2  Eating Problems in Adults

Amanda Joelle Brown, Ph.D.
Janet Schebendach, Ph.D.
B. Timothy Walsh, M.D.

Eating problems and unhealthy weight-control behaviors are common to the point of being almost normative among adults in developed countries. In a U.S. population-based study (Neumark-Sztainer et al. 2011), 59% of young adult women reported currently dieting, 21% endorsed extreme weight-control behaviors (e.g., self-induced vomiting, inappropriate use of laxatives), and 14% reported binge eating with loss of control over a period of 1 year. Although the rates of diagnosable eating disorders are substantially lower, they are still notable, with lifetime prevalence rates of anorexia nervosa (AN), bulimia nervosa (BN), and binge-eating disorder (BED) ranging from 1% to 4% in epidemiological studies (Smink et al. 2012). Individuals with disordered eating often have complex histories and a range of symptoms that may not be easily observable or readily disclosed by the patient in the absence of direct questioning. The goal of any clinical assessment of eating problems in adults is to elicit sufficiently detailed information from the patient to facilitate the accurate description of his or her presenting symptoms and to guide appropriate treatment recommendations.

In this chapter, we describe an approach to the assessment of eating problems that is meant to be applicable in a variety of settings, including primary care and general psychiatric clinics. The approach includes an assessment of broad categories of eating-related symptoms, concerns about body shape and weight, medical and psychiatric comorbidities, social and occupational functioning, and treatment needs. Subgroups based on clusters of symptoms, including the diagnostic categories defined in DSM-5 (American Psychiatric Association 2013), are identified and described. We intend this approach to be useful for the early identification of feeding and eating disorders, the clinical management of early warning signs, and the identification of patients who should be referred for specialized care. We also comment on some of the potential challenges inherent in assessing individuals with eating disorders, including their tendency to minimize symptoms and frequent reluctance to admit the severity of their problems. The reader is encouraged to view Video 2, “Assessing eating problems in the primary care setting.”

The Clinical Interview: An Overview

A variety of factors may prompt a clinician to conduct an in-depth evaluation of eating pathology. Significant increases, decreases, or fluctuations in weight over a relatively short period of time are clear signals for clinicians to ask a patient about his or her eating behavior. In addition, description of increasingly restrictive eating patterns, excessive concern with body shape and weight, and unexplained laboratory results (e.g., hypokalemia) may all be early warning signs of an eating disorder and should prompt follow-up questioning. The clinician conducting the interview may be the first treatment provider to assess the eating problem or may have received a referral from another provider who had reason to suspect an eating problem. When the patient has been referred, it may be helpful to start the interview by asking the patient to describe his or her understanding of why the referral was made, both to assess the patient’s level of insight about the eating problem and to avoid “blindsiding” him or her with sensitive questions if the reasons for the referral were not previously clarified.

The primary goal of the clinical interview is to allow the patient to describe his or her current symptoms and to reflect on the development of these problems from his or her perspective. Patients with eating disorders are not always the most reliable reporters of their own struggles because of influences such as cognitive impairment from nutritional deprivation, the tendency to deny the potentially serious nature of their disorder, deliberate or unconscious minimization of symptoms, and ambivalence about treatment and/or recovery. Therefore, obtaining collateral information from the patient’s family, other clinicians involved in his or her care, and previous treatment providers can be critically helpful and informative.

Given the aforementioned challenges to obtaining accurate self-reported information from patients with eating problems, it is essential that clinicians assume a collaborative, nonjudgmental stance during the clinical interview. The creation of a strong therapeutic alliance, through such tactics as asking open-ended questions and inquiring about the patient’s understanding of his or her difficulties, facilitates the collection of accurate information and can be instrumental in strengthening patients’ motivation for change. A patient may deny any understanding of the reason for the evaluation, may express annoyance at having to speak with a clinician, and may not feel that he or she has a significant clinical problem. In such instances, the clinician can assure the patient that the clinician is not making any value judgments about the patient’s behavior and should aim to ally with the patient to help him or her better understand why other people might be concerned about his or her health and well-being. In many cases, the clinician’s view of the patient’s symptoms may differ from the patient’s view; however, in all circumstances, open and empathic dialogue will assist in the formation of a therapeutic alliance and increase the likelihood of obtaining accurate information.

Video 2 presents a sample clinical assessment by a general practitioner.

images Video Illustration 2: Assessing eating problems in the primary care setting (3:24)

Assessment of Eating Behaviors

Development of Eating Problems

Once the patient understands the reason for the assessment, the focus of the interview should shift to a review of the development of the patient’s eating symptoms. A history of changes in weight and eating behaviors should be obtained, beginning with open-ended questions about changes in the recent past or during the current disordered eating “episode.” The patient should be encouraged to describe events or experiences (e.g., emotional or environmental) that he or she considers relevant to the development or exacerbation of the current eating problems. Because the onset of an eating disorder is frequently associated with a significant life change or interpersonal event, the clinician should ask the patient to describe the circumstances of his or her life at the time that symptoms began. Furthermore, while obtaining historical information about the evolution of eating symptoms, the clinician should be sensitive to information about personal life events that may have had a direct or indirect influence on illness progression.

