General Information (including ICD-9/-10 Codes)

Description :

  • eating disorder characterized by restrictive eating to the point of self-starvation, severe self-induced weight loss

ICD-9 Codes :

  • 307.1 anorexia nervosa

ICD-10 Codes :

  • F50.0 anorexia nervosa
  • F50.1 atypical anorexia nervosa
  • F50.8 other eating disorders
  • F50.9 eating disorders, unspecified

Types :

  • binge-purge subtype -- may use laxatives, vomiting, diuretics to achieve weight loss
  • restricting subtype -- patients limit their intake of food to lose weight

Who is most affected :

  • female
  • peaks in adolescence
  • family history of eating disorders
  • case report of anorexia nervosa in adolescent male can be found in Child Psychiatry Hum Dev 1990 Winter;21(2):79
  • anorexia nervosa may exist in various cultures
    • based on study of 668 students in Ghana
      • 10 women with body mass index < 17.5 kg/m 2 had "self starvation" as only cause
      • reasons were not based on weight or shape but these students had beliefs about self control and hunger denial that were viewed positively toward food restriction and in religious terms
      • Reference - Br J Psychiatry 2004 Oct;185:312 full-text
    • discussion of eating disorders in Asian populations can be found in Am J Orthopsychiatry 2005 Oct;75(4):553

Incidence/Prevalence :

  • 1.2% women and 0.29% men had anorexia nervosa among Swedish twins
    • based on prospective study of 31,406 persons born 1935-1958 in Swedish Twin Registry
    • prevalence higher in persons born after 1945
    • heritability estimated to account for 56% cases
    • Reference - Arch Gen Psychiatry 2006 Mar;63(3):305
  • 2.2% lifetime prevalence of anorexia nervosa among female Finnish twins
    • based on study of 2,881 women born 1975-1979 in Finnish twin cohort
    • incidence of anorexia nervosa in women aged 15-19 years was 270 per 100,000 person-years
    • Reference - Am J Psychiatry 2007 Aug;164(8):1259
  • weight concerns common among young adolescents
    • based on survey of 2,331 young adolescents (grades 6-8)
    • 23.8% considered themselves overweight
    • 45% trying to lose weight
    • 34% dieting
    • 59.4% exercising to lose or maintain weight
    • 6.7% vomiting or taking laxatives
    • 6.8% taking diet pills
    • Reference - Arch Pediatr Adolesc Med 1998 Sep;152(9):884 in Pediatric Notes 1998 Oct 15;22(42):166
  • in study of Australian school children (888 girls and 811 boys) ages 14-15 years at beginning of study and followed 3 years

Causes and Risk Factors

Likely risk factors :

  • early warning signs
    • persistent dieting
    • arrest in weight gain during puberty
    • social isolation
    • compulsive exercise
    • preoccupation with thinness and body image
  • genetic risk factors reported with linkage regions on chromosomes 1,3, and 4 for anorexia nervosa (Am J Pharmacogenomics 2004;4(4):209)
  • risk factors for development of eating disorders include dieting and psychiatric co-morbidity
  • perfectionism and negative self-evaluation are common precedents to anorexia nervosa

Possible risk factors :

