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Eating Disorders Assessment
Part 1
Instructor: Dr. Dawn-Elise Snipes, PhD, LPC, LMHC
Podcast Host: Counselor Toolbox & Happiness Isn’t Brain Surgery
~ Review the prevalence of eating disorders
~ Identify assessment areas
~ Identify risk and protective factors
~ Explore complications
~ Explore potential guidelines for treatment

~ Based on APA Guidelines for Eating Disorders, the NICE Guidelines for Eating Disorder Recognition and Treatment, and the NEDA Coach and Trainer’s Toolkit
Prevalence of Eating Disorders
~ 20% of women struggle with disordered eating
~ 10-15% of people with eating disorders are male
~ 40% of male football players were found to engage in disordered eating
~ Muscle dysmorphia and body fat preoccupation is seen in a majority of bodybuilders and wrestlers
~ 90% of people with eating disorders become symptomatic between 12 and 25

Risk Factors
~ The exact causes of anorexia nervosa are unknown. However, the condition sometimes runs in families; young women with a parent or sibling with an eating disorder are likelier to develop one themselves.
~ People with anorexia come to believe that their lives would be better if only they were thinner.
~ These people tend to be perfectionists and overachievers.
~ The typical person with anorexia is a good student involved in school and community activities.
~ Many experts think that anorexia is part of an unconscious attempt to come to terms with unresolved conflicts or painful childhood experiences.
~ While sexual abuse has been shown to be a factor in the development of bulimia, it is not associated with the development of anorexia.

Risk Factors
~ Biological factors may include an abnormal biochemical make up of the brain
~ The hypothalamic-pituitary-adrenal axis (HPA) is responsible for releasing certain neurotransmitters including serotonin, norepinephrine, and dopamine, which regulate stress, mood, and appetite.
~ People with eating disorders tend to have lower levels of serotonin and norephinephrine
~ Starving, bingeing and purging in and of themselves can alter brain chemistry
~ Both undereating and overeating can activate brain chemicals that produce feelings of peace and euphoria, thus temporarily dispelling anxiety and depression. Leading some to conclude that food is used to self-medicate painful feelings and distressing moods.
~ New research suggests that there is a biological link between stress and the drive to eat. Comfort foods — high in sugar, fat, and calories — seem to calm the body’s response to chronic stress.
Risk Factors
~ Psychological Risk Factors
~ Low self-worth and low-self esteem /Feelings of inadequacy
~ Obsessive behaviors regarding food and diets and may often also display obsessive-compulsive personality traits in other parts of their life.
~ A strong, even extreme drive for perfectionism.
~ They have unrealistic expectations of themselves and others
~ In spite of their many achievements, they feel inadequate.
~ They see the world dichotomously
~ individuals who develop anorexia are led to think that they are never thin enough regardless of how much weight is lost.
~ Negative affect: depression, anxiety, anger, stress or loneliness
~ A sense of lack of control in life
Risk Factors
~ Psychological Risk Factors
~ Wanting to take control and fix things in an unhappy life, but not really knowing how, and under the influence of a culture that equates success and happiness with thinness, the person tackles her/his body instead of the problem at hand.
~ Dieting, bingeing, purging, exercising, and other strange behaviors are not random craziness, but misguided and ineffective, attempts to take charge in a world that seems overwhelming.
Risk Factors
~ Interpersonal
~ Troubled personal relationships
~ Difficulty expressing emotions and feelings (including alexthymia)
~ History of being teased or ridiculed based on size or weight;
~ History of physical or sexual abuse.
~ Some people with eating disorders use the behaviors to avoid sexuality.
~ Others use them to try to take control of themselves and their lives by creating and winning the power struggles inside
Risk Factors
~ Interpersonal
~ Inside they still they feel weak, powerless, victimized, defeated, and resentful.
~ People with eating disorders often lack a sense of identity. They try to define themselves by manufacturing a socially approved and admired exterior.
~ People with eating disorders often are legitimately angry, but because
~ They seek approval and fear criticism,
~ They do not know how to express their anger in healthy ways.
~ They feel “fat.”
~ They turn it against themselves by starving or stuffing.

