Validating the Eating Disorder Inventory-2 (EDI-2) in Sweden

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1 ORIGINAL RESEARCH PAPER Validating the Eating Disorder Inventory-2 (EDI-2) in Sweden L. Nevonen, and A.G. Broberg Department of Psychology, Göteborg University and Child and Adolescent Psychiatry Centre, the Queen Silvia Children s Hospital, Göteborg, Sweden ABSTRACT. Objective: To validate the Eating Disorder Inventory-2 (EDI-2) on a Swedish population by investigating differences between 1) young women with eating disorder symptoms (patients and non-patients), and normal controls and 2) patients with different eating disorder diagnoses, regarding symptom load and psychological characteristics. Another objective was to update EDI as a screening instrument. Method: Patients (n=194) with DSM- IV confirmed eating disorder diagnoses (anorexia nervosa AN; bulimia nervosa BN; eating disorder not otherwise specified, EDNOS) were compared with each other and with randomly selected and matched controls consisting of young women with self-reported eating disorder symptoms (n=51) and women without such symptoms (n=188). Results: In general, women with eating disorder problems, whether or not they were patients, scored significantly higher on both symptoms and personality characteristics compared to normal controls. Patients with DSM verified eating disorders did not differ from women with self-reported eating disorders symptoms on body dissatisfaction, perfectionism and impulsiveness. Women with self-reported symptoms did not differ from women without symptoms on interpersonal distrust and maturity fears. Amongst the patient groups, BN patients scored highest, and AN patients lowest, on self-reported pathology. Most of the EDI-2 scales and all the three indexes had acceptable specificity and sensitivity. Conclusion: EDI-2 discriminates well between women with eating disorder symptoms and normal controls, but responses from patients with AN should be interpreted with care. The EDI-2 indexes are especially recommended for screening purposes. Key words: Eating Disorder Inventory, EDI-2, anorexia nervosa, bulimia nervosa, EDNOS. Correspondence to: L. Nevonen, Ph.D, Anorexia- Bulimia Unit, Sahlgrenska University Hospital/East, SE Göteborg, Sweden. Received: February 8, 2000 Accepted: September 6, 2000 INTRODUCTION Disordered eating habits and body shape concerns, including dieting, binge eating and body dissatisfaction, are increasingly regarded as more or less normal, among young women in Western societies (1). Does this popular notion reflect reality or is it a myth? How big is the difference between symptoms of disordered eating in a random selection of young women compared to eating disorder (ED) patients? Are symptoms of disordered eating related to specific psychological characteristics also present in the general population, or is this relation confined to patients with a diagnosed disorder? The Eating Disorder Inventory (EDI/EDI-2) (2), being the most well known self-report measure both for disordered eating behaviour and for personality characteristics related to ED, is especially well suited to answer these questions. A literature search in Medline and Psychlit for the years 1990 to 1999, using EDI/EDI-2 as key word, gave 16 references. In 12 of these, patients with a variety of eating disorders were compared with normal controls, while 4 compared patients with different ED diagnoses with each other. In seven studies where women with a variety of ED were compared with controls without eating disorders (NORM), the ED group scored higher in four studies on all of the EDI s original eight sub-scales (Table 1) (3-6). The sub-scale ineffectiveness seemed to be especially typical of ED patients, since they scored significantly higher than the NORM-group in all studies (3-14). One study (7) compared patients with bulimia nervosa (BN) with a normal control group. BN patients scored significantly higher than the NORM group on all of the EDI s original eight sub-scales. The four studies which compared NORM with 59