  • perinatal factors (cephalhematoma, very preterm birth, small for gestational age) associated with increased risk for anorexia nervosa
    • based on population-based study with 781 girls ages 10-21 years with anorexia nervosa and 3,905 controls matched by year and hospital of birth
    • Reference - Arch Gen Psychiatry 1999 Jul;56(7):634
    • DynaMed commentary -- not clear that confounding risk factors were accounted for
  • diabetes mellitus type 1 associated with increased risk for eating disorders
    • based on comparison of 356 Canadian females aged 12-19 years with type 1 diabetes vs. 1,098 age-matched non-diabetic controls
    • comparing girls with diabetes vs. controls
      • 10% vs. 4% had eating disorders that met DSM-IV criteria (p < 0.001)
      • 14% vs. 8% had subthreshold eating disorders (p < 0.001)
    • Reference - BMJ 2000 Jun 10;320(7249):1563 full-text
  • eating alone may be a risk factor for developing eating disorders
    • based on study of 2,862 girls aged 12-21 years
    • patients were evaluated twice 18 months apart with 90 (3%) developing eating disorders during follow-up
    • risk factors for incident eating disorder were
      • younger age
      • usually eating alone
      • frequently reading girls' magazines and listening to radio programs
      • parents not being married
    • Reference - Pediatrics 2003 Feb;111(2):315 full-text, commentary can be found in Evid Based Nurs 2003 Oct;6(4):120
  • < 5 family meals weekly associated with increased risk of disordered eating in girls and unhealthy weight control behaviors in boys
    • based on observational study
    • 2,516 adolescents surveyed regarding family meal frequency and surveyed for disordered eating behaviors 5 years later
    • comparing girls having < 5 meals vs. ≥ 5 meals weekly with family
      • extreme weight control behaviors (self-induced vomiting and use of laxatives, diet pills, or diuretics) in 26% vs. 17% (p < 0.001)
      • unhealthy weight control behaviors (eating very little, fasting, using food substitutes, skipping meals, or smoking) in 64.4% vs. 57.4% (p = 0.008)
      • binge eating in 12.7% vs. 9.2% (p = 0.046)
      • chronic dieting in 18.5% vs. 13.9% (p = 0.02)
    • in boys
      • unhealthy weight control behaviors in 29% boys having < 5 family meals weekly vs. 35.4% boys having ≥ 5 family meals weekly (p = 0.02)
      • no significant differences with number of family meals on extreme weight control behaviors, binge eating and chronic dieting
    • Reference - Arch Pediatr Adolesc Med 2008 Jan;162(1):17

Complications and Associated Conditions

Complications :

  • increased mortality and suicide risk, especially if severe alcohol use disorder
    • based on prospective study of 246 women with anorexia nervosa (136) or bulimia nervosa (110)
    • 11 women (4.5%) died over 4 years
    • anorexia nervosa associated with 7.4% crude mortality
    • anorexia nervosa associated with increased standardized mortality ratios for all causes (11.6) and suicide (56.9)
    • severity of alcohol use disorder predicted mortality
    • history of hospitalization for affective disorder associated with reduced mortality
    • Reference - Arch Gen Psychiatry 2003 Feb;60(2):179
  • cardiac complications
    • sudden death - ventricular arrhythmias (especially ventricular tachycardia if prolonged QT), sinus arrest
    • mitral valve prolapse may be reversible complication of anorexia nervosa
      • caused by ventriculovalvular disproportion due to starvation-induced myocardial atrophy and intravascular volume depletion
      • myxomatous degeneration of mitral valve may disappear with refeeding
      • Reference - letter in Am Fam Physician 1997 Jul;56(1):52
      • DynaMed commentary -- mitral valve prolapse may be overdiagnosed in thinner patients
    • review of cardiac effects of anorexia nervosa can be found in Int J Eat Disord 1995 May;17(4):313
  • osteoporosis
    • increased fracture risk persists long-term after diagnosis of anorexia nervosa
      • based on retrospective cohort study
      • 193 women and 15 men first diagnosed with anorexia nervosa between 1935-1989 had 2,689 person-years of follow-up
      • 45 patients developed 88 fractures which was substantially higher than expected numbers of fractures
      • fractures of hip, spine and forearm were late complications
      • 57% cumulative incidence of any fracture at 40 years after diagnosis of anorexia nervosa
      • Reference - Mayo Clin Proc 1999 Oct;74(10):972
    • in 130 women (mean age 24 years) with anorexia nervosa, 47-57% had osteopenia (depending on site measured), 13-24% had osteoporosis and 26% had history of fracture (Ann Intern Med 2000 Nov 21;133(10):790 PDF), editorial can be found in Ann Intern Med 2000 Nov 21;133(10):828 PDF, commentary can be found in Ann Intern Med 2001 Nov 6;135(9):843
  • history of anorexia nervosa not associated with adverse birth outcomes
    • based on prospective cohort study of all 837,582 primiparous women who gave birth in Sweden 1983-2002
    • 1,000 women with history of hospital discharge with diagnosis of anorexia nervosa compared to 827,582 controls without such history
    • no significant differences between groups for perinatal mortality, prematurity, birthweight, Apgar score, size for gestational age, pre-eclampsia, instrumental delivery
    • Reference - BJOG 2006 Aug;113(8):925
  • during pregnancy, women with eating disorders may be more likely to have anemia and hyperemesis and deliver infants with lower mean birth weight and smaller head circumference
    • based on 49 pregnant women with history of eating disorder compared with 68 controls
    • comparing women with history of eating disorder vs. controls
      • 8 vs. 0 had infant with microcephaly (p < 0.05)
      • 12 vs. 1 had small for gestational age infant (p < 0.05)
    • Reference - Obstet Gynecol 2005 Feb;105(2):255 in J Watch Online 2005 Mar 4
  • end organ damage from malnutrition (liver, brain, kidney, skin, pancreas)
  • metabolic disturbances - hypokalemia, hypothermia, endocrinopathy
  • cognitive changes, depression
  • infertility
  • growth retardation reported in 11 of 12 male adolescents with anorexia nervosa (Pediatrics 2003 Feb;111(2):270 full-text)
  • refeeding syndrome with profound hypophosphatemia, editorial review can be found in BMJ 2004 Apr 17;328(7445):908 full-text
  • high prevalence of hemodynamic, hematologic, endocrine, and bone density abnormalities reported in group of 60 adolescent girls with anorexia nervosa treated as outpatients (Pediatrics 2004 Dec;114(6):1574 full-text), commentary can be found in Am Fam Physician 2005 Oct 1;72(7):1353

