1
Form)
1
II. Anger Mild or greater LEVEL 2—Anger—Adult (PROMIS Emotional Distress—Anger—Short Form)
III. Mania Mild or greater LEVEL 2—Mania—Adult (Altman Self-Rating Mania Scale)
1
IV. Anxiety Mild or greater LEVEL 2—Anxiety—Adult (PROMIS Emotional Distress—Anxiety—Short Form)
V. Somatic Symptoms Mild or greater LEVEL 2—Somatic Symptom—Adult (Patient Health Questionnaire 15 Somatic
Symptom Severity [PHQ-15])
VI. Suicidal Ideation Slight or greater None
VII. Psychosis Slight or greater None
1
VIII. Sleep Problems Mild or greater LEVEL 2—Sleep Disturbance - Adult (PROMIS—Sleep Disturbance—Short Form)
IX. Memory Mild or greater None
X. Repetitive Thoughts Mild or greater LEVEL 2—Repetitive Thoughts and Behaviors—Adult (adapted from the Florida
and Behaviors Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B])
XI. Dissociation Mild or greater None
XII. Personality Mild or greater None
Functioning
XIII. Substance Use Slight or greater LEVEL 2—Substance Abuse—Adult (adapted from the NIDA-modified ASSIST)
1
The PROMIS Short Forms have not been validated as an informant report scale by the PROMIS group.

Copyright © 2013 American Psychiatric Association. All Rights Reserved.

This material can be reproduced without permission by researchers and by clinicians for use with their patients.

172
 LEVEL 2—Depression—Adult*
*
PROMIS Emotional Distress—Depression—Short Form

Name: _______________________________ Age: ____ Sex: Male Female Date:_________

If the measure is being completed by an informant, what is your relationship with the individual receiving care? ___________

In a typical week, approximately how much time do you spend with the individual receiving care? ___________ hours/week

Instructions: On the DSM-5 Level 1 cross-cutting questionnaire that you just completed, you indicated that during the past 2
weeks you (the individual receiving care) have been bothered by “no interest or pleasure in doing things” and/or “feeling
down, depressed, or hopeless” at a mild or greater level of severity. The questions below ask about these feelings in more
detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past
7 days. Please respond to each item by marking ( or x) one box per row.

Clinician
Use
In the past SEVEN (7) DAYS.... Item
Never Rarely Sometimes Often Always Score

1. I felt worthless. 1 2 3 4 5

2. I felt that I had nothing to look forward to. 1 2 3 4 5

3. I felt helpless. 1 2 3 4 5

4. I felt sad. 1 2 3 4 5

5. I felt like a failure. 1 2 3 4 5

6. I felt depressed. 1 2 3 4 5

7. I felt unhappy. 1 2 3 4 5

8. I felt hopeless. 1 2 3 4 5
Total/Partial Raw Score:
Prorated Total Raw Score:
T-Score:
©2008-2012 PROMIS Health Organization (PHO) and PROMIS Cooperative Group.
This material can be reproduced without permission by clinicians for use with their patients.
Any other use, including electronic use, requires written permission of the PHO.

173
Instructions to Clinicians
The DSM-5 Level 2—Depression—Adult measure is the 8-item PROMIS Depression Short Form that assesses the pure domain
of depression in individuals age 18 and older. The measure is completed by the individual prior to a visit with the clinician. If
the individual receiving care is of impaired capacity and unable to complete the form (e.g., an individual with dementia), a
knowledgeable informant may complete the measure as done in the DSM-5 Field Trials. However, the PROMIS Depression
Short Form has not been validated as an informant report scale by the PROMIS group. Each item asks the individual receiving
care (or informant) to rate the severity of the individual’s depression during the past 7 days.

Scoring and Interpretation

Each item on the measure is rated on a 5-point scale (1=never; 2=rarely; 3=sometimes; 4=often; and 5=always) with a range
in score from 8 to 40 with higher scores indicating greater severity of depression. The clinician is asked to review the score on
each item on the measure during the clinical interview and indicate the raw score for each item in the section provided for
“Clinician Use.” The raw scores on the 8 items should be summed to obtain a total
raw score. Next, the T-score table should be used to identify the T-score associated
with the individual’s total raw score and the information entered in the T-score row
on the measure.

Note: This look-up table works only if all items on the form are answered. If 75% or
more of the questions have been answered; you are asked to prorate the raw score
and then look up the conversion to T-Score. The formula to prorate the partial raw
score to Total Raw Score is:

(Raw sum x number of items on the short form)

Number of items that were actually answered

If the result is a fraction, round to the nearest whole number. For example, if 6 of 8
items were answered and the sum of those 6 responses was 20, the prorated raw
score would be 20 X 8/ 6 = 26.67. The T-score in this example would be the T-score
associated with the rounded whole number raw score (in this case 27, for a T-score of
64.4).

The T-scores are interpreted as follows:

Less than 55 = None to slight

55.0—59.9 = Mild
60.0—69.9 = Moderate
70 and over = Severe

Note: If more than 25% of the total items on the measure are missing the scores
should not be used. Therefore, the individual receiving care (or informant) should be
encouraged to complete all of the items on the measure.
©2008-2012 PROMIS Health Organization
(PHO) and PROMIS Cooperative Group.

Frequency of Use
To track change in the severity of the individual’s depression over time, the measure may be completed at regular intervals as
clinically indicated, depending on the stability of the individual’s symptoms and treatment status. For individuals with
impaired capacity, it is preferred that completion of the measures at follow-up appointments is by the same knowledgeable
informant. Consistently high scores on a particular domain may indicate significant and problematic areas for the individual
that might warrant further assessment, treatment, and follow-up. Your clinical judgment should guide your decision.

Instructions, scoring, and frequency of use on this page only: Copyright © 2013 American Psychiatric Association. All rights reserved.
This material can be reproduced without permission by researchers and by clinicians for use with their patients.

174
 LEVEL 2—Anxiety—Adult*
*PROMIS Emotional Distress—Anxiety—Short Form

Name: _______________________ Age: ____ Sex: Male Female Date:_____________

If the measure is being completed by an informant, what is your relationship with the individual? _____________________

In a typical week, approximately how much time do you spend with the individual? _______________________hours/week

Instructions to patient: On the DSM-5 Level 1 cross-cutting questionnaire that you just completed, you indicated that during
the past 2 weeks you (individual receiving care) have been bothered by “feeling nervous, anxious, frightened, worried, or on
edge”, “feeling panic or being frightened”, and/or “avoiding situations that make you anxious” at a mild or greater level of
severity. The questions below ask about these feelings in more detail and especially how often you (individual receiving care)
have been bothered by a list of symptoms during the past 7 days. Please respond to each item by marking ( or x) one box
per row.

Clinician
Use
In the past SEVEN (7) DAYS.... Item
Never Rarely Sometimes Often Always Score

1. I felt fearful. 1 2 3 4 5

2. I felt anxious. 1 2 3 4 5

3. I felt worried. 1 2 3 4 5

4. I found it hard to focus on anything 1 2 3 4 5

other than my anxiety.

5. I felt nervous. 1 2 3 4 5

6. I felt uneasy. 1 2 3 4 5

7. I felt tense. 1 2 3 4 5

Total/Partial Raw Score:

Prorated Total Raw Score:
T-Score:
©2008-2012 PROMIS Health Organization (PHO) and PROMIS Cooperative Group.
This material can be reproduced without permission by clinicians for use with their patients.
Any other use, including electronic use, requires written permission of the PHO.

175
Instructions to Clinicians
The DSM-5 Level 2—Anxiety—Adult measure is the 7-item PROMIS Anxiety Short Form that assesses the pure domain of
anxiety in individuals age 18 and older. The measure is completed by the individual prior to a visit with the clinician. If the
individual receiving care is of impaired capacity and unable to complete the form (e.g., an individual with dementia), a
knowledgeable informant may complete the measure as done in the DSM-5 Field Trials. However, the PROMIS Anxiety Short
Form has not been validated as an informant report scale by the PROMIS group. Each item asks the individual receiving care
(or informant) to rate the severity of the individual’s anxiety during the past 7 days.

Scoring and Interpretation

Each item on the measure is rated on a 5-point scale (1=never; 2=rarely; 3=sometimes; 4=often; and 5=always) with a range
in score from 7 to 35 with higher scores indicating greater severity of anxiety. The clinician is asked to review the score on
each item on the measure during the clinical interview and indicate the raw score for each item in the section provided for
“Clinician Use.” The raw scores on the 7 items should be summed to obtain a total raw score. Next, the T-score table should
be used to identify the T-score associated with the total raw score and the information entered in the T-score row on the
measure.

Note: This look-up table works only if all items on the form are answered. If
75% or more of the questions have been answered; you are asked to prorate
the raw score and then look up the conversion to T-Score. The formula to
prorate the partial raw score to Total Raw Score is:

(Raw sum x number of items on the short form)

Number of items that were actually answered

If the result is a fraction, round to the nearest whole number. For example, if
6 of 7 items were answered and the sum of those 6 responses was 20, the
prorated raw score would be 20 X 7/ 6 = 23.33. The T-score in this example
would be that T-score associated with the rounded whole number raw score
(in this case 23, for a T-score of 63.8).

The T-scores are interpreted as follows:

Less than 55 = None to slight
55.0—59.9 = Mild
60.0—69.9 = Moderate
70 and over = Severe

Note: If more than 25% of the total items on the measure are missing the
scores should not be used. Therefore, the individual receiving care (or
informant) should be encouraged to complete all of the items on the
measure.

Frequency of Use
To track change in the severity of the individual’s anxiety over time, the
measure may be completed at regular intervals as clinically indicated,
depending on the stability of the individual’s symptoms and treatment
status. For individuals with impaired capacity, it is preferred that completion
of the measures at follow-up appointments is by the same knowledgeable
informant. Consistently high scores on a particular domain may indicate
significant and problematic areas for the individual that might warrant
further assessment, treatment, and follow-up. Your clinical judgment ©2008-2012 PROMIS Health Organization (PHO) and PROMIS
should guide your decision. Cooperative Group.

Instructions, scoring, and frequency of use on this page only: Copyright © 2013 American Psychiatric Association. All rights reserved.
This material can be reproduced without permission by researchers and by clinicians for use with their patients.

176
 LEVEL 2—Repetitive Thoughts and Behaviors—Adult*
*Adapted from the Florida Obsessive-Compulsive Inventory (FOCI) Severity Scale (Part B)

Name: _______________________________ Age: ____ Sex: Male Female Date:_________________

If the measure is being completed by an informant, what is your relationship with the individual receiving care? __________________

In a typical week, approximately how much time do you spend with the individual receiving care? __________________ hours/week

Instructions: On the DSM-5 Level 1 cross-cutting questionnaire that you just completed, you indicated that during the past 2
weeks you have been bothered by “unwanted repeated thoughts, images, or urges” and/or “being driven to perform certain
behaviors or mental acts over and over” at a mild or greater level of severity. The questions below ask about these feelings in
more detail and especially how often you have been bothered by a list of symptoms during the past 7 days. Please respond to
each item by marking ( or x) one box per row.

Clinician
Use
Item
During the past SEVEN (7) DAYS….
Score
1. On average, how much
time is occupied by these 0—None 1—Mild 2—Moderate 3—Severe 4—Extreme
thoughts or behaviors (Less than an (1 to 3 hours a day) (3 to 8 hours a day) (more than 8
each day? hour a day) hours a day)
2. How much distress do
these thoughts or 0—None 1—Mild 2—Moderate 3—Severe (very 4—Extreme
behaviors cause you? (slightly (disturbing but still disturbing) (overwhelming
disturbing) manageable) distress)
3. How hard is it for you to
control these thoughts or 0—Complete 1—Much control 2—Moderate control 3—Little control 4—No control
behaviors? control (usually able to (sometimes able to (infrequently able (unable to
control thoughts control thoughts or to control thoughts control thoughts
or behaviors) behaviors) or behaviors) or behaviors)
4. How much do these
thoughts or behaviors 0—No 1—Mild 2—Moderate 3—Severe 4 - Extreme
cause you to avoid doing avoidance (occasional (regularly avoid (frequent and (nearly complete
anything, going anyplace, avoidance) doing these things) extensive avoidance;
or being with anyone? avoidance) house- bound)
5. How much do these
thoughts or behaviors 0—None 1—Mild 2— Moderate; 3—Severe 4—Extreme
interfere with school, (slight (definite (substantial (near-total
work, or your social or interference) interference interference) interference;
family life? with functioning, but incapacitated)
still manageable)
Total/Partial Raw Score:
Prorated Total Raw Score (if 1 item is left unanswered):
Average Total Score:
© 1994 Wayne K. Goodman, MD and Eric Storch, PhD. This material can be reproduced without permission by clinicians for use with their own patients.
Any other use, including electronic use, requires written permission from Dr. Goodman (wkgood@gmail.com)

177
Instructions to Clinicians
The DSM-5 Level 2—Repetitive Thoughts and Behavior—Adult measure is an adapted version of the 5-item
Florida Obsessive-Compulsive Inventory (FOCI) Severity Scale (Part B) that is used to assess the domain of
repetitive thoughts and behaviors in individuals age 18 and older. The measure is completed by an individual
prior to a visit with the clinician. If the individual receiving care is of impaired capacity and unable to complete
the form (e.g., an individual with dementia), a knowledgeable informant may complete the measure. Each
item asks the individual (or informant) to rate the severity of the individual’s repetitive thoughts and behaviors
during the past 7 days.

