Protocol - Eating Disorders Examination - Bariatric Surgery Interview

The EDE rating scheme

If it is difficult to choose between two ratings, the lower rating (i.e. less symptomatic) should be chosen,

ORIENTATION TO THE TIME PERIOD

[These should be noted at the appropriate point on the calendar.]

[These should be noted at the appropriate place on the calendar.]

[Having oriented the subject to the specific time period being assessed, it is best to open the interview by asking a number of introductory questions designed to obtain a general picture of the subject’s eating habits. Suitable questions are suggested below.]

[The definition (and number) of weekdays and weekend days that best fits the patient’s lifestyle needs to be established at this point (e.g., check if the subject’s days off work regularly fall on weekdays).]

[Ask about months 2 and 3]

[Ask about months 4, 5 and 6]

*Over the past four weeks have you had problems with the small opening in your stomach becoming plugged, or food becoming stuck in the small opening of your stomach?

Which foods cause plugging?

0-feature absent
1 -feature present

What situations are associated with plugging?

0-feature absent
1 -feature present

Does plugging come as a surprise to you, that is, happen unexpectedly? [ ]

0-Never
1 -Sometimes
2-Always

How do you react?

0-feature absent
1 -feature present

*Over the past four weeks have you had problems with dumping during or up to 3 hours after food intake?

If Yes: Review SIGSTAD’S CLINICAL DIAGNOSTIC INDEX and rate if index total score is > 5.

Total Index Score [ ]

What foods cause dumping?

0-feature absent
1 -feature present

Does dumping come as a surprise to you, that is, happen unexpectedly? [ ]

0-Never
1 -Sometimes
2-Always

How do you react?

0-feature absent
1 -feature present

SIGSTAD’s CLINICAL DIAGNOSTIC INDEX: Weighting factors allocated to postprandial symptoms and signs of the dumping syndrome. Identify those that usually occur following sweet ingestion.

A clinical diagnostic index of +7 or above indicates dumping

• Indices of 5-6 indicates subthreshold dumping and should be rated
• Indices of + 4 or below indicates non-dumping.
• Eructation and vomiting are weighted negatively in order to distinguish dumping from the afferent loop and small stomach syndromes.

OTHER-SYMPTOMS

We are interested in possible changes in eating habits before and after you had bariatric surgery.

In the last 28 days, how would you describe your level of hunger?

How would you describe your appetite?

What are your favorite foods?

1.
2.
3.
4.
5.

Do you experience cravings for food? [ ] yes [ ] no

Please rate the following aspects of eating:

PATTERN OF EATING

*I would like to ask about your pattern of eating. Over the past four weeks which of these meals or snacks have you eaten on a regular basis?

[Rate each meal and snack separately, usually accepting the subject’s classification (within the guidelines above). Ask about weekdays and weekends separately. Meals or snacks should be rated even if they lead on to a "binge". "Brunch" should generally be classed as lunch. With the exception of nocturnal eating, rate up (i.e., give a higher rating) if it is difficult to choose between two ratings. Rate 8 if meals or snacks are difficult to classify (e.g., due to shift work).]

0 - Meal or snack not eaten
1 - Meal or snack eaten on 1 to 5 days
2 - Meal or snack eaten on less than half the days (6 to 12 days)
3 - Meal or snack eaten on half the days (13 to 15 days)
4 - Meal or snack eaten on more than half the days (16 to 22 days)
5 - Meal or snack eaten almost every day (23 to 27 days)
6 - Meal or snack eaten every day

[Rate the number of days on which picking (nibbling) has occurred. To count as picking (or nibbling) the episode of eating should have been unplanned, the amount eaten should have been uncertain at the time that the episode started, and the eating should have had a repetitious element to it. The total amount eaten should not have been trivial (e.g., not simply one edge of a piece of toast). Picking (nibbling) may be contrasted with eating a "snack". A snack is an episode of eating in which the amount eaten was modest (smaller than a meal), known at the outset with some certainty and without the repetitious element. Episodes of picking which merge into meals or "binges" should not be rated.]

0 - No nibbling
1 - Nibbling on 1 to 5 days
2 - Nibbling on less than half the days (6 to 12 days)
3 - Nibbling on half the days (13 to 15 days)
4 - Nibbling on more than half the days (16 to 22 days)
5 - Nibbling almost every day (23 to 27 days)
6 - Nibbling every day

Days Rate
[ ]     [ ]

*Over the past four weeks have you been consciously trying to restrict (cut back) the overall amount that you eat, whether or not you have succeeded?

Has this been to influence your shape or weight, or to avoid triggering an episode of overeating?

[Rate the number of days on which the subject has consciously attempted to restrict his or her overall food intake (i.e., energy intake), whether or not he or she has succeeded. The restriction should have affected a range of food items and not just certain specific foods (c.f., "Food avoidance"). This restriction should have been intended either to influence shape, weight or body composition, or to avoid triggering an episode of overeating, although this may not have been the sole or main reason. It should have consisted of planned attempts at restriction, rather than spur-of-the-moment attempts such as the decision to resist a second helping.]

