By Sarah O’Neil, MD (bio)
On another page on this website, I discussed the reasons why I think it is important for all mental health clinicians to screen all our patients for possible eating disorder—even if we ourselves don’t treat eating disorders.
On this page, I will discuss the “how-to”— how to screen all our patients in order to identify eating disorders and disordered eating so that they can be referred for appropriate treatment.
Whom should we screen for eating disorders?
ALL patients—irrespective of their age, race, ethnicity, gender, sexual orientation, weight, body, socioeconomic status or level of educational attainment. And, irrespective of the problem for which they came to us.
Eating disorders do not discriminate; they can affect anybody. They are no longer considered to be afflictions of perfectionist, white, upper-middle-class teenage girls.
Please remember—you can NOT tell be looking at someone (or by weighing them) whether or not they have an eating disorder.
Let’s screen everybody!
Nothing to SCOFF at
There is a simple 5-question screening tool called the SCOFF that was developed for use by both clinicians and non-clinicians like ballet instructors, wrestling coaches, personal trainers, teachers (Morgan et al., 1999).
The SCOFF has high sensitivity, is available at no cost, and is easy to incorporate into one’s routine initial intake evaluation.
Here is what the letters of the acronym SCOFF stand for:
S: Do you make yourself SICK because you feel uncomfortably full?
C: Do you worry you have lost CONTROL over how much you eat?
O: Have you recently lost more than ONE STONE (about 15 pounds) in a three-month period? (The SCOFF was developed in England)
F: Do you believe yourself to be FAT when others say you are thin?
F: Would you say that FOOD dominates your life?
So, we can remember the five screening questions in the SCOFF questionnaire by the keywords Sick, Control, One stone, Fat, and Food.
An answer of yes to TWO OR MORE of these five questions suggests the possibility of anorexia nervose or bulimia nervosa. That is, the screen is positive. This does not mean that the person HAS an eating disorder but only that further assessment for an eating disorder is warranted.
How well does the SCOFF do in screening for eating disorders?
By Rajnish Mago, MD (bio)
As discussed on another page on this website, the most important characteristic of a questionnaire to be used for screening is SENSITIVITY. That is, almost all persons with the condition being screened for should be picked up by the questionnaire even though the price to be paid for that is there will also be many false positives.
The sensitivity of any screening questionnaire depends in part on the population in which it was validated. The SCOFF has shown high sensitivity in screening various populations for possible eating disorders.
– When evaluated in a sample of women with an eating disorder who had been referred to a specialty clinic, it had a sensitivity of 100% for identifying both anorexia nervosa and bulimia nervosa (Morgan et al., 1999). In my opinion, identifying 100% of the cases is not surprising since patients referred to a specialty clinic probably had more clear-cut illness.
– When evaluated in unselected women who came to a primary care clinic and agreed to participate in the study, it had a sensitivity of 85% (Luck et al., 2002). It identified all the cases of anorexia nervosa and bulimia nervosa but missed 2 of the 9 cases of eating disorder not otherwise specified.
Since the SCOFF questionnaire was developed before binge-eating disorder came into use in our official nomenclature, it was designed to screen for anorexia nervosa and bulimia nervosa but not for binge-eating disorder. Its sensitivity for identifying binge-eating disorder is not known.
While there are other screening questionnaires for eating disorders (e.,g., the Eating Disorders Examination-Questionnaire), the SCOFF has the advantage of being short and most convenient for widespread use.
Administer verbally or orally?
By Rajnish Mago, MD (bio)
A small study found that, in general, there was high agreement between the SCOFF questionnaire administered orally or in writing (Perry et al., 2002).
But, when subjects were given the SCOFF in writing and filled it out on their own, the scores were higher. The authors concluded that this suggests that subjects may be more willing to disclose symptoms suggestive of an eating disorder when asked the questions on a written form than when asked the same questions face to face. This is similar to the findings of other studies that patients are more willing to reveal sexual problems on written questionnaires than when asked orally face to face.