A critical component of the assessment of individuals with disordered eating is obtaining a picture of the patient’s current eating habits by asking the patient to describe the frequency and content of meals and snacks on a recent typical day. The clinician should also specifically inquire about several eating-related behaviors. The following sections outline categories of eating and eating-related symptoms that need specific attention in a clinical evaluation of a potential eating problem. Readers are referred to Table 2–1 for sample interview questions related to this approach.

Energy and Macronutrient Restriction

Individuals with eating disorders typically restrict their calorie intake; some do so consistently, whereas others eat normal amounts of food or binge eat between periods of restriction. Many patients attempt to adhere to a daily calorie limit. This amount should be ascertained by the clinician and assessed within the context of normal energy requirements. For example, a healthy adult female (age 25 years, height 64 inches, weight 120 pounds, body mass index 20.6 kg/m2) requires about 2,000-2,400 kcal/day at low to moderate levels of physical activity for weight maintenance (U.S. Department of Agriculture and U.S. Department of Health and Human Services 2010). On average, patients with AN consume about 1,300 kcal/day (Forbush and Hunt 2014). Eating patterns outside of binge episodes are inconsistent in BN; some individuals restrict their food and energy intake, some eat normally, and others overeat (Forbush and Hunt 2014). Individuals with BED typically do not restrict their intake outside of binge episodes, often leading to substantial weight gain and obesity (American Psychiatric Association 2013).

Patients frequently monitor their food intake and count calories. It is noteworthy, however, that individuals with AN tend to overestimate their energy intake by approximately 20% (Schebendach et al. 2012). If the patient sets a daily calorie limit, the clinician should ask if there are consequences to exceeding that limit. For example, the individual may further decrease calorie intake, fast, increase exercise, or engage in purging behaviors on the following day.

In patients with AN, calorie restriction is typically accomplished by limiting fat intake (Forbush and Hunt 2014). Given that fat is the most energy-dense macronutrient (i.e., 9 kcal/g for fat vs. 4 kcal/g for carbohydrate and protein), there is logic to fat avoidance. Furthermore, with public health campaigns promoting low-fat, heart-healthy eating, patients can easily cloak their disordered eating behavior in the guise of a healthy lifestyle. Current U.S. dietary guidelines recommend that 20%-35% of total calorie intake be provided by fat; for a healthy, normal-weight female, this translates into 44-93 g/day of fat (U.S. Department of Agriculture and U.S. Department of Health and Human Services 2010). Patients with eating disorders often set a daily fat-gram limit and monitor their intake and derive a significantly lower fraction of their caloric intake from fat (Mayer et al. 2012). The evaluating clinician should therefore assess the degree of dietary fat restriction, as well as the inclusion or exclusion of added fats (e.g., oil, salad dressing, mayonnaise, butter) and fat-containing foods (e.g., dairy products, red meat, desserts).

TABLE 2–1. Sample questions to assess diet and eating behaviors

Energy and macronutrients

Do you limit your intake of calories, fat, carbohydrates, or protein?

Do you have a specific daily limit or an acceptable range?

Do you self-monitor your intake?

What happens if you exceed your limit?

Do you avoid any specific foods or food groups, such as added fats, red meat, fried foods, or desserts?

Are you on a vegetarian or vegan diet?

Other dietary restrictions

Is your food choice limited by any condition or restriction?

Food allergies?

Food intolerances (e.g., lactose, gluten)?

Religious or culturally based diet restrictions?

Meal patterns

How many meals and snacks do you eat each day?

What are your typical mealtimes and snack times?

Do you eat differently on different days of the week

Workdays versus days off?

Weekdays versus weekends?

Eating behaviors

Do you engage in any specific behaviors related to your food?

Follow a strictly planned diet (i.e., calories, percentage of fat/carbohydrates/protein)?

Weigh and measure your food intake?

Use utensils to eat foods that are typically eaten by hand?

Eat very slowly or very quickly?

Prefer to eat alone and avoid others seeing you eat?

Avoid eating foods prepared by others?

Binge eating

Do you ever feel a sense of loss of control over your eating?

What are the contents of a typical binge-eating episode for you?

Types of food consumed?

Amounts (large vs. average/small)?

How often do you binge eat in a given day, week, or month?

Are your binge-eating episodes typically planned or impulsive?

Purging

Do you do anything to purge food or “get rid of” calories?

How often do you purge in a given day, week, or month?

Do you use laxatives or enemas?

Type/brand, dose, frequency?

Do you take diuretics?

Type/brand, dose, frequency?

Do you exercise excessively and/or feel driven or compelled to exercise?

Type/intensity/frequency of exercise?

How do you feel if you are unable to exercise?

