Assessment Instruments of Eating Disorders for free use in scientific studies and clinical practice

To support scientists and clinical practitioners in practice and clinical research we developed several assessment instruments for eating disorders:
A) Munich Eating Disorder Questionnaire (Munich ED-Quest)
B) Structured Inventory for Anorexic and Bulimic Eating Disorders (SIAB-EX and SIAB-S)
C) Anorexia Nervosa Inventory for Self-rating (ANIS)

These instruments are suitable for the diagnosis of eating disorders according to DSM-5 and ICD-10 (Munich ED-Quest, SIAB-EX, SIAB-S) and/or for screening and severity rating of eating disorders (ANIS, Munich ED-Quest, SIAB-EX, SIAB-S).
Each instrument will be described in detail below and is available as download from this page for free use in scientific studies and clinical practice.

A) Munich Eating Disorder Questionnaire (Munich ED-Quest)

General Information

The Munich ED-Quest is a self-rating questionnaire suitable for diagnostic purposes and severity rating in clinical practice and research in subjects 12 to 65 years old. This paper-and-pencil instrument is dedicated to the use by psychologists, medical doctors, pedagogues and other health workers. It can be used for assessing possibly deviant eating behaviour.

Application

The Munich ED-Quest covers attitudes and behaviours frequently found in eating disordered individuals and other symptoms often associated with eating disorders in adolescents and adults aged 12 to 65 years. The questionnaire may be applied in single or group sessions.

Fields of application

•    Diagnosis of eating disorders according to DSM-5 (APA, 2013) in clinical therapy. Identification of individual problem areas which should be addressed in therapy. The patient may fill-out the self-rating questionnaire before the first interview.
•    Clinical research on the course of eating disorders and the effects and outcome of medical treatment and psychotherapy.
•    Screening for eating disorders in epidemiological studies and identification of high-risk groups for eating disorders.

Content and scoring

The Munich ED-Quest comprises 65 items. Some items are broken down in several partial items.
For most items the results are coded on a five-point scale ranging from 0 (symptom/problem not present) to 4 (symptom/problem very severely/often present). Additional items ask for the frequency of binge eating and inappropriate compensatory behaviors.
For most items the cross-sectional status (was the symptom present in the last 3 months) and the maximal expression of the symptom in the past is rated by the proband. The past rating will usually cover the time from prepuberty up to 3 months before answering the questionnaire. The present status covers the maximal expression of the symptom/problem area in the last 3 months before filling out the questionnaire.
The following DSM-5 diagnoses (APA, 2013) can be made by the Munich ED-Quest: Anorexia Nervosa (restrictive and binge-eating/purging type), Bulimia Nervosa, Binge Eating Disorder, Avoidant/Restrictive Food Intake Syndrome, Rumination Syndrome, Atypical Anorexia Nervosa, Bulimia nervosa of low frequency and/or limited duration, Binge Eating Disorder of low frequency and/or limited duration, Purging Disorder, Purging Disorder according to Keel & Striegel-Moore (2009), and Night Eating Syndrome.

The Munich ED-Quest has several superior characteristics
1.    It covers a wide range of symptoms related to eating disorders.
2.    Symptoms are assessed for current and past as well as lifetime
3.    Reliability and validity are checked
4.    Clinical assessments as well as factor analytic methods were applied resulting in the identification of important areas of psychopathology
5.    Besides quantitative information on the severity of eating disorders a solid data base for diagnostic classification according to DSM-5 is provided
6.    There exists a standardized algorithm for diagnostic classification of Anorexia Nervosa (restrictive and binge-eating/purging type), Bulimia Nervosa, Binge Eating Disorder, Avoidant/Restrictive Food Intake Syndrome, Rumination Syndrome, Atypical Anorexia Nervosa, Bulimia nervosa of low frequency and/or limited duration, Binge Eating Disorder of low frequency and/or limited duration, Purging Disorder, Purging Disorder according to Keel & Striegel-Moore (2009), and Night Eating Syndrome.

Time required

About 20 minutes.

Subscales

Measurement is made at two time points: severity of symptoms in the last three months before assessment (current), and assessment for the past worst status.
In a factor analysis of the Munich ED-Quest the following subscales were identified:
•    Preoccupation with Figure and Weight
•    Bingeing and Vomiting
•    Inappropriate Compensatory Behavior
•    Total Score derived from the items of the three subscales.
The same subscale pattern is utilized for the present and past state.

Data analysis

Standardized algorithms for computing sum scores and eating disorder diagnoses are available as paper forms and computer algorithms.

