Eating disorder symptom non-endorsers in hospitalised patients with anorexia nervosa: Who are they?

OBJECTIVE: Impaired insight and illness denial are common in anorexia nervosa (AN). Missing an AN diagnosis may delay treatment and negatively impact outcomes.

METHOD: The current retrospective study examined the prevalence and characteristics of AN symptom non-endorsement (i.e., scoring within the normal range on the Eating Disorder Examination Questionnaire [EDE-Q] or the Eating Disorder Examination [EDE] interview) in three independent samples of hospitalised patients with AN (N1  = 154; N2  = 300; N3  = 194). A qualitative chart review of a subsample of non-endorsers (N4  = 32) extracted reports of disordered eating behaviours observed by the treatment team.

RESULTS: The prevalence of non-endorsement ranged from 11% to 34% across sites. Non-endorsers were more likely to be diagnosed with AN restricting type (AN-R) and reported fewer symptoms of co-occurring psychopathology than endorsers. Groups benefitted equally from treatment. The qualitative chart review indicated that objective symptoms of AN were recorded by staff in over 90% of non-endorsers.

CONCLUSIONS: Eating disorder symptom assessments using the EDE-Q or EDE may miss symptomatology in up to a third of individuals hospitalised with AN. This study highlights the potential utility of multi-modal assessment including patient interviews, collateral informants, and behavioural observation to circumvent non-endorsement.