0 - No attempt at restraint
1 - Attempted to exercise restraint on 1 to 5 days
2 - Attempted to exercise restraint on less than half the days (6 to 12 days)
3 - Attempted to exercise restraint on half the days (13 to 15 days)
4 - Attempted to exercise restraint on more than half the days (16 to 22 days)
5 - Attempted to exercise restraint almost every day (23 to 27 days)
6 - Attempted to exercise restraint every day

Days Rate
[ ]     [ ]

Some people consciously try to restrict their eating for other reasons. In the last 28 days have you been consciously trying to restrict the overall amount that you eat for the following reasons?

[Rate the number of days on which there has been at least eight hours abstinence from eating food (soup and milkshakes count as food, whereas drinks in general do not) during waking hours. It may be helpful to illustrate the length of time (e.g., 9 a.m. to 5 p.m.). The abstinence must have been at least partly self-imposed rather than being due to force of circumstances. It should have been intended to influence shape, weight or body composition, or to avoid triggering an episodes of overeating, although this may not have been the sole or main reason (i.e., fasting for religious or political reasons would not count). The rating should be compatible with those obtained earlier on "Pattern of eating".]

0 - No such days
1 - Avoidance on 1 to 5 days
2 - Avoidance on less than half the days (6 to 12 days)
3 - Avoidance on half the days (13 to 15 days)
4 - Avoidance on more than half the days (16 to 22 days)
5 - Avoidance almost every day (23 to 27 days)
6 - Avoidance every day

Days Rate
[ ]     [ ]

Some people have gone for periods of 8 or more waking hours without eating anything for other reasons. In the last 28 days have you gone 8 or more waking hours without eating anything for the following reasons?

[Rate the number of days on which the subject has had a definite desire to have a completely empty stomach for reasons to do with dieting, shape or weight. This desire should not simply be a response to episodes of perceived overeating; rather, it should exist between any such episodes. The rating of "Empty stomach" should not be confused with a desire for the stomach to feel empty or be flat (c.f., "Flat stomach".]

0 - No definite desire to have an empty stomach
1 - Definite desire on 1 to 5 days
2 - Definite desire on less than half the days (6 to 12 days)
3 - Definite desire on half the days (13 to 15 days)
4 - Definite desire on more than half the days (16 to 22 days)
5 - Definite desire almost every day (23 to 27 days)
6 - Definite desire every day

Days Rate
[ ]     [ ]

[Rate the number of days on which the subject has actively attempted to avoid eating specific foods (which he or she likes) whether or not he or she succeeded. The goal should have been to exclude the foods altogether and not merely to restrict their consumption. Drinks do not count as food. The avoidance should have been planned and intended either to influence shape, weight or body composition, or to avoid triggering an episode of overeating, although this may not have been the sole or main reason.]

0 - No attempts to avoid foods
1 - Attempted to avoid foods on 1 to 5 days
2 - Attempted to avoid foods on less than half the days (6 to 12 days)
3 - Attempted to avoid foods on half the days (13 to 15 days)
4 - Attempted to avoid foods on more than half the days (16 to 22 days)
5 - Attempted to avoid foods almost every day (23 to 27 days)
6 - Attempted to avoid foods every day

Days Rate
[ ]     [ ]

[Dietary rules should be rated as present if the subject has been attempting to follow "definite" (i.e., specific) dietary rules regarding his or her food intake. The rules should be self-imposed, although originally they may have been prescribed (i.e., prescribed rules can be rated if they have been adopted by the subject). They should have concerned what the subject should have eaten or when eating should have taken place. They might consist of a calorie limit (e.g., below 1,200 kcals), not eating before a certain time of day, not eating certain types of food or not eating at all. They should have been specific rules and not general guidelines. If the subject is aware that he or she has occasionally broken a personal dietary rule, this indicates that one or more specific rules has been present. In such cases the interviewer should ask in detail about the transgression in an attempt to identify the underlying rule. The rules should have been intended to influence shape, weight or body composition, although this may not have been the sole or main reason. Rate 0 if no dietary rule can be identified. If there has been more than one rule straddling different time periods within the four weeks, these periods should be combined to make the rating.]

0 - Has not attempted to obey such rules
1 - Attempted to obey such rules on 1 to 5 days
2 - Attempted to obey such rules on less than half the days (6 to 12 days)
3 - Attempted to obey such rules on half the days (13 to 15 days)
4 - Attempted to obey such rules on more than half the days (16 to 22 days)
5 - Attempted to obey such rules almost every day (23 to 27 days)
6 - Attempted to obey such rules every day

Days Rate
[ ]     [ ]

[Concentration is regarded as impaired if there have been intrusive thoughts about food, eating, or calories which have interfered with activities rather than one’s mind simply drifting off the matter at hand. Rate the number of days on which this has happened, whether or not bulimic episodes occurred.]

