Assessment of an Eating Disorder

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• Chief complaint: You want to know what's wrong from the client's perspective. This will depend on whether they were forced to get treatment, or came in voluntarily, but either way the chief complaint usually changes the safer the client feels with the clinician. Ask the client, "What are you doing with food that you would like to stop doing?" "What can't you do with food that you would like to be able to do?" "What do others want you to do or stop doing?" Ask what physical symptoms the client has and what thoughts or feelings get in her way.

• Interference: Find out how much the disordered eating, body image, or weight control behaviors are interfering with the client's life. For example: Do they skip school because they feel sick or fat? Do they avoid people? Are they spending a lot of money on their habits? Are they having a hard time concentrating? How much time do they spend weighing themselves? How much time do they spend buying food, thinking about food, or cooking food? How much time do they spend exercising, purging, buying laxatives, reading about weight loss, or worrying about their bodies?

• Psychiatric history: Has the client ever had any other mental problems or disorders? Have any family members or relatives had any mental disorders? The clinician needs to know if the client has other psychiatric conditions, such as obsessive- compulsive disorder or depression, that would complicate treatment or indicate a different form of treatment (e.g., signs of depression and a family history of depression that might warrant antidepressant medication sooner than later in the course of treatment). Symptoms of depression are common in eating disorders. It is important to explore this and see how persistent or bad the symptoms are. Many times clients are depressed because of the eating disorder and their unsuccessful attempts to deal with it, thus increasing low self-esteem. Clients also get depressed because their relationships often fall apart over the eating disorder. Furthermore, depression can be caused by nutritional inadequacies. However, depression may exist in the family history and in the client before the onset of the eating disorder. Sometimes these details are hard to sort out. The same is often true for other conditions such as obsessive-compulsive disorder. A psychiatrist experienced in eating disorders can provide a thorough psychiatric evaluation and recommendation regarding these issues. It is important to note that antidepressant medication has been shown to be effective in bulimia nervosa even if the individual does not have symptoms of depression.

• Medical history: The clinician (other than a physician) doesn't have to go into great specifics here because one can get all the details from the physician (see chapter 15, "Medical Management of Anorexia Nervosa and Bulimia Nervosa"). However, it is important to ask questions in this area to get an overall picture and because clients don't always tell their doctors everything. In fact, many individuals do not tell their doctors about their eating disorder. It is valuable to know if the client is often sickly or has some current or past problems that could have affected or have been related to their eating behaviors. For example, ask if the client has regular menstrual cycles, or if she is cold all the time, or constipated. It is also important to distinguish between true anorexia (loss of appetite) and anorexia nervosa. It is important to determine if a person is genetically obese with fairly normal food intake or is a binge eater. It is critical to discover if vomiting is spontaneous and not willed or self-induced. Food refusal can have other meanings than those found in the clinical eating disorders. An eight-year-old was brought in because she had been gagging on food and refusing it and had therefore been diagnosed with anorexia nervosa. During my assessment I discovered she was afraid of gagging due to sexual abuse. She had no fear of weight gain or body image disturbance and had been inappropriately diagnosed.
   

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• Family patterns of health, food, weight, and exercise: This may have a great bearing on the cause of the eating disorder and/or the forces that sustain it. For example, clients with overweight parents who have struggled with their own weight unsuccessfully over the years may provoke their children into early weight loss regimens, causing in them a fierce determination not to follow the same pattern. Eating disorder behaviors may have become the only successful diet plan. Also, if a parent pushes exercise, some children may develop unrealistic expectations of themselves and become compulsive and perfectionistic exercisers. If there is no nutrition or exercise knowledge in the family or there is misinformation, the clinician may be up against unhealthy but long-held family patterns. I'll never forget the time I told the parents of a sixteen-year-old binge eater that she was eating too many hamburgers, french fries, burritos, hot dogs, and malts. She had expressed to me that she wanted to have family meals and not be sent for fast food all the time. Her parents didn't supply anything nutritious in the house, and my client wanted help and wanted me to talk to them. When I approached the subject, the father got upset with me because he owned a fast-food drive-through stand where the whole family worked and ate. It was good enough for him and his wife and it was good enough for his daughter, too. These parents had their daughter working there and eating there all day, providing no other alternative. They had brought her into treatment when she had tried to kill herself because she was "miserable and fat" and they wanted me to "fix" her weight problem.

