Evidence-based assessment/Anorexia nervosa (assessment portfolio)

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What is a "portfolio"?[edit | edit source]

For background information on what assessment portfolios are, click the link in the heading above. Want even 'more' information about this topic? There's an extended version of this page here.

Preparation phase[edit | edit source]

Diagnostic criteria for anorexia nervosa[edit | edit source]

ICD-11 Criteria

Anorexia Nervosa is characterized by significantly low body weight, which is less than minimal normal/expected weight for the individual’s height, sex, age and developmental stage (body mass index (BMI) less than 18.5 kg/m2 in adults and BMI-for-age under fifth percentile in children and adolescents) that is not due to another health condition or to the unavailability of food. Low body weight is accompanied by a persistent pattern of behaviors to prevent restoration of normal weight, which may include behaviors aimed at reducing energy intake (restricted eating), purging behaviors (e.g., self-induced vomiting, misuse of laxatives), and behaviors aimed at increasing energy expenditure (e.g., excessive exercise), typically associated with a fear of weight gain. Low body weight or shape is central to the person's self-evaluation or is inaccurately perceived to be normal or even excessive.

Changes in DSM-5

  • The diagnostic criteria for anorexia nervosa changed slightly from DSM-IV to DSM-5. Summaries are available here and here.


Base rates of anorexia nervosa in different populations and clinical settings[edit | edit source]

This section describes the demographic setting of the population(s) sampled, base rates of diagnosis such as prevalence rates, country/region sampled, and the diagnostic method that was used. Using this information, clinicians will be able to anchor the rate of adolescent depression that they are likely to see in their clinical practice.

  • To see prevalence rates across multiple disorders, click here.
Demography Setting (Reference) Base Rate Diagnostic Method
Nationally representative US sample of adults Non-clinical: Population-based (NCS-R)[1] .9% Female, .3% Male World Health Organization-Clinical International Diagnostic Interview (WHO-CIDI)
Nationally representative US sample of adolescents Non-clinical: Population-based (NCS-A)[2] .3% Female, .3% Male WHO-CIDI
Nationally representative US sample of 9- and 10-year old children Non-clinical: US Population-based prevalence (Adolescent Brain Cognitive Development (ABCD) study[3] 0.1%, no sex differences DSM-5 using Kiddie Schedule for Affective Disorders and Schizophrenia (KSADS)
Latino Households in the US Non-clinical: Latinos in US[4] .12% Female, .03% Male WHO-CIDI
National probability sample of adult and adolescent African Americans and Caribbean Black people Non-clinical: African Americans and Caribbean Black people in the US (NSAL)[5] .14% Female, .2% Male WHO-CIDI
Asian American adults in US households Non-clinical: National Latino and Asian American Study (NLAAS) .12% Female, .05% Male WHO-CIDI
US African American college females Non-clinical; college students[6] .0% Eating Disorder Diagnostic Questionnaire (EDD-Q)
US Female Adolescents Non-clinical; Adolescents[7] .8% Eating Disorder Diagnosis Interview (EDDI)
US Division-I Varsity Student Athletes Non-clinical; student-athletes[8] .0% Eating Disorder Inventory-2 (EDI-2)
Active duty females in US Army, Navy,

Airforce, and Marines

Non-clinical; Military[9] 1.1% EDI-2
US Caucasian female same-sex twins Non-clinical; Commonwealth of Virginia Mid-Atlantic Twin Registry (MATR)[10] 1.62% (narrow), 3.70% (broad) Structured Clinical Interview for DSM Disorders (SCID)
South Australian older adolescents and adults Non-clinical; Health Omnibus Survey (HOS) .46% (3 months; combined) Eating Disorder Examination (EDE)
US Military Military[11] .04% (combined) ICD codes from electronic records
US Military Academy cadets Non-clinical; Military .02% (7 years) Female,

0.0% (7 years) Males

Eating Attitudes Test- 26 items (EAT-26)[12]
US Navy female nurses Non-clinical; Military 1.1% (current & past) Female DSM-III
US veterans Non-clinical; Military .04% Female, .005% Males ICD-9-CM
Active duty males in US Navy Non-clinical; Military 2.5% Males N/A
US alcohol-dependent adults from San Diego, St. Lois, Iowa City, Farmington, New York, & Indianapolis Clinical; Collaborative Study on the Genetics of Alcoholism (COGA)[13] 1.41% (lifetime) Female,