0 - No concentration impairment
1 - Concentration impairment on 1 to 5 days
2 - Concentration impairment on less than half the days (6 to 12 days)
3 - Concentration impairment on half the days (13 to 15 days)
4 - Concentration impairment on more than half the days (16 to 22 days)
5 - Concentration impairment almost every day (23 to 27 days)
6 - Concentration impairment every day

Days Rate
[ ]     [ ]

[Rate the number of days on which a definite fear of losing control over eating has been present, irrespective of whether the subject has felt he or she has been in control. "Loss of control" involves a sense that one will not be able to resist or stop eating. If the subject feels unable to answer this question because he or she has already totally lost control, rate 9.]

0 - No Fear of losing control
1 - Fear of losing control present on 1 to 5 days
2 - Fear of losing control present on less than half the days (6 to 12 days)
3 - Fear of losing control present on half the days (13 to 15 days)
4 - Fear of losing control present on more than half the days (16 to 22 days)
5 - Fear of losing control present almost every day (23 to 27 days)
6 - Fear of losing control present every day

Days Rate
[ ]     [ ]

Classificatory Scheme

Four forms of episodic "overeating" are distinguished. The distinction is based upon the presence or absence of two characteristics:

The classificatory scheme is summarised below.

Definitions

"Loss of control". The interviewer should ask the subject whether he or she experienced a sense of loss of control over eating at any point in the episode. If this is clearly described, "Loss of control" should be rated as present. Similarly, if the subject describes having felt "driven" or "compelled" to eat, "Loss of control" should be rated as present.

If the subject reports having had no sense of loss of control yet describes having felt unable to stop eating once eating had started or having felt unable to prevent the episode from occurring, "Loss of control" should be rated as present. If subjects report that they are no longer trying to control their eating because overeating is inevitable, "Loss of control" should once again be rated as present. Thus "Loss of control" may be rated positively even if the episode had been planned (i.e., the subject knew that he or she was going to overeat and had made provision for this).

The decision whether or not "loss of control" was present should be made by the interviewer; it does not require the agreement of the subject. If the interviewer remains in doubt, "Loss of control" should be rated as absent.

"Large amount of food". The decision whether or not the amount eaten was "large" should also be made by the interviewer; it does not require the agreement of the subject. The notion of "large" may refer to the amount of any particular type of food consumed or the overall quantity of food eaten. The amount should have been unequivocally large but it does not have to have been enormous. (Guidelines for what constitutes "large" are included at the end of the schedule.) In deciding whether the amount was "large", the interviewer should take into account what would be the usual amount eaten under the circumstances. This requires some knowledge of the eating habits of the subject’s general, but not necessarily immediate, social group (e.g., those of students, women in their 50s) as well as circumstances that tend to influence eating (e.g., Thanksgiving Day). What else was eaten during the day is not taken into account when making this rating, nor is the speed of eating or whether or not the subject subsequently spat out or vomited the food.

If the interviewer remains in doubt, the amount should not be classified as "large".

Interviewers should not share with the patient their view on the amount eaten and they should avoid using potentially emotive terms such as such as "binge" and "large".

The number of episodes of overeating. When calculating the number of episodes of overeating, the subject’s definition of separate episodes should be accepted unless, within a period of eating, there was an hour or more when the subject was not eating. In this case the initial episode should be regarded as having been completed. An exception is if the episode was temporarily interrupted by an outside event and then restarted afterwards, and it was experienced as one single episode (somewhat like operating the pause button on a tape recorder). When estimating the length of any gap, do not count the time spent vomiting. Note that "purging" (self-induced vomiting or laxative misuse) is not used to define the end of individual episodes of overeating.

Guidelines for Proceeding Through the Overeating Section

The interviewer should ask about each form of overeating. It is important to note that the four forms of overeating are not mutually exclusive: it is possible for subjects to have had several different forms within the time period being considered. With some subjects it is helpful to explain the classificatory scheme.

There are five steps in making this series of ratings:

1. In general it is best to start by asking the asterisked questions to identify the various types of perceived or true overeating that have occurred over the previous 28 days.
2. Each form should be noted down on the blank section of the coding sheet.
3. Then, detailed information should be obtained about a representative example of each form of overeating to decide whether or not it involved eating a "large" amount of food and whether or not there was "loss of control" (as defined above).
4. The next task is to establish for each form of overeating the number of days on which it occurred and the total number of occasions.
5. Finally, check with the subject to ensure that no misunderstandings have arisen (e.g., that no types of episode have been omitted).

It is advisable to make comprehensive notes.

[The asterisked questions should be asked in every case.]

Additional Probe Questions

[For subjective bulimic episodes to be eligible, they must have been viewed by the subject as having involved eating an excessive amount of food (i.e., they involved "overeating").]

To assess the amount of food eaten

To assess the social context

To assess "loss of control"

[For objective bulimic episodes, subjective bulimic episodes and eipisodes of objective overeating the following two ratings should be made:

Objective Bulimic Episodes (OBE)

Objective Overeating Episodes (OOE)

Subjective Bulimic Episodes (SBE)

Subjective Overeating Episodes (SOE)

Sense of Loss of Control While Eating (LOC)

[Only enter this module if the subject has had at least 12 objective bulimic episodes over the past three months. These questions need not be asked of patients who have regularly "purged" (i.e., vomited or misused laxatives or diuretics) defined as at least 24 episodes of one of these forms of behaviour over the past three months.]

