76575695

7/28/2019 76575695

1/9

Journal of Counseling & Development July 2012 Volume 90262

2012 by the American Counseling Association. All rights reserved.

Received 06/01/11Revised 09/30/11

Accepted 10/08/11

Assessment and Diagnosis ofEating Disorders: A Guide for

Professional CounselorsKelly C. Berg, Carol B. Peterson, and Patricia Frazier

Despite the prevalence o and risk associated with disordered eating, there are ew guidelines or counselors on how

to conduct an eating disorder assessment. Given the importance o the clinical interview, the purpose o this article

is to provide recommendations or the assessment and diagnosis o eating disorders that (a) specically ocus on

assessment in the context o a clinical interview and (b) can be used by counselors whether or not they specialize in

eating disorder treatment.

Keywords:assessment, clinical interview, eating disorders, anorexia nervosa, bulimia nervosa

Kelly C. Berg and Crol B. Peterson, Department o Psychiatry, and Ptrici Frzier, Department o Psychology, University oMinnesota, Minneapolis. This work was supported, in part, by grants rom the National Institute o Mental Health (T32 MH082761-01) and the National Institute o Diabetes and Digestive and Kidney Diseases (P30DK 50456). Correspondence concerning thisarticle should be addressed to Kelly C. Berg, Department o Psychiatry, University o Minnesota, 606 24th Avenue South, Suite 602,Minneapolis, MN 55454 (e-mail: [email protected]).

Eating disorders are serious mental illnesses that are associ-

ated with a broad range o medical and psychiatric problems,

including increased risk o mortality (Crow, 2005; Crow et

al., 2009). Although the prevalence o eating disorders is lessthan 5% o the general population (Hoek & van Hoeken, 2003;

Swanson, Crow, Le Grange, Swendsen, & Merikangas, 2011),

some studies have ound much higher rates o subthreshold eat-

ing disorder symptoms in adolescent and young adult emales

(e.g., weekly binge eating or weekly sel-induced vomiting;

Berg, Frazier, & Sherr, 2009). Historically, eating disorders

were thought to be problems limited to Caucasian emales

rom privileged backgrounds. However, more recent epide-

miological research has demonstrated that eating disorders

are increasingly common in broader age ranges, both genders,

and diverse ethnic groups (Swanson, Crow, et al., 2011). Ad-

ditionally, although weight status or changes in weight status

can be indicative o an eating disorder, individuals presenting

at normal weight or without signicant weight changes maysuer rom eating disorders as well. Thus, because there are

signicant medical and psychiatric risks associated with eating

disorders and disordered eating, because eating disorders are

not restricted to any specic subgroup o clients, and because

eating disorders may not be visually apparent, we recommend

that the assessment o eating disorders should be considered

an essential element o an intake assessment in all counseling

settings and with all clients.

Although assessing eating disorders may seem like a daunt-

ing prospect to some, it can have enormous benets or both

therapy outcome and the therapeutic relationship (Peterson,

2005). First, assessment is the oundation o ongoing treat-

ment because it inorms diagnosis, guides treatment planning,

and can be used to measure progress and outcome. Careulassessment can also be used to detect potentially serious

medical and psychiatric complications and, in some cases,

determine treatment priorities. Finally, assessment has been

ound to produce improvement in eating disorder symptoms

and, when conducted well, it can acilitate trust and reduce

the likelihood o attrition (Peterson, 2005).The bookAssessment o Eating Disorders (Mitchell &

Peterson, 2005) represents the most comprehensive resource

or clinicians and researchers interested in eating disorder as-

sessment; however, this resource may be most applicable to

counselors who regularly treat eating disorder clients and may

be too specialized or many proessional counselors. Recom-

mendations or eating disorder assessment are also provided in

a recently published article (Anderson, Lundgren, Shapiro, &

Paulosky, 2004); however, these recommendations are largely

constrained to the use o structured assessment tools such as

semistructured interviews and sel-report questionnaires. Al-

though there are advantages to using structured assessments,

the clinical interview remains the most common assessment

modality in proessional counseling (Jones, 2010). Becausethere are no published guidelines or proessional counselors

on incorporating eating disorder assessment into a clinical

interview, we outline recommendations or the assessment

and diagnosis o eating disorders that (a) specically ocus

on assessment in the context o a clinical interview and (b)

can be used by counselors whether or not they specialize in

eating disorder treatment. As such, this article will cover the

ollowing: (a) the diagnostic criteria or eating disorders,

(b) how to integrate assessment o eating disorders into an

unstructured clinical interview, and (c) special considerations

during an eating disorder assessment.

Diagnostic Criteria for Eating Disorders

TheDiagnostic and Statistical Manual o Mental Disorders

(4th ed., text rev.;DSM-IV-TR; American Psychiatric Asso-

Earn CE credit.Visit http://learning.counseling.orgto purchase and complete the test online.

