Advance Praise for

Handbook of Assessment and

Treatment of Eating Disorders

“Dr. Timothy Walsh is one of the world’s leading authorities on eating

disorders. This well-researched and thorough guide, which he coau-
thored, will not only help clinicians and researchers better understand the
condition but will also enable sufferers to get the help they so desperately
need and deserve.”

Joy Bauer, M.S., RDN, nutrition and health expert for NBC’s Today show,
#1 New York Times best-selling author, founder of Nourish Snacks

“This book, written by experts on the various aspects of eating disorders,

will be particularly useful for those interested in the diagnosis and assess-
ment of eating disorders. Too many books skip lightly over these impor-
tant areas. Here you will find much substance.”

Stewart Agras, M.D., Professor of Psychiatry Emeritus, Stanford University

School of Medicine, Stanford, California
This page intentionally left blank
 H A N D B O O K O F

Assessment and
Treatment of
Eating Disorders
This page intentionally left blank
 H A N D B O O K O F
Assessment and
Treatment of
Eating Disorders

EDITED BY

B. Timothy Walsh, M.D.

Evelyn Attia, M.D.
Deborah R. Glasofer, Ph.D.
Robyn Sysko, Ph.D.
Note: The authors have worked to ensure that all information in this book is ac-
curate at the time of publication and consistent with general psychiatric and med-
ical standards, and that information concerning drug dosages, schedules, and
routes of administration is accurate at the time of publication and consistent with
standards set by the U.S. Food and Drug Administration and the general medical
community. As medical research and practice continue to advance, however, ther-
apeutic standards may change. Moreover, specific situations may require a specific
therapeutic response not included in this book. For these reasons and because hu-
man and mechanical errors sometimes occur, we recommend that readers follow
the advice of physicians directly involved in their care or the care of a member of
their family.
Books published by American Psychiatric Association Publishing represent the
findings, conclusions, and views of the individual authors and do not necessarily
represent the policies and opinions of American Psychiatric Association Publish-
ing or the American Psychiatric Association.
If you wish to buy 50 or more copies of the same title, please go to www.appi.org/
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Copyright © 2016 American Psychiatric Association
ALL RIGHTS RESERVED
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Library of Congress Cataloging-in-Publication Data
Handbook of assessment and treatment of eating disorders / edited by B. Timothy
Walsh, Evelyn Attia, Deborah R. Glasofer, and Robyn Sysko.—First edition.
p. ; cm.
Assessment and treatment of eating disorders
Includes bibliographical references and index.
ISBN 978-1-58562-509-3 (pb : alk. paper)—ISBN 978-1-61537-039-9 (eb)
I. Walsh, B. Timothy, 1946- , editor. II. Attia, Evelyn, editor. III. Glasofer, Deb-
orah R., 1979- , editor. IV. Sysko, Robyn, editor. V. American Psychiatric Associa-
tion, issuing body. VI. Title: Assessment and treatment of eating disorders.
[DNLM: 1. Eating Disorders—diagnosis. 2. Eating Disorders—therapy. WM 175]
RC552.E18
616.85'26—dc23
2015024909
British Library Cataloguing in Publication Data
A CIP record is available from the British Library.
 Contents

Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . xi

Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . .xvii
Kathleen M. Pike, Ph.D.

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxi
B. Timothy Walsh, M.D.
Evelyn Attia, M.D.
Deborah R. Glasofer, Ph.D.
Robyn Sysko, Ph.D.

Video Guide . . . . . . . . . . . . . . . . . . . . . . . . xxv

PART I
Introduction

1 Classification of Eating Disorders . . . . . . . . . 3

B. Timothy Walsh, M.D.
Evelyn Attia, M.D.
Robyn Sysko, Ph.D.
 PART I I
Evaluation and Diagnosis of
Eating Problems

2 Eating Problems in Adults. . . . . . . . . . . . . . . 23

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

3 Eating Problems in Children

and Adolescents . . . . . . . . . . . . . . . . . . . . . . 45
Neville H. Golden, M.D.
Rollyn M. Ornstein, M.D.

4 Eating Problems in Individuals With

Overweight and Obesity . . . . . . . . . . . . . . . . 65
Marsha D. Marcus, Ph.D.
Jennifer E. Wildes, Ph.D.

5 Assessment of Eating Disorders and

Problematic Eating Behavior in
Bariatric Surgery Patients . . . . . . . . . . . . . . . 83
Eva M. Conceição, Ph.D.
James E. Mitchell, M.D.

6 Eating-Related Pathology in
Men and Boys . . . . . . . . . . . . . . . . . . . . . . . 105
Thomas Hildebrandt, Psy.D.
Katherine Craigen, Ph.D.
 7 Eating Problems in Special Populations
CULTURAL CONSIDERATIONS . . . . . . . . . . . . . . 119
Anne E. Becker, M.D., Ph.D., S.M.

PART I I I
Assessment Tools

8 Assessment Measures, Then and Now

A LOOK BACK AT SEMINAL MEASURES AND A
LOOK FORWARD TO THE BRAVE NEW WORLD . . . 137
Jennifer J. Thomas, Ph.D.
Christina A. Roberto, Ph.D.
Kelly C. Berg, Ph.D., LP

9 Self-Report Assessments of
Eating Pathology . . . . . . . . . . . . . . . . . . . . 157
Kelsie T. Forbush, Ph.D., LP
Kelly C. Berg, Ph.D., LP

10 Use of the Eating Disorder

Assessment for DSM-5 . . . . . . . . . . . . . . . 175
Deborah R. Glasofer, Ph.D.
Robyn Sysko, Ph.D.
B. Timothy Walsh, M.D.
11 Diagnosis of Feeding and Eating
Disorders in Children and Adolescents . . . 207
Natasha A. Schvey, Ph.D.
Kamryn T. Eddy, Ph.D.
Marian Tanofsky-Kraff, Ph.D.

12 Application of Modern Technology

in Eating Disorder Assessment
and Intervention. . . . . . . . . . . . . . . . . . . . . . 231
Jo M. Ellison, Ph.D.
Stephen A. Wonderlich, Ph.D.
Scott G. Engel, Ph.D.

PART IV
Treatment

13 Treatment of Restrictive Eating and

Low-Weight Conditions, Including
Anorexia Nervosa and Avoidant/
Restrictive Food Intake Disorder . . . . . . . . 259
Joanna Steinglass, M.D.
Laurel Mayer, M.D.
Evelyn Attia, M.D.

14 Treatment of Binge Eating,

Including Bulimia Nervosa
and Binge-Eating Disorder . . . . . . . . . . . . . 279
Loren Gianini, Ph.D.
Allegra Broft, M.D.
Michael Devlin, M.D.
15 Treatment of Other Eating Problems,
Including Pica and Rumination . . . . . . . . . 297
Eve Khlyavich Freidl, M.D.
Evelyn Attia, M.D.

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311
This page intentionally left blank
 Contributors
Evelyn Attia, M.D.
Professor of Psychiatry, Columbia University Medical Center; Professor of
Psychiatry, Weill Cornell Medical College; Director, Eating Disorders Re-
search Unit, New York State Psychiatric Institute, New York, New York

Anne E. Becker, M.D., Ph.D., S.M.

Maude and Lillian Presley Professor of Global Health and Social Medi-
cine, Department of Global Health and Social Medicine, Harvard Medical
School, Boston, Massachusetts

Kelly C. Berg, Ph.D., LP

Assistant Professor, Department of Psychiatry, University of Minnesota,
Minneapolis, Minnesota

Allegra Broft, M.D.

Assistant Professor of Psychiatry, Columbia University Medical Center,
New York State Psychiatric Institute, New York, New York

Amanda Joelle Brown, Ph.D.

Clinical Psychologist, Eating Disorders Research Unit, New York State
Psychiatric Institute, New York, New York

Eva M. Conceição, Ph.D.

Research Fellow, School of Psychology, University of Minho, Braga,
Portugal

Katherine Craigen, Ph.D.

Clinical Instructor, Eating and Weight Disorders Program, Icahn School of
Medicine at Mount Sinai, New York, New York

Michael Devlin, M.D.

Professor of Clinical Psychiatry, Columbia University Medical Center,
New York State Psychiatric Institute, New York, New York

xi
xii Handbook of Assessment and Treatment of Eating Disorders

Kamryn T. Eddy, Ph.D.

Co-director, Eating Disorders Clinical and Research Program, Massachu-
setts General Hospital; Assistant Professor of Psychology, Department of
Psychiatry, Harvard Medical School, Boston, Massachusetts

Jo M. Ellison, Ph.D.
Psychologist, Neuropsychiatric Research Institute, Fargo, North Dakota

Scott G. Engel, Ph.D.

Research Scientist, Neuropsychiatric Research Institute; Associate Profes-
sor, Department of Psychiatry and Behavioral Science, University of North
Dakota School of Medicine and Health Sciences, Fargo, North Dakota

Kelsie T. Forbush, Ph.D., LP

M. Erik Wright Assistant Professor, Department of Psychology, University
of Kansas, Lawrence, Kansas

Eve Khlyavich Freidl, M.D.

Assistant Professor of Psychiatry, Columbia University Medical Center,
New York, New York

Loren Gianini, Ph.D.

Postdoctoral Research Fellow, Columbia University Medical Center, New
York State Psychiatric Institute, New York, New York

Deborah R. Glasofer, Ph.D.

Assistant Professor of Clinical Psychology in Psychiatry, Columbia
University College of Physicians and Surgeons, New York State
Psychiatric Institute, New York, New York

Neville H. Golden, M.D.

Professor of Pediatrics, and Chief, Division of Adolescent Medicine,
Lucile Packard Children’s Hospital, Stanford University School of
Medicine, Stanford, California

Thomas Hildebrandt, Psy.D.

Program Director, Eating and Weight Disorders Program, Icahn School of
Medicine at Mount Sinai, New York, New York

Marsha D. Marcus, Ph.D.

Professor of Psychiatry and Psychology, University of Pittsburgh School of
Medicine, Pittsburgh, Pennsylvania
Contributors xiii

Laurel Mayer, M.D.

