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 for 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
• 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 for 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 eating disorder 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 eating disorders 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.

• 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.
• 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 - Å“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).

• 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?

These are all things that the clinician needs to assess during the early stages of eating disorders 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
• Binge eating
• 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.

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

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

next: Eating Disorders Require Medical Attention
~ eating disorders library
~ all articles on eating disorders