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Int J Eat Disord. Author manuscript; available in PMC 2016 July 01.
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Published in final edited form as:

Int J Eat Disord. 2015 July ; 48(5): 452–463. doi:10.1002/eat.22388.

The Eating Disorder Assessment for DSM-5 (EDA-5):

Development and Validation of a Structured Interview for
Feeding and Eating Disorders
Robyn Sysko, PhD1,2, Deborah R. Glasofer, PhD1,2, Tom Hildebrandt, PsyD3, Patrycja
Klimek, BA3, James E. Mitchell, MD4,5, Kelly C. Berg, PhD6, Carol B. Peterson, PhD6,
Stephen A. Wonderlich, PhD4,5, and B. Timothy Walsh, MD1,2
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1Division of Clinical Therapeutics, New York State Psychiatric Institute, New York, NY
2Department of Psychiatry, College of Physicians and Surgeons of Columbia University, New
York, NY
3Eatingand Weight Disorders Program, Department of Psychiatry, Icahn School of Medicine at
Mount Sinai, New York, NY
4University of North Dakota School of Medicine and Health Sciences, Fargo, ND
5Neuropsychiatric Research Institute, Fargo, ND
6Department of Psychiatry, University of Minnesota, Minneapolis, Minnesota

Abstract
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Objective—Existing measures for DSM-IV eating disorder diagnoses have notable limitations,
and there are important differences between DSM-IV and DSM-5 feeding and eating disorders.
This study developed and validated a new semi-structured interview, the Eating Disorders
Assessment for DSM-5 (EDA-5).

Method—Two studies evaluated the utility of the EDA-5. Study 1 compared the diagnostic
validity of the EDA-5 to the Eating Disorder Examination (EDE) and evaluated the test-retest
reliability of the new measure. Study 2 compared the diagnostic validity of an EDA-5 electronic
application (“app”) to clinician interview and self-report assessments.

Results—In Study 1, the kappa for EDE and EDA-5 eating disorder diagnoses was 0.74 across
all diagnoses (n= 64), with a range of κ=0.65 for Other Specified Feeding or Eating Disorder
(OSFED)/Unspecified Feeding or Eating Disorder (USFED) to κ=0.90 for Binge Eating Disorder
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(BED). The EDA-5 test-retest kappa coefficient was 0.87 across diagnoses. For Study 2, clinical
interview versus “app” conditions revealed a kappa of 0.83 for all eating disorder diagnoses
(n=71). Across individual diagnostic categories, kappas ranged from 0.56 for OSFED/USFED to
0.94 for BN.

Corresponding author and address reprint requests to: Dr. Robyn Sysko, Eating and Weight Disorders Program, Icahn School of
Medicine at Mount Sinai, One Gustave L Levy Place, Box 1230, New York, NY, 10029, [email protected].
Disclosure of Conflicts
Drs. Sysko, Glasofer, Hildebrandt, Mitchell, Wonderlich, Berg, Peterson, and Walsh, and Ms. Klimek have no conflicts to declare.
 Sysko et al. Page 2

Discussion—High rates of agreement were found between diagnoses by EDA-5 and the EDE,
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and EDA-5 and clinical interviews. As this study supports the validity of the EDA-5 to generate
DSM-5 eating disorders and the reliability of these diagnoses, the EDA-5 may be an option for the
assessment of Anorexia Nervosa, Bulimia Nervosa, and BED. Additional research is needed to
evaluate the utility of the EDA-5 in assessing DSM-5 feeding disorders.

A number of interview-based assessment tools are available to assign DSM-IV1 eating

disorder diagnoses. Commonly used measures in research studies include the Eating
Disorder Examination (EDE2) and the Structured Clinical Interview for DSM-IV (SCID-
IV3). However, these measures have limitations. For example, although the DSM-IV criteria
for anorexia nervosa (AN) include disturbances in the experience of body weight or shape
and a lack of recognition of the seriousness of low weight (Criterion C), these features are
not evaluated by the EDE4. Further, diagnostic agreement using DSM-IV assessment
interviews is variable. For example, using the standards described by Landis and Koch
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(19775), kappa statistics for the diagnosis of AN are moderate for the interviewer-based
EDE in comparison to self-report (κ=0.566). Moderate to substantial agreement has been
observed for AN (κ=0.68) and for eating disorder not otherwise specified (κ=0.60), with
higher agreement for bulimia nervosa (BN; κ=0.83) between clinician interview and SCID-
IV7. Taken together, these findings suggest that the current diagnostic instruments provide
an incomplete assessment of DSM-IV eating disorder criteria and have inconsistent
reliability estimates across diagnoses.

In addition, with the publication of the fifth edition of the Diagnostic and Statistical Manual
of Mental Disorders (DSM-58), the category of feeding and eating disorders has been
revised. Both modest (e.g., reducing the frequency of binge eating and/or purging behaviors
for the diagnosis of BN), and major (e.g., merging feeding and eating disorders into one
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category; designating binge eating disorder (BED) and avoidant/restrictive food intake
disorder (ARFID) as formal diagnostic categories) changes were made from earlier versions
of the DSM. Given the limitations of the existing measures for DSM-IV eating disorder
diagnoses, and the differences between DSM-IV and DSM-5 diagnostic criteria for feeding
and eating disorders, new diagnostic assessment tools are needed.

In constructing a new diagnostic instrument, we elected to develop an interview-based

instrument for feeding and eating disorders that aimed to reduce participant and staff burden
in research settings with a focused diagnostic evaluation that did not also assess related
psychopathology. Such a measure might also be helpful in non-research settings to assist in
determining if an individual’s symptoms meet DSM-5 criteria. Thus, we created a semi-
structured interview for feeding and eating disorder diagnosis, the Eating Disorders
Assessment for DSM-5 (EDA-5). Two studies, described below, evaluated the initial
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psychometric properties of the EDA-5. Study 1 evaluated the diagnostic validity of the
EDA-5 relative to the EDE, the test-retest reliability of diagnoses generated by the EDA-5,
and the acceptability of the measure. Study 2 used an electronic application (“app”) of the
EDA-5 and examined the diagnostic validity of the EDA-5 to an unstructured clinician
interview and a self-report diagnostic measure. Study 2 also examined group differences
between diagnostic groups identified by the EDA-5 on two self-report measures of eating
disorder psychopathology.