Six-month Frequency of Binge Eating

[In line with the DSM-IV criteria for binge eating disorder, the focus of the six-month assessment is on the number of days on which objective bulimic episodes have occurred rather than on the number of individual episodes.

Since it is difficult for subjects to provide a six-month average, it is best to focus initially on the preceding two months (months 2 and 3) and then move on to the three months prior to that (months 4 to 6). The goal is to arrive at a six-month figure.]

[Now ask about the three months prior to that.]

[Finally, estimate the average number of days per week on which objective bulimic episodes have occurred over the past six months.]

[Rate between 0 and 7. Rate 9 if not asked.] [ ]

[Also rate the longest continuous period in weeks free (not due to force of circumstances, such as illness) from objective bulimic episodes over the past six months. Rate 99 if not asked.]

OBE

If yes:

[ ]

If yes:

[ ]

SBE

"Over the past 3 months has there been a period of two or more consecutive weeks in which you have not had an episode like [SBE]?"

If yes:

[ ]

If yes:

[ ]

Features Associated with Binge Eating (DSM-IV Appendix)

[Only rate these items if, on average over the past six months, there have been at least two days per week on which episodes of binge eating have occurred. Otherwise rate 9.]

[Rate each feature individually using the binary scheme below.]

0 - Feature not present
1 - Feature present

1 - Not at all
2 - Slightly
3 - Moderately
4 - Greatly
5 - Extremely

Now I would like to ask you a few questions regarding the course of your overeating episodes.

Over the last 28 days, on average, how long have your episodes of overeating lasted from beginning to end? [ ] [ ]hours [ ] [ ]minutes

Have the participant complete the section below.

__________________________________________________________________

Please rate how often you experience the following during a typical episode of overeating. Consider the following scale as you respond to the questions below and rate episodes that are 2 hours or less separately from those episodes that are more than 2 hours.

[Ask the Age of Onset questions, then continue with next section of the EDE]

[ ] [ ]

[ ] [ ]

[ ] [ ]

[ ] [ ]

At what age did your weight first became a problem? _________

What has been your heaviest weight? ___________

Directions: Please circle ONE answer for each question.

1. How hungry are you usually in the morning?

2. When do you usually eat for the first time?

3. Do you have cravings or urges to eat snacks after supper, but before bedtime?

4. How much control do you have over your eating between supper and bedtime?

5. How much of your daily food intake do you consume after suppertime?

6. Are you currently feeling blue or down in the dumps?

7. When you are feeling blue, is your mood lower in the:

8. How often do you have trouble getting to sleep?

9. Other than only to use the bathroom, how often do you get up at least once in the middle of the night?

10. Do you have cravings or urges to eat snacks when you wake up at night?

11. Do you need to eat in order to get back to sleep when you awake at night?

12. When you get up in the middle of the night, how often do you snack?

13. When you snack in the middle of the night, how aware are you of your eating?

14. How much control do you have over your eating while you are up at night?

15. How long have your current difficulties with night eating been going on?

___ mos. ___ year

[Only rate this item if there have been at least 12 days on which there have been objective bulimic episodes over the past three months.]

[Ask about actual food intake outside the objective and subjective bulimic episodes. Rate a typical day (whether or not it involves an episode of overeating). The dietary restriction should have been intended to influence shape, weight or body composition, although this may not have been the sole or main reason. Rate each of the past three months separately. Rate 9 if not asked.]

0 - No extreme restriction outside objective bulimic episodes
1 - Extreme restriction outside objective bulimic episodes
(i.e., purposeful low energy intake (<1,200 kcals))
2 - No eating outside objective bulimic episodes (i.e., purposeful "fasting")

month 1 [ ]

month 2 [ ]

month 3 [ ]

[NB: This is the first severity item. Rate the degree of concern about eating normal or less than normal amounts of food in front of others. Do not consider objective bulimic episodes or episodes of objective overeating. Also, do not consider concern restricted to family members if they are aware that the subject has an eating problem. One index of the severity of such concern is whether it has led to avoidance. In common with all severity items, the rating should represent the mode for the entire month. If the possibility of eating with others has not arisen, rate 9. ]

[ ]

0 - No concern about being seen eating by others and no avoidance of such occasions.
1 -
2 - Has felt slight concern at being seen eating by others
3 -
4 - Has felt definite concern at being seen eating by others
5 -
6 - Has felt extreme concern at being seen eating by others

[Rate the number of days on which there has been at least one episode of secret eating. Do not consider objective bulimic episodes or episodes of objective overeating. Secret eating refers to eating which is furtive and which the subject wishes to conceal because he or she does not want to be seen eating. Do not rate secrecy that stems from a desire not to be interrupted or a wish not to share food. Avoidance of eating in front of others should be rated under "Social eating". If the possibility of eating with others has not arisen, rate 9. ]

[ ]

0- Has not eaten in secret
1- Has eaten in secret on 1 to 5 days
2- Has eaten in secret on less than half the days (6 to 12 days)
3- Has eaten in secret on more than half the days (16 to 22)
4- Has eaten in secret almost every day (23 to 27 days)
5- Has eaten in secret almost every day (23 to 27)
6- Has eaten in secret every day

[NB: This rating is based on occasions. Rate the proportion of times on which feelings of guilt have followed eating. Do not consider objective bulimic episodes, but do consider other episodes of overeating. These feelings of guilt should relate to the effects of eating on shape, weight or body composition. Distinguish guilt from regret: guilt refers to a feeling that one has done wrong.]