.00% (lifetime) Male

SSAGA
Healthcare provider records Non-clinical; healthcare members .0269% (current)
US high school students in west central Oregon Non-clinical; high school students . 00% (point), .45% (lifetime) Female

.00% (point), .00% (lifetime) Males

DSM-III-R4
Canadian treatment-seeking substance users Clinical; substance users .4% (lifetime), .3% (current) Female

.4% (lifetime), .3% (current) Males

DIS9
Europe
Adolescent females residing in Navarra, Spain Non-clinical; adolescents .3% Female EAT-403
Adolescents in secondary schools in Sør-Trøndelag, County in Norway Non-clinical; adolescents .7% (lifetime) Female, .2% Male SEDs10
Adolescents in a comprehensive school in Ostrobothnia district in Finland Non-clinical; adolescents .7% (point; age 15), 1.8% (lifetime, age 15), .00% (point, age 18), 2.6% (lifetime, age 18), .9% (3 years) Female

.00% (point & lifetime) Males

RAB-T11 & RAB-R12
Australia
Adolescent females residing in Victoria, Australia Non-clinical; adolescents .00% (full), 1.8% (partial) Female BET13
Central & South America
Mexican first & second year college females Non-clinical; college students .00% Female EAT-403
East Asia
Adolescent and adult Japanese patients at a university hospital Clinical; eating disorder patients .53% Female DSM-III-R4
Korean adults Non-clinical; Korean Epidemiologic Catchment Area (KECA) Study .1% (lifetime), .1% (12 months) Female

.2% (lifetime), .00% (12 months)

Males

K-CIDI15 2.1
Alcohol-dependent adults Centers participating in the Collaborative Study on the Genetics of Alcoholism in San Diego; St. Louis; Iowa City; Farmington, CN; New York; & Indianapolis 1.41% Females Semi-Structured Assessment for the Genetics of Alcoholism; criteria based on DSM-III-R

Prediction phase[edit | edit source]

Psychometric properties of screening instruments for anorexia nervosa[edit | edit source]

The following section contains a list of screening and diagnostic instruments for eating disorders, including anorexia nervosa. The Eating Disorder Diagnosis Scale (EDDS) outputs diagnostic categories of various eating disorders based on the DSM. The section includes administration information, psychometric data, and PDFs or links to the screenings.

  • Screenings are used as part of the prediction phase of assessment; for more information on interpretation of this data, or how screenings fit in to the assessment process, click here.
  • For a list of more broadly reaching screening instruments, click here.
Measure Format (Reporter) Age Range Administration/

Completion Time

Where to Access
Eating Disorder Examination Questionnaire (EDE-Q)[14] Questionnaire

(Patient)

14+ 15-20 min PDF
Assessment Center Online Version
Eating Disorder Diagnosis Scale (EDDS)[15] Questionnaire

(Patient)

13 - 65 10-15 min PDF
Eating Attitudes Test- 26(EAT-26; Adult version)[16]

Child Eating Attitudes Test - 26 (ChEAT-26; child version)[17]

Questionnaire (Patient) 13+ (adult version)

8 -13 (child version)

5-10 min PDFs

Note: Reliability and validity are included in the extended version. This table includes measures with Good or Excellent ratings.

Likelihood ratios and AUCs of screening instruments for anorexia nervosa[edit | edit source]

  • For a list of the likelihood ratios for more broadly reaching screening instruments, click here.
[18]Screening Measure (Primary Reference) AUC DiLR+ (Score) DiLR- (Score) Clinical Generalizability Where to access
Serum leptin level[19] 0.984 (N=139) 14.72 (<2.31) 0.10 (2.31+) Adolescent and adult patients in the acute phase of AN according to the DSM-IV and no AN pretreatment versus female volunteer university students who have no eating disorder diagnoses and are not overweight None
Body Mass Index (BMI)[19] 0.936 (N=139) 5.89 (<17.10) 0.11 (17.10+) Adolescent and adult patients in the acute phase of AN according to the DSM-IV and no AN pretreatment versus female volunteer university students who have no eating disorder diagnoses and are not overweight None
EAT-26 [18][20] .90 (N=129) 12.83 (20+) .24 (<20) Low-moderate: College women with no eating disorder versus college women with a DSM-IV eating disorder. Eating disorders were not separated. PDFs
EDE-Q [21] .96  [21](N=1170) 6.57 (2.3+)[22] 0.09 (<2.3)[22] Moderate: Dutch treatment-seeking females meeting DSM-IV criteria for an eating disorder versus female adult general population sample recruited through advertisements and personal contacts. Eating disorders were not separated. [21]