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Study 1
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Overview
Study 1 was designed to: (1) compare diagnostic agreement between the EDA-5 and the
EDE, (2) examine the test-retest reliability of the EDA-5, and (3) evaluate the acceptability
of the EDA-5 with regard to the duration and participants’ perceptions of the measure.

Method
Measures
EDA-5: Our goal in developing the EDA-5 was to provide an instrument that could be
administered with limited training and would assess the DSM-5 criteria for feeding and
eating disorders and the frequencies of salient behavioral disturbances characteristic of these
conditions (e.g., the number of objective and subjective binge eating episodes and
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compensatory behaviors). As the EDA-5 was developed solely as a diagnostic instrument,

associated psychopathology and other psychiatric symptoms are not evaluated. The items in
the EDA-5 were developed through an iterative process by three of the authors (RS, DG,
BTW) using a checklist initially developed by Dr. Walsh (c.f., 9–11) that corresponded to
each DSM-5 feeding and eating disorder criterion. The initial version of the EDA-5 tested in
Study 1 provided probe questions and responses in a paper-and-pencil format, similar in
style to the SCID-IV. As implemented, the EDA-5 relies on an algorithm that selects
subsequent questions based on answers already obtained. Therefore, the number of questions
administered varies across individuals. For example, a patient with AN, restricting subtype,
would answer between 11 and 20 questions, depending on whether subjective binge eating
episodes and excessive exercise were endorsed. Rather than use the time-line follow-back
method employed by the EDE, which suggests the interviewer utilize a calendar to focus
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carefully on the preceding months, the EDA-5 instead asks for recent information on the
frequencies of behaviors. For example, for binge eating, participants are asked the number
of times binge eating episodes were experienced in the prior week, whether the frequency is
consistent over the prior three months, and if not, how the frequency of episodes was
different.

The following diagnoses can be generated by the EDA-5: AN (restricting or binge-eating/

purging type), BN, BED, ARFID, pica, rumination disorder, other specified feeding or
eating disorder (OSFED), or unspecified feeding and eating disorder (USFED). Diagnoses
of AN, binge-eating/purging subtype, are assigned by the EDA-5 if the individual reports
either objective binge episodes or purging at least once monthly, on average, over the prior
three months. As the EDE does not differentiate between subtypes of anorexia nervosa, and
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reliability rates for the subtypes of AN could therefore not be calculated. Additional data
relevant to subtype were not coded.

EDE: The diagnostic items from the EDE, version 162, were administered. Since Study 1
was initiated in 2012, the diagnostic algorithms for this study were applied as operationally
defined by Fairburn and Cooper (199312) with modification for DSM-5 (e.g., using a
frequency of once weekly objective bulimic episodes for BN and BED). In April of 2014, a
seventeenth edition of the EDE was released with scoring to generate DSM-5 diagnoses

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(http://www.credo-oxford.com/pdfs/EDE_17.0D.pdf). Three primary changes were made to

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the EDE version 17: (1) removing the amenorrhea item for AN, (2) reducing the six-month
time frame for questions evaluating BED, and (3) altering references to “whose weight
might make them eligible for the diagnosis of AN” have been replaced by “whose weight
might be viewed as ‘significantly low.’” As described below, discrepancies with the EDE
and EDA-5 do not appear primarily related to differences on the basis of the algorithms
used. In prior research,13 test-retest reliability correlations for diagnostic symptoms on the
EDE (e.g., objective bulimic episodes, vomiting episodes) in a clinical sample ranged from
0.83 to 0.97.

Procedure: Participants were individuals seeking or receiving treatment at one of three

tertiary care centers: the Columbia Center for Eating Disorders (CCED), Mount Sinai Eating
and Weight Disorders Program (Mt. Sinai), both in New York City, and Sanford Eating
Disorder & Weight Management Center/Neuropsychiatric Research Institute (Sanford/NRI)
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in Fargo, ND. Initial and subsequent interviews were completed by a bachelor’s level
research assistant (CCED, Mt. Sinai) or a Master’s level project coordinator (Sanford/NRI).
Assessments were conducted by phone at the CCED and Sanford/NRI sites, and in-person at
Mt. Sinai. Verbal consent was obtained for phone interviews and written consent for
interviews conducted in-person. Institutional Review Boards at each site reviewed and
approved the protocol.

Initial Testing: Participants were interviewed using the EDA-5 and EDE within 24 hours.
The order of the interviews was counterbalanced, the EDA-5 and EDE were conducted by
different interviewers, and the length of each interview was recorded. Interviewers
conducted both the EDE and EDA-5. Participants provided feedback to the interviewer
about their experience in completing both assessments (e.g., interview preference,
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similarities/differences between interview style, structure and content, perceived variations

in symptom reports between interviews). After completing initial testing, each participant
received compensation ($50 at Mt. Sinai, $75 at Sanford, and $100 at the CCED). Fifty
percent of the individuals completing the initial interviews were randomized to complete a
second EDA-5 interview to assess test-retest reliability. Between seven and 14 days after the
initial interview, another research assistant or project coordinator contacted the participants
randomized to complete a second EDA-5. Participants who successfully completed this
interview received an additional $25–50.

Statistical Analysis
Statistical calculations were performed with SPSS for WINDOWS software (version 21;
SPSS). Means and standard deviations (SD) were calculated for continuous demographic
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measures, and one way ANOVAs were used to assess differences across sites (CCED, Mt
Sinai, Sanford) using the least significant difference test. Two-way ANOVAs (Site X
Diagnosis) compared the difference in the time needed to complete the EDE and EDA-5
across sites and EDE diagnosis (No diagnosis, AN, BN, BED, OSFED/USFED), and chi-
squares analyzed the proportion of participants reporting a preference for the EDE or
EDA-5. Effect sizes (d) were calculated as the mean difference between the two

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comparisons (e.g., participants completing the EDE and EDA-5) for a given variable divided
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by the mean SD of that variable.

