Assessment of an Eating Disorder

continued

These are all things that the clinician needs to assess during the early stages of treatment. It may take a few sessions or even longer to get information in each of these areas. In some sense, assessment actually continues to take place throughout therapy. It may actually take months of therapy for a client to divulge certain information and for the clinician to get a clear picture of all the issues outlined above and to sort them out as they relate to the eating disorder. Assessment and treatment are ongoing processes tied together.

STANDARDIZED TESTS

A variety of questionnaires for mental measurement have been devised to help professionals assess behaviors and underlying issues commonly involved in eating disorders. A brief review of a few of these assessments follows.

EAT (EATING ATTITUDES TEST)

One assessment tool is the Eating Attitudes Test (EAT). EAT is a rating scale that is designed to distinguish patients with anorexia nervosa from weight-preoccupied, but otherwise healthy, female college students, which these days is a formidable task. The twenty-six item questionnaire is broken down into three subscales: dieting, bulimia and food preoccupation, and oral control.

The EAT can be useful in measuring pathology in underweight girls but caution is required when interpreting the EAT results of average weight or overweight girls. The EAT also shows a high false-positive rate in distinguishing eating disorders from disturbed eating behaviors in college women. The EAT has a child version, which researchers have already used to gather data. It has shown that almost 7 percent of eight- to thirteen-year-old children score in the anorexic category, a percentage that closely matches that found among adolescents and young adults.

There are advantages to the self-report format of the EAT, but there are also limitations. Subjects, particularly those with anorexia nervosa, are not always honest or accurate when self-reporting. However, the EAT has been shown to be useful in detecting cases of anorexia nervosa, and the assessor can use whatever information is gained from this assessment combined with other assessment procedures to make a diagnosis.

EDI (EATING DISORDER INVENTORY)

The most popular and influential of the available assessment tools is the Eating Disorder Inventory, or EDI, developed by David Garner and colleagues. The EDI is a self-report measure of symptoms. Although the intent of the EDI was originally more limited, it is being used to assess the thinking patterns and behavioral characteristics of anorexia nervosa and bulimia nervosa. The EDI is easy to administer and provides standardized subscale scores on several dimensions that are clinically relevant to eating disorders. Originally there were eight subscales. Three of the subscales assess attitudes and behaviors concerning eating, weight, and shape. These are drive for thinness, bulimia, and body dissatisfaction. Five of the scales measure more general psychological traits relevant to eating disorders. These are ineffectiveness, perfectionism, interpersonal distrust, awareness of internal stimuli, and maturity fears. The EDI 2 is a follow-up to the original EDI and includes three new subscales: asceticism, impulse control, and social insecurity.

The EDI can provide information to clinicians that is helpful in understanding the unique experience of each patient and in guiding treatment planning. The easy-to-interpret graphed profiles can be compared to norms and to other eating disordered patients and can be used to track progress of the patient during the course of treatment. The EAT and the EDI were developed to assess the female population who most likely have or are susceptible to developing an eating disorder. However, both of these assessment tools have been used with males with eating problems or compulsive exercise behaviors.

In nonclinical settings the EDI provides a means of identifying individuals who have eating problems or those at risk for developing eating disorders. The body dissatisfaction scale has been successfully used to predict the emergence of eating disorders in high-risk populations.

There is a twenty-eight-item, multiple-choice, self-report measure for bulimia nervosa known as BULIT-R that was based on the DSM III-R criteria for bulimia nervosa and is a mental measurement tool to assess the severity of this disorder.

BODY IMAGE ASSESSMENTS

Body image disturbance has been found to be a dominant characteristic of eating disordered individuals, a significant predictor of who might develop an eating disorder and an indicator of those individuals having received or still receiving treatment who might relapse. As Hilda Bruch, a pioneer in eating disorder research and treatment, pointed out, "Body image disturbance distinguishes the eating disorders, anorexia nervosa and bulimia nervosa, from other psychological conditions that involve weight loss and eating abnormalities and its reversal is essential to recovery." This being true, it is important to assess body image disturbance in those with disordered eating. One way to measure body image disturbance is the Body Dissatisfaction subscale of the EDI mentioned above. Another assessment method is the PBIS, Perceived Body Image Scale, developed at British Columbia's Children's Hospital.