Moderate: “Clinically significant eating disorder” from a community sample versus female adults individuals without “clinically significant eating disorder” from same sample. Eating disorders were not separated.[22]

PDF

Interpreting anorexia nervosa screening measure scores[edit | edit source]

Prescription phase[edit | edit source]

Gold standard diagnostic interviews[edit | edit source]

  • For a list of broad reaching diagnostic interviews sortable by disorder with PDFs (if applicable), click here.

Recommended diagnostic interviews for anorexia nervosa[edit | edit source]

Diagnostic instruments for anorexia nervosa
Measure Format (Reporter) Age Range Administration/

Completion Time

Where to access
Eating Disorder Examination (EDE) [23] [24] Semistructured (child and adult) 8-16 (child version)

16+ (adult version)

45-75 minutes PDFs
Structured Clinical Interview for DSM-5-Clinician Version (SCID-5-CV)[25] Semistructured Interview (Adult ) 16+ Varies Website to purchase
Development and Well-Being Assessment (DAWBA) [26] Structured (child/adolescent and parent) 11-18 10-20 minutes for the eating disorder module English PDF

Additional languages

Note: Reliability and validity are included in the extended version. This table includes measures with Good or Excellent ratings.

Process phase[edit | edit source]

The following section contains a brief overview of treatment options for anorexia nervosa and a list of process and outcome measures for anorexia nervosa. The section includes benchmarks based on published norms for several outcome and severity measures, as well as information about commonly used process measures. It is worth noting, however, in inpatient or other acute care settings, weight restoration is the primary goal of treatment for anorexia nervosa, making body weight the most closely monitored process indicator. Process and outcome measures are used as part of the process phase of assessment. For more information on the differences between process and outcome measures, see the page on the process phase of assessment.

Process measures[edit | edit source]

Body weight is commonly monitored by clinicians throughout the AN treatment process as helping individuals regain and maintain a healthy weight is a primary treatment goal for AN. Many treatment centers have policies prohibiting patients from seeing their weight.

Motivational Stages of Change may be used to monitor individuals’ readiness to take action against eating disorder behaviors. It has demonstrated predictive validity in a sample of female adolescents attending eating disorder treatment groups.[27] See Appendix E.

Outcome and severity measures[edit | edit source]

This table includes clinically significant benchmarks for anorexia nervosa specific outcome measures

  • Information on how to interpret this table can be found here.
  • Additionally, these vignettes might be helpful resources for understanding appropriate adaptation of outcome measures in practice.
  • For clinically significant change benchmarks for the CBCL, YSR, and TRF total, externalizing, internalizing, and attention benchmarks, see here.
Clinically significant change benchmarks with common instruments for anorexia nervosa
Benchmarks Based on Published Norms
Measure Subscale Cut-off scores Critical Change
(unstandardized scores)
A B C 95% 90% SEdifference
EDE-Q [28] Global 1.4 3.2 2.3 .7 .6 .3
Restraint (-.3) 3.6 1.8 1.5 1.2 .8
Eating Concern .1 2.0 1.2 1.1 .9 .6
Weight Concern 1.5 3.9 2.6 1.0 .9 .5
Shape Concern 2.1 4.8 3.2 .9 .7 .4
EDE [28] Global 1.7 2.3 1.9 1.9 1.6 1.0
Restraint .3 3.3 1.9 1.8 1.5 .9
Eating Concern (-.5) .9 .5 .8 .7 .4
Weight Concern 2.0 2.8 2.4 1.3 1.1 .7
Shape Concern 2.0 3.2 2.6 1.2 1.0 .6
EAT-26 [29] Total 6.5 19.6 15.0 7.9 6.7 4.0

Note: “A” = Away from the clinical range, “B” = Back into the nonclinical range, “C” = Closer to the nonclinical than clinical mean.

