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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.
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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
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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?
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Assessment and Diagnosis o Eating Disorders
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
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Berg, Peterson, & Frazier
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
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Assessment and Diagnosis o Eating Disorders
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
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Journal of Counseling & Development July 2012 Volume 90268
Berg, Peterson, & Frazier
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.
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