7/28/2019 76575695

2/9

Journal of Counseling & Development July 2012 Volume 90 263

Assessment and Diagnosis o Eating Disorders

ciation [APA], 2000) recognizes two ormal eating disorders:

anorexia nervosa and bulimia nervosa. Criteria or anorexia

include minimal body weight or age, gender, and height;

ear o weight gain; at least one cognitive symptom (i.e.,

overevaluation o shape and weight, body image disturbance,

or a denial o the seriousness o being at a low body weight);and amenorrhea (i.e., missing three consecutive menstrual

cycles). TheDSM-IV-TR also species two subtypes o an-

orexia: restricting (i.e., no regular binge eating or purging)

and binge-eating/purging (i.e., regular binge eating, regular

purging, or both). For bulimia, theDSM-IV-TR criteria include

binge eating, dened as the consumption o an unusually

large amount o ood coupled with a subjective sense o a

loss o control, and compensatory behaviors (i.e., sel-induced

vomiting, abuse o laxatives or diuretics, excessive exercise,

or asting) occurring at least twice per week or the previ-

ous 3 months and overevaluation o shape and weight. Two

subtypes o bulimia are specied in the DSM-IV-TR: purg-

ing subtype (i.e., regular use o sel-induced vomiting and/

or abuse o laxatives or diuretics) and nonpurging subtype

(i.e., use o excessive exercise or asting, but no regular use o

purging behaviors). The criteria also speciy that a diagnosis

o anorexia trumps a diagnosis o bulimia, meaning that

an underweight individual with bulimic symptoms would

be diagnosed with anorexia, binge-eating/purging subtype,

rather than bulimia.

The DSM-IV-TR includes a third category titled eating

disorder not otherwise specied (EDNOS), which is to be

assigned to individuals with clinically signicant eating

disorder symptoms who do not meet criteria or either an-

orexia or bulimia (APA, 2000). Examples o EDNOS include

purging without binge eating, binge eating without the use

o compensatory behaviors (i.e., binge eating disorder), and

meeting all criteria or anorexia, except amenorrhea. Epi-

demiological studies and clinical data suggest that rates o

EDNOS are signicantly higher than those o anorexia and

bulimia (e.g., Fairburn et al., 2007; Hoek, 2006) and that

the associated psychopathology, psychosocial impairment,

treatment response, and medical/suicide risk o EDNOS are

comparable with those o anorexia and bulimia (e.g., Crow

et al., 2009; Fairburn et al., 2007).

The proposed criteria or the DSM-5 (APA, 2011) have

attempted to reduce the prevalence o EDNOS by institut-

ing the ollowing changes: (a) eliminating the amenorrhea

requirement or anorexia, (b) including behavioral indices

o ear o weight gain or anorexia (e.g., dietary restriction,

use o compensatory behaviors), (c) reducing the required

requency o binge eating and compensatory behaviors or

bulimia to once per week, (d) including binge eating disorder

(BED) as a ormal eating disorder diagnosis, and (e) reducing

the required requency o binge eating or BED to once per

week or 3 months. Pilot testing has demonstrated that these

changes result in a substantial decrease in EDNOS (e.g., Berg,

Stiles-Shields, et al., 2011; Keel, Brown, Holm-Denoma, &

Bodell, 2011). The proposed changes to the DSMwill be

nalized in 2012 and published in 2013 (APA, 2011).

In summary, assessment o the ollowing variables is es-

sential or diagnosing eating disorders: (a) weight status (as

determined by height, weight, age, and gender), (b) ear o

weight gain, (c) overevaluation o shape and weight, (d) bodyimage disturbance, (e) presence and requency o binge eat-

ing, () presence and requency o compensatory behaviors,

and (g) menstrual status. I the client is underweight, it may

also be necessary to determine whether the client is aware

o the potential consequences associated with low weight. In

addition, behaviors such as dietary restriction (e.g., skipping

meals, avoidance o specic oods or ood groups, overall

caloric restriction) will be necessary or the diagnosis o

DSM-5 eating disorders.

Integrating Eating Disorders AssessmentInto a Clinical Interview

In any clinical interview, it is important to balance the dual

goals o obtaining a comprehensive assessment with develop-

ing and maintaining rapport with the client (Peterson, 2005).

Given that not all clients present with eating disorders or

disordered eating, a comprehensive assessment o all eat-

ing disorder symptoms may not be necessary or easible.

Thereore, we recommend that counselors conduct a screen

or eating disorder symptoms and ollow up with a more

comprehensive assessment i necessary.

How to Screen or Eating Disorders

Screening questions or eating disorders can be easily inte-

grated into an unstructured clinical interview. Sleep and eating

patterns are typically assessed at intake, and these questions

can provide a good segue into an eating disorders screen.

We recommend starting with general questions (e.g., What

is your general eating pattern?, Do you ever skip meals?,

Have you ever been on a diet?) that can serve as an eective

strategy or introducing the topic o eating disorders without

causing initial discomort. These general questions can then

lead into more specic questions regarding binge eating and

compensatory behaviors (e.g., Have you ever elt a sense

o loss o control over your eating?, Have you ever done

anything to compensate or ood youve consumed such as

sel-induced vomiting or laxative use?).

Clinical interviews also typically include questions about

exercise in the context o evaluating general sel-care, and

these questions can also provide inormation about eating

disorders risk. When assessing activity level, we recommend

assessing type, duration, and intensity o exercise. However,

it is important to remember that the quantity o exercise is

not always indicative o an eating disorder. For example,

individuals participating on sports teams or training or ath-

letic events such as marathons do not necessarily suer rom

eating disorders despite substantial commitments to tness

7/28/2019 76575695

3/9


Berg, Peterson, & Frazier

routines. Thus, it is also important to gently probe about the

motivation or exercise, whether the individual eels driven

or compelled to do it, whether the client exercises when ill

or injured, and whether he or she exercises at the expense

o other activities (e.g., work, school, amily, or social com-

mitments). Last, general questions about sel-esteem (e.g.,How do you eel about yoursel as a person?) can also be

used as an introduction to asking more specic questions

about body image (e.g., How do you eel about your weight

and shape?). For additional examples o screening ques-

tions we recommend, see Table 1.