Scoring and Interpretation

Each item on the measure is rated on a 5-point scale (i.e., 0 to 4) with the response categories having different
anchors depending on the item. The total score for the measure can range of score from 0 to 20, with higher
scores indicating greater severity of repetitive thoughts and behaviors. The clinician is asked to review the
score of each item on the measure during the clinical interview and indicate the raw score for each item in the
section provided for “Clinician Use.” The raw scores on the 5 items should be summed to obtain a total raw
score. If the individual has a score of 8 or higher, you may want to consider a more detailed assessment for an
obsessive compulsive disorder. In addition, the clinician is asked to calculate and use the average total score.
The average total score reduces the overall score to a 5-point scale, which allows the clinician to think of the
individual’s repetitive thoughts and behavior in terms of none (0), mild (1), moderate (2), severe (3), or
extreme (4). The use of the average total score was found to be reliable, easy to use, and clinically useful to the
clinicians in the DSM-5 Field Trials. The average total score is calculated by dividing the raw total score by
number of items in the measure (i.e., 5).

Note: If 2 or more items are left unanswered on the measure (i.e., more than 25% of the total items are
missing), the total scores should not be calculated. Therefore, the individual (or informant) should be
encouraged to complete all of the items on the measure. If only 4 of the 5 items on the measure are answered,
you are asked to prorate the raw score by first summing the scores of items that were answered to get a
partial raw score. Next, multiply the partial raw score by the total number of items on the measure (i.e., 5).
Finally, divide the value by the number of items that were actually answered (i.e., 4) to obtain the prorated
total raw score.

Prorated Score = (Partial Raw Score x number of items on the measure)

Number of items that were actually answered

If the result is a fraction, round to the nearest whole number.

Frequency of Use
To track change in the severity of the individual’s repetitive thoughts and behavior over time, the measure
may be completed at regular intervals as clinically indicated, depending on the stability of the individual’s
symptoms and treatment status. For individuals of impaired capacity, it is preferred that completion of the
measure at follow-up appointments is by the same knowledgeable informant. Consistently high scores on the
measure may indicate significant and problematic areas for the individual that might warrant further
assessment, treatment, and follow-up. Your clinical judgment should guide your decision.

Instructions, scoring, and frequency of use on this page only: Copyright © 2013 American Psychiatric Association. All rights reserved.
This material can be reproduced without permission by researchers and by clinicians for use with their patients.

178
 LEVEL 2—Substance Use—Adult*
*
Adapted from the NIDA-Modified ASSIST

Name: ____________________________ Age: ____ Sex: Male Female Date:_______________

If the measure is being completed by an informant, what is your relationship with the individual receiving care? ______________

In a typical week, approximately how much time do you spend with the individual receiving care? ________________ hours/week

Instructions: On the DSM-5 Level 1 cross-cutting questionnaire that you just completed, you indicated that during
the past 2 weeks you (the individual receiving care) have been bothered by “using medicines on your own without
a doctor’s prescription, or in greater amounts or longer than prescribed, and/or using drugs like marijuana,
cocaine or crack, and/or other drugs” at a slight or greater level of severity. The questions below ask how often
you (the individual receiving care) have used these medicines and/or substances during the past 2 weeks. Please
respond to each item by marking ( or x) one box per row.

During the past TWO (2) WEEKS, about how often did you use any of the following
Clinician
medicines ON YOUR OWN, that is, without a doctor’s prescription, in greater amounts
Use
or longer than prescribed?
One or Several More than Nearly
Not at all
two days days half the days every day Item Score
a. Painkillers (like Vicodin) 0 1 2 3 4
b. Stimulants (like Ritalin, Adderall) 0 1 2 3 4
c. Sedatives or tranquilizers (like sleeping 0 1 2 3 4
pills or Valium)
Or drugs like:

d. Marijuana 0 1 2 3 4

e. Cocaine or crack 0 1 2 3 4
f. Club drugs (like ecstasy) 0 1 2 3 4

g. Hallucinogens (like LSD) 0 1 2 3 4

h. Heroin 0 1 2 3 4

i. Inhalants or solvents (like glue) 0 1 2 3 4

j. Methamphetamine (like speed) 0 1 2 3 4

Total Score:
Courtesy of National Institute on Drug Abuse.
This Instrument may be reproduced without permission by clinicians for use with their own patients.

179
Instructions to Clinicians
The DSM-5 Level 2—Substance Use—Adult is an adapted version of the NIDA-Modified ASSIST. The 15-item
measure is used to assess the pure domain of prescription medicine, and illicit substance use in adults age 18 and
older. It is completed by the individual prior to a visit with the clinician. If the individual receiving care is of
impaired capacity and unable to complete the form (e.g., an individual with dementia), a knowledgeable
informant may complete the measure. Each item asks the individual receiving care (or informant) to rate the
severity of the individual’s use of various substances during the past 2 weeks.

Scoring and Interpretation

Each item on the measure is rated on a 5-point scale (i.e., 0=not at all; 1=1 or 2 days; 2=several days; 3=more than
half the days; 4=nearly every day). The clinician is asked to review the score of each item on the measure during
the clinical interview and indicate the raw score for each item in the section provided for “Clinician Use.” Scores
on the individual items should be interpreted independently because each item inquires about the use of a
distinct substance. The rating of multiple items at scores greater than 0 indicates greater severity and complexity
of substance use.

Frequency of Use
To track change in the severity of the individual’s use of alcohol, tobacco/nicotine, prescription or illicit substance
over time, the measure be may completed at regular intervals as clinically indicated, depending on the stability of the
individual’s symptoms and treatment status. For individuals of impaired capacity, it is preferred that completion of
the measures at follow-up appointments is by the same knowledgeable informant. Consistently high scores on the
measure may indicate significant and problematic areas that might warrant further assessment, treatment, and
follow-up. Your clinical judgment should guide your decision.

Courtesy of National Institute on Drug Abuse.

This material may be reproduced without permission by clinicians for use with their own patients.

180
 DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure—Child Age 11–17
Name: ________________________________ Age: ____ Sex: Male Female Date:___________

Instructions: The questions below ask about things that might have bothered you. For each question, circle the number that best
describes how much (or how often) you have been bothered by each problem during the past TWO (2) WEEKS.
None Slight Mild Moderate Severe Highest
Not at all Rare, less Several More than
Nearly Domain
than a day days half the
every Score
During the past TWO (2) WEEKS, how much (or how often) have you… or two days day (clinician)
I. 1. Been bothered by stomachaches, headaches, or other aches and pains? 0 1 2 3 4
2. Worried about your health or about getting sick? 0 1 2 3 4
II. Been bothered by not being able to fall asleep or stay asleep, or by waking
3. 0 1 2 3 4
up too early?
III. Been bothered by not being able to pay attention when you were in class or
4. 0 1 2 3 4
doing homework or reading a book or playing a game?
IV. 5. Had less fun doing things than you used to? 0 1 2 3 4
6. Felt sad or depressed for several hours? 0 1 2 3 4
V. & 7. Felt more irritated or easily annoyed than usual? 0 1 2 3 4
VI. 8. Felt angry or lost your temper? 0 1 2 3 4
VII. 9. Started lots more projects than usual or done more risky things than usual? 0 1 2 3 4
10. Slept less than usual but still had a lot of energy? 0 1 2 3 4
VIII. 11. Felt nervous, anxious, or scared? 0 1 2 3 4
12. Not been able to stop worrying? 0 1 2 3 4
Not been able to do things you wanted to or should have done, because
13. 0 1 2 3 4
they made you feel nervous?
IX. Heard voices—when there was no one there—speaking about you or telling
14. 0 1 2 3 4
you what to do or saying bad things to you?
Had visions when you were completely awake—that is, seen something or
15. 0 1 2 3 4
someone that no one else could see?
X. Had thoughts that kept coming into your mind that you would do
16. something bad or that something bad would happen to you or to someone 0 1 2 3 4
else?
Felt the need to check on certain things over and over again, like whether a
17. 0 1 2 3 4
door was locked or whether the stove was turned off?
Worried a lot about things you touched being dirty or having germs or being
18. 0 1 2 3 4
poisoned?
Felt you had to do things in a certain way, like counting or saying special
19. 0 1 2 3 4
things, to keep something bad from happening?
In the past TWO (2) WEEKS, have you…
XI. 20. Had an alcoholic beverage (beer, wine, liquor, etc.)? Yes No
21. Smoked a cigarette, a cigar, or pipe, or used snuff or chewing tobacco? Yes No
Used drugs like marijuana, cocaine or crack, club drugs (like Ecstasy),
22. hallucinogens (like LSD), heroin, inhalants or solvents (like glue), or Yes No
methamphetamine (like speed)?
Used any medicine without a doctor’s prescription to get high or change
the way you feel (e.g., painkillers [like Vicodin], stimulants [like Ritalin or
23. Yes No
Adderall], sedatives or tranquilizers [like sleeping pills or Valium], or
steroids)?
XII. In the last 2 weeks, have you thought about killing yourself or committing
24. Yes No
suicide?
25. Have you EVER tried to kill yourself? Yes No
Copyright © 2013 American Psychiatric Association. All Rights Reserved.
This material can be reproduced without permission by researchers and by clinicians for use with their patients.

181
Instructions to Clinicians
The DSM-5 Level 1 Cross-Cutting Symptom Measure is a self-rated measure that assesses mental health domains that are important
across psychiatric diagnoses. It is intended to help clinicians identify additional areas of inquiry that may have significant impact on
the child’s treatment and prognosis. In addition, the measure may be used to track changes in the child’s symptom presentation
over time.

This child-rated version of the measure consists of 25 questions that assess 12 psychiatric domains, including depression, anger,
irritability, mania, anxiety, somatic symptoms, inattention, suicidal ideation/attempt, psychosis, sleep disturbance, repetitive
thoughts and behaviors, and substance use. Each item asks the child, age 11–17, to rate how much (or how often) he or she has
been bothered by the specific symptom during the past 2 weeks. The measure was found to be clinically useful and had good test-
retest reliability in the DSM-5 Field Trials conducted in pediatric clinical samples across the United States.

Scoring and Interpretation

Nineteen of the 25 items on the measure are each rated on a 5-point scale (0=none or not at all; 1=slight or rare, less than a day or
two; 2=mild or several days; 3=moderate or more than half the days; and 4=severe or nearly every day). The suicidal ideation,
suicide attempt, and substance abuse items are each rated on a “Yes or No” scale. The score on each item within a domain should
be reviewed. Because additional inquiry is based on the highest score on any item within a domain, the clinician is asked to indicate
that score in the “Highest Domain Score” column. Table 1 (below) outlines threshold scores that may be used to guide further
inquiry for the domains. With the exception of inattention and psychosis, a rating of mild (i.e., 2) or greater on any item within a
domain that is scored on the 5-point scale may serve as a guide for additional inquiry and follow-up to determine if a more detailed
assessment for that domain is needed. The DSM-5 Level 2 Cross-Cutting Symptom measures listed in Table 1 may be used as a
resource to provide more detailed information on the symptoms associated with some of the Level 1 domains.

Frequency of Use
To track change in the child’s symptom presentation over time, it is recommended that the measure be completed at regular
intervals as clinically indicated, depending on the stability of the child’s symptoms and treatment status. Consistently high scores on
a particular domain may indicate significant and problematic symptoms for the child that might warrant further assessment,
treatment, and follow-up. Clinical judgment should guide decision making.

