Adaptation and validation of the Spanish version of the Clinical Impairment Assessment Questionnaire

Quality of Life and Clinical Impairment in Spanish Adolescent Anorexia Nervosa Patients

Eating disorders have serious physical, mental and social consequences that can affect the quality of life of the sufferer. This study aimed to evaluate the relationship between the severity of ED-related psychopathology and clinical impairment in adolescents with anorexia nervosa (AN) as well as their perception of health-related quality of life. Eighty-six Spanish young women with AN completed a set of questionnaires assessing eating disorder pathology, clinical impairment, and quality of life. The set included the following instruments: the Eating Disorder Examination Questionnaire, Clinical Impairment Assessment, Short Form-12 Item Health Survey, and the Eating Disorder-Specific Heath-Related Quality of Life instrument. Descriptive and regression analyses were applied to identify associations between variables. Higher scores on clinical impairment domains were associated with greater impairment of mental and physical health. Moreover, clinical impairment domains and concerns due to ED were related to a lower quality of life. In conclusion, adolescents with AN have a poor quality of life. Moreover, the findings suggest that the clinical features of impairment may serve as severity indicators of quality of life.

Validation of the Spanish version of the eating disorders quality of life instrument (EDQOL)

BACKGROUND

The Eating Disorders Quality of Life instrument (EDQOL) is a disease-specific health related quality of life self-report questionnaire designed for disordered eating patients. Although the EDQOL is one of the most suitable and widely used questionnaires in many countries, no prior research has addressed the psychometric properties of the Spanish adaptation of the EDQOL. Therefore, the aim of this study is to examine the psychometric properties of the Spanish version of the EDQOL among ED patients.

METHODS

141 female eating disorder patients, with a mean age of 18.06 years (SD = 6.31), completed the EDQL in addition to the Eating Disorder Examination Questionnaire (EDEQ), the Depression, Anxiety and Stress Scales (DASS-21), the Clinical Impairment Assessment (CIA 3.0) and the Health Survey (SF-12). We calculated item/scale characteristics, internal consistencies and bivariate correlations with other measures of quality of life and adjustments. We assessed the goodness-of-fit of the 4-factor model using confirmatory factors analysis and explored the sensitivity of change following skill-based interventions.

RESULTS

The fit of the 4-factor model was acceptable (Root Mean Square Error of Approximation: 0.07, Standard Root Mean Square Residual: 0.07). Cronbach's alpha was excellent for the total (.91) and acceptable for all subscales (0.78-0.91). The construct validity was found with measures of psychological distress, depression, anxiety, quality of life and clinical impairment. The psychological and physical/cognitive scales and the EDQOL global scale were responsive to change.

CONCLUSION

The Spanish EDQOL version is a useful instrument to assess quality of life in eating disorder patients and to evaluate outcomes of skills-based interventions.

Chinese translation of the Clinical Impairment Assessment (CIA 3.0): Psychometric properties and measurement invariance across sex and age in adolescents, young adults, and adult men

The Clinical Impairment Assessment (CIA) is the most widely used instrument for assessing psychosocial impairment related to eating disorders (EDs). The CIA was translated into Chinese based on standard procedures. The psychometric properties of the Chinese CIA (C-CIA) were assessed among four adolescent and adult samples [i.e., 792 junior high school students (47.0% boys; M_age = 13.09 years), 1324 senior high school students (44.2% boys; M_age = 16.06 years), 812 undergraduate students (36.3% boys; M_age = 18.88 years), and 406 male adults from a general population (M_age = 28.53 years)]. The three-factor structure of the CIA was replicated. Excellent internal consistencies of the C-CIA were revealed, α = 0.93-0.98. The C-CIA showed moderate and good test-retest reliability in a six-month interval for junior high school students (ICC = 0.69) and senior high school students (ICC = 0.76), respectively. The C-CIA had good test-retest reliability in a two-week interval for undergraduate students (ICC = 0.78) and general adult men (ICC = 0.81). Our results supported good construct validity, known-group validity of the C-CIA, and measurement invariance across sex and age. These findings suggest that the C-CIA can be a useful tool assessing psychosocial impairment related to EDs for Chinese adolescents, young adults, and adult men.

The validation of a Farsi version of the Clinical Impairment Assessment (F-CIA) among Iranian adolescent boys and girls

PURPOSE

Although some studies have been conducted to examine general psychosocial impairment in Iran, there is no research to date on clinical impairment secondary to disordered eating in Iranian adolescents. The purpose of this study was to evaluate the Farsi version of the Clinical Impairment Assessment (F-CIA) among Iranian adolescents.