2 L. Nevonen, and A.G. Broberg TABLE 1 Comparisons between eating disordered patients vs normal controls on the Eating Disorder Inventory. Source Country Study Normal Level Results Berman et al. (7) Canada BN vs N 30/30 Sub-scales* BN>N: 1-8 Boyadjieva et al. (8) Bulgaria AN vs N 22/212 Sub-scales* AN>N: 1, 2, 4, 7 Butow et al. (9) Australia ED vs N 98/133 Sub-scales* ED>N: 4, 6 Gilbert (10) USA ED vs N 45/26 Sub-scales* ED>N: 2, 4, 6-7, 8 Niv et al. (11) Israel AN vs N 29/67 Sub-scales** AN>N:1, 3-11 Pigott et al. (3) USA ED vs N 32/35 Sub-scales* ED>N: 1-8 Podar et al. (12) Estonia ED vs N 29/44 Sub-scales** ED>N:1, 2, 4, 6-11 Smolak et al. (4) USA ED vs N 38/134 Sub-scales* ED>N: 1-8 Steinhausen et al. (13) Germany AN vs N 37/280 Sub-scales* AN>N: 4, 5, 8 Sunday et al. (5) USA ED vs N 150/45 Sub-scales* ED>N: 1-8 Taylor et al. (14) England AN vs N 48/30 Sub-scales* AN>N: 1-8 Thiel et al. (6) Germany ED vs N 93/183 Sub-scales* ED>N: 1-8 *EDI sub-scales 1-8, ** EDI-2 sub-scales 1-11, ED=eating disorder; AN=anorexia nervosa; BN=bulimia nervosa; and N=normal control. anorexia nervosa (AN) patients (8, 11, 13, 14) revealed a mixed picture. In one study (14), all the eight original EDI scales differentiated between AN and NORM. In another study (11) which used the EDI-2, all subscales except the bulimia sub-scale differed significantly between AN and NORM. In two studies (8, 13) AN patients differed from NORM on all scales except body dissatisfaction and interpersonal distrust. Ineffectiveness differentiated between AN and NORM in all four studies. In three of the four studies comparing patients with different ED diagnoses, the diagnostic groups differed. Two studies compared AN and BN. One found no significant differences between the groups (10), whilst in the other BN patients scored higher than patients with AN on the symptom scales 1-3 (3). In one study, patients with EDNOS scored significantly higher compared to AN patients on body dissatisfaction and ineffectiveness (15). Comparing AN patients with and without purging behaviour, the former scored higher on the bulimia scale (16). Taken together these studies clearly indicate a significant difference between ED patients and normal controls with regard both to disordered eating behaviours and psychological characteristics. Differences between diagnostic groups are smaller and generally confined to the symptom scales which, by definition, should differentiate between patients with and without bulimic behaviours. Unfortunately, the statistical significance rather than the magnitude of differences has been the focus of most studies. Moreover, the majority of the studies are from Anglo-Saxon countries, making comparisons with other cultures difficult. Lastly, comparisons have been made between normal controls and ED patients, not between women with and without disordered eating behaviours. This is a serious shortcoming, since being a psychiatric patient, rather than having symptoms of disordered eating, can account for the differences, especially regarding psychological characteristics. In Sweden, Norring et al. validated the EDI in the middle of the 1980s (17). Their study was based on 158 ED patients (M=26 years, range 15-60), 139 university students (M=23.3 years, range 19-46), 84 former patients (M=25.8 years, range 13-49) and 44 people belonging to a Weight Watcher program (M=35.4 years, range 21-59). All groups, except the Weight Watchers, consisted of 60

3 EDI-2 in Sweden females. Patients scored themselves substantially higher, compared to controls and recovered patients, on all eight EDI scales, except on body dissatisfaction, in which Weight Watchers scored highest. Patients with BN scored higher than AN patients on the bulimia and body dissatisfaction scales. Patients who binged, regardless of diagnostic group, scored higher than those with restricted eating on drive for thinnes, bulimia and body dissatisfaction. Norring et al. also tested EDI as a screening method and suggested cut-off values for the various scales. This study, that was carried out with the original version of EDI about 15 years ago, is the only published study from the Nordic countries. It was based on a sample of relatively old patients, which is unfortunate especially regarding cut-off points for screening purposes (screening is most often carried out with women in their late teens or early adult