Having patients do screening questionnaires in writing on their own time before they see us for the evaluation is also more time-efficient, so I recommend that we should routinely ask all patients who see us to complete the SCOFF questionnaire, along screening questionnaires for other conditions. On another page on this website, I will discuss which conditions we should routinely screen for by using written questionnaires (on paper or electronically) during our initial evaluations.
Translations into other languages
By Rajnish Mago, MD (bio)
The SCOFF has become widely adopted as a screening questionnaire for eating disorders and the original English version has been validated in some countries outside of the United Kingdom (e.g., Wan Wahida et al., 2017).
I am not aware of a specific study validating the SCOFF in the United States. But, probably the only important change from British English would be to change the wording from “one stone” to “15 pounds”
It has also been translated into several other languages. Our readers who see patients who prefer one of these languages to English can obtain the SCOFF questionnaire in the following languages:
Arabic (Aoun et al., 2015)
Catalan (Muro-Sans et al., 2008)
Chinese (Leung et al., 2009; Liu et al., 2015)
Danish (Lichtenstein et al., 2017)
Finnish (Lähteenmäki et al., 2009)
German (Richter et al., 2017)
French (Garcia et al., 2010, 2011)
Spanish (Garcia-Campayo et al., 2005)
Important essential tips on screening for eating disorders
By Sarah O’Neil, MD (bio)
Here are two more questions that we want you to ask in addition to the five questions of SCOFF and some important tips about how to ask the questions.
– While the team that developed SCOFF recommended a cut off of two ore more “Yes” answers (as discussed above), there isn’t a single question out of the five SCOFF questions a person could answer “Yes” to that wouldn’t raise a red flag for me and warrant further evaluation. Agree?
– Along with the five SCOFF questions, asking another question increases the sensitivity of our screening for bulimia nervosa: “Do you eat in secret?”
– A “yes” to the question “Do you eat in secret?” or to “Do you worry you have lost control over how much you eat?” (one of the five SCOFF questions) should prompt further assessment for possible binge-eating disorder because these are two of the diagnostic criteria for binge-eating disorder.
– But, another single question should be asked because it specifically screens for current binge-eating disorder. The question is: “During the last 3 months, did you have any episodes of excessive overeating (i.e., eating significantly more than what most people would eat in a similar period of time)?” This question is the first question of the Binge-Eating Disorder Screener (BEDS-7; Herman et al., 2016). In the BEDS-7 questionnaire, if a person says “No” to this question, the other six questions are not asked. Screening for binge-eating disorder will be discussed in more detail on another page on this website.
– So, finally, we end up with a total of 7 questions to screen for eating disorders: the 5 SCOFF questions plus “Do you eat in secret” plus the question specifically for binge-eating disorder.
– It’s also worth saying that screening for a possible eating disorder doesn’t have to be only a one-time thing. If we aren’t convinced that the person doesn’t have an eating disorder or have a gut feeling about it (or seriously crave bacon double cheeseburgers after sitting with a patient :-)), we should revisit the screening questions with that patient, in whole or in part, perhaps using different wording from the first time.
– In my experience, people will happily tell me all about their food preoccupation and “clean” eating but they are more likely to disclose binging or purging if I ask gently and normalize it to some extent. For example, we may say something like, “It can be pretty common for someone who has been dieting to get so hungry they overeat. That’s what our body is made to do to keep us alive since it can’t tell the difference between a diet and a famine. Does that ever happen to you?”
Next, please click on the links below to read these two articles that are directly related to what was discussed on this page:
How to screen for binge-eating disorder
How to evaluate persons who have or may have an eating disorder
Related Pages
Why it is important for all of us to screen for eating disorders
How to screen for binge-eating disorder
How to evaluate persons who have or may have an eating disorder
Clinicians’ guide to screening tests in mental health
Binge-Eating Disorder
New medication approved by the FDA for Binge-Eating Disorder
Yale Food Addiction Scale
Instruction sheet for the Yale Food Addiction Scale
Should we prescribe medications for weight loss?