Table 1: DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure—Child Age 11–17: domains, thresholds for further
inquiry, and associated Level 2 measures
Domain Domain Name Threshold to guide DSM-5 Level 2 Cross-Cutting Symptom Measure available online
further inquiry
I. Somatic Symptoms Mild or greater LEVEL 2—Somatic Symptom—Child Age 11–17 (Patient Health Questionnaire
Somatic Symptom Severity [PHQ-15])
II. Sleep Problems Mild or greater LEVEL 2—Sleep Disturbance—Child Age 11-17 (PROMIS—Sleep Disturbance—
1
Short Form)
III. Inattention Slight or greater None
IV. Depression Mild or greater LEVEL 2—Depression—Child Age 11–17 (PROMIS Emotional Distress—
Depression—Pediatric Item Bank)
V. Anger Mild or greater LEVEL 2—Anger—Child Age 11–17 (PROMIS Emotional Distress—Calibrated
Anger Measure—Pediatric)
VI. Irritability Mild or greater LEVEL 2—Irritability—Child Age 11–17 (Affective Reactivity Index [ARI])
VII. Mania Mild or greater LEVEL 2—Mania—Child Age 11–17 (Altman Self-Rating Mania Scale [ASRM])
VIII. Anxiety Mild or greater LEVEL 2—Anxiety—Child Age 11–17 (PROMIS Emotional Distress—Anxiety—
Pediatric Item Bank)
IX. Psychosis Slight or greater None
X. Repetitive Thoughts Mild or greater LEVEL 2—Repetitive Thoughts and Behaviors—Child 11–17 (adapted from the
& Behaviors Children’s Florida Obsessive-Compulsive Inventory [C-FOCI] Severity Scale)
XI. Substance Use Yes/ LEVEL 2—Substance Use—Child Age 11–17 (adapted from the NIDA-modified
Don’t Know ASSIST)
XII. Suicidal Ideation/ Yes/ None
Suicide Attempts Don’t Know
1
Not validated for children by the PROMIS group but found to have acceptable test-retest reliability with child informants in the DSM-5 Field Trial.

Copyright © 2013 American Psychiatric Association. All Rights Reserved.

This material can be reproduced without permission by researchers and by clinicians for use with their patients.

182
 LEVEL 2—Depression—Child Age 11–17*
*
PROMIS Emotional Distress—Depression—Pediatric Item Bank

Name: _______________________ Age: ____ Sex: Male Female Date:_____________

Instructions to the child: On the DSM-5 Level 1 cross-cutting questionnaire that you just completed, you indicated that
during the past 2 weeks you have been bothered by “having little interest or pleasure in doing things” and/or “feeling
down, depressed, or hopeless” at a mild or greater level of severity. The questions below ask about these feelings in
more detail and especially how often you have been bothered by a list of symptoms during the past 7 days. Please
respond to each item by marking ( or x) one box per row.

Clinician
Use
In the past SEVEN (7) DAYS…
Almost Almost Item Score
Never Never Sometimes Often Always
1. I could not stop feeling sad. 1 2 3 4 5
2. I felt alone. 1 2 3 4 5
3. I felt everything in my life went wrong. 1 2 3 4 5
4. I felt like I couldn’t do anything right. 1 2 3 4 5
5. I felt lonely. 1 2 3 4 5
6. I felt sad. 1 2 3 4 5
7. I felt unhappy. 1 2 3 4 5
8. I thought that my life was bad. 1 2 3 4 5
Being sad made it hard for me to do
9. 1 2 3 4 5
things with my friends.
10. I didn’t care about anything. 1 2 3 4 5
11. I felt stressed. 1 2 3 4 5
12. I felt too sad to eat. 1 2 3 4 5
13. I wanted to be by myself. 1 2 3 4 5
14. It was hard for me to have fun. 1 2 3 4 5
Total/Partial Raw Score:
Prorated Total Raw Score:
T-Score:
*
The PROMIS measure was developed for and can be used with children ages 8-17 but was tested in children ages 11–17 in the DSM-5 Field Trials.
©2008-2012 PROMIS Health Organization (PHO) and PROMIS Cooperative Group.
This material can be reproduced without permission by clinicians for use with their patients.
Any other use, including electronic use, requires written permission of the PHO.

183
Instructions to Clinicians
The DSM-5 Level 2—Depression—Child Age 11–17 measure is the 14-item PROMIS Depression Short Form that assesses
the pure domain of depression in children and adolescents. The PROMIS Depression scale was developed for and can be
used with children ages 8–17; however, it was tested only in children ages 11–17 in the DSM-5 Field Trials. The measure
is completed by the child prior to a visit with the clinician. Each item asks the child receiving care to rate the severity of
his or her depression during the past 7 days.

Scoring and Interpretation

Each item on the measure is rated on a 5-point scale (1=never; 2=almost never; 3=sometimes; 4=often; and 5=almost
always) with a range in score from 14 to 70 with higher scores indicating greater severity of depression. The clinician is
asked to review the score on each item on the measure during the clinical interview and indicate the raw score for each
item in the section provided for “Clinician Use.” The raw scores on the 14 items should be summed to obtain a total raw
score. Next, the T-score table should be used to identify the T-score associated with the child’s total raw score and the
information entered in the T-score row on the measure.

Score T-Score SE Score T-Score SE Note: This look-up table works only if all items on the form
are answered. If 75% or more of the questions have been
14 31.7 5.9 43 63.1 2.7
answered, you are asked to prorate the raw score and then
15 35.2 5.3 44 63.8 2.7 look up the conversion to T-Score. The formula to prorate
16 36.9 5.2 45 64.4 2.7 the partial raw score to Total Raw Score is:
17 39.1 4.8 46 65.1 2.7
18 40.6 4.7 47 65.7 2.7 (Raw sum x number of items on the short form)
19 42.4 4.3 48 66.4 2.7 Number of items that were actually answered
20 43.8 4.1 49 67 2.7
If the result is a fraction, round to the nearest whole
21 45.2 3.9 50 67.7 2.7
number. For example, if 12 of 14 items were answered and
22 46.5 3.7 51 68.4 2.7 the sum of those 12 responses was 40, the prorated raw
23 47.6 3.5 52 69 2.7 score would be 40 X 14/12 = 47, after rounding. The T-score
24 48.7 3.4 53 69.7 2.7 in this example would be 65.7.
25 49.7 3.3 54 70.4 2.7
26 50.6 3.2 55 71.1 2.7 The T-scores are interpreted as follows:
27 51.5 3.1 56 71.8 2.7
Less than 55 = None to slight
28 52.4 3 57 72.6 2.8 55.0—59.9 = Mild
29 53.2 3 58 73.3 2.8 60.0—69.9 = Moderate
30 54 2.9 59 74.1 2.8 70 and over = Severe
31 54.8 2.9 60 74.9 2.9
32 55.6 2.8 61 75.7 3 If more than 25% of the total items (in this case more than
33 56.3 2.8 62 76.6 3 3) are missing a response, the scores should not be used.
Therefore, the child receiving care should be encouraged to
34 57 2.8 63 77.5 3.1
complete all of the items on the measure.
35 57.7 2.8 64 78.4 3.2
36 58.4 2.8 65 79.4 3.3 Frequency of Use
37 59.1 2.7 66 80.6 3.5 To track change in the severity of the child’s depression
38 59.8 2.7 67 81.7 3.6 over time, the measure may be completed at regular
39 60.4 2.7 68 83.1 3.7 intervals as clinically indicated, depending on the stability of
the child’s symptoms and treatment status. Consistently
40 61.1 2.7 69 84.6 3.8
high scores on a particular domain may indicate significant
41 61.8 2.7 70 86.6 4 and problematic areas for the child that might warrant
42 62.4 2.7 further assessment, treatment, and follow-up. Your clinical
©2008-2012 PROMIS Health Organization (PHO) judgment should guide your decision.
and PROMIS Cooperative Group.

Instructions, scoring, and frequency of use on this page only: Copyright © 2013 American Psychiatric Association. All rights reserved.
This material can be reproduced without permission by researchers and by clinicians for use with their patients.

184
 LEVEL 2—Anxiety—Child Age 11–17*
*
PROMIS Emotional Distress—Anxiety—Pediatric Item Bank

Name: _______________________ Age: ____ Sex: Male Female Date:_____________

Instructions to the child: On the DSM-5 Level 1 cross-cutting questionnaire that you just completed, you indicated that
during the past 2 weeks you have been bothered by “feeling nervous, anxious, or scared”, “not being able to stop
worrying” and/or “not being able to do things you wanted to or should have done because they made you feel nervous”
at a mild or greater level of severity. The questions below ask about these feelings in more detail and especially how
often you have been bothered by a list of symptoms during the past 7 days. Please respond to each item by marking
( or x) one box per row.

Clinician
Use
In the past SEVEN (7) DAYS.… Item Score

Almost Almost
Never Never Sometimes Often Always
1. I felt like something awful might happen. 1 2 3 4 5
2. I felt nervous. 1 2 3 4 5
3. I felt scared. 1 2 3 4 5
4. I felt worried. 1 2 3 4 5
5. I worried about what could happen to me. 1 2 3 4 5
6. I worried when I went to bed at night. 1 2 3 4 5
7. I got scared really easy. 1 2 3 4 5
8. I was afraid of going to school. 1 2 3 4 5
9. I was worried I might die. 1 2 3 4 5
10. I woke up at night scared. 1 2 3 4 5
11. I worried when I was at home. 1 2 3 4 5
12. I worried when I was away from home. 1 2 3 4 5
13. It was hard for me to relax. 1 2 3 4 5
Total/Partial Raw Score:
Prorated Total Raw Score:
T-Score:
*
The PROMIS measure was developed for and can be used with children ages 8-17 but was tested in children ages 11–17 in the DSM-5 Field Trials.
©2008-2012 PROMIS Health Organization (PHO) and PROMIS Cooperative Group.
This material can be reproduced without permission by clinicians for use with their patients.
Any other use, including electronic use, requires written permission of the PHO.

185
Instructions to Clinicians
The DSM-5 Level 2—Anxiety—Child Age 11–17 measure is the 13-item PROMIS Anxiety Short Form that assesses the
pure domain of anxiety in children and adolescents. The PROMIS Anxiety scale was developed for and can be used with
children ages 8–17; however, it was tested only in children ages 11–17 in the DSM-5 Field Trials. The measure is
completed by the child prior to a visit with the clinician. Each item asks the child receiving care to rate the severity of his
or her anxiety during the past 7 days.

Scoring and Interpretation

Each item on the measure is rated on a 5-point scale (1=never; 2=almost never; 3=sometimes; 4=often; and 5=almost
always) with a range in score from 13 to 65 with higher scores indicating greater severity of anxiety. The clinician is
asked to review the score on each item on the measure during
Score T-Score SE Score T-Score SE the clinical interview and indicate the raw score for each item
13 32.3 5.7 40 64.5 3.1 in the section provided for “Clinician Use.” The raw scores on
14 36.6 4.8 41 65.3 3.1 the 13 items should be summed to obtain a total raw score.
15 38.9 4.6 42 66 3.1 Next, the T-score table should be used to identify the T-score
16 41.1 4.3 43 66.8 3.1 associated with the child’s total raw score and the information
entered in the T-score row on the measure.
17 42.8 4.1 44 67.5 3.1
18 44.3 3.9 45 68.2 3.1 Note: This look-up table works only if all items on the form are
19 45.7 3.8 46 69 3.1 answered. If 75% or more of the questions have been
20 47 3.7 47 69.7 3.1 answered, you are asked to prorate the raw score and then
21 48.2 3.6 48 70.5 3.1 look up the conversion to T-Score. The formula to prorate the
22 49.4 3.5 49 71.3 3.1 partial raw score to Total Raw Score is:
23 50.4 3.4 50 72 3.1
(Raw sum x number of items on the short form)
24 51.4 3.4 51 72.8 3.2 Number of items that were actually answered
25 52.4 3.3 52 73.6 3.2
26 53.3 3.3 53 74.4 3.2 If the result is a fraction, round to the nearest whole number.
27 54.2 3.3 54 75.3 3.2 For example, if 12 of 13 items were answered and the sum of
28 55.1 3.3 55 76.1 3.3 those 12 responses was 40, the prorated raw score would be
29 56 3.2 56 77 3.3 40 X 13/12 = 43, after rounding. The T-score in this example
would be 66.8.
30 56.8 3.2 57 77.9 3.4
31 57.6 3.2 58 78.9 3.4 The T-scores are interpreted as follows:
32 58.4 3.2 59 79.9 3.5
33 59.2 3.2 60 81 3.6 Less than 55 = None to slight
34 60 3.2 61 82.1 3.7 55.0—59.9 = Mild
35 60.8 3.2 62 83.3 3.7 60.0—69.9 = Moderate
70 and over = Severe
36 61.6 3.1 63 84.7 3.8
37 62.3 3.1 64 86.1 3.8 If more than 25% of the total items (in this case more than 3)
38 63.1 3.1 65 88 3.8 are missing a response, the scores should not be used.
39 63.8 3.1 Therefore, the child receiving care should be encouraged to
©2008-2012 PROMIS Health Organization (PHO) complete all of the items on the measure.
and PROMIS Cooperative Group.