The EDE was used as the reference instrument in all analyses. Similar to other diagnostic
instruments (e.g., 14), criterion validity was subsequently analyzed for AN, BN, BED, and
OSFED/USFED by testing kappa, sensitivity, specificity, positive predictive value, negative
predictive value, and accuracy. Kappa represents the agreement between diagnoses assigned
by the EDE and EDA-5, taking into account the probability of chance agreement. Sensitivity
and specificity indicate the proportion of participants with a positive or negative EDE
diagnosis, respectively, who were correctly identified by the EDA-5. Positive predictive
value is the proportion of participants classified as having a positive diagnosis by the EDA-5
who met criteria for the diagnosis by EDE, whereas negative predictive value signifies the
proportion of participants not assigned a diagnosis by EDA-5 who did not meet criteria for a
diagnosis by EDE. Finally, accuracy is the proportion of participants for whom the EDA-5
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diagnosis matched their EDE diagnoses. To facilitate comparisons across studies, including
research on diagnostic reliability for eating disorders (e.g., 13–15) and our previous work on
the test-retest reliability of DSM-5 eating disorder diagnoses16, we interpreted κ using two
standards5,17. The standards described by Fleiss (198117) describe κ< 0.40 to be ”poor,” κ of
0.40–0.75 to be “fair,” and κ> 0.75 to be “excellent.” Landis and Koch (19775) indicate a κ
of 0–0.20 is “poor,” κ of 0.21–0.40 is “fair,” κ of 0.41–0.60 is “moderate,” κ of 0.61–0.80 is
“substantial,” and κ of 0.81 to 1.00 is “almost perfect.”

Results
A total of 66 treatment-seeking individuals were enrolled in Study 1. Two participants at the
CCED did not complete both interviews at initial testing, and were excluded from the
sample, leaving 64 adolescents or adults who completed the initial testing (n=10 Sanford/
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NRI, n=19 Mt. Sinai, n=32 CCED). Demographic information is presented in Table 1.
Participants from the Sanford/NRI site were found to have significantly higher body mass
indices than patients enrolled at Mt. Sinai or Columbia [F(2, 61)= 8.83, p<0.001], but the
samples did not differ significantly on age, gender, or ethnicity.

Discrepancies between the EDE and EDA-5

One discrepancy between the EDE and EDA-5 was an interviewer error (i.e., the diagnosis
checked on a summary sheet was not justified by the symptoms noted as endorsed during the
interview). As this error did not reflect a difference in symptom assessment between the
interviews, it was not included in the discrepancies reported below. A total of 52 of 64
participants, or 81.3%, had matching diagnoses. Across all eating disorder diagnoses, the
EDE and EDA-5 eating disorder diagnoses had a kappa of 0.74, or “fair” to “substantial”
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agreement. When considering individual diagnostic categories, a range of fair/substantial

(κ= 0.65 for OSFED/USFED) to excellent/almost perfect (κ= 0.90 for BED) was observed.
Additional information about criterion validity is presented in Table 2.

Among the 12 participants with discrepant diagnoses (Table 3), one participant was not
assigned an eating disorder diagnosis by the EDE, but the EDA-5 conferred a residual
OSFED/USFED diagnosis, a discrepancy due to differences in patient report of symptoms

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between the two interviews. The majority of the remaining 11 differences (n=6/11, 54.5%)
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related to the assessment of low body weight in each interview (see Table 4 for a
comparison of the EDE and EDA-5 items for this criterion). Six participants diagnosed with
AN by EDA-5 did not endorse the “maintained low weight” item on the EDE and were
subsequently diagnosed with either BN (n=3) or OSFED/USFED (n=3). Other discrepancies
were more disparate. One underweight participant (BN by EDE, AN by EDA-5) denied fear
of weight gain item on the EDE but endorsed the criterion by EDA-5, and two individuals
(OSFED/USFED by EDE, BN by EDA-5) did not meet criterion for the overvaluation of
shape/weight on the EDE but did meet this criterion by EDA-5 (Table 4). Among the
remaining two participants, one received a BN diagnosis by EDE and an OSFED (BN of
low frequency/limited duration) diagnosis by EDA-5 because of reported difficulty
providing detail about the content of binge eating episodes to the interviewer, and the other
(OSFED/USFED by EDE, BED by EDA-5) reported an average of more than twice weekly
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binge episodes over the prior three months with two or more weeks without the presence of
any binge eating episodes, which disqualified the participant from a BED diagnosis by EDE.

Interview Length and Preference

Time needed to complete the diagnostic items of the EDE and the EDA-5 differed
significantly by site [F(2, 63)= 6.7, p= 0.003 and F(2, 63)= 3.3, p= 0.04, respectively]. The
CCED site required significantly longer to complete both interviews (p’s < 0.01), a
difference not explained by altered distributions of eating disorder diagnoses [EDE
diagnosis: F(4, 63)= 0.97, p= 0.43; EDA-5 diagnosis: [F(4, 63)= 1.8, p= 0.15]. The pattern
of the EDA-5 requiring significantly less time in comparison to the EDE was noted at the
CCED, Mt. Sinai, and Sanford/NRI sites [CCED: 21.5 ± 5.0 minutes for EDA-5 versus 35.4
± 11.7 minutes for EDE; t(34) = 7.3, p < 0.001, d =1.6; Mt. Sinai and Sanford/NRI: 16.5 ±
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5.2 minutes for EDA-5 versus 24.7 ± 8.0 minutes for EDE; t(26) = 5.1, p < 0.001, d =1.2].
Data for interview preference were missing for three participants, and nine participants
(n=9/61; 14.8%) did not report a preference between the EDE and EDA-5. Among those
who reported a preference for one of the two interviews (n=52/61; 85.2%), a larger
proportion of individuals preferred the EDA-5 (n=33/61; 54.1%) versus the EDE (n=19/61;
31.1%; χ2(2)=14.3, p = 0.001). Qualitative data from participants suggested that the EDE
was preferred for reasons including: use of the calendar, the type of questions (e.g.,
“thought-provoking,” “relevant,” “elaborate” questions), or ease of completing the
interview. The EDA-5 was described as easier/simpler, requiring less detail, quicker, and
focused on important symptoms.

Test-Retest Reliability
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Thirty participants were randomized to evaluate the test-retest reliability of the EDA-5, and
21 (70%) successfully completed a second interview [n= 5 in Sanford (100% of randomized
participants), n= 5 at Mt. Sinai (55.6% of randomized participants), and 11 at CCED (68.8%
of randomized participants)]. The second EDA-5 was completed, on average, 9.2 ± 2.6 days
after the first EDA-5 interview (range: 7–17 days). Two interviewer coding errors were
noted (a failure to check off the appropriate diagnosis on a summary form on the basis of
information collected during the first or second interviews). After these errors were
corrected, diagnostic agreement was achieved in 19 of 21 cases (90.5%), and the test-retest

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kappa coefficient was 0.87 across diagnoses, which would be considered excellent to almost
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perfect. One participant reported a slightly different amount of recent weight loss across
interviews, and was assigned an Atypical AN diagnosis by EDA-5 at Time 1 and a Purging
Disorder diagnosis by the EDA-5 at Time 2. The second case was described previously; due
to difficulty describing binge eating episodes discrepant Time 1 EDE (BN) and EDA-5 (BN
low frequency/limited duration) diagnoses were noted, and subsequently, a diagnosis of BN
was assigned in the second EDA-5 interview.