When to Follow Up With Additional Questions

A counselors observation o certain physical characteristics

or a clients endorsement o certain behavioral or cognitive

symptoms may require urther evaluation. For example, ad-

ditional probing is indicated in the ollowing circumstances:

(a) low body weight (in children and adolescents, this may

present as ailure to meet height and weight expectations or

delays/interruptions to pubertal development), (b) signicant

weight changes, (c) recurrent binge eating, (d) purging behav-

iors, (e) regular asting or extreme restriction, or () exercise

that intereres with psychosocial unctioning or that occurs

in the context o illness or injury. In some cases, cognitive

symptoms (e.g., presence o body image disturbance, over-evaluation o shape or weight, intense ear o weight gain, or

extreme distress about appearance) unaccompanied by eating

or weight problems can warrant urther evaluation.

What Questions to Ask toMake Dierential Diagnoses

I an eating disorder is suspected, the rst diagnostic priority is

establishing that the problematic behavior, weight, or cognitions

refect an eating disorder and are not an indication o another

medical or psychiatric condition. For example, weight change

can be a symptom o an underlying medical (e.g., hyperthyroid-

ism, cancer, or gastrointestinal problems) or psychiatric (e.g.,

depression or substance dependence) problem. Questions about

TaBLE 1

Exmples of Questions Tht Cn Be Used to assess Eting Disorder Symptoms

Type

ScreeningEating behaviors

Compensatory behaviors

Body esteem

DiagnosticFear o weight gain

Overevaluation o shape/weight

Body image disturbance

Seriousness o low body weight

Binge eating

Compensatory behaviors

Dietary restriction

Smple Questions

What is your general eating pattern?Do you ever skip meals?Have you ever been on a diet? What about ollowing rules about what, when, or how much you can eat?Have you ever elt like your eating is out o control?

Do you exercise? I so, what kind o exercise do you do? How oten?Have you ever done anything to compensate or what you have eaten, such as sel-induced vomiting or

taking laxatives? What about asting or 24 hours or longer?

How do you eel about your shape and weight?Have you ever elt dissatised with your shape or weight?

Have you ever been araid o gaining weight?How would you eel i your weight changed?

Does your shape/weight infuence how you eel about yoursel?I you imagine the things that infuence how you eel about yoursel, such as your perormance at

work/school or your relationships, and put the settings in order o importance to your sel-evaluation,where does shape/weight t in?

Do you (or at your lowest weight, did you) still eel that your body or part o your body was too large?

Has anyone told you (or when you were at your lowest weight, did anyone tell you) that it could bedangerous to be as thin as you are? I so, what do you think? I not, what would you think i some-one told you that?

Have you ever had a binge eating episode? For example, eating an unusually large amount o oodand eeling like your eating was out o control?

Have there been any times when youve eaten an amount o ood other people might consider unusuallylarge?

Have you ever elt like your eating was out o control? For example, like you couldnt stop or resist eating?Or like you elt driven or compelled to eat?

Can you think o a specic time when thats happened and describe what you had to eat and howmuch?

How oten have episodes like that happened?Have you ever sel-induced vomiting to control your shape or weight? How oten?Have you ever taken laxatives or diuretics to control your shape or weight? How oten?Have you ever exercised to control your shape or weight? What kind o exercise do you do? How o-

ten? Do you ever eel driven or compelled to exercise? Do you ever exercise when youre sick/injuredor instead o spending time with amily or riends?

Have you ever asted or 24 hours or more to control your shape or weight? How oten?

Have you ever tried to ollow any dietary rules such as rules about how much you can eat, what typeso oods you can eat, or when you can eat?

7/28/2019 76575695

4/9



the onset and nature o symptoms and reerral to a medical

specialist can clariy whether the weight change is due to an

eating disorder or other condition. Other conditions that can

resemble eating disorders include anxiety disorders and body

dysmorphic disorder. Determining the ocus o anxiety (e.g., Is

the individuals anxiety in social situations refective o a ear osaying something humiliating or a ear o judgment about body

shape?), avoidance (e.g., not eating or ear o vomiting versus

not eating in an attempt to lose weight), or body checking (e.g.,

scrutinizing or signs o skin imperections vs. scrutinizing or

signs o weight gain) can reveal the extent to which an eating

disorder is present.

Once other medical and psychiatric conditions have been

ruled out, additional probing can be used to speciy the eating

disorder diagnosis (see Table 1 or examples o specic ques-

tions we recommend). O primary importance to dierential

diagnosis is weight status, particularly the extent to which

the individual is underweight. Although the DSM-IV-TR

recommends that underweightbe dened as less than 85%

o expected weight, upcoming revisions (DSM-5) allow coun-

selors to use more clinical judgment in determining weight

status (examples can be ound at www.dsm5.org). With regard

to a diagnosis o bulimia, the hallmark symptoms are binge

eating and the use o compensatory behaviors. However, as

stated earlier, i these behaviors occur in the context o an

individual being underweight, a diagnosis o anorexia (not

bulimia) would be given. In contrast to bulimia, individuals

with BED engage in binge eating without purging or other

compensatory behaviors. Thus, the presence o binge eating

accompanied by regular asting or excessive exercise indicates

a diagnosis o ull or subthreshold bulimia rather than BED.