Frequency of Use
To track change in the severity of the child’s anxiety over time, the measure may be completed at regular intervals as
clinically indicated, depending on the stability of the child’s symptoms and treatment status. Consistently high scores on
a particular domain may indicate significant and problematic areas for the child that might warrant further assessment,
treatment, and follow-up. Your clinical judgment should guide your decision.

Instructions, scoring, and frequency of use on this page only: Copyright © 2013 American Psychiatric Association. All rights reserved.
This material can be reproduced without permission by researchers and by clinicians for use with their patients.

186
 LEVEL 2—Repetitive Thoughts and Behaviors—Child Age 11–17*
*
Adapted from the Children’s Florida Obsessive-Compulsive Inventory (C-FOCI) Severity Scale

Name: _______________________ Age: ____ Sex: Male Female Date: _____________

Instructions to the child: On the DSM-5 Level 1 cross-cutting questionnaire that you just completed, you indicated that
during the past 2 weeks you have been bothered by “thoughts that kept coming into your mind that you would do
something bad or that something bad would happen to you or to someone else”, “feeling the need to check on certain
things over and over again, like whether a door was locked or whether the stove was turned off”, “worrying a lot about
things you touched being dirty or having germs or being poisoned”, and/or “feeling you had to do things in a certain
way, like counting or saying special things, to keep something bad from happening” at a mild or greater level of severity.
The questions below ask about these feelings in more detail and especially how often you have been bothered by a list
of symptoms during the past 7 days. Please respond to each item by marking ( or x) one box per row.

Clinician
Use
Item
During the past SEVEN (7) DAYS….
Score
1. On average, how much
time is occupied by these 0—None 1—Mild 2—Moderate 3—Severe 4—Extreme
thoughts or behaviors (Less than an (1 to 3 hours a day) (3 to 8 hours a day) (more than 8
each day? hour a day) hours a day)
2. How much do they
bother you? 0—None 1—Mild 2—Moderate 3—Severe (very 4—Extreme
(slightly (upsetting but still upsetting) (overwhelming
upsetting) manageable) distress)
3. How hard is it for you to
control them? 0—Complete 1—Much control 2—Moderate control 3—Little control 4—No control
control (usually able to (sometimes able to (not usually able to (unable to
control thoughts control thoughts or control thoughts or control thoughts
or behaviors) behaviors) behaviors) or behaviors)
4. How much do they
cause you to avoid doing 0—No 1—Mild 2—Moderate 3—Severe 4—Extreme
things, going places or avoidance (occasionally (regularly avoids (frequently avoids (nearly complete
being with people? avoids things) doing these things) these things) avoidance; can’t
leave the house)
5. How much do they
interfere with school, your 0—None 1—Mild 2— Moderate; 3—Severe 4—Extreme
social or family life, or your (slight (definite (substantial (near-total
job? interference) interference interference) interference)
with functioning, but
can still manage)
Total/Partial Raw Score:
Prorated Total Raw Score (if 1 item is left unanswered):
Average Total Score:
© 1994 Wayne K. Goodman, MD, and Eric Storch, PhD. This material can be reproduced without permission by clinicians for use with their own patients.
Any other use, including electronic use, requires written permission from Dr. Goodman (wkgood@gmail.com)

187
Instructions to Clinicians
The DSM-5 Level 2—Repetitive Thoughts and Behavior—Child Age 11–17 is an adapted version of the 5-item
Children’s Florida Obsessive-Compulsive Inventory (C-FOCI) Severity Scale that is used to assess the domain of
repetitive thoughts and behaviors in children and adolescents. The C-FOCI Severity Scale was developed for and
can be used with children ages 7–17; however, it was tested only in children ages 11-17 in the DSM-5 Field Trials.
The measure is completed by the child prior to a visit with the clinician. Each item asks the child to rate the
severity of his or her repetitive thoughts and behaviors during the past 7 days.

Scoring and Interpretation

Each item on the measure is rated on a 5-point scale (i.e., 0 to 4) with the response categories having different
anchors depending on the item. The total score can range from 0 to 20, with higher scores indicating greater
severity of repetitive thoughts and behaviors. The clinician is asked to review the score of each item on the
measure during the clinical interview and indicate the raw score for each item in the section provided for
“Clinician Use.” The raw scores on the 5 items should be summed to obtain a total raw score. If the child
receiving care has a score of 8 or higher, you may want to consider a more detailed assessment for an
obsessive compulsive disorder. In addition, the clinician is asked to calculate and use the average total score.
The average total score reduces the overall score to a 5-point scale, which allows the clinician to think of the
child’s repetitive thoughts and behavior in terms of none (0), mild (1), moderate (2), severe (3), or extreme (4).
The use of the average total score was found to be reliable, easy to use, and clinically useful to the clinicians in
the DSM-5 Field Trials. The average total score is calculated by dividing the raw total score by number of items
in the measure (i.e., 5).

Note: If 2 or more items are left unanswered on the measure (i.e., more than 25% of the total items are
missing), the scores should not be used. Therefore, the child should be encouraged to complete all of the items
on the measure. If only 4 of the 5 items on the measure are answered, you are asked to prorate the raw score
by first summing the scores of the items that were answered to get a partial raw score. Next, multiply the
partial raw score by the total number of items on the measure (i.e., 5). Finally, divide the value by the number
of items that were actually answered (i.e., 4) to obtain the prorated total raw score.

Prorated Score = (Partial Raw Score x number of items on the measure)

Number of items that were actually answered

If the result is a fraction, round to the nearest whole number.

Frequency of Use
To track change in the severity of the child’s repetitive thoughts and behavior over time, the measure may be
completed at regular intervals as clinically indicated, depending on the stability of the child’s symptoms and
treatment status. Consistently high scores on the measure may indicate significant and problematic areas for
the child that might warrant further assessment, treatment, and follow-up. Your clinical judgment should
guide your decision.

Instructions, scoring, and frequency of use on this page only: Copyright © 2013 American Psychiatric Association. All rights reserved.
This material can be reproduced without permission by researchers and by clinicians for use with their patients.

188
 LEVEL 2—Substance Use—Child Age 11–17*
*
Adapted from the NIDA-Modified ASSIST

Name: _______________________ Age: ____ Sex: Male Female Date: _____________

Instructions to the child: On the DSM-5 Level 1 cross-cutting questionnaire that you just completed, you indicated that
during the past 2 weeks you have been bothered by “having an alcoholic beverage”; “smoking a cigarette, a cigar, or
pipe or used snuff or chewing tobacco”; “using drugs like marijuana, cocaine or crack, club drugs (like ecstasy),
hallucinogens (like LSD), heroin, inhalants or solvents (like glue), or methamphetamine (like speed)”; and/or “using any
medicine ON YOUR OWN, that is, without a doctor’s prescription, to get high or change the way you feel.” The questions
below ask about these feelings in more detail and especially how often you have been bothered by a list of symptoms
during the past two (2) weeks. Please respond to each item by marking ( or x) one box per row.

Clinician
Use
Less More
Than a Than Nearly
Not Day or Several Half the Every
at All Two Days Days Day Item Score
During the past TWO (2) weeks, about how often did you …
a. Have an alcoholic beverage (beer, wine, liquor, etc.)? 0 1 2 3 4
b. Have 4 or more drinks in a single day? 0 1 2 3 4
c. Smoke a cigarette, a cigar, or pipe or use snuff or chewing
0 1 2 3 4
tobacco?
During the past TWO (2) weeks, about how often did you use any of
the following medicines ON YOUR OWN, that is, without a doctor’s
prescription or in greater amounts or longer than prescribed?
d. Painkillers (like Vicodin) 0 1 2 3 4
e. Stimulants (like Ritalin, Adderall) 0 1 2 3 4
f. Sedatives or tranquilizers (like sleeping pills or Valium) 0 1 2 3 4
Or drugs like:
g. Steroids 0 1 2 3 4
h. Other medicines 0 1 2 3 4
i. Marijuana 0 1 2 3 4
j. Cocaine or crack 0 1 2 3 4
k. Club drugs (like ecstasy) 0 1 2 3 4
l. Hallucinogens (like LSD) 0 1 2 3 4
m. Heroin 0 1 2 3 4
n. Inhalants or solvents (like glue) 0 1 2 3 4
o. Methamphetamine (like speed) 0 1 2 3 4
Courtesy of National Institute on Drug Abuse.
This Instrument may be reproduced without permission by clinicians for use with their own patients.

189
Instructions to Clinicians
The DSM-5 Level 2—Substance Use—Child Age 11–17 is an adapted version of the NIDA-Modified
ASSIST. The 15-item measure is used to assess the pure domain of alcohol, tobacco/nicotine,
prescription medicine, and illicit substance use in children and adolescents. It is completed by the child
prior to a visit with the clinician. Each item asks the child to rate the severity of his/her use of various
substances during the past 2 weeks.

Scoring and Interpretation

Each item on the measure is rated on a 5-point scale (i.e., 0=not at all; 1=less than a day or two;
2=several days; 3=more than half the days; 4=nearly every day). The clinician is asked to review the
score of each item on the measure during the clinical interview and indicate the raw score for each item
in the section provided for “Clinician Use.” Scores on the individual items should be interpreted
independently because each item inquires about the use of a distinct substance. The rating of multiple
items at scores greater than 0 indicates greater severity and complexity of substance use.

Frequency of Use
To track change in the severity of the child’s use of alcohol, tobacco/nicotine, prescription or illicit
substance over time, the measure be may completed at regular intervals as clinically indicated,
depending on the stability of the child’s symptoms and treatment status. Consistently high scores on the
measure may indicate significant and problematic areas for the child that might warrant further
assessment, treatment, and follow-up. Your clinical judgment should guide your decision.

Courtesy of National Institute on Drug Abuse.

This material may be reproduced without permission by clinicians for use with their own patients.

190
 The Personality Inventory for DSM-5 (PID-5)—Adult
Name/ID: ______________________________ Age: ____ Sex: Male Female Date:_____________

Instructions to the individual receiving care: This is a list of things different people might say about themselves. We are
interested in how you would describe yourself. There are no “right” or “wrong” answers. So you can describe yourself as Clinician
honestly as possible, we will keep your responses confidential. We’d like you to take your time and read each statement Use
carefully, selecting the response that best describes you.
Very False Sometimes Sometimes Very True
Item
or Often or Somewhat or Somewhat or Often
score
False False True True
1 I don’t get as much pleasure out of things as others seem to. 0 1 2 3
2 Plenty of people are out to get me. 0 1 2 3
3 People would describe me as reckless. 0 1 2 3
4 I feel like I act totally on impulse. 0 1 2 3
5 I often have ideas that are too unusual to explain to anyone. 0 1 2 3
I lose track of conversations because other things catch my
6 0 1 2 3
attention.
7 I avoid risky situations. 0 1 2 3
8 When it comes to my emotions, people tell me I’m a “cold fish”. 0 1 2 3
9 I change what I do depending on what others want. 0 1 2 3
10 I prefer not to get too close to people. 0 1 2 3
11 I often get into physical fights. 0 1 2 3
12 I dread being without someone to love me. 0 1 2 3
13 Being rude and unfriendly is just a part of who I am. 0 1 2 3
14 I do things to make sure people notice me. 0 1 2 3
15 I usually do what others think I should do. 0 1 2 3
I usually do things on impulse without thinking about what might
16 0 1 2 3
happen as a result.
17 Even though I know better, I can’t stop making rash decisions. 0 1 2 3
18 My emotions sometimes change for no good reason. 0 1 2 3
19 I really don’t care if I make other people suffer. 0 1 2 3
20 I keep to myself. 0 1 2 3
21 I often say things that others find odd or strange. 0 1 2 3
22 I always do things on the spur of the moment. 0 1 2 3
23 Nothing seems to interest me very much. 0 1 2 3
24 Other people seem to think my behavior is weird. 0 1 2 3
People have told me that I think about things in a really strange
25 0 1 2 3
way.
26 I almost never enjoy life. 0 1 2 3
27 I often feel like nothing I do really matters. 0 1 2 3
28 I snap at people when they do little things that irritate me. 0 1 2 3
29 I can’t concentrate on anything. 0 1 2 3
30 I’m an energetic person. 0 1 2 3
31 Others see me as irresponsible. 0 1 2 3
32 I can be mean when I need to be. 0 1 2 3
33 My thoughts often go off in odd or unusual directions. 0 1 2 3
I’ve been told that I spend too much time making sure things are
34 0 1 2 3
exactly in place.
35 I avoid risky sports and activities. 0 1 2 3
I can have trouble telling the difference between dreams and
36 0 1 2 3
waking life.