Risk Factors
~ Interpersonal
~ Appearance-obsessed friends or romantic partners, sorority houses, theatre troupes, dance companies and sports that emphasize size and weight can foster eating disordered behavior
~ Some may be withdrawn with only superficial or conflicted connections to other people.
~ Others may seem to be living exciting lives filled with friends and social activities, but will confess that they do not feel they really fit in, that no one seemed to really understand them, and that they had no true friends or confidants with whom they could share thoughts, feelings, doubts, insecurities, fears, hopes, ambitions,
~ Often they desperately want healthy connections to others but fear criticism and rejection

Risk Factors
~ Family Risk Factors
~ Family history of an eating disorder
~ Familial attitudes toward weight, dieting and eating
~ Overvaluing appearance
~ Making jokes about appearance
~ Deficit in emotional support
~ Overly enmeshed or detached family dynamics: Smothered in overprotective families, or abandoned, misunderstood, and alone
~ Addiction within the family or other causes of significant family disruption
~ Parents who focus primarily on success and performance rather than on the youth as a whole person.

Risk Factors
~ Family Risk Factors
~ These families tend to be overprotective, rigid, and ineffective at resolving conflict.
~ Sometimes mothers are emotionally cool while fathers are physically or emotionally absent.
~ There are high expectations of achievement and success.
~ Children learn not to disclose doubts, fears, anxieties, and imperfections.
~ Instead they try to solve their problems by manipulating weight and food.
~ (Am J Clin Nutr 2003;78:215) indicates that when parents restrict eating, children are more likely to eat when they are not hungry. The more severe the restriction, the stronger the desire to eat prohibited foods, setting the stage for a full blown eating disorder in the future

Risk Factors
~ Sociocultural Risk Factors
~ Western culture’s desire for thinness and displays of extreme, unrealistic thinness as beautiful
~ Success and self-worth are commonly associated with being thin in this culture.
~ Peer pressure and teasing others about looks or weight.
~ Sports that emphasize appearance, weight requirements or muscularity. For example: gymnastics, diving, bodybuilding or wrestling.
~ Sports that focus on the individual rather than the entire team. For example: gymnastics, running, figure skating, dance or diving, versus teams sports such as basketball or soccer.
~ Endurance sports such as track and field/running, swimming.
~ Overvalued belief that lower body weight will improve performance.
~ Training for a sport since childhood or being an elite athlete.

Risk Factors
~ Sociocultural Risk Factors
~ Western culture’s desire for thinness and displays of extreme, unrealistic thinness as beautiful
~ Success and self-worth are commonly associated with being thin in this culture.
~ Peer pressure and teasing others about looks or weight.
~ Sports that emphasize appearance, weight requirements or muscularity. For example: gymnastics, diving, bodybuilding or wrestling.
~ Endurance sports such as track and field/running, swimming.
~ Overvalued belief that lower body weight will improve performance.
~ Training for a sport since childhood or being an elite athlete.
~ Media
~ Reading between the lines of many ads reveals a not-so-subtle message — “You are not acceptable the way you are. The only way you can become acceptable is to buy our product and try to look like our model (who is six feet tall and wears size four jeans — and is probably anorexic). If you can’t quite manage it, better keep buying our product. It’s your only hope.”
~ An important question for people who watch TV, read magazines, and go to movies — do these media present images that open a window on the real world, or do they hold up a fun house mirror in which the reflections of real people are distorted into impossibly tall, thin sticks