Cognitive symptoms are also important to the diagnoses o

anorexia, bulimia, and BED. For a diagnosis o anorexia,

ear o weight gain and denial o the seriousness o low body

weight, body image distortion, or overevaluation o shape and

weight are required. Similarly, overevaluation o shape and

weight and distress regarding binge eating are required or

diagnoses o bulimia and BED, respectively.

How to Assess Psychiatric Risk

The rates o co-occurring psychiatric symptoms and syndromes

are high among individuals with all eating disorder diagnoses.

Suicide and sel-injury pose the primary psychiatric risks or

clients with eating disorders. Thus, detailed questions about sui-

cidal ideation, plan, means, and intent are critically important

to the assessment process. Sel-injury without suicidal intent

also occurs in individuals with eating disorders and should be

evaluated in the assessment process. Assessment o nonsuicidal

sel-injury should include an evaluation o location o sel-harm

(e.g., arms, legs, stomach), type o sel-harm (e.g., cutting,

scratching, burning), and severity (e.g., Did the client draw

blood? Was medical attention required?). Because clients with

eating disorders may sel-injure body parts that they believe are

particularly problematic (e.g., stomach, thighs), it is important

to assess sel-injurious behavior even i such behavior is not

visibly apparent.

Even i suicidality or nonsuicidal sel-injury are not present,

co-occurring psychiatric disorders can complicate treatment.

Rates o co-occurring mood disturbances are particularly high

in clients with eating disorders (e.g., Wonderlich & Mitchell,1997); however, the direct causal relationship between these

disorders is unclear. For example, mood disorders may exac-

erbate eating disorder symptoms or vice versa. Additionally,

the diagnosis o depression is complicated by the presence o

semistarvation, which can mimic many o the symptoms o

depression (e.g., low mood, inertia, poor concentration; Keys,

Brozek, Henschel, Mickelsen, & Taylor, 1950). In such cases,

restoration o weight may alleviate depressive symptoms. Stud-

ies o comorbidity suggest that major depression is the most

common mood disorder in individuals with eating disorders;

however, bipolar disorder is also observed in a minority o

clients (e.g., Wonderlich & Mitchell, 1997). Although binge

eating can refect impulsivity associated with mania, binge

eating should not be counted as a symptom o mania i it is

better explained by an eating disorder. In summary, assessment

o eating disorders should always be accompanied by a careul

screening o mood disorder symptoms.

In addition to mood disorders, anxiety disorders such as

phobias, obsessive-compulsive disorder, generalized anxiety

disorder, and posttraumatic stress disorder are common in per-

sons with eating disorders (e.g., Wonderlich & Mitchell, 1997).

Notably, anxiety symptoms that are better explained by an eat-

ing disorder (e.g., ear o weight gain, rituals related to eating,

weighing, or exercise) should not be considered evidence o a

co-occurring anxiety disorder. Rather, i an eating disorder is

present, the content o a co-occurring anxiety disorder should

be unrelated to eating, shape, weight, exercise, and so on. Ad-

ditionally, there is evidence that semistarvation can lead to

anxiety symptoms, including obsessive thinking and hoarding

(Keys et al., 1950).

Substance abuse and dependence are observed in a signicant

minority o eating disorder clients (estimates ranging rom 0%

to 55%), particularly those with anorexia, binge eating/purging

type, and bulimia (e.g., Holderness, Brooks-Gunn, & Warren,

1994; Wonderlich & Mitchell, 1997). Symptoms o Axis II per-

sonality disorders are also common in individuals with eating

disorders. Borderline personality disorder symptoms, includ-

ing impulsivity, intense anger, idealization/devaluation, ear o

abandonment, eelings o emptiness, and sel-injurious behavior

are especially common in those with eating disorders (e.g., Won-

derlich & Mitchell, 1997). Other common Axis II personality

disorders among those with eating disorders include avoidant,

obsessive-compulsive, narcissistic, and dependent personality

disorders (e.g., Wonderlich & Mitchell, 1997).

How to Assess Medical Risk

Medical risk is signicant in all eating disorder diagnoses,

including EDNOS; thus, an important part o eating disorder

7/28/2019 76575695

5/9



assessments is a concurrent medical examination conducted

by a physician or other medical provider. In general, any indi-

vidual with eating disorder symptoms should be reerred or

medical screening, regardless o symptom severity. Certain

conditions do require more immediate medical attention,

including the ollowing: (a) low body mass index (BMI), (b)recent and signicant changes in weight status, (c) purging

(which can result in electrolyte disturbance), and (d) condi-

tions that indicate cardiac abnormalities (e.g., ainting, dizzi-

ness). Medical examinations should include an assessment o

height and weight, vital signs (e.g., pulse, orthostatic hyper-

tension blood pressure, electrocardiogram), electrolytes (e.g.,

potassium, sodium, glucose, calcium, phosphorous), bone

density (e.g., dual-energy X-ray absorptiometry, or DEXA),

and menstrual status (Crow & Swigart, 2005). Ideally, weight

should be obtained with the client wearing a gown to improve

the accuracy o measurement (Peterson, 2005). For example,

the weight o a clients clothes can make it dicult to estab-

lish weight status at baseline and/or track weight changes

over time. Additionally, clients may put heavy objects such

as coins in their pockets to increase their observed weight.