Associate Professor of Psychiatry, Columbia University Medical Center,
New York State Psychiatric Institute, New York, New York

James E. Mitchell, M.D.

President and Scientific Director, Neuropsychiatric Research Institute;
Chair, Department of Psychiatry and Behavioral Science, University of
North Dakota, School of Medicine and Health Sciences, Fargo,
North Dakota

Rollyn M. Ornstein, M.D.

Associate Professor of Pediatrics, and Interim Division Chief, Division of
Adolescent Medicine and Eating Disorders, Penn State Hershey Chil-
dren’s Hospital, Hershey, Pennsylvania

Kathleen M. Pike, Ph.D.

Professor of Psychology in Psychiatry and Epidemiology, and Director,
Global Mental Health Program, Columbia University, New York,
New York

Christina A. Roberto, Ph.D.

Assistant Professor of Social and Behavioral Sciences and Nutrition,
Harvard School of Public Health, Boston, Massachusetts

Janet Schebendach, Ph.D.

Assistant Professor of Neurobiology in Psychiatry, Columbia University
Medical Center; Director of Research Nutrition, Eating Disorders Re-
search Unit, New York State Psychiatric Institute, New York, New York

Natasha A. Schvey, Ph.D.

Postdoctoral Fellow, Department of Medical and Clinical Psychology,
Uniformed Services University of the Health Sciences, Department of
Defense, Bethesda, Maryland

Joanna Steinglass, M.D.

Associate Professor of Clinical Psychiatry, Columbia University Medical
Center, New York State Psychiatric Institute, New York, New York

Robyn Sysko, Ph.D.

Assistant Professor of Psychiatry, Eating and Weight Disorders Program,
Department of Psychiatry, Icahn School of Medicine at Mount Sinai,
New York, New York
xiv Handbook of Assessment and Treatment of Eating Disorders

Marian Tanofsky-Kraff, Ph.D.

Associate Professor, Department of Medical and Clinical Psychology,
Uniformed Services University of the Health Sciences, Department of
Defense, Bethesda, Maryland

Jennifer J. Thomas, Ph.D.

Co-director, Eating Disorders Clinical and Research Program, Massachu-
setts General Hospital; Assistant Professor of Psychiatry, Harvard Medical
School, Boston, Massachusetts

B. Timothy Walsh, M.D.

Ruane Professor of Pediatric Psychopharmacology in Psychiatry, Colum-
bia University College of Physicians and Surgeons; Director, Division
of Clinical Therapeutics, New York State Psychiatric Institute,
New York, New York

Jennifer E. Wildes, Ph.D.

Assistant Professor of Psychiatry and Psychology, University of Pittsburgh
School of Medicine, Pittsburgh, Pennsylvania

Stephen A. Wonderlich, Ph.D.

Chester Fritz Distinguished Professor, Associate Chairman, Department
of Psychiatry and Behavioral Science, University of North Dakota School
of Medicine and Health Sciences; Director, Clinical Research, Neuropsy-
chiatric Research Institute; Chair, Eating Disorders, Sanford Health,
Fargo, North Dakota

Disclosure of Competing Interests

The following contributors to this book have indicated a financial interest in or
other affiliation with a commercial supporter, a manufacturer of a commercial
product, a provider of a commercial service, a nongovernmental organization, and/
or a government agency, as listed below:

Evelyn Attia, M.D.—Research support: Eli Lilly and Company

Anne E. Becker, M.D., Ph.D., S.M.—Honoraria: John Wiley & Sons, Inc.
for service as Associate Editor of the International Journal of Eating Disorders;
Book royalties: University of Pennsylvania Press
Contributors xv

Kelsie T. Forbush, Ph.D., LP—Author and copyright holder: Eating Pathol-

ogy Symptoms Inventory (EPSI) and Iowa Eating Behaviors Question-
naire (IEBQ), which are free, publicly available self-report measures of
eating disorder symptoms

Eve Khlyavich Freidl, M.D.—Travel funds: AACAP Annual Meeting

(2014) as recipient of AACAP Pilot Research Award for junior faculty and
child and adolescent psychiatry residents, supported by Lilly USA, LLC

Thomas Hildebrandt, Psy.D.—Scientific advisor: Noom, Inc.

Joanna Steinglass, M.D.—Current support: National Institute of Mental

Health, Global Foundation for Eating Disorders, and New York state

Robyn Sysko, Ph.D.—Common stock: Pfizer Pharmaceuticals; Book royal-

ties: Chapter on binge-eating disorder, UpToDate

B. Timothy Walsh, M.D.—Research support: AstroZeneca; Royalties:

McGraw-Hill and UpToDate

Jennifer E. Wildes, Ph.D.—Paid consultant: McKesson Health Solutions, LLC

The following contributors to this book have indicated no competing interests to dis-
close during the year preceding manuscript submission:

Kelly C. Berg, Ph.D., LP Neville H. Golden, M.D.

Allegra Broft, M.D. Marsha D. Marcus, Ph.D.
Amanda Joelle Brown, Ph.D. Laurel Mayer, M.D.
Eva M. Conceição, Ph.D. James E. Mitchell, M.D.
Katherine Craigen, Ph.D. Rollyn M. Ornstein, M.D.
Michael Devlin, M.D. Christina A. Roberto, Ph.D.
Kamryn T. Eddy, Ph.D. Janet Schebendach, Ph.D.
Jo M. Ellison, Ph.D. Natasha A. Schvey, Ph.D.
Scott G. Engel, Ph.D. Marian Tanofsky-Kraff, Ph.D.
Loren Gianini, Ph.D. Jennifer J. Thomas, Ph.D.
Deborah R. Glasofer, Ph.D. Stephen A. Wonderlich, Ph.D.
This page intentionally left blank
 Foreword

In the words of Dr. Martin Luther King Jr., education has

a twofold function. Education must first, “enable one to sift and weigh ev-
idence, to discern the true from the false, the real from the unreal, and the
facts from the fiction” (King 1947, p. 10). But education cannot stop here;
it must further guide one’s studies to ensure that “worthy objectives” are
the targets of concentrated efforts (King 1947, p. 10).
The Handbook of Assessment and Treatment of Eating Disorders is masterful
in achieving this twofold mission. It is a scholarly volume that provides
thoughtful review and critical analysis of the state of the field. Each chapter
grapples with complex and imperfect data; each chapter also provides
practical and thoughtful integration of material to guide clinical practice
and inform future research. It is easy to get bogged down by the lacunae
in the empirical database, leading some mental health professionals to dis-
tance themselves from research and discount what is known. It is also easy
to go into overdrive research mode to fill these gaps and lose sight of the
priority clinical issues that should guide our work to maximize impact.
This handbook has achieved the fine balance between research and clini-
cal practice, between quantitative and qualitative ways of knowing, and
between articulating clearly what we don’t yet know and, nonetheless,
working with what we do know to produce a useful text to guide clinical
care and future research.
The impetus for the handbook was the publication of DSM-5 (Ameri-
can Psychiatric Association 2013), and this is most appropriate given that
any study of eating disorders should begin with a careful consideration of
our diagnostic system—what we call an eating disorder and the related phe-
nomenology. Developed under the auspices of the American Psychiatric
Association, the Diagnostic and Statistical Manual (DSM) system is an
American classification system; however, it has been adapted to varying
degrees in countries around the world, particularly with regard to research
programs. As described in several chapters in the book, the success of
DSM is variable in terms of its ability to accurately capture the clinical

xvii
xviii Handbook of Assessment and Treatment of Eating Disorders

syndromes of eating pathology that cause suffering and propel individuals

to seek treatment. DSM is further challenged in its ability to capture the
most important aspects of eating disorders for diverse segments of the pop-
ulation (e.g., men) and across cultures. Around the globe, these are critical
issues that will become more and more prominent in the near future as eat-
ing disorders become increasingly recognized in diverse cultural and eco-
nomic contexts.
The Global Burden of Disease Study demonstrates that the health
burden of eating disorders is steadily increasing (Vos et al. 2012), primar-
ily because eating disturbances outside high-income, Western countries
are rapidly growing in concert with rising rates of population weight.
This is true in terms of both disability-adjusted life years and years lived
with disability. In 81% of countries around the world, population weight
has increased significantly over the past 30 years, with 36.9% of men and
38% of women falling in the overweight or obese categories today
(Vandevijvere et al. 2015). In the United States, 39.96% of men and
29.74% of women are overweight, and an additional 35.04% of men and
36.84% of women are obese (Yang and Colditz 2015). Such demographic
trends in eating and weight pathology call for global innovative interven-
tions, including translation of assessment instruments, adaptation of treat-
ment interventions, leveraging new technologies for assessment and
treatment, and development of more aggressive treatments such as bar-
iatric surgery.
Although the health consequences of eating disorders are well under-
stood, the significance of the disability burden has largely been ignored
within the global health field. Even more broadly, despite the fact that
mental illness is the leading cause of disability around the world, mental
health remains largely overlooked, if not invisible, within the health
agendas and budgets of many nations around the globe. This failure
might be considered unfortunate but understandable given the myriad
health and other priorities that burden governments everywhere, until we
consider the following: We have treatments for eating disorders that can
reduce suffering for the majority of individuals; we have evidence of the
successful implementation of psychotherapies for depression in low- and
middle-income countries, suggesting that we can do the same for eating
disorders; and we know that focusing on women’s health has a multipli-
cative effect for families and communities. In the same way that focusing
on women’s education and empowerment has a positive impact on the
educational achievement of the next generation, focusing on women’s
mental health must become a priority that is appreciated for the benefits
accrued to the individual as well as the positive pay-it-forward benefits for
the next generation.
Foreword xix

The wisdom contained in the Handbook of Assessment and Treatment of

Eating Disorders has the potential to guide both research agenda setting and
clinical care for the field of eating disorders. Each chapter sifts and weighs
evidence, discerns the true from the false, the real from the unreal, and the
facts from the fiction. Each chapter provides incisive guidance on the wor-
thy objectives for the field of eating disorders. Collectively, these chapters
represent a volume of knowledge that promises to enhance every reader’s
education about eating disorders and better prepare us to carry forward
the work of advancing understanding and care for individuals suffering
from eating disorders around the world.