PID-5—Adult (Full Version), page 1

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191
 Name/ID (individual receiving care):___________________

The Personality Inventory for DSM-5 (PID-5)—Adult, continued

Instructions to individual receiving care: Please continue to complete the questionnaire. Remember, this is a list of things
different people might say about themselves. We are interested in how you would describe yourself. There are no “right” Clinician
or “wrong” answers. So you can describe yourself as honestly as possible, we will keep your responses confidential. We’d Use
like you to take your time and read each statement carefully, selecting the response that best describes you.
Very False Sometimes Sometimes Very True
Item
or Often or Somewhat or Somewhat or Often
score
False False True True
Sometimes I get this weird feeling that parts of my body feel like
37 0 1 2 3
they’re dead or not really me.
38 I am easily angered. 0 1 2 3
39 I have no limits when it comes to doing dangerous things. 0 1 2 3
40 To be honest, I’m just more important than other people. 0 1 2 3
I make up stories about things that happened that are totally
41 0 1 2 3
untrue.
42 People often talk about me doing things I don’t remember at all. 0 1 2 3
43 I do things so that people just have to admire me. 0 1 2 3
It’s weird, but sometimes ordinary objects seem to be a different
44 0 1 2 3
shape than usual.
45 I don’t have very long-lasting emotional reactions to things. 0 1 2 3
46 It is hard for me to stop an activity, even when it’s time to do so. 0 1 2 3
47 I’m not good at planning ahead. 0 1 2 3
48 I do a lot of things that others consider risky. 0 1 2 3
49 People tell me that I focus too much on minor details. 0 1 2 3
50 I worry a lot about being alone. 0 1 2 3
I’ve missed out on things because I was busy trying to get
51 0 1 2 3
something I was doing exactly right.
52 My thoughts often don’t make sense to others. 0 1 2 3
53 I often make up things about myself to help me get what I want. 0 1 2 3
54 It doesn’t really bother me to see other people get hurt. 0 1 2 3
55 People often look at me as if I’d said something really weird. 0 1 2 3
56 People don’t realize that I’m flattering them to get something. 0 1 2 3
57 I’d rather be in a bad relationship than be alone. 0 1 2 3
58 I usually think before I act. 0 1 2 3
I often see vivid dream-like images when I’m falling asleep or
59 0 1 2 3
waking up.
I keep approaching things the same way, even when it isn’t
60 0 1 2 3
working.
61 I’m very dissatisfied with myself. 0 1 2 3
I have much stronger emotional reactions than almost everyone
62 0 1 2 3
else.
63 I do what other people tell me to do. 0 1 2 3
64 I can’t stand being left alone, even for a few hours. 0 1 2 3
65 I have outstanding qualities that few others possess. 0 1 2 3
66 The future looks really hopeless to me. 0 1 2 3
67 I like to take risks. 0 1 2 3
68 I can’t achieve goals because other things capture my attention. 0 1 2 3
When I want to do something, I don’t let the possibility that it
69 0 1 2 3
might be risky stop me.
70 Others seem to think I’m quite odd or unusual. 0 1 2 3
71 My thoughts are strange and unpredictable. 0 1 2 3
72 I don’t care about other people’s feelings. 0 1 2 3

PID-5—Adult (Full Version), page 2

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192
 Name/ID (individual receiving care):___________________

The Personality Inventory for DSM-5 (PID-5)—Adult, continued

Instructions to individual receiving care: Please continue to complete the questionnaire. Remember, this is a list of things
different people might say about themselves. We are interested in how you would describe yourself. There are no “right” Clinician
or “wrong” answers. So you can describe yourself as honestly as possible, we will keep your responses confidential. We’d Use
like you to take your time and read each statement carefully, selecting the response that best describes you.
Very False Sometimes Sometimes Very True
Item
or Often or Somewhat or Somewhat or Often
score
False False True True
73 You need to step on some toes to get what you want in life. 0 1 2 3
74 I love getting the attention of other people. 0 1 2 3
75 I go out of my way to avoid any kind of group activity. 0 1 2 3
76 I can be sneaky if it means getting what I want. 0 1 2 3
Sometimes when I look at a familiar object, it’s somehow like I’m
77 0 1 2 3
seeing it for the first time.
78 It is hard for me to shift from one activity to another. 0 1 2 3
79 I worry a lot about terrible things that might happen. 0 1 2 3
I have trouble changing how I’m doing something even if what I’m
80 0 1 2 3
doing isn’t going well.
81 The world would be better off if I were dead. 0 1 2 3
82 I keep my distance from people. 0 1 2 3
83 I often can’t control what I think about. 0 1 2 3
84 I don’t get emotional. 0 1 2 3
85 I resent being told what to do, even by people in charge. 0 1 2 3
86 I’m so ashamed by how I’ve let people down in lots of little ways. 0 1 2 3
87 I avoid anything that might be even a little bit dangerous. 0 1 2 3
I have trouble pursuing specific goals even for short periods of
88 0 1 2 3
time.
89 I prefer to keep romance out of my life. 0 1 2 3
90 I would never harm another person. 0 1 2 3
91 I don’t show emotions strongly. 0 1 2 3
92 I have a very short temper. 0 1 2 3
I often worry that something bad will happen due to mistakes I
93 0 1 2 3
made in the past.
I have some unusual abilities, like sometimes knowing exactly what
94 0 1 2 3
someone is thinking.
95 I get very nervous when I think about the future. 0 1 2 3
96 I rarely worry about things. 0 1 2 3
97 I enjoy being in love. 0 1 2 3
98 I prefer to play it safe rather than take unnecessary chances. 0 1 2 3
99 I sometimes have heard things that others couldn’t hear. 0 1 2 3
100 I get fixated on certain things and can’t stop. 0 1 2 3
101 People tell me it’s difficult to know what I’m feeling. 0 1 2 3
102 I am a highly emotional person. 0 1 2 3
103 Others would take advantage of me if they could. 0 1 2 3
104 I often feel like a failure. 0 1 2 3
If something I do isn’t absolutely perfect, it’s simply not
105 0 1 2 3
acceptable.
I often have unusual experiences, such as sensing the presence of
106 0 1 2 3
someone who isn’t actually there.
107 I’m good at making people do what I want them to do. 0 1 2 3
108 I break off relationships if they start to get close. 0 1 2 3
109 I’m always worrying about something. 0 1 2 3
110 I worry about almost everything. 0 1 2 3

PID-5—Adult (Full Version), page 3

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193
 Name/ID (individual receiving care):___________________

The Personality Inventory for DSM-5 (PID-5)—Adult, continued

Instructions to individual receiving care: Please continue to complete the questionnaire. Remember, this is a list of things
different people might say about themselves. We are interested in how you would describe yourself. There are no “right” Clinician
or “wrong” answers. So you can describe yourself as honestly as possible, we will keep your responses confidential. We’d Use
like you to take your time and read each statement carefully, selecting the response that best describes you.
Very False Sometimes Sometimes Very True
Item
or Often or Somewhat or Somewhat or Often
score
False False True True
111 I like standing out in a crowd. 0 1 2 3
112 I don’t mind a little risk now and then. 0 1 2 3
113 My behavior is often bold and grabs peoples’ attention. 0 1 2 3
114 I’m better than almost everyone else. 0 1 2 3
115 People complain about my need to have everything all arranged. 0 1 2 3
116 I always make sure I get back at people who wrong me. 0 1 2 3
117 I’m always on my guard for someone trying to trick or harm me. 0 1 2 3
I have trouble keeping my mind focused on what needs to be
118 0 1 2 3
done.
119 I talk about suicide a lot. 0 1 2 3
120 I’m just not very interested in having sexual relationships. 0 1 2 3
121 I get stuck on things a lot. 0 1 2 3
122 I get emotional easily, often for very little reason. 0 1 2 3
Even though it drives other people crazy, I insist on absolute
123 0 1 2 3
perfection in everything I do.
124 I almost never feel happy about my day-to-day activities. 0 1 2 3
125 Sweet-talking others helps me get what I want. 0 1 2 3
126 Sometimes you need to exaggerate to get ahead. 0 1 2 3
127 I fear being alone in life more than anything else. 0 1 2 3
I get stuck on one way of doing things, even when it’s clear it won’t
128 0 1 2 3
work.
129 I’m often pretty careless with my own and others’ things. 0 1 2 3
130 I am a very anxious person. 0 1 2 3
131 People are basically trustworthy. 0 1 2 3
132 I am easily distracted. 0 1 2 3
133 It seems like I’m always getting a “raw deal” from others. 0 1 2 3
134 I don’t hesitate to cheat if it gets me ahead. 0 1 2 3
135 I check things several times to make sure they are perfect. 0 1 2 3
136 I don’t like spending time with others. 0 1 2 3
I feel compelled to go on with things even when it makes little
137 0 1 2 3
sense to do so.
I never know where my emotions will go from moment to
138 0 1 2 3
moment.
139 I have seen things that weren’t really there. 0 1 2 3
140 It is important to me that things are done in a certain way. 0 1 2 3
141 I always expect the worst to happen. 0 1 2 3
142 I try to tell the truth even when it’s hard. 0 1 2 3
143 I believe that some people can move things with their minds. 0 1 2 3
144 I can’t focus on things for very long. 0 1 2 3
145 I steer clear of romantic relationships. 0 1 2 3
146 I’m not interested in making friends. 0 1 2 3
147 I say as little as possible when dealing with people. 0 1 2 3
148 I’m useless as a person. 0 1 2 3

PID-5—Adult (Full Version), page 4

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194
 Name/ID (individual receiving care):___________________

The Personality Inventory for DSM-5 (PID-5)—Adult, continued

Instructions to individual receiving care: Please continue to complete the questionnaire. Remember, this is a list of things
different people might say about themselves. We are interested in how you would describe yourself. There are no “right” Clinician
or “wrong” answers. So you can describe yourself as honestly as possible, we will keep your responses confidential. We’d Use
like you to take your time and read each statement carefully, selecting the response that best describes you.
Very False Sometimes Sometimes Very True
Item
or Often or Somewhat or Somewhat or Often
score
False False True True
149 I’ll do just about anything to keep someone from abandoning me. 0 1 2 3
Sometimes I can influence other people just by sending my
150 0 1 2 3
thoughts to them.
151 Life looks pretty bleak to me. 0 1 2 3
I think about things in odd ways that don’t make sense to most
152 0 1 2 3
people.
153 I don’t care if my actions hurt others. 0 1 2 3
Sometimes I feel “controlled” by thoughts that belong to someone
154 0 1 2 3
else.
155 I really live life to the fullest. 0 1 2 3
156 I make promises that I don’t really intend to keep. 0 1 2 3
157 Nothing seems to make me feel good. 0 1 2 3
158 I get irritated easily by all sorts of things. 0 1 2 3
159 I do what I want regardless of how unsafe it might be. 0 1 2 3
160 I often forget to pay my bills. 0 1 2 3
161 I don’t like to get too close to people. 0 1 2 3
162 I’m good at conning people. 0 1 2 3
163 Everything seems pointless to me. 0 1 2 3
164 I never take risks. 0 1 2 3
165 I get emotional over every little thing. 0 1 2 3
166 It’s no big deal if I hurt other peoples’ feelings. 0 1 2 3
167 I never show emotions to others. 0 1 2 3
168 I often feel just miserable. 0 1 2 3
169 I have no worth as a person. 0 1 2 3
170 I am usually pretty hostile. 0 1 2 3
171 I’ve skipped town to avoid responsibilities. 0 1 2 3
I’ve been told more than once that I have a number of odd quirks
172 0 1 2 3
or habits.
173 I like being a person who gets noticed. 0 1 2 3
174 I’m always fearful or on edge about bad things that might happen. 0 1 2 3
175 I never want to be alone. 0 1 2 3
I keep trying to make things perfect, even when I’ve gotten them
176 0 1 2 3
as good as they’re likely to get.
177 I rarely feel that people I know are trying to take advantage of me. 0 1 2 3
178 I know I’ll commit suicide sooner or later. 0 1 2 3
179 I’ve achieved far more than almost anyone I know. 0 1 2 3
180 I can certainly turn on the charm if I need to get my way. 0 1 2 3
181 My emotions are unpredictable. 0 1 2 3
182 I don’t deal with people unless I have to. 0 1 2 3
183 I don’t care about other peoples’ problems. 0 1 2 3
184 I don’t react much to things that seem to make others emotional. 0 1 2 3
185 I have several habits that others find eccentric or strange. 0 1 2 3
186 I avoid social events. 0 1 2 3

