E
Eating Disorder Diagnostic Scale
Cara Bohon1 and Eric Stice2
1
Stanford University School of Medicine,
Stanford, CA, USA
2
Clinical Psychology, Oregon Research Institute,
Eugene, OR, USA
Definition
The Eating Disorder Diagnostic Scale is a brief
self-report scale to diagnose eating disorders,
such as anorexia nervosa, bulimia nervosa, and
binge eating disorder. An updated version of the
scale was developed recently to incorporate
changes to the diagnostic criteria in the Diagnos-
tic and Statistical Manual of Mental Disorders
(5th ed.; DSM-5; American Psychiatric Associa-
tion 2013), including the addition of other spec-
ified eating disorders, such as atypical anorexia
nervosa and purging disorder.
Historical Background
When the first version of the Eating Disorder
Diagnostic Scale (EDDS) was developed,
research on eating disorders was challenged by
a lack of a self-report scale that provided a diag-
nosis for the eating disorders. Structured clinical
interviews, such as the Eating Disorder Examina-
tion (EDE; Fairburn and Cooper 1993) and the
# Springer Science+Business Media Singapore 2015
T. Wade (ed.), Encyclopedia of Feeding and Eating Disorders,
DOI 10.1007/978-981-287-087-2_109-1
Structured Clinical Interview for DSM (Spitzer
et al. 1990), were the only means to obtain a
diagnosis. Self-report measures, such as the
Bulimia Test-Revised (BULIT-R; Thelen
et al. 1991), Questionnaire on Eating and Weight
Patterns (QEWP; Spitzer et al. 1992), and the
Eating Disorder Examination-Questionnaire
(EDE-Q; Fairburn and Beglin 1994), provided
scaled scores of related cognitions, attitudes,
and behaviors rather than a diagnosis. The Ques-
tionnaire for Eating Disorder Diagnoses (QEDD;
Mintz et al. 1997) generates diagnoses, but is
lengthy, and the diagnoses are not well validated
with diagnostic interviews. In general, these self-
report measures are quite long and burdensome,
and the structured clinical interviews require
trained interviewers to complete. This made it
challenging to utilize these tools in large-scale
research studies with limited time and funds to
conduct lengthy interviews. A brief self-report
tool would address that concern, as well as pro-
vide a tool for repeated measures in longitudinal
studies, where long self-report measures or inter-
views create participant burden and, in clinical
settings, where a brief tool to identify eating
disorders could lead to earlier identification and
treatment referrals. Thus, Stice et al. (2000) cre-
ated the EDDS to address this need.
The EDDS was developed by adapting items
from structured clinical interviews (EDE and
SCID) and cross-referencing the diagnostic
criteria from the current DSM at the time
(DSM-IV) for anorexia nervosa, bulimia nervosa,
2 Eating Disorder Diagnostic Scale
and binge eating disorder. The initial version was
then sent to eating disorder experts in the field
who ensured that all diagnostic criteria were mea-
sured and no extraneous items were included.
They also offered suggestions on wording and
other items to include. Pilot participants then
provided feedback on the measure. This resulted
in a 22-item scale that provided diagnoses of
anorexia nervosa, bulimia nervosa, and binge
eating disorder, according to the DSM-IV
criteria. An initial study of reliability and validity
suggested good temporal reliability (mean
k = 0.80), criterion validity (with interview diag-
noses; mean k = 0.83), and convergent validity
with other validated measures of eating distur-
bances for diagnoses from the EDDS, as well as
test-retest reliability (r = 0.87), internal consis-
tency (mean a = 0.89), and convergent validity
with eating pathology for the overall symptom
composite generated by the EDDS (Stice
et al. 2000). A series of follow-up studies pro-
vided further evidence of the reliability and valid-
ity of the EDDS, including evidence that the
continuous symptom measure and the diagnoses
from the EDDS were sufficiently sensitive to
detect intervention effects in a controlled evalu-
ation of an eating disorder prevention interven-
tion (Stice et al. 2004). That manuscript also
reported evidence that the EDDS has good pre-
dictive validity, in that participants with higher
scores on the EDDS symptom composite showed
a stronger response to the eating disorder preven-
tion program relative to those with lower initial
scores and that elevated scores on this measure
predicted increased risk for subsequent onset of
binge eating and compensatory behaviors and
onset of major depression (Stice et al. 2004).
Sample items from the original EDDS based
on DSM-IV criteria include: “Has your weight
influenced how you think about [judge] yourself
as a person?,” “During the past 6 months, have
there been times when you felt you have eaten
what other people would regard as an unusually
large amount of food [e.g., a quart of ice cream]
given the circumstances?,” “How many times per
week on average over the past 3 months have you
made yourself vomit to prevent weight gain or
counteract the effects of eating?,” and “Over the
past 3 months, how many menstrual periods have
you missed?”