Norms

Comparison values and percentile norms of 605 males and females which were treated as in-patients because of their eating disorder, clinical controls (psychosomatic inpatients without eating disorder) as well as data on 547 healthy young women are available. Data on diagnostic subgroups Anorexia Nervosa and Bulimia Nervosa are also given.

Objectivity, Validity and Reliability

Objectivity regarding data collection, data analysis, and interpretation of the results are given.
Data on convergent and discriminative construct validity, test-retest reliability, and internal consistency are available. High diagnostic validity was confirmed by ROC analysis for subscales and comparison of DSM-5 diagnoses with SIAB-EX diagnoses.

Versions of the Munich ED-Quest in English and German language are available for free use in scientific studies and clinical practice. The relevant instruments are listed below:
•    Questionnaire
•    Subscale Scoring Sheet
•    Diagnostic Algorithm according to DSM-5 (present and past)
•    Percentile Norm Table

Munich ED-Quest - References

Fichter, M.M., Quadflieg, N., Gierk, B., Voderholzer, U. & Heuser, J. (2015). The Munich Eating and Feeding Disorder Questionnaire (Munich ED-Quest) DSM-5/ICD-10: Validity, Reliability, Sensitivity to Change, and Norms. European Eating Disorder Review, 23, 229 – 240.

Munich ED-Quest Downloads

You can download each component of the Munich ED-Quest in English and German language for free use in scientific studies and clinical practice .
Please note that the Munich ED-Quest is mainly designed for clinical research. Therefore, the inventory should be handled by experts with a psychological or psychiatric background.

B) Structured Inventory for Anorexic and Bulimic Eating Disorders SIAB-EX and SIAB-S

General Information

The SIAB is available as a structured clinical interview for experts (SIAB-EX) and as a parallel self-rating questionnaire (SIAB-S).

Application

The SIAB is an inventory for the assessment of eating disorders and other symptoms often associated with eating disorders (depression, anxiety) in adolescents and adults aged 12 to 65 years. Items on sexuality and partnership are also included. The SIAB-EX is applied in individual interview settings either face to face or by telephone by trained clinical expert interviewers. The SIAB-S is filled out by the patient or proband.

Fields of application

•    Diagnosis of eating disorders according to DSM-IV (APA, 1994) and ICD-10 (WHO, 1992) in clinical therapy. Identification of individual problem areas which should be adressed in therapy. The patient may fill-out the self-rating version before the first interview. This can be used as a basis of the first interview using the expert rating SIAB-EX.
•    Clinical research on the course of eating disorders and the effects and outcome of medical treatment and psychotherapy.
•    Determination of the phenotype in studies on the genetics of eating disorders.
•    Screening for eating disorders in epidemiological studies and identification of high-risk groups for eating disorders by the use of the self-rating SIAB-S. In a second stage diagnoses can be definitely confirmed by application of the expert interview SIAB-EX on individuals with high risk.

Content and scoring

The third revision of the SIAB-EX comprises 87 items. Some items are broken down in several partial items. For the diagnostic classification according to DSM-IV and ICD-10 the SIAB was supplemented with some items referring to specific aspects newly introduced by these recent diagnostic systems.

For most items the results are coded on a five-point scale ranging from 0 (symptom/problem not present) to 4 (symptom/problem very severely present). Generally the scale is defined as follows:

0 = symptom/problem area not present

1 = symptom/problem area slightly or rarely present

2 = symptom/problem area markedly or sometimes present

3 = symptom/problem area severely or frequently present

4 = symptom/problem area very severely or very frequently present

The SIAB contains some additional questions needed for the clear diagnostic classification according to DSM-IV and ICD-10. The content of other items refers to all areas relevant to eating disorders as well as other symptoms of disturbed behavior (depression, anxiety).

For most items the cross-sectional status (was the symptom present in the last 3 months) and the maximal expression of the symptom in the past is rated by the expert interviewer. The past rating will usually cover the time from prepuberty up to 3 months before the interview. The present status covers the maximal expression of the symptom/problem area in the last 3 months before the interview if not specified otherwise.

The following DSM-IV diagnoses (APA, 1994) can be made by the SIAB-EX or the SIAB-S: Anorexia Nervosa (restrictive and binge-eating/purging type); Bulimia Nervosa (purging/non-purging type): Binge Eating Disorder and Eating Disorders not otherwise specified.

According to ICD-10 (WHO, 1992) diagnoses of Anorexia Nervosa, Atypical Anorexia Nervosa and Bulimia Nervosa are possible.

