Keywords

Description of the Disorder

The term “eating disorders” (EDs) broadly refers to psychiatric disorders marked by maladaptive eating patterns and attitudes about eating, body shape, and body weight. The four ED diagnoses described in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013) include anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED), and “other specified feeding or eating disorder” (OSFED; American Psychiatric Association, 2013).

Age of onset for the DSM-5 EDs varies by disorder, with age of onset for AN typically occurring in early-to-middle adolescence (Attia & Walsh, 2007) and age of onset for BN and BED occurring in the late teenage years to young adulthood (Kessler et al., 2013). Recent examination of prevalence rates for the DSM-5 EDs in adolescents estimates prevalence rates to be 5.7% in females and 1.2% in males (Smink, van Hoeken, Oldehinkel, & Hoek, 2014). Recent epidemiologic research conducted in Australia reported a three-month point prevalence rate of 16.3% for any DSM-5 ED, with the majority of ED cases accounted for by BED and OSFED, and rates of less than 1% each for AN and BN (Hay, Girosi, & Mond, 2015). Research in the United States found a combined ED prevalence of 13.1% by age 20 (Stice, Marti, & Rohde, 2013). Thus, in contrast to views of EDs as rare psychiatric disorders, they are relatively common in the general population.

In the following section, the DSM-5 diagnostic criteria for EDs are described:

Anorexia Nervosa

AN is characterized by restriction of energy intake that results in a significantly low body weight, given a person’s age, sex, and other developmental and physical health factors (Criterion A). Persons with AN may display an intense fear of weight gain or engage in persistent behaviors to avoid weight gain (Criterion B). People with AN may report a distorted perception of their weight and body shape, deny the seriousness of their low body weight, or base their self-evaluation on their weight or shape (Criterion C). It is important to note that a person with AN may not report any concerns with body image or perceptual disturbance but may still meet criteria if there are persistent behaviors that are designed to prevent weight gain (e.g., excessive exercise, restricting food intake, etc.) and the person does not think that their low weight is a problem.

Body weight is typically assessed in adults by calculating a person’s body mass index (BMI); for children and adolescents, additional information conveyed by BMI-for-age percentiles should be considered to account for growth trajectories. The DSM-5 does not provide a specific BMI cutoff for defining “significantly low body weight.” However, BMI cutoffs are included in the new DSM-5 severity categories for AN that define severity from mild to extreme based on BMI thresholds.

The DSM-5 specifies two subtypes for AN: (1) restricting type, in which no binge eating or purging behaviors occur, and (2) binge eating/purging type, in which the person engages in binge eating and/or purging behaviors, such as self-induced vomiting and misuse of laxatives and/or diuretics.

Bulimia Nervosa

BN is characterized by repeated episodes of binge eating and inappropriate compensatory behavior at least once per week (on average) for a period of 3 months. The person must also report that their self-evaluation is unduly influenced by their shape and weight. An individual cannot simultaneously meet criteria for AN and BN. Thus, significantly low body weight is an exclusion criterion for BN and an inclusion criterion for AN.

An objective binge eating episode refers to a discrete period of time (e.g., within 2 hours) in which an individual consumes an objectively large amount of food, in addition to experiencing a sense of loss-of-control (LOC). Although there are no caloric guidelines for what is considered large, the DSM-5 indicates that the amount eaten needs to be “definitely larger” than what most other people would eat under similar circumstances. Interviewers may also want to consider the person’s body size and height, gender, and physical activity patterns when making judgments of whether or not the eating episodes are large. LOC may be expressed by individuals in terms that include, but are not limited to, feeling as though binge episodes were inevitable, like they could not stop eating once they started, or that they could not control what or how much was consumed. See the dialogue for an example of how to assess for binge eating episodes.

Inappropriate compensatory behaviors (ICBs) are categorized into purging and non-purging methods. Purging ICBs refer to forced expelling of food from the body (through means such as self-induced vomiting, laxatives, diuretics) or misuse of certain substances (e.g., insulin omission in persons with type 1 diabetes or misuse of thyroid medicine to prevent weight gain or compensate for an eating episode). Non-purging ICBs refer to non-purging behaviors that are used to compensate for binge episodes by excessive exercise or restricting caloric intake.

Binge Eating Disorder

BED requires that an individual engage in recurrent episodes of binge eating (see above) in the absence of low body weight and ICBs. In addition, an individual must meet criteria for three out of five associated cognitive features for BED, such as (1) eating much more rapidly than normal; (2) eating until uncomfortably full; (3) eating large amounts of food when not physically hungry; (4) eating alone because of embarrassment associated with how much one is eating; and (5) feeling disgusted, depressed, or guilty after a binge has occurred. Finally, marked distress over binge eating is necessary for diagnosis.

Other Specified Feeding or Eating Disorder

The DSM-5 also includes a category called “OSFED” to encompass ED presentations that cause significant distress or impairment but do not meet diagnostic criteria for AN, BN, or BED. OSFED is the most common ED diagnosis (Keel, Brown, Holm-Denoma, & Bodell, 2011). OSFED does not necessarily imply that the person’s ED is less severe but rather encompasses the large proportion of serious ED presentations. A meta-analysis of mortality rates in the various ED diagnoses identified similar mortality rates in OSFED and full-threshold BN (Arcelus, Mitchell, Wales, & Nielsen, 2011).

The DSM-5 provides five specific examples of presentations that fall within the OSFED category. For example, Atypical AN is an OSFED characterized by clinically significant, substantial weight loss (not better explained by a medical condition) that occurred rapidly in a person with a higher premorbid weight. Given that the person with atypical AN developed their illness at a higher baseline weight, this diagnosis is provided to intervene earlier in the illness course, rather than waiting until the person reaches a significantly low body weight. Purging disorder is an OSFED in which the person purges due to experiencing LOC after eating what most other people would consider a small or normal amount of food. Night eating syndrome is an OSFED characterized by recurrent consumption of food after waking up from sleep or the excessive consumption of food following an evening meal; the individual has full awareness and recollection of food consumption. Other OSFEDs include BN and BED of lower frequency or duration.