Individuals with AN have also been described as carbohydrate avoid-ant (Russell 1967). However, carbohydrate restriction appears to be less pronounced than fat restriction. The U.S. dietary guidelines recommend carbohydrate intakes in the range of 45%-65% of calories; this translates into approximately 225-390 g/day for a female (U.S. Department of Agriculture and U.S. Department of Health and Human Services 2010). The fraction of calories from carbohydrates among individuals with AN is similar to or even a bit greater than that among healthy individuals (Mayer et al. 2012). Patients with restrictive eating typically avoid high-sugar foods, such as desserts, sweetened beverages, and added sugars, but they may also restrict their intake of natural carbohydrate sources, such as milk, fruit, fruit juice, and grains. In recent years, gluten-free diets have been adopted by many individuals for the purpose of weight loss, and patients with eating disorders may be similarly influenced by this dieting trend. Once again, the clinician should determine the presence and degree of dietary carbohydrate restriction, as well as self-monitoring (i.e., carbohydrate counting) behaviors.

Total protein intake may also be inadequate. In general, patients are less likely to restrict or monitor their protein intake, and some may even take protein and amino acid supplements. However, in an effort to decrease fat intake, many individuals narrow their repertoire of high-protein food choices by excluding red meat, cheese, milk, eggs, and nuts. Some individuals adopt vegetarian and vegan (i.e., no animal products) dietary practices during the course of their illness. The clinician should determine the timeline for adoption of a vegetarian or vegan diet and ask whether other household members eat a similar diet.

Claims of food allergies, food intolerances (e.g., lactose, gluten), and religious or cultural dietary practices may complicate the clinical assessment of eating disorders. The clinician should determine whether the diagnosis of a food allergy or intolerance has been confirmed by broadly accepted objective testing. Food restriction due to cultural norms and religious practices should be assessed within the context of family and peer group practices. Meal patterns, mealtimes, and the amount of time needed to consume a meal or snack should be ascertained. Behaviors such as preplanning food intake, weighing and measuring foods, only eating alone, not eating foods prepared by others, unusual cutting and food-handling behaviors, blotting oil or fat off foods, and atypical handling of eating utensils should also be explored.

Avoidant/restrictive food intake disorder (ARFID) is a DSM-5 diagnosis characterized by a general lack of interest in food (i.e., a “picky” or “lazy” eater), sensory food aversions (e.g., to appearance, smell, color, texture/consistency, taste, or temperature), concern about an aversive consequence of eating (e.g., choking), and/or a diet that consists of a markedly limited range of foods and little day-to-day variation in food intake. ARFID-related eating behaviors may result in a persistent failure to meet energy and nutrient requirements, and enteral feedings or oral nutritional supplements may be necessary (American Psychiatric Association 2013). During the assessment interview, the patient should be asked about current food intake (i.e., range of choice, amounts); duration of avoidant/restrictive behaviors; use of dietary supplements; and the degree to which current eating behaviors cause distress or interfere with day-to-day functioning (Bryant-Waugh 2013).

Binge Eating

The occurrence (times of day), duration, and frequency (episodes per day and week) of binge-eating episodes should be explored with all patients undergoing an evaluation for disordered eating. Binge eating is a defining characteristic of BN and BED and is also seen among a subset of individuals with the binge-eating/purging subtype of AN. Although the DSM-5 definition of binge eating requires the consumption of an objectively large amount of food, many individuals refer to the consumption of a modest or even small amount of food they had not intended to eat as a binge (i.e., a subjective binge). A shared characteristic of objective and subjective binge-eating episodes is a sense of loss of control over what or how much is eaten. The clinician should ascertain what is consumed during a typical episode of binge eating, as well as whether binge episodes tend to be planned or impulsive. Potential binge “triggers,” such as emotional precipitants (e.g., stress, anxiety, depression, sadness), particular settings (e.g., restaurants, buffets, bakeries, supermarkets, social gatherings), and food cravings, should also be explored.

Purging Behaviors

The occurrence and frequency of purging behaviors, such as self-induced vomiting and laxative or diuretic misuse, should also be determined. Vomiting may be induced by stimulating the gag reflex with a finger, pencil, toothbrush, eating utensil, and so forth. Dental erosion, parotid gland hypertrophy, and Russell’s sign (scarring of the dorsum of the hand) may suggest a longer duration of vomiting behavior. Use of an instrument to induce vomiting warrants exploration because of the potential risk of swallowing the device during the process. Syrup of ipecac is less commonly used to induce vomiting than in the past. Where the vomiting occurs (e.g., in a private vs. public bathroom, into a trash receptacle) may suggest how entrenched the purging behavior is for a given individual. If laxatives and diuretics are used, the type and brand, amount taken, and frequency of use should be ascertained. In addition to exploring the actual behavior, the clinician should question the patient’s beliefs about the efficacy of purging methods. For example, the patient may believe that vomiting eliminates all calories consumed during a binge or that laxatives interfere with calorie absorption; inquiries into the patient’s assumptions and beliefs provide an opportunity for psychoeducation about the relative inefficacy of purging (see Kaye et al. 1993).

Rumination

Patients with eating disorders may engage in rumination behavior—that is, regurgitating, re-chewing, and re-swallowing or spitting out of food. This behavior should be specifically queried. If the rumination behavior occurs exclusive of another eating disorder (i.e., AN, BN, BED, ARFID) or a medical condition and the severity of the behavior necessitates clinical attention, then a DSM-5 diagnosis of rumination disorder is warranted (American Psychiatric Association 2013).