Study 1 Discussion and Rationale for Study 2

Diagnoses obtained by EDA-5 showed substantial levels of agreement with the EDE,
ranging from 88% for residual diagnoses (OSFED/USFED) to 98% for BED. The largest
proportion of disagreements related to some subtle but important distinctions in how the
interviews code symptoms related to low weight. Discrepancies such as these are expected,
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as the EDE and EDA-5 not only use different coding schemes for the diagnostic algorithms,
but also differ in the degree to which the questions align with the DSM-5 criteria.

Rates of test-retest reliability of the EDA-5 in this study were high, and in comparison to the
EDE, the EDA-5 required significantly less time to complete and was preferable to
participants. These findings provide preliminary support for the validity of the EDA-5 in the
diagnosis of DSM-5 eating disorders. However, based on feedback from interviewers, and
aforementioned errors in coding, we concluded that the structure and skip rules required by
the paper version of the EDA-5 were sufficiently complex to lead occasionally to confusion.
Although the EDA-5 was completed more quickly than the EDE, assessors reported
difficulty knowing when to leave a given section, as they needed time during the interview
to read the instructions before deciding on the next appropriate follow-up questions.
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Feedback from assessors about the complexity of the interview suggested that additional
modification and testing of the EDA-5 were needed. Further, as structured interviews like
the EDE are less commonly used to evaluate eating disorder symptoms outside of tertiary
care centers, it was important to evaluate the performance of the EDA-5 against diagnoses
assigned by clinician interviews, which are more typical measures in clinical settings. Thus,
we conducted a second study (Study 2), with the aims of: (1) developing an electronic
application of the EDA-5 (the EDA-5 “App”); (2) comparing diagnoses assigned by the
EDA-5 and clinician interview; (3) examining interview-based diagnoses on the EDA-5 to
self-reported eating disorder diagnoses from the Eating Disorder Diagnostic Scale; and (4)
evaluating the construct validity of the EDA-5 by comparing scores on the Eating Pathology
Symptoms Inventory across EDA-5 diagnoses.
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Study 2

EDA-5—The paper-and-pencil version of the EDA-5 was adapted to an electronic format

(available at www.eda5.org) for administration in this study. Automatic skip rules were built
into the revised instrument, such that the electronic version chooses subsequent questions
that should be administered on the basis of answers provided earlier in the interview. As in
DSM-5, the EDA-5 App utilizes a diagnostic hierarchy (e.g., if criteria for AN are met, the
BN and BED sections are skipped as a diagnosis of AN supersedes those of BN and of

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BED). Binge eating and compensatory behaviors and the Pica section are administered for
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all participants, as information related to binge eating and/or compensatory behaviors is

required to rule in or out several diagnoses and because it is possible to assign a diagnosis of
Pica even in the presence of another feeding or eating disorder. Additional information
about the administration of the EDA-5 App can be found in Glasofer, Sysko, & Walsh18.
Eating Disorder Diagnostic Scale (EDDS19). The EDDS is a brief self-report scale that
generates both eating disorder diagnoses and a composite score. Adequate criterion,
predictive, and convergent validity, internal consistency, sensitivity, and test-retest
reliability were documented for the version of the EDDS developed for DSM-IV,14,20 and
the measure was recently adapted for DSM-5. Eating Pathology Symptom Index (EPSI21).
The EPSI is a 45-item self-report measure of eating disorder psychopathology with strong
psychometric properties, including excellent discriminant, convergent, and criterion-related
validity21. Eight reliable internally-consistent subscales were identified empirically and
replicated across men and women, and normative data are available for the EPSI.21,22
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Procedure—Participants were enrolled at one of four tertiary care centers: the CCED, Mt.
Sinai, Neuropsychiatric Research Institute (NRI; Fargo), or the University of Minnesota
Eating Disorders Research Program (Minnesota). The EDA-5 was administered by a
bachelor’s level research assistant (CCED, Mt. Sinai) or a Master’s or doctoral-level project
coordinator (NRI, Minnesota), and clinical interviews were conducted by doctoral-level
clinicians. Assessments were intended to be completed in-person at all four sites; however,
in some cases, the EDA-5 was completed by phone. Institutional Review Boards at each site
reviewed and approved the protocol, and all participants provided informed consent.

Interview and Questionnaire Administration—The EDA-5 App and clinician

interviews were used to derive DSM-5 feeding and eating disorder diagnoses, and
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participants also completed the EDDS and EPSI. Interviews were intended to occur within
3–7 days (average time between = 1.3 ± 2.4 days, range of 0–11 days), and were conducted
by different members of the staff. The length of EDA-5 interviews was recorded and
clinicians completed a checklist to identify individual diagnostic criterion and final DSM-5
diagnoses. Participants received $25 after completing the interviews and self-report
questionnaires.

Statistical Analysis
As in Study 1, means and standard deviations were calculated for continuous demographic
measures, and one way ANOVAs with least significant difference tests to evaluate
differences in these characteristics across sites (CCED, Mt. Sinai, NRI, Minnesota). Two-
way ANOVAs (Site X Study) compared the difference in the time needed to complete the
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EDA-5 in Study 1 and Study 2 across sites, with effect sizes (d) as above. The clinician
interview was used as the reference instrument for interview-based diagnoses; for the self-
report diagnostic assessment (EDDS), the interview measure (EDA-5) was the reference for
the analyses because psychometric data is not yet available for the DSM-5 version of the
EDDS. As in Study 1, kappa, sensitivity, specificity, positive predictive value, negative
predictive value, and accuracy were calculated for AN, BN, BED, and the residual diagnoses
of OSFED/USFED. The κ standards used in Study 15,17 were applied to data from Study 2.