Avoidant/Restrictive Food Intake Disorder

Previously conceptualized in the DSM-IV (APA, 1994) as “feeding disorder of infancy or early childhood,” the DSM-5 reconceptualized this disorder as “avoidant and restrictive food intake disorder” (ARFID). It is important to note that ARFID is designated as a feeding disorder, not an ED. However, we included ARFID in this chapter because cases of ARFID are often seen in ED treatment settings. ARFID is characterized by limited interest in food, avoidance of food due to sensory characteristics, preoccupation with potentially undesirable consequences of food consumption (such as contracting an illness or disease from food, etc.) that is accompanied by substantial weight loss or nutritional deficiency or marked psychosocial impairment.

Due to the consequences of nutritional deficiency in both AN and ARFID, there are considerable similarities in how these two disorders present clinically. It is important to note, however, that body image disturbances and persistent behaviors to prevent weight gain are not a component of the ARFID diagnosis in the DSM-5. For this reason, it can be difficult to differentiate cases of ARFID from cases of AN (Eddy et al., 2015), particularly in which symptoms of fat phobia are absent [non-fat-phobic AN; (Kennedy, Wick, & Keel, 2018)]. However, to make a definitive diagnosis of ARFID, the clinician must rule out AN and BN, and ARFID symptoms should not be attributable to cultural practices, a lack of food resources, or a concurrent medical condition that better explains low weight. For more information about other feeding disorders, interested readers are referred to Morris, Knight, Bruni, Sayers, and Drayton (2017).

Procedures for Gathering Information

EDs are complex psychiatric disorders that, if left untreated, result in substantial psychiatric and medical morbidity and high mortality rates (Arcelus et al., 2011). Given that EDs have the highest mortality rate of any mental disorder (Smink, Van Hoeken, & Hoek, 2012), proper assessment and early diagnosis are essential. Procedures for clinical interviewing should be given careful consideration, including identifying the problem area, establishing rapport, and providing appropriate clinical recommendations (see Table 15.1 for “dos and don’ts”). In addition to utilizing well-validated self-report and interview-based tools to ensure proper diagnosis, it is important for clinicians to include the following additional components in their unstructured clinical interviews: (1) weight and dieting history; (2) current and past patterns of disordered eating behaviors and cognitions [including binge eating, ICBs, and body dissatisfaction (including desire for greater muscularity)]; (3) history of weight-based teasing or bullying; (4) social support and relationships; (5) suicidal ideation, self-harm, and suicide attempt histories; and (6) treatment history.

Table 15.1 Dos and don’ts
Full size table

We find it useful to collaboratively develop a timeline of the ED behaviors and cognitions that begins with the person’s first attempt to diet up until the present time. The interviewer should attempt to gather information on the temporal relationships between past dieting behaviors and weight fluctuations. For example, the interviewer will want to know how much weight was lost after the first attempt to diet, over what period time the diet occurred, how much was consumed during that time, what other behaviors occurred during and after the diet ceased, and how the behaviors and thoughts affected their day-to-day functioning, their social relationships, and their self-image. The interviewer will also want to obtain the client’s lowest and highest body weights for their height (excluding pregnancy) and inquire about the eating behaviors, ICBs, and physical activity patterns the person was engaging in during that time. Obtaining a full weight history is important because people often “migrate” among ED diagnoses over time (e.g., from AN to BN) without recovering. Thus, obtaining information on weight history will enable the clinician to see the “full picture” with respect to the scope and severity of the ED. Throughout the diagnostic interviewing process, the interviewer should work to remain non-judgmental, supportive, and collaborative while also obtaining detailed information necessary to make an accurate diagnosis and develop an effective treatment plan. Given that lay definitions of various ED behaviors differ from clinical and diagnostic definitions, we encourage the clinician to err on the side of obtaining objective information and informant reports, when appropriate.

Finally, it is important that clinicians are sensitive to the physical and cognitive needs of clients with EDs. Clinics that see people with EDs should be able to accommodate a full range of body shapes and sizes. For example, there should be sufficient seat padding or extra cushions to prevent people with low body weights from bruising and bariatric-sized chairs for people with higher body weights. Keep in mind how embarrassing it would feel if you were a client who was seeking help for your eating issues and you could not fit through the clinic front doors or you sat down and broke a clinic chair! You will also want to be mindful of the fact that clients who are malnourished may be slow to respond to questions or be forgetful. It is important to note that malnutrition is not perfectly aligned with body weight – many clients who are severely restricting their food intake (even clients living in larger bodies) may experience cognitive effects associated with inadequate caloric intake. Thus, depending on the client’s needs, the clinician may want to break up the intake session into a few shorter sessions.

Case Illustrations

Dialogue About Binge Eating Episodes

Therapist: :

You mentioned that there have been times when you felt as though your eating was out of control. What do you typically eat during these eating episodes?

Sarah: :

Umm…I don’t know. [Long pause] …I guess a little of everything.

Therapist: :

A little of everything; okay. What are some foods you typically eat?

Sarah: :

Pizza, ice cream, candy…ugh, I feel so gross.

Therapist: :

I’m here to support you and not pass judgment about your eating habits. I wouldn’t even know to ask about your eating habits if other people didn’t struggle with similar eating issues. I can imagine that it must be uncomfortable sharing this information with me, particularly because we don’t yet know each other well, and please know that it does not change my view of you in the slightest.

Sarah: :

Thank you. I’ve never told anyone about these binges before, so it’s kind of hard for me to talk about.

Therapist: :

I really appreciate your willingness to talk with me, especially because it’s something that you’ve held inside for so long. Do you mind if I ask more specific questions to try to get a better picture of your eating habits? That might help us work together to come up with a good plan to figure out how to address the food issues that you said you’d like to change.

