Documente Academic
Documente Profesional
Documente Cultură
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
iii
Acknowledgments
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
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
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
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
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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
vi
Abstract
By
Sara D. Klausner
The diagnostic system for psychiatric illnesses in the DSM has been widely
criticized for lack of empirical backing, ambiguous validity pertaining to its categories,
Eating disorder diagnoses in particular have raised concerns with regard to having a poor
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
restricting type (AN-R), and Impulsive Profile, which describes core symptoms of binge-
clinically significant personality traits for an inclusive and personalized diagnosis. This
project presents an extensive literature review to substantiate this proposal and explores
viii
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
diagnosis, thus creating issues pertaining to managed healthcare plan reimbursement and
individuals have notably fallen into the residual category of other specified feeding or
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
symptom expression varies (Eddy et al., 2002; Fairburn & Cooper, 2011; Fairburn &
Harrison, 2003; Tozzi et al., 2005), raising questions surrounding the longitudinal
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;
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
Recent empirical data support that the current categorical classification system of
address existing diagnostic deficiencies (van Elburg & Treasure, 2013; Franko & Omori,
1999; Kozak & Cuthbert, 2016; Wildes & Marcus, 2013). A dimensional diagnostic
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
The APA has acknowledged the many shortcomings of categorical diagnosis and
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
2
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
instruments in Section III to be utilized in routine clinical practice for assessment and
Purpose of Project
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
This diagnostic approach yields clinical utility by addressing two fundamental diagnostic
concerns: (a) eliminating the residual category of unspecified EDs and (b) minimizing
following psychometric measures: the Eating Disorder Inventory, Third Edition (EDI-3;
3
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
including the type and frequency of ED behaviors, level of impairment due to eating
substance abuse), and clinically significant personality traits. Clinicians in both inpatient
and outpatient settings can utilize the assessment and diagnostic procedures to inform
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.
imaginative processes […], and externally oriented cognitive style related to the
4
Binge eating: Eating a subjectively large volume of food in a discrete period of time
Categories: Discrete entities that are discontinuous with one another (Williamson et al.,
2005)
entities, such that groups sharing similar features can be “clustered” together (e.g.,
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”
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
fear of fatness, excessive preoccupation with body shape and weight, and undue
2015)
5
Endophenotype: Genetically influenced symptoms or neurobiological traits that may
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
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
6
have discrete, discontinuous properties (Meehl, 1995; Williamson, Womble,
Transdiagnostic: Describes a feature or set of features that cuts across multiple diagnoses
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
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
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
7
Chapter II
Literature Review
Introduction
assessment and diagnosis of eating disorders (EDs). The literature review discusses the
following: (a) features of EDs, including symptomatology, etiology and risk factors,
categorical diagnosis; (c) innovative modifications presented in the DSM-5 and evident
using categorical and dimensional methods that have been proposed for general
psychiatric nosology and specifically EDs; (f) unique and overlapping features of ED
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
8
0.3%, 0.5%, and 2.0% among men, respectively (Hudson, Hiripi, Harrison, Pope, Jr., &
Kessler, 2007).
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.
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
calories absorbed. Binges are typically characterized by a sense of losing control and
with BN do not present as emaciated like those with AN; typically weight is within
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
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
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),
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 &
Garner (1993) contends that EDs, specifically AN and BN, are “multidetermined
disorders” that have shared symptomatology resulting from complex and varied
the expression of ED symptoms (Garner and Desai, 2000). A study on risk factors
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
media) and personality traits (e.g., rigidity, perfectionism, negative affect; Culbert et al.,
10
2015). The primary age group of the prodromal eating disorder population is children 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
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 &
(Treasure & Kanakam, 2012). Research linking the genetic contribution to certain
personality traits such as neuroticism and perfectionism also suggests that hereditary
component for AN, with rates of 56% in monozygotic twins and 5% in dizygotic twins,
11
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
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.,
and family environment may lead to greater vulnerability to ED development (Strober &
Peris, 2011).
predisposition. Factors including parental attitudes toward body image and eating (Dring,
2015; Kluck, 2008), parental expectations of perfectionism and conformity (Dring, 2015),
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
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
12
higher conflict (Kang et al., 2014), while an interaction of family issues and sexual abuse
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
with anorexic tendencies (Steiger, Richardson, Schmitz, Israel, Bruce, & Gauvin, 2009).