METHODS

A total of 1112 adolescents (age_{M [SD]} = 15.55 [1.59], body mass index [zBMI] _{M [SD]} = - 0.00 [1.0]; 54.6% girls) were recruited from four cities (Tehran [Capital], Tabriz [North-Western], Kurdistan [West], and Rasht [North]) in Iran. After translation and back-translation procedures, the F-CIA, Eating Disorder Examination Questionnaire (EDE-Q), and Beck Depression Inventory-Second Edition (BDI-II) were administered to adolescents. We used confirmatory factor analysis (CFA), measurement invariance, independent samples t tests, Pearson correlation, chi-square tests, and internal consistency to test validity and reliability.

RESULTS

CFA indicated that F-CIA demonstrated good fit to the data and supported a three-factor model. The scale was invariant across gender and zBMI. The F-CIA had good internal consistency (αs = 0.76-0.93) and positive associations (rs = 0.13-0.62; p < 0.001) with zBMI, disordered eating symptoms, and binge/purge symptoms. We found no gender differences across mean scores on the F-CIA, but adolescents with higher zBMI reported higher scores on the F-CIA relative to those with lower zBMIs. Finally, adolescents scoring above CIA cutoffs reported higher zBMI, disordered eating outcomes, and depression.

CONCLUSION

Findings suggested that the F-CIA is a reliable and valid measure of clinical eating disorder-related impairment in Iranian adolescents.

LEVEL OF EVIDENCE

III; Evidence obtained from well-designed observational study, including case-control design for relevant aspects of the study.

Classification of subtypes of patients with eating disorders by correspondence analysis

BACKGROUND

Grouping eating disorders (ED) patients into subtypes could help improve the establishment of more effective diagnostic and treatment strategies.

AIM

To identify clinically meaningful subgroups among subjects with ED using multiple correspondence analysis (MCA).

METHODS

A prospective cohort study was conducted of all outpatients diagnosed for an ED at an Eating Disorders Outpatient Clinic to characterize groups of patients with ED into subtypes according to sociodemographic and psychosocial impairment data, and to validate the results using several illustrative variables. In all, 176 (72.13%) patients completed five questionnaires (clinical impairment assessment, eating attitudes test-12, ED-short form health-related quality of life, metacognitions questionnaire, Penn State Worry Questionnaire) and sociodemographic data. ED patient groups were defined using MCA and cluster analysis. Results were validated using key outcomes of subtypes of ED.

RESULTS

Four ED subgroups were identified based on the sociodemographic and psychosocial impairment data.

CONCLUSION

ED patients were differentiated into well-defined outcome groups according to specific clusters of compensating behaviours.

Factor structure and psychometric properties of the clinical impairment assessment 3.0 (CIA) in a clinical eating disorder sample

PURPOSE

The aim of this study was to investigate the psychometric properties and the factor structure of the Clinical Impairment Assessment 3.0 (CIA) utilizing a confirmatory factor analysis in a large clinical sample of ED patients.

METHODS

A total of 260 patients between the ages of 18 and 45 who completed assessments in a partial hospitalization or residential treatment program at an ED treatment facility between December 2012 and December 2016 were included in the analyses. Assessment measures included the CIA, EDE-Q, BDI-II, WHODAS, and a demographic questionnaire.

RESULTS

Results favored a bifactor model with a strong general factor and three unreliable subfactors. The CIA showed strong construct validity with other measures of ED pathology (EDE-Q) and health-related QoL (WHODAS). Furthermore, admission CIA scores were predictive of treatment outcomes.

CONCLUSIONS

The CIA assesses general psychosocial impairment, supporting the use of a total, but not subscale scores, among symptomatic ED samples in the United States.

Development of a new Japanese version of the Clinical Impairment Assessment Questionnaire

Background

The Clinical Impairment Assessment questionnaire (CIA) is used to measure the severity of psychosocial impairment in patients with eating disorders. The purpose of the present study was to develop a new Japanese version of the CIA (CIA-J) and to evaluate its reliability and validity.

Methods

We translated the sixteen items of the CIA into Japanese, back-translated them into English, and had them verified by a native English speaking professional editor. Participants were 152 Japanese-speaking patients (30.4 ± 10.6 years) under treatment for eating disorders and 173 healthy controls (29.5 ± 8.3 years). In addition to the CIA-J, the participants were asked to answer the Eating Attitudes Test (EAT26), The Positive and Negative Affect Schedule (PANAS), and the Hospital Anxiety and Depression Scale (HADS). We performed confirmatory factor analyses to evaluate the factor structure, calculated the Cronbach’s alphas of the CIA-J to assess the reliability, and calculated the correlation coefficients between the CIA-J score and those of EAT26, PANAS, and HADS to assess concurrent validity. We also used a Kruskal-Wallis test followed by Steel-Dwass test to compare the scores of the subtypes of eating disorders and the healthy control group.