[ ]

0 - No guilt after eating
1 -
2 - Has felt guilty after eating on less than half the occasions
3 -
4 - Has felt guilty after eating on more than half the occasions

5 -
6 - Has felt guilty after eating on every occasion

[Rate the number of discrete episodes of self-induced vomiting. Accept the subject’s definition of an episode. Rate 777 if the number is so great that it cannot be calculated. Rate 000 if no vomiting.]

Self Induced Vomiting: Weight and Shape Related

Which foods cause plugging?

How distressed were you about the vomiting? (Rate from 0 = not at all to 6 = extreme) [ ]

0 - Feature not present
1 - Feature present

Which foods cause plugging?

How distressed were you about the vomiting? (Rate from 0 = not at all to 6 = extreme) [ ]

[Rate the number of discrete episodes of spontaneous vomiting. Accept the subject’s definition of an episode. Rate 777 if the number is so great that it cannot be calculated. Rate 000 if no vomiting.]

Which foods cause plugging?

How distressed were you about the vomiting? (Rate from 0 = not at all to 6 = extreme) [ ]

0 - Feature not present
1 - Feature present

Which foods cause plugging?

How distressed were you about the vomiting? (Rate from 0 = not at all to 6 = extreme) [ ]

What Foods?

1.

2.

3.

4.

5.

Which foods cause plugging?

How distressed have you been about chewing and spitting?(0 = not at all 6 = extreme) [ ]

0 - Feature not present
1 - Feature present

To get the taste of foods that may cause plugging or dumping?" [ ]

Because you enjoy the sense of chewing? " [ ]

Other _________ [ ]

What Foods?

1.
2.
3.
4.
5.

Which foods cause plugging?

How distressed have you been about chewing and spitting? (0 = not at all 6 = extreme) [ ]

*Over the past four weeks have you ruminated food, that is, on purpose, brought food back up again, chewed and swallowed it again to influence your shape or weight?

What Foods?

1.
2.
3.
4.
5.

Which foods cause plugging?

How distressed have you been about (rumination)? [ ]

(0 = not at all 6 = extreme)

0 - Feature not present
1 - Feature present

To get the taste of foods that may cause plugging or dumping? [ ]

Because you enjoy the sense of chewing? [ ]

Other _________ [ ]

What Foods?

1.
2.
3.
4.
5.

Which foods cause plugging?

How distressed have you been about (rumination)?(0 = not at all 6 = extreme) [ ]

0 - Feature not present
1 - Feature present

[Rate the number of episodes of laxative-taking as a means of controlling shape, weight or body composition. This should have been the main reason for the laxative-taking, although it may not have been the sole reason. Only rate the taking of substances with a true laxative effect. Rate 00 if there was no laxative use or there is doubt whether the laxative-taking was primarily to influence shape, weight or body composition.]

Laxative Use: Weight and Shape Related

Which foods cause plugging?

[Rate the average number of laxatives taken on each occasion. Rate 999 if not applicable. Rate 777 if not quantifiable, e.g., use of bran.] [ ]

[Note the type of laxative taken.] Type __________

0 - Feature not present
1 - Feature present

Laxative Use: Not Weight and Shape Related

Which foods cause plugging?

[Rate the average number of laxatives taken on each occasion. Rate 999 if not applicable. Rate 777 if not quantifiable, e.g., use of bran.]

[ ]

[Note the type of laxative taken.] Type __________

[Rate the number of episodes of diuretic-taking as a means of controlling shape, weight or body composition. This should have been the main reason for the diuretic-taking, although it may not have been the sole reason. Only rate the taking of substances with a true diuretic effect. Rate 00 if there was no diuretic use or there is doubt whether the diuretic-taking was primarily to influence shape, weight or body composition.]

Which foods cause plugging?

[Rate the average number of diuretics taken on each occasion. Rate 999 if not applicable] [ ]

[Note the type of diuretic taken.] Type __________

0 - Feature not present
1 - Feature present

Which foods cause plugging?

[Rate the average number of diuretics taken on each occasion. Rate 999 if not applicable.] [ ]

[Note the type of diuretic taken.] Type __________

[Rate the number of days on which the subject has engaged in "driven" exercising. Such exercising should have had a "compulsive" quality to it. The subject should describe having felt compelled to exercise. Other indices of this compulsive quality are exercising even when it might have done one harm (e.g., when possibly injured) or having had a strong negative reaction to being unable to exercise. Only rate driven exercising that was predominantly intended to use calories or change shape, weight, or body composition. If in doubt, the exercising should not be classed as "driven". Rate 00 if no such driven exercising.]

Which foods cause plugging?