Pica

Patients should be queried regarding pica, the consumption of nonfood items. The diagnosis of pica is characterized by a persistent ingestion of one or more nonnutritive, nonfood substances (e.g., chalk, soap, cloth, nails, paper, soil) over a period of at least 1 month. Although this behavior may occur in patients with other psychiatric disorders (e.g., developmental disorders, autism, schizophrenia) or medical conditions (e.g., pregnancy), a separate DSM-5 diagnosis of pica is made when the severity of the eating behavior warrants specific clinical management (American Psychiatric Association 2013).

Assessment of Shape and Weight Concerns

In addition to obtaining detailed information about the patient’s current eating habits and the development of restricting, binge-eating, and purging behaviors, it is essential to the proper characterization of eating problems for the clinician to assess the patient’s experience of his or her body shape and weight. Regardless of the patient’s likely diagnosis, any assessment of eating-related pathology should include documentation of changes in weight and body size, including lifetime highest and lowest weights and any significant weight fluctuations. The clinician should also inquire about the patient’s ideal weight, the patient’s view of his or her current weight (e.g., too high, too low, tolerable, unacceptable), and the importance of shape or weight in the patient’s self-evaluation.

Shape and weight concerns are important to both the onset and maintenance of eating-disordered thoughts and behaviors, and they play an essential role in differential diagnosis. Pica, rumination disorder, and ARFID are not associated with significant disturbances in the perception or evaluation of body shape and weight (American Psychiatric Association 2013). Individuals whose restrictive eating behaviors lead to significantly low body weight may meet DSM-5 diagnostic criteria for either AN or ARFID; shape and weight concerns distinguish these diagnoses from one another. Shape and weight concerns are a salient distinguishing feature of these diagnoses. Disturbances in the experience of body shape or weight, undue influence of body weight or shape on self-evaluation, and persistent lack of recognition of the seriousness of the current low body weight are characteristic of individuals with AN, whereas there is no evidence of a disturbance in the way in which one’s body weight or shape is experienced among individuals with ARFID.

Furthermore, many individuals with AN report an intense fear of gaining weight or becoming fat. Explicit endorsement of this fear was a diagnostic requirement for AN in DSM-IV, but the criterion has been expanded in DSM-5 to include persistent behavior that interferes with weight gain despite the patient being at a significantly low weight. Focused inquiry regarding what foods the patient actually consumes and his or her emotional reaction to weight gain may elucidate the patient’s level of concern about body shape and weight. Family members and treatment providers familiar with the patient’s eating attitudes and behaviors may offer additional evidence to support or refute strong fears of weight gain.

DSM-5 also requires that individuals with BN endorse overconcern with body shape and weight. Although it is normal for body image to play a role in the regulation of self-esteem, individuals with BN overvalue shape and weight compared to individuals without eating disorders. Individuals with BED also typically endorse shape and weight concerns to a higher degree than individuals of a similar body size who do not binge eat, but such concern is not required for the diagnosis of BED according to DSM-5 criteria. Notably, overvaluation of shape and weight plays a key role in the transdiagnostic model of AN, BN, and BED and informs cognitive-behavioral therapy for eating disorders (Fairburn et al. 2003).

Assessment of Medical and Psychological Features Associated With Eating Problems

Physical Assessments

An essential component of the assessment of adults with eating problems is obtaining objective measures of current physical health status. Measuring height and weight, taking vital signs (e.g., pulse, blood pressure), performing a general physical examination, and obtaining laboratory tests are all important and can be done either by the clinician assessing the history, if he or she has the requisite training and experience, or by a physician who serves a general medical role. The nature of the presenting problem and the clinician’s observations of the patient should inform the necessity for and extensiveness of the physical examination. For example, a patient with a history of substantial weight loss or of frequent purging is in more urgent need of a full medical workup than one with a normal, stable weight whose main presenting problem is psychological overconcern with body size.

Medical Complications

In addition to conducting an extensive assessment of the patient’s current physical health status, the clinician should ask whether the patient has experienced any physical problems as a consequence of his or her eating disturbance. Specific inquiry should be made about emergency room visits, less acute medical and dental care, and the existence of physical or medical complications such as changes to skin, hair, or nails; dental complications, including dental caries and/or enamel erosion; and stress fractures or other evidence of osteoporosis. Medical complications associated with AN and BN are listed in Table 2–2. The medical complications associated with BED are those associated with overweight and obesity, including hypertension, cardiovascular disease, and diabetes.

Laboratory assessments, including blood tests for hemoglobin, white blood cell count, and a chemistry panel, should be included in a comprehensive physical assessment, because blood cell counts may be low in the context of undernutrition, and metabolic and electrolyte disturbances are common. One of the most dangerous electrolyte disturbances is low potassium, or hypokalemia, which often is a result of recurrent vomiting but may also occur secondary to severe and prolonged food restriction. Hypokalemia can result in cardiac arrhythmias and therefore must be regularly monitored, especially in high-risk cases (e.g., individuals with purging behaviors). Prolongation of QT and QTc (rate corrected) intervals is also possible, even in the absence of electrolyte abnormalities, and this risk may rise with decreasing weight (Takimoto et al. 2004). Electrocardiograms are essential to further evaluate the acuity of the hypokalemia and assess for signs of arrhythmias. Hypomagnesemia may also occur with hypokalemia and if left untreated will prevent sustained normalization of potassium.

