Introduction

Chapter 1: Defining Eating Disorders

Chapter 2: Soical Precipitants

Chapter 3: Psychological Precipitants

CHAPTER SIX MAKING THE DIAGNOSIS

The DSM-III-R criteria explained in Chapter One is the accepted guideline established by the American Medical Association for diagnosing eating disorders.  In addition, various diagnostic tests have been developed.  In general these diagnostic tests are viewed as having limited usefulness when employed exclusively (Bryant-Waugh and Lask, 1992).  However, they can be helpful when used in conjunction with the structured assessment.  A personal in-depth interview with the patient will provide important information necessary to formulate an appropriate treatment program.  It also serves to establish rapport with the patient who may initially present with denial, distrust and resistance.

The following are some of diagnostic test available:

• Body Satisfaction Scale:  Slade, Dewey and Ashcroft, 1986
• Body Shape Questionnaire:  Cooper, Taylor, Cooper and Fairburn, 1987.
• Eating Attitudes Test (EAT):  Garner, Olmstead, Bohr and Garfinkel, 1982.
• Children’s Eating Attitude Test (ChEAT):  Maloney, McGuire and Daniels, 1988.
• Eating Disorder Inventory (EDI):  Garner, Olmstead and Polivy, 1983.
• Eating disorder Examination:  Cooper and Fairburn, 1987.
• Clinical Eating Disorder Rating Instrument:  Palmer, Christie, Cordle and Kenrick, 1987.
• Setting Conditions for Anorexia Nervosa Scale (SCANS):  Slade and Dewey, 1986.

THE ASSESSMENT

Connars and Johnson feel that the first five minutes of the assessment interview are extremely important (Connars and Johnson, 1987).  They recommend beginning the interview by asking how the person is feeling about coming for the consultation.  It is important to assess whether the individual is there voluntarily or due to the coercion of family or friends.  They may or may not be presenting with a particular complaint about eating behavior.  It may be some other distressing issue which actually brings them into therapy, such as feeling depressed and possibly even suicidal, having relationship difficulties, feeling stressed out or anxious.  The patient may, in fact, be in denial about the extent of the eating disorder, and not see it as a problem at all.  To the anorexic patient, her food related behavior may seem like the only part of her life which is under control and makes any sense.  The bulimic patient may not see her eating behavior as a problem, but rather see herself as the problem; a failure, worthless, not good at anything, unable to achieve her goals, feeling taken advantage of by others, etc.  It is up to the clinician to extract the proper diagnostic information, and then help the patient to admit there is a problem and agree to treatment.

The interviewer should ask if the patient has ever talked with anyone specifically about difficulties with food.  Though the patient may present to the clinician acknowledging the eating disorder, she may never have exposed this to anyone else.  Bulimics, in particular, are quite ashamed of their behavior and carry it on in secret as much as possible.  Interestingly, though, more bulimic patients present for treatment than anorexics (Connars and Johnson, 1987).  This is probably due to the fact that patients who restrict their diets feel in control and actually quite proud of their willpower and strength.  They gain a sense of accomplishment from this that perhaps they don’t receive anywhere else in their lives.  Bulimics, however, feel quite out of control and panicky about their behavior.  They want desperately to regain some control and will look for professional help in doing so.  Anorexics, in general, are in much more denial and are quite resistant to treatment, often seeing nothing wrong with their eating habits.

If the patient has been in treatment before, the interviewer can ask what she found to be helpful and what was not helpful.  Also, ask if the eating disorder was addressed at all.

Once these introductory questions are answered, the agenda for the consultation can be explained to the patient.  The clinician explains that he/she has many questions to ask which may at times seem intrusive.  However, the reason for asking so many questions is to quickly ascertain where the patient is in the course of the eating disorder and to make an appropriate treatment recommendation.

Connars and Johnson feel that the most important task of the first five minutes is to convey to the patient that the clinician is interested in a collaborative inquiry, rather than an inquisition into the patient’s personal history which may have caused the development of her eating disorder.

Connars and Johnson recommended using a structured interview format, using specific questions which indicate to the patient that the clinician has an understanding of the particular issues and behaviors which accompany an eating disorder.  The following is a list of their suggested questions.

Weight History

The objective of obtaining a weight history is to ascertain how weight preoccupations and fluctuations have affected the patient’s self-esteem and life adjustment (Connars and Johnson, 1987).  First, the clinician obtains the patient’s current height, weight and ideal weight for metabolic functioning.  It is advisable to investigate whether there are occupational considerations that affect the patient’s attitude towards her body.  For example, the fashion and entertainment industries generally place unrealistic demands on a woman’s appearance and thus the patient’s self-esteem and livelihood are tied in together.