years). More over, as normal control group Norring et al. used university students, rather than a random selection of women, with unknown presence/absence of eating disorder symptoms. A new Nordic study using the EDI-2, and where the shortcomings of the previous study are dealt with, is called for. The overall aim of the current study is to address issues regarding the link between disordered eating behaviours and certain psychological characteristics of psychotherapeutic importance, in patients as well as in the normal population. We first address whether young women with ED symptoms differ from normal controls, and if so, whether the differences are confined to women who have already become psychiatric patients. Secondly, we ask whether patients with different ED diagnoses differ from one another regarding psychological characteristics as measured with the EDI-2. A final aim of the current study is to update EDI as a screening instrument. MATERIALS AND METHODS Procedures All those aged 18 to 24 who seek help for some kind of ED at the Anorexia and Bulimia Unit of the Queen Silvia Children s Hospital, Göteborg, are asked to take part in an evaluation and follow-up study and 97% agree to do so. The examination begins with a semistructured interview. The interview takes about an hour, after which the patient s height and weight is measured. Before the treatment commences, a number of selfreports, including the EDI-2 and a background questionnaire, is administered. A normal control group was put together with the help of the county administration s civic registry. The EDI-2 and the background questionnaire were sent to the control group together with a prepaid return envelope. Two reminders were sent out and participants were not paid or otherwise rewarded for returning the questionnaires. The study was approved by the ethical committee of Sahlgrenska University Hospital, Göteborg, Sweden and written informed consent was obtained from all participants. Subjects The clinical group (PAT) consisted of 194 consecutive female patients (AN; n=26; BN, n=107; and EDNOS, n=61) aged 18 to 24 (M=20.9, SD.2.0). The normal controls were 239 young women (out of 315 approached). The response rate was 76% on average, and varied between 90% among Swedish citizens in socially well-to-do areas and 59% amongst immigrants in socially neglected areas. The controls were divided into two groups: a normal group without ED problems (NORM, n=188) and a group with self-reported eating disorder problems (NORM-Ed, n=51). All groups were similar with regard to the background variables: age, marital status, housing, education and occupation. Measures The Rating of Anorexia and Bulimia (RAB) Interview (18) is a newly developed, semi-structured Swedish interview instrument designed to map out ED psychopathology from a broad perspective, and assist the interviewer in reaching a DSM IV diagnosis of AN, BN or EDNOS. The revised version (RAB rev ) used in the current study has been shown to be reliable and valid (19). The EDI (2) is a self-report instrument developed to assess psychological characteristics and behaviour patterns relevant in various forms of eating problems (4, 20). It consists of a number of clinically and theoretically derived scales. EDI consisted originally of 64 statements, distributed over eight scales. The first three: drive for thin- 61

4 L. Nevonen, and A.G. Broberg ness, bulimia and body dissatisfaction together form an index of ED attitudes and behaviours. The other five are: ineffectiveness, perfectionism, interpersonal distrust, interoceptive awareness, and maturity fears. These measure more general psychological characteristics that have been theoretically and empirically associated with ED. EDI-2 (11) has added another three scales: asceticism, impulse regulation, and social insecurity. These scales are called preliminary and their reliability has not been clearly defined. The eleven scales can be combined into a symptom index (EDI 1-3), a personality index (EDI 4-11) and a total index (EDI 1-11). Several studies have established the reliability and validity of EDI s original eight scales (2, 21). This is corroborated in the current study, where seven show high (Chronbach s alpha 0.80) and