Low sodium, or hyponatremia, may be present and is commonly accompanied by low chloride levels, or hypochloremia. The hyponatremia associated with eating disorders generally results from one of two possible mechanisms (Bahia et al. 2011). The more common is that related to increased water intake. Through normal homeostatic processes, patients lose sodium and water through sweat and urine. Drinking water alone is insufficient to replace these losses, and the sodium concentration in the blood is ultimately diluted. A second potential etiology of hyponatremia is the development of the syndrome of inappropriate antidiuretic hormone secretion (SIADH). In both cases, water restriction is usually the treatment of choice for clinically significant hyponatremia. If fluid restriction is insufficient to fully restore electrolyte balance (sodium levels), medical consultation should be obtained. Although the low sodium in patients with AN is often the result of a gradual and chronic state, acute hyponatremia can precipitate seizures, and thus regular monitoring of electrolytes is indicated.

TABLE 2–2. Some physical and laboratory findings associated with anorexia nervosa and bulimia nervosa
 

Anorexia nervosaa

Bulimia nervosa

Skin/extremities

Lanugo (fine hair on trunk/face)

Red/blue fingers

Edema

Callus on back of hand

Cardiovascular

Low pulse rate

Low blood pressure

Gastrointestinal

Salivary gland enlargement

Slow stomach emptying

Constipation

Liver abnormalities

Salivary gland enlargement

Dental erosion

Hematopoietic

Anemia

Low white blood cell count

Fluid/electrolyte

Decreased kidney function

Low blood potassium

Low blood sodium

Low blood phosphate

Low blood potassium

Low blood sodium

Reduced blood acidity

Endocrine

Low blood sugar

Low estrogen or testosterone

Low-normal thyroid hormone levels

Increased cortisol

Bone

Decreased bone density

aPatients with the binge-eating/purging subtype of anorexia nervosa are at risk for the physical and laboratory findings associated with bulimia nervosa in the context of frequent purging.
Source. Adapted from Walsh and Attia 2011.

Signs of dehydration are common and can include tachycardia, orthostatic hypotension, and laboratory abnormalities suggestive of prerenal azotemia, including elevated creatinine and blood urea nitrogen levels. These issues generally resolve with resumption of regular food and fluid intake. However, the patient with symptoms of dehydration (e.g., light-headedness, syncope) may require intravenous hydration, which will normalize these physical and laboratory abnormalities more quickly.

Refeeding syndrome, which can occur during the initial stages of weight recovery, is marked by metabolic disturbances and volume overload manifesting as edema (pedal and/or pulmonary) and cardiac failure. Reports indicate that early hypophosphatemia is a harbinger of refeeding syndrome (Ornstein et al. 2003; Trent et al. 2013). The mechanism of refeeding syndrome is thought to be related to changes in insulin-glucose functioning and the requirements for phosphorus, magnesium, and other elements in the catabolic process. Despite normal serum levels of phosphorus on initial evaluation, phosphorus levels may fall upon initiation of refeeding, with the nadir often occurring 3-4 days following the initiation of refeeding. Thus, phosphate levels should be monitored regularly during initial resumption of regular food intake and repleted as necessary.

In cases of significant food restriction, specific nutrient or vitamin deficiencies may be present, even if absolute weight is close to normal. For example, individuals who avoid fruits and vegetables or who eat a limited range of foods may need vitamin supplements. Those who refuse to swallow a recommended multivitamin supplement because of its feel or smell should be monitored for vitamin deficiencies.

Almost all of these medical complications are reversible with adequate nutrition. Supportive measures such as careful monitoring of cardiac function or electrolyte levels may be necessary for successful and safe refeeding. Slowed gastric motility becomes important during nutritional rehabilitation (see Chapter 13, “Treatment of Restrictive Eating and Low-Weight Conditions, Including Anorexia Nervosa and Avoidant/Restrictive Food Intake Disorder”); fullness and possible constipation may cause the refeeding process to be physically uncomfortable.

Comorbid Conditions

Because of the frequent occurrence of mood disturbance and substance abuse among individuals with eating disorders, symptoms of these and other psychiatric disorders should be reviewed during the clinical assessment of concerns related to eating and weight. Specific questions about the use of drugs and alcohol, both currently and in the past, should be asked directly in a nonjudgmental fashion. The clinician should be mindful of patients’ potential reluctance to disclose such information and should assume an open, curious stance. Individuals at significantly low weight almost invariably endorse depressive symptoms, because such symptoms are associated with the pathophysiology of starvation and malnutrition (Keys et al. 1950, as cited in Kalm and Semba 2005). A detailed assessment of the course of mood symptoms and eating pathology may elucidate the relationship between these two domains, such as if a mood disorder was present prior to the onset of eating disorder symptoms or if mood disturbance developed solely in the context of weight loss or malnutrition.