PID-5—Adult (Full Version), page 5

Krueger RF, Derringer J, Markon KE, Watson D, Skodol AE. Copyright ©2013 American Psychiatric Association. All Rights Reserved.
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195
 Name/ID (individual receiving care):___________________

The Personality Inventory for DSM-5 (PID-5)—Adult, continued

Instructions to individual receiving care: Please continue to complete the questionnaire. Remember, this is a list of things
different people might say about themselves. We are interested in how you would describe yourself. There are no “right” Clinician
or “wrong” answers. So you can describe yourself as honestly as possible, we will keep your responses confidential. We’d Use
like you to take your time and read each statement carefully, selecting the response that best describes you.
Very False Sometimes Sometimes Very True
Item
or Often or Somewhat or Somewhat or Often
score
False False True True
187 I deserve special treatment. 0 1 2 3
It makes me really angry when people insult me in even a minor
188 0 1 2 3
way.
189 I rarely get enthusiastic about anything. 0 1 2 3
190 I suspect that even my so-called “friends” betray me a lot. 0 1 2 3
191 I crave attention. 0 1 2 3
Sometimes I think someone else is removing thoughts from my
192 0 1 2 3
head.
I have periods in which I feel disconnected from the world or
193 0 1 2 3
from myself.
I often see unusual connections between things that most people
194 0 1 2 3
miss.
I don’t think about getting hurt when I’m doing things that might
195 0 1 2 3
be dangerous.
196 I simply won’t put up with things being out of their proper places. 0 1 2 3
197 I often have to deal with people who are less important than me. 0 1 2 3
198 I sometimes hit people to remind them who’s in charge 0 1 2 3
199 I get pulled off-task by even minor distractions. 0 1 2 3
200 I enjoy making people in control look stupid. 0 1 2 3
201 I just skip appointments or meetings if I’m not in the mood. 0 1 2 3
202 I try to do what others want me to do. 0 1 2 3
203 I prefer being alone to having a close romantic partner. 0 1 2 3
204 I am very impulsive. 0 1 2 3
I often have thoughts that make sense to me but that other
205 0 1 2 3
people say are strange.
206 I use people to get what I want. 0 1 2 3
I don’t see the point in feeling guilty about things I’ve done that
207 0 1 2 3
have hurt other people.
208 Most of the time I don’t see the point in being friendly. 0 1 2 3
I’ve had some really weird experiences that are very difficult to
209 0 1 2 3
explain.
210 I follow through on commitments. 0 1 2 3
211 I like to draw attention to myself. 0 1 2 3
212 I feel guilty much of the time. 0 1 2 3
I often “zone out” and then suddenly come to and realize that a lot
213 0 1 2 3
of time has passed.
214 Lying comes easily to me. 0 1 2 3
215 I hate to take chances. 0 1 2 3
216 I’m nasty and short to anybody who deserves it. 0 1 2 3
217 Things around me often feel unreal, or more real than usual. 0 1 2 3
218 I’ll stretch the truth if it’s to my advantage. 0 1 2 3
219 It is easy for me to take advantage of others. 0 1 2 3
220 I have a strict way of doing things. 0 1 2 3

PID-5—Adult (Full Version), page 6

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196
Personality Trait Facet and Domain Scoring: The Personality Inventory for DSM-5 (PID-5)—Adult
Step 1: Reverse the scores on the following items (i.e., 3 becomes 0, 2 becomes 1, 1 becomes 2, and 0 becomes 3): 7, 30,
35, 58, 87, 90, 96, 97, 98, 131, 142, 155, 164, 177, 210, and 215.

Step 2: Compute the Personality Trait Facet Scores using the Facet Table below. As a reminder, the reverse scored items
from Step 1 are marked with the letter R in the Table (e.g., 7R).

Step 3: Compute the Personality Trait Domain Scores using the Domain Table below.

A. Personality Trait B. PID-5 items C. Total/Partial D. Prorated E. Average

Facet Raw Facet Raw Facet Facet Score
Score Score
Anhedonia 1, 23, 26, 30R, 124, 155R, 157, 189
Anxiousness 79, 93, 95, 96R, 109, 110, 130, 141, 174
Attention Seeking 14, 43, 74, 111, 113, 173, 191,211
11, 13, 19, 54, 72, 73, 90R, 153, 166, 183, 198, 200,
Callousness
207, 208
Deceitfulness 41, 53, 56, 76, 126, 134, 142R, 206, 214, 218
27, 61, 66, 81, 86, 104, 119, 148, 151, 163, 168,
Depressivity
FOR CLINICIAN USE ONLY

169, 178, 212

Distractibility 6, 29, 47, 68, 88, 118, 132, 144, 199
Eccentricity 5, 21, 24, 25, 33, 52, 55, 70, 71, 152, 172,185, 205
Emotional Lability 18, 62, 102, 122, 138, 165, 181
Grandiosity 40, 65, 114, 179, 187, 197
Hostility 28, 32, 38, 85, 92, 116, 158, 170, 188, 216
Impulsivity 4, 16, 17, 22, 58R, 204
Intimacy Avoidance 89, 97R, 108, 120, 145, 203
Irresponsibility 31, 129, 156, 160, 171, 201, 210R
Manipulativeness 107, 125, 162, 180, 219
Perceptual Dysregulation 36, 37, 42, 44, 59, 77, 83, 154, 192, 193, 213, 217
Perseveration 46, 51, 60, 78, 80, 100, 121, 128, 137
Restricted Affectivity 8, 45, 84, 91, 101, 167, 184
Rigid Perfectionism 34, 49, 105, 115, 123, 135, 140, 176, 196, 220
3, 7R, 35R, 39, 48, 67, 69, 87R, 98R, 112, 159, 164R,
Risk Taking
195, 215R
Separation Insecurity 12, 50, 57,64, 127, 149, 175
Submissiveness 9, 15, 63, 202
Suspiciousness 2, 103, 117, 131R, 133, 177R, 190
Unusual Beliefs & Experiences 94, 99, 106, 139, 143, 150, 194, 209
Withdrawal 10, 20, 75, 82, 136, 146, 147, 161, 182, 186

A. Personality Trait B. PID-5 Facet Scales Contributing C. Total of Average D. Overall Average of
Domain Primarily to Domain Facet Scores (from Facet Scores (The total in
column E of Facet column C of this table
FOR CLINICIAN USE ONLY

Table) divided by 3 [i.e., the

number of scales listed in
column B])
Negative Affect Emotional Lability, Anxiousness, Separation Insecurity
Detachment Withdrawal, Anhedonia, Intimacy Avoidance
Antagonism Manipulativeness, Deceitfulness, Grandiosity
Disinhibition Irresponsibility, Impulsivity, Distractibility
Unusual Beliefs & Experiences, Eccentricity, Perceptual
Psychoticism
Dysregulation

Copyright ©2013 American Psychiatric Association. All Rights Reserved.

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197
Instructions to Clinicians
This Personality Inventory for DSM-5 (PID-5)—Adult is a 220 item self-rated personality trait assessment scale for adults
age 18 and older. It assesses 25 personality trait facets including Anhedonia, Anxiousness, Attention Seeking, Callousness,
Deceitfulness, Depressivity, Distractibility, Eccentricity, Emotional Lability, Grandiosity, Hostility, Impulsivity, Intimacy
Avoidance, Irresponsibility, Manipulativeness, Perceptual Dysregulation, Perseveration, Restricted Affectivity, Rigid
Perfectionism, Risk Taking, Separation Insecurity, Submissiveness, Suspiciousness, Unusual Beliefs and Experiences, and
Withdrawal, with each trait facet consisting of 4 to 14 items. Specific triplets of facets (groups of three) can be combined
to yield indices of the five broader trait domains of Negative Affect, Detachment, Antagonism, Disinhibition, and
Psychoticism. The measure is completed by the individual prior to a visit with the clinician. Each item asks the individual
to rate how well the item describes him or her generally.

Scoring and Interpretation

Each item on the measure is rated on a 4-point scale. The response categories for the items are 0=very false or often
false; 1=sometimes or somewhat false; 2=sometimes or somewhat true; 3=very true or often true. For items 7, 30, 35, 58,
87, 90, 96, 97, 98, 131, 142, 155, 164, 177, 210, and 215, the items are reverse-coded prior to entering into scale score
computations (see instructions above).

The scores on the items within each trait facet should be summed and entered in the appropriate raw facet score box. In
addition, the clinician is asked to calculate and use average scores for each facet and domain. The average scores reduce
the overall score as well as the scores for each domain to a 4-point scale, which allows the clinician to think of the
individual’s personality dysfunction relative to observed norms.1 The average facet score is calculated by dividing the raw
facet score by the number of items in the facet (e.g., if all the items within the “Anhedonia” facet are rated as being
“sometimes or somewhat true,” then the average facet score would be 16/8 = 2, indicating moderate anhedonia). The
average domain scores are calculated by summing and then averaging the 3 facet scores contributing primarily to a
specific domain. For example, if the average facet scores on Emotional Lability, Anxiousness, and Separation Insecurity
(scales primarily indexing negative affect) are all 2, then the sum of these scores would be 6, and the average domain
score would be 6/3 = 2. Higher average scores indicate greater dysfunction in a specific personality trait facet or domain.

Note: If more than 25% of the items within a trait facet are left unanswered, the corresponding facet score should not be
used. Therefore, the individual receiving care should be encouraged to complete all of the items on the measure.
Nevertheless, if 25% or less of the items are unanswered for a specific facet, you are asked to prorate the facet score by
first summing the number of items that were answered to get a partial raw score. Next, multiply the partial raw score by
the total number of items contributing to that facet (i.e., 4-14). Finally, divide the resulting value by the number of items
that were actually answered to obtain the prorated total or domain raw score.

Prorated Score = (Partial Raw Score x number of items on the PID-5)

Number of items that were actually answered

If the result is a fraction, round to the nearest whole number.

Domain scores should not be computed if any one of the three contributing facet scores cannot be computed because of
missing item responses.

Frequency of Use
To track change in the severity of the individual’s personality dysfunction over time, it is recommended that the
measure be completed at regular intervals as clinically indicated, depending on the stability of the individual’s
symptoms and treatment status. Consistently high scores on a facet or domain may indicate significant and
problematic areas for the individual receiving care that might warrant further assessment, treatment, and follow-up.
Your clinical judgment should guide your decision.
1
Krueger, R. F., Derringer, J., Markon, K. E., Watson, D., & Skodol, A. E. (2012). Initial construction of a maladaptive personality trait model and
inventory for DSM-5. Psychological Medicine, 42, 1879-1890.

Copyright ©2013 American Psychiatric Association. All Rights Reserved.

This material can be reproduced without permission by researchers and by clinicians for use with their patients.