Risk Factors
~ Three risk factors are thought to particularly contribute to a female athlete’s vulnerability to developing an eating disorder:
~ Social influences emphasizing thinness
~ Performance anxiety
~ Negative self-appraisal of athletic achievement.
~ A fourth factor is identity solely based on participation in athletics.
Risk Factors
~ The Female Athlete Triad
~ Disordered eating, amenorrhea, and osteoporosis.
~ Disordered eating can cause amenorrhea which leads to calcium and bone loss, putting the athlete at greatly increased risk for stress fractures of the bones.
~ While any female athlete can develop the triad, adolescent girls are most at risk because of the active biological changes and growth spurts, peer and social pressures, and rapidly changing life circumstances that go along with the teenage years.
~ A panel at the 2004 International Conference on Eating Disorders in Orlando, Florida, suggested the following screening checklist
~ High weight concerns before age 14
~ High level of perceived stress
~ Behavior problems before age 14
~ History of dieting
~ Mother/sibling/peers diet and is concerned about appearance
~ Negative self-evaluation
~ Perfectionism
~ No male friends
~ Parental control/enmeshment
~ Rivalry with one or more siblings
~ Competitive with siblings’ shape and/or appearance
~ Shy and/or anxious
~ Distressed by parental arguments or life events occurring in the year before the illness develops
~ Critical comments or teasing from family members or friends about weight, shape and eating

Protective Factors
~ Protective Factors:
~ Positive, person-oriented coaching/parenting style rather than negative, performance-oriented coaching style.
~ Social influence and support from teammates/friends with healthy attitudes towards size and shape.
~ Coaches/parents who emphasize factors that contribute to personal success such as motivation and enthusiasm rather than body weight or shape.
~ Coaches and parents who educate, talk about and support the changing female body
~ Coaches and parents who model as well as teach healthy coping skills and how to deal with failure

Red Flags
~ Skipping meals
~ Making excuses for not eating
~ Eating only a few certain “safe” foods
~ Adopting rigid meal or eating rituals, such as spitting food out after chewing
~ Cooking elaborate meals for others but refusing to eat
~ Repeated weighing or measuring of themselves
~ Frequent checking in the mirror for perceived flaws
~ Complaining about being fat
~ Not wanting to eat in public
~ Calluses on the knuckles and eroded teeth if inducing vomiting
~ Covering up in layers of clothing
~ Disappearing shortly after a meal
~ Swollen salivary glands and/or puffy face

~ Be alert throughout assessment and treatment to signs of bullying, teasing, abuse (emotional, physical and sexual) and neglect.
~ When assessing a person with a suspected eating disorder, find out what they and their family members know about eating disorders and address any misconceptions.
~ Offer people with an eating disorder and their family members education and information on:
~ the nature and risks of the eating disorder and how it is likely to affect them
~ the treatments available and their likely benefits and limitations.
~ When communicating with people with an eating disorder and their family members
~ Be sensitive when discussing a person's weight and appearance
~ Be aware that family members may feel guilty and responsible for the eating disorder (or may have no issue with it)
~ Show empathy, compassion and respect
~ Provide information in a format suitable for them, and check they understand it.
Areas for Assessment
~ History
~ General clinical
~ Height/weight
~ Blood pressure
~ Pulse
~ Nutrition
~ Exercise
~ Mental Status
~ Orientation
~ Obsessions
Areas for Assessment cont…
~ History
~ A disproportionate concern about their weight or shape
~ Problems managing a chronic illness that affects diet, such as diabetes or celiac disease
~ Menstrual or other endocrine disturbances, or unexplained gastrointestinal symptoms
~ Physical signs of malnutrition, including poor circulation, dizziness, palpitations, fainting or pallor, delayed puberty
~ Compensatory behaviors, including laxative or diet pill misuse, vomiting or excessive exercise
~ Abdominal pain that is associated with vomiting or restrictions in diet, and that cannot be fully explained by a medical condition
~ Whether they take part in activities associated with a high risk of eating disorders (i.e. professional sport, dance, or modeling).