[Rate the average amount of time (in minutes) per day spent exercising in this way. Only consider days on which the subject exercised. Rate 999 if no such exercising.] [ ]

[Only ask this question if at least one of the key forms of weight-control behaviour has been rated positively at the specified severity level over the past three months (see the section on "Eating disorder diagnoses"). The five forms of behaviour are as follows:

− fasting

− self-induced vomiting

− laxative misuse

− diuretic misuse

− driven exercise

[Ask as for individual items. Ascertain the number of consecutive weeks over the past three months "free" (i.e., not above threshold levels) from all five forms of extreme weight-control behaviour. Do not

[Only rate dissatisfaction due to weight being regarded as too high. Assess the subject’s attitude to his or her weight and rate accordingly. In common with all severity items, the rating should represent the mode for the entire month. Only rate 4, 5 or 6, if there has been distress. Do not prompt with the terms "slight", "moderate" or "marked". This rating can be made with subjects who do not know their exact weight. Only rate 9 with subjects who are totally unaware of their weight.]

[ ]

0 - No dissatisfaction
1 -
2 - Slight dissatisfaction (no associated distress)
3 -
4 - Moderate dissatisfaction (some associated distress)
5 -
6 - Marked dissatisfaction (extreme concern and distress; weight totally unacceptable)

[Rate the number of days on which there has been a strong desire to lose weight. This rating can be made with subjects who do not know their exact weight. Only rate 9 with subjects who are totally unaware of their weight.]

0 - No strong desire to lose weight
1 - Strong desire on 1 to 5 days
2 - Strong desire on less than half the days (6 to 12 days)
3 - Strong desire on half the days (13 to 15 days)
4 - Strong desire on more than half the days (16 to 22 days)
5 - Strong desire almost every day (23 to 27 days)
6 - Strong desire every day

Days Rate
[ ]     [ ]

[Rate weight in kilograms. Rate 888 if the subject is not interested in his or her weight. Rate 777 if no specific weight would be low enough. Rate 666 if the subject is primarily interested in his or her shape but has some concern about weight (but not a specific weight).]

[ ]

[Calculate the approximate frequency that the subject has weighed himself or herself. Do not count being weighed by others. If the subject has not weighed himself or herself determine whether this is the result of avoidance. Rate 777 if it is due to avoidance.]

[ ]

[Rate the strength of negative reaction to the prospect of having to weigh once weekly (no more often, no less often) over the subsequent four weeks. This assumes that the subject would thereby be made aware of his or her weight. Positive reactions should be rated 9. In common with all severity items, the rating should represent the mode for the entire month. Ask the subject to describe in detail how he or she would have reacted and rate accordingly. Check whether other aspects of the subject’s life would have been influenced. Do not prompt with the terms "slight", "moderate" or "marked". If the subject would not have complied with such weighing because it would have been extremely disturbing, rate 6.]

[ ]

0 - No reaction
1 -
2 - Slight reaction
3 -
4 - Moderate reaction (definite reaction, but manageable)
5 -
6 - Marked reaction (pronounced reaction which would affect other aspects of the subject’s life)

[Ascertain what weight gain (from the subject’s average weight over the past four weeks) would have led to a marked negative reaction. Check several numbers. Be particularly careful to code the number correctly. This should represent the average degree of sensitivity for the entire month.]

[ ]

0 - 7 lb OR 3.5 kg (or more) would have generated a marked negative reaction, or no amount of weight gain would generate this type of reaction
1 - 6 lb or 3 kg would have generated a marked negative reaction
2 - 5 lb or 2.5 kg would have generated a marked negative reaction
3 - 4 lb or 2 kg would have generated a marked negative reaction
4 - 3 lb or 1.5 kg would have generated a marked negative reaction
5 - 2 lb or 1 kg would have generated a marked negative reaction
6 - 1 lb or 0.5 kg (i.e., any weight gain) would have generated a marked negative reaction

[Only rate dissatisfaction with overall shape or figure because it is viewed as too large. This dissatisfaction may include concerns about relative proportions of the body but not dissatisfaction restricted to specific body parts. Do not rate concerns about body tone. Assess the subject’s attitude to his or her shape and rate accordingly. In common with all severity items, the rating should represent the mode for the entire month. Only rate 4, 5, or 6, if there has been associated distress. Do not prompt with the terms "slight", "moderate" or "marked". Reports of disgust or revulsion should be rated 6.]

[ ]

0 - No dissatisfaction with shape
1 -
2 - Slight dissatisfaction with shape (no associated distress)
3 -
4 - Moderate dissatisfaction with shape (some associated distress)
5 -
6 - Marked dissatisfaction with shape (extreme concern and distress; shape totally unacceptable)

[Concentration is regarded as impaired if there have been intrusive thoughts about shape or weight which have interfered with activities rather than one’s mind simply drifting off the matter at hand. Rate the number of days on which this has happened.]