Sarah: :

Sure. That makes sense.

The therapist used several strategies to support the client in opening up about her binge eating episodes. The therapist assured the patient that while it is uncomfortable to discuss binge eating episodes, the therapist would not judge her for the amount or types of foods she ate. The therapist also did not refer to the binge eating episodes as “binges” until the client had done so, which is helpful in the event that the client might not perceive their eating to be “binge eating.”

Therapist: :

You said you eat pizza; what type of pizza do you typically eat?

Sarah: :

My go-to is to order pizza for delivery.

Therapist: :

What pizza place do you tend to order from?

Sarah: :

I usually get Pizza Hut pizza.

Therapist: :

What size and what type of toppings?

Sarah: :

My usual order is a large, thin-crust with pepperoni and sausage, and an order of breadsticks.

Therapist: :

How much will you typically eat?

Sarah: :

The whole pizza and four or five breadsticks, usually.

Therapist: :

Typically, more like four or more like five breadsticks?

Sarah: :

Probably five. I’ll sometimes also have ice cream.

Therapist: :

What kind?

Sarah: :

Cookie dough. I usually get the generic brand.

Therapist: :

How much of the ice cream will you have?

Sarah: :

The whole container.

Therapist: :

What size container?

Sarah: :

Just the standard pint-size.

Therapist: :

Okay, so Pizza Hut pizza and breadsticks, and cookie dough ice cream. What else?

Sarah: :

Candy, sometimes. Usually Snickers, and I’ll eat one of those regular-sized bars.

Therapist: :

What else?

Sarah: :

That’s it.

Therapist: :

And over what period of time do you eat these foods?

Sarah: :

It’s usually on my lunch break, so an hour.

Therapist: :

Thank you for going through that with me. I would imagine it could be difficult to discuss the binges if you’ve never told anyone about them before. Just know I really appreciate you telling me because it helps me get a clear sense of your eating patterns so that we can later come up with a plan together to address them.

The therapist used several more strategies to ask about the binge eating episodes. You can see the level of detail the therapist asked for in detailing the foods consumed. A useful guideline is to get enough detail that you could go to the store (or restaurant) and recreate the exact meal or snack. With some patients, using a portion or measurement guide may be helpful (i.e., helping them to describe their eating episodes with descriptors like cups, teaspoons, and ounces). The reason for obtaining such detailed information on eating episodes is because the size of the episode (small or typical meal or snack vs. an amount that is definitely large) determines whether the person should be diagnosed with purging disorder, BN, or BED.

Another helpful strategy is to use the phrase “What else?” in asking about foods consumed in the binge eating episode. This phrasing tells the patient that you expect there to be more foods consumed, as opposed to the phrasing “Anything else?” which can suggest to the client that the amount of food he or she has described is already large enough. In this dialogue, the therapist asked, “What else?” until the patient reported being finished describing the eating episode. The therapist provided positive reinforcement (praise) to the patient for discussing the binge eating episodes and reiterated the rationale for why this information was sought.

Dialogue About Loss-of-Control over Eating

Therapist: :

You’ve described episodes of overeating when you’ll have five peanut butter sandwiches, which includes 10 slices of white bread and 15 ounces of peanut butter. Do you feel a sense of loss-of-control over your eating during these times?

Will: :

Not really, no.

Therapist: :

Do you feel like you could’ve stopped eating once you started?

Will: :

Yeah, I planned to have a binge so I just let myself go on until I was full.

Therapist: :

So, it sounds like this was a planned event. Did you feel it was inevitable you’d eat that amount of food?

Will: :

I guess so, because I had planned it out. I’ve just been overeating like this for so long that I’m kind of numb to it now. It’s just something I plan to do. When it first started, it felt way more out-of-control. Now I just plan it into my week because I know it’s going to happen.

The therapist asked about loss-of-control, and the patient denied having that experience during his recent binge eating episodes. The therapist then asked follow-up questions about loss-of-control in different ways that might resonate with the patient (e.g., feeling like he couldn’t stop eating once he had started and feeling it was inevitable he would eat that amount of food). Each of these strategies was used to assess loss-of-control, which the patient eventually endorsed. In our experience, many times the sense of being out of control over binge eating episodes will lessen over the course of the ED illness. The sense of loss-of-control might go away or lessen because the person has experienced the episodes for a long period of time and/or because they plan to have a binge eating episode. This does not preclude them from experiencing a sense of loss-of-control over their eating, even if it is to a lesser degree than when he/she first started binge eating. The take-home message is that loss-of-control does not need to be severe to be considered present.

Dialogue About Exercise

Therapist: :

Do you ever exercise or participate in sports?

Betsy: :

Of course, but I usually exercise to maintain a healthy heart… not necessarily to lose weight.

Therapist: :

Being healthy is important to you. Tell me more about what a typical exercise session looks like for you.

Betsy: :

I have a job as a fitness instructor, so I usually teach classes during the week.

Therapist: :

Okay, what types of classes do you teach and how long do they last?

Betsy: :

I teach a cardio aerobics class and sometimes yoga. Classes are typically 1 hour with a 5-minute warm-up and a 5-minute cool-down.

Therapist: :

I’m familiar with some of those group classes. I also know that some instructors differ in how much they actually exercise in the class. Some instructors don’t do all the exercises or they use really light weights. They might walk around to give modifications and additional instructions to folks. Other instructors use class time to get their own work out in and do all of the exercises. How would you describe your teaching style?

Betsy: :

Oh, I do all of the exercises, all of the time. I also tend to push myself pretty hard. My goal is to encourage my classes to test their physical limits and to get stronger. I have to model working hard for them.

Therapist: :

You want everyone to get a great workout in. How many classes do you typically teach in a day?

Betsy: :

On average, about two or three.

Therapist: :

Alright, do you do any other types of physical activity in addition to teaching classes?