The interviewer then asks about the patient’s highest and lowest past weights since the age of thirteen.  If there are periods of significant weight fluctuations, the interviewer can explore potential correlations with stressful life events, such as family problems, losses or transitions.  Having this information allows the therapist to work with the patient on identifying how she has learned to cope with stressful situations and then to learn new, healthier ways of dealing with life.
Next, inquire about how much attention the family and peers placed on thinness, dieting and appearance in childhood and adolescence.  Ask about how the patient felt about her weight, given her family and peer group attitudes.  Was she ever teased about her body, because of excessive weight or mature development?  Who did the teasing or made comments, and how did this make the patient feel?

During periods of significant weight loss, what methods were used and how quickly did the patient lose?  This is where the interviewer can determine whether the patient uses restriction as a means to control weight or bingeing and purging.  It is also important to note whether amenorrhea ever developed as a result of weight loss and at what weight this occurred.  This information helps the interviewer to establish what the minimal biologically acceptable weight is for the patient.

Body Image

The primary task of this phase of questioning is threefold; 1) to assess the level of body image distortion, 2) to uncover the psychological adaptation it may be serving and 3) to investigate the extent to which it interferes with life adjustment (Connars and Johnson).  While the majority of women would admit that they are dissatisfied with their bodies, this dissatisfaction does not consume them as it does eating disorder patients.  They are not completely obsessed and preoccupied with food and weight as an eating disorder patient, and this dissatisfaction does not interfere with the functioning of their overall life.

To obtain this information the interviewer can ask if the patient’s self-consciousness about her body prevents her from doing various things, such as dating, becoming sexually involved, exercising or participating in activities which would expose the body.

At this point the patient’s perception of her body size and her actual size can be compared to assess the level of distortion involved.  If the perception is quite distorted, the interviewer can ask if others agree or disagree with the patient’s assessment of her body.  Patients who have a high level of distortion or delusional thought regarding their body will generally feel threatened by this line of inquiry and may react with hostile resistance.  “Patient’s who present with more delusional perceptions of their body size are often quite paranoid, have fragile and brittle intrapsychic resources, are treatment resistant and consequently have poorer outcomes (Connars and Johnson).”

Dieting Behavior

The primary purpose of this section is to assess the length of time the patient has dieted, why and whether there was a source of encouragement for dieting.  It is significant to note if other family members are diet or weight preoccupied.  It is common for eating disorder patients to come from such families.

Early onset of dieting, and frequent dieting, are predictive of bulimic behavior among adolescents.  Of significance here is how psychologically and physiologically deprived this patient is feeling.  As discussed earlier in this study, feelings of deprivation, both psychological and physiological, lead to binge eating and subsequent purging.

It is important to assess the cognitive-behavioral attitudes that have developed around the patient’s eating behavior.  Does the patient think of certain foods as either “good” or “bad”, and how does she feel when she eats “bad” foods?  The interviewer can assess how much magical or superstitious thinking the patient has around food related behavior.  This can be obtained by asking the patient to explain what calories are, how the body digests food, what the function of fat is and how fad diets work.

Scale Behavior and Exercise

Ritualistic behavior around body measurement and exercise are common among eating disorder patients.  In this section the interviewer assesses how frequently the patient weights herself, how ritualized the behavior is and how fluctuations affect self-concept and daily activities.

It is also important to find out what has been the longest period of time during the past six months that the patient has abstained from weighing or measuring herself.  Investigate the events that correlate with this period of time, and have they reoccurred with the same resultant behavior change.

Exercise, though healthy and appropriate for most people, is often a highly ritualized and obsessional activity for those with an eating disorder.  The interviewer wants to assess what adaptive function the exercise serves.  A good way to find this out is by asking the patient how she feels when unable to exercise.  Exercise can serve a variety of purposes for the eating disorder patient, for example, to regulate such emotionally tense states as anger, anxiety or depression, particularly since many of these patients have found it difficult to express their true emotions within their family of origin.  Another adaptive function of exercise is seen in its use as a self-punishment mechanism when having “lost control” of her eating, or it can also be seen as a narcissistic attention seeking behavior for the ability to perform in a manner high above the average person.