Kathleen M. Pike, Ph.D.

Professor of Psychology in Psychiatry and Epidemiology
Director, Global Mental Health Program
Columbia University, New York, New York

References
American Psychiatric Association: Diagnostic and Statistical Manual of Mental
Disorders, 5th Edition. Arlington, VA, American Psychiatric Association,
2013
King ML Jr: The purpose of education. The Maroon Tiger, February 1947, p 10
Vandevijvere S, Chow CC, Hall KD, et al: Increased food energy supply as a ma-
jor driver of the obesity epidemic: a global analysis. Bull World Health Organ
93:446–456, 2015
Vos T, Flaxman AD, Naghavi M, et al: Years lived with disability (YLDs) for 1160
sequelae of 289 diseases and injuries 1990-2010: a systematic analysis for the
Global Burden of Disease Study 2010. Lancet 380(9859):2163–2196, 2012
23245607
Yang L, Colditz GA: Prevalence of overweight and obesity in the United States,
2007-2012. JAMA Intern Med June 22, 2015 26098405 [Epub ahead of print]
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 Preface

The major impetus for this book was the publication in

the spring of 2013 of DSM-5 (American Psychiatric Association 2013).
DSM-5 introduced both major and minor changes to the conceptualization
of, and to the diagnostic criteria for, feeding and eating disorders. We felt it
would be timely to review these changes and to embed them in a broader,
up-to-date description of the assessment and treatment of individuals with
eating disorders. In addition, in this new diagnostic era, there have been
important developments in the technologies available to aid diagnosis, re-
search, and treatment. Thus, this volume aims throughout the text to en-
gage the reader (and the field in general) in thoughtful consideration of
when, how, and why technology might be used to improve assessment and
treatment.
The opening chapter in Part I (“Introduction”) describes the evolution
of the DSM-5 section on feeding and eating disorders. The rationale for
making diagnoses is reviewed, including both advantages and disadvan-
tages of the DSM approach. The specific alterations in the diagnostic cri-
teria for each disorder are described, and guidance is provided for
clinicians regarding how to apply criteria in practice. Two major changes
in DSM-5 are highlighted, the official recognition of binge-eating disorder
and the formulation of the newly named avoidant/restrictive food intake
disorder.
Following Chapter 1, content is organized in three parts. Part II, “Eval-
uation and Diagnosis of Eating Problems,” comprising six chapters, pro-
vides guidance for clinicians on the evaluation of individuals who have
symptoms suggesting a possible eating disorder. The approaches to adults
and to children and adolescents are described in Chapters 2 and 3; these
chapters highlight the fundamental principles and practices necessary for
careful assessments of individuals with eating disorders. Chapters 4–6 are
guides to the assessment of individuals with more specialized problems,
including overweight individuals, those considering bariatric surgery, and

xxi
xxii Handbook of Assessment and Treatment of Eating Disorders

men and boys. Part II concludes with a description of the impact of culture
on the manifestation and assessment of eating problems (Chapter 7).
Part III, “Assessment Tools,” describes tools available to clinicians to
assist in the assessment of eating disorders. The initial chapter of this sec-
tion, Chapter 8, provides a critical review of the first assessment methods
developed to assess eating disorders and the recent evolution of new in-
struments. Chapter 9 describes self-report measures; given the time pres-
sures on modern clinical practice, such measures serve to enhance both
the accuracy and the efficiency of patient care. Chapter 10 outlines how to
use the Eating Disorder Assessment for DSM-5 (EDA-5), a semistructured
interview developed by the group from the Columbia Center for Eating
Disorders to rigorously but quickly determine whether DSM-5 criteria for
a feeding or eating disorder are satisfied; this interview is available at
www.eda5.org. Chapter 11 details methods to aid the assessment of chil-
dren and adolescents, and Chapter 12 reviews the cutting edge of eating
disorder assessments, namely, the use of handheld devices such as smart-
phones.
Part IV of the volume, “Treatment,” consisting of three chapters, pro-
vides an overview of treatment. Chapter 13 focuses on restrictive eating
disorders, such as anorexia nervosa and avoidant/restrictive feeding in-
take disorder. Chapter 14 reviews the treatment of binge eating, as seen in
bulimia nervosa and binge-eating disorder. Chapter 15 addresses less com-
monly seen problems such as pica and rumination.
In association with the text, the authors have produced several short
videos to highlight methods of patient assessment and diagnosis. The
reader will find references to these videos in relevant chapters of the book.
The videos may be accessed at www.appi.org/Walsh.
A critical part of our field’s progress is an appreciation for all types of
clinical expertise at all levels of experience. We ourselves represent differ-
ent eras, and while each of us arrived at this project with a unique perspec-
tive on the past and present state of the assessment and treatment of eating
disorders, our shared investment is certainly in its future. We greatly ap-
preciate the equally diverse group of esteemed colleagues who have col-
laborated with us on this project. Among our authors are adult and child
psychiatrists, psychologists, pediatricians, nutritionists, and postdoctoral
fellows. Some of us have been devoted to this field for decades, while oth-
ers have joined more recently with the hope of carrying the work forward
for decades to come.
And we would be remiss not to mention Christine Call, A.B., our re-
search assistant, without whom this project would not have gotten off the
ground and certainly would never have landed safely!
Preface xxiii

Finally, we would especially like to thank our patients, from whom we

continue to learn, for their courage in sharing their symptoms and strug-
gles and for the privilege of allowing us to collaborate on their path to re-
covery.
We hope that whether you come to this text as a student or a seasoned
professional, as a general practitioner or an eating disorders specialist, as
a researcher or a clinician, our book will help to answer some of your ques-
tions and inspire new ones.

B. Timothy Walsh, M.D.

Evelyn Attia, M.D.
Deborah R. Glasofer, Ph.D.
Robyn Sysko, Ph.D.

Reference
American Psychiatric Association: Diagnostic and Statistical Manual of Mental
Disorders, 5th Edition. Arlington, VA, American Psychiatric Association,
2013
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 Video Guide
The Video Learning Experience
The companion videos can be viewed at www.appi.org/Walsh.

Using the Book and the Videos Together

We recommend that readers use the boldface video prompts embed-
ded in the text as indicators for viewing the associated clips. The cues iden-
tify the vignettes by number and title. Chapters 1, 2, 3, 4, 6, 7, 8, and 14
have associated videos.

Description of the Videos

The first video presents a brief roundtable discussion among clinicians.
Each of the remaining four videos presents a brief interaction between a
patient and a clinician; these videos aim to highlight general issues that can
arise in the assessment of feeding and eating disorders and to illustrate
some specific strategies for clinical intervention.

Video 1: Diagnostic issues in the age of DSM-5 (8:11)

For use with Chapters 1 and 8
This video, featuring clinical researchers involved in the development of
DSM-IV and DSM-5, provides a window into the process of diagnostic
changes described in DSM-5. Panelists discuss the rationale for the reor-
ganization of DSM-5, including the developmental perspective now in-
cluded in each diagnostic section. The discussion also highlights the new
additions to the list of formally recognized conditions, including binge-
eating disorder and avoidant/restrictive food intake disorder.

The clinical cases are fictional. Any resemblance to real persons is purely coinci-
dental. The videos feature the work of volunteer clinicians and actor patients.

xxv
xxvi Handbook of Assessment and Treatment of Eating Disorders

Video 2: Assessing eating problems

in the primary care setting (3:24)
For use with Chapters 2, 3, and 14
This video depicts a clinical encounter between a primary care physician
and a young woman who is reluctant to disclose the eating disorder behav-
iors that underlie her physical complaints. The discussion highlights ways
to sensitively obtain critical clinical information in a primary care setting
and how to engage a patient in next treatment steps.

Video 3: Assessing eating problems

in overweight adults (5:52)
For use with Chapter 4
In this brief interaction, an eating disorder specialist (psychiatrist) meets
with an overweight female patient to evaluate her eating behavior and as-
sociated psychological symptoms. The vignette demonstrates ways that a
clinician can explain and assess a range of disturbances in eating behavior.
It also models the importance of a nonjudgmental stance in the assessment
of overweight individuals.

Video 4: Assessing eating problems in men (5:32)

For use with Chapter 6
In this vignette, an eating disorder specialist evaluates a male patient who
presents with eating problems and preoccupation with body shape and
weight, consistent with an eating disorder diagnosis. The video illustrates
similarities and differences in the assessment of a male patient from that of
a female patient. Examples of ways to ask questions about exercise habits,
eating patterns, and compensatory behaviors, as well as the functional im-
pairment of symptoms, are provided.

Video 5: Cultural considerations in the assessment

of eating problems (6:10)
For use with Chapter 7
The video depicts a clinical encounter, exemplifying the assessment of an
Asian woman with an eating disorder by a white clinician. The patient
presents with somatic complaints and initially denies several commonly
described eating disorder symptoms. In the interview, the clinician dem-
onstrates how to probe for additional information sufficient to make a pre-
liminary diagnosis and provides examples of some of what might be asked
in the course of a comprehensive assessment.
Video Guide xxvii

Video Credits
We thank our wonderful video producer Joe Faria and the entire Digital
Communications Department of the New York State Psychiatric In-
stitute for their assistance in shooting, producing, and editing the videos
accompanying the book. We also gratefully acknowledge the talented vol-
unteer clinicians and actors without whom we could not have scripted or
created this video content.

Evelyn Attia, M.D. (scriptwriter; videos 1 and 4), is Professor of Psychi-

atry at Columbia University Medical Center and Weill Cornell Medical
College, and Director of the Eating Disorders Research Unit at New York
State Psychiatric Institute.

Christine Call, A.B. (scriptwriter), is a doctoral candidate in clinical psy-

chology in the Department of Psychology at Drexel University.

Wonda Clyatt (Video 5) is an actor.

Michael J. Devlin, M.D. (scriptwriter; videos 1 and 3), is Professor of

Clinical Psychiatry at Columbia University College of Physicians and
Surgeons and Associate Director of the Eating Disorders Research Unit
at New York State Psychiatric Institute.

Michael First, M.D. (Video 1), is Professor of Clinical Psychiatry at Co-

lumbia University, and Research Psychiatrist at the Biometrics Depart-
ment at the New York State Psychiatric Institute.