Given that a physician or other medical personnel is best

qualied to assess medical risk and that medical risk should

be evaluated on an ongoing basis, some clients may need to

undergo weekly physical examinations. To ensure clear, on-

going communication across treatment providers, counselors

who treat clients with eating disorders may nd it useul to

develop working relationships with medical providers to

whom they can reer clients in need o medical monitoring.

Regardless o whether clients with eating disorders are be-

ing monitored by a physician or medical personnel, height

and weight should also be assessed regularly in the context

o therapy to monitor weight status (particularly among

clients who are underweight), which requires counselors

to maintain calibrated scales in their oces or clinics or to

collaborate with medical sta or dietitians who can obtain

regular measurements. Menstrual status should also be as-

sessed regularly in therapy, and although it is an inconsis-

tent indicator o disease status, resumption o menses can

be a useul indicator o recovery (e.g., Attia & Roberto,

2009). Additional resources and detailed recommendations

can be ound at http://www.aedweb.org/AM/Template.

cm?Section=Resources_or_Proessionals&Template=/CM/

ContentDisplay.cm&ContentID=2593.

Determining Level o Care

Ater the counselor has established the diagnostic status o the

client, it is important to determine the level o care at which

the client should be treated. Eating disorders are treated at

all levels o care, including outpatient, intensive outpatient

or partial day treatment, inpatient, and residential. Initial and

ongoing assessment o eating disorder severity, co-occurring

psychiatric symptoms, medical risk, and acute risk o sel-

injury/suicide can be used to determine the appropriate level

o care and reerral, i necessary. For example, clients with

more severe symptoms (e.g., low BMI, suicide risk), medical

instability, or symptoms that are unresponsive to outpatient

counseling may require hospitalization, intensive outpatient

treatment, or residential care. Fluctuations in level o care are

not uncommon in those with eating disorders, and counselorsoten nd it helpul to maintain relationships with other clinics

and providers to ensure continuity o care.

In summary, the rates o co-occurring psychiatric symp-

toms and syndromes are high among individuals with all eat-

ing disorder diagnoses, and some psychiatric problems (e.g.,

substance dependence, mania) may necessitate treatment prior

to treatment o the eating disorder. Although psychological

counseling has demonstrated ecacy equal to or surpassing

that o psychotropic medication or eating disorders (e.g.,

Shapiro et al., 2007), reerral to a psychiatrist or an evalua-

tion and/or ongoing medication management can be useul,

particularly i the client presents with multiple psychiatric

problems or is not helped by psychological interventions.

Special Considerations During anEating Disorder Assessment

As in all psychological assessments, evaluation o clients

with eating disorder symptoms can be compromised by vari-

ous biases (e.g., denial, minimization, conusion regarding

terminology, recall biases). However, assessment o eating

disorders is especially challenging or several reasons, in-

cluding cognitive disturbances caused by semistarvation,

the egosyntonic nature o eating disorder symptoms, ear o

orced treatment, and limitations in insight.

Denial/Minimization

Clients with eating disorders may minimize or deny symptoms

or a number o reasons. Some clients, especially children and

adolescents, may have limited capacity or sel-awareness.

Others may deliberately withhold inormation about symptom

severity because o eelings o shame, ear o hospitalization

or treatment, or an attachment to their eating disorder symp-

toms (e.g., Vitousek, Watson, & Wilson, 1998). Additionally,

some o the symptoms associated with eating disorders are

abstract concepts that are complex to dene and describe (e.g.,

binge eating, overevaluation o shape and weight) and can

lead to conusion and inadvertent minimization. To enhance

accurate sel-disclosure, counselors may nd it helpul to use

the ollowing techniques: (a) Maintain a collaborative and

empathic stance; (b) avoid criticism and conrontation; (c)

pose questions or statements in an open-ended ormat (e.g.,

Tell me more about your decision to become a vegetarian);

(d) provide detailed and concrete inormation about the ques-

tions being asked (e.g., By binge eating, I mean eating an

amount o ood that other people may consider unusually

large and eeling as though youre unable to control what or

how much youre eating); (e) obtain concrete inormation

7/28/2019 76575695

6/9



whenever possible (e.g., specic examples o quantity and

type o ood consumed during a binge, measured rather than

sel-reported height and weight); and () do not make as-

sumptions (e.g., clients may be restricting or health reasons

rather than shape- or weight-related reasons). Additionally,

counselors can reassure clients o their expertise by conveyinga matter-o-act and accepting attitude about topics that may

be a source o shame or embarrassment (e.g., requency and/

or method o purging, quantity or type o ood consumed dur-

ing a binge). Lengthy silences, hesitation, and unsupportive

nonverbal signals can imply judgment, lack o expertise, or

ear and should also be avoided (Miller & Rollnick, 2002;

Vitousek et al., 1998).