Anxiety disorders, obsessive-compulsive and related disorders, and trauma- and stressor-related disorders may also be comorbid with eating disorders. Once again, it may be difficult to accurately attribute symptoms to one disorder or another, and clinicians should be aware that eating disorders, particularly AN, often involve heightened obsessionality and anxiety, both in the domain of food and eating and in other domains. The clinician should also be alert for indications of personality disorders, which are relatively common among individuals with eating disturbances. Personality traits commonly associated with eating disorders include perfectionism, impulsivity, and novelty seeking (Cassin and von Ranson 2005).

Differential Diagnosis

Before concluding that a patient’s difficulties are best attributed to the existence of an eating disorder, the clinician should consider whether the eating disturbances are better accounted for by another psychiatric disorder or whether the symptoms may be secondary to a general medical condition. For example, binge-eating episodes may occur in association with major depressive disorder, and many medical illnesses can lead to substantial weight loss. Clinicians should consider the possibility that another medical or psychological issue accounts for the patient’s eating or weight symptoms, particularly when the history is unclear or the features are unusual.

Differential diagnosis when the primary symptoms are restrictive eating and/or low weight involves assessment of the underlying assumptions and motivations for the abnormal eating behavior. Mood, anxiety, and psychotic disorders may occasionally be associated with weight loss and disturbances in eating behavior, but the concerns about shape and weight that are characteristic of AN are not present in these illnesses. Similarly, some of the psychological characteristics of individuals with social anxiety disorder, obsessive-compulsive disorder, or body dysmorphic disorder resemble those of patients with AN; however, individuals with these disorders do not exhibit the unrelenting drive for thinness seen in patients with AN.

Overeating with loss of control, a defining feature of BN and BED, may sometimes occur in association with major depressive disorder with atypical features and with borderline personality disorder. These disorders may be comorbid with BN or BED, and if a patient meets criteria for both BN or BED and another mental disorder, both diagnoses should be given. However, if the patient does not endorse overconcern with body shape and weight, a diagnosis of BN should not be given. Also, if binge eating does not occur at an average frequency of at least one episode a week, an alternative diagnosis should be considered. In this case, if no other psychological disorder is warranted and the eating symptoms are significant enough to cause distress or impairment, the diagnosis should be other specified feeding or eating disorder (e.g., BN or BED of low frequency and/or limited duration).

Many serious medical illnesses are associated with substantial weight loss, including gastrointestinal illnesses such as Crohn’s disease and celiac disease, brain tumors and other malignancies, and AIDS. Some medical and neurological conditions, such as Kleine-Levin syndrome, are associated with binge eating. These and other medical illnesses should be considered in the differential diagnosis. Occasionally, an eating disorder and a medical illness occur together and multiple diagnoses are warranted. Key features are the intense psychological reward associated with losing weight and the fear of weight gain in AN and the use of compensatory behaviors to control weight and the overconcern with shape and weight that characterize BN.

Assessment of Family History and Social and Occupational Functioning

Two other areas warranting attention are the familial history of eating disorders and the patient’s occupational and social history. Regardless of whether other family members have been formally diagnosed with eating disorder, the family’s attitudes toward eating and accompanying behaviors (e.g., dieting), especially if taken to an extreme, can play a significant role in the formation of patients’ attitudes and behaviors. The clinician should inquire about these family patterns, if not already volunteered by the patient, and the effect on his or her relationship to food. Similarly, the emphasis on shape and weight within the family structure and its influence on the patient’s perceptions of shape and weight should be discussed.

A standard assessment of social, interpersonal, and occupational difficulties should be conducted, specifically noting the impact of the eating problem on the formation and maintenance of interpersonal relationships (e.g., loss of friendships due to avoidance of social eating) and on work or academic performance. Individuals with eating disturbances frequently engage in occupations in which shape and weight are highly emphasized (e.g., personal trainer) or food is the focal point (e.g., waitress). Whether the pursuit of such careers is a contributing factor to or a by-product of the eating disturbance undoubtedly varies, but the relationship of these occupations to the chronology of changes in eating and dieting practices should be reviewed. Such information may prove valuable in treatment planning when a consideration of career plans can be more thoroughly evaluated.

Assessment of Treatment Needs

The final step in the clinical evaluation of eating problems in adults is the assessment of treatment needs and the formulation of a plan for follow-up care. Various treatment settings (e.g., inpatient, partial hospitalization, outpatient), modalities (e.g., behavioral, cognitive, interpersonal, family oriented, psychopharmacological, medical), and intensities are currently employed in the treatment of eating disorders (see Part 4, “Treatment,” in this volume). The nature of the patient’s past treatments should be assessed, with the caveat that these treatments may be difficult for the patient (or clinician) to characterize accurately. Furthermore, for a patient with a long history of illness, a complete history of treatment may be too lengthy to obtain in a single assessment. The clinician should strongly consider, with the patient’s permission, speaking with past treatment providers and obtaining a copy of important historical documents (e.g., hospital discharge summaries). It is important to ascertain whether and how often the patient has been hospitalized for treatment of an eating disorder or its complications, what psychological strategies and medication interventions have been attempted, and what the patient has found to be most and least helpful. It is also useful to determine the reason for termination of past treatment (e.g., expiration of insurance coverage, the patient’s leaving treatment against medical advice).