Associated conditions :

History

Chief Concern (CC) :

  • typically patient is brought to attention of caregiver by relative or friend concerned about severe weight loss and malnutrition
  • fatigue (ominous sign)
  • pre-menarchal girls with eating disorder have height and weight deficits in growth charts long before weight loss, based on review of growth charts of 45 such girls (Acta Paediatr 2003 Oct;92(10):1133)

History of Present Illness (HPI) :

  • weight loss of 15% ideal body weight
  • amenorrhea for 3 consecutive months
  • intense fear of being/becoming obese
  • disturbed body image (often of delusional proportion)
  • persistent desire to lose weight despite emaciation
  • excessive exercise may be common component of or warning sign of anorexia nervosa
    • based on interviews of hospitalized eating disordered patients
    • 78% of patients had excessive exercise
    • 60% were competitive athletes prior to onset of eating disorder
    • 75% had steady increase in exercise during period of maximal decrease in food intake and weight
    • Reference - Psychol Med 1994 Nov;24(4):957
  • may be associated with purging behavior, laxative or diuretic abuse, ipecac ingestion
  • record extensive dietary history, chronology of weight loss including maximum weight and rate of weight loss

Medication History :

  • diuretics
  • cathartics (laxatives)
  • ipecac

Social History (SH) :

  • discontentment with body weight and shape strongly related to frequency of reading fashion magazines in survey of preadolescent and adolescent girls, 47% reported wanting to lose weight because of magazine pictures (Pediatrics 1999 Mar;103(3):e36 full-text)

Review of Systems (ROS) :

Physical

General Physical :

  • cachexia
  • decreased vital signs (pulse, temperature, respiratory rate, blood pressure)
  • lethargy (ominous sign)
  • hyperactivity despite malnutrition (typical)
  • reluctance to be weighed
  • baggy and loose clothing may be worn to conceal thinness
  • skimpy clothing may be worn to flaunt thin body

Skin :

  • manifestations of anorexia nervosa associated malnutrition
    • dry skin (common)
    • lanugo hair (common)
    • hair loss (common)
    • hypercarotenemia (common)
    • acrocyanosis (occasional)
    • nail dystrophy (occasional)
    • pellagra (rare)
    • angular stomatitis - fissuring of corners of mouth (occasional)
  • manifestations of anorexia nervosa associated behaviors
    • cutting, burning or other signs of self-afflicted harm (common)
    • hair pulling (trichotillomania) (occasional)
  • rare cutaneous associations of anorexia nervosa
    • acne
    • chilblains
    • pili torti - twisting hair shaft abnormality
  • Reference - J Cutan Med Surg 2002 Jul-Aug;6(4):345 PDF

Extremities :

  • peripheral edema suggests medical cause or severe malnutrition (hypoproteinemia)

Diagnosis

Making the diagnosis :

  • DSM-IV-TR criteria
    • refusal to maintain weight over minimal normal leading to body weight 15% below expected
    • intense fear of gaining weight or becoming fat even though underweight
    • disturbance in image of weight or shape, undue influence of body weight or shape on self-evaluation, or denial of seriousness of current low body weight
    • in females absence of at least 3 consecutive menstrual cycles

Rule out :