Deborah R. Glasofer, Ph.D. (scriptwriter; Video 5), is Assistant Profes-

sor of Clinical Psychology in Psychiatry at Columbia University College
of Physicians and Surgeons, and a psychologist at the Eating Disorders
Research Unit at New York State Psychiatric Institute.

Gabriella Guzman, A.B. (Video 2), is a research assistant at the Eating

Disorders Research Unit at New York State Psychiatric Institute.

Matthew Shear, M.D., M.P.H. (Video 4), is Instructor in Psychiatry at

Weill Cornell Medical College.

Karen Soren, M.D. (Video 2), is Associate Professor of Pediatrics and

Public Health at Columbia University Medical Center and Director of
Adolescent Medicine at New York Presbyterian Morgan Stanley Chil-
dren's Hospital.
xxviii Handbook of Assessment and Treatment of Eating Disorders

B. Timothy Walsh, M.D. (Video 1), is Ruane Professor of Pediatric Psy-

chopharmacology in Psychiatry at Columbia University College of Phy-
sicians and Surgeons, and Director of the Division of Clinical
Therapeutics at New York State Psychiatric Institute

Teresa Yenque (Video 3) is an actor.

We also thank Professional Actors Training & Helping, LLC, for their
assistance.
PA RT I
Introduction
This page intentionally left blank
1 Classification
of Eating Disorders
B. Timothy Walsh, M.D.
Evelyn Attia, M.D.
Robyn Sysko, Ph.D.

DSM-5 was published in the spring of 2013 (American

Psychiatric Association 2013). Seven years in the making and almost 20 years
since the publication of DSM-IV (American Psychiatric Association 1994),
DSM-5 formalized significant changes in the official classification of eating
disorders. The two biggest changes were the recognition of binge-eating
disorder (BED) and the reconceptualization of feeding disorder of infancy
or early childhood as avoidant/restrictive food intake disorder (ARFID).
A number of important, but less far-reaching, changes were made to the
diagnostic criteria for the other eating disorders. The purpose of this chap-
ter is not only to review these changes, and the background and rationale
justifying them, but also to provide a broad overview regarding the value
of diagnostic categories. Video 1, “Diagnostic issues in the age of DSM-5,”
explores these changes in a roundtable discussion.

Introduction to the DSM Approach

Why Make a Diagnosis?
The thinking of Greek philosophers almost two millennia ago suggested
to them that it was wise to define boundaries among phenomena where

3
4 Handbook of Assessment and Treatment of Eating Disorders

they naturally occurred, leading to the notion that science should “cleave
nature at its joints.” The work of the eighteenth-century Swedish botanist
Carl Linnaeus, whose writings are cited as the basis for the distinctions
“animal, vegetable, and mineral,” is thought to be an excellent example of
the utility of such an approach.
The application of this approach to the understanding of human diseases
is of enormous potential value. If successful, it permits the identification of
the cause or causes of a disease, eventually yielding major advances in im-
proved knowledge of the pathological mechanisms underlying an illness
and in the development of specific treatments targeting the underlying cause
or causes. For example, the ability to go beyond the description of a patient’s
problem as “fever and a bad cough” to either “pneumonia secondary to in-
fection with the pneumococcus bacterium” or “pneumonia secondary to in-
fection with the influenza virus” is extremely useful for choosing the most
effective treatment—an antibiotic for the former or an antiviral agent such as
oseltamivir (Tamiflu) for the latter. Unfortunately, it has proven challenging
to extend this model to the diagnosis of mental illness.

Diagnosis of Mental Illness

In 1960, Thomas Szasz, in The Myth of Mental Illness (Szasz 1960), argued
that traditional psychiatric practice mislabeled individuals who were “dis-
abled by living” as having a mental illness. Although this view has largely
been relegated to the history books, there remain major challenges in
knowing exactly where to draw the line between widely variable normal
human behavior and the patterns of thinking and behaving that are gen-
erally conceived as illnesses.
The publication of DSM-III (American Psychiatric Association 1980)
heralded a major shift in mainstream psychiatry from attempting to classify
psychiatric illnesses based on theories of their etiology to a primarily de-
scriptive approach. DSM-III grappled with the challenge inherent in
Szasz’s work: “How should a mental disorder be defined?” The authors of
DSM-III and its successors, including DSM-5, recognized that there is no
clear, strict, and universally accepted definition of a mental disorder. This
is equally true of nonpsychiatric medical disorders; that is, perhaps surpris-
ingly, there is no clear and universally accepted definition of what consti-
tutes a disease (Allison et al. 2008). DSM-5 did not significantly alter the
fundamental conceptualization of a mental disorder presented in DSM-III,
and after considerable debate, the authors of DSM-5 settled on the follow-
ing definition:

A mental disorder is a syndrome characterized by clinically significant dis-

turbance in an individual’s cognition, emotion regulation, or behavior that
Classification of Eating Disorders 5

reflects a dysfunction in the psychological, biological, or developmental

processes underlying mental functioning. (American Psychiatric Associa-
tion 2013, p. 20)

DSM-5 also states that an expectable response “to a common stressor

or loss...is not a mental disorder” (p. 20), thereby addressing the concerns
of Szasz that socially deviant behavior and conflicts between the individ-
ual and society, of themselves, are not mental disorders. Finally, DSM-5
notes that mental disorders are usually associated with impairment of
function or distress.
The goal of DSM-III was to provide clear and reliable diagnostic criteria
for mental illnesses that would allow both clinicians and researchers to com-
municate accurately. DSM-III and its successors have largely met that goal.
Although the reliability of diagnosis among different clinicians is certainly not
perfect, agreement comparable to that of many nonpsychiatric medical diag-
noses was achieved. A more ambitious goal of the DSM system beginning
with DSM-III was to provide clear and reliable diagnostic criteria that would
facilitate the identification of homogeneous groups of patients with identical
problems. The hope was that studies of such groups would provide a founda-
tion for the identification of causal factors underlying the illnesses. If almost all
individuals with a particular form of depression had very similar symptoms,
such as the degree to which they had lost the ability to enjoy life, developed
insomnia, and lost their appetite, it would be possible for psychiatrists to dis-
tinguish the causes of that specific form of depression from other types of
mood disturbance, much as physicians can distinguish between viral and bac-
terial pneumonia (as mentioned in the preceding subsection).

Problems With the DSM Approach

Unfortunately, except in rare instances, this goal has not been achieved.
For example, there are few sharp dividing lines among the varied presen-
tations of mood disturbance, and it increasingly appears that the genetic
risks for developing many major psychiatric illnesses are not specific to a
single disorder—even one that is very narrowly defined. Rather, multiple
genes often exert small but cumulatively important effects for a range of
disorders (e.g., Ruderfer et al. 2014). More generally, although many risk
factors—environmental, genetic, and developmental—have been de-
scribed, very few causes of specific mental disorders have been identified.
In this regard, mental health continues to lag well behind areas such as car-
diology and infectious disease, in which major strides have been made
over the last several decades in identifying causative pathways for many
disorders, thereby permitting the development of objective methods of di-
agnostic testing and of targeted treatment interventions.
6 Handbook of Assessment and Treatment of Eating Disorders

The strategy employed in DSM-III and its successors also has had sev-
eral unfortunate consequences. The articulation of many clearly but nar-
rowly defined disorders and the understandable decision not to restrict the
number of disorders that could be assigned to an individual have pro-
duced a high frequency of comorbidity. Individuals meeting criteria for
one disorder often meet criteria for another. For example, many individu-
als meeting DSM criteria for an eating disorder also meet criteria for a de-
pressive disorder, and current knowledge does not allow one disorder to
be considered a result of or secondary to the other. In other words, it is
generally difficult to know with certainty that an individual’s bulimia ner-
vosa is best attributed to her major depressive disorder or vice versa, or
whether the two are independent.
A similar problem has been the high frequency of residual diagnoses,
referred to in DSM-IV as “not otherwise specified” (NOS). Because diag-
nostic categories are narrowly defined in the DSM system, many individ-
uals with a significant problem do not meet criteria for a specific DSM
disorder. In the DSM-IV system, the eating disorders section provided a
prime example of this problem. DSM-IV specifically defined only two
eating disorders, anorexia nervosa (AN) and bulimia nervosa (BN). All
other eating disorders of clinical significance received a formal diagnosis
of eating disorder not otherwise specified (EDNOS), which included in-
dividuals with symptoms that barely missed the diagnostic threshold for
AN or BN, along with individuals who met criteria for BED (a provisional
diagnosis in DSM-IV). Despite the goals of DSM, the EDNOS moniker
conveyed essentially no information beyond the fact that the individual
had described a clinically significant eating problem. In some eating dis-
order programs, an EDNOS diagnosis was assigned to more than half of
the patients presenting for treatment (Fairburn and Bohn 2005)!