[ ]

0 - No concentration impairment
1 - Concentration impairment on 1 to 5 days
2 - Concentration impairment on less than half the days (6 to 12 days)
3 - Concentration impairment on half the days (13 to 15 days)
4 - Concentration impairment on more than half the days (16 to 22 days)
5 - Concentration impairment almost every day (23 to 27 days)
6 - Concentration impairment every day

[Rate the degree of importance the subject has placed on body weight and its position in his or her scheme for self-evaluation. The rating can be made with subjects who do not know their exact weight - the importance of their presumed weight can be rated. To make the rating, comparisons need to be made with other aspects of the subject’s life which are of importance in his or her scheme for self-evaluation (e.g., quality of relationships, being a parent, performance at work or in leisure activities). In common with all severity items, the rating should represent the mode for the entire month.

This can be a difficult item to rate. It is recommended that the two mandatory probe questions be asked in tandem. Then the interviewer should help the subject formulate his or her answer. It is then often a good idea to repeat the two probe questions to ensure that the subject has fully grasped what is being assessed. The questions in brackets should only be asked if the subject is denying that weight is important yet his or her behaviour suggests otherwise. Do not prompt with the terms "some", "moderate" or "supreme". If the subject has regarded both shape and weight as being of equivalent "supreme" importance, rate 6 on this item and on "Importance of shape".]

0 - No importance
1 -
2 - Some importance (definitely an aspect of self-evaluation)
3 -
4 - Moderate importance (definitely one of the main aspects of self-evaluation)
5 -
6 - Supreme importance (nothing is more important in the subject’s scheme for self-evaluation)

month 1 [ ]

month 2 [ ]

month 3 [ ]

[Rate the degree of importance the subject has placed on body shape and its position in his or her scheme for self-evaluation. To make this rating, comparisons need to be made with other aspects of the subject’s life which are of importance in his or her scheme for self-evaluation (e.g., quality of relationships, being a parent, performance at work or in leisure activities). In common with all severity items, the rating should represent the mode for the entire month.

This can be a difficult item to rate. It is recommended that the two mandatory probe questions be asked in tandem. Then the interviewer should help the subject formulate his or her answer. It is then often a good idea to repeat the two probe questions to ensure that the subject has fully grasped what is being assessed. The questions in brackets should only be asked if the subject is denying that shape is important yet his or her behaviour suggests otherwise. Do not prompt with the terms "some", "moderate" or "supreme". If the subject has regarded both shape and weight as being of equivalent "supreme" importance, rate 6 on this item and on "Importance of weight".]

0 - No importance
1 -
2 - Some importance (definitely an aspect of self-evaluation)
3 -
4 - Moderate importance (definitely one of the main aspects of self-evaluation)
5 -
6 - Supreme importance (nothing is more important in the subject’s scheme for self-evaluation)

month 1 [ ]

month 2 [ ]

month 3 [ ]

[Rate degree of acceptance. Note that acceptance is not the same as resignation. Complete acceptance is a positive state in which subjects do not view their shape or weight at all negatively. Moderate acceptance commonly includes a preference for being somewhat thinner or lighter (or heavier) although this preference must not have a significant effect on their psychological well-being. In common with all severity items, the rating should represent the mode for the entire month.]

[ ]

0 - Complete acceptance (viewed as fine; no desire for shape/weight to be different)
1 -
2 - Moderate acceptance (viewed as okay, although would prefer shape/weight to be different)
3 -
4 - Some acceptance (viewed as tolerable but would much prefer shape/weight to be different)
5 -
6 - No acceptance (viewed as intolerable)

[Rate the extent to which subjects have evaluated themselves negatively as a result of their shape (which may be viewed as too large or too small) or weight (too high or too low). Rate the more salient of the two. Note that this rating is not about control over eating.

Typical thoughts include the view that their shape or weight reflect lack of self-control or willpower, or they are evidence of lack of self-respect. The rating should be based on their own views and not those of others. In common with all severity items, the rating should represent the mode for the entire month.]

[ ]

0 - No shape or weight-related negative self-evaluation
1 -
2 - Some shape or weight-related negative self-evaluation (such thoughts have occurred at times but have either been infrequent or mild in intensity)
3 -
4 - Moderate shape or weight-related negative self-evaluation (such thoughts have occurred and have either been moderately frequent or intense or both)
5 -
6 - Extreme shape or weight-related negative self-evaluation (such thoughts have been frequent and intense)

[Rate the degree of importance the subject has placed on maintaining complete control over eating and its position in his or her scheme for self-evaluation. To make the rating, comparisons need to be made with other aspects of the subject’s life which are of importance in his or her scheme for self-evaluation (e.g., quality of relationships, being a parent, performance at work or in leisure activities). In common with all severity items, the rating should represent the mode for the entire month.

This can be a difficult item to rate. It is recommended that the second and third mandatory probe questions be asked in tandem. Then the interviewer should help the subject formulate his or her answer. It is then often a good idea to repeat these two probe questions to ensure that the subject has fully grasped what is being assessed. Do not prompt with the terms "some", "moderate" or "supreme".]

[ ]

0 - No importance
1 -
2 - Some importance (definitely an aspect of self-evaluation)
3 -
4 - Moderate importance (definitely one of the main aspects of self-evaluation)
5 -
6 - Supreme importance (nothing is more important in the subject’s scheme for self-evaluation)

[Rate the number of days on which a definite fear has been present. Exclude reactions to actual weight gain.]