  • inflammatory bowel disease (Crohn's disease, ulcerative colitis)
  • hypothalamic or pituitary tumor
  • cancer
  • depression
  • schizophrenia
  • hyperthyroidism
  • Addison's disease
  • autoimmune disease
  • disordered upper gastrointestinal motor activity may mimic anorexia nervosa
    • based on study of esophageal motor activity in 30 consecutive patients meeting diagnostic criteria for primary anorexia nervosa
    • 7 had achalasia
    • 1 had diffuse esophageal spasm
    • 1 had severe gastro-esophageal reflux and upper esophageal sphincter hypertonicity
    • 6 had partly non-propulsive and repetitive high amplitude, long duration contractions in lower esophagus
    • Reference - Gut 1986 Oct;27(10):1120

Testing to consider :

  • check hCG in patients with amenorrhea
  • blood tests
    • CBC and differential
    • electrolytes
    • BUN
    • creatinine
    • glucose
    • liver function tests
    • total protein
    • albumin
    • thyroid function tests (TSH and T4)
  • ECG
  • bone density determination if amenorrhea > 6 months, or to establish baseline
  • brain MRI in males with weight loss or atypical cases

Blood tests :

  • pancytopenia is common
  • electrolytes may be abnormal in cases of water intoxication, purging, laxative or diuretic abuse, or poor salt intake
  • total protein and albumin may be decreased, serves as a marker of nutritional status, low or normal erythrocyte sedimentation rate (ESR)
  • endocrine abnormalities (not necessary for diagnosis or treatment)
    • typically decreased FSH, LH, T4 (mild), T3 (mild), estrone, and estradiol
    • prepubertal levels of FSH and LH, no cyclic surge of LH
    • typically increased cortisol, GH, rT3 and T3RU
    • normal free T4 and TSH

Urine studies :

  • decreased urinary 17-OH steroids

Imaging studies :

EKG :

Prognosis

Prognosis :

  • variable, spontaneous remission common, may evolve to bulimia
  • typical cases is chronic and relapsing
  • anorexia nervosa often treatment-resistant but many patients recover
  • 5-year clinical recovery rate 66.8%
  • treatment dropout rates are high in anorexia nervosa
    • treatments of anorexia nervosa complicated by high dropout rate
      • based on randomized trial without clinical outcome
      • 122 patients randomized to cognitive-behavioral therapy vs. fluoxetine vs. combination of both for 1 year
      • 21 patients (17%) withdrawn, mainly due to treatment failure
      • 56 remaining patients (55%) dropped out
      • among 89 patients who accepted treatment, only predictor of treatment completion was high self-esteem (86% rate of treatment completion vs. 40% rate with low self-esteem)
      • Reference - Arch Gen Psychiatry 2005 Jul;62(7):776
    • comorbid psychiatric disorders, problematic family behaviors, and long term family therapy may be associated with higher dropout and lower rate of remission
      • based on randomized trial comparing short-term vs. long-term family therapy
      • lower rates or remission associated with comorbid psychiatric diagnoses, older age, and problematic family behaviors
      • Reference - Int J Eat Disord 2006 Dec;39(8):639
  • multiple studies report increased mortality rates in patients with anorexia nervosa
    • 5.9% mortality associated with anorexia
    • 3.2% 5-year mortality in prospective study
      • based on prospective study of 216 patients with eating disorders followed for 5 years
      • 3 (3.2%) of 95 with anorexia died
      • 56% of anorexic patients had no diagnosable eating disorder at 5 years but treatment did not appear to be effective
      • Reference - Lancet 2001 Apr 21;357(9264);1254 commentary can be found in Lancet 2001 Sep 15;358(9285):926
    • mortality in patients with anorexia nervosa in Sweden has decreased from 1980 to 1990
      • based on comparison of 2 cohorts in Sweden
      • 564 patients born 1958-1967 and hospitalized for anorexia nervosa 1977-1981 were followed until 1992, during which time 25 (4.4%) died
      • 554 patients born 1968-1977 and hospitalized for anorexia nervosa 1987-1991 were followed until 2002, during which time 7 (1.3%) died
      • authors suggest that introduction of specialized care units may account for mortality difference
      • Reference - Am J Psychiatry 2006 Aug;163(8):1433
    • no long-term mortality increase reported in population-based community cohort
  • 21-year follow-up of 84 patients with anorexia nervosa
    • 51% had made full recovery
    • 10% still met full diagnostic criteria for anorexia nervosa
    • 16% had died from causes related to anorexia nervosa
    • Reference - Lancet 2000 Feb 26;355(9205):721
  • admitted patients tend to have continued treatment needs over subsequent years
    • based on prospective study of 338 patients hospitalized for eating disorder
    • 242 (72%) were followed for mean 6.4 years, 90% had anorexia nervosa, > 90% were female
    • mean BMI 14.3 kg/m 2
    • average patient had > 4 months total time of hospitalization and was in some kind of treatment for 30% of time over 6 years
    • 50% required second hospitalization, 25% required third hospitalization
    • 7 patients (3%) died as consequence of eating disorder
    • 80% normalized weight, eating behavior and menstruation at follow-up
    • Reference - Eur Child Adolesc Psychiatry 2003;12 Suppl 1:I91 in Pediatric Notes 2003 Jul 31;27(31):121)
  • resolution of orthostatic pulse changes may take 3 weeks in patients admitted to hospital for anorexia nervosa
    • based on retrospective study of 36 patients ages 12-23 years admitted for anorexia nervosa
    • mean time to resolution of orthostatic pulse changes 21.6 days
    • resolution of orthostatic pulse changes occurred upon attainment of 80% ideal body weight
    • Reference - J Adolesc Health 2003 Jan;32(1):73