Recall Biases

Inormation provided retrospectively by clients with eating

disorders may be infuenced by a number o biases that are

related to psychological and biological actors. Semistarvation

can result in cognitive impairment, including concentration

and memory problems, and indecisiveness (Keys et al., 1950),

all o which can compromise the accuracy o inormation

provided during an eating disorder assessment. In addition,

retrospective recall bias, in which clients current mood

and behavior infuences their recollection o past events,

is common and can limit the accuracy o how well clients

can remember symptoms (Schacter, 1999). Because certain

symptoms (e.g., binge eating, purging, exercise) are thought

to unction as strategies to avoid negative aect (Heatherton

& Baumeister, 1991), these symptoms may be particularly di-

cult or clients to recall accurately. To enhance or maximize

accurate recall, the timeline ollow-back procedure (TLFB)

can be used (e.g., Fairburn & Cooper, 1993; Sobell, Sobell,

Klajner, Pavan, & Basian, 1986). The TLFB procedure is a

structured interview that orients participants to the past 12

weeks and then asks participants to recall the requency o

behaviors during that period. This procedure can be helpul in

enhancing memory accuracy when assessing behavior, cogni-

tions, and emotion. In addition, the use o detailed questions

and examples can reduce potential overgeneralization (e.g.,

What about during last months vacation?, Can you give

me a specic example?).

Assessment o Eating Disorders in Childrenand Adolescents

There is considerable overlap between the symptom presenta-

tions o youth and adults with eating disorders; however, there

are several issues that are unique to the assessment o eating

disorders in children and adults. First, the criteria or both

anorexia and bulimia require cognitive skills such as abstract

reasoning and metacognition (e.g., overevaluation o shape

and weight, loss o control over eating), which may not be

ully developed in younger clients (Bravender et al., 2011).

To enhance comprehension, age-appropriate metaphors (e.g.,

describing loss o control as a car rolling down a hill with

no brakes) and concrete examples (e.g., Weight is what you

see when you look at a scale and shape is what you see when

you look in the mirror.) are useul techniques. Consideration

may also be given to parental reports and behavioral indica-

tors (e.g., changes in dietary patterns, ood preerences, or

exercise) when assessing potential eating disorder symptomsin children and adolescents.

A second potential problem is that weight status is dicult

to calculate in children and adolescents because they may not

have reached their adult height and because growth rates vary

by gender, age, and pubertal stage (Bravender et al., 2011).

BMI percentiles, which can be calculated online (http://apps.

nccd.cdc.gov/dnpabmi/) and take into account age, gender,

and height, may be used to determine weight status in children

and adolescents. However, BMI percentiles do not account

or developmental status, which may vary between same-aged

individuals; thus, it has been recommended that theDSM-5

criteria allow counselors to use clinical judgment (e.g., physi-

cal evidence o malnutrition) to determine weight status.

Third, retrospective recall o type and quantity o ood con-

sumed during binges may be particularly dicult or children

and adolescents. Relatedly, determining whether an amount o

ood is unusually large can be problematic because the nutri-

tional requirements or children and adolescents vary by age,

gender, height, and developmental status (Tanosky-Kra,

Yanovski, & Yanovski, 2011). As with adults, using the TLFB

procedure and obtaining concrete examples can enhance ret-

rospective recall. Additionally, counselors may nd it useul

to use pictures o ood or play ood to help younger clients

arrive at more accurate estimates o the quantity o ood

consumed. Finally, some counselors may consider concepts

such as sel-induced vomiting and laxative or diuretic abuse

to be inappropriate topics or younger clients. In such cases,

phrasing questions more generally (e.g., Do you remember

the last time you threw up? When was that? Do you know

why you threw up?, and Some types o medicines make

you go to the bathroom; have you ever taken any o those

kinds o medicines?) may provide sucient inormation to

determine whether the symptom is present.

Assessment o Eating Disorders With DiverseClient Groups

Recent epidemiological research in the United States dem-

onstrated that although anorexia tended to be more common

in non-Hispanic White Americans, bulimia was signicantly

more common in Hispanic participants, and BED may be

more common in ethnic minorities than in non-Hispanic

White Americans (Swanson, Crow et al., 2011). Addition-

ally, ethnic minorities born and raised in the United States

may be at even higher risk or eating disorders (Swanson,

Saito, & Breslau, 2011) compared with ethnic minorities

living outside the United States or rst-generation immi-

grants to the United States. Given the high prevalence o

eating disorders in ethnic minorities, it is recommended that

7/28/2019 76575695

7/9



counselors assess eating disorders in diverse client groups.

However, assessing eating disorders in diverse client groups

can also pose unique challenges because eating disorders

consist o both cognitive and behavioral symptoms that can

only be clinically signicant relative to culturally normative

experiences. For example, behaviors such as overeating andasting may be culturally normative and, as such, would

not be indicative o an eating disorder (Becker, 2011). Ad-

ditionally, eating disorders may maniest dierently across

cultures. For example, at phobia and/or drive or thinness

may not be endorsed by Asian women with eating disorders

(Lee, Ho, & Hsu, 1993). Other variations have also been

noted, including the use o alternative compensatory behav-

iors such as herbal purgatives (Thomas, Crosby, Wonderlich,

Striegel-Moore, & Becker, 2011) and variability in the extent

to which shape and weight infuence sel-evaluation (Lynch,

Crosby, Wonderlich, & Striegel-Moore, 2011). Additional

problems or counselors to consider are that culturally

diverse clients may misunderstand counselors questions

i the question includes concepts that do not exist in the

clients culture (Becker, 2011). Relatedly, counselors may

misunderstand clients responses. For example, one study

demonstrated that respondents endorsed preoccupation with

ood because o their experience with poverty and ood

insecurity (Le Grange, Louw, Breen, & Katzman, 2004).

Thus, it is important to take a fexible, curious approach,

ask open-ended questions, provide concrete examples, and

ask or clarication to ensure accurate assessment.