Current Knowledge
Since its development, the EDDS has been trans-
lated and validated in countries beyond the
United States. Specifically, a translated version
was tested in a community sample of Hong Kong
school children (boys and girls age 12–19). This
study found good internal reliability and con-
struct validity, but weak test-retest reliability
over 30 days (Lee et al. 2007). Interestingly, the
study also noted better test-retest reliability for
the more cognitive items assessing body dissatis-
faction and poorer reliability for behavioral
items. It is possible that eating disorder behaviors
are less stable constructs over 30 days than eating
disorder cognitions, particularly in a nonclinical
sample. Another study examined a Dutch version
of the EDDS in both a clinical and nonclinical
sample of young women (Krabbenborg
et al. 2012). This study found that the EDDS
showed internal consistency, 2-week test-retest
reliability, criterion validity (agreement between
the EDDS and EDE on diagnosis resulted in a
k = 0.89), and good convergent validity. Agree-
ment with EDE diagnoses was higher for AN and
BN diagnoses than for BED (Krabbenborg
et al. 2012). The original EDDS has also been
translated into French, Icelandic, Spanish, Finn-
ish, Japanese, and Pakistani, all of which are
freely available from Dr. Stice.
One study compared the reliability and valid-
ity of the EDDS in samples of white and black
women (Kelly et al. 2012). The EDDS showed
internal consistency in both black and white sam-
ples (k = 0.80 and k = 0.83, respectively) and
convergent validity. The study found that the
factor structure was not invariant across the sam-
ples, although the measure’s ability to differenti-
ate diagnostic groups was not examined in the
study (Kelly et al. 2012).
Since the original development of the scale,
the American Psychiatric Association published
the DSM-5, which altered the diagnostic criteria
for anorexia nervosa, bulimia nervosa, and binge
Eating Disorder Diagnostic Scale
eating disorder, as well as adding in “other spec-
ified feeding and eating disorders,” including
atypical anorexia nervosa, bulimia nervosa of
low duration or frequency, binge eating disorder
of low duration or frequency, purging disorder,
and night eating syndrome. Some researchers
began adapting the scoring of the original
EDDS to address this change (i.e., Flament
et al. 2015), but the specific items and structure
of the measure was not designed for these
updated criteria. Thus, a revised version of the
EDDS was created to better assess DSM-5 diag-
noses (see the complete revised measure and
coding at http://www.ori.org/sticemeasures/). To
do so, the original items of the EDDS were
directly compared to the DSM-5 criteria for the
three originally included diagnoses, anorexia
nervosa, bulimia nervosa, and binge eating disor-
der. Items that were no longer necessary were
noted, such as the item about missed menstrual
periods, as well as criteria that needed to be added
or items that needed to be revised to better reflect
the new diagnostic criteria. The authors revised
the measure collaboratively with Dr. Will Devlin
and utilized collective experience administering
the original EDDS to try to simplify the measure
further and increase ease of use. Keeping the
measure at a single page was a priority in order
to reduce participant burden. The measure was
then sent to top researchers in the field of eating
disorders, including some who had been a part of
the committee developing the diagnostic criteria
for the feeding and eating disorders in the
DSM-5. After incorporating their feedback and
input, the measure included 23 items, resulting in
diagnoses of AN, BN, BED, atypical AN,
low-frequency BN, low-frequency BED, purging
disorder, and night eating syndrome. Although
the DSM-5 also included avoidant restrictive
food intake disorder (ARFID), pica, and rumina-
tion disorder with the other eating disorders,
assessing those diagnoses was beyond the scope
of this measure.
Although the revised EDDS for DSM-5 has
not yet been validated in the same rigorous man-
ner as the original, one study compared this
revised version to a newly developed diagnostic
interview for DSM-5 diagnoses, the Eating
3
Disorder Assessment for DSM-5 (EDA-5;
Sysko et al. 2015). Kappas for the various diag-
noses between the two measures ranged from
0.27 to 0.77, with the greatest agreement in AN
and the lowest in “no diagnosis.” The greatest
disagreement between the two measures was in
missed diagnoses by the EDDS (n = 9 classified
as no diagnoses on EDDS, but had a diagnosis on
the EDA-5, 13 % of sample) and in those diag-
nosed as BN by the EDDS, but diagnosed BED
by the EDA-5 (n = 5, 7.2 % of sample). Missed
diagnoses on the EDDS were typically due to
denial of symptoms, and diagnoses of BN rather
than BED were due to the endorsement of com-
pensatory behaviors that was not present in the
diagnostic interview (Sysko et al. 2015).
Current Controversies
Symptoms assessed by questionnaire often show
poor agreement with diagnostic interviews (Berg
et al. 2011). Further, diagnostic interviews often
generate more accurate diagnoses than self-report
measures because trained interviewers can clarify
definitions and probe for additional information
as needed to ensure accurate diagnoses. This
could impact the decision to utilize a self-report
measure for diagnosis, although benefits of such a
measure for screening purposes and for large-
scale research still remain.
Future Directions
The revised EDDS – DSM-5 version will be
examined further for validity and reliability.
Some of these studies are already underway.
One challenge in validation is that there is not
yet a gold standard diagnostic tool for the DSM-5
diagnoses. Thus, discrepancies between diagno-
ses of various measures may relate to challenges
with either or both measures. As the field
develops stronger consensus on the assessment
of the diagnostic criteria for the DSM-5 eating
disorders, we will be better able to evaluate the
validity and overall success of this diagnostic
screening tool.
4 Eating Disorder Diagnostic Scale
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