• Weight, eating, diet history: A physician or dietitian on the team can get detailed information in these areas, but it is important for the therapist to have this information as well. In cases where there is no physician or dietitian, it becomes even more important for the therapist to explore these areas in detail. Get a detailed history of all weight issues and concerns. How often does the client weigh herself? How has the client's weight changed over the years? What was her weight and eating like when she was little? Ask clients what was the most they ever weighed and the least? How did they feel about their weight then? When did they first start feeling bad about their weight? What kind of eater were they? When did they first diet? How did they try to diet? Did they take pills, when, how long, what happened? What different diets have they tried? What are all the ways they tried to lose weight, and why do they think these ways haven't worked? What, if anything, has worked? These questions will reveal healthy or unhealthy weight loss, and they also tell how chronic the problem is. Find out about each client's current dieting practices: What kind of diet are they on? Do they binge, throw up, take laxatives, enemas, diet pills, or diuretics? Are they currently taking any drugs? Find out how much of these things they take and how often. How well do they eat now, and how much do they know about nutrition? What is an example of what they consider a good day of eating and a bad one? I may even give them a mini–nutrition quiz to see how much they really know and to "open their eyes" a little bit if they are misinformed. However, a thorough dietary assessment should be performed by a registered dietitian who specializes in eating disorders.

• Substance abuse: Often, these clients, especially bulimics, abuse other substances besides food and diet-related pills or items. Be careful when asking about these matters so clients do not think you are categorizing them or just deciding they are hopeless addicts. They often see no connection between their eating disorders and their use or abuse of alcohol, marijuana, cocaine, and so on. Sometimes they do see a connection; for example, "I snorted coke because it made me lose my appetite. I wouldn't eat so I lost weight, but now I really like the coke all the time and I eat anyway." Clinicians need to know about other substance abuse that will complicate treatment and may give further clues into the client's personality (e.g., that they are a more addictive personality type or the type of person who needs some form of escape or relaxation, or they are destructive to themselves for an unconscious or subconscious reason, and so on).
   

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• Any other physical or mental symptoms: Make sure you explore this area fully, not just as it pertains to the eating disorder. For example, eating disorder clients often suffer from insomnia. They often do not connect this to their eating disorders and neglect to mention it. To varying degrees, insomnia has an effect on the eating disorder behavior. Another example is that some anorexics, when questioned often report a history of past obsessive-compulsive behavior such as having to have their clothes in the closet arranged perfectly and according to colors or they had to have their socks on a certain way every day, or they may pull out leg hairs one by one. Clients may not have any idea that these types of behaviors are important to divulge or will shed any light on their eating disorder. Any physical or mental symptom is important to know. Keep in your mind, and let the client know as well, that you are treating the whole person and not just the eating disorder behaviors.

• Sexual or physical abuse or neglect: Clients need to be asked for specific information about their sexual history and about any kind of abuse or neglect. You will need to ask specific questions about the ways they were disciplined as children; you will need to ask if they were ever hit to a degree that left marks or bruises. Questions about being left alone or being fed properly are also important, as is information such as their age the first time they had intercourse, whether their first intercourse was consensual, and if they were touched inappropriately or in a way that made them uncomfortable. Clients often do not feel comfortable revealing this kind of information, especially at the beginning of treatment, so it is important to ask if the client felt safe as a child, who the client felt safe with, and why. Come back to these questions and issues after treatment has been under way for a while and the client has developed more trust.

• Insight: How aware is the client about her problem? How deeply does the client understand what is going on both symptomatically and psychologically? How aware is she of needing help and of being out of control? Does the client have any understanding of the underlying causes of her disorder?

• Motivation: How motivated and/or committed is the client to get treatment and to get well?
   

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