Why it is important to treat obesity
Medications for the treatment of obesity: Overview
Melanocortin 4 receptor (MC4R) and weight gain
What are the BEST books on each topic related to psychiatry/ mental health?
References
Aoun A, Azzam J, Jabbour FE, Hlais S, Daham D, Amm CE, Honein K, Déchelotte P. Validation of the Arabic version of the SCOFF questionnaire for the screening of eating disorders. East Mediterr Health J. 2015 Aug 27;21(5):326-31. PubMed PMID: 26343121.
Garcia-Campayo J, Sanz-Carrillo C, Ibañez JA, Lou S, Solano V, Alda M. Validation of the Spanish version of the SCOFF questionnaire for the screening of eating disorders in primary care. J Psychosom Res. 2005 Aug;59(2):51-5. PubMed PMID: 16185998.
Garcia FD, Grigioni S, Allais E, Houy-Durand E, Thibaut F, Déchelotte P. Detection of eating disorders in patients: validity and reliability of the French version of the SCOFF questionnaire. Clin Nutr. 2011 Apr;30(2):178-81. doi: 10.1016/j.clnu.2010.09.007. Epub 2010 Oct 25. PubMed PMID: 20971536.
Garcia FD, Grigioni S, Chelali S, Meyrignac G, Thibaut F, Dechelotte P. Validation of the French version of SCOFF questionnaire for screening of eating disorders among adults. World J Biol Psychiatry. 2010 Oct;11(7):888-93. doi: 10.3109/15622975.2010.483251. PubMed PMID: 20509759.
Hill LS, Reid F, Morgan JF, Lacey JH. SCOFF, the development of an eating disorder screening questionnaire. Int J Eat Disord. 2010 May;43(4):344-51. doi: 10.1002/eat.20679. PubMed PMID: 19343793.
Lähteenmäki S, Aalto-Setälä T, Suokas JT, Saarni SE, Perälä J, Saarni SI, Aro H, Lönnqvist J, Suvisaari JM. Validation of the Finnish version of the SCOFF questionnaire among young adults aged 20 to 35 years. BMC Psychiatry. 2009 Feb 8;9:5. doi: 10.1186/1471-244X-9-5. PubMed PMID: 19200401; PubMed Central PMCID: PMC2656502.
Lichtenstein MB, Hemmingsen SD, Støving RK. Identification of eating disorder symptoms in Danish adolescents with the SCOFF questionnaire. Nord J Psychiatry. 2017 Jul;71(5):340-347. doi: 10.1080/08039488.2017.1300322. Epub 2017 Mar 14. PubMed PMID: 28290749.
Leung SF, Lee KL, Lee SM, Leung SC, Hung WS, Lee WL, Leung YY, Li MW, Tse TK, Wong HK, Wong YN. Psychometric properties of the SCOFF questionnaire (Chinese version) for screening eating disorders in Hong Kong secondary school students: a cross-sectional study. Int J Nurs Stud. 2009 Feb;46(2):239-47. doi: 10.1016/j.ijnurstu.2008.09.004. Epub 2008 Oct 21. PubMed PMID: 18945428.
Liu CY, Tseng MC, Chen KY, Chang CH, Liao SC, Chen HC. Sex difference in using the SCOFF questionnaire to identify eating disorder patients at a psychiatric outpatient clinic. Compr Psychiatry. 2015 Feb;57:160-6. doi: 10.1016/j.comppsych.2014.11.014. Epub 2014 Nov 14. PubMed PMID: 25542817.