Betsy: :

Oh yeah, I usually try to get my own workout in four times a week.

Therapist: :

When do those fit in? On days when you teach classes or on your days off from teaching?

Betsy: :

Typically, days that I teach classes because I’m already at the gym and dressed to workout.

Therapist: :

Okay, so it sounds like part of the reason you exercise is for the health benefits and because it is your job. I totally get that. I’m wondering if there is any added benefit that you might lose weight or change your body shape by working out.

Betsy: :

Oh yeah, it is definitely an additional benefit. It also makes me feel less guilty about when I might overeat or drink too much alcohol over the weekend.

Therapist: :

Okay, now that I have a better idea of your exercise patterns and the reasons why you exercise, I’m going to ask some more specific questions. Would that be alright?

Betsy: :

Yeah, that’s fine.

Therapist: :

How many days per week, on average, do you exercise for 2 or more hours?

Betsy: :

Six days a week, typically.

Therapist: :

Okay, and have you ever exercised when you were sick or injured?

Betsy: :

I have to. I can’t miss work every time I’m sick or have an injury.

Therapist: :

Okay, when you are sick or injured, do you still push yourself very hard or do you modify what you are doing?

Betsy: :

I always push myself. It’s important to be an upbeat workout instructor.

Therapist: :

Could you give me some examples of when you might have exercised when you were sick or injured?

Betsy: :

I had a twisted ankle a few times.

Therapist: :

Ouch, those can really hurt! I’m wondering if you ever went to a doctor for your twisted ankles?

Betsy: :

A few times. They just tell me to rest my ankle. They don’t understand that I have a job to do and can’t afford to take time off.

The therapist used several strategies to fully assess the patient’s exercise behaviors. The patient initially mentioned that her exercise was about health and that she exercised frequently for her job but not to influence body shape or weight. Because exercise can be a healthful behavior for many people, patients with EDs will sometimes frame their exercise in a positive manner. The therapist, however, should continue to ask about the patient’s exercise pattern in a non-judgmental manner to better understand how the ED and exercise might be related. The therapist in this case validated what the patient was saying and asked whether there was any added benefit that her shape and/or weight could be influenced by her exercise behaviors. The patient also framed her exercise as being necessary for work, so the therapist asked detailed questions about how much effort the patient put into exercise (e.g., more than other instructors) as well as the frequency of exercise (i.e., including additional workouts in addition to teaching exercise classes as part of her job). It is also important to inquire about days when exercise persisted despite an injury or illness or when against medical advice. Finally, the patient volunteered that she exercised to compensate for an overeating episode. If she had not volunteered this information, it would have been important for the clinician to ask if exercise was used to compensate for an eating episode.

Recommendations for Formal Assessment

We highly recommend that clinicians include some type of formal assessment (in addition to unstructured clinical interviewing) as a part of their routine assessment practice for clients with an ED. Past research has shown that 30% of disorders can be missed by the interviewer if unstructured interviews are administered without any formal diagnostic interview (Zimmerman & Mattia, 1999). Moreover, other research indicates that (1) early response in the first month of treatment as defined by 2.88% weight gain (for persons with AN) or ≥70% reduction in binge eating or purging (for persons with BED or BN) is one of the only prognostic indicators for end-of-treatment response (Linardon, Brennan, & De la Piedad Garcia, 2016) and (2) clinicians who engage in routine assessment of cognitions and behaviors are able to treat clients faster and more effectively (Boswell, Kraus, Miller, & Lambert, 2015). Clinicians who routinely assess at intake and throughout treatment, therefore, have a better likelihood of seeing meaningful improvements in their clients. Below, we highlight some suggested diagnostic interviews for general psychiatric and ED-specific concerns.

Given that many people with an ED have a comorbid mental health condition (Hudson, Hiripi, Pope Jr., & Kessler, 2007) and/or a lifetime history of suicidal ideation or suicide attempts (Forrest, Zuromski, Dodd, & Smith, 2017), we recommend assessing non-ED psychopathology (e.g., depression, anxiety, obsessive-compulsive disorder, substance misuse) in addition to ED-specific psychopathology.

The selected measures (see below) do not represent an exhaustive list of assessments from which to choose. Clinicians should use their judgment of individual client’s needs and up-to-date information on the reliability and validity of a measure to make selections about which assessment to use for a particular client.

Self-Report and Screening Measures

The Eating Disorder Examination Questionnaire (EDE-Q; Fairburn & Beglin, 1994) is a 28-item self-report version of the Eating Disorder Examination (EDE) interview (see below). The EDE-Q measures constructs that are targeted in Enhanced Cognitive Behavior Therapy for EDs (CBT-E; Fairburn, Cooper, & Shafran, 2003). Thus, the EDE-Q is a valuable tool for clinicians interested in monitoring changes in relevant CBT-E constructs over the course of therapy. The EDE-Q performs similarly to the EDE interview (Fairburn & Beglin, 1994). Strengths of the EDE-Q include strong reliability and convergent validity. However, recent research has shown that the reliability of binge eating may be lower in men compared to women (Forbush, Hilderbrand, Bohrer, & Chapa, 2017). Another important limitation is that the factor structure of the EDE-Q has not replicated well across samples (Berg, Peterson, Frazier, & Crow, 2012). The EDE-Q is free for non-commercial research or clinical use (https://www.rcpsych.ac.uk/pdf/EDE-Q.pdf). The EDE-Q is also available within the Recovery Record, Inc. mobile app (https://www.recoveryrecord.com/).