Advantages of the DSM Approach

In light of these problems, why should the DSM approach be used at all?
The short answer is that the DSM system, notwithstanding its significant
limitations, is quite useful in communicating about the problem with the
patient, with individuals close to the patient, and with other health care
professionals. The DSM system is also useful in undertaking research to
describe the development and course of mental disorders and to investi-
gate treatment response. In short, the DSM categories have proven to
have substantial clinical utility, even though their definitions are not based
on fundamental knowledge of the causes of the disorders.
Classification of Eating Disorders 7

Path From DSM-IV to DSM-5

History
DSM-IV was published in 1994, 7 years after DSM-III-R (American Psy-
chiatric Association 1987), which itself was published 7 years after the
landmark promulgation of DSM-III in 1980. Planning for DSM-5 began
in the early years of the new millennium with a series of conferences and
edited volumes sponsored by the American Psychiatric Association (APA)
to consider new ideas and approaches to the diagnostic system. One
prominent example that had a significant impact on the DSM-5 develop-
ment process was an emphasis on the dimensional nature of virtually all
mental disorders (Helzer et al. 2008). This concept was most fully embraced
in the proposed revisions of the personality disorders section, which suggested
that individuals with such problems should first be characterized as having im-
pairments in several broad areas of personality functioning, such as in devel-
oping and maintaining intimate interpersonal relationships, and then
described in detail using a number of facets of personality function, such as
emotional lability. This creative and carefully considered proposal provoked
a storm of criticism from investigators and clinicians concerned about the
magnitude of the change from the DSM-IV system and, in the end, was
judged by the APA leadership to be too controversial to be officially recog-
nized in DSM-5. The proposed new diagnostic approach for personality dis-
orders is presented in DSM-5 in Section III, “Emerging Measures and
Models.” Regardless of the controversy, the dimensional perspective had a
pervasive influence on DSM-5, leading, for example, to the incorporation of
severity measures for many disorders, including the eating disorders.
Among the early and far-reaching decisions made by DSM-5 leadership
was the elimination of the section of DSM-IV titled “Disorders Usually First
Diagnosed in Infancy, Childhood, or Adolescence.” Several important obser-
vations led to this decision. Among them was the fact that many disorders not
included in this section of DSM-IV, such as anxiety disorders, mood disor-
ders, and psychotic disorders, are also often recognized during childhood and
adolescence. In the years since the publication of DSM-IV, it also became
clear that many individuals with disorders listed in that section are first diag-
nosed later in life, including adults with attention-deficit and disruptive behav-
ior disorders. Therefore, in DSM-5, the disorders previously included in the
DSM-IV section on disorders usually first diagnosed in infancy, childhood, or
adolescence were redistributed in DSM-5 to other sections, and a develop-
mental perspective was incorporated throughout the text, including in the de-
8 Handbook of Assessment and Treatment of Eating Disorders

scriptions of each disorder. Pica, rumination disorder, and feeding disorder of

infancy or early childhood joined the DSM-5 eating disorders section. Their
inclusion led to the change in the title of this section to “Feeding and Eating
Disorders,” underlining the links to the two original sections of DSM-IV.

Approach and Process Leading to DSM-5

Work began in earnest on the eating disorders section of DSM-5 in 2006–
2007 with the appointment of the 12 members of the Eating Disorders
Work Group. This group comprised prominent clinical investigators from
North America and Europe and included five psychiatrists, five psycholo-
gists, a nurse investigator, and a physician specializing in adolescent med-
icine. The work group continued work through the end of 2012 and
achieved consensus on all recommendations regarding changes to the di-
agnostic criteria for feeding and eating disorders.
The initial review of the diagnostic landscape by the work group indi-
cated that although the existing criteria for eating disorders had some prob-
lems, they were not completely “broken.” In other words, the community
of investigators and clinicians focused on eating disorders fundamentally
agreed about the core diagnostic conceptualization of AN and BN. Further-
more, there was a clear consensus that the clinical features of these two dis-
orders, while overlapping in some important regards, were sufficiently
different to warrant their remaining distinct disorders. For example, it was
clear that the course, complications, and treatment response of individuals
with AN differed substantially from those of individuals with BN, emphasiz-
ing the clinical utility of separating the two groups diagnostically.
As noted, the major problem with the DSM-IV system for eating dis-
orders was the unacceptably high frequency of the diagnosis of EDNOS
in clinical populations. It was quickly apparent that from a logical perspec-
tive, there were only two ways to address this problem: to expand criteria
for the existing disorders, allowing “near misses” to meet criteria for one
of them, and to recognize new disorders. In the end, the work group rec-
ommended both. Several critical limitations restricted the breadth of
changes considered. If the expansion of criteria was too radical, individu-
als now meeting the revised criteria for an existing diagnosis might not
share the same core clinical characteristics captured by the original crite-
ria. This could potentially be a major problem because it might invalidate
decades of accumulated research and experience on the course, outcome,
and treatment response of individuals with a disorder. A related and chal-
lenging issue throughout the process was a lack of good data to address the
impact of many changes that might be considered. One of the standards
employed by the work group was not to make significant changes without
Classification of Eating Disorders 9

being reasonably confident of their impact on clinical utility. Therefore,

despite the seeming appeal of a number of potential alterations to the di-
agnostic criteria, the work group endeavored to avoid recommendations
not supported by evidence regarding the impact of the changes.
The first years of the work group’s efforts were devoted to identifying
specific possible options for change and to conducting a careful examina-
tion not only of existing literature but also of unpublished information in
search of answers. Thirteen literature reviews, led by members of the work
group, were published in 2009–2010 in the International Journal of Eating
Disorders. These reviews were significantly augmented by several confer-
ences jointly supported by the National Institute of Mental Health and the
APA, culminating in an edited volume published in 2011 (Striegel-Moore
et al. 2011). The work group’s initial recommendations were presented in
late 2010 on a Web site devoted to the DSM-5 effort and were discussed
and debated at multiple international conferences over the next 3 years.
The work group was fortunate to receive extensive comments from inves-
tigators and clinicians and from individuals who had experienced or were
experiencing eating disorders, which led to important changes in the rec-
ommendations. A number of field trials, either sponsored by the APA or
carried out by interested investigators who generously shared their results
with the work group, provided concrete information on the utility and the
problems of the recommended changes.
The final recommendations of the Eating Disorders Work Group were
submitted to the DSM-5 Task Force by late 2012. After rigorous review by
several internal committees and some minor text editing for consistency,
the revised criteria were published in DSM-5 in the spring of 2013 largely
as recommended.
Video 1, “Diagnostic issues in the age of DSM-5,” features a round-
table discussion with B. Timothy Walsh, M.D., and colleagues involved in
changes to feeding and eating disorder diagnoses in DSM-5.

Video Illustration 1: Diagnostic issues in the age of DSM-5 (8:11)

In the remainder of this chapter, we briefly describe the evolution of

the feeding and eating disorders included in DSM-5.

Anorexia Nervosa
A Very Brief History
Although significant eating disturbances have presumably occurred since
the dawn of human history, AN was the first to be clearly recognized as a
10 Handbook of Assessment and Treatment of Eating Disorders

clinical disorder. Richard Morton, in his Treatise of Consumptions, published

in 1694, described an 18-year-old girl with what he termed “nervous con-
sumption” (Morton 1694). Because Morton did not have the benefit of
DSM, we cannot be certain that this young woman, who went on to die of
her disorder, met today’s formal criteria for AN. AN received its name al-
most 200 years later when, in 1873, Sir William Gull in England coined the
term for the problems of three young women whose symptoms would
clearly satisfy the DSM-III, DSM-IV, and DSM-5 definitions of this dis-
order (Gull 1997).
This brief history makes clear that the fundamental presentation and
conceptualization of AN have remained impressively stable over centu-
ries. The core features of the disorder are not in dispute. The challenge for
DSM has been how best to capture them in a useful but concise set of di-
agnostic criteria.

DSM-IV to DSM-5
DSM-IV (pp. 544–545) required that individuals meet four criteria to
merit a diagnosis of AN. The key features can be summarized as follows:

• Criterion A: “Refusal to maintain body weight at or above a minimally

normal weight for age and height (e.g., weight loss leading to mainte-
nance of body weight less than 85% of that expected...)”
• Criterion B: “Intense fear of gaining weight or becoming fat...”
• Criterion C: “Disturbance in the way in which one’s body weight or
shape is experienced, undue influence of body weight or shape on self-
evaluation, or denial of the seriousness of the current low body weight”
• Criterion D: Amenorrhea

The work group reviewed these criteria and recommended changes to

each. The DSM-5 criteria for AN are presented in Box 1–1, and the suc-
ceeding subsections describe the major changes from DSM-IV and the ra-
tionale supporting the revised criteria.

Box 1–1. DSM-5 Criteria for Anorexia Nervosa

A. Restriction of energy intake relative to requirements, leading to a signif-
icantly low body weight in the context of age, sex, developmental tra-
jectory, and physical health. Significantly low weight is defined as a
weight that is less than minimally normal or, for children and adoles-
cents, less than that minimally expected.
B. Intense fear of gaining weight or of becoming fat, or persistent behavior
that interferes with weight gain, even though at a significantly low
weight.
Classification of Eating Disorders 11

C. Disturbance in the way in which one’s body weight or shape is experi-

enced, undue influence of body weight or shape on self-evaluation, or
persistent lack of recognition of the seriousness of the current low body
weight.
Excerpted from the Diagnostic and Statistical Manual of Mental Disorders, 5th Edi-
tion, Arlington, VA, American Psychiatric Association, 2013. Used with permission.
Copyright © 2013 American Psychiatric Association.

Low Body Weight

The salient physical characteristic of individuals with AN is low body
weight. Although the DSM-IV Criterion A captured this feature, there
were several problems.
The term refusal suggested that the individual’s reluctance to consume
sufficient calories to maintain a normal weight was a conscious and active
decision and implied a degree of defiance. Although both of these charac-
teristics are sometimes present, more frequently the basis of the inade-
quate calorie intake is complex, the individual’s understanding of its
persistence is poor, and his or her attitude about the problem is quite vari-
able. Refusal also has a somewhat pejorative tone.
The example provided by DSM-IV in parentheses suggested that a
low weight might be defined as one that was less than 85% of that ex-
pected, which was ultimately a source of significant confusion and contro-
versy. Although intended only as an example, in many settings it became
reified into a rigid rule. In addition, it was unclear what standard should
be employed for the determination of the “expected” weight.
The DSM-5 Eating Disorders Work Group recommended that al-
though the concept of low body weight was fundamental to AN, the word-
ing of Criterion A should be substantially altered. The term refusal was
eliminated in favor of a straightforward description of the behavior: “re-
striction of energy intake relative to requirements.” The choice of energy in-
take as opposed to the more specific food intake reflected the work group’s
desire to make the definition broadly applicable, even to the very rare in-
stances in which the individual’s primary source of calorie intake was par-
enteral (e.g., via a gastric feeding tube or an intravenous line). The term
“relative to requirements” encompasses situations in which the individ-
ual’s caloric intake is statistically normal but inadequate based on unusual
requirements, such as intense exercise.
To avoid the confusion that accompanied the inclusion of the example
of “85% of expected” in DSM-IV, no numerical guidelines are provided
within DSM-5 Criterion A; however, the text of DSM-5 reviews the diag-
nostic features in two paragraphs with detailed descriptions of standards
that can be employed to assist the crucial judgment about whether an in-
12 Handbook of Assessment and Treatment of Eating Disorders

dividual’s weight is “significantly low.” In the end, this judgment is made

by the clinician on the basis of all the information available.