The SIAB has several superior characteristics

1.    It covers a wide range of symptoms related to eating disorders (anorexia nervosa, bulimia nervosa, binge eating disorder, eating disorder NOS).
2.    Symptoms are assessed for current and past as well as lifetime
3.    Reliability and validity are checked
4.    Clinical assessments as well as factor analytic methods were applied resulting in the identification of important areas of psychopathology
5.    Besides quantitative information on the psychopathology a solid data base for diagnostic classification according to DSM-IV and ICD-10 is provided
6.    There exists a computer algorithm for diagnostic classification of anorexia nervosa (restrictive type, binge eating/purging type), bulimia nervosa (purging and non-purging type), and eating disorders not otherwise specified including binge eating disorder. A computer algorithm for the sum scores of all scales is also available.

Time required

Interview SIAB-EX 30-60 minutes, questionnaire SIAB-S about 30 minutes.

Subscales

Measurement is made at two time points: severity of symptoms in the last three months before assessment (current), and assessment for the past.

In a factor analysis of the SIAB-EX interview the following subscales for the past state were identified (Fichter et al., 1998, Fichter & Quadflieg, 2000, 2001):

I. Body Image and Slimness Ideal
II. General Psychopathology
III. Sexuality and Social Integration
IV. Bulimic Symptoms
V. Inappropriate Compensatory Behaviors to Counteract Weight Gain, Fasting and Substance Abuse
VI. Atypical Binges

Slightly different subscale patterns were found for the current state of the SIAB-EX and for the SIAB-S.

Data analysis

Standardized algorithms for computing sum scores and eating disorder diagnoses are available as paperforms and computer algorithms.

Norms

Comparison values of 377 males and females which were treated as in-patients because of their eating disorder as well as data on healthy women are available.
Data on diagnostic subgroups Anorexia Nervosa and Bulimia Nervosa according to DSM-IV are also given Results on English-speaking subjects with eating disorders can be provided (see Downloads normative data).

Objectivity, Validity and Reliability

Objectivity regarding data collection, data analysis, and interpretation of the results are given.

Data on convergent and discriminative construct validity, inter-rater reliability (SIAB-EX), internal consistency, and agreement of SIAB-EX and SIAB-S are available.


A free version of the SIAB in English is available for use in scientific studies and clinical practice. The relevant instruments are listed below:
•    SIAB Manual
•    SIAB-EX - expert interview
o    Interview
o    DSM-IV Algorithm
o    ICD-10 Algorithm
o    Scoring Sheet (SIAB-EX)
•    SIAB-S - self-rating questionnaire
o    Questionnaire
o    DSM-IV Algorithm
o    ICD-10 Algorithm
o    Scoring Sheet (SIAB-S)

 SIAB - References

1.    Fichter, M.M., Elton, M., Engel, K., Meyer, A.E., Mally, H. & Poustka, F. (1991). Structured Interview for Anorexia and Bulimia Nervosa (SIAB). Development of a New Instrument for the Assessment of Eating Disorders. International Journal of Eating Disorders, 10, 571-592.
2.    Fichter, M. M., Herpertz, S., Quadflieg, N. & Herpertz-Dahlmann, B. (1998). Structured Interview for Anorexic and Bulimic Disorders for DSM-IV and ICD-10: Updated (Third) Revision. International Journal of Eating Disorders, 24, 227 - 249.
3.    Fichter, M. & Quadflieg, N. (1999). Strukturiertes Inventar fuer Anorektische und Bulimische Essstoerungen (SIAB). Fragebogen (SIAB-S) und Interview (SIAB-EX) nach DSM-IV und ICD-10. Handanweisung. Hogrefe, Goettingen.
4.    Fichter, M. M. & Quadflieg, N. (2000). Comparing Self- and Expert Rating: A Self-report Screening Version (SIAB-S) of the Structured Interview for Anorexic and Bulimic Syndromes for DSM-IV and ICD-10 (SIAB-EX). European Archives of Psychiatry and Clinical Neuroscience, 250, 175 - 185.
5.    Fichter, M. M. & Quadflieg, N. (2001). The Structured Interview for Anorexic and Bulimic Disorders for DSM-IV and ICD-10 (SIAB-EX): Reliability and Validity. European Psychiatry, 16, 38 - 48.
6.    Fichter, M. & Quadflieg, N. (2001). Das Strukturierte Interview für Anorektische und Bulimische Ess-Stoerungen nach DSM-IV und ICD-10 zur Expertenbeurteilung (SIAB-EX) und dazugehoeriger Fragebogen zur Selbsteinschaetzung (SIAB-S). Verhaltenstherapie, 11, 314 - 325.
7.    Fichter, M. & Quadflieg, N. (2002). SIAB-S. Strukturiertes Inventar fuer Anorektische und Bulimische Essstoerungen (Fragebogen zur Selbstbeurteilung). In: Braehler, E. & Schumacher, J. (eds). Diagnostische Verfahren in der Psychotherapie. Hogrefe, Goettingen, 316-320.
8.    Fichter, M. & Quadflieg, N. (2003). Diagnostica e valutazione pscologica dei disturbi della condotta alimentare mediante l'applicazione del SIAB secondo DSM-IV e ICD-10. Noos, 1, 27-47.