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Results
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A total of 72 participants enrolled in Study 2. One participant at Mt. Sinai did not complete a
clinician interview and was excluded from the sample, and data from the remaining 71
adults who completed the initial testing (n=9 Minnesota, n=9 NRI, n=23 Mt. Sinai, n=30
CCED) were examined. One participant failed to complete the EPSI (1.4%), and missing
data precluded analyzing the EDDS in two cases (2.8%). Study 2 demographic information
appears in Table 5. As reflected in Table 5, site differences were observed for age and body
mass index, but the samples did not differ in gender or ethnicity.

Discrepancies between the Clinical Interview and EDA-5

The EDA-5 App and the clinician interview assigned the identical diagnosis for 62 of 71
participants (87.3%) resulting in a kappa of 0.83, or “excellent” to “almost perfect”
agreement. Among individual diagnostic categories, kappas ranged from fair/moderate (κ=
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0.56 for OSFED/USFED) to excellent/almost perfect (κ= 0.94 for BN). Additional
information about criterion validity between the EDA-5 and clinical interview is presented
in Table 6.

Nine participants received discrepant diagnoses (Table 7). In general, discrepancies occurred
as the result of differences in patient report across interviews. Among three cases assigned a
diagnosis of AN by clinicians (n=2 Atypical AN, n=1 USFED by EDA-5), different reports
of low weight were provided and symptoms of AN (e.g., restricting, shape/weight concern,
fear of fat, etc.) were denied in the EDA-5 interviews. Binge size and binge frequency were
at issue in four cases, including the one discrepant case of BN and three of the residual cases
by clinician interview (n=1 purging disorder, n=2 BED, n=1 BN by EDA-5 interview).
These patients reported differently sized binge episodes or frequency of binge eating
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episodes to the clinician and EDA-5 interviewer. Denial of BED criteria on the EDA-5 (i.e.,
distress about binge episodes and features related to binge eating episodes) explained the
difference in the final two discrepant cases (BED by clinician interview and OSFED/
USFED by EDA-5 interview).

Interview Length
As in Study 1, the time needed to complete the EDA-5 differed significantly [F(3, 134)=
20.5, p<0.001], with the CCED (p’s < 0.01) and Minnesota (p’s < 0.05) requiring
significantly longer to complete the EDA-5 in comparison to Mt. Sinai and NRI. A
significant main effect indicated that utilizing the electronic application of the EDA-5
significantly shortened the length of time needed to administer the interview from Study 1 to
Study 2, from an average of 19.3 ± 5.6 minutes (range of 5–34 minutes) in Study 1 to 14.0 ±
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6.2 minutes (range of 5–30 minutes) in Study 2 [F(1, 134) = 29.2, p < 0.001, d= 0.90].

Comparisons with Self-Report Questionnaires

Tables 6 and 7 include data relevant to criterion validity and discrepancies between
diagnostic assignments by EDA-5 and EDDS. As reflected in measures of criterion validity
from Table 6, notable differences between the EDA-5 and EDDS diagnoses included the
number with a feeding or eating disorder by interview who had no diagnosis by EDDS (n=9;

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13.0% of sample), and the number with a BED diagnosis by EDA-5 who were classified as
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BN by EDDS (n=5; 7.2% of sample).

As displayed in Table 7, four of the cases without a feeding or eating disorder by EDDS
were diagnosed with AN, one with BN, one with BED, and three with OSFED/USFED by
EDA-5. The most common reason for differences in diagnosis (n=4; 44.4% of cases) was
the denial of functional impairment on the EDDS (“How much does any eating or body
image problem impact your relationships with friends and family, work performance, and
school performance?” rated as “not at all” or “slightly”), which occurred with one case of
AN, one case of BED, and two OSFED/USFED cases by EDA-5. Two individuals without a
diagnosis by EDDS (22.2%) did not report body mass indices below 18.5 kg/m2 but were
given a diagnosis of AN by EDA-5 on the basis of clinician judgment of low weight over the
prior three months. One (11.1%) participant without an EDDS diagnosis denied fear of
weight gain but endorsed Criterion B by EDA-5 and was diagnosed with AN. Another
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(11.1%) denied a clinically significant degree of shape and weight concern by EDDS but
answered affirmatively on the EDA-5 and received a diagnosis of BN. The final participant
without a diagnosis by EDDS reported only two of five features associated with binge eating
episodes and was given an OSFED/USFED diagnosis (Binge eating disorder of low
frequency or limited duration) by EDA-5. All five discrepancies in which BED was
diagnosed by EDA-5 and BN by EDDS related to the way in which compensatory behaviors
are evaluated by EDDS. As assessed by the EDDS, fasting, skipping at least two meals in a
row, was endorsed at least once weekly by three of the five participants (60.0%), and “more
intense exercise specifically to counteract the effects of overeating” at least once weekly was
endorsed by all five of these participants.

Construct Validity: Group Differences

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As illustrated in Table 8, EDDS symptom composite scale scores did not differ significantly
across eating disorder diagnoses assigned by EDA-5. Significant differences were identified
between at least two diagnostic groups on six of the eight EPSI scales, with Excessive
Exercise and Muscle Building failing to discriminate between groups. Individuals with a BN
or BED diagnosis by EDA-5 scored significantly higher than individuals with AN or
OSFED/USFED on the Binge Eating Scale of the EPSI and patients diagnosed with BN by
EDA-5 had significantly higher scores on the EPSI Purging scale in comparison to all other
diagnostic groups. In comparison to those diagnosed with BN or BED by EDA-5, patients
given an AN diagnosis scored significantly higher on the Restraint scale, as did those with
an OSFED/USFED diagnoses compared to those with a BED diagnosis. Further, mean
scores similar to those reported by Forbush and colleagues18 for individuals with AN and
BN were identified in the Study 2 sample for the majority of the subscales.
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Study 2 Discussion
As in Study 1, substantial levels of agreement were observed between the EDA-5 App and
clinician interview, with accuracy rates ranging from 87% for residual diagnoses (OSFED/
USFED) to 97% for BN. Most disagreements were due to how participants described
symptoms between interviews (e.g., frequency of binge eating episodes, degree of low
weight). Diagnoses from information collected by the EDA-5 versus self-report by EDDS

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revealed a larger number of discrepancies, however, the distinctions primarily related to the
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assessment of functional impairment, which may be expressed differently by interview than

questionnaire, and the definitions of fasting and exercise employed across instruments.
Symptom composite scores from the EDDS did not differ across groups, but this finding
may relate to the overall level of severity of individuals included in this study, all of whom
were evaluated in tertiary care centers specializing in eating disorders. On the basis of
published data with the EPSI21, expected differences were found between diagnostic groups
on the EPSI. By adapting the paper version of the EDA-5 to electronic format, the time
needed to complete the interview was significantly reduced without compromising the utility
of the EDA-5 in assessing the diagnostic criteria for feeding and eating disorders. These data
provide additional support for the validity of the EDA-5 to diagnose adults with eating
disorders.