one (perfectionism) acceptable (Chronbach s alpha = 0.71) internal consistency. The three preliminary scales are less well researched, and existing evidence points to their lower internal consistency. This is also substantiated in the current study (Chronbach s alpha ). The background questionnaire included questions regarding social background, such as education and occupation, from which the Hollingshead Four Factor Index of Social Position (22) was calculated. It also comprised a question regarding ED symptoms: Have you, according to your own understanding, had eating problems, i.e. engaged in self-starvation or binge eating? The response choice was Yes or No. If the response was Yes, the respondent indicated the type of problems and when they had occurred (self-starvation now, previously, now/previously or binge eating now, previously, now/previously). In addition, there was space for comments and explanations. The responses were used to divide the controls into a group without ED problems (NORM) and one with self-reported ED problems (NORM-Ed). The latter included all subjects who had reported current or historical problems of self-starvation or bingeing. In this randomly selected group of young women living in the city of Göteborg (Sweden s second largest city with approximately 500,000 inhabitants) 21% (n=51) reported that they had, or had had, problems with self-starvation or bingeing. RESULTS How do women with and without ED differ on the EDI-2 scales? Significant differences between the NORM, NORM-Ed and PAT groups appeared on all the fourteen EDI-2 variables. In nine, all three groups differed from each other (Table 2). The NORM group scored lowest, followed by the NORM-Ed and the PAT groups. On five scales and the three indexes, the mean differences between the PAT and NORM groups were more than two standard deviations. The PAT group scored significantly higher than the NORM-Ed on the three indexes and on all scales except body dissatisfaction, perfectionism, and impulsiveness. The NORM-Ed group scored higher than the NORM group on the three indexes, as well as on all scales except interpersonal distrust and maturity fears. Do women with different ED diagnoses differ according to the EDI-2? Table 3 shows the PAT group divided into AN (n=26), BN (n=107), and EDNOS (n=61). We found significant differences between the groups on 11 of the 14 investigated variables. Only ineffectiveness, maturity fears, and asceticism did not differentiate between any of the groups. BN patients scored higher than those with AN or EDNOS on all indexes and scales except maturity fears. The AN group scored lowest on all scales except interpersonal distrust and maturity fears. The EDNOS group placed itself between the BN and AN groups on all variables except interpersonal distrust, where it had the lowest score. EDI for Screening In Table 4, results using the cut-off points suggested by Norring et al. (17) are presented. The scales drive for thinness, ineffectiveness, and interoceptive awareness all have a sensitivity and specificity of at least 80 as in their study. For the other scales sensitivity varies between 28 (maturity fears) and 86 (drive for thinness), and specificity varies between 62 (body dissatisfaction) and 98 (bulimia). Table 5 presents suggestions for cut-off points for the three preliminary scales as 62

5 EDI-2 in Sweden TABLE 2 Comparisons between normal controls and eating disorder (ED) patients on the Eating Disorder Inventory-2 (EDI-2). Normal Normal ED patients controls controls with self- (n=194) (n=188) reported ED (n=51) EDI-2 sub-scales M SD M SD M SD F Post hoc* EDI 1 Drive for thinness ** 1<2<3 EDI 2 Bulimia ** 1<2<3 EDI 3 Body dissatisfaction ** 1<2,3 EDI 4 Ineffectiveness ** 1<2<3 EDI 5 Perfectionism ** 1<2, 3 EDI 6 Interpersonal distrust ** 1, 2<3 EDI 7 Interoceptive awareness ** 1<2<3 EDI 8 Maturity fears ** 1, 2<3 EDI 9 Asceticism ** 1, 2<3 EDI 10 Impulse regulation ** 1<2, 3 EDI 11 Social insecurity ** 1<2<3 EDI 1-3 Symptom index ** 1<2<3 EDI 4-11 Personality index ** 1<2<3 EDI Total index ** 1<2<3 *Post hoc Tukey s HSD. **p< well as for the symptom index (scales 1-3), personality index (scales 4-11) and total index (total score). Those for the three