Fear of Gaining Weight

A small but significant fraction of individuals exhibiting other core charac-
teristics of AN deny that they are afraid of gaining weight (Wolk et al. 2005).
However, their overt behavior—classically, the steadfast avoidance of high-
calorie foods and reluctance to consume foods outside a very narrow range—
appears to belie their assertion. Therefore, in DSM-5, the phrase “persistent
behavior that interferes with weight gain” was added to the DSM-IV Crite-
rion B to include such presentations within full-threshold DSM-5 AN.

Distortion of Body Image

The work group’s only concern about Criterion C focused on a single
word, denial. This term might imply some underlying intrapsychic mech-
anism, which was not the intent. Therefore, the work group recommended
that this term be changed to “persistent lack of recognition,” which was
thought to offer a more explicit description of the phenomenon.

Amenorrhea
The greatest change to the DSM-IV criteria for AN was the elimination of
Criterion D, which had required amenorrhea. This decision was based on
two observations. First, the DSM-IV criterion included a number of ex-
ceptions to this criterion, such as being male or being a woman who was
taking oral contraceptives. Therefore, in practice, this criterion was often
waived. Second, a literature review on this topic documented that there
were a number of descriptions of women who met all the other criteria for
AN but reported some menstrual activity (Attia and Roberto 2009). There-
fore, to allow such individuals to receive the diagnosis of AN rather than
EDNOS, the work group deleted this criterion.
The DSM-5 text, however, emphasizes that amenorrhea is a common
physiological disturbance associated with AN, and its presence provides
additional support for the diagnosis.

Bulimia Nervosa
A Very Brief History
The syndrome of BN was first clearly described and named in 1979 in a
landmark paper by Professor Gerald Russell, a major figure in the eating
disorders field at that time (Russell 1979). His clear summary of the symp-
toms of 30 patients captured the essential features of this disorder. DSM-III,
Classification of Eating Disorders 13

published in 1980, included criteria for the syndrome, which was called
simply “bulimia.” In 1987, DSM-III-R refined those criteria and renamed
the disorder “bulimia nervosa” in accordance with Russell. Only minor
changes were made to the DSM-III-R criteria in DSM-IV and DSM-5
(presented in Box 1–2).

Box 1–2. DSM-5 Criteria for Bulimia Nervosa

A. Recurrent episodes of binge eating. An episode of binge eating is char-
acterized by both of the following:
1. Eating, in a discrete period of time (e.g., within any 2-hour period),
an amount of food that is definitely larger than what most individuals
would eat in a similar period of time under similar circumstances.
2. A sense of lack of control over eating during the episode (e.g., a
feeling that one cannot stop eating or control what or how much one
is eating).
B. Recurrent inappropriate compensatory behaviors in order to prevent
weight gain, such as self-induced vomiting; misuse of laxatives, diuret-
ics, or other medications; fasting; or excessive exercise.
C. The binge eating and inappropriate compensatory behaviors both oc-
cur, on average, at least once a week for 3 months.
D. Self-evaluation is unduly influenced by body shape and weight.
E. The disturbance does not occur exclusively during episodes of an-
orexia nervosa.
Excerpted from the Diagnostic and Statistical Manual of Mental Disorders, 5th Edi-
tion, Arlington, VA, American Psychiatric Association, 2013. Used with permission.
Copyright © 2013 American Psychiatric Association.

DSM-IV to DSM-5
The DSM-IV criteria, closely mirroring those of DSM-III-R, required that
individuals engage in both binge eating and inappropriate methods to
avoid weight gain, such as self-induced vomiting; that both behaviors oc-
cur, on average, at least twice a week over the prior 3 months; and that
shape or weight exert an undue influence on self-evaluation.
In the development of DSM-5, no data suggested the need for major
changes to the DSM-IV criteria for BN. Only two, relatively small, alter-
ations were suggested by the work group. A literature review (Wilson and
Sysko 2009) found limited evidence to support the twice-weekly binge-
eating and compensatory behavior frequency requirement; a small num-
ber of individuals presented for clinical care who met all the DSM-IV
criteria but reported binge eating and purging only once a week. There-
fore, in line with the effort to reduce the use of EDNOS, the work group
recommended that the frequency criterion (Criterion C) be changed to
14 Handbook of Assessment and Treatment of Eating Disorders

“at least once a week.” Another literature review found that the scheme
in DSM-IV to classify individuals with BN as having either the purging
or the nonpurging type was of limited utility and was frequently not em-
ployed (van Hoeken et al. 2009). Therefore, in DSM-5, the DSM-IV re-
quirement that individuals be assigned to either the purging or the
nonpurging type has been eliminated.

Binge-Eating Disorder
A Very Brief History
In 1959, the late Albert Stunkard, an eminent psychiatrist who was among
the first mental health professionals to think carefully about the problems
of individuals with obesity, published a paper on eating patterns among
obese individuals that provided the first clear description of binge eating.
These observations received surprisingly little attention until the develop-
ment of DSM-IV was under way. Spearheaded by Robert Spitzer, the
leader of the development of DSM-III, a major effort was made to de-
velop criteria to capture the essential features of binge eating without the
purging characteristic of BN. These efforts resulted in the first criteria for
BED. Although there was significant interest in this disorder’s being for-
mally recognized in DSM-IV, in the end it was felt that sufficient data
about its clinical characteristics, course, and outcome were unavailable,
and the criteria were therefore included in DSM-IV in an appendix pro-
viding criteria sets for further study.

DSM-IV to DSM-5
A critical question considered by the DSM-5 work group concerning BED
was whether to recommend that this disorder be formally recognized. To
address this question, Stephen Wonderlich led a comprehensive review of
the literature on BED that had emerged since DSM-IV (Wonderlich et al.
2009). This review documented the publication of over 1,000 articles in
the medical literature since the preliminary criteria for BED were promul-
gated. These articles amply documented the breadth of clinical interest in
this syndrome and provided detailed information on the characteristics of
individuals meeting the provisional criteria. In particular, the data indi-
cated that individuals with BED as defined by DSM-IV demonstrated an
objective disturbance in eating behavior during meals observed in labora-
tory settings and had an increased frequency of mood and anxiety distur-
bance compared to similarly overweight or obese individuals without
Classification of Eating Disorders 15

BED. In addition, there were tentative indications that, to achieve the best
clinical outcomes, individuals with BED should receive specific treatment
interventions. For these reasons, the work group recommended that BED
be formally recognized in DSM-5. After careful review by the DSM-5
Task Force, this recommendation was accepted (see Box 1–3 for criteria).
Not surprisingly, this change contributed to a significant reduction in the
frequency of use of EDNOS.

Box 1–3. DSM-5 Criteria for Binge-Eating Disorder

A. Recurrent episodes of binge eating. An episode of binge eating is char-
acterized by both of the following:
1. Eating, in a discrete period of time (e.g., within any 2-hour period),
an amount of food that is definitely larger than what most people
would eat in a similar period of time under similar circumstances.
2. A sense of lack of control over eating during the episode (e.g., a
feeling that one cannot stop eating or control what or how much one
is eating).
B. The binge-eating episodes are associated with three (or more) of the
following:
1. Eating much more rapidly than normal.
2. Eating until feeling uncomfortably full.
3. Eating large amounts of food when not feeling physically hungry.
4. Eating alone because of feeling embarrassed by how much one is
eating.
5. Feeling disgusted with oneself, depressed, or very guilty afterward.
C. Marked distress regarding binge eating is present.
D. The binge eating occurs, on average, at least once a week for 3 months.
E. The binge eating is not associated with the recurrent use of inappropri-
ate compensatory behavior as in bulimia nervosa and does not occur
exclusively during the course of bulimia nervosa or anorexia nervosa.
Excerpted from the Diagnostic and Statistical Manual of Mental Disorders, 5th Edi-
tion, Arlington, VA, American Psychiatric Association, 2013. Used with permission.
Copyright © 2013 American Psychiatric Association.

The work group also considered whether the draft criteria for the diag-
nosis of BED should be modified in any way. The available literature sup-
ported only a single small change. Specifically, to make the frequency
requirement for BED identical to that for BN, the DSM-IV criterion was
changed from a minimum of binge episodes occurring on at least 2 days
per week, on average, over the last 6 months to a minimum of at least one
episode of binge eating per week, on average, over the last 3 months (Wil-
son and Sysko 2009).
16 Handbook of Assessment and Treatment of Eating Disorders

Avoidant/Restrictive Food Intake Disorder

As described in the section “Path From DSM-IV to DSM-5,” an early and
important decision in the development of DSM-5 was to combine, in a sin-
gle section, the syndromes previously listed among the eating disorders
and the feeding and eating disorders of infancy or early childhood sections
of DSM-IV. The greatest challenge in doing so was presented by the
DSM-IV diagnosis of feeding disorder of infancy or early childhood.
This diagnosis made its first appearance in the DSM system in DSM-IV
and was intended to capture presentations of infants and young children
who, for some reason, perhaps related to difficult interactions with their
caregivers or other developmental issues, were not growing as they should.
Members of the DSM-5 Eating Disorders Work Group performed a litera-
ture review to examine this diagnosis in detail and uncovered a number of
problematic issues (Bryant-Waugh et al. 2010). Clinicians appeared to
rarely use this diagnosis in practice, and virtually no scholarly research had
focused on feeding disorder of infancy or early childhood. Furthermore, the
work group became aware that there were a number of clinically significant
eating problems particularly affecting young people that were not covered
by this or any other DSM-IV diagnosis. Therefore, after extensive consul-
tation with clinicians caring for young people with a range of eating prob-
lems, the work group recommended that the existing diagnosis of feeding
disorder of infancy or early childhood be expanded and retitled avoidant/
restrictive food intake disorder (ARFID). Studies initiated by a group of ad-
olescent medicine specialists interested in eating disorders were generously
made available to the work group during the final stages of DSM-5 devel-
opment. Data from these studies indicated that in specialist practices focus-
ing on eating problems of young people, the criteria for ARFID (presented
in Box 1–4) successfully captured a significant number of individuals who
did not meet criteria for any other eating disorder (Fisher et al. 2014; Orn-
stein et al. 2013).