Search terms: [Anorexia Nervosa OR eating disorder] AND [validity OR clinical significance] in Google Scholar

Treatment[edit | edit source]

More information on treatment for AN
  • Treatment of AN typically consists of restoring the individual to a healthy weight and addressing thoughts and behaviors which are related to the eating disorder. It may involve re-nutrition, psychotherapy, nutritional counseling, and medication.
  • Literature reviews of existing research indicate that evidence supporting AN treatment is lacking. A systematic review of AN treatment efficacy studies by Bulik[30] found that evidence supporting medications, medications and behavioral interventions, and behavioral interventions alone in adults is weak.
  • There is moderately strong evidence suggesting that behavioral interventions may be helpful for adolescents. In particular, adolescents may benefit from family therapy.
  • Clinical trials investigating AN treatment suffer from high rates of attrition, as key features of AN (e.g., denial, fear of weight gain) may contribute to low motivation for remaining in treatment.
  • More severe cases of AN may be treated in inpatient settings, which are equipped to manage the re-nutrition process and provide medical monitoring.
  • Partial hospitalization and intensive outpatient programs may provide intermediate levels of treatment intensity to assist individuals in the transition from intensive care to outpatient care after weight restoration.


External resources[edit | edit source]

  1. ICD-10 diagnostic criteria
  2. Find-a-Therapist
    1. This is a curated list of find-a-therapist websites where you can find a provider
  3. NIMH: Eating Disorders--About More Than Food and Eating Disorders
    1. These NIMH website posts provide more information on anorexia nervosa
  4. John's Hopkins Resource (guide about anorexia nervosa, treatment, and more)
  5. OMIM (Online Mendelian Inheritance in Man)
    1. Anorexia nervosa
  6. Effective Child Therapy page for anorexia nervosa
    1. Effective Child Therapy is website sponsored by Division 53 of the American Psychological Association (APA), or The Society of Clinical Child and Adolescent Psychology (SCCAP), in collaboration with the Association for Behavioral and Cognitive Therapies (ABCT). Use for information on symptoms and available treatments.

References[edit | edit source]