The Eating Disorder Inventory 3 (EDI-3; Garner, 2004) is a 91-item self-report measure that is licensed by the Psychological Assessment Resources. The EDI-3 takes approximately 20 minutes to administer and 20 minutes to score (although interested clinicians can purchase an online scoring package). The EDI-3 is appropriate for use in persons aged 13 to 53 years. Three scales – Drive for Thinness, Body Dissatisfaction, and Bulimia – directly pertain to EDs, whereas the other nine scales assess correlated psychopathology (e.g., Maturity Fears, Perfectionism, and Emotion Dysregulation). The EDI-3 has good reliability and convergent validity (Cumella, 2006), although it has limited discriminant validity from depression (Anderson, Williamson, Duchmann, Gleaves, & Barbin, 1999). The EDI-3 has substantial normative data available and computerized scoring, and it provides useful supplementary materials (e.g., ED risk scores and ability to purchase an additional self-report diagnostic measure).

The Eating Pathology Symptoms Inventory (EPSI; Forbush et al., 2013) is a 45-item self-report measure that assesses body dissatisfaction, binge eating, cognitive restraint, muscle building, purging, restricting, excessive exercise, and negative attitudes toward obesity. The EPSI is freely available for non-commercial research or clinical use [although any adaptations must be approved in writing from the copyright holder (Dr. Kelsie Forbush) prior to use]. The EPSI is also available within the Recovery Record, Inc. mobile app (https://www.recoveryrecord.com/). Strengths of the EPSI include strong psychometric properties in men and women and in persons with high and low body weights and a stable factor structure (Forbush et al., 2013). (Note, however, that Muscle Building tends to have lower reliability in women and generally should not be interpreted in women.) Although the EPSI is a new measure, it has a large, burgeoning support for its clinical utility, reliability, and validity. To download the EPSI, go to: https://psych.ku.edu/sites/psych.ku.edu/files/docs/cv/EPSI.pdf.

The SCOFF (Morgan, Reid, & Lacey, 2000) is a five-item self-report tool that is designed to screen for the possible presence of an ED. The content assessed in the SCOFF includes (1) making oneself “sick” (i.e., self-induced vomiting) due to eating large amounts of food, (2) losing control over eating, (3) losing more than one stone (i.e., 15 pounds) over a three-month period, (4) feeling one is “fat” when others disagree, and (5) endorsing the belief that food dominates one’s life. Individuals who provide affirmative answers to two or more questions on the SCOFF should be referred for a comprehensive ED assessment. Past research has shown that the SCOFF has high specificity (>0.90) and adequate sensitivity (>0.50) for screening EDs (Solmi, Hatch, Hotopf, Treasure, & Micali, 2015). A disadvantage of the SCOFF is the relatively high false-positive rate.

Structured and Semi-structured Interviews

General Interviews

The Structured Clinical Interview for DSM-5 Disorders (SCID; First & Williams, 2016) is a semi-structured interview that assesses most of the common mental disorders. Although the SCID for DSM-5 disorders includes a module to assess feeding and EDs, it may be worthwhile for the clinician to administer an additional ED-specific interview, given that there are many aspects of ED psychopathology that are not measured in the SCID (e.g., internalized weight stigma, body checking, frequency of self-weighing) or that are not assessed comprehensively (e.g., excessive exercise). However, the SCID provides coverage of mood, anxiety, obsessive-compulsive, psychotic, and substance use disorders (and other disorders), providing important diagnostic breadth. A limitation of the SCID is that it can be challenging to learn to administer correctly, particularly if the clinician is not familiar with a broad range of psychopathological presentations. Thus, clinicians who wish to administer the SCID should receive appropriate training and supervision prior to use (see https://www.columbiapsychiatry.org/scid-5-training-media-0).

The Mini-International Neuropsychiatric Interview (MINI; Hergueta, Baker, & Dunbar, 1998) is a structured diagnostic interview that provides coverage of 17 common psychiatric disorders and has been translated into 70 languages. The MINI takes approximately 15 minutes to administer, making it a widely used instrument in clinical settings and epidemiological research. The MINI includes AN, BN, and BED, but does not directly assess OSFEDs.

Eating Disorder-Specific Interviews

The Eating Disorder Examination (EDE; Cooper & Fairburn, 1987) is a semi-structured interview that assesses ED diagnostic criteria and other relevant constructs (e.g., reaction to prescribed weighing, which is not a diagnostic criterion for EDs but may give clinically relevant information). There are four EDE sub-scales: Eating Concern, Weight Concern, Shape Concern, and Restraint; the EDE also features behavioral items to assess specific ED behaviors (e.g., binge eating, purging, etc.). The EDE is a free, downloadable measure available from https://www.rcpsych.ac.uk/pdf/EDE_16.0.pdf. The EDE is an “investigator-based interview,” which means that the interviewer should have training in ED-relevant concepts and diagnostic criteria. There is evidence for test-retest reliability over periods of 1–2 weeks for EDE sub-scales and most behavioral items; there is also evidence for inter-rater reliability and internal consistency (Berg et al., 2012). The factor structure of the EDE has not been consistently replicated, and there is mixed evidence for the EDE’s construct validity (for a comprehensive review, see Berg et al., 2012).

The Eating Pathology Symptoms Inventory—Clinician Rated Version (EPSI-CRV; Forbush, Wildes, Bohrer, Chapa, & Hagan, 2018) is a semi-structured interview that was created based on the EPSI self-report measure (Forbush et al., 2013). The EPSI-CRV was designed to be used with less training than the EDE. The EPSI-CRV includes the eight dimensions of the self-reported version of the EPSI as well as additional modules that are used to formulate current (past 3-month) ED diagnoses. The EPSI-CRV enables diagnosis of multiple forms of EDs, including OSFED. To facilitate accurate recall, interviewees are provided with a food measurement guide, and the interviewer assists the interviewee in constructing a detailed calendar for the past 3 months. The EPSI-CRV has strong convergence with the self-reported version of the EPSI.

The Eating Disorder Assessment for DSM-5 (EDA-5; Sysko et al., 2015) is a semi-structured interview for the assessment of DSM-5 feeding and EDs. The computerized version, available from https://eda5.org/, uses an algorithm to reduce the number of questions asked of interviewees (i.e., they are only asked relevant questions based on their answers); the paper-and-pencil and computerized versions had excellent diagnostic agreement with one another (kappa = 0.83). The EDA-5 demonstrated diagnostic agreement with the EDE (kappa = 0.74) and evidence for test-retest reliability over a 7–17-day period (kappa = 0.87; Sysko et al., 2015).