198
 The Personality Inventory for DSM-5 (PID-5)—Child Age 11–17
Name/ID: ______________________________ Age: ____ Sex: Male Female Date:_____________

Instructions to the child receiving care: This is a list of things different people might say about themselves. We are
interested in how you would describe yourself. There are no “right” or “wrong” answers. So you can describe yourself as Clinician
honestly as possible, we will keep your responses confidential. We’d like you to take your time and read each statement Use
carefully, selecting the response that best describes you.
Very False Sometimes Sometimes Very True
Item
or Often or Somewhat or Somewhat or Often
score
False False True True
1 I don’t get as much pleasure out of things as others seem to. 0 1 2 3
2 Plenty of people are out to get me. 0 1 2 3
3 People would describe me as reckless. 0 1 2 3
4 I feel like I act totally on impulse. 0 1 2 3
5 I often have ideas that are too unusual to explain to anyone. 0 1 2 3
I lose track of conversations because other things catch my
6 0 1 2 3
attention.
7 I avoid risky situations. 0 1 2 3
8 When it comes to my emotions, people tell me I’m a “cold fish”. 0 1 2 3
9 I change what I do depending on what others want. 0 1 2 3
10 I prefer not to get too close to people. 0 1 2 3
11 I often get into physical fights. 0 1 2 3
12 I dread being without someone to love me. 0 1 2 3
13 Being rude and unfriendly is just a part of who I am. 0 1 2 3
14 I do things to make sure people notice me. 0 1 2 3
15 I usually do what others think I should do. 0 1 2 3
I usually do things on impulse without thinking about what might
16 0 1 2 3
happen as a result.
17 Even though I know better, I can’t stop making rash decisions. 0 1 2 3
18 My emotions sometimes change for no good reason. 0 1 2 3
19 I really don’t care if I make other people suffer. 0 1 2 3
20 I keep to myself. 0 1 2 3
21 I often say things that others find odd or strange. 0 1 2 3
22 I always do things on the spur of the moment. 0 1 2 3
23 Nothing seems to interest me very much. 0 1 2 3
24 Other people seem to think my behavior is weird. 0 1 2 3
People have told me that I think about things in a really strange
25 0 1 2 3
way.
26 I almost never enjoy life. 0 1 2 3
27 I often feel like nothing I do really matters. 0 1 2 3
28 I snap at people when they do little things that irritate me. 0 1 2 3
29 I can’t concentrate on anything. 0 1 2 3
30 I’m an energetic person. 0 1 2 3
31 Others see me as irresponsible. 0 1 2 3
32 I can be mean when I need to be. 0 1 2 3
33 My thoughts often go off in odd or unusual directions. 0 1 2 3
I’ve been told that I spend too much time making sure things are
34 0 1 2 3
exactly in place.
35 I avoid risky sports and activities. 0 1 2 3
I can have trouble telling the difference between dreams and
36 0 1 2 3
waking life.

PID-5—Child (Full Version), Page 1

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199
 Name/ID (child receiving care): _________________

The Personality Inventory for DSM-5 (PID-5)—Child Age 11–17, continued

Instructions to child receiving care: Please continue to complete the questionnaire. Remember, this is a list of things
different people might say about themselves. We are interested in how you would describe yourself. There are no “right” Clinician
or “wrong” answers. So you can describe yourself as honestly as possible, we will keep your responses confidential. We’d Use
like you to take your time and read each statement carefully, selecting the response that best describes you.
Very False Sometimes Sometimes Very True
Item
or Often or Somewhat or Somewhat or Often
score
False False True True
Sometimes I get this weird feeling that parts of my body feel like
37 0 1 2 3
they’re dead or not really me.
38 I am easily angered. 0 1 2 3
39 I have no limits when it comes to doing dangerous things. 0 1 2 3
40 To be honest, I’m just more important than other people. 0 1 2 3
I make up stories about things that happened that are totally
41 0 1 2 3
untrue.
42 People often talk about me doing things I don’t remember at all. 0 1 2 3
43 I do things so that people just have to admire me. 0 1 2 3
It’s weird, but sometimes ordinary objects seem to be a different
44 0 1 2 3
shape than usual.
45 I don’t have very long-lasting emotional reactions to things. 0 1 2 3
46 It is hard for me to stop an activity, even when it’s time to do so. 0 1 2 3
47 I’m not good at planning ahead. 0 1 2 3
48 I do a lot of things that others consider risky. 0 1 2 3
49 People tell me that I focus too much on minor details. 0 1 2 3
50 I worry a lot about being alone. 0 1 2 3
I’ve missed out on things because I was busy trying to get
51 0 1 2 3
something I was doing exactly right.
52 My thoughts often don’t make sense to others. 0 1 2 3
53 I often make up things about myself to help me get what I want. 0 1 2 3
54 It doesn’t really bother me to see other people get hurt. 0 1 2 3
55 People often look at me as if I’d said something really weird. 0 1 2 3
56 People don’t realize that I’m flattering them to get something. 0 1 2 3
57 I’d rather be in a bad relationship than be alone. 0 1 2 3
58 I usually think before I act. 0 1 2 3
I often see vivid dream-like images when I’m falling asleep or
59 0 1 2 3
waking up.
I keep approaching things the same way, even when it isn’t
60 0 1 2 3
working.
61 I’m very dissatisfied with myself. 0 1 2 3
I have much stronger emotional reactions than almost everyone
62 0 1 2 3
else.
63 I do what other people tell me to do. 0 1 2 3
64 I can’t stand being left alone, even for a few hours. 0 1 2 3
65 I have outstanding qualities that few others possess. 0 1 2 3
66 The future looks really hopeless to me. 0 1 2 3
67 I like to take risks. 0 1 2 3
68 I can’t achieve goals because other things capture my attention. 0 1 2 3
When I want to do something, I don’t let the possibility that it
69 0 1 2 3
might be risky stop me.
70 Others seem to think I’m quite odd or unusual. 0 1 2 3
71 My thoughts are strange and unpredictable. 0 1 2 3
72 I don’t care about other people’s feelings. 0 1 2 3

PID-5—Child (Full Version), Page 2

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200
 Name/ID (child receiving care): _________________

The Personality Inventory for DSM-5 (PID-5)—Child Age 11–17, continued

Instructions to child receiving care: Please continue to complete the questionnaire. Remember, this is a list of things
different people might say about themselves. We are interested in how you would describe yourself. There are no “right” Clinician
or “wrong” answers. So you can describe yourself as honestly as possible, we will keep your responses confidential. We’d Use
like you to take your time and read each statement carefully, selecting the response that best describes you.
Very False Sometimes Sometimes Very True
Item
or Often or Somewhat or Somewhat or Often
score
False False True True
73 You need to step on some toes to get what you want in life. 0 1 2 3
74 I love getting the attention of other people. 0 1 2 3
75 I go out of my way to avoid any kind of group activity. 0 1 2 3
76 I can be sneaky if it means getting what I want. 0 1 2 3
Sometimes when I look at a familiar object, it’s somehow like I’m
77 0 1 2 3
seeing it for the first time.
78 It is hard for me to shift from one activity to another. 0 1 2 3
79 I worry a lot about terrible things that might happen. 0 1 2 3
I have trouble changing how I’m doing something even if what I’m
80 0 1 2 3
doing isn’t going well.
81 The world would be better off if I were dead. 0 1 2 3
82 I keep my distance from people. 0 1 2 3
83 I often can’t control what I think about. 0 1 2 3
84 I don’t get emotional. 0 1 2 3
85 I resent being told what to do, even by people in charge. 0 1 2 3
86 I’m so ashamed by how I’ve let people down in lots of little ways. 0 1 2 3
87 I avoid anything that might be even a little bit dangerous. 0 1 2 3
I have trouble pursuing specific goals even for short periods of
88 0 1 2 3
time.
89 I prefer to keep romance out of my life. 0 1 2 3
90 I would never harm another person. 0 1 2 3
91 I don’t show emotions strongly. 0 1 2 3
92 I have a very short temper. 0 1 2 3
I often worry that something bad will happen due to mistakes I
93 0 1 2 3
made in the past.
I have some unusual abilities, like sometimes knowing exactly what
94 0 1 2 3
someone is thinking.
95 I get very nervous when I think about the future. 0 1 2 3
96 I rarely worry about things. 0 1 2 3
97 I enjoy being in love. 0 1 2 3
98 I prefer to play it safe rather than take unnecessary chances. 0 1 2 3
99 I sometimes have heard things that others couldn’t hear. 0 1 2 3
100 I get fixated on certain things and can’t stop. 0 1 2 3
101 People tell me it’s difficult to know what I’m feeling. 0 1 2 3
102 I am a highly emotional person. 0 1 2 3
103 Others would take advantage of me if they could. 0 1 2 3
104 I often feel like a failure. 0 1 2 3
If something I do isn’t absolutely perfect, it’s simply not
105 0 1 2 3
acceptable.
I often have unusual experiences, such as sensing the presence of
106 0 1 2 3
someone who isn’t actually there.
107 I’m good at making people do what I want them to do. 0 1 2 3
108 I break off relationships if they start to get close. 0 1 2 3
109 I’m always worrying about something. 0 1 2 3
110 I worry about almost everything. 0 1 2 3

PID-5—Child (Full Version), Page 3

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201
 Name/ID (child receiving care): _________________

The Personality Inventory for DSM-5 (PID-5)—Child Age 11–17, continued

Instructions to child receiving care: Please continue to complete the questionnaire. Remember, this is a list of things
different people might say about themselves. We are interested in how you would describe yourself. There are no “right” Clinician
or “wrong” answers. So you can describe yourself as honestly as possible, we will keep your responses confidential. We’d Use
like you to take your time and read each statement carefully, selecting the response that best describes you.
Very False Sometimes Sometimes Very True
Item
or Often or Somewhat or Somewhat or Often
score
False False True True
111 I like standing out in a crowd. 0 1 2 3
112 I don’t mind a little risk now and then. 0 1 2 3
113 My behavior is often bold and grabs peoples’ attention. 0 1 2 3
114 I’m better than almost everyone else. 0 1 2 3
115 People complain about my need to have everything all arranged. 0 1 2 3
116 I always make sure I get back at people who wrong me. 0 1 2 3
117 I’m always on my guard for someone trying to trick or harm me. 0 1 2 3
I have trouble keeping my mind focused on what needs to be
118 0 1 2 3
done.
119 I talk about suicide a lot. 0 1 2 3
120 I’m just not very interested in having sexual relationships. 0 1 2 3
121 I get stuck on things a lot. 0 1 2 3
122 I get emotional easily, often for very little reason. 0 1 2 3
Even though it drives other people crazy, I insist on absolute
123 0 1 2 3
perfection in everything I do.
124 I almost never feel happy about my day-to-day activities. 0 1 2 3
125 Sweet-talking others helps me get what I want. 0 1 2 3
126 Sometimes you need to exaggerate to get ahead. 0 1 2 3
127 I fear being alone in life more than anything else. 0 1 2 3
I get stuck on one way of doing things, even when it’s clear it won’t
128 0 1 2 3
work.
129 I’m often pretty careless with my own and others’ things. 0 1 2 3
130 I am a very anxious person. 0 1 2 3
131 People are basically trustworthy. 0 1 2 3
132 I am easily distracted. 0 1 2 3
133 It seems like I’m always getting a “raw deal” from others. 0 1 2 3
134 I don’t hesitate to cheat if it gets me ahead. 0 1 2 3
135 I check things several times to make sure they are perfect. 0 1 2 3
136 I don’t like spending time with others. 0 1 2 3
I feel compelled to go on with things even when it makes little
137 0 1 2 3
sense to do so.
I never know where my emotions will go from moment to
138 0 1 2 3
moment.
139 I have seen things that weren’t really there. 0 1 2 3
140 It is important to me that things are done in a certain way. 0 1 2 3
141 I always expect the worst to happen. 0 1 2 3
142 I try to tell the truth even when it’s hard. 0 1 2 3
143 I believe that some people can move things with their minds. 0 1 2 3
144 I can’t focus on things for very long. 0 1 2 3
145 I steer clear of romantic relationships. 0 1 2 3
146 I’m not interested in making friends. 0 1 2 3
147 I say as little as possible when dealing with people. 0 1 2 3
148 I’m useless as a person. 0 1 2 3

PID-5—Child (Full Version), Page 4

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202
 Name/ID (child receiving care): _________________