Click here for references
  1. Hudson, James I.; Hiripi, Eva; Pope, Harrison G.; Kessler, Ronald C. (2007-02-01). "The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication".Biological Psychiatry 61 (3): 348–358. doi:10.1016/j.biopsych.2006.03.040. ISSN 0006-3223. PMC 1892232. PMID 16815322
  2. Swanson, Sonja A.; Crow, Scott J.; Le Grange, Daniel; Swendsen, Joel; Merikangas, Kathleen R. (2011-07-01). "Prevalence and correlates of eating disorders in adolescents. Results from the national comorbidity survey replication adolescent supplement". Archives of General Psychiatry 68 (7): 714–723. doi:10.1001/archgenpsychiatry.2011.22. ISSN 1538-3636.PMID 21383252
  3. Rozzell, Kaitlin; Moon, Da Yeoun; Klimek, Patrycja; Brown, Tiffany; Blashill, Aaron J. (2019-01-01). "Prevalence of Eating Disorders Among US Children Aged 9 to 10 Years: Data From the Adolescent Brain Cognitive Development (ABCD) Study". JAMA Pediatrics 173 (1): 100. doi:10.1001/jamapediatrics.2018.3678. ISSN 2168-6203. PMID 30476983. PMC PMC6583451. http://archpedi.jamanetwork.com/article.aspx?doi=10.1001/jamapediatrics.2018.3678. 
  4. Alegria, Margarita; Woo, Meghan; Cao, Zhun; Torres, Maria; Meng, Xiao-li; Striegel-Moore, Ruth (2007-11-01). "Prevalence and correlates of eating disorders in Latinos in the United States".The International Journal of Eating Disorders. 40 Suppl: S15–21. doi:10.1002/eat.20406. ISSN 0276-3478. PMC 2680162. PMID 17584870
  5. Taylor, Jacquelyn Y.; Caldwell, Cleopatra Howard; Baser, Raymond E.; Faison, Nakesha; Jackson, James S. (2007-11-01). "Prevalence of eating disorders among Blacks in the National Survey of American Life". The International Journal of Eating Disorders. 40 Suppl: S10–14. doi:10.1002/eat.20451. ISSN 0276-3478. PMC 2882704. PMID 17879287
  6. Tyler ID. A true picture of eating disorders among African American women: a review of literature. ABNF J. 2003;14(3):73-4.
  7. Stice, E., Becker, C. B., & Yokum, S. (2013). Eating disorder prevention: Current evidence-base and future directions. Int. J. Eat. Disord. International Journal of Eating Disorders, 46(5), 478-485.
  8. Johnson C, Powers PS, Dick R. Athletes and eating disorders: the national collegiate athletic association study. Int J Eat Disord 1999;26:179e88.
  9. McNulty, PAF. (2001). Prevalence and contributing factors of eating disorder behaviors in active duty service women in the Army, Navy, Air Force and Marines. Military Medicine, 166(1), 53-58. 
  10. Kendler KS, Walters EE, Neale MC, Kessler R, Heath A, Eaves L. The structure of genetic and environmental risk factors for six major psychiatric disorders in women. Archives of general psychiatry. 1995;52:374–383.
  11. Antczak, Amanda J.; Brininger, Teresa L. (2008-12-01). "Diagnosed eating disorders in the U.S. Military: a nine year review". Eating Disorders 16 (5): 363–377. doi:10.1080/10640260802370523. ISSN 1532-530X. PMID 18821361. http://www.ncbi.nlm.nih.gov/pubmed/18821361. 
  12. admin. "EAT-26: Eating Attitudes Test & Eating Disorder Testing – Use the EAT-26 to help you determine if you need to speak to a mental health professional to get help for an eating disorder". Retrieved 2022-05-30.
  13. Schuckit, M. A.; Tipp, J. E.; Anthenelli, R. M.; Bucholz, K. K.; Hesselbrock, V. M.; Nurnberger, J. I. (1996-01-01). "Anorexia nervosa and bulimia nervosa in alcohol-dependent men and women and their relatives". The American Journal of Psychiatry 153 (1): 74–82. doi:10.1176/ajp.153.1.74. ISSN 0002-953X. PMID 8540597. http://www.ncbi.nlm.nih.gov/pubmed/8540597. 
  14. Cooper, Zafra; Fairburn, Christopher (1987-01). <1::aid-eat2260060102>3.0.co;2-9 "The eating disorder examination: A semi-structured interview for the assessment of the specific psychopathology of eating disorders". International Journal of Eating Disorders 6 (1): 1–8. doi:10.1002/1098-108x(198701)6:1<1::aid-eat2260060102>3.0.co;2-9. ISSN 0276-3478. http://dx.doi.org/10.1002/1098-108x(198701)6:1<1::aid-eat2260060102>3.0.co;2-9. 
  15. Stice, Eric; Telch, Christy F.; Rizvi, Shireen L. (2000). "Development and validation of the Eating Disorder Diagnostic Scale: A brief self-report measure of anorexia, bulimia, and binge-eating disorder.". Psychological Assessment 12 (2): 123–131. doi:10.1037/1040-3590.12.2.123. ISSN 1939-134X. http://doi.apa.org/getdoi.cfm?doi=10.1037/1040-3590.12.2.123. 
