Recommended Screening Tools for Eating Disorders and Alcohol Use
For eating disorder screening, use the SCOFF questionnaire as your initial screening tool in primary care settings, and for alcohol use assessment, use the AUDIT, AUDIT-C, or single-question screening approach—all three have excellent performance characteristics and are endorsed by the USPSTF. 1
Eating Disorder Screening
Primary Recommendation: SCOFF Questionnaire
The SCOFF questionnaire is the most widely validated and practical screening tool for eating disorders in primary care settings 2, 3. This tool demonstrates:
- Pooled sensitivity of 86% and specificity of 83% across diverse populations 3
- Particularly high sensitivity (97.88%-100%) for detecting bulimia nervosa, though specificity is somewhat lower (89.6%-94.4%) 4
- Best performance in young women with anorexia nervosa and bulimia nervosa 3
Important caveats:
- The SCOFF has limited evidence for screening binge eating disorder and the full spectrum of DSM-5 eating disorders 3
- Performance is lower in men, community samples, and when screening for binge eating disorder specifically 3
- Consider using the EDE-Q (Eating Disorder Examination Questionnaire) or BEDS-7 (Binge Eating Disorder Screener-7) as alternatives, though evidence for their use in primary care remains limited 5, 4
Implementation Approach
According to the American Psychiatric Association, screening for eating disorders should be part of the initial psychiatric evaluation 2. When screening is positive, conduct a comprehensive assessment including:
- Weight history: maximum/minimum weight, recent changes
- Eating patterns: restrictive eating, binge eating, food avoidance, narrowing of food variety
- Compensatory behaviors: purging, laxative use, excessive exercise, medication misuse
- Time preoccupied with food, weight, and body shape
- Physical examination: vital signs including orthostatic measurements, BMI calculation
- Co-occurring conditions: psychiatric disorders and medical complications 2
Alcohol Use Screening
Primary Recommendations: AUDIT, AUDIT-C, or Single-Question Screening
The USPSTF identifies three equally preferred screening tools for alcohol misuse in adults aged 18 years and older 1:
1. AUDIT (Alcohol Use Disorders Identification Test)
- 10 questions, takes 2-5 minutes to administer
- Optimal cutoff scores:
- ≥4 points: sensitivity 84-85%, specificity 77-84%
- ≥5 points: sensitivity 70-92%, specificity 73-94%
- Sex-specific adjustment: Women require a cutoff 1 point lower than men for similar sensitivity 1
- Detects the full spectrum of alcohol misuse: hazardous drinking, harmful drinking, and alcohol dependence 6, 7
2. AUDIT-C (Abbreviated Version)
- 3 questions, takes 1-2 minutes to complete
- Optimal cutoff scores:
- ≥4 points: sensitivity 74-76%, specificity 80-83%
- ≥3 points: sensitivity 74-88%, specificity 64-83%
- Sex-specific adjustment: Again, women require a cutoff 1 point lower 1
3. Single-Question Screening
- Takes less than 1 minute
- Ask: "How many times in the past year have you had 5 or more drinks in a day (for men) or 4 or more drinks in a day (for women and adults older than 65 years)?"
- Performance: sensitivity 82-87%, specificity 61-79% 1
Tools to Avoid
Do NOT use the CAGE questionnaire for primary care screening—it has poor sensitivity for risky or hazardous drinking, particularly in:
- Older adults (sensitivity only 14-39%)
- Pregnant women (sensitivity only 38-49%) 1
Follow-Up After Positive Screening
When screening is positive, provide brief multicontact behavioral counseling (6-15 minutes per contact, multiple sessions), which has the strongest evidence for:
- Reducing binge drinking episodes (12% absolute increase in those reporting no heavy drinking at 1 year)
- Decreasing weekly alcohol consumption
- Increasing adherence to recommended drinking limits 1
Note: Very brief single-contact interventions (≤5 minutes) have limited effectiveness 1