The severity of the patient’s current eating problems is the most important factor to consider in determining a recommended level of care. Medical instability, including such disturbances as low heart rate (e.g., <40 beats per minute), low blood pressure (e.g., <90/60 mmHg), electrolyte imbalance, dehydration, and organ failure requiring acute treatment, requires inpatient hospitalization. In addition, suicidal ideation with a specific plan or intent is a clear indicator of a need for hospitalization and should be assessed during the clinical interview. Maintenance of a body weight below 80% of expected weight for age, sex, and height or acute weight loss in the context of food refusal also suggests that a higher level of care (e.g., inpatient, residential) may be warranted. If a high degree of structure seems necessary for the patient to eat and gain weight, partial or full hospitalization should be considered. Success or failure in less intensive treatments may be the best indicator of this necessity (Yager et al. 2006).

A patient’s motivation for change, cooperativeness, insight, and ability to control obsessive thoughts about food and eating should be at least fair if outpatient treatment is to be considered. Patients with severe symptoms but poor insight, little motivation, and constant preoccupation with eating-related obsessions require a higher level of care. In addition, any comorbid psychiatric illness requiring hospitalization (e.g., psychotic illness, severe obsessive-compulsive disorder) precludes the recommendation of outpatient or day programs. Finally, severe environmental stress, including family conflict, absent or inadequate social support, or unstable living arrangements, may influence clinical decision making about the proper level of care (Yager et al. 2006).

Patients for whom highly structured treatment programs are recommended should be aware that such programs represent only the beginning step in what is likely to be a lengthy process of treatment and recovery. The least restrictive environment that provides adequate support for the patient to practice making healthier eating choices should always be recommended, because practicing new behaviors in a familiar environment has the greatest potential to effect substantive and lasting change.

Challenges and Obstacles in the Assessment of Eating Problems

Cognitive Impairment

The clinician should be aware that severe malnutrition is associated not only with serious physical problems but also with significant psychological and cognitive disturbances. Underweight patients may exhibit delays in speech, illogical thought patterns, and difficulty concentrating. These disturbances may interfere with a patient’s ability to reflect on his or her condition or to accurately report on his or her symptoms. It may be clinically useful to gently, without blame or judgment, draw the patient’s attention to these psychological consequences of starvation in order to foster greater insight. At the same time, it is important to recognize that malnourished patients may misremember autobiographical information, experience intrusive thoughts during the course of the interview, and have difficulty answering more complex questions. Framing questions simply and directly will help patients maintain their focus and provide the most accurate information.

Patient Reluctance to Provide Information

For a variety of reasons, patients may be reluctant to provide accurate information about their difficulties. In some instances, patients are ashamed of beliefs or behaviors that they recognize as abnormal but feel unable to control. Patients may deny that they purge, may overreport their daily calorie consumption, or may consume excessive amounts of liquids or carry concealed objects when they are weighed. No approach to such denial and subterfuge is universally effective; however, it may be useful for the clinician to note that individuals with eating problems commonly have difficulties being open about all aspects of their disorder and therefore to ask, in a nonconfrontational manner, whether there are symptoms the patient has difficulty admitting. The clinician should avoid criticizing the patient for not being open, because such maneuvers are unlikely to yield more accurate information and will undermine the development of a therapeutic alliance.

Minimization of Symptom Severity and/or Need for Treatment

The final challenge in obtaining information from patients with eating disorders is their difficulty admitting that their behaviors are problematic or potentially harmful (Vitousek et al. 1990). Many deny that they have a psychiatric illness and decline offers for help. Individuals with AN, in particular, often vehemently deny that their weight is dangerously low or that their eating behaviors are not healthy, and many report extreme distortions in body image, often using words such as “obese,” “enormous,” and “whalelike” to describe their perception of their emaciated bodies. Individuals with BN and BED, particularly those seeking treatment, typically do not describe such drastic differences between their internal experience and the observations of others, but they may minimize the severity of aspects of their eating disorder they consider shameful or embarrassing, such as binge eating, purging, or laxative misuse. Furthermore, patients of any diagnosis who tend toward perfectionism and agreeableness may show overcompliance during the interview, answering questions in the way that he or she interprets as being “right.”

We reiterate that there is no one way to deal with minimization, denial, or distortion in a clinical interview. The clinician can reflect back inconsistencies and discrepancies in the information provided by the patient in an open, curious manner, without assuming that the patient is deliberately trying to mislead. Efforts to normalize symptoms may increase patients’ willingness to disclose information; for example, the clinician might ask, “Some people who try to keep their weight down do so by cutting out certain food groups—have you ever done that?” or “How many times would you say you binge eat in a given day or week?” By assuming a relatively high degree of symptom frequency or severity, the clinician can communicate to the patient that the symptoms are within the realm of what is typically encountered and may also engender the patient’s trust in the clinician as someone who has experienced other individuals with similar struggles.