Adaptive Significance of Binge Eating

This phase involves looking at the binge eating behavior on two different levels, the Macro-assessment and the Micro-assessment (Connars and Johnson).  First, with the Macro-assessment, the interviewer is interested in a general picture about when the binge eating behavior began, what circumstances were surrounding it and have fluctuations in her pattern of eating correlated with particular life events, such as bingeing during times of increased stress and abstinence during more emotionally stable times.  Inquire as to the longest period of abstinence from the behavior, what were her life circumstances during this period of time and what was her emotional response to this symptom-free period.  It is important to ask if the patient’s binge eating behavior is exacerbated by her menstrual cycle.

The Micro-assessment focuses on very detailed information about the patient’s daily routines.  It is helpful to give the patient a diary to note what foods were eaten, when she ate, describe binge episodes, what events might have preceded her binge and the emotions she was feeling at the time.  It is also helpful to have the patients describe in detail what she ate that she considers a reasonable meal and what she ate that she considers a binge.  Because of the distortion around food, eating disorder patients often interpret any consumption of food as a binge, or total loss of control. 

Phenomenological Experience

The goal of this phase is to determine what type of tension state they are attempting to regulate through the behavior around food.  This is unique for each patient.  It has been found that the act of bingeing and purging serves a variety of functions for patients, such as affect regulation, impulse expression, self-nurturance, oppositionality and self-punishment (Connars and Johnson).

Purging Behavior

As with bingeing, the interviewer wants to investigate the onset, precipitants, duration, frequency and method of purging behavior.  The interviewer may be direct and ask if the patient does in fact purge, and what method she uses.  Ask detailed questions about how often the patient purges; is it after every meal, just after a binge, associated with a particular life circumstance such a job stress, or a particular emotion such as low self-esteem and what was happening just prior to the purge.  As with binge behavior, it is important to inquire about the longest period of abstinence the patient has experienced, what were the significant life events, how did the patient feel about the abstinence, did it simultaneously affect her bingeing and what successful methods did she use to abstain.

Personality Features

Many bulimics have difficulty with interoceptive awareness, or the ability to identify and articulate internal states.  The degree of deficit in this area can be assessed by observing how quickly and precisely patients are able to talk about their feelings.  In making this assessment it is important to distinguish between patients who are reluctant to express their feelings from those who do not know what they are feeling.

Affective instability is also common among bulimics.  They often present with symptoms that are characteristic of agitated depression, anxiety disorder or panic states.  These patients will complain of mood variability, recurrent anxiety, irritability, restlessness, boredom, difficulty falling asleep, short attention span and low frustration tolerance.  Their anxious driven feelings often result in impulsive behavior (Connars and Johnson).

Though the majority of patients present with the above profile, there is a small group that present with symptoms of vegetative depression; low mood, persistent fatigue and lethargy, difficulty awakening and rising in the morning, frequent crying episodes and lack of motivation are common symptoms among this group (Connars and Johnson).  As opposed to the larger population of bulimic patients whose behavior is highly impulsive, this group will plan a binge and looks forward to it, for the comfort it offers (Connars and Johnson).

Experience of Self and Others

This phone of the interview questioning should give the clinician information about how the patient views herself and others and how these perceptions will affect her ability to engage in a therapeutic relationship (Connars and Johnson).

When asked how others see her and how she sees herself, the eating disorder patient will generally report a favorable and even above average opinion from others, as opposed to highly inadequate from the patient’s point of view.  This indicates a false self organization.  These patients will generally display perceptions reflective of a low self-esteem.  Feelings of inadequacy, worthlessness, ineffectiveness, self-criticalness, shame and guilt are quite characteristic.

As to how eating disorder patients view the world in relation to them, many see others as malevolent beings who are intrusive, manipulative, exploitive, abusive, destructive, dangerous and unreliable.  Naturally, this type of patient would have difficulty establishing a trusting therapeutic relationship.

There are also those eating disorder patients who view others as caring and loving, generally coupled with their own sense of not deserving this type of attention from others, presenting a therapeutic alliance problem of a different nature.

Bulimics are usually so sensitive to the reactions and opinions of others that they will sensor their own feeling and responses rather than risk anger, rejection or ridicule.  This can result in social avoidance and reclusive behavior.  Or, remaining in dissatisfying relationships rather than risk assertiveness.

Cognitive Style and Defensive Adaptations

During the course of the assessment interview, the interviewer will be analyzing the patient’s cognitive style.  Is the patient concrete in her thinking?  Is she obsessive or impulsive in her responses?  Does she have the capacity for introspective thought?  Does she have the ability to de-center from herself and view herself in a broader perspective (Connars and Johnson)?