General Discussion
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These two studies aimed to evaluate the psychometric properties of a novel, semi-structured
interview for the diagnosis of DSM-5 feeding and eating disorders. High levels of agreement
with the EDA-5 and the EDE (Study 1) and between the EDA-5 App and clinician interview
were found. Consistent with prior research7, concordance in the comparisons for both Study
1 and Study 2 (EDE vs. EDA-5 and clinician interview vs. EDA-5 App) were lowest for
OSFED and USFED. Because OSFED/USFED captures all patients with sub-threshold
presentations, heterogeneity of symptoms may be a general barrier to the reliable assessment
of individuals in this category. Most of the discrepant cases between interviews occurred
between a full-threshold diagnostic classification and a residual category (e.g., AN vs.
OSFED/USFED), not between two full-threshold categories (e.g., AN vs. BN).

Two primary issues contributed to the observed discrepancies between the EDA-5 and the
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reference instruments in Study 1 and Study 2: the assessment of low weight and dissimilar
patient reports across interviews. A number of discrepancies (n=6) were found in the
diagnosis of AN between the EDE and EDA-5, which are expected when using alternative
methods of classifying low weight, and in this case are likely related to small differences in
how the instruments attempt to assess DSM-5 Criterion A. Study 2 did not identify
differences between EDA-5 and clinician interview for the assessment of low weight among
15 cases of AN, which suggests that the EDA-5 recommendation of assigning current
diagnosis of AN for adults at a body mass index less than 18.5 kg/m2 in the past three
months (even if not underweight at time of assessment) is similar to usual clinical practice in
tertiary care. In both Study 1 and Study 2, several discrepant diagnoses were assigned on the
basis of different reports of symptoms from patients (e.g., dissimilar binge episodes,
different frequencies of binge episodes per week, etc.), and inconsistent expression by
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patients is a primary source of variability in estimates of diagnostic reliability.23 It is not

known whether reports on individual diagnostic criteria relate to the way questions were
asked, differences in participant recall, or other factors. There are several well-known
challenges in the assessment of eating disorder symptoms, as patients may consciously or
unconsciously omit, conceal, or misrepresent behavior or internal experience, deny the
presence of a disorder, or avoid questions about the extent of their symptomatology.24 Other
specific difficulties with the interpretation of low weight, short-term symptom fluctuations,

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and the presence of weight and shape concerns have also been cited previously7. Thus, some
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differences in patient report across measurements are to be anticipated.

As described by Kraemer and colleagues,23 test-retest reliability reflects the effect of the
diagnosis on clinical decision making, and incorporates variability due to both patients and
raters. Our kappa statistic (κ = 0.87) for test-retest reliability of the EDA-5 in Study 1 was
excellent to almost perfect by the standards of Fleiss (198117) and Landis and Koch (19775),
and was similar to rates of test-retest reliability of the EDE (κ = 0.83–0.9713), and eating
disorder diagnoses by the SCID-IV (κ = 0.6415) and the EDDS (κ = 0.71–0.9514). In sum,
without notable sacrifices in accuracy, the EDA-5 was significantly faster to complete than
the EDE, and with modifications to develop an electronic version of this instrument,
administration time was reduced significantly further, to an average of 14 minutes.

These studies had several important strengths, including: the inclusion of multiple sites in
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distinct geographical locations in the US; the inclusion of a heterogeneous eating disorder
sample, including participants diagnosed with AN, BN, BED, and OSFED/USFED; and
interviewers with differing levels of experience (BA, MA, and doctoral-level assessors)
successfully using the assessment instruments. There were also several limitations to Study
1 and Study 2, including site differences in methodology (e.g., Study 1 telephone vs. in-
person interviews), the limited age range of participants (primarily adults), the inclusion
only of individuals evaluated in specialty tertiary care centers, and the lack of data on the
assessment of the feeding disorders (i.e., Avoidant/Restrictive Feeding and Eating Disorder,
Rumination Disorder, Pica). At least two discrepancies in the diagnosis of AN resulted from
a participant providing a different weight history over the three months prior to the
assessment by EDA-5 and in the clinician interview. Although information about weight
over the last three months may often rely on self-report, the opening page of the EDA-5
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strongly advises interviewer “to obtain objective information (i.e., clinician-measured height
and weight) whenever possible.” It is possible that the rates of reliability observed with the
EDA-5 will be different when the instrument is used with community samples, with
individuals receiving treatment outside of specialist programs, or with younger patients. In
addition, as observed in our prior work16, reliability may be affected because, in comparison
to general practice settings or primary care clinics, the staff of specialty programs is familiar
with the assessment of feeding and eating disorder symptoms, including research
assessments like the EDE, and the diagnostic criteria, regardless of their degree status25.
Finally, only a small number of individuals without a feeding or eating disorder diagnosis
were identified in our studies, which does not allow any examination of how effectively the
EDA-5 distinguishes between case and non-case status.
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To address these limitations and further develop the utility of the EDA-5, future research
should: (1) determine whether this assessment successfully evaluates individuals with
DSM-5 feeding disorders and distinguishes these diagnoses from DSM-5 eating disorders
(e.g., AN vs. ARFID); (2) make developmentally appropriate adaptations to the existing
measure to allow for use across age groups, and (3) evaluate whether the measure could
collect a more limited amount of diagnostic information (e.g., 26) to enhance suitability for
private practice and help guide referrals to specialty care. However, on the basis of the data
collected for these studies, the existing version of the EDA-5 offers the ability to quickly

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 Sysko et al. Page 13

and reliably generate DSM-5 eating disorder diagnoses. This instrument may therefore have
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utility for diagnosing eating disorders in both research and clinical settings. In particular, the
EDA-5 should be considered for expediently eliciting a DSM-5 eating disorder diagnosis
when supplementary information about other associated psychopathology can be obtained
through other means (e.g., self-report questionnaires). For situations where a comprehensive
eating disorder measure is needed, trained interviewers are available, and length of the
assessment is not a concern, the EDE may be preferred. Finally, for any of the interviews,
level of interviewer training may affect choice—the EDA-5 requires the least training,
followed by the EDE, and finally the clinician interview.