Results

A three-factor structure was obtained, similar to the original version. The Cronbach’s alphas of both the global and subscale scores of the CIA-J were high. The CIA-J had significant positive correlations with the EAT26, the negative affect subscale of the PANAS, and the HADS. The global and subscale scores for all subtypes of eating disorders were significantly higher than those of the healthy control group.

Conclusions

The CIA-J was determined to be reliable and valid for assessing the severity of psychosocial impairment in patients with eating disorders.

Validation of the Portuguese version of the Clinical Impairment Assessment (CIA) in eating disorders' patients

PURPOSE

The purpose of the study was to assess the psychometric properties of the Portuguese version of the Clinical Impairment Assessment (CIA) in eating disorders (ED) patients.

METHOD

The CIA is a 16-item brief self-reported instrument developed to assess psychosocial impairment secondary to EDs. The CIA was administered to a clinical sample of 237 women with EDs and a college sample of 196 women. The clinical sample completed the Eating Disorders Examination Questionnaire, the Beck Depression Inventory and the Outcome-45 Questionnaire. Reliability, confirmatory factor analysis, validity, and clinically significant change were calculated.

RESULTS

Confirmatory factor analysis validated the original 3-factor structure showing an adequate model fit. CIA showed good psychometric properties with high internal consistency, good convergent validity with the EDE-Q, the OQ-45, and the BDI. For divergent validity, participants CIA scores in the clinical sample were significantly higher than in the non-clinical sample. ROC curve analysis provided a cutoff of 15. For known-groups validity participants' scoring above CIA cutoff reported significantly higher CIA scores. In addition, non-underweight participants and participants reporting the presence of dysfunctional ED behaviors had significantly higher CIA scores. Finally, for clinically significant change, a reliable change index of 5 points was obtained to consider a reliable change in the CIA global score.

CONCLUSIONS

Our findings support the validity and clinical utility of the CIA as a good self-report measure to be used in both clinical and research settings.

LEVEL OF EVIDENCE

Level V. Cross-sectional descriptive study.

Severity and Endurance in Eating Disorders: An Exploration of a Clinical Sample From Chile

INTRODUCTION

One in five patients with eating disorders (EDs) may take a lasting course. It has been proposed that this enduring group exhibits increased severity, such as low treatment response, severe symptomatology, and poor quality of life. However, there is no consensus defining this group. Moreover, most of the literature comes from high-income societies and may not apply to developing countries.

AIMS

This study aimed to evaluate the association between endurance (length of ED) and severity (previous treatments, hospitalizations, medical complications, symptomatology and clinical impairment) in individuals with EDs from Chile. In addition, it aimed to explore the association between endurance and delays seeking specialized treatment.

METHODS

Forty-one women with EDs (16 with anorexia nervosa, 11 with bulimia nervosa, 10 with binge eating disorder and 4 with other specified EDs) completed a social-demographic survey, the Eating Disorders Examination Questionnaire, and the Clinical Impairment Assessment. Also, Body Mass Index, length of ED, and complications were retrieved from participants' medical records. Spearman correlation coefficient and linear regression were used to explore the association between length of ED and measures of severity and treatment seeking behavior.

RESULTS

There was no significant association between endurance (length of ED) and measures of severity. There was a significant association between length of ED and delays seeking specialized treatment (r_s=0.72; p<0.01). Regression indicated that for each month in delay visiting a specialized ED treatment team, the ED duration increased by 0.87 months (F(1,38)=75.93; p<0.01; R²= 0.66).

DISCUSSION

The findings suggest that in developing countries, where specialized treatment access is not widespread, defining SEED solely by the length of illness may not be clinically significant, and other criteria (e.g., timely access to evidence-based treatments) should be considered.

Anxiety and depressive symptoms are related to core symptoms, general health outcome, and medical comorbidities in eating disorders

OBJECTIVE

The goal of this study is to identify potential factors that have a significant effect on anxiety and depression of patients with eating disorders (ED) using the beta-binomial regression (BBR) approach on a broad sample of patients.