0 - No definite fear of fatness or weight gain
1 - Definite fear of fatness or weight gain on 1 to 5 days
2 - Definite fear of fatness or weight gain on less than half the days (6 to 12 days)
3 - Definite fear of fatness or weight gain on half the days (13 to 15 days)
4 - Definite fear of fatness or weight gain on more than half the days (16 to 22 days)
5 - Definite fear of fatness or weight gain almost every day (23 to 27 days)
6 - Definite fear of fatness or weight gain every day

[Only rate discomfort about overall shape or figure because it is viewed as too large. The discomfort should not stem from sensitivity about specific aspects of appearance (e.g., acne) or from modesty. One index of the severity of such discomfort is whether it has led to avoidance (ask for examples, e.g., when washing). In common with all severity items, the rating should represent the mode for the entire month.]

[ ]

0 - No discomfort about seeing body
1 -
2 - Some discomfort about seeing body
3 -
4 - Definite discomfort about seeing body
5 -
6 - Extreme discomfort about seeing body

[Only rate discomfort arising from concerns about overall shape or figure (because it is viewed as too large). The discomfort should not stem from sensitivity about specific aspects of appearance (e.g., acne) or from modesty. One index of the severity of such discomfort is whether it has led to avoidance (ask for examples, e.g., when dressing). If the possibility of exposure has not arisen, rate 9. In common with all severity items, the rating should represent the mode for the entire month. ]

[ ]

0 - No discomfort about seeing body
1 -
2 - Some discomfort about seeing body
3 -
4 - Definite discomfort about seeing body
5 -
6 - Extreme discomfort about seeing body

[Only rate social discomfort arising from concerns about overall appearance (because it is viewed as too large). The discomfort should not stem from sensitivity about specific aspects of appearance (e.g., acne). One index of the severity of such discomfort is whether it has led to avoidance (ask for examples). In common with all severity items, the rating should represent the mode for the entire month. ]

[ ]

0 - No social discomfort
1 -
2 - Some social discomfort
3 -
4 - Definite social discomfort
5 -
6 - Extreme social discomfort

[Rate the number of days on which the subject has "felt fat" accepting his or her use of this expression. Distinguish "feeling fat" from feeling bloated premenstrually, unless this is experienced as feeling fat.]

0 ‑ Has not felt fat
1 - Has felt fat on 1 to 5 days
2 - Has felt fat on less than half the days (6 to 12 days)
3 - Has felt fat on half the days (13 to 15 days)
4 - Has felt fat on more than half the days (16 to 22 days)
5 - Has felt fat almost every day (23 to 27 days)
6 - Has felt fat every day

[Rate the number of days on which the subject has felt that part of her body is definitely too ’fat’.]

0 - No regional fatness
1 - Regional fatness on 1 to 5 days
2 - Regional fatness on less than half the days (6 to 12 days)
3 - Regional fatness on half the days (13 to 15 days)
4 - Regional fatness on more than half the days (16 to 22 days)
5 - Regional fatness almost every day (23 to 27 days)
6 - Regional fatness every day

Days Rate
[ ]     [ ]

[Rate the number of days on which the subject has actively monitored his or her shape with the intention of detecting any changes. The subject should believe that the method used is capable of detecting change.]

0 - No vigilance
1 - Vigilance on 1 to 5 days
2 - Vigilance on less than half the days (6 to 12 days)
3 - Vigilance on half the days (13 to 15 days)
4 - Vigilance on more than half the days (16 to 22 days)
5 - Vigilance almost every day (23 to 27 days)
6 - Vigilance every day

Days Rate
[ ]     [ ]

[Omit this item if the subject is obviously overweight and rate 7.]

[Rate the number of days on which the subject has had a definite desire to have a flat or concave stomach. Subjects who already have a flat stomach can be rated, whereas the desire to have a "flatter" (i.e., less protruding) stomach should not be rated.]

0 - No definite desire to have a flat stomach
1 - Definite desire to have a flat stomach on 1 to 5 days
2 - Definite desire to have a flat stomach on less than half the days (6 to 12 days)
3 - Definite desire to have a flat stomach on half the days (13 to 15 days)
4 - Definite desire to have a flat stomach on more than half the days (16 to 22 days)
5 - Definite desire to have a flat stomach almost every day (23 to 27 days)
6 - Definite desire to have a flat stomach every day

Days Rate
[ ]     [ ]

[Rate the strength of the subject’s concern about the proportion of fat in his or her body. Do not rate concern about "being fat" or concerns about particular parts of the body. Do not prompt with the terms ’slight’, ’moderate’ or ’marked’. In common with all severity items, the rating should represent the mode for the entire month.]

0 ‑ No concern about body composition
1 ‑
2 ‑ Slight concern about body composition (aware of the notion, but it is not of personal importance to the subject)
3 ‑
4 ‑ Moderate concern about body composition (clearly interested in composition of body and regularly thinks about it)
5 ‑
6 ‑ Marked concern about body composition (extreme interest in actual make‑up of body and frequently thinks about it)

Days Rate
[ ]     [ ]