  16. Garner, David M.; Garfinkel, Paul E. (1979-05). "The Eating Attitudes Test: an index of the symptoms of anorexia nervosa". Psychological Medicine 9 (2): 273–279. doi:10.1017/s0033291700030762. ISSN 0033-2917. http://dx.doi.org/10.1017/s0033291700030762. 
  17. Almeida, M.C.; Carvalho, D.L.D.B.; Rigolino, R. (2012-07). "Reliability of a Brazilian version of children's eating attitude test". Neuropsychiatrie de l'Enfance et de l'Adolescence 60 (5): S158. doi:10.1016/j.neurenf.2012.04.196. ISSN 0222-9617. http://dx.doi.org/10.1016/j.neurenf.2012.04.196. 
  18. 18.0 18.1 Mintz, L. B.; O'Halloran, M. S. (June 2000). "The Eating Attitudes Test: validation with DSM-IV eating disorder criteria". Journal of Personality Assessment 74 (3): 489–503. doi:10.1207/S15327752JPA7403_11. ISSN 0022-3891. PMID 10900574. https://www.ncbi.nlm.nih.gov/pubmed/10900574. 
  19. 19.0 19.1 Föcker, M.; Timmesfeld, N.; Scherag, S.; Bühren, K.; Langkamp, M.; Dempfle, A.; Sheridan, E. M.; Zwaan, M. de et al. (2011-04-01). "Screening for anorexia nervosa via measurement of serum leptin levels". Journal of Neural Transmission 118 (4): 571–578. doi:10.1007/s00702-010-0551-z. ISSN 0300-9564. https://link.springer.com/article/10.1007/s00702-010-0551-z. 
  20. Garner, D. M.; Olmsted, M. P.; Bohr, Y.; Garfinkel, P. E. (1982-11-01). "The eating attitudes test: psychometric features and clinical correlates". Psychological Medicine 12 (4): 871–878. ISSN 0033-2917. PMID 6961471. http://www.ncbi.nlm.nih.gov/pubmed/6961471. 
  21. 21.0 21.1 21.2 Fairburn, C. G.; Beglin, S. J. (1994-12-01). "Assessment of eating disorders: interview or self-report questionnaire?". The International Journal of Eating Disorders 16 (4): 363–370. ISSN 0276-3478. PMID 7866415. http://www.ncbi.nlm.nih.gov/pubmed/7866415. 
  22. 22.0 22.1 22.2 Fairburn, C. G.; Beglin, S. J. (December 1994). "Assessment of eating disorders: interview or self-report questionnaire?". The International Journal of Eating Disorders 16 (4): 363–370. ISSN 0276-3478. PMID 7866415. https://www.ncbi.nlm.nih.gov/pubmed/7866415. 
  23. Assessment of disorders in childhood and adolescence. Eric Arden Youngstrom, Mitchell J. Prinstein, Eric J. Mash, Russell A. Barkley (Fifth edition ed.). New York. 2020. ISBN 978-1-4625-4365-6. OCLC 1160972551. https://www.worldcat.org/oclc/1160972551. 
  24. A guide to assessments that work. John Hunsley, Eric J. Mash. New York: Oxford University Press. 2008. ISBN 0-19-804245-0. OCLC 314222270. https://www.worldcat.org/oclc/314222270. 
  25. Shabani, Amir; Masoumian, Samira; Zamirinejad, Somayeh; Hejri, Maryam; Pirmorad, Tahereh; Yaghmaeezadeh, Hooman (2021-05). "Psychometric properties of Structured Clinical Interview for DSM‐5 Disorders‐Clinician Version (SCID‐5‐CV)". Brain and Behavior 11 (5). doi:10.1002/brb3.1894. ISSN 2162-3279. PMID 33729681. PMC PMC8119811. https://onlinelibrary.wiley.com/doi/10.1002/brb3.1894. 
  26. Assessment of disorders in childhood and adolescence. Eric Arden Youngstrom, Mitchell J. Prinstein, Eric J. Mash, Russell A. Barkley (Fifth edition ed.). New York. 2020. ISBN 978-1-4625-4365-6. OCLC 1160972551. https://www.worldcat.org/oclc/1160972551. 
  27. Gusella, Joanne; Butler, Gordon; Nichols, Laura; Bird, Debbie (2003-01-01). "A brief questionnaire to assess readiness to change in adolescents with eating disorders: its applications to group therapy". European Eating Disorders Review 11 (1): 58–71. doi:10.1002/erv.481. ISSN 1099-0968. http://onlinelibrary.wiley.com/doi/10.1002/erv.481/abstract. 
  28. 28.0 28.1 Mond, J. M.; Hay, P. J.; Rodgers, B.; Owen, C.; Beumont, P. J. V. (May 2004). "Validity of the Eating Disorder Examination Questionnaire (EDE-Q) in screening for eating disorders in community samples". Behaviour Research and Therapy 42 (5): 551–567. doi:10.1016/S0005-7967(03)00161-X. ISSN 0005-7967. PMID 15033501. https://www.ncbi.nlm.nih.gov/pubmed/15033501. 
  29. Mintz, L. B.; O'Halloran, M. S. (2000-06-01). "The Eating Attitudes Test: validation with DSM-IV eating disorder criteria". Journal of Personality Assessment 74 (3): 489–503. doi:10.1207/S15327752JPA7403_11. ISSN 0022-3891. PMID 10900574. http://www.ncbi.nlm.nih.gov/pubmed/10900574. 
  30. Bulik, Cynthia M.; Berkman, Nancy D.; Brownley, Kimberly A.; Sedway, Jan A.; Lohr, Kathleen N. (2007-05-01). "Anorexia nervosa treatment: a systematic review of randomized controlled trials". The International Journal of Eating Disorders 40 (4): 310–320. doi:10.1002/eat.20367. ISSN 0276-3478. PMID 17370290. http://www.ncbi.nlm.nih.gov/pubmed/17370290.