preliminary scales demonstrate specificity between 63 and 84 when one has striven for a high sensitivity and the lowest possible differences between sensitivity and specificity. Sensitivity varies between 74 and 90, and specificity between 63 and 84. Those for the three indexes all reach both sensitivity and specificity over 80%. DISCUSSION In a representative sample of young women from Göteborg, Sweden, as many as 21% reported that they had, or had had, problems with bingeing or self-starvation. In statistical terms, therefore, disordered eating behaviours can indeed be referred to as common. Those young women also differed from other normal controls in their personality characteristics as measured by the EDI-2. They scored substantially higher than the rest of the normal control group on a majority of these variables. They even scored as high as the patient group on some scales. Thus, a substantial proportion of normal young women have problems on a clinical level with regard to body dissatisfaction, perfectionism and impulse regulation, and higher than normal scores with regard to drive for thinness, bulimia, ineffectiveness, interoceptive awareness and social insecurity. These results extend the differences between ED patients and normal controls reported in other studies (4-6, 10) to individuals with ED problems from the general population. On the scales interpersonal distrust, maturity fears, and asceticism, women with and without ED problems from the random sample did not differ, but both groups scored significantly lower than patients from our ED clinic. Asceticism, in partic- 63

6 L. Nevonen, and A.G. Broberg TABLE 3 Comparisons between anorexia nervosa (AN), bulimia nervosa (BN) and eating disorder not otherwise specified (EDNOS) patients on the Eating Disorder Inventory-2 (EDI-2). AN EDNOS BN (n=26) (n=61) (n=107) EDI-2 sub-scales M SD M SD M SD F Post hoc EDI 1 Drive for thinness *** 1<2<3 EDI 2 Bulimia *** 1<2<3 EDI 3 Body dissatisfaction ** 1<2, 3 EDI 4 Ineffectiveness EDI 5 Perfectionism * 1<3 EDI 6 Interpersonal distrust *** 2<3 EDI 7 Interoceptive awareness * 1<3 EDI 8 Maturity fears EDI 9 Asceticism EDI 10 Impulse regulation * 1<3 EDI 11 Social insecurity * 1, 2<3 EDI 1-3 Symptom index *** 1<2<3 EDI 4-11 Personality index * 1, 2<3 EDI Total Index *** 1<2<3 *p<0.05, **p<0.001, ***p<0.0001, Post hoc Tukey s HSD. ular, differentiated patients from the other two groups. Asceticism is one of the new scales in EDI-2. Its specific ability to differentiate patients from non-patients has not been previously described. In what way do people with dissimilar ED diagnoses differ? Our study supports the notion that eating problems are not clearly distinguishable. They are better conceptualised as lying on a seriousness continuum with BN being the most serious as measured by the EDI-2 responses. On most scales, responses from BN patients were higher (more pathological) compared to AN patients. The AN group did not score higher than the BN group on any of the investigated variables, except maturity fears. Steinhausen (23) found similar results in a German sample which contrasted with findings by Norring et al. (17) and Garner et al. (2). Speculations about cultural differences regarding the attitudes of patients with AN, or differences between the German and the original English EDI versions were put forward by Steinhausen. It is very important to cast more light on this issue, especially since the relatively low EDI scores of our AN patients were in contrast to our clinical impression. Adult AN patients are generally regarded as seriously ill and as having difficulty admitting the seriousness of their situation (24). They may therefore underestimate and/or deny their problems when responding to self-report instruments. In our study, 92% were restricted AN (AN-r) patients who could have been especially prone to underreport their problems. If this is true of AN-r patients in general, it has important implications especially with regard to follow-up studies. A paradoxical effect of successful treatment could be that their EDI points increase as their tendency to deny their problems decreases. Only studies where AN patients self-reports are compared with other assessments before, during and after treatment can shed light on this issue. We tested the cut-off points suggested by 64

