Assessment of an Eating Disorder

Assessing The Situation

Once it is suspected that someone has an eating disorder, there are several ways of assessing the situation further, from a personal as well as a professional level. This chapter will review assessment techniques that can be used by loved ones and significant others, in addition to those used in professional settings. Advances in our understanding and treatment of anorexia nervosa and bulimia nervosa have resulted in improvements in assessment tools and techniques for these disorders. Standard assessments for binge eating disorder are still being developed because less is known about the clinical features involved in this disorder. An overall assessment should ultimately include three general areas: behavioral, psychological, and medical. A thorough assessment should provide information on the following: history of body weight, history of dieting, all weight loss–related behaviors, body image perception and dissatisfaction, current and past psychological, family, social, and vocational functioning, and past or present stressors.

ASSESSING THE SITUATION IF YOU ARE A SIGNIFICANT OTHER

If you suspect that a friend, relative, student, or colleague has an eating disorder and you want to help, first you need to gather information in order to substantiate your concerns. You can use the following checklist as a guide.

CHECKLIST OF OBSERVABLE AND NONOBSERVABLE SIGNS OF AN EATING DISORDER

• Does anything to avoid hunger and avoids eating even when hungry

• Is terrified about being overweight or gaining weight

• Obsessive and preoccupied with food

• Eats large quantities of food secretly

• Counts calories in all foods eaten

• Disappears into the bathroom after eating

• Vomits and either tries to hide it or is not concerned about it

• Feels guilty after eating

• Is preoccupied with a desire to lose weight

• Must earn food through exercising

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  Uses exercise as punishment for overeating

• Is preoccupied with fat in food and on the body

• Increasingly avoids more and more food groups

• Eats only nonfat or "diet" foods

• Becomes a vegetarian (in some cases will not eat beans, cheese, nuts, and other vegetarian protein)

• Displays rigid control around food: in the type, quantity, and timing of food eaten (food may be missing later)

• Complains of being pressured by others to eat more or eat less

• Weighs obsessively and panics without a scale available

• Complains of being too fat even when normal weight or thin, and at times isolates socially because of this

• Always eats when upset

• Goes on and off diets (often gains more weight each time)

• Forgoes nutritious food on a regular basis for sweets or alcohol

• Complains about specific body parts and asks for constant reassurance regarding appearance

• Constantly checks the fitting of belt, ring, and "thin" clothes to see if any fit too tightly

• Checks the circumference of thighs particularly when sitting and space between thighs when standing

Is found using substances that could affect or control weight such as:

• Laxatives

• Diuretics

• Diet pills

• Caffeine pills or large amounts of caffeine

• Other amphetamines or stimulants

• Herbs or herbal teas with diuretic, stimulant, or laxative effects

• Enemas

• Ipecac syrup (household item that induces vomiting for poison control)

• Other

If the person you care about displays even a few of the behaviors on the checklist, you have reason to be concerned. After you have assessed the situation and are reasonably sure there is a problem, you will need help deciding what to do next.

ASSESSING THE SITUATION IF YOU ARE A PROFESSIONAL

Assessment is the first important step in the treatment process. After a thorough assessment, a treatment plan can be formulated. Since the treatment of eating disorders takes place on three simultaneous levels, the assessment process must take all three into consideration:

• Physical correction of any medical problem.

• Resolving underlying psychological, family, and social problems.

• Normalizing weight and establishing healthy eating and exercise habits.

There are several avenues the professional can use for assessing an individual with disordered eating, including face-to-face interviews, inventories, detailed history questionnaires, and mental measurement testing. The following is a list of specific topics that should be explored.

ASSESSMENT TOPICS

• Eating behaviors and attitudes

• History of dieting

• Depression

• Cognitions (thought patterns)

• Self-esteem

• Hopelessness and suicidality

• Anxiety

• Interpersonal skills

• Body image, shape, and weight concerns

• Sexual or other trauma

• Perfectionism and obsessive-compulsive behavior

• General personality

• Family history and family symptoms

• Relationship patterns

• Other behaviors (e.g., drug or alcohol abuse)

ASSESSMENT STRATEGIES AND GUIDELINES

It is important to get necessary information from clients while at the same time establishing rapport and creating a trusting, supportive environment. If less information is gathered in the first interview because of this, that is acceptable, as long as the information is eventually obtained. It is of primary importance that the client knows that you are there to help and that you understand what she is going through. The following guidelines for gathering information will help:

• Data: Gather the most important identifying data—age, name, phone, address, occupation, spouse, and so on. Presentation: How does the client look, act, and present herself?

• Reason for seeking treatment: What is her reason for coming for help? Don't assume that you know. Some bulimics are coming because they want to be better anorexics. Some clients are coming for their depression or relationship problems. Some come because they think you have a magic answer or a magic diet to help them lose weight. Find out from the client's own words!

• Family information: Find out information about the parents and/or any other family members. Find out this information from the client and, if possible, from the family members, too. How do they get along? How do they see the problem? How have they, or do they, attempt to deal with the client and the problem?

• Support systems: Who does the client usually go to for help? From whom does the client get her normal support (not necessarily regarding the eating disorder)? With whom does she feel comfortable sharing things? Who does she feel really cares? It is helpful to have a support system in recovery other than the treating professionals. The support system can be the family or a romantic partner but doesn't have to be. It may turn out that members of a therapy or support group and/or a teacher, friend, or coach provide the needed support. I have found that clients with a good support system recover much faster and more thoroughly than those without.

• Personal goals: What are the client's goals regarding recovery? It is important to determine these, as they may be different from those of the clinician. To the client, recovery may mean being able to stay 95 pounds, or gaining 20 pounds because "my parents won't buy me a car unless I weigh 100 pounds." The client may want to learn how to lose more weight without throwing up, even though only weighing 105 at a height of 5'8". You must try to find out the client's true goals, but don't be surprised if she really doesn't have any. It may be that the only reason some clients come for treatment is that they were forced to be there or they are trying to get everyone to stop nagging them. However, usually underneath, all clients want to stop hurting, stop torturing themselves, stop feeling trapped. If they don't have any goals, suggest some—ask them if they wouldn't like to be less obsessed and, even if they want to be thin, wouldn't they also like to be healthy. Even if clients suggest an unrealistic weight, try not to argue with them about it. This does no good and scares them into thinking you are going to try to make them fat. You might respond that the client's weight goal is an unhealthy one or that she would have to be sick to reach or maintain it, but at this point it is important to establish understanding without judgment. It is fine to tell clients the truth but is important that they know the choice for how to deal with that truth is theirs. As an example, when Sheila first came in weighing 85 pounds, she was still on a losing weight pattern. There was no way I could have asked her to start gaining weight for me or for herself; that would have been premature and would have ruined our relationship. So, instead, I got her to agree to remain at 85 pounds and not lose any more weight and to explore with me how much she could eat and still stay that weight. I had to show her, help her to do that. Only after time was I able to gain her trust and alleviate her anxiety in order for her to gain weight. Clients, whether anorexic, bulimic, or binge eaters, don't have any idea what they can eat just to maintain their weight. Later, when they trust the therapist and are feeling safer, another weight goal can be established.

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By Carolyn Costin, MA, M.Ed., MFCC - Medical Reference from "The Eating Disorders Sourcebook"

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