The Personality Inventory for DSM-5 (PID-5)—Child Age 11–17, continued

Instructions to child receiving care: Please continue to complete the questionnaire. Remember, this is a list of things
different people might say about themselves. We are interested in how you would describe yourself. There are no “right” Clinician
or “wrong” answers. So you can describe yourself as honestly as possible, we will keep your responses confidential. We’d Use
like you to take your time and read each statement carefully, selecting the response that best describes you.
Very False Sometimes Sometimes Very True
Item
or Often or Somewhat or Somewhat or Often
score
False False True True
149 I’ll do just about anything to keep someone from abandoning me. 0 1 2 3
Sometimes I can influence other people just by sending my
150 0 1 2 3
thoughts to them.
151 Life looks pretty bleak to me. 0 1 2 3
I think about things in odd ways that don’t make sense to most
152 0 1 2 3
people.
153 I don’t care if my actions hurt others. 0 1 2 3
Sometimes I feel “controlled” by thoughts that belong to someone
154 0 1 2 3
else.
155 I really live life to the fullest. 0 1 2 3
156 I make promises that I don’t really intend to keep. 0 1 2 3
157 Nothing seems to make me feel good. 0 1 2 3
158 I get irritated easily by all sorts of things. 0 1 2 3
159 I do what I want regardless of how unsafe it might be. 0 1 2 3
160 I often forget to pay my bills. 0 1 2 3
161 I don’t like to get too close to people. 0 1 2 3
162 I’m good at conning people. 0 1 2 3
163 Everything seems pointless to me. 0 1 2 3
164 I never take risks. 0 1 2 3
165 I get emotional over every little thing. 0 1 2 3
166 It’s no big deal if I hurt other peoples’ feelings. 0 1 2 3
167 I never show emotions to others. 0 1 2 3
168 I often feel just miserable. 0 1 2 3
169 I have no worth as a person. 0 1 2 3
170 I am usually pretty hostile. 0 1 2 3
171 I’ve skipped town to avoid responsibilities. 0 1 2 3
I’ve been told more than once that I have a number of odd quirks
172 0 1 2 3
or habits.
173 I like being a person who gets noticed. 0 1 2 3
174 I’m always fearful or on edge about bad things that might happen. 0 1 2 3
175 I never want to be alone. 0 1 2 3
I keep trying to make things perfect, even when I’ve gotten them
176 0 1 2 3
as good as they’re likely to get.
177 I rarely feel that people I know are trying to take advantage of me. 0 1 2 3
178 I know I’ll commit suicide sooner or later. 0 1 2 3
179 I’ve achieved far more than almost anyone I know. 0 1 2 3
180 I can certainly turn on the charm if I need to get my way. 0 1 2 3
181 My emotions are unpredictable. 0 1 2 3
182 I don’t deal with people unless I have to. 0 1 2 3
183 I don’t care about other peoples’ problems. 0 1 2 3
184 I don’t react much to things that seem to make others emotional. 0 1 2 3
185 I have several habits that others find eccentric or strange. 0 1 2 3
186 I avoid social events. 0 1 2 3

PID-5—Child (Full Version), Page 5

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203
 Name/ID (child receiving care): _________________

The Personality Inventory for DSM-5 (PID-5)—Child Age 11–17, continued

Instructions to child receiving care: Please continue to complete the questionnaire. Remember, this is a list of things
different people might say about themselves. We are interested in how you would describe yourself. There are no “right” Clinician
or “wrong” answers. So you can describe yourself as honestly as possible, we will keep your responses confidential. We’d Use
like you to take your time and read each statement carefully, selecting the response that best describes you.
Very False Sometimes Sometimes Very True
Item
or Often or Somewhat or Somewhat or Often
score
False False True True
187 I deserve special treatment. 0 1 2 3
It makes me really angry when people insult me in even a minor
188 0 1 2 3
way.
189 I rarely get enthusiastic about anything. 0 1 2 3
190 I suspect that even my so-called “friends” betray me a lot. 0 1 2 3
191 I crave attention. 0 1 2 3
Sometimes I think someone else is removing thoughts from my
192 0 1 2 3
head.
I have periods in which I feel disconnected from the world or
193 0 1 2 3
from myself.
I often see unusual connections between things that most people
194 0 1 2 3
miss.
I don’t think about getting hurt when I’m doing things that might
195 0 1 2 3
be dangerous.
196 I simply won’t put up with things being out of their proper places. 0 1 2 3
197 I often have to deal with people who are less important than me. 0 1 2 3
198 I sometimes hit people to remind them who’s in charge 0 1 2 3
199 I get pulled off-task by even minor distractions. 0 1 2 3
200 I enjoy making people in control look stupid. 0 1 2 3
201 I just skip appointments or meetings if I’m not in the mood. 0 1 2 3
202 I try to do what others want me to do. 0 1 2 3
203 I prefer being alone to having a close romantic partner. 0 1 2 3
204 I am very impulsive. 0 1 2 3
I often have thoughts that make sense to me but that other
205 0 1 2 3
people say are strange.
206 I use people to get what I want. 0 1 2 3
I don’t see the point in feeling guilty about things I’ve done that
207 0 1 2 3
have hurt other people.
208 Most of the time I don’t see the point in being friendly. 0 1 2 3
I’ve had some really weird experiences that are very difficult to
209 0 1 2 3
explain.
210 I follow through on commitments. 0 1 2 3
211 I like to draw attention to myself. 0 1 2 3
212 I feel guilty much of the time. 0 1 2 3
I often “zone out” and then suddenly come to and realize that a lot
213 0 1 2 3
of time has passed.
214 Lying comes easily to me. 0 1 2 3
215 I hate to take chances. 0 1 2 3
216 I’m nasty and short to anybody who deserves it. 0 1 2 3
217 Things around me often feel unreal, or more real than usual. 0 1 2 3
218 I’ll stretch the truth if it’s to my advantage. 0 1 2 3
219 It is easy for me to take advantage of others. 0 1 2 3
220 I have a strict way of doing things. 0 1 2 3

PID-5—Child (Full Version), Page 6

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204
Personality Trait Facet and Domain Scoring: The Personality Inventory for DSM-5 (PID-5)—Child Age 11–17
Step 1: Reverse the scores on the following items (i.e., 3 becomes 0, 2 becomes 1, 1 becomes 2, and 0 becomes 3): 7, 30,
35, 58, 87, 90, 96, 97, 98, 131, 142, 155, 164, 177, 210, and 215.

Step 2: Compute the Personality Trait Facet Scores using the Facet Table below. As a reminder, the reverse scored items
from Step 1 are marked with the letter R in the Table (e.g., 7R).

Step 3: Compute the Personality Trait Domain Scores using the Domain Table below.

A. Personality Trait Facet B. PID-5 items C. Total/Partial D. Prorated E. Average

Raw Facet Raw Facet Facet Score
Score Score
Anhedonia 1, 23, 26, 30R, 124, 155R, 157, 189
Anxiousness 79, 93, 95, 96R, 109, 110, 130, 141, 174
Attention Seeking 14, 43, 74, 111, 113, 173, 191,211
11, 13, 19, 54, 72, 73, 90R, 153, 166, 183, 198, 200,
Callousness
207, 208
Deceitfulness 41, 53, 56, 76, 126, 134, 142R, 206, 214, 218
27, 61, 66, 81, 86, 104, 119, 148, 151, 163, 168,
Depressivity
FOR CLINICIAN USE ONLY

169, 178, 212

Distractibility 6, 29, 47, 68, 88, 118, 132, 144, 199
Eccentricity 5, 21, 24, 25, 33, 52, 55, 70, 71, 152, 172,185, 205
Emotional Lability 18, 62, 102, 122, 138, 165, 181
Grandiosity 40, 65, 114, 179, 187, 197
Hostility 28, 32, 38, 85, 92, 116, 158, 170, 188, 216
Impulsivity 4, 16, 17, 22, 58R, 204
Intimacy Avoidance 89, 97R, 108, 120, 145, 203
Irresponsibility 31, 129, 156, 160, 171, 201, 210R
Manipulativeness 107, 125, 162, 180, 219
Perceptual Dysregulation 36, 37, 42, 44, 59, 77, 83, 154, 192, 193, 213, 217
Perseveration 46, 51, 60, 78, 80, 100, 121, 128, 137
Restricted Affectivity 8, 45, 84, 91, 101, 167, 184
Rigid Perfectionism 34, 49, 105, 115, 123, 135, 140, 176, 196, 220
3, 7R, 35R, 39, 48, 67, 69, 87R, 98R, 112, 159, 164R,
Risk Taking
195, 215R
Separation Insecurity 12, 50, 57,64, 127, 149, 175
Submissiveness 9, 15, 63, 202
Suspiciousness 2, 103, 117, 131R, 133, 177R, 190
Unusual Beliefs & Experiences 94, 99, 106, 139, 143, 150, 194, 209
Withdrawal 10, 20, 75, 82, 136, 146, 147, 161, 182, 186

A. Personality Trait B. PID-5 Facet Scales Contributing C. Total of Average D. Overall Average of
Domain Primarily to Domain Facet Scores (from Facet Scores (The total in
column E of Facet column C of this table
FOR CLINICIAN USE ONLY

Table) divided by 3 [i.e., the

number of scales
listed in column B])
Negative Affect Emotional Lability, Anxiousness, Separation Insecurity
Detachment Withdrawal, Anhedonia, Intimacy Avoidance
Antagonism Manipulativeness, Deceitfulness, Grandiosity
Disinhibition Irresponsibility, Impulsivity, Distractibility
Unusual Beliefs & Experiences, Eccentricity, Perceptual
Psychoticism
Dysregulation

Copyright © 2013 American Psychiatric Association. All rights reserved.

This material can be reproduced without permission by researchers and by clinicians for use with their patients.

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Instructions to Clinicians
This Personality Inventory for DSM-5 (PID-5)—Child Age 11–17 is a 220 item self-rated personality trait assessment scale
for children ages 11 to 17. It assesses 25 personality trait facets including Anhedonia, Anxiousness, Attention Seeking,
Callousness, Deceitfulness, Depressivity, Distractibility, Eccentricity, Emotional Lability, Grandiosity, Hostility, Impulsivity,
Intimacy Avoidance, Irresponsibility, Manipulativeness, Perceptual Dysregulation, Perseveration, Restricted Affectivity,
Rigid Perfectionism, Risk Taking, Separation Insecurity, Submissiveness, Suspiciousness, Unusual Beliefs and Experiences,
and Withdrawal, with each trait facet consisting of 4 to 14 items. Specific triplets of facets (groups of three) can be
combined to yield indices of the five broader trait domains of Negative Affect, Detachment, Antagonism, Disinhibition,
and Psychoticism. The measure is completed by the child prior to a visit with the clinician. Each item asks the child
receiving care to rate how well the item describes him or her generally.

Scoring and Interpretation

Each item on the measure is rated on a 4-point scale. The response categories for the items are 0=very false or often
false; 1=sometimes or somewhat false; 2=sometimes or somewhat true; 3=very true or often true. For items 7, 30, 35, 58,
87, 90, 96, 97, 98, 131, 142, 155, 164, 177, 210, and 215, the items are reverse-coded prior to entering into scale score
computations (see instructions above).

The scores on the items within each trait facet should be summed and entered in the appropriate raw facet score box. In
addition, the clinician is asked to calculate and use average scores for each facet and domain. The average scores reduce
the overall score as well as the scores for each domain to a 4-point scale, which allows the clinician to think of the child’s
personality dysfunction relative to observed norms.1 The average facet score is calculated by dividing the raw facet score
by the number of items in the facet (e.g., if all the items within the “Anhedonia” facet are rated as being “sometimes or
somewhat true,” then the average facet score would be 16/8 = 2, indicating moderate anhedonia). The average domain
scores are calculated by summing and then averaging the 3 facet scores contributing primarily to a specific domain. For
example, if the average facet scores on Emotional Lability, Anxiousness, and Separation Insecurity (scales primarily
indexing negative affect) are all 2, then the sum of these scores would be 6, and the average domain score would be 6/3
= 2. Higher average scores indicate greater dysfunction in a specific personality trait facet or domain.

Note: If more than 25% of the items within a trait facet are left unanswered, the corresponding facet score should not be
calculated. Therefore, the child should be encouraged to complete all of the items on the measure. Nevertheless, if 25%
or less of the items are unanswered for a specific facet, you are asked to prorate the facet score by first summing the
scores of items that were answered to get a partial raw score. Next, multiply the partial raw score by the total number of
items contributing to that facet (i.e., 4-14). Finally, divide the resulting value by the number of items that were actually
answered to obtain the prorated total or domain raw score.

Prorated Score = (Partial Raw Score x number of items on the PID-5)

Number of items that were actually answered

If the result is a fraction, round to the nearest whole number.

Domain scores should not be computed if any one of the three contributing facet scores cannot be computed because of
missing item responses.

Frequency of Use
To track change in the severity of the child’s personality dysfunction over time, it is recommended that the measure
be completed at regular intervals as clinically indicated, depending on the stability of the child’s symptoms and
treatment status. Consistently high scores on a facet or domain may indicate significant and problematic areas for the
child receiving care that might warrant further assessment, treatment, and follow-up. Your clinical judgment should
guide your decision.
1
Krueger RF, Derringer J, Markon KE, Watson D, Skodol AE. (2012). Initial construction of a maladaptive personality trait model and inventory for
DSM-5. Psychological Medicine, 42, 1879-1890.

Copyright © 2013 American Psychiatric Association. All rights reserved.

This material can be reproduced without permission by researchers and by clinicians for use with their patients.

206