Acknowledgments
We would like to acknowledge the assistance of Jon Cohen, Jo Ellison, PhD, Chad Lystad, MS, Heather Simonich,
MA, and the Columbia Center for Eating Disorders research assistants, including: Stephanie Brewer, Christine Call,
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Zoe Grunbaum, Sima Kaplan, Jonathan Hersch, Lindsay Kenney, Amelia Kidd, Katrina Kostro, Meg Martinez,
Alexandra McGlade, Jeanne McPhee, Esther Neustadt, Melissa Prusky, Molly Siegel.

Dr. Sysko is supported by the National Institute of Diabetes and Digestive and Kidney Diseases grant K23
DK088532.

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Table 1

Demographic Characteristics of the Study 1 Samples

Sanford/NRI (n=10) Sinai (n=19) CCED (n=27) Total Across Sites (n=64)
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Mean ± SD (range) Mean ± SD (range) Mean ± SD (range) Mean ± SD (range) Statistic

Age 36.6 ± 13.2 (18–56) 29.6 ± 10.9 (14–56) 30.0 ± 10.2 (18–58) 30.9 ± 11.0 (14–58) F(2, 61)= 1.6, p=0.20
Body Mass Index (kg/m2) 31.9 ± 12.4 (18.5–46.8) 21.6 ± 4.2 (17.3–33.1) 20.9 ± 7.1 (11.2–38.0) 22.8 ± 8.4 (11.2–46.8) F(2, 61)= 8.8, p<0.001, Sanford > CCED
Sanford > Sinai

N (%) N (%) N (%) N (%)

Female 8 (80.0%) 17 (89.5%) 32 (91.4%) 57 (89.1%) χ2(2)=1.1, p=0.59
Caucasian 9 (90.0%) 14 (73.7%) 27 (77.1%) 50 (78.1%) χ2(8)=7.5, p=0.48

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Table 2

Study 1 Agreement of the Eating Disorder Assessment for DSM-5 (EDA-5) with the Eating Disorder Examination (EDE)

Eating Disorder κ Sensitivity Specificity Positive Predictive Value Negative Predictive Value Accuracy
Sysko et al.

AN 0.77 1.00 0.83 0.76 1.0 0.89

BN 0.70 0.71 0.96 0.86 0.90 0.89
BED 0.90 1.00 0.98 0.83 1.0 0.98
Residual [EDNOS (EDE) or OSFED/USFED (EDA-5)] 0.65 0.65 0.96 0.85 0.88 0.88

Note. AN = anorexia nervosa; BN = bulimia nervosa; BED = binge eating disorder; EDNOS = eating disorder not otherwise specified; OSFED/USFED = other specified or unspecified feeding and eating
disorder

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Table 3

Diagnoses assigned by the Eating Disorder Examination (EDE) and Eating Disorder Assessment for DSM-5 (EDA-5; Study 1)

EDA-5 diagnosis assigned

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No FED AN BN BED Residual

EDE diagnosis assigned No FED 2 0 0 0 1

AN 0 22 0 0 0

BN 0 4 12 0 1

BED 0 0 0 5 0

Residual 0 3 2 1 11

Note. Shaded boxes identify diagnostic agreement between the EDE and EDA-5. FED = feeding and eating disorder; AN = anorexia nervosa; BN = bulimia nervosa; BED = binge eating disorder;
Residual= OSFED/USFED = other specified or unspecified feeding and eating disorder

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Table 4

Items With Discrepancies in the Diagnostic Algorithm for Eating Disorders from the Eating Disorder
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Examination (EDE) and Eating Disorder Assessment for DSM-5 (EDA-5) in Study 1.

EDE Question and Rating EDA-5 Question and Rating

Anorexia Measurement of height and weight. What are your current height and weight? What was
Nervosa, Over the past three months, have you been trying to lose your lowest weight in the past 3 months?
Criterion A: Low weight? A current diagnosis of AN is considered for adults who
body weight Item is coded for: attempts either to lose weight or to avoid have been at a body mass index less than 18.5 kg/m2 in
weight gain over the past three months for reasons the past three months (even if not underweight at time of
concerning shape or weight. assessment).

Anorexia Over the past four weeks have you been afraid that you Are you afraid of gaining weight?
Nervosa, might gain weight? If no: Are you worried that if you start to gain weight,
Criterion B: Fear Item is coded for: a definite fear of weight gain on more you will continue to gain weight and will become fat?
of gaining weight than half the days (16 or more days), for the prior 3 months Do you try to cut back on calories or amounts or types
or becoming fat of food? What do you try to do? Do you exercise? What
OR persistent do you do and how often? Do you vomit or use any
behavior types of pills (such as diet pills, diuretics, or laxatives)?
interfering with Do you do anything else that might make it hard for you
weight gain to gain or maintain weight?
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Item is coded if YES to any of the above

Bulimia Nervosa, I am now going to ask you a rather complex question – you Does your body shape or weight impact how you feel
Criterion D: may not have thought about this before. Over the past four about yourself?
Disturbance in weeks has your weight (the number on the scale) been For example, if you were to have a day when you did
experience of important in influencing how you feel about (judge, think, not like the number on the scale, or the way your clothes
body weight or evaluate) yourself as a person? …If you imagine the things fit, or how your body shape felt in general, how much
shape which influence how you feel about (judge, think, evaluate) would that impact you? Would it make you feel very
yourself-such as (your performance at work, being a parent, badly about yourself? Please tell me a little about this.
your marriage, how you get on with other people)- and put Item coded if participant report shape/weight exert
these things in order of importance, where does your weight undue influence on sense of self-worth or on self-
fit in? evaluation.
What about your shape? How has it compared in importance
with your weight in influencing how you feel about
yourself?
Over the past four weeks have you “felt fat”?
Item is coded if: body shape OR weight are of at least
moderate importance (definitely one of the main aspects of
self-evaluation) for the prior 3 months OR participant has
felt fat on more than half of the days of the month (16 or
more) for the prior 3 months
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Table 5