In addition to the patient’s cognitive style, her defense mechanism should be assessed in order to plan a therapeutic strategy.  The following are defensive characteristics common to eating disorder patients:

Denial – Can the patient acknowledge that there is a problem?  Patients in complete denial are usually in treatment involuntarily and are at risk for non-compliance and termination.

Avoidance of affect – Patients who are either frightened of various affects, or who have difficulty showing affect will use such strategies as suppression, repression, dissociation, distraction, splitting and intellectualization.

Projection – An individual uncomfortable with her own thoughts and feelings will illicit thoughts and feelings in another that resemble her own.  For example, if a patient is feeling anger, but is uncomfortable with that emotion, she will provoke an angry response in the therapist.

Opposition – Does the patient demonstrate a need to undo, resist or customize her treatment?  This is indicative of her need to feel in control.

Patients will generally present as one of two different cognitive/defensive styles, either paranoid or hysterical.  The predominantly paranoid-obsessive style will display suspiciousness, hypervigilance to details, rumination, phobic concerns, projection and distancing.  Patients with hysterical styles, are diffuse, impulsive, frantic, form quick attachments and are idealistic.  Understanding these differences will help the clinician to plan an effective style and structure of treatment.

Family Characteristics

The patient’s behavior may e serving some type of adaptive function within the family system, and that will need to be explored in order to help the patient to recognize the dynamic, as well as to change her behavior to a more healthy coping strategy.  Also, the style of communication within the family will need to be assessed in order to implement the most appropriate and effective treatment approach.  Patients from disengaged and chaotic families would benefit from an active and direct approach in therapy.  On the other hand, patients from enmeshed and overprotective families would respond better to a less active style of therapy.

The following family dynamics should be explored:

Cohesiveness – The quantity and quality of involvement within in a family may be unhealthy.  There may be either under- or over-involvement, which would both result in self-regulatory deficits.  It is important to explore family boundaries, which refer to the rules that govern interpersonal issues, such as distance versus intimacy and autonomy versus symbiosis.  A balance between these issues would be healthy.

In families of eating disorder patients, boundaries may be either weak or disengaged.  In a family with weak boundaries there would be enmeshment, with extreme closeness and intensity in the family interaction and a high degree of over-protectiveness.  This would cause the patient to have difficulty with self-regulation when separated from her family, since she would be used to family members regulating her behavior.  She would also have poor ego differentiation, since she is accustomed to being defined by her role within the family.  The food related behavior is often an attempt to regulate behavior in the absence of the family, or the external control.

The disengaged family is the opposite of the enmeshed family in their communication dynamic.  These families have boundaries which are over-defined, rigid and insensitive to individual need.  These patients feel disconnected from family members and lack meaningful involvement with others.  These eating disorder patients are forced to develop autonomy prematurely and are often withdrawn.  The self-regulatory deficits these patients develop are as a result of under-involvement from the family.  In the absence of external controls, these individuals make unhealthy attempts at establishing a sense of control by their behavior with food.

Communication Style – It is important to explore how the family exchanges information.  There are three characteristic communication problems within families of eating disorder patients:

•  Disqualification and disconfirmation – the family conveys to the patient that her thoughts and feelings are inaccurate or not valued.  Parents become almost god-like and their ability to control the patient’s behavior through the idea that they have the only correct thoughts and feelings.
• Incongruence and shifting of focus – narcissistic communication styles from the parents which result in the child withdrawing from efforts to communicate because it is an empty and disorganizing experience.
• Double-binding – the child is given mutually exclusive messages, “This is okay for him but not for you”.  The result is anxious conflict and feelings of being trapped, paralyzed and hopeless (Connars and Johnson).

Conflict Resolution – It is important to assess how the family style of conflict resolution has affected the patient’s freedom to express conflict, and whether the individual has had the opportunity within the family to deal with conflict when it arises.  Very often, families of eating disorder patients deny conflict in an effort to maintain a pseudo-homeostasis within the family system.  The patient may even have been attacked, criticized or rejected for expressing conflict.  This results in patients feeling intimidated or nonassertive and they attempt to resolve these conflicts through food-related behavior.

Behavior Control – The family’s method for rewarding or punishing behavior is important to examine.  A healthy system would clearly state the rules and the punishment would be an appropriate and logical consequence of an infringement.  However, the dysfunctional families of many eating disorder patients often demonstrate a system of rigidly enforced rules, which would contribute to the development of all-or-none thinking, and where the punishment is inappropriate for the behavior.  An opposite and equally dysfunctional system would be absent or chaotic rules.  This leaves the patient feeling abandoned, confused and needing to implement her own sense of control through food related behavior.