Conclusion

In summary, given the serious medical and psychiatric conse-

quences associated with eating disorders, careul assessment

o eating disorder symptoms should be conducted with allclients regardless o gender, age, weight status, race/ethnicity, or

socioeconomic status. Additionally, when conducted eec-

tively, an eating disorder assessment can potentially inorm

treatment planning and enhance therapeutic rapport. All

eating disorder assessments should include an evaluation

o both the cognitive and behavioral symptoms o eating

disorders, which can be incorporated into general screening

questions regarding sel-care and sel-esteem. I an eating

disorder is suspected, urther evaluation o potential medi-

cal and psychiatric risk is necessary regardless o symptom

severity. Although problems such as denial, minimization,

and recall biases may be particularly pronounced with eat-

ing disorders, counselors may be able to enhance accuracy

by assuming an empathic, nonjudgmental stance, using theTLFB procedure, providing clear denitions o concepts, and

obtaining concrete examples. Assessing eating disorders in

children, adolescents, and clients rom diverse backgrounds

can be particularly dicult; however, the use o open-ended

questions, metaphors, clarication, and a fexible approach

can enhance comprehension and accuracy.

ReferencesAmerican Psychiatric Association. (2000).Diagnostic and statisti-

cal manual o mental disorders (4th ed., text rev.). Washington,

DC: Author.

American Psychiatric Association. (2011). DSM-5 development.Retrieved rom http://www.dsm5.org

Anderson, D. A., Lundgren, J. D., Shapiro, J. R., & Paulosky, C.

A. (2004). Assessment o eating disorders: Review and recom-

mendations or clinical use.Behavior Modifcation, 28,763782.

doi:10.1177/0145445503259851

Attia, E., & Roberto, C. A. (2009). Should amenorrhea be a diag-

nostic criterion or anorexia nervosa?International Journal o

Eating Disorders, 42, 581589. doi:10.1002/eat.20720

Becker, A. E. (2011). Culture and eating disorders classication.

In R. H. Striegel-Moore, S. A. Wonderlich, B. T. Walsh, & J. E.

Mitchell (Eds.),Developing an evidence-based classifcation o

eating disorders: Scientifc fndings or DSM-5 (pp. 257266).

Arlington, VA: American Psychiatric Association.

Berg, K. C., Frazier, P., & Sherr, L. (2009). Change in eatingdisorder attitudes and behavior in college women: Prevalence

and predictors.Eating Behaviors, 10, 137142. doi:10.1016/j.

eatbeh.2009.03.003

Berg, K. C., Stiles-Shields, E. C., Swanson, S. A., Peterson, C.

B., Lebow, J., & Le Grange, D. (2011, August 8). Diagnostic

concordance o the interview and questionnaire versions o the

eating disorder examination. International Journal o Eating

Disorders. Advance online publication. doi:10.1002/eat20948

Bravender, T. D., Bryant-Waugh, R., Herzog, D. B., Katzman, D.,

Kreipe, R. E., Lask, B., . . . , Zucker, N. (2011). Classication o

eating disturbance in children and adolescents. In R. H. Striegel-

Moore, S. A. Wonderlich, B. T. Walsh, & J. E. Mitchell (Eds.),

Developing an evidence-based classifcation o eating disorders:

Scientifc fndings or DSM-5 (pp. 167184). Arlington, VA:American Psychiatric Association.

Crow, S. (2005). Medical complications o eating disorders. In S.

Wonderlich, J. Mitchell, M. de Zwaan, & H. Steiger (Eds.),Eating

disorders review: Part 1 (pp. 127136). Oxord, England: Radclie.

Crow, S., & Swigart, S. (2005). Medical assessment. In J. E. Mitch-

ell & C. B. Peterson (Eds),Assessment o eating disorders (pp.

120128). New York, NY: Guilord Press.

Crow, S. J., Peterson, C. B., Swanson, S. A., Raymond, N. C.,

Specker, S., Eckert, E. D., & Mitchell, J. E. (2009). Increased

mortality in bulimia nervosa and other eating disorders.Ameri-

can Journal o Psychiatry, 166, 13421346. doi:10.1176/appi.

ajp.2009.09020247

Fairburn, C. G., & Cooper, Z. (1993). The Eating Disorder Exami-

nation. In C. G. Fairburn & G. T. Wilson (Eds.), Binge eating:Nature, assessment, and treatment(pp. 317360). New York,

NY: Guilord Press.

Fairburn, C. G., Cooper, Z., Bohn, K., OConnor, M. E., Doll, H. A.,

& Palmer, R. L. (2007). The severity and status o eating disorder

NOS: Implications or DSM-V.Behavior Research and Therapy,

45, 17051715. doi:10.1016/j.brat.2007.01.010

7/28/2019 76575695

8/9



Heatherton, T. F., & Baumeister, R. F. (1991). Binge eating as es-

cape rom sel-awareness.Psychological Bulletin, 110, 86108.

doi:10.1037/0033-2909.110.1.86

Hoek, H. W. (2006). Incidence, prevalence, and mortality o anorexia

nervosa and other eating disorders. Current Opinion in Psy-

chiatry, 19, 389394. doi:10.1097/01.yco.0000228759.95237.78

Hoek, H. W., & van Hoeken, D. (2003). Review o the prevalence

and incidence o eating disorders.International Journal o Eating

Disorders, 34, 383396. doi:10.1002/eat.10222

Holderness, C. C., Brooks-Gunn, J., & Warren, M. P. (1994).

