REVIEW Open Access
Assessment of anorexia nervosa: an overview of
universal issues and contextual challenges
Lois J Surgenor1* and Sarah Maguire2
Abstract
Aim: Anorexia Nervosa (AN) is a complex and clinically challenging syndrome. Intended for specialist audiences,
this narrative review aims to summarise the available literature related to assessment in the adult patient context,
synthesising both research evidence and clinical consensus guidelines.
Method: We provide a review of the available literature on specialist assessment of AN focusing on common
trajectories into assessment, obstacles accessing assessment, common presenting issues and barriers to the
assessment process, the necessary scope of assessment, and tools and techniques. It describes the further step of
synthesising assessment information in ways that can inform resultant care plans.
Results: In addition to assessment of core behaviours and diagnostic skills, considerations for the expert assessor
include the functions of primary care, systemic and personal barriers, knowledge of current assessment tools and
research pertaining to comorbid pathology in AN, assessing severity of illness, role of family at assessment, as well
as medical, nutritional and compulsory elements of assessment.
Conclusion: Comprehensive assessment of AN in the current healthcare context still remains largely the remit of
the specialist ED clinician. Assessment should remain an on-going process, paying particular attention to available
empirical evidence, thereby reducing the gap between research and practice.
Keywords: Anorexia nervosa, Assessment, Eating disorders
Introduction
Most health workers recognise that anorexia nervosa
(AN) is a serious disorder that results in significant disability
and impaired quality of life. Unfortunately for some,
this disorder becomes a chronic or life-shortening illness.
It is well-established that AN has the highest mortality
rate of all psychiatric disorders [1]; compared with their
peers without the illness the risk of premature death is approximately
ten-fold in a person with AN [2]. Health consequences
are widespread, both in terms of direct physical
and mental health effects and economic costs to society
overall; a recent Australian analysis placed the total yearly
direct health system costs of AN at $59.8 million [3]. This
means that although AN and AN-like conditions are relatively
rare, severe and enduring forms of AN have impairment
outcomes comparable to people with moderately
severe depression and schizophrenia [3].
Assessment and a resulting early diagnosis become a
vital task for the health system and current research
continues to suggest that, although primary care is the
context of most presentation [4] areas with specialist
services have more than double the number of diagnosable
eating disorder (ED) cases, suggesting a sizeable
proportion of diagnoses do not occur until the specialist
service level [5]. What this means for both settings is
worth discussion, but regardless, assessment skills and
knowledge of the evidence base pertaining to diagnoses
remain an important part of the skill set of the specialist
clinician.
Regardless of the setting and complexity, there are
descriptions of ‘ideal practice’ in the assessment of the
disorder and associated health difficulties. However,
assessment approaches do vary, along with models of
service delivery, admission thresholds and the resources
available in specialist settings [5]. Such factors will influence
the composition of a multidisciplinary assessment
team. There are suggestions about what constitutes an
* Correspondence: lois.surgenor@otago.ac.nz
1Department of Psychological Medicine, University of Otago at Christchurch,
4 Oxford Terrace, Christchurch 8140, New Zealand
Full list of author information is available at the end of the article
© 2013 Surgenor and Maguire; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the
Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work is properly cited.
Surgenor and Maguire Journal of Eating Disorders 2013, 1:29
http://www.jeatdisord.com/content/1/1/29
‘ideal’ assessment team, but rarely will services have all
recommended components, and multiple tasks may fall to
‘mini teams’ [6]. There is however areas of general consensus
about many necessary and desirable tasks of assessment
and given the above constraints it often falls to the
specialist clinician working in relative isolation to be well
versed in all factors pertinent to a comprehensive assessment.
Focusing primarily on adult populations, this paper
aims to reduce the gap between research and practice
(as it relates to assessment of AN) by firstly providing a
comprehensive review of the current literature relating
to assessment pathways, barriers to assessment, diagnostic
issues, instruments for assessment of illness and
severity, role of the family at assessment, comorbid presentations
relevant to assessment, medical, nutritional
and compulsory assessment practises. Secondly, it discusses
the process of synthesising information gathered
at assessment for the purposes of formulation and
ultimately to direct treatment.