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
13
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
Högdahl, & Von Hausswolff-Juhlin, 2015). Another study investigating the comorbid
Sacks, Yeh, & Lavori, 1992). The most common comorbid disorder was major
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
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
have been found among individuals with BN and BED than those with AN-R (Hudson et
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, &
anxiety disorder, including social phobia, other specified phobias, and separation anxiety
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
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
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,
typically associated with AN, which is also linked to perfectionism, scrupulosity, and
OCD traits (e.g., food ritualization, repetitive weighing) from OCD diagnosis and that a
15
appropriate (Woodside & Staab, 2006). It is widely conjectured that OCD and EDs have
Substance use. EDs and substance use disorders co-occur frequently and may
share causal aspects (Cohen & Gordon, 2009). Approximately one-fourth of individuals
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
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
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
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-
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
17
novelty and risk-taking, and extreme preoccupation with criticisms from others (APA,
risk taking, and proclivities toward NSSI and suicidal ideation (APA, 2013). Pervasive
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
The current diagnostic criteria for AN, BN, and BED are described below.
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
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).
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
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
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
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
subsequently reviewed.
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
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
for psychiatric illnesses is that new editions of the DSM are essentially refined and
innovative diagnostic classification systems (Fairburn & Cooper, 2011). One of the most
20
central concerns with the current diagnostic approach is the pervasive comorbid
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).
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
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
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-
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
with mental health providers, managed health care personnel, and clients; utilizing
clinical management needs. Improved clinical utility can be marked by improved use of
practice. Kendler (1990) advocates for scientifically informed nosology with an advisory
model, in which empirical evidence objectively informs diagnostic classification and can
& 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
determined that symptoms relegated to specific disorders are in fact shared by other
degree of fluidity among them in order to better reflect clinical reality. Most disorders
suggested that dimensional measures cutting across various diagnoses could serve as a
criteria. The DSM-5 was reorganized with the intent to structure diagnostic classes “to
psychological and physiological cross-cutting factors that are not bound by strict
categorical designations” (p. 10). These cross-cutting features allow for more accurate
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
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
Part of the DSM-5 task force, a diagnostic spectra study group was assigned to
regroup related disorders (APA, 2013). Disorders were then arranged based on the
following 11 domains: “shared neural substrates, family traits, genetic risk factors,
high comorbidity, and shared treatment response” (p. 12). Diagnoses were also regrouped
anxious, and somatic symptomatology, and the externalizing group represents disorders
involving dysregulated impulse control, conduct, and substance abuse. These related
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,
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
(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
for further insight into incidence rates, course, underlying mechanisms, treatment, and
treatment outcomes for disorders and clusters of symptoms, which may “contribute to the
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
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;
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
(Gehart, 2014). Some of the disorders that now contain dimensional components include
schizophrenia, and intellectual disability (APA, 2013; Gehart, 2014). The DSM-5 also
diagnosis (e.g., “with catatonia,” “with anxious distress,” “with mixed features;” APA,
2013).
(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
a severity dimension (APA, 2013; Pike, 2013; Wildes & Marcus, 2013). Severity for AN
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.
community of mental health practitioners is likely to see more and more changes in years
to come.
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).
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
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.
validity of the diagnostic parameters for AN, BN, and BED (Striegel-Moore, Wonderlich,
reduce the overuse of the residual diagnostic category following research publications
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
severity (Santonastaso, Bosello, Schiavone, Tenconi, Degortes, & Favaro, 2009). The
episodes for BN (i.e., from twice per week to once per week) following the completion of
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
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
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
(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
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
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”
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,
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
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;
rates are still far too high for a residual diagnostic category (Birgegård et al., 2012; Uher
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
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
accurately reflect clinical reality, indicating defective nosological standards (Uher &
Rutter, 2012). Additionally, valid prognostic value of the current ED diagnoses remains
32
Despite the modifications to ED diagnoses effective in the DSM-5, multiple
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
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
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
efficacy (Andersen, Bowers, & Watson, 2001; Fairburn & Bohn, 2005). The high
prevalence of unspecified ED cases, despite the modifications put forth in the DSM-5,
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
create a “mixed eating disorder” diagnosis to catch remaining cases not eligible for
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
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,
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
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;
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
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
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
personality traits. Fairburn and Cooper (2011) contend that EDs are one diagnosis with a
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
(APA, 2013, p. 12). ED subtypes demonstrate poor predictive validity and frequently
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
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
16). Cutoff criteria excludes individuals from meeting diagnostic criteria for EDs, often
(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).
models for EDs have been proposed and will be discussed in subsequent sections.