METHOD

This cross-sectional study involved 520 ED patients. The effect of sociodemographics, core symptoms, general health outcomes, and medical comorbidities in anxiety and depression were analysed jointly using the beta-binomial mixed-effects model.

RESULTS

Two hundred fifty-five (49.4%) patients had anorexia nervosa, 173 (33.3%) patients had bulimia nervosa, and 92 (17.7%) had ED not otherwise specified. A high level of anxiety was associated, among other variables, with having a restrictive ED subtype as compared with purgative and binge ED subtypes (β = -0.2, p < 0.001, OR = 0.82 and β = -0.16, p < 0.03, OR = 0.85, respectively), with having a high level of ED symptomatology or with living not alone (β = -0.23, p = 0.002, OR = 0.80). A high level of depression was associated, among other variables, with older age (β = 0.74, p < 0.001, OR = 2.1).

CONCLUSIONS

The results of our study suggest that depressive and anxiety symptoms are related to ED symptoms, health status, ED subtype, medical comorbitidy, and educational level. In addition, another interesting finding is the inverse association between symptomatology of anxiety and living alone. Finally, BBR may be a useful approach in interpreting patient-reported outcome as odds.

The clinical impairment assessment questionnaire: validation in Italian patients with eating disorders

BACKGROUND

The Clinical Impairment Assessment (CIA) is a measure of functional impairment secondary to eating disorder symptoms.

AIM

The aim of this study was to examine the psychometric proprieties of the Italian-language version of the CIA.

METHODS

The tool was translated into Italian and administered to 259 Italian-speaking in- and outpatients with eating disorders and 102 healthy controls. The clinical group also completed the Eating Disorder Examination Questionnaire (EDE-Q) and the Brief Symptom Inventory (BSI).

RESULTS

Confirmatory factor analysis revealed a good fit for the original three-factor structure. Internal consistency was high for both the global CIA and all subscale scores, and test-retest reliability was acceptable. The high correlation between CIA and EDE-Q and BSI confirmed the convergent validity of the instrument. T test indicated higher raw scores on CIA in patients with eating disorders than healthy controls, and a cut-off score of 16 on the CIA discriminated between eating disorder and general psychopathology scores. Finally, global CIA and subscale scores were significantly higher in patients who reported objective bulimic episodes, purging behaviours, and excessive exercising than in those who did not; in underweight than in not-underweight patients, and in inpatients than outpatients, confirming the good known-groups validity of the tool.

CONCLUSIONS

Overall, the study showed the good psychometric properties of the Italian version of the CIA, and validated its use in Italian-speaking eating disorder patients.

LEVEL OF EVIDENCE

Level V, Descriptive study.

Evidence That the Clinical Impairment Assessment (CIA) Subscales Should Not Be Scored: Bifactor Modelling, Reliability, and Validity in Clinical and Community Samples

Aim: The Clinical Impairment Assessment (CIA 3.0) is the most widely used instrument assessing psychosocial impairment secondary to eating disorder symptoms. However, there is conflicting advice regarding the dimensionality and optimal method of scoring the CIA. We sought to resolve this confusion by conducting a comprehensive factor analytic study of the CIA in a community sample ( N = 301) and clinical sample comprising patients with a diagnosed eating disorder ( N = 209). Convergent and discriminant validity were also assessed. Method: The CIA and measures of eating disorder symptoms were administered to both samples. Results: Factor analyses indicated there is a general impairment factor underlying all items on the CIA that is reliably measured by the CIA Global score. CIA Global demonstrated good convergent and discriminant validity. Conclusions: CIA Global is a reliable and valid measure of psychosocial impairment secondary to eating disorder symptoms; however, subscale scores should not be computed.

Predictors of quality of life in patients with eating disorders

BACKGROUND

The aims of this study were to analyse the quality of life (QoL) of a broad sample of patients with eating disorders (ED) and to identify potential factors that predict QoL.

METHODS

This prospective cohort study involved 528 patients diagnosed with ED and treated over a 15-year period in the Eating Disorders Outpatient Clinic. Information on sociodemographic and clinical data were gathered. Patients completed five self-administered instruments: the Eating Attitudes Test-26 (EAT-26); the Eating Disorder Diagnostic Scale (EDDS); the Hospital Anxiety and Depression Scale (HADS); the Short-Form 12 (SF-12); and the Quality of Life in ED-short form (HeRQoLED-s). Descriptive, univariate analyses and multivariate linear regression models were applied to identify factors associated with QoL.