Demographic Characteristics of the Study 2 Sample

Minnesota (n=9) NRI(n=9) Sinai (n=23) CCED (n=30) Total Across Sites (n=71)
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Mean ± SD (range) Mean ± SD (range) Mean ± SD (range) Mean ± SD (range) Mean ± SD (range) Statistic
Age 33.3 ± 13.4 (18–55) 49.2 ± 8.2 (39–65) 31.2 ± 11.0 (19–54) 28.6 ± 8.9 (18–47) 32.7 ± 11.9 (18–65) F(3, 67)= 9.6, p< 0.001, NRI > CCED, NRI >
Sinai, NRI > Minnesota
Body Mass 29.3 ± 8.2 (20.3–46.5) 30.0 ± 5.0 (21.5–36.8) 25.4 ± 5.9 (17.3–36.0) 20.8 ± 4.7 (14.3–33.3) 24.5 ± 6.6 (14.3–46.5) F(3, 67)= 9.7, p< 0.001, CCED < Sinai, CCED <
Index (kg/m2) Minnesota, CCED < NRI, Mt. Sinai < NRI

N (%) N (%) N (%) N (%) N (%)

Female 8 (88.8%) 8 (88.8%) 22 (95.7%) 29 (96.7%) 67 (94.4%) χ2(3)=1.4, p=0.71
Caucasian 7 (77.8%) 8 (88.8%) 18 (78.3%) 24 (80.0%) 57 (80.3%) χ2(9)=5.7, p=0.77

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Table 6

Study 2 Agreement of the Eating Disorder Assessment for DSM–5 (EDA-5) with Clinician Interview (n=71) and Eating Disorder Diagnostic Scale
(n=69).
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Clinician Interview1
Eating Disorder κ Sensitivity Specificity Positive Predictive Value Negative Predictive Value Accuracy
AN 0.88 0.83 1.0 1.0 0.95 0.96
BN 0.94 0.96 0.98 0.96 0.98 0.97
BED 0.82 0.86 0.97 0.86 0.97 0.94
OSFED/USFED 0.56 0.73 0.90 0.57 0.95 0.87

EDDS2
Eating Disorder κ Sensitivity Specificity Positive Predictive Value Negative Predictive Value Accuracy
No Diagnosis 0.27 1.0 0.87 0.18 1.0 0.87
AN 0.77 0.73 0.98 0.92 0.93 0.93
BN 0.73 0.92 0.84 0.77 0.95 0.87
BED 0.46 0.38 0.98 0.83 0.87 0.87
OSFED/USFED 0.57 0.54 0.96 0.77 0.90 0.88

Note. AN = anorexia nervosa; BN = bulimia nervosa; BED = binge eating disorder; OSFED/USFED = residual diagnoses of other specified or unspecified feeding and eating disorder;
1
Clinical interview= reference assessment for analyses;
2
EDA-5=reference assessment for analyses

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Table 7

Diagnoses assigned by the Eating Disorder Assessment for DSM-5 (EDA-5; Study 2) and Clinician Interview or Eating Disorder Diagnostic Scale
(EDDS)
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EDA-5 diagnosis assigned

No FED AN BN BED Residual (OSFED/USFED)

Clinician diagnosis assigned No FED 2 0 0 0 0

AN 0 15 0 0 3

BN 0 0 25 0 1

BED 0 0 0 12 2

Residual (OSFED/USFED) 0 0 1 2 8

No FED 2 4 1 1 3

AN 0 11 1 0 0

EDDS diagnosis assigned BN 0 0 24 5 2

BED 0 0 0 5 1

Residual (OSFED/USFED) 0 0 0 2 7

Note. Shaded boxes identify diagnostic agreement between the EDE and clinician diagnosis. FED = feeding and eating disorder; AN = anorexia nervosa; BN = bulimia nervosa; BED = binge eating
disorder; OSFED/USFED = other specified or unspecified feeding and eating disorder

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Table 8

Eating Disorder Diagnostic Scale (EDDS) and Eating Pathology Symptoms Index (EPSI) Scores by Diagnoses assigned by the Eating Disorder
Assessment for DSM-5 (EDA-5; Study 2)1
Sysko et al.

Eating Disorder Diagnosis by EDA-5

No Diagnosis (n=2) AN (n=15) BN (n=26) BED (n=14) OSFED/USFED (n=13)

EDDS Symptom Composite 28.0 ± 1.4 41.1 ± 22.2 63.0 ± 14.1 45.6 ± 9.8 43.2 ± 20.6

EPSI Body Dissatisfaction2 11.5 ± 0.71 18.0 ± 6.7 22.3 ± 5.2 21.6 ± 5.5 20.3 ± 6.6

EPSI Binge Eating3 9.5 ± 7.8 12.8 ± 7.7 23.6 ± 4.9 21.9 ± 6.2 13.7 ± 7.4

EPSI Cognitive Restraint4 9.0 ± 0.0 9.4 ± 2.0 8.6 ± 3.1 6.3 ± 2.4 9.3 ± 2.8

EPSI Purging5 3.0 ± 1.4 4.9 ± 3.4 9.5 ± 5.3 2.9 ± 2.6 6.2 ± 6.2

EPSI Restricting6 7.0 ± 0.0 12.9 ± 6.1 7.0 ± 5.3 4.9 ± 5.2 10.8 ± 7.8

EPSI Excessive Exercise 9.0 ± 7.1 11.2 ± 7.3 9.5 ± 7.3 7.0 ± 2.3 8.8 ± 7.2

EPSI Negative Attitudes toward Obesity2 0.50 ± 0.71 6.5 ± 5.3 10.6 ± 5.8 10.4 ± 6.1 10.5 ± 5.0

EPSI Muscle Building 5.0 ± 1.4 3.1 ± 2.7 3.2 ± 4.2 2.1 ± 3.0 2.8 ± 2.6

Note. AN = anorexia nervosa; BN = bulimia nervosa; BED = binge eating disorder; OSFED/USFED = other specified or unspecified feeding and eating disorder; post-hoc tests are not reported for
individuals without a feeding or eating disorder diagnosis due to sample size (n=2);
1
Raw EDDS composite score reported in table, z-scores used for analyses, EDDS composite scores and EPSI scale scores compared by one-way ANOVA with least significant difference post-hoc
comparisons;
2
BN> AN (p < 0.05);
3
BN and BED> AN and OSFED/USFED (all p’s≤0.001);

Int J Eat Disord. Author manuscript; available in PMC 2016 July 01.
4
AN, BN, and OSFED/USFED > BED (all p’s < 0.01);
5
BN> AN, BED, and OSFED/USFED (all p’s < 0.05);
6
AN > BN and BED (p’s < 0.01) and OSFED/USFED > BED (p = 0.01).
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