Box 1–4. DSM-5 Criteria for Avoidant/Restrictive Food

Intake Disorder
A. An eating or feeding disturbance (e.g., apparent lack of interest in eat-
ing or food; avoidance based on the sensory characteristics of food;
concern about aversive consequences of eating) as manifested by per-
sistent failure to meet appropriate nutritional and/or energy needs as-
sociated with one (or more) of the following:
1. Significant weight loss (or failure to achieve expected weight gain or
faltering growth in children).
2. Significant nutritional deficiency.
Classification of Eating Disorders 17

3. Dependence on enteral feeding or oral nutritional supplements.

4. Marked interference with psychosocial functioning.
B. The disturbance is not better explained by lack of available food or by
an associated culturally sanctioned practice.
C. The eating disturbance does not occur exclusively during the course of
anorexia nervosa or bulimia nervosa, and there is no evidence of a dis-
turbance in the way in which one’s body weight or shape is experi-
enced.
D. The eating disturbance is not attributable to a concurrent medical con-
dition or not better explained by another mental disorder. When the eat-
ing disturbance occurs in the context of another condition or disorder,
the severity of the eating disturbance exceeds that routinely associated
with the condition or disorder and warrants additional clinical attention.
Excerpted from the Diagnostic and Statistical Manual of Mental Disorders, 5th Edi-
tion, Arlington, VA, American Psychiatric Association, 2013. Used with permission.
Copyright © 2013 American Psychiatric Association.

The final criteria for ARFID intentionally encompass a range of pre-

sentations. Individuals meeting the DSM-IV criteria for feeding disorder
of infancy or early childhood are included in ARFID. In addition, individ-
uals who have a problem with food intake associated with other problems
may also meet criteria for this disorder. Common examples are individu-
als who have experienced a frightening or particularly difficult but tran-
sient gastrointestinal problem, such as an episode of acute vomiting after
eating, and subsequently severely restrict their food intake to avoid an-
other such episode. Another presentation is that of individuals who avoid
foods of a certain texture or color. Minor variants of such problems occur
commonly, especially among children, but the criteria for ARFID and the
text of DSM-5 emphasize that the diagnosis should be assigned only in sit-
uations in which the food restriction leads to a clinically significant nutri-
tional disturbance or to a serious impairment in psychosocial functioning.
It is also critical to distinguish ARFID from AN. Although both disorders
are associated with serious nutritional problems, individuals with AN, un-
like those with ARFID, describe a marked overconcern about shape and
weight and an intense fear of gaining weight or becoming obese.

Pica
Pica refers to persistent consumption of nonnutritive, nonfood items that
is inappropriate for the individual’s developmental age. Pica may occur in
association with a number of medical conditions, including during normal
pregnancy. The disorder should not be assigned if it is occurring in the
18 Handbook of Assessment and Treatment of Eating Disorders

context of another mental or medical condition or disorder unless it is so

severe that it warrants additional clinical attention.
The only changes recommended to the DSM-IV criteria for pica were mi-
nor alterations to the wording of the criteria for clarification and to make clear
that the disorder could be assigned to the behavior of adolescents and adults
as well as children. The DSM-5 criteria for pica are presented in Box 1–5.

Box 1–5. DSM-5 Criteria for Pica

A. Persistent eating of nonnutritive, nonfood substances over a period of
at least 1 month.
B. The eating of nonnutritive, nonfood substances is inappropriate to the
developmental level of the individual.
C. The eating behavior is not part of a culturally supported or socially nor-
mative practice.
D. If the eating behavior occurs in the context of another mental disorder
(e.g., intellectual disability [intellectual developmental disorder], autism
spectrum disorder, schizophrenia) or medical condition (including preg-
nancy), it is sufficiently severe to warrant additional clinical attention.
Excerpted from the Diagnostic and Statistical Manual of Mental Disorders, 5th Edi-
tion, Arlington, VA, American Psychiatric Association, 2013. Used with permission.
Copyright © 2013 American Psychiatric Association.

Rumination Disorder
Rumination refers to the persistent, repeated regurgitation of food that has
already been swallowed. Relatively little is known about this phenome-
non. Rumination occurs among some individuals with AN and BN, but in
such cases, an additional diagnosis of rumination disorder is not assigned.
As in the case of pica, the only changes recommended to the DSM-IV
criteria for rumination disorder were for the purpose of clarification and
to make clear that this disorder can be assigned to individuals across the
life span. The DSM-5 criteria for rumination disorder are presented in
Box 1–6.

Box 1–6. DSM-5 Criteria for Rumination Disorder

A. Repeated regurgitation of food over a period of at least 1 month. Re-
gurgitated food may be re-chewed, re-swallowed, or spit out.
B. The repeated regurgitation is not attributable to an associated gastro-
intestinal or other medical condition (e.g., gastroesophageal reflux, py-
loric stenosis).
C. The eating disturbance does not occur exclusively during the course of
anorexia nervosa, bulimia nervosa, binge-eating disorder, or avoidant/
restrictive food intake disorder.
Classification of Eating Disorders 19

D. If the symptoms occur in the context of another mental disorder (e.g.,

intellectual disability [intellectual developmental disorder] or another
neurodevelopmental disorder), they are sufficiently severe to warrant
additional clinical attention.
Excerpted from the Diagnostic and Statistical Manual of Mental Disorders, 5th Edi-
tion, Arlington, VA, American Psychiatric Association, 2013. Used with permission.
Copyright © 2013 American Psychiatric Association.

Conclusion
Virtually all of the diagnostic categories used to describe mental disorders,
including the feeding and eating disorders, are based on descriptions of sa-
lient psychological and behavioral features but not on a detailed under-
standing of the underlying causes of the disorders. Nevertheless, the
categories are of substantial clinical utility in facilitating accurate commu-
nication among patients, clinicians, and investigators. Changes to diagnos-
tic criteria for feeding and eating disorders in DSM-5 should significantly
reduce the use of residual categories (“not otherwise specified”), encour-
age continued research, including about ARFID and BED, and, it is
hoped, provide a useful foundation for improved care of patients.

Key Clinical Points

• The fundamental features required for the diagnosis of anorexia
nervosa (AN) and bulimia nervosa are unchanged in DSM-5.
• Binge-eating disorder was formally recognized in DSM-5.
• The avoidant/restrictive food intake disorder (ARFID) description in-
cludes a range of abnormal eating patterns that lead to significant
nutritional or psychosocial problems.
• An important feature distinguishing ARFID from AN is the absence
of fear of gaining weight or becoming fat.
• Although the feeding and eating disorders often develop during
childhood or adolescence, they can occur throughout the lifetime
and may present in adulthood.

References
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Attia E, Roberto CA: Should amenorrhea be a diagnostic criterion for anorexia
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blesome “not otherwise specified” (NOS) category in DSM-IV. Behav Res
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PA RT I I
Evaluation
and Diagnosis
of Eating Problems
This page intentionally left blank
2 Eating Problems in Adults
Amanda Joelle Brown, Ph.D.
Janet Schebendach, Ph.D.
B. Timothy Walsh, M.D.

Eating problems and unhealthy weight-control behaviors

are common to the point of being almost normative among adults in de-
veloped countries. In a U.S. population-based study (Neumark-Sztainer et
al. 2011), 59% of young adult women reported currently dieting, 21% en-
dorsed extreme weight-control behaviors (e.g., self-induced vomiting, in-
appropriate use of laxatives), and 14% reported binge eating with loss of
control over a period of 1 year. Although the rates of diagnosable eating
disorders are substantially lower, they are still notable, with lifetime prev-
alence rates of anorexia nervosa (AN), bulimia nervosa (BN), and binge-
eating disorder (BED) ranging from 1% to 4% in epidemiological studies
(Smink et al. 2012). Individuals with disordered eating often have complex
histories and a range of symptoms that may not be easily observable or
readily disclosed by the patient in the absence of direct questioning. The
goal of any clinical assessment of eating problems in adults is to elicit suf-
ficiently detailed information from the patient to facilitate the accurate de-
scription of his or her presenting symptoms and to guide appropriate
treatment recommendations.
In this chapter, we describe an approach to the assessment of eating
problems that is meant to be applicable in a variety of settings, including
primary care and general psychiatric clinics. The approach includes an as-

23
24 Handbook of Assessment and Treatment of Eating Disorders

sessment of broad categories of eating-related symptoms, concerns about

body shape and weight, medical and psychiatric comorbidities, social and
occupational functioning, and treatment needs. Subgroups based on clus-
ters of symptoms, including the diagnostic categories defined in DSM-5
(American Psychiatric Association 2013), are identified and described. We
intend this approach to be useful for the early identification of feeding and
eating disorders, the clinical management of early warning signs, and the
identification of patients who should be referred for specialized care. We
also comment on some of the potential challenges inherent in assessing in-
dividuals with eating disorders, including their tendency to minimize
symptoms and frequent reluctance to admit the severity of their problems.
The reader is encouraged to view Video 2, “Assessing eating problems in
the primary care setting.”