Conclusion

In this chapter, we have attempted to summarize the essential components of a thorough clinical assessment of individuals with suspected eating disorders. The clinician should obtain a comprehensive description of the patient’s eating behavior and the psychological and emotional concomitants of that behavior. The clinician should also attempt to understand how these disturbances began and how they have evolved over time and should assess the patient’s commitment to change. Physical assessments should be conducted to identify any medical complications of the disordered eating behavior. Other psychiatric disorders and general medical conditions that involve disturbances in eating and weight should be considered as alternative explanations of the presenting concern. Although the assessment of eating pathology in adults can be challenging because of the shame and secrecy typically involved in these disorders, carrying out the assessment in a thorough but empathic fashion should facilitate the formation of a strong therapeutic alliance with the patient.

Finally, it should be noted that the assessment approach described in this chapter is a semistructured method that can be used in most general clinical settings. A range of more structured assessment methods are available, including the Eating Disorder Assessment for DSM-5 (EDA-5; Sysko et al. 2015), as discussed in Part 3 (“Assessment Tools”) of this volume. Such structured and semistructured assessments are routinely used in research settings, and they may also be usefully employed in routine clinical practice to obtain objective measures of the patient’s symptoms.

Key Clinical Points

References

American Psychiatric Association: Feeding and eating disorders, in Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. Arlington, VA, American Psychiatric Association, 2013 pp 329—354

Bahia A, Chu ES, Mehler PS: Polydipsia and hyponatremia in a woman with anorexia nervosa. Int J Eat Disord 44(2):186-188, 2011 20127934

Bryant-Waugh R: Avoidant restrictive food intake disorder: an illustrative case example. Int J Eat Disord 46(5):420-423, 2013 23658083

Cassin SE, von Ranson KM: Personality and eating disorders: a decade in review. Clin Psychol Rev 25(7):895-916, 2005 16099563

Fairburn CG, Cooper Z, Shafran R: Cognitive behaviour therapy for eating disorders: a “transdiagnostic” theory and treatment. Behav Res Ther 41(5):509-528, 2003 12711261

Forbush KT, Hunt TK: Characterization of eating patterns among individuals with eating disorders: what is the state of the plate? Physiol Behav 134:92-109, 2014 24582916

Kalm LM, Semba RD: They starved so that others be better fed: remembering Ancel Keys and the Minnesota experiment. J Nutr 135(6):1347-1352, 2005 15930436

Kaye WH, Weltzin TE, Hsu LKG, et al: Amount of calories retained after binge eating and vomiting. Am J Psychiatry 150(6):969-971,1993 8494080

Mayer LE, Schebendach J, Bodell LP, et al: Eating behavior in anorexia nervosa: before and after treatment. Int J Eat Disord 45(2):290-293, 2012 21495053

Neumark-Sztainer D, Wall M, Larson NI, et al: Dieting and disordered eating behaviors from adolescence to young adulthood: findings from a 10-year longitudinal study. J Am Diet Assoc 111(7):1004-1011, 2011 21703378

Ornstein RM, Golden NH, Jacobson MS, et al: Hypophosphatemia during nutritional rehabilitation in anorexia nervosa: implications for refeeding and monitoring. J Adolesc Health 32(1):83-88, 2003 12507806

Russell GFM: The nutritional disorder in anorexia nervosa. J Psychosom Res 11(1):141-149, 1967 6049025

Schebendach JE, Porter KJ, Wolper C, et al: Accuracy of self-reported energy intake in weight-restored patients with anorexia nervosa compared with obese and normal weight individuals. Int J Eat Disord 45(4):570-574, 2012 22271488

Smink FRE, van Hoeken D, Hoek HW: Epidemiology of eating disorders: incidence, prevalence and mortality rates. Curr Psychiatry Rep 14(4):406-414, 2012 22644309

Sysko R, Glasofer DR, Hildebrandt T, et al: The Eating Disorder Assessment for DSM-5 (EDA-5): development and validation of a structured interview for feeding and eating disorders. Int J Eat Disord Jan 30, 2015 [Epub ahead of print] 25639562

Takimoto Y, Yoshiuchi K, Kumano H, et al: QT interval and QT dispersion in eating disorders. Psychother Psychosom 73(5):324-328, 2004 15292631

Trent SA, Moreira ME, Colwell CB, et al: ED management of patients with eating disorders. Am J Emerg Med 31(5):859-865, 2013 23623238

U.S. Department of Agriculture, U.S. Department of Health and Human Services: Dietary Guidelines for Americans, 7th Edition. Washington, DC, U.S. Government Printing Office, 2010

Vitousek KB, Daly J, Heiser C: Reconstructing the internal world of the eating-disordered individual: overcoming denial and distortion in self-report. Int J Eat Disord 10:647-666, 1990

Walsh BT, Attia E: Eating disorders, in Harrison’s Principles of Internal Medicine, 18th Edition. Edited by Longo DL, Fauci AS, Kasper DL, et al. New York, McGraw-Hill, 2011, pp 636-641

Yager J, Devlin MJ, Halmi KA, et al: Practice Guideline for the Treatment of Patients With Eating Disorders, 3rd Edition. Washington, DC, American Psychiatric Association, 2006