Treatment

Treatment overview :

Diet :

  • strict behavioral protocols may be needed to ensure weight gain
  • American Dietetic Association recommendations for treatment of anorexia nervosa include
    • gradual adjustments in nutrient intake and weight progress
    • stepping up caloric intake from baseline level of 30-40 kilocalories/kg of weight per day (starting at 1,000- 1,200 kcal per day) to achieve a weight gain of 0.5-1 lbs (0.23-0.45 kg) per week
    • eventual goal of nutritional rehabilitation is restoration of healthful weight and resumption of normal eating patterns
    • Reference - J Am Diet Assoc 2006 Dec;106(12):2073
  • complications of nutritional replacement include
    • development of truncal obesity
    • refeeding syndrome
      • can precipitate cardiac failure related to hypophosphatemia
      • usually occurs within 4 days of resuming feeding
      • discussion of refeeding syndrome can be found in BMJ 2004 Apr 17;328(7445):908 full-text

Activity :

Counseling :

Medications :

Consultation and referral :

  • treatment for anorexia nervosa is demanding and complex
  • potentially useful consultants include
    • psychiatrist specializing in treatment of eating disorders
    • psychologist specializing in treatment of eating disorders
    • dietitian

Other management :

  • consider hospitalization
    • inpatient treatment does not appear more effective than outpatient treatment for initial treatment of anorexia nervosa in adolescents (level 2 [mid-level] evidence)
      • based on randomized trial with low adherence rates
      • 167 adolescents aged 12-18 years with anorexia nervosa in United Kingdom were randomized to inpatient vs. specialized outpatient vs. general child and adolescent mental health service (CAMHS) treatment
      • adherence to treatment in 50% inpatient vs. 75% specialized outpatient vs. 69% CAMHS groups
      • all 3 groups had considerable progress at 1 year with further improvement at 2 years
      • full recovery rates only 33% at 2 years
      • adherence to inpatient treatment only 50%, some CAMHS outpatients subsequently admitted
      • inpatient treatment (by actual behavior) associated with poor outcomes
      • Reference - Br J Psychiatry 2007 Nov;191:427
    • potential indications for hospitalization
      • weight < 75% ideal body weight
      • weight < 85% ideal body weight if weight loss has been rapid over brief time period
      • exhaustion
      • abnormal vital signs - hypotension, bradycardia, hypothermia
      • hypokalemia
      • suicidality
      • acute food refusal
      • uncontrollable bingeing and purging
      • ipecac abuse
    • if hospitalization
      • admit to pediatric, medical or medical-psychiatric unit familiar with treatment of anorexia
      • goal - medical and psychiatric stabilization
  • behavior modification (using socialization as reward/isolation as punishment to encourage weight gain) did not have significant effect (level 2 [mid-level] evidence) in randomized trial of 81 hospitalized anorexics followed for 35 days (Br J Psychiatry 1979 Jan;134:55)
  • self-help manual may reduce some eating disorder symptoms in adults (level 2 [mid-level] evidence)
    • based on Cochrane review of mostly small trials of variable quality
    • systematic review of 12 randomized and 3 controlled trials of manual-based pure self-help or guided self-help in adults with bulimia nervosa, binge eating disorder or eating disorder not otherwise specified
    • compared to waiting list
      • non-significant differences in abstinence from binging or purging
      • greater improvement in other eating disorder symptoms
      • greater improvement in psychiatric symptoms but not depression
      • greater improvement in interpersonal functioning
    • compared to other psychological therapies, no significant differences
    • Reference - systematic review last updated 2006 May 24 (Cochrane Library 2006 Issue 3:CD004191)
    • DynaMed commentary -- none of these trials were specific to patients with anorexia nervosa
  • intensive feedback treatment using computer support associated with prolonged remission (level 2 [mid-level] evidence)
    • based on small randomized trial without attention control
    • 32 patients with anorexia nervosa randomized to computer-based intensive feedback vs. wait-list control
    • intervention group ate in front of computer monitor for 3 meals per day and recorded satiety at 1-minute intervals; after eating, patients rested in warm room for 1 hour
    • patients were followed for up to 60 months after remission (median follow-up 21.6 months)
    • 14 of 16 (88%) in treatment group vs. 1 of 16 (6%) in control group were in remission at follow-up (p = 0.0057, NNT 2)
    • Reference - Proc Natl Acad Sci U S A 2002 Jul 9;99(14):9486 full-text
  • spirituality group associated with faster improvement than cognitive and emotional group (level 2 [mid-level] evidence)
    • based on randomized trial without allocation concealment
    • 122 women ages 13-52 years admitted to hospital for treatment with eating disorder (including 42 with anorexia nervosa) were randomized to spirituality group vs. cognitive group vs. emotional support group
      • spirituality and cognitive groups received self-help workbooks
      • all 3 groups had weekly 60-minute group sessions
    • mean length of inpatient stay 68 days
    • all 3 groups had improvements in multiple psychologic outcomes measured weekly
    • spirituality group had faster improvements in some outcomes compared to other groups
    • Reference - Eat Disord 2006 Oct-Dec;14(5):401