Medical Assessment

If psychological assessment suggests an ED, there are specific physical assessments that should be performed. Vital signs, including orthostatic blood pressure and heart rate, temperature, and last menstrual period (for females of childbearing age), should be assessed at each visit. Changes in orthostatic vital signs could indicate acute dehydration or chronic malnutrition. In the adolescent population, blood pressure changes are not often seen, but heart rate changes are common. Malnourishment may present with a low heart rate (bradycardia), low body temperature (hypothermia), or prolonged missed periods (secondary amenorrhea).

During history-taking, it is important to ask about symptoms that are related to a state of starvation. All organs can be affected during this state, but early and most common complaints include gastrointestinal (GI) complications such as constipation, slowing of the stomach (gastroparesis), bloating, or reflux; cold or bluish coloration of the skin (cyanotic extremities); dizziness or fainting; infrequent menstruation (oligomenorrhea); fatigue or difficulty concentrating. In adolescents, other common presentations to the pediatrician include a decrease in athletic ability or an unexpected drop in grades.

The physical examination should include aspects that incorporate the above complaints, paying particular attention to the GI and cardiovascular systems. The integumentary system is also important to monitor, as lack of subcutaneous fat can result in frequent bruising or pressure ulcers, which usually have delayed healing time and are, therefore, at risk for infection. It is important to note that because bone marrow suppression can be seen during a state of malnutrition, patients may not present with typical signs and symptoms of an infection, so there should be a low threshold to treat. In adolescents who are premenarchal, it is essential to determine pubertal progression so menarche can be accurately anticipated, as it can be delayed due to malnutrition. For those who use vomiting as a method of purging, additional signs on exam include calluses on the back of the hand (Russell’s sign), swollen salivary glands (parotiditis), and a swollen or red throat. The patient may also have fluid retention or marked diuresis, so utilizing weight gain as a marker of progress can be misleading.

Monitoring physical health through laboratory and radiology findings is essential. Ongoing medical complications of EDs include electrolyte abnormalities that may reflect water loading, vomiting, laxative or diuretic use, arrhythmias, and osteopenia or osteoporosis due to chronic bone loss. Treatment should be focused on re-nourishment, using “food as your medicine.” Patients can be treated symptomatically to help alleviate discomfort during the refeeding process. Laxatives are not encouraged due to the high rate of abuse, but polyethylene glycol is a viable option. Patients need to be followed closely during their recovery, as acute complications and need for hospitalization are common. Thus, therapists should work closely with a physician who has experience treating patients who have EDs.

Impact of Gender, Race, Culture, Age, and Other Aspects of Diversity

Ethnicity and Culture

Research on ethnicity and culture is limited in the ED field. Asian and Pacific Islander populations are among the most understudied groups (Thomas, Lee, & Becker, 2016). The following section will focus on all ethnic minority populations and associated prevalence, risk factors, and considerations for assessment.

Recent studies suggested that ED prevalence among African American, Latinx, Asian, Pacific Islander, and/or Native American ethnic minority groups are comparable to, or higher than, ED rates among non-Latinx European Americans (Marques et al., 2011). Despite the fact that members of ethnic-racial minorities are not protected from developing an ED, ethnic-racial minorities are less likely to receive a referral for ED assessment or treatment than European Americans (Franko, Becker, Thomas, & Herzog, 2007). Even when referred for treatment, ethnic and racial minorities are less likely to utilize mental health resources than their European American counterparts (Jimenez, Cook, Bartels, & Alegria, 2013). The lack of treatment referral and treatment receipt in ethnic minority groups is theorized to be the result of increased stigmatization of mental health services (Cheng, Kwan, & Sevig, 2013; Rao, Feinglass, & Corrigan, 2007). Ethnic-racial minority groups make up a significant proportion of low-income families and homes in the United States, when compared to European American peers. For this reason, considering financial barriers is important when making treatment recommendations. Another important consideration is the potential need to include the family in the assessment and treatment process (Griner & Smith, 2006). For example, excluding family members from clinical services could violate the Latinx cultural value of familismo, which refers to a strong identification and attachment to the nuclear and extended families.

Ethnic-racial minority patients who appear for services may be more likely to present with a higher level of psychiatric impairment (e.g., difficulties in work, social, and interpersonal functioning due to the ED) and/or disorder severity (e.g., high levels of dietary restraint, shape concerns, and frequent binge episodes; Grilo, Lozano, & Masheb, 2005; Lydecker & Grilo, 2016; Marques et al., 2011). Presentation with high severity may be due to cultural stigma, which suggests that ethnic-racial minorities may live with ED symptoms longer and wait to seek treatment until they are severely impaired (Becker, Hadley Arrindell, Perloe, Fay, & Striegel-Moore, 2010; Cheng et al., 2013).

Despite having greater symptom severity upon initial treatment presentation, certain minority groups may simultaneously report lower body image concerns than their European American counterparts. For example, African American persons may present with a (relatively) lower desire to be thin, although the literature is mixed with some studies suggesting no differences in body image disturbance between African American and European American persons. Researchers suggested that potential differences in body image disturbance may be due to cultural preference for “curvier” body sizes among members of certain ethnic and racial groups (Gentles & Harrison, 2006; Gordon, Castro, Sitnikov, & Holm-Denoma, 2010; Sánchez-Johnsen et al., 2004). Asian individuals are likely to prioritize body image based on thinness, and culturally important features, such as eye shape and skin clarity (Brady et al., 2017). Finally, for first-generation ethnic-racial minorities, clinicians should evaluate the role of acculturation in the onset and maintenance of ED symptoms (for additional information and suggestions, see Wildes & Forbush, 2015).