Areas for Assessment
~ History
~ Family
~ MH/Addiction
~ Obesity
~ Attitudes about weight, shape and eating
~ Family interactions in relation to the patient’s disorder
~ Family attitudes toward eating, exercise, and appearance
~ Identify family stressors whose amelioration may facilitate recovery
~ Involve parents/household members and, whenever appropriate, health professionals who routinely work with the patient

~ When assessing for an eating disorder or deciding whether to refer people for assessment, take into account any of the following that apply:
~ An unusually low or high BMI or body weight for their age
~ Rapid weight loss
~ Dieting or restrictive eating practices (such as dieting when they are underweight) that are worrying them, their family members, or professionals
~ Family members report a change in eating behavior
~ Social withdrawal, particularly from situations that involve food
~ Other mental health problems

Ongoing Assessment
~ During treatment, it is important to monitor the patient for
~ Shifts in weight
~ Blood pressure
~ Pulse and other cardiovascular parameters
~ Behaviors likely to provoke physiological decline and collapse
~ Increasing levels of anxiety, self-harm and/or suicidal ideation
~ Patients with a history of purging behaviors should also be referred for a dental examination
~ Bone density examinations should be obtained for patients who have been amenorrheic for 6 months or more
Physical Complications of Anorexia
~ Weakness
~ Fatigue
~ Palpitations
~ Faintness
~ Shortness of breath
~ Chest pain
~ Bradycardia
~ Hypotension
~ Cold intolerance
~ Abdominal pain
~ Apathy
~ Poor concentration
~ Food obsessions
~ Irritability
~ Depression
~ Seizures
~ Reduced bone density
~ Cavities
~ Gingivitis
~ Hair loss or brittle hair
~ Muscle weakness
~ Arrested development of secondary sex characteristics

Additional Complications with Bulimia
~ Swollen salivary glands
~ Stress fractures (exercise)
~ Ruptured esophagus
~ Lazy bowel

Assessment Instruments
~ (EDI-3™) Eating Disorder Inventory-3™ (Garner)
~ Behavior and attitudes toward food, weight and body image, ineffectiveness, low self-esteem, perfectionism, interpersonal distrust, interoceptive awareness, identification and maturity fears
~ EDE-Q Eating Disorders Examination Questionnaire (Fairburn)
~ Restraint, weight concern, shape concern
~ ACTA Attitude Regarding Change inEating Disorders (Beato)
~ Assessment of attitude regarding change in ED
~ Other instruments including the BDI, STAI, Barratt Impulsiveness Scale, Millon Clinical Multiaxial Inventory (personality)
~ Factors suggesting that hospitalization may be appropriate include:
~ Rapid or persistent decline in oral intake
~ A decline in weight despite maximally intensive outpatient or partial hospitalization interventions
~ The presence of additional stressors that may interfere with the patient’s ability or willingness to eat
~ Knowledge of the weight at which instability previously occurred
~ Co-occurring psychiatric problems
~ The degree of the patient’s denial and resistance to participate in his or her own care in less intensively supervised settings
~ Partial Hospitalization
~ The more successful programs meet at least 5 days/week for 8 hours/day
~ Careful monitoring includes weight determinations 2-3x/week done directly after the patient voids and while the patient is wearing the same class of garment
~ It is important to routinely monitor
~ Serum electrolytes
~ Urine specific gravity
~ Blood pressure
~ Oral temperatures
~ There are a myriad of psychological, biological, interpersonal, familial and sociocultural factors which may contribute to the development of eating disorders
~ Unlike mood disorders, clinicians working with patients with eating disorders must be vigilant about monitoring basic vital signs and ensuring health monitoring
~ The initial assessment needs to explore not only biological and psychological factors which may have contributed to the development, but also what is maintaining that.
~ It is important to remember that many patients with eating disorders have poured over literature regarding health and nutrition, and the disorder is about much more than food.
~ What does it mean to gain weight?
~ What will happen if you gain 5 pounds?

~ People with eating disorders are very afraid of rejection and criticism and may lash out or lash in at perceived slights
~ Help the person with an eating disorder
~ Understand the function of food/shape/restriction for them
~ Develop a healthier self esteem and sense of self efficacy
~ Learn how to cope with stress
~ Improve communication skills and emotional vocabulary
~ Develop strategies to deal with the media and cultural and peer pressure