SIAB Download

For the English, Italian and Spanish version of the SIAB you can download each component of the inventory. The English, Italian and Spanish version of the SIAB is free for use in scientific studies and clinical practice.
Please note that the SIAB is mainly designed for clinical research. Therefore, the inventory should be handled by experts with a psychological or psychiatric background.

C) Anorexia Nervosa Inventory for Self-rating (ANIS)

General Information

The ANIS is a self-rating questionnaire suitable for diagnostic purposes in clinical practice and research in subjects 12 to 65 years old. This paper-and-pencil instrument is dedicated to the use by psychologists, medical doctors, pedagogues and other health workers. It can be used for assessing possibly deviant eating behaviour, especially anorexia nervosa and bulimia nervosa. The ANIS covers attitudes and behaviours frequently found in eating disordered individuals and may be applied in single or group sessions.
The ANIS is available in German and English language. The copyright holder Prof. Dr. Manfred Fichter agrees to the use of the ANIS for research and medical purposes without cost to the user. The questionnaire and scoring sheet of the ANIS (English and German version) may be downloaded from these pages.

Scope of Application

•    Screening for eating disorder, e. g. in
o    unselected samples of epidemiologic community studies (students etc.)
o    in- and outpatients
•    Assessing severity of a verified eating disorder
•    Evaluating the course of a verified eating disorder
Due to the concise and clearly structured design of the ANIS application and scoring is quick and simple.
Among others aims of application of the ANIS may be documentation of the course of treatment, baseline evaluation of a patient, quality and process control during therapy, and evaluation of therapy outcome.

Time Needed for Application

About eight minutes for filling out the questionnaire and about four minutes for scoring.

Theoretical Background of the ANIS

The ANIS is partially based on the theoretical concepts of Hilde Bruch (1973) of body image disturbance, disturbed proprio- and interoceptive awareness, and an all-pervasive feeling of insufficiency in anorexia nervosa. During work on the ANIS the concept of disturbed proprio- and interoceptive awareness emerged as not suitable for assessment by self-rating questionnaire. Both other concepts of Hilde Bruch could be confirmed by factor analysis: a) figure consciousness, and b) insufficiency. Other areas covered by the ANIS concern typical symptoms which are frequently found to be associated with anorexia nervosa. Obsessive-compulsive behaviour is a common feature in anorexics and is assessed by the ANIS very concisely and related to eating behaviour. Feelings of negative effects of meals are a feature of all types of anorexia nervosa, while disinhibited eating binges mark the bulimic type of anorexia nervosa. Both features describe a substantial part of the disturbed attitudes and behaviours in anorexia nervosa. General questionnaires do not cover these areas at all. Additional items of the ANIS refer to sexual anxieties and rejection of intimate contacts frequently found in anorexia nervosa.

Items and Subscales

One hundred and fifty-two potential items were collected from clinical experience and the literature. Expert-rating resulted in 48 items rated as relevant and suitable for self-rating. The sample consisted of 101 female patients with anorexia nervosa and 118 age-matched female controls. Exploratory factor analysis (maximum likelihood, varimax rotation) resulted in a six-factor solution including 31 items. The number of factors extracted was determined by clinical interpretability, simple structure and reproducibility in different analyses. The work of Rathner and Rainer (1998) confirmed the six-factor solution in a sample of 1402 German speaking female student aged 11 to 20 years in the Southern Tyrol.
Items are assessed for the present state on a six grade scale coded from 0 to 5.
A six-factor-solution was derived from factor analysis by Fichter and Keeser (1980):
1.    Figure Consciousness (Items 3, 6, 9, 12, 15, 19, 21, 23, 27 and 29)
2.    Insufficiency (Items 2, 4, 14, 16, 20, 25 and 31)
3.    Anancasm (Items 1, 8, 11, 13 and 30)
4.    Negative Effects of Meals (Items 7, 17, 22 and 28)
5.    Sexual Anxieties (Items 5, 18 and 26)
6.    Binge-eating (Items 10 and 24)
A total scale is derived from items 1 to 31. Item 32 is a reliability item.
The questionnaire is in a closed format with graduations from
0 = applies not at all
1 = applies a little
2 = applies moderately
3 = applies considerably
4 = applies pretty much
5 = applies very much
Endorsed values are added to sum scores without weighting. No inversed items are included. Scoring of any subscale should not be made when subjects missed answering more than two (one for binge-eating scale) items. No total score should be computed if one or more sub scores could not be computed.