7 EDI-2 in Sweden TABLE 4 Testing cut-off scores for screening of the Eating Disorder Inventory (EDI), sub-scale 1-8. Cut-off score* Sensitivity in Specificity in normal patient group controles without eating disorder symptoms Drive for thinness (EDI 1) Bulimia (EDI 2) Body dissatisfaction (EDI 3) Ineffectiveness (EDI 4) Perfectionism (EDI 5) Interpersonal distrust (EDI 6) Interoceptive awareness (EDI 7) Maturity fears (EDI 8) * Persons scoring above this limit were defined as cases by Norring et al. (17). Norring et al. (17) for EDI-2 in screening and found that drive for thinness, ineffectiveness, and interoceptive awareness had sensitivity and specificity over 80. The scales for perfectionism, interpersonal distrust and maturity fears were the most problematic, primarily because of their low sensitivity values. Our suggested cut-off points for the symptom, personality, and total indexes displayed > 80% sensitivity and specificity, indicating that these indexes should work well for screening young women. It is worth noting that the personality index works just as well as the symptom index for screening purposes. CONCLUSIONS The current study supports earlier studies that have disclosed marked differences between young women with ED and normal controls in both disordered eating behaviour and ineffectiveness, interoceptive awareness and social insecurity (3-6, 9, 10, 12). We have expanded earlier studies by showing that these differences are not explained by patient status, since they also exist between women with and without self-reported ED in the general population. A feeling of ineffectiveness is one of the factors that distinguish young women with TABLE 5 Testing preliminary sub-scales and index cut-off scores for screening based on identification of at least 80% of patients in the patient group. Suggested Sensitivity in Specificity in normal cut-off score* patient group controls without eating disorder symptoms Asceticism (EDI 9) Impulse regulation (EDI 10) Social insecurity (EDI 11) Symptom index (EDI 1-3) Personality index (EDI 4-11) EDI Total *Persons scoring above this limit were defined as cases. EDI=Eating Disorder Inventory. 65

8 L. Nevonen, and A.G. Broberg ED, since it reflects low self-confidence, feelings of low worth and loneliness. Such experiences are especially common among teenage girls when they start to establish interpersonal relationships, a time that coincides with a bodily development to womanhood (25, 26). Criticism and belittling of oneself and one s body, combined with interpersonal difficulties during this sensitive developmental phase, can lead to disordered eating behaviours. The ED thus triggered results in a further reduction of self-confidence and self-esteem (27). Interoceptive awareness, which indicates lack of confidence and confusion in the identification of sensations of hunger and satiety as well as affective and bodily functions (2), also distinguishes young women with ED. Lastly, the social insecurity scale assesses feelings and beliefs that social relationships are insecure and tense, and disordered subjects prefer to be by themselves than with others (28). The interoceptive awareness and social insecurity present in people with ED symptoms may be a secondary consequence of the distress caused by the loss of control over eating, the impact of disturbed eating habits, concerns of body shape and weight and feelings of shame and guilt. The implications for treatment are that it is not enough to concentrate on the disordered eating behaviour of ED patients. Establishment of their self-confidence and their formation of close and lasting relationships with people of importance in their surroundings are equally desirable treatment goals. ACKNOWLEDGEMENTS The authors are indebted to Katarina Andersson for her assistance in the data collection and preparation of the manuscript. REFERENCES 1. Wilfley D.E., Rodin J.: Cultural influences on eating disorders. In: Brownell K.D., Fairburn C.G. (Eds.), Eating Disorders and Obesity: A Comprehensive Handbook. New York, Guilford Press, Garner D.M., Olmstedt M.P., Polivy J.: Development