The PBIS provides an evaluation of body image dissatisfaction and distortion in eating disordered patients. The PBIS is a visual rating scale consisting of eleven cards containing figure drawings of bodies ranging from emaciated to obese. Subjects are given the cards and asked four different questions that represent different aspects of body image. Subjects are asked to pick which of the figure cards best represents their answers to the following four questions:

• Which body best represents the way you think you look?

• Which body best represents the way you feel you are?

• Which body best represents the way you see yourself in the mirror?

• Which body best represents the way you would like to look?

The PBIS was developed for easy and rapid administration to determine which components of body image are disturbed and to what degree. The PBIS is useful not only as an assessment tool but also as an interactive experience facilitating the therapy.

There are other assessment tools available. In assessing body image it is important to keep in mind that body image is a multifaceted phenomenon with three main components: perception, attitude, and behavior. Each of these components needs to be considered.

Other assessments can be done to gather information in the various domains, such as the "Beck Depression Inventory" to assess depression, or assessments designed specifically for dissociation or obsessive-compulsive behavior. A thorough psychosocial evaluation should be done to gather information on family, job, work, relationships, and any trauma or abuse history. Additionally, other professionals can perform assessments as part of a treatment team approach. A dietitian can do a nutrition assessment and a psychiatrist can perform a psychiatric evaluation. Integrating the results of various assessments allows the clinician, patient, and treatment team to develop an appropriate, individualized treatment plan. One of the most important assessments of all that needs to be obtained and maintained is the one performed by a medical doctor to evaluate the individual's medical status.

MEDICAL ASSESSMENT

The information on the following pages is an overall summary of what is needed in a medical assessment. For a more detailed and thorough discussion of medical assessment and treatment, see chapter 15, "Medical Management of Anorexia Nervosa and Bulimia Nervosa."

Eating disorders are often referred to as psychosomatic disorders, not because the physical symptoms associated with them are "all in the person's head," but because they are illnesses where a disturbed psyche directly contributes to a disturbed soma (body). Aside from the social stigma and psychological turmoil that an eating disorder causes in an individual's life, the medical complications are numerous, ranging all the way from dry skin to cardiac arrest. In fact, anorexia nervosa and bulimia nervosa are two of the most life-threatening of all psychiatric illnesses. The following is a summary of the various sources from which complications arise.

SOURCES OF MEDICAL SYMPTOMS IN PATIENTS WITH EATING DISORDERS

• Self-starvation

• Self-induced vomiting

• Laxative abuse

• Diuretic abuse

• Ipecac abuse

• Compulsive exercise

• Bingeing

• Exacerbation of preexisting diseases (e.g., insulin-dependent diabetes mellitus)

• Treatment effects of nutritional rehabilitation and psychopharmacological agents (drugs prescribed to alter mental functioning)

A THOROUGH MEDICAL ASSESSMENT INCLUDES

• A physical exam

• Laboratory and other diagnostic tests

• A nutritional assessment/evaluation

• A written or oral interview of weight, dieting, and eating behavior

• Continued monitoring by a physician. The physician must treat any medical or biochemical cause for the eating disorder, treat the medical symptoms that arise as a result of the eating disorder, and must rule out any other possible explanations for symptoms such as malabsorption states, primary thyroid disease, or severe depression resulting in loss of appetite. Additionally, medical complications may arise as consequences of the treatment itself; for example, refeeding edema (swelling that results from the starved body's reaction to eating again—see chapter 15) or complications from mind-altering medications prescribed

• Assessment and treatment of any needed psychotropic medication (most often referred to a psychiatrist)

A normal lab report is not a guarantee of good health, and physicians need to explain this to their patients. In some cases at the discretion of the physician, more invasive tests like an MRI for brain atrophy or bone marrow test may have to be performed to show abnormality. If lab tests are even slightly abnormal, the physician should discuss these with the eating disordered patient and show concern. Physicians are unaccustomed to discussing abnormal lab values unless they are extremely out of range, but with eating disorder patients this may be a very useful treatment tool.

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Once it is determined or likely that an individual has a problem that needs attention, it is important to get help not only for the person with the disorder but for those significant others who are also affected. Significant others not only need assistance in understanding eating disorders and in getting their loved ones help but in getting help for themselves as well.

Those who have tried to help know all too well how easy it is to say the wrong thing, feel like they are getting nowhere, lose patience and hope, and become increasingly frustrated, angry, and depressed themselves. For these reasons and more, the following chapter offers guidelines for family members and significant others of individuals with eating disorders.

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