Luck AJ, Morgan JF, Reid F, O’Brien A, Brunton J, Price C, Perry L, Lacey JH. The SCOFF questionnaire and clinical interview for eating disorders in general practice: comparative study. BMJ. 2002 Oct 5;325(7367):755-6. PubMed PMID: 12364305; PubMed Central PMCID: PMC128378. A PDF of this paper is available free at this link: https://www.bmj.com/content/bmj/325/7367/755.full.pdf
Morgan JF, Reid F, Lacey JH. The SCOFF questionnaire: assessment of a new screening tool for eating disorders. BMJ. 1999 Dec 4;319(7223):1467-8. PubMed PMID: 10582927; PubMed Central PMCID: PMC28290. The full text of this paper is available free at this link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC28290
Muro-Sans P, Amador-Campos JA, Morgan JF. The SCOFF-c: psychometric properties of the Catalan version in a Spanish adolescent sample. J Psychosom Res. 2008 Jan;64(1):81-6. PubMed PMID: 18158003.
National Eating Disorders Association (NEDA) Binge Eating Disorder.
Perry L, Morgan J, Reid F, Brunton J, O’Brien A, Luck A, Lacey H. Screening for symptoms of eating disorders: reliability of the SCOFF screening tool with written compared to oral delivery. Int J Eat Disord. 2002 Dec;32(4):466-72. PubMed PMID: 12386911.
Richter F, Strauss B, Braehler E, Adametz L, Berger U. Screening disordered eating in a representative sample of the German population: Usefulness and psychometric properties of the German SCOFF questionnaire. Eat Behav. 2017 Apr;25:81-88. doi: 10.1016/j.eatbeh.2016.06.022. Epub 2016 Jun 16. PubMed PMID: 27354266.
Wan Wahida WMZ, Lai PSM, Abdul Hadi H. Validity and reliability of the english version of the sick, control, one stone, fat, food (SCOFF) in Malaysia. Clin Nutr ESPEN. 2017 Apr;18:55-58. doi: 10.1016/j.clnesp.2017.02.001. Epub 2017 Feb 23. PubMed PMID: 29132739.
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I am curious about the recommendation for other written screening instruments to be completed before the first visit. Has that been tackled yet?
1. We have written about some screening questionnaires (see links below) but I plan to add more over time.
ADHD: https://simpleandpractical.com/screen-patients-adult-adhd/
Sleep apnea: https://simpleandpractical.com/stop-bang-questionnaire/, https://simpleandpractical.com/how-to-screen-for-sleep-apnea/
Excessive sleepiness: https://simpleandpractical.com/epworth-sleepiness-scale/
Adult autism spectrum disorder: https://simpleandpractical.com/adult-autism-spectrum-disorder-screening/
Eating disorders: https://simpleandpractical.com/eating-disorders-screening/
2. We recommended screening questions for some disorders:
Alcohol use disorder: https://simpleandpractical.com/how-to-screen-for-alcohol-use-disorder/
Borderline personality disorder: https://simpleandpractical.com/screen-borderline-personality-disorder/
3. We also recommended AGAINST using any screening questionnaires for bipolar disorders (https://simpleandpractical.com/dont-use-screening-questionnaires-bipolar-disorder/) including not using the Mood Disorders Questionnaire or MDQ to screen for bipolar disorders (https://simpleandpractical.com/mood-disorders-questionnaire-used-inappropriately/)
Full text of the Morgan et al 1999 paper can be found here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC28290/
Both this and the study by Luck et al chose to test the SCOFF for sensitivity and specificity on a clinical population because the “right” answer was already known, that is, it was clear that if the SCOFF worked as intended it would suggest a diagnosis that could easily be confirmed by checking the patient’s record. It can otherwise sometimes take weeks of assessment and gathering of collateral information to make a diagnosis you are certain of.
I have not seen a study that lowered the required number of positive answers from 2 to 1, but that may be a better way to use the SCOFF in a general population. Anyone who has a yes to:
Sick
lost Control
lost 15 pounds
feel Fat
Food preoccupied
may not go on to have or develop an eating disorder, but any “yes” puts them in a higher risk category.
Thank you, Raj, for your work in compiling the additional and very useful information about the SCOFF and for clarifying a screening vs a diagnostic test.