Does the family have normal and sensitive expectations, or are they unrealistic and self-seeking?  Does the family reward positive behavior and high performance, which would foster self-esteem, or do they constantly criticize and ask for more and better levels of performance?

Roles – In a dysfunctional family each member has a role that fortifies and supports the family dynamic and the role of all the other members.  It is important to assess the roles of each family member, and particularly the patient in regards to her food related behavior.

Do her “sickness and frailty” allow her middle-aged parents to hang onto her and thus not have to experience their own mid-life issues?  Does the patient’s thin figure give the parents a sense of gratification and achievement, when they may feel insecure about their own opportunities and success?  Does the “sick” individual unite distanced parents around her illness?

The patient wields a lot of power in her role, and subconsciously knows that.  Changing her role to a healthy one means she forces her family to face their own issues, and risk the crumbling of the family structure.

Capacity to Have Fun – Does the patient have any hobbies or activities she engages in regularly?  Does she socialize?  Or is she so driven to achieve, or simply get things done, that she can’t take time out to have fun?  If the patient is so hard on herself that she does not allow for fun in her life, or if she has isolated herself due to low self-esteem, bingeing may be her only outlet for non-performance related behavior.

Isolation may also be a barometer for how a patient’s eating behavior has taken over her life.  The bulimic patient will feel so much shame around her behavior that she often cuts off social interaction.  The anorexic may have difficulty socializing since many events center around food.

Priorities and Willingness to Change – It is important to explore with the patient her goals and what is important to her.  The patient may either recite what she considers to be socially appropriate goals, or she may be at a complete loss, being so out of touch with her own needs and feelings.  Weight and appearance may indeed come up as the most important issues to the patient.  A confrontive, yet realistic question is, “Would you be willing to gain ten pounds in exchange for giving up your behavior towards food?”.  The answer to this question may largely depend on how the behavior has affected the patient’s life.  Is she depressed, isolated, feeling terrible about herself, unable to engage in social activities due to low self-esteem?  Or has her more slender body helped her to achieve career and social success she didn’t have when she was heavier?  If the latter is true, treatment will be more difficult.  This patient may have experienced size discrimination prior to her eating disorder.  It will be difficult to help her find reasons to give it up.  She will be terrified to give u the behavior which she feels has gained her so much.

Motivation – If the patient is seriously debilitated by depression she may need to be treated with antidepressants before any progress can be made.  Bulimic patients in particular are often paralyzed by their feelings of hopelessness, as they have seen how little control they have over their behavior.  Without some motivation, treatment will not succeed.  Though the patient may not have the capacity for motivation initially, it is part of the function of the interviewer in this preliminary assessment to impart a sense of hope to the patient.  The interviewer can have a great influence on the patient’s motivation to continue into treatment.  Thus, the time taken to thoroughly and compassionately assess the patient gives the individual a sense that someone understands her problem, knows what to do about it and that help is available.  This can give the patient a sense of hope when she feels at a loss to help herself.

Medical Issues

A medical examination should always be done prior to implementing a treatment program.  It is important to assess whether any medical conditions existed prior to the onset of the eating disorder which may be precipitating factors, as well as treating the medical complications that have developed from the food-related behavior.

Lab tests should include a complete blood count (CBC), liver function, electrolytes, BUN, and glucose, calcium, phosphorous and magnesium levels.  An EKG is recommended, and with some anorexics, a neurological assessment.  A thorough cardiac assessment is suggested for patients who misuse ipecac.  A urine sample may be obtained to detect diuretic and laxative use.

Personal Adjustment Issues

Life Adjustment – How has the eating behavior affected the patient’s life, in regards to work, relationships and activities?  How unmanageable has the patient’s life become?  Did the behavior originally yield positive results, and now become negative?  What is the overall quality of the patient’s life?

Capacity To Be Alone – Most bulimics have difficulty with unstructured alone time.  The evening is the most common time for bingeing.  During the day when the patient has outside influences, such as school or work to help her feel in control, she is able to abstain from bingeing.  However, the unstructured alone time is the evening causes these patients to feel lost, abandoned and even panicky.  The binge can be felt as soothing, nurturing, with the resultant purge as a release of pent up tension.

For patients who are obsessive and highly achievement oriented, unstructured alone time only serves as a void for rumination about things undone, and pressure to accomplish more and more in this “free time”.  This is the classic “woman who does too much”.  These individuals either exhaust themselves with endless chores that can never wait, or exhaust themselves by thinking about them, and berating themselves for not getting more done.  A binge is a distracting activity for these compulsive individuals.

Next: CHAPTER SEVEN TREATMENT