RESULTS

Predictive variables for a low level of QoL in patients with anorexia nervosa (AN) included antidepressant treatment (P=0.009), substance abuse disorder, (P=0.03) and other organic comorbidities (P<0.0001). For patients with bulimia nervosa (BN), they included osteoporosis (P≤0.0001), obesity (P=0.0004) or being a student (P=0.04). For patients with eating disorders not otherwise specified (EDNOS), they included anxiolytic treatment (P=0.003), having circulatory disease (P=0.001), more years since start of ED treatment (P=0.03) and living alone (P<0.0001).

CONCLUSIONS

We found a significant difference in QoL between the diagnostic ED groups. With regard to the variables predicting QoL in ED patients, the findings of this study suggest that organic or psychiatric comorbidities and some data of social normality might be more relevant to QoL in ED than age, type of compensatory behaviour, BMI or number of visits to hospital emergency department.

Eating Disorder Examination Questionnaire (EDE-Q) and Clinical Impairment Assessment (CIA): clinical norms and functional impairment in male and female adults with eating disorders

AIM

The aim of the current study was to collect clinical normative data for the Clinical Impairment Assessment questionnaire (CIA) and the Eating Disorder Examination Questionnaire (EDE-Q) from adult patients with eating disorders (EDs). This study also examined unique contributions of eating disorder (ED) symptoms on levels of ED-related impairment.

METHODS

A sample of 667 patients, 620 females and 47 males, was recruited from six specialist centres across Norway. The majority of the sample (40.3%) was diagnosed with eating disorder not otherwise specified (EDNOS), 34.5% had bulimia nervosa (BN), and 25.2% were diagnosed with anorexia nervosa (AN).

RESULTS

There were significant differences for global EDE-Q and CIA scores between females and males. In the female sample, significant differences were found on several EDE-Q sub-scales between the AN and BN group, and between the AN and EDNOS group. No significant differences were found between the diagnostic groups on the CIA. In the male sample, no significant differences were found between diagnostic groups on the EDE-Q or CIA. A multiple regression analysis revealed that 46.8% of the variance in impairment as measured by the CIA was accounted for by ED symptoms.

CONCLUSIONS

Body mass index, Eating Concern, Shape/Weight Concern, and binge eating served as significant, unique predictors of impairment. The results from the present study contribute to the interpretation of EDE-Q and CIA scores in ED samples.

Predictors of change in psychosocial impairment secondary to an eating disorder

Eating disorders (ED) can significantly impair psychosocial health in patients. However, no published studies have so far used a standardized and specific instrument to evaluate predictive factors in ED-related psychosocial impairment. This prospective cohort study involved 177 patients receiving outpatient treatment for an ED at baseline and 115 patients at the 1-year follow-up. Patients completed three self-administered questionnaires: the Clinical Impairment Assessment (CIA), the Eating Attitudes Test-12 (EAT-12), and the Health-Related Quality of Life in ED-short form (HeRQoLED-s). Descriptive statistics, ANOVA, chi-square, and Fisher's exact test were applied to examine intervariable relationships. Multivariate linear regression was used to determine predictors of change in CIA scores. An improvement was reported by patients with restrictive anorexia nervosa (AN) compared to those with purgative AN. In the multivariate analysis, employment status, subtype of ED, and the bulimia and food preoccupation factor of the EAT-12 were significant predictors of change in the CIA scores.

Impairment due to eating disorder pathology: Identifying the cut-off score on the Clinical Impairment Assessment in a clinical and community sample

OBJECTIVE

The Clinical Impairment Assessment (CIA) is a self-report measure of impairment secondary to eating disorder (ED) features. The purpose of this study was to identify the global CIA cut-off score that maximized sensitivity and specificity to discriminate impairment due to eating disorder pathology in a community versus clinical ED sample using receiver operating characteristic (ROC) analyses.

METHOD

Participants were 1,468 female community participants and 552 eating disorder patients.

RESULTS

Mean global CIA scores were 5.17 (SD 7.61) and 32.50 (SD 10.20). The ROC analysis demonstrated excellent accuracy of the global CIA score (AUC = 0.97; 95% CI: 0.96-0.98). A cut-off score of 16.0 yielded a sensitivity of 0.91 (95% CI: 0.88-0.93) and a specificity of 0.91 (95% CI: 0.89-0.93).

DISCUSSION

This study is the first to replicate findings from the original development study of the CIA and lends support to initial recommendations. Data provide strong evidence of the discriminant validity of the CIA and suggest the utility of assessing eating-disorder related impairment for classification purposes. © 2016 Wiley Periodicals, Inc. (Int J Eat Disord 2016; 49:635-638).