Pathways to assessment
Links with primary care providers
Given the scarcity of specialist ED services, most people
with AN will not be seen by a specialist service in the
first instance, and for a significant number, specialist
assessment may not occur at any stage. Half of those
with an ED are first diagnosed by their primary care
physician, although of concern a sizeable minority may
go through life without any help whether this is for AN
or other emotional problems [4]. General practitioners
(GPs) and other primary health care providers are best
placed to be the health practitioners first involved in
conducting preliminary assessments, providing initial
triage, and thereafter sharing case management with
other clinicians [7]. This is partly because people with
eating disorders attend GPs and other medical speciality
services more frequently than their peer group, albeit
often for conditions seemingly unrelated to the disorder.
The presence of an ED also increases the rate of presentations
to Emergency Departments [4]. In terms of accuracy
of diagnosis, AN is the ED most often accurately
diagnosed by primary care physicians [8]. Atypical cases,
or those who do not present with all diagnostic criteria,
can be misdiagnosed [9] or considered ‘less serious’
despite clearly having a clinically significant disorder that
squarely sits within the AN spectrum.
A number of obstacles arise for primary care health
professionals in their attempt to detect AN and refer on
to ED services. Setting obstacles include the limited consultation
time available and relatively limited exposure
to AN. Clinical obstacles include patient minimisation of
behavioural and psychological symptoms, the diversity of
symptom expression, and well-hidden symptoms [7].
Further, there may be difficulty in determining which
symptoms are most important in assessing medical
acuity or how severe the condition has become.
Systemic issues also contribute to rates of diagnosis
and their accuracy. GP education about risk factors and
early warning signs as well as screening instruments like
the SCOFF [10] can assist detection and management,
particularly where GPs are expected to coordinate and
manage concurrent medical and psychiatric conditions.
Close and regular liaison with ED specialists may
encourage more regular enquiry about eating difficulties
in those who frequently present with emotional and/or
physical problems. GPs are referral “gatekeepers” (whether
intended or otherwise), and ED clinicians have a role in
supporting and educating their colleagues about frontline
assessment practices and referral thresholds. In the
regions where there are specialist services, GPs are likely
to have greater awareness of eating disorders and in turn
refer to specialist services more frequently [6]. In any
event, presentation to primary care or emergency services
should always be used as an opportunity to introduce, or
re-engage with an ED clinician or ED service if one is
available.
Facilitating assessment following referral
Early identification and treatment of AN is consistently
argued as a means to reduce the duration of AN [11,12].
A systematic review of treatment seeking has recently
estimated that the median delay from onset to treatment
for AN is 15 years [13]. Identifying the barriers between
these two time points becomes pivotal, and will likely
vary. A significant minority of people referred for ED
problems fail to attend an initial assessment [14], and
further significant attrition occurs between assessment
and providing and/or completing treatment. The following
sections discuss common obstacles and possible solutions.
System and resource barriers
There are extensive system factors contributing to delays
in accessing assessment. The shortage of services often
results in prolonged waiting lists for assessment, meaning
that by the time of assessment, patients may be
demotivated or otherwise less likely to engage in what is
offered. Tatham et al. [15] trialled an active ‘opt in’
waitlist management strategy for an ED clinic, whereby
following initial assessment patients were required to
actively select to remain on the waitlist for treatment.
While ‘opting in’ letters may reduce the waiting time for
an assessment [16], this triage approach is not without
significant risk. Specifically, those most in need of
assessment may be the least able or willing to ‘opt in’.
Long assessment waiting lists are likely to pose a barrier
to engaging in any subsequent assessment - just as these
do in many other health settings. It has been reported by
patients that this can send a distorted message that the
Surgenor and Maguire J