The Clinical Interview: An Overview

A variety of factors may prompt a clinician to conduct an in-depth evalua-
tion of eating pathology. Significant increases, decreases, or fluctuations in
weight over a relatively short period of time are clear signals for clinicians
to ask a patient about his or her eating behavior. In addition, description of
increasingly restrictive eating patterns, excessive concern with body shape
and weight, and unexplained laboratory results (e.g., hypokalemia) may all
be early warning signs of an eating disorder and should prompt follow-up
questioning. The clinician conducting the interview may be the first treat-
ment provider to assess the eating problem or may have received a referral
from another provider who had reason to suspect an eating problem. When
the patient has been referred, it may be helpful to start the interview by ask-
ing the patient to describe his or her understanding of why the referral was
made, both to assess the patient’s level of insight about the eating problem
and to avoid “blindsiding” him or her with sensitive questions if the reasons
for the referral were not previously clarified.
The primary goal of the clinical interview is to allow the patient to de-
scribe his or her current symptoms and to reflect on the development of
these problems from his or her perspective. Patients with eating disorders
are not always the most reliable reporters of their own struggles because of
influences such as cognitive impairment from nutritional deprivation, the
tendency to deny the potentially serious nature of their disorder, deliberate
or unconscious minimization of symptoms, and ambivalence about treat-
ment and/or recovery. Therefore, obtaining collateral information from the
patient’s family, other clinicians involved in his or her care, and previous
treatment providers can be critically helpful and informative.
Eating Problems in Adults 25

Given the aforementioned challenges to obtaining accurate self-reported

information from patients with eating problems, it is essential that clini-
cians assume a collaborative, nonjudgmental stance during the clinical in-
terview. The creation of a strong therapeutic alliance, through such tactics
as asking open-ended questions and inquiring about the patient’s under-
standing of his or her difficulties, facilitates the collection of accurate infor-
mation and can be instrumental in strengthening patients’ motivation for
change. A patient may deny any understanding of the reason for the eval-
uation, may express annoyance at having to speak with a clinician, and
may not feel that he or she has a significant clinical problem. In such in-
stances, the clinician can assure the patient that the clinician is not making
any value judgments about the patient’s behavior and should aim to ally
with the patient to help him or her better understand why other people
might be concerned about his or her health and well-being. In many cases,
the clinician’s view of the patient’s symptoms may differ from the patient’s
view; however, in all circumstances, open and empathic dialogue will as-
sist in the formation of a therapeutic alliance and increase the likelihood
of obtaining accurate information.
Video 2 presents a sample clinical assessment by a general practitioner.

Video Illustration 2: Assessing eating problems in the primary

care setting (3:24)

Assessment of Eating Behaviors

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

A critical component of the assessment of individuals with disordered

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

Energy and Macronutrient Restriction

Individuals with eating disorders typically restrict their calorie intake; some
do so consistently, whereas others eat normal amounts of food or binge eat
between periods of restriction. Many patients attempt to adhere to a daily
calorie limit. This amount should be ascertained by the clinician and as-
sessed within the context of normal energy requirements. For example, a
healthy adult female (age 25 years, height 64 inches, weight 120 pounds,
body mass index 20.6 kg/m2) requires about 2,000–2,400 kcal/day at low
to moderate levels of physical activity for weight maintenance (U.S. De-
partment of Agriculture and U.S. Department of Health and Human Ser-
vices 2010). On average, patients with AN consume about 1,300 kcal/day
(Forbush and Hunt 2014). Eating patterns outside of binge episodes are in-
consistent in BN; some individuals restrict their food and energy intake,
some eat normally, and others overeat (Forbush and Hunt 2014). Individ-
uals with BED typically do not restrict their intake outside of binge epi-
sodes, often leading to substantial weight gain and obesity (American
Psychiatric Association 2013).
Patients frequently monitor their food intake and count calories. It is
noteworthy, however, that individuals with AN tend to overestimate their
energy intake by approximately 20% (Schebendach et al. 2012). If the pa-
tient sets a daily calorie limit, the clinician should ask if there are conse-
quences to exceeding that limit. For example, the individual may further
decrease calorie intake, fast, increase exercise, or engage in purging be-
haviors on the following day.
In patients with AN, calorie restriction is typically accomplished by
limiting fat intake (Forbush and Hunt 2014). Given that fat is the most
energy-dense macronutrient (i.e., 9 kcal/g for fat vs. 4 kcal/g for carbohy-
drate and protein), there is logic to fat avoidance. Furthermore, with public
health campaigns promoting low-fat, heart-healthy eating, patients can
easily cloak their disordered eating behavior in the guise of a healthy life-
style. Current U.S. dietary guidelines recommend that 20%–35% of total
calorie intake be provided by fat; for a healthy, normal-weight female, this
Eating Problems in Adults 27

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

behaviors
Energy and Do you limit your intake of calories, fat,
macronutrients carbohydrates, or protein?
Do you have a specific daily limit or an acceptable
range?
Do you self-monitor your intake?
What happens if you exceed your limit?
Do you avoid any specific foods or food groups, such
as added fats, red meat, fried foods, or desserts?
Are you on a vegetarian or vegan diet?
Other dietary restrictions Is your food choice limited by any condition or
restriction?
Food allergies?
Food intolerances (e.g., lactose, gluten)?
Religious or culturally based diet restrictions?
Meal patterns How many meals and snacks do you eat each day?
What are your typical mealtimes and snack times?
Do you eat differently on different days of the week
Workdays versus days off?
Weekdays versus weekends?
Eating behaviors Do you engage in any specific behaviors related to
your food?
Follow a strictly planned diet (i.e., calories,
percentage of fat/carbohydrates/protein)?
Weigh and measure your food intake?
Use utensils to eat foods that are typically eaten by
hand?
Eat very slowly or very quickly?
Prefer to eat alone and avoid others seeing you eat?
Avoid eating foods prepared by others?
Binge eating Do you ever feel a sense of loss of control over your
eating?
What are the contents of a typical binge-eating
episode for you?
Types of food consumed?
Amounts (large vs. average/small)?
How often do you binge eat in a given day, week, or
month?
Are your binge-eating episodes typically planned or
impulsive?
28 Handbook of Assessment and Treatment of Eating Disorders

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

behaviors (continued)
Purging Do you do anything to purge food or “get rid of”
calories?
How often do you purge in a given day, week, or
month?
Do you use laxatives or enemas?
Type/brand, dose, frequency?
Do you take diuretics?
Type/brand, dose, frequency?
Do you exercise excessively and/or feel driven or
compelled to exercise?
Type/intensity/frequency of exercise?
How do you feel if you are unable to exercise?

translates into 44–93 g/day of fat (U.S. Department of Agriculture and

U.S. Department of Health and Human Services 2010). Patients with eat-
ing disorders often set a daily fat-gram limit and monitor their intake and
derive a significantly lower fraction of their caloric intake from fat (Mayer
et al. 2012). The evaluating clinician should therefore assess the degree of
dietary fat restriction, as well as the inclusion or exclusion of added fats
(e.g., oil, salad dressing, mayonnaise, butter) and fat-containing foods (e.g.,
dairy products, red meat, desserts).
Individuals with AN have also been described as carbohydrate avoid-
ant (Russell 1967). However, carbohydrate restriction appears to be less
pronounced than fat restriction. The U.S. dietary guidelines recommend
carbohydrate intakes in the range of 45%–65% of calories; this translates
into approximately 225–390 g/day for a female (U.S. Department of Ag-
riculture and U.S. Department of Health and Human Services 2010). The
fraction of calories from carbohydrates among individuals with AN is sim-
ilar to or even a bit greater than that among healthy individuals (Mayer et
al. 2012). Patients with restrictive eating typically avoid high-sugar foods,
such as desserts, sweetened beverages, and added sugars, but they may
also restrict their intake of natural carbohydrate sources, such as milk,
fruit, fruit juice, and grains. In recent years, gluten-free diets have been ad-
opted by many individuals for the purpose of weight loss, and patients
with eating disorders may be similarly influenced by this dieting trend.
Once again, the clinician should determine the presence and degree of di-
etary carbohydrate restriction, as well as self-monitoring (i.e., carbohy-
drate counting) behaviors.
Eating Problems in Adults 29

Total protein intake may also be inadequate. In general, patients are

less likely to restrict or monitor their protein intake, and some may even
take protein and amino acid supplements. However, in an effort to de-
crease fat intake, many individuals narrow their repertoire of high-protein
food choices by excluding red meat, cheese, milk, eggs, and nuts. Some in-
dividuals adopt vegetarian and vegan (i.e., no animal products) dietary
practices during the course of their illness. The clinician should determine
the timeline for adoption of a vegetarian or vegan diet and ask whether
other household members eat a similar diet.
Claims of food allergies, food intolerances (e.g., lactose, gluten), and
religious or cultural dietary practices may complicate the clinical assess-
ment of eating disorders. The clinician should determine whether the di-
agnosis of a food allergy or intolerance has been confirmed by broadly
accepted objective testing. Food restriction due to cultural norms and reli-
gious practices should be assessed within the context of family and peer
group practices. Meal patterns, mealtimes, and the amount of time needed
to consume a meal or snack should be ascertained. Behaviors such as pre-
planning food intake, weighing and measuring foods, only eating alone,
not eating foods prepared by others, unusual cutting and food-handling
behaviors, blotting oil or fat off foods, and atypical handling of eating uten-
sils should also be explored.
Avoidant/restrictive food intake disorder (ARFID) is a DSM-5 diag-
nosis characterized by a general lack of interest in food (i.e., a “picky” or
“lazy” eater), sensory food aversions (e.g., to appearance, smell, color,
texture/consistency, taste, or temperature), concern about an aversive
consequence of eating (e.g., choking), and/or a diet that consists of a
markedly limited range of foods and little day-to-day variation in food in-
take. ARFID-related eating behaviors may result in a persistent failure to
meet energy and nutrient requirements, and enteral feedings or oral nu-
tritional supplements may be necessary (American Psychiatric Associa-
tion 2013). During the assessment interview, the patient should be asked
about current food intake (i.e., range of choice, amounts); duration of
avoidant/restrictive behaviors; use of dietary supplements; and the de-
gree to which current eating behaviors cause distress or interfere with
day-to-day functioning (Bryant-Waugh 2013).

Binge Eating
The occurrence (times of day), duration, and frequency (episodes per day
and week) of binge-eating episodes should be explored with all patients
undergoing an evaluation for disordered eating. Binge eating is a defining
characteristic of BN and BED and is also seen among a subset of individ-
30 Handbook of Assessment and Treatment of Eating Disorders

uals with the binge-eating/purging subtype of AN. Although the DSM-5

definition of binge eating requires the consumption of an objectively large
amount of food, many individuals refer to the consumption of a modest
or even small amount of food they had not intended to eat as a binge (i.e.,
a subjective binge). A shared characteristic of objective and subjective
binge-eating episodes is a sense of loss of control over what or how much
is eaten. The clinician should ascertain what is consumed during a typical
episode of binge eating, as well as whether binge episodes tend to