Co-morbidity o eating disorders and substance abuse review

o the literature. International Journal o Eating Disorders,

16, 134. doi:10.1002/1098-108X(199407)16:13.0.CO;2-T

Jones, K. D. (2010). The unstructured clinical interview.Journal o

Counseling & Development, 88, 220226.

Keel, P. K., Brown, T. A., Holm-Denoma, J., & Bodell, L. P. (2011).

Comparison o DSM-IV versus proposed DSM-5 diagnostic

criteria or eating disorders: Reduction o eating disorders not

otherwise specied and validity.International Journal o Eating

Disorders, 44, 553560. doi:10.1002/eat.20892

Keys, A., Brozek, J., Henschel, A., Mickelsen, O., & Taylor, H. L.

(1950). The biology o human starvation (Vols. I & II). Min-

neapolis: University o Minnesota Press.

Le Grange, D., Louw, J., Breen, A., & Katzman, M. A. (2004). The

meaning o sel-starvation in impoverished Black adolescents

in South Arica. Culture, Medicine, and Psychiatry, 28, 439461.

doi:10.1007/s11013-004-1064-8

Lee, S., Ho, T. P., & Hsu, L. K. G. (1993). Fat phobic and non-at

phobic anorexia nervosa: A comparative study o 70 Chinese

patients in Hong Kong.Psychological Medicine, 23, 9991017.

doi:10.1017/S0033291700026465

Lynch, W. C., Crosby, R. D., Wonderlich, S. A., Striegel-Moore,

R. H. (2011). Eating disorder symptoms o Native American

and White adolescents. In R. H. Striegel-Moore, S. A. Won-

derlich, B. T. Walsh, & J. E. Mitchell (Eds.)Developing an

evidence-based classifcation o eating disorders: Scientifc

fndings or DSM-5 (pp. 285297). Ar lington, VA: American

Psychiatric Association.

Miller, W. R., & Rollnick, S. (2002).Motivational interviewing(2nd

ed.): Preparing people or change. New York, NY: Guilord Press.

Mitchell, J. E., & Peterson, C. B. (2005). Assessment o eating

disorders. New York, NY: Guilord Press.

Peterson, C. B. (2005). Conducting the diagnostic interview. In J. E.

Mitchell & C. B. Peterson (Eds.),Assessment o eating disorders

(pp. 3258). New York, NY: Guilord Press.

Schacter, D. L. (1999). The seven sins o memory: Insights rom

psychology and cognitive neuroscience.American Psychologist,

54, 182203. doi:10.1037/0003-066X.54.3.182

Shapiro, J. R., Berkman, N. D., Brownley, K. A., Sedway, J. A.,

Lohr, K. N., Bulik, C. M. (2007). Bulimia nervosa treatment: A

systematic review o randomized controlled trials.International

Journal o Eating Disorders, 40,321336. doi:10.1002/eat.20372

Sobell, M. B., Sobell, L. C., Klajner, F., Pavan, D., & Basian,

E. (1986). The reliability o a timeline method or assessing

normal drinker college students recent drinking history: Util-

ity or alcohol research. Addictive Behaviors, 11, 149161.

doi:10.1016/0306-4603(86)90040-7

Swanson, S. A., Crow, S. J., Le Grange, D., Swendsen, J., & Merikan-

gas, K. R. (2011). Prevalence and correlates o eating disorders

in adolescents. Archives o General Psychiatry, 68, 714723.

doi:10.1001/archgenpsychiatry.2011.22

Swanson, S. A., Saito, N., Breslau, J. (2011).Binge eating disorder

and migration among Mexicans and Mexican-Americans: Results

rom population-based samples across two countries. Paper

presented at the 17th Eating Disorders Research Society annual

meeting, Edinburgh, United Kingdom.

Tanosky-Kra, M., Yanovski, S. Z., & Yanovski, J. A. (2011).

Loss o control over eating in children and adolescents. In R. H.

Striegel-Moore, S. A. Wonderlich, B. T. Walsh, & J. E. Mitchell

(Eds.), Developing an evidence-based classifcation o eating

disorders: Scientifc fndings or DSM-5 (pp. 221236). Arling-

ton, VA: American Psychiatric Association.

Thomas, J. J., Crosby, R. D., Wonderlich, S. A., Striegel-Moore, R.

H., & Becker, A. E. (2011). A latent prole analysis o the typol-

ogy o bulimic symptoms in an indigenous Pacic population.

In R. H. Striegel-Moore, S. A. Wonderlich, B. T. Walsh, & J. E.

Mitchell (Eds.),Developing an evidence-based classifcation o

eating disorders: Scientifc fndings or DSM-5 (pp. 365386).

Arlington, VA: American Psychiatric Association.

Vitousek, K., Watson, S., & Wilson, G. T. (1998). Enhancing motivation

or change in treatment-resistant eating disorders. Clinical Psychol-

ogy Review, 18, 391420. doi: 10.1016/S0272-7358(98)00012-9

Wonderlich, S. A., & Mitchell, J. E. (1997). Eating disorders and

comorbidity: Empirical, conceptual, and clinical implications.

Psychopharmacology Bulletin, 33, 381390.

7/28/2019 76575695

9/9

Copyright of Journal of Counseling & Development is the property of Wiley-Blackwell and its content may not

be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written

permission. However, users may print, download, or email articles for individual use.

76575695

Documents