Follow-up :

Prevention and Screening

Prevention :

  • no evidence to support programs to prevent eating disorders in children and adolescents; systematic review of 8 trials last updated 2002 Feb 8 (Cochrane Library 2002 Issue 2:CD002891)
  • school-based intervention may reduce purging or using diet pills to control weight
  • dissonance-inducing activities and healthy weight management prevention programs may reduce risk factors for eating disorders in adolescent girls
    • 481 adolescent girls with body dissatisfaction randomized to 1 of 4 programs
      • eating disorder prevention program with dissonance-inducing activities that reduce thin-ideal internalization
      • prevention program promoting healthy weight management
      • expressive writing control condition
      • assessment-only control condition
    • dissonance participants had significantly greater reductions in eating disorder risk factors and bulimic symptoms than 3 other groups
    • dissonance and healthy weight participants had significantly lower binge eating and obesity onset and reduced service utilization through 12 months than other 2 groups
    • Reference - J Consult Clin Psychol 2006 Apr;74(2):263
  • internet program associated with improvement in body image and decrease in drive for thinness at 3 months (level 3 [lacking direct] evidence) in randomized trial in 60 college women (J Consult Clin Psychol 2000 Apr;68(2):346)

Screening :

  • SCOFF acronym may be useful for screening for eating disorders
    • 5 questions
      • Do you make yourself Sick because you feel uncomfortably full?
      • Do you worry you have lost Control over how much you eat?
      • Have you recently lost Over 10 pounds in a 3 month period (original description was One stone = 14 pounds = 6.3 kg)?
      • Do you believe yourself to be Fat when others say you are too thin?
      • Would you say that Food dominates your life?
    • 2 or more positive answers suggests eating disorder
    • validation of this screening questionnaire done by comparing 116 women 18-40 with confirmed anorexia or bulimia in eating disorders clinic with 96 controls, so unknown if applicable to general population or younger women
    • Reference - BMJ 1999 Dec 4;319(7223):1467 full-text
    • SCOFF questionnaire had 85% sensitivity, 90% specificity, 24% positive predictive value and 99.3% negative predictive value for eating disorder in study of 341 women (BMJ 2002 Oct 5;325(7367):755 BMJ 2002 Oct 5;325(7367):755), correction can be found in BMJ 2002 Dec 7;325(7376):1331, commentary can be found in Evidence-Based Medicine 2003 May-Jun;8(3):90
    • SCOFF screening tool equally effective when administered in oral or written format, based on 178 student volunteers completing both screening approaches in random order (Int J Eat Disord 2002 Dec;32(4):466)

References including Reviews and Guidelines

General references used :

Reviews :

Guidelines :

Patient Information

Patient information :