Assessment Tip

During assessment and treatment, it is important to consider the cultural practices of the population. While something may seem abnormal or maladaptive, it may be common practice in certain cultures. Cultural context is important in establishing and maintaining rapport with ethnic minority clients. Racism, discrimination, and sexism are also risk factors for maladaptive behaviors (including ED behaviors and cognitions), so maintaining cultural humility and working to the best of one’s ability to understand the client’s experience is important when working with minority patients.

Gender

Women have a higher prevalence of EDs compared to men (Hudson et al., 2007; Smink et al., 2012). It could be that ED behaviors are less likely to be identified in men (Robinson, Mountford, & Sperlinger, 2012), that men are less likely to seek treatment (Räisänen & Hunt, 2014), or that the current diagnostic system does not capture the experience of EDs in men. Compared to other EDs, men are most likely to be diagnosed with BED (Smink et al., 2012) and to report overeating (Striegel-Moore et al., 2009).

Assessment Tip

Clinicians may have difficulty assessing ED behaviors if they are unfamiliar with how EDs present in men. For example, restricting and binge eating in men may be different than in women because men typically have larger statures and higher caloric needs. Moreover, body dissatisfaction in men may be focused more on building muscle than losing weight or becoming thin. When the desire to build muscle is endorsed by a client, we recommend assessing for excessive protein intake and use of illicit substances to facilitate muscle gain (e.g., steroids).

Gender plays a critical role in how EDs are experienced. Much of ED research, however, has been limited to a dichotomized definition of gender (i.e., man or woman). The experience of gender for many people is fluid and better defined as a continuous variable in which a person can identify anywhere along the continuum of “womanness” and “manness.” We define the term transgender broadly to be inclusive of any person whose gender identity does not match the gender that would correspond with their sex assigned at birth. It is estimated that approximately 1.4 million adults and 150,000 youth in the United States identify as transgender (Flores, Brown, & Herman, 2016), and this is important, given the association between EDs and transgender experiences. For example, levels of body dissatisfaction are high among transgender individuals who believe that their body is too feminine (i.e., perception of having too large breasts, hips, or proportion of body fat as compared to muscle) or too masculine (i.e., perception of having too much muscle mass and an undesired V-shaped torso) in comparison with their self-identified gender (Ålgars, Alanko, Santtila, & Sandnabba, 2012; I. Becker et al., 2016; Hepp & Milos, 2002; Surgenor & Fear, 1998). To influence their body weight or shape in a way that is more personally desirable, transgendered individuals may engage in disordered eating and unhealthy exercise (Ålgars, Santtila, & Sandnabba, 2010; Guss, Williams, Reisner, Austin, & Katz-Wise, 2017; Vocks, Stahn, Loenser, & Legenbauer, 2009) that could result in the development of an ED. The transgender community is susceptible to EDs; however, due to limited research, it is unclear what the prevalence of EDs is among individuals who identify as transgendered.

Assessment Tip

When working with clients, it is critical to ask about their preferred pronouns and to use these pronouns in every subsequent interaction. Asking about pronouns should be done with every client (rather than assuming an individual’s preferred pronouns based on their outward physical appearance). Questions about pronouns and gender could be added to the intake process, on demographic paperwork, or during clinical interviews. Finally, careful assessment of body image may be helpful in working with persons who identify as transgendered.

Sexual Orientation

Although the literature on sexual minority populations is increasing, there is still a dearth of research on EDs among lesbian, gay, and bisexual (LGB) individuals. Recent studies have found the prevalence of EDs among gay or bisexual males is higher than that of their heterosexual counterparts but comparable in gay or bisexual women (Feldman & Meyer, 2007; Shearer et al., 2015). LGB men and women are reported to experience greater overall ED symptom levels, in addition to increased risk factors, such as discrimination, prejudice, sexual violence (Kuna & Sobów, 2017), and displacement (Aichhorn et al., 2008). Overall, gay and bisexual men are more likely to report clinically significant ED symptoms and disordered eating behaviors when compared to heterosexual men (Matthews-Ewald, Zullig, & Ward, 2014). Sexual minority women are more likely to report binge eating, purging (Meneguzzo et al., 2018), and dieting behaviors to lose weight (Matthews-Ewald et al., 2014).

To facilitate effective assessment and treatment, it is important for clinicians to assess social support and assist in the maintenance and development of strong social support systems. Strong social support, as well as engagement within the LGB community, are reported as protective factors for LGB individuals (Shearer et al., 2015). While social support can fluctuate during the “coming out” process, for LGB individuals “coming out” can positively influence ED symptom severity (Watson, Velez, Brownfield, & Flores, 2016). Other social relationships, specifically decreased satisfaction within an LGB romantic relationship, can intensify the link between sexual minority status and increased bulimic symptoms, with exception to young adult men (Essayli, Murakami, & Latner, 2018).

Assessment Tip

When assessing for EDs in a sexual minority population, it is important to consider social and environmental stressors and their impact on the client’s life experience and ED diagnosis.

Age

ED onset most typically occurs in adolescent and young adult populations (Hudson et al., 2007). However, recent research has shown that maladaptive eating behaviors and cognitions occur at significant rates among children and older adults (Campbell & Peebles, 2014; Lapid et al., 2010; Mitchison, Hay, Slewa-Younan, & Mond, 2014; Pinhas, Morris, Crosby, & Katzman, 2011). According to the Centers for Disease Control and Prevention (2018), about 42% of children and adolescents between grades 9 and 12 reported feeling too fat or wanting to be thinner, and about 81% reported being afraid of becoming fat as early as 10 years of age (CDC, 2018). Additionally, about 5% reported taking diet pills that were not prescribed by a doctor, vomiting or taking laxatives (4.4%), and/or not eating for 24 hours or more (13%; Hudson et al., 2007; CDC, 2018).