and validation of a multidimensional Eating Disorder Inventory for anorexia and bulimia. Int. J. Eat. Disord., 2, 15-34, Pigott T.A., Altemus M., Rubenstein C.S., Hill J.L., Bihari K., L Heureux F., Bernstein S., Murphy D.L.: Symptoms of eating disorders in patients with obsessive-compulsive disorder. Am. J. Psychiatry, 148, , Smolak L., Levin M.P.: Separation-individuation difficulties and the distinction between bulimia nervosa and anorexia nervosa in college women. Int. J. Eat. Disord., 14, 33-41, Sunday S.R., Halmi K.A., Werdann L., Levey C.: Comparison of body size estimation and Eating Disorder Inventory scores in anorexia and bulimia patients with obese, and restrained and unrestrained controls. Int. J. Eat. Disord., 11, , Thiel A., Broocks A., Ohlmeier M., Jacoby G.E., Schüssler G.: Obsessive-compulsive disorder among patients with anorexia nervosa and bulimia nervosa. Am. J. Psychiatry, 152, 72-75, Berman K., Lam R.W., Goldner E.M.: Eating attitudes in seasonal affective disorder and bulimia nervosa. J. Affective Disord., 29, , Boyadjieva S., Steinhausen H.-C.: The eating attitudes test and the eating disorders inventory in four Bulgarian clinical and non clinical samples. Int. J. Eat. Disord., 19, 93-98, Butow P., Beumont P., Touyz S.: Cognitive processes in dieting disorders. Int. J. Eat. Disord., 14, , Gilbert C.S.: Fear of success in anorexic young women. J. Adolesc. Health, 14, , Niv N., Kaplan Z., Mitrani E., Shiang J.: Validity Study of the EDI-2 in Israeli population. Isr. J. Psychiatry Relat. Sci., 35, , Podar I., Hannus A., Allik J.: Personality and affectivity characteristics associated with eating disorders: A comparison of eating disordered, weight-preoccupied, and normal samples. J. Pers. Assess., 73, , Steinhausen H.-C., Neumärker K.J., Vollrath M., Dudeck U., Neumärker U.: A transcultural comparison of the Eating Disorder Inventory in former east and west Berlin. Int. J. Eat. Disord., 12, , Taylor G.J., Parker J.D.A., Bagby R.M., Bourke M.P.: Relationships between alexithymia and psychological characteristics associated with eating disorders. J. Psychosom. Res., 41, ,

9 EDI-2 in Sweden 15. Geist R., Davis R., Heinmaa M.: Binge/purge symptoms and comorbidity in adolescents with eating disorders. Can. J. Psychiatry, 43, , Pryor T., Wiederman M.W., McGilley B.: Clinical correlates of anorexia nervosa subtypes. Int. J. Eat. Disord., 19, , Norring C., Sohlberg S.: Eating Disorder Inventory in Sweden: description, cross-cultural comparison, and clinical utility. Acta Psychiatr. Scand., 78, , Clinton D., Norring C.: The Rating of Anorexia and Bulimia (RAB) Interview: Development and preliminary validation. Eur. Eat. Disord. Rev., 7, , Nevonen L., Broberg A.G.: A measure for the assessment of eating disorders: reliability and validity studies of the rating of anorexia and bulimia interview-revised version (RAB rev ) (submitted). 20. Norring C., Sohlberg S., Rosmark B., Humble K., Holmgren S., Nordqvist C.: Ego functioning in eating disorders: Description and relation to diagnostic classification. Int. J. Eat. Disord., 8, , Eberenz K.P., Gleaves D.H.: An examination of the internal consistency and factor structure of the Eating Disorder Inventory-2 in a clinical sample. Int. J. Eat. Disord., 16, , Hollingshead A.B.: Four factor index of social position, unpublished manuscript, Yale University, Department of Sociology, New Haven, CT, Steinhausen H.-C.: Anorexia Nervosa: transcultural comparisons. Pediatrician, 12, , Beumont P.J.V., Russell J.D., Touyz S.W.: Treatment of anorexia nervosa. Lancet, 341, , Schwartz D.M., Thompson M.G., Johnson C.L.: Anorexia nervosa and bulimia: The socio-cultural context. Int. J. Eat. Disord., 1, 20-36, Brooks-Gunn J., Burrow C., Warren M.P.: Attitudes toward eating and body weight in different groups of female adolescent athletes. Int. J. Eat. Disord., 7, , Nevonen L., Broberg A.G.: Emergence of eating disorders: An exploratory study. Eur. Eat. Disord. Rev. (in press) 28. Beumont P.J.V.: The clinical presentation of anorexia nervosa and bulimia nervosa. In: Brownell K.D., Fairburn C.G. (Eds.), Eating Disorders and Obesity: A comprehensive handbook. New York, Guilford Press,

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