Data Analysis

No inverted items are included in the ANIS. The values endorsed are added to sub scores (see list above for items included in each subscale) and the total score. All items bear the weight of 1.

Norms

For each subscale means and standard deviations in anorexia nervosa and healthy controls are available (Fichter & Keeser, 1980). For female students age 11-20 means, standard deviations and percentiles separately for age groups, body weight and eating behaviour are available (Rathner & Rainer, 1997; Rathner & Waldherrr, 2005).

Objectivity, Validity and Reliability

Objectivity in applying, scoring and interpreting the ANIS is given. In the order listed above factors/subscales explained 10.1%, 8.5%, 7.1%, 9.1%, 5.2% and 4.9% of the total variance summing up to a total of44.9% of the variance explained. The factor solution was stable in three anorexic patient groups differentiated by symptom severity and in healthy controls. All items had loads above 0.40 in all samples except item 8 which was retained for clinical reasons.
Cronbach’s alpha of the total score was 0.89 to 0.94 in different samples and above 0.80 in the subscales except for anancasm.

ANIS - References

1.    Fichter, M.M. (1989). Instrumente zur Erfassung relevanter Symptombereiche bei Essstörungen (Anorexia-nervosa-Inventar zur Selbstbeurteilung) in Fichter, M.M. (Hrsg.) Bulimia nervosa. Enke Verlag Stuttgart 296-299
2.    Fichter, M.M. (1990). Self-Report Instruments for the assessment of relevant symptoms in eating disorders (Anorexia nervosa Inventory for self rating (Anis)) in Fichter, M.M. (Ed) Bulimia nervosa: Basic research, diagnosis and therapy. John Wiley & Sons. Chichester, UK
3.    Fichter, M., Keeser, W. (1980). Das Anorexia-nervosa-Inventar zur Selbstbeurteilung (ANIS). Archiv für Psychiatrie und Nervenkrankheiten, 228, 67-89. Springer Verlag
4.    Fichter, M.M., Elton, M., Sourdi, L., Weyerer, S., Koptagel-Ilal, G. (1988). Anorexia Nervosa in Greek and Turkish Adolescents. European Archives of Psychiatry and Neurological Science. 336, 200
5.    Fichter, M.M., Quadflieg, N., Georgopoulou, E., Xepapadakos, F., Fthenakis, W.E. (2005): Time Trends in Eating Disturbances in Young Greek Migrants. International Journal of Eating Disorders, 38, 310-322
6.    Rathner, G. (1992). Aspects of the natural history of normal and disordered eating and some methodological considerations. In: W. Herzog, H.C. Deter, W. Vandereycke (Hrsg.), The Course of Eating Disorders. Long-term follow-up studies of anorexia and bulimia nervosa. Springer, Berlin Heidelberg New York, pp 273-303.
7.    Rathner, G. & Meßner, K. (1993). Detection of eating disorders in a small rural town: an epidemiological study. Psychological Medicine, 23, 175-184.
8.    Rathner, G., Rainer, B. (1998). The Factor Structure of the Anorexia Nervosa Inventory for Self-Rating in a population-based sample and derivation of a shortened form. European Archives of Psychiatry and Clinical Neuroscience, 248, 171-179
9.    Rathner, G., Rainer, B. (1997). Normen für das Anorexia-nervosa-Inventar zur Selbstbeurteilung bei weiblichen Adoleszenten der Risikogruppe für Essstörungen. Klinische Psychologie, Psychiatrie & Psychotherapie. 45, 3, 302-318.
10.    Rathner, G., Rumpold, G. (1994). Convergent Validity of the Eating Disorder Inventory and the Anorexia Nervosa Inventory for Self-Rating in an Austrian Nonclinical Population. International Journal of Eating Disorders. 16, 4, 381-393
11.    Rathner, G. & Waldherr, K. (2005). Prozentrangnormen des ANIS. In B. Tuschen-Caffier, M. Pook & A. Hilbert (Hrsg.), Diagnostik von Essstörungen und Adipositas (S. 45-46). Göttingen: Hogrefe.

ANIS Downloads

You can download each component of the ANIS in English and German language for free use in scientific studies and clinical practice.
Please note that the ANIS is mainly designed for clinical research. Therefore, the inventory should be handled by experts with a psychological or psychiatric background.