Similarly, extreme dieting behaviors in older adults have been found to increase with age (Mangweth-Matzek, Kummer, & Pope, 2016; Mitchison et al., 2014). For men over the age of 45, the frequency of purging behaviors has increased, when compared to younger individuals (Mitchison et al., 2014). Although literature on older adults is limited, recent literature found increased body dissatisfaction among older adult women (Kilpela, Becker, Wesley, & Stewart, 2015; Mangweth-Matzek, Hoek, & Pope Jr., 2014).

Assessment Tip

When assessing both children and older adults, therapists should be specific and clear in their questions. For older adults, specifically, a thorough medical and ED history should be established to identify temporal relationships between life events and determine where medical causes can be ruled out. Social factors for children and adolescents are also important to consider. The American Academy of Pediatrics provides specific recommendations for ED cues in children (Campbell & Peebles, 2014). Clinicians should also assess body image in the context of normal shape and weight changes that occur during menopause or through the normal process of aging.

Athletes

Among athletes, the estimated prevalence of EDs is 13.5% to 32.8% in Norwegian samples (Sundgot-Borgen & Torstveit, 2004; Torstveit, Rosenvinge, & Sundgot-Borgen, 2008), although more epidemiological research is needed to better understand the rate of EDs in other cultures and parts of the world. Some research suggests that not all athletes are equally susceptible to developing an ED. Risk for an ED is higher in sports that emphasize anti-gravitation (e.g., ski jumping, jockeying) for men and esthetics (e.g., ballet/dancing) for women (Sundgot-Borgen & Torstveit, 2004). Athletes appear to have a higher rate of EDs compared to non-athletes (Smolak, Murnen, & Ruble, 2000). Athletes may be exposed to additional risk factors that non-athletes do not encounter; these additional risk factors include (1) the belief that sport performance is optimal at a lower weight, (2) revealing uniforms, and (3) reinforcement from judges and/or coaches for certain body types.

Due to the serious health risks and medical complications associated with EDs for the general population (e.g., irregular heart rate, imbalanced electrolytes, bone deterioration; Mitchell & Crow, 2006), athletes who continue to participate in their sport with an ED are highly susceptible to physical injury, anemia, chronic fatigue, irregular menstruation (for women), and other serious medical problems [see Mountjoy et al., (2014) for a review].

To ameliorate medical complications and to keep athletes healthy and safe, it is critical to identify EDs as soon as possible, although the assessment of EDs in athletes may be tricky. Clinicians will want to fully understand if and how the athlete’s exercise patterns are contributing to their ED. Identifying unhealthy exercise behaviors in athletes might be challenging because (1) physical activity and sport participation are typically considered healthful behaviors and (2) athletes who exercise more than their coach recommends or when sick or injured may appear dedicated to their sport and/or team (and might even be rewarded). However, when patients engage in exercise past the point of their physical capacity, despite sickness or injury, against medical advice, or to compensate for an eating episode, it is unhealthful. Exercising more than recommended by coaches, against medical (or sport trainer) advice, or when sick or injured may be suggestive of an underlying ED rather than indicative of sport commitment.

Assessment Tip

For an example dialogue of exercise assessment, see the dialogue earlier in this chapter. When working with athletes, it is also recommended that you ask for collateral information from coaches, coaches’ assistants, and/or sports medicine staff.

Information Critical to Making a Diagnosis

ED diagnoses are nuanced. It is important to consider several critical pieces of information in order to accurately diagnose EDs. Please see Fig. 15.1 for information critical to making ED diagnoses.

Fig. 15.1
Four boxes provide information on E D diagnosis. It includes anorexia nervosa, bulimia nervosa, binge E D, and general considerations.

Information critical to make a diagnosis. Note: OBE = objective binge eating; ICB = inappropriate compensatory behavior.1OBEs and/or purging behaviors are important to consider, as the presence of either OBEs or purging behaviors is necessary for the diagnosis of the binge eating/purging subtype of anorexia nervosa.2The size of the binge eating episodes is crucial to diagnosis. The presence of subjective binge eating episodes (SBEs) in the absence of OBEs would indicate a diagnosis of purging disorder [or another “other specified feeding or ED” (OSFED)].3A diagnosis of bulimia nervosa requires the individual to engage in OBEs and ICBs at least once a week, on average, for a duration of 3 months (i.e., at least 12 OBEs and 12 ICBs in a 3-month period). A diagnosis of OSFED (bulimia nervosa of low frequency and/or limited duration) can be considered for persons who engage in OBEs and/or ICBs less frequently.4A diagnosis of bulimia nervosa requires the individual to be at or above a normal body weight; a diagnosis of anorexia nervosa or OSFED should be considered for individuals who are at a low body weight.5A diagnosis of binge ED requires the individual to be at or above a normal body weight. The diagnosis does not require the individual to be overweight or obese, although overweight and obesity can be associated with binge ED.6It is important to consider the amount of food consumed during an episode of restricting. Some persons may report restricting yet consume an amount of food that would not be small enough to be considered restricting. It is also important to consider duration of the restricting episode, which should be considered alongside the amount of food consumed during the restricting episode (e.g., not eating anything for 8 hours vs. eating very small amounts of food throughout the day)

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Summary

EDs are complex psychiatric disorders that, if untreated, adversely affect social relationships, work productivity, and physical health and can lead to premature death. Despite common stereotypes, EDs have a prevalence that is similar to depression or anxiety. Moreover, EDs occur across the lifespan, in persons with food insecurity, in all genders, and in ethnic-racial minority groups. Having a rudimentary understanding of how to assess and diagnose EDs is, therefore, a requisite for mental health clinicians and physicians. This chapter provided information on the key signs and symptoms of EDs and how to assess these issues. We encourage the interested reader to refer to additional information and helpful resources provided by the National Eating Disorder Association (https://www.nationaleatingdisorders.org/) and Academy for Eating Disorders (https://www.aedweb.org/home) to learn more about the assessment, diagnosis, and treatment of EDs.