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
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
classes, anorexia nervosa and behaviorally similar disorders (AN-BSD), bulimia nervosa
and behaviorally similar disorders (BN-BSD), and binge eating disorder and behaviorally
38
clinical severity. A residual category of EDNOS remains for those not eligible for
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
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
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
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
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
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
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).
results that the heterogeneous sample (i.e., individuals diagnosed with an ED with a BMI
(Fairburn et al., 2009). These outcomes question the clinical utility of maintaining
outcomes unknown. Further, critics of the single-category theory contend that it may be
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
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
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
success with early intervention, response to specific interventions unique to the stage of
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-
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
These diagnostic models may demonstrate some benefits but fail to address most
42
informal clinical intuition about the clustering of presenting symptoms – as opposed to
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
psychopathology” (Widiger & Samuel, 2005, p. 496). Widiger and Gore (2014) offer
They contend that dimensional symptom assessment and treatment are already seen in
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
Correia, Esparza, Saxena, & Maj, 2011). The highest-rated purposes of psychiatric
43
integration of dimensional assessment into diagnostic categories in order to make
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
symptoms yields a more realistic and comprehensive diagnostic approach, which in turn
may facilitate improved treatment strategies (Garner & Garfinkel, 1988). Multiple studies
presentations (e.g., Franko & Omori, 1999; Stice, Killen, Hayward, & Taylor, 1998; Stice,
Ziemba, Margolis, & Flick, 1996; Tylka & Subich, 1999). These research efforts
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
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
definitions of remission under purely categorical systems. Some researchers thus suggest
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
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
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
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
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
fatness/compensatory behaviors dimension, low on drive for thinness, and high on binge-
eating.
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
46
dimensional system (Olatunji , Kim, & Wall, 2015). Three-dimensional models for EDs
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
symptoms in the center (Mintz et al., 1997). Tylka and Subich (1999) evaluated the
personality traits, body dissatisfaction, dieting locus of control across women with EDs,
the Eating Disorder Inventory, Revised (EDI-2; Garner, 1991). The researchers
discovered evidence supporting the continuum model, as neuroticism, eight of nine EDI-
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
47
psychological (e.g., neuroticism) factors of EDs and found that these domains function
eating behaviors may intercept the development of an ED. This study was limited by its
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
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
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
consistently high across presentations of EDs (e.g., Bulik et al., 2000; Lavender et al.,
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
associations with EDs has been of particular empirical interest (e.g., Goldner,
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
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
researchers propose that certain configurations of personality traits may account for
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,
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
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
measures (Westen & Harnden-Fischer, 2001). Participants were clustered into three
were characterized by overall restriction across multiple facets, including food, needs,
understanding for others. This group is further described as dysphoric and feeling empty,
51
samples and constructs utilized in each study, three main categories emerged:
class is characterized by impulsivity and risky behaviors, while the “overcontrolled” class
is characterized by compulsivity, inhibition, rigidity, and avoidance. The final group with
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
direction for identifying shared underlying mechanisms across multiple disorders and
2013).
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
psychiatric illness based on the latest findings in neuroscience, the National Institute of
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
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
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
may be more aptly placed in regulatory systems. Critics of RDoC contend that the
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
impulsivity and compulsivity appears to have value for classifying multiple psychiatric
disorders, including EDs (Robbins et al., 2012). Impulsivity and compulsivity are
Oldham, Hollander, and Skodol (1996) contend that these characteristics are aspects of a
dimensional model for nosology conceptualization that accounts for the “biopsychosocial
(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).
which persist, have no obvious relationship to the overall goal and often result in
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
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
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
55
Impulse-control spectrum model. Recent findings in neuroscience support the
Figure A8). This model is largely based on genetic data (Brooks et al., 2012) and
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
interpersonal difficulties, substance abuse, and risky behaviors, are related to increases in
mesolimbic rewards in response to food stimuli. This framework accounts for diagnostic
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).
(Sanislow et al., 2010) and address that psychopathological disorders are inherently
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
feature of all EDs and likely a result of dysfunctional neural circuitry connecting the
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
Strober (2004) proposes that individuals with AN suffer from poor emotional
regulation due to dysfunctional neural systems associated with fear-based learning. They
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
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.
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
diagnostic information would provide context with regard to ED etiology, risk factors,
internalizing and externalizing factors, respectively, described in the DSM-5 (APA, 2013;
58
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
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
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,
59
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
awareness was predictive of both restrictive and impulsive inclinations but had “greater
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
hypervigilant and avoid harm, discomfort, or negative affect (Hollander, 1998). AN tends
to present with more obsessive and compulsive features (Dawe & Loxton, 2004;
60
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;
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
Impulsive profile. Those with impulsive traits seek pleasure and rewards and may
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
pleasure response to anticipating food reward (Soussignan, Schaal, Boulanger, Gaillet, &
Jiang, 2012). BED and BN show further evidence of nosological proximity. When
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
61
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
The profiles described above will include multiple critical dimensions designed to
central to these profiles, with RP and IP grounded in dominant tendencies toward food
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,
62
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).
O’Connor, Palmer, & Fairburn, 2008). This dimension also mirrors the severity scales
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
symptoms (see Table A1), significant trends emerged. Most research efforts identified
three clusters of participants, which were generally classified as resilient and higher-
63
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
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
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”
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.
64
Individuals with AN-R are more often characterized by features of avoidant and
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
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
are more often described for individuals with AN (Kessler, Schwarze, Filipic, Traue, &
von Weitersheim, 2006; Kucharska-Pietura, Nikolaou, Masiak, & Treasure, 2004), as the
65
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
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 &
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.
participants were more likely to carry the triallelic 5HTTLPR gain-of-function LA allele,
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.
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.,
66
Fichter et al., 2008; Garner et al., 1983; Izydorczyk, 2014; Stice, 2002). Related
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
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
Assessments
The correct diagnostic profile with relevant and appropriate dimensions can be
articulated based on psychometric data and clinical observations. This project proposes
concern can be expressly identified and targeted for treatment. The resulting information
into clinical practice. “Traditionally, mental health clinicians have excelled at focusing on
67
the whole person but have sometimes failed to routinely and systematically assess core
al., 2009, p. 1374). Sessions can be more structured, collecting more reliable data with
and suicidal ideation are less likely to be missed if the clinician is accustomed to
symptoms (e.g., substance use) may affect treatment responses and require additional
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
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
Eating Disorder Inventory, third edition. “The EDI was developed on the
premise […] that eating disorders are multidetermined and multidimensional” (Garner,
68
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:
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
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
Drive for thinness. A “cardinal” trait of EDs, drive for thinness describes extreme
Bulimia. The bulimia domain evaluates for ideation of and engagement in binge-
eating episodes and tendencies toward compensatory behaviors (Garner et al., 1983;
individual’s general discontentment with perceived body image and size of particular
body parts (e.g., hips; Garner et al., 1983; Garner, 1991; 2004).
69
(Garner, 2004). This construct was originally labeled ineffectiveness (Garner, 1983;
1991), this construct assesses for interpersonal issues, including social withdrawal and
relationships (e.g., lack of trust, disappointment, and feeling trapped) and insecure
difficulty interpreting and expressing emotion (Garner, 2004). This quality is related to
alexithymia and is common to all EDs (e.g., Behar & Arancibia, 2014).
tendency toward self-harm (Garner, 2004). Two items assess for related substance abuse
behavior (e.g., Milos et al., 2004). Results of this subscale may reveal BPD traits (Garner,
2004).
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
2015) and is grounded in the sociocultural drive for success (Garner, 1983).
70
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
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
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).
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
affective complications (Fairburn, 2008). The CIA was developed to address the dearth of
71
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
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
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
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
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”
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,
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,
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
(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
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-
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
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
any of the assessment measures and gather information surrounding potential etiological,
assessment of symptom severity and functional impairment can be performed at this time.
74
Conclusion
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
The proposed assessment and diagnostic system will be explored in further detail in the
subsequent chapters.
75
Chapter III
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
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
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
76
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
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
While participating in the marriage and family therapy graduate program, it was
Intended Audience
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
Personal Qualifications
The assessment and diagnostic system can be useful for all mental health
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
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
78
Formative Evaluation
constructs. I have also sought the opinions of ED specialists in the mental health field for
additional guidance.
Project Outline
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
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
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
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,
Measure (CCSM), CCSM Level 2 forms, and Personality Inventory for DSM-5 (PID-5)
81
clarify conflicting test results, gather etiological information, and make appropriate
referrals.
Evaluation
While these opinions are tentative in the absence of empirical validation, they provide a
and the multi-faceted dimensional criteria integrated in the model. Further lauded was the
development may be recognized. A licensed marriage and family therapist with 15 years
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
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
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
(Castellini et al., 2011). Findings have suggested that even when considering categorical
83
support for this classification system, but empirical evidence is required to justify its
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
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
2015). It is suggested then that two additional assessment measures be included for a
(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
84
Conclusion
working with individuals who struggle with distorted perceptions of self and eating
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
I would also like to emphasize the sensitive and critical nature of at-risk and
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.
toward doctoral studies in clinical psychology. The next directions for my research
85
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Appendix A
Figure A1. Broad Categories for the Diagnosis of Eating Disorders (Walsh & Sysko,
2009).
129
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).
133
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.
134
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).
135
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.
136
Figure A8. A spectrum-based impulse-control diagnostic model for eating disorders
mediated by temperamental dominance (Brooks et al., 2012).
137
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
138
Appendix B
Assessment Procedure
Psychometric Measures:
*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 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.
139
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).
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).
140
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.
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:
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
141
Substance Use. Subscales Depression, Anxiety, and Personality Functioning are
Transdiagnostic Dimensions and can thus be assigned to either Restrictive
Profile or Impulsive Profile.
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.
1. Negative Affect
2. Detachment
3. Antagonism
4. Disinhibition
5. Psychoticism
142
These domains are composite scores reflecting results of the following
personality trait facets:
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.
143
Restrictive Profile Psychometric
Subscale(s)
Dimension Measure
Eating Disorder Symptomatology
Comorbid Psychopathology
144
Impulsive Profile Psychometric
Subscale(s)
Dimension Measure
Eating Disorder Symptomatology
Comorbid Psychopathology
Neurobiological Mechanisms
145
Transdiagnostic Psychometric
Subscale(s)
Dimension Measure
Eating Disorder Symptomatology
Neurobiological Mechanisms
146
Psychometric Measures
Clinical Interview
The clinical interview should be conducted following the completion and scoring
of all psychometric measures. This session serves as an opportunity to:
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
149
Transdiagnostic Dimensions
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
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
Severity
30 (moderate impairment)
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
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)
154
Venn Diagram Conceptualization of Eating Disorder Diagnostic Model
155
Venn Diagram Conceptualization of Eating Disorder Diagnostic Model
(with Dimensional Specifiers)
156
Appendix D
Psychometric Measures
Table of Contents
Eating Disorder Inventory, Third Edition
(Sample Subscale Descriptions and Score Report) ................................................................ 158
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).
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.
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
E
Present Weight: 94 pounds
BMI: 17.8
PL
M
Highest past adult weight: 125 pounds
Version: 3.00.016
162
Client: Sample Client Test Date: 10/20/2004
ID#: SAM 1 Page 2 of 7
Scale Classification
Inconsistency (IN) Typical
E
Drive for Thinness (DT)
Bulimia (B) 15 52 57 Typical Clinical
Raw T Qualitative
Scale score score %ile classification
SA
163
Client: Sample Client Test Date: 10/20/2004
ID#: SAM 1 Page 3 of 7
Raw T Qualitative
Scale score score %ile classification
Ineffectiveness Composite (IC) 105 52 56 Typical Clinical
E
PL
M
SA
164
Client: Sample Client Test Date: 10/20/2004
ID#: SAM 1 Page 4 of 7
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
%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
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
Bulimia (B) 5
Ineffectiveness (I) 12
Perfectionism (P) 9
E
Interoceptive Awareness (IA) 9
Asceticism (A) 12
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
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 …
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)]?
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.
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.
172
LEVEL 2—Depression—Adult*
*
PROMIS Emotional Distress—Depression—Short Form
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
3. I felt helpless. 1 2 3 4 5
4. I felt sad. 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.
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:
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).
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
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
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
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.
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:
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).
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)
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.
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.
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
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
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.
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.
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.
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.
182
LEVEL 2—Depression—Child Age 11–17*
*
PROMIS Emotional Distress—Depression—Pediatric Item Bank
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.
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
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.
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
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.
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.
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
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.
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.
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.
191
Name/ID (individual receiving care):___________________
192
Name/ID (individual receiving care):___________________
193
Name/ID (individual receiving care):___________________
194
Name/ID (individual receiving care):___________________
195
Name/ID (individual receiving care):___________________
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 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
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.
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.
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.
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.
199
Name/ID (child receiving care): _________________
200
Name/ID (child receiving care): _________________
201
Name/ID (child receiving care): _________________
202
Name/ID (child receiving care): _________________
203
Name/ID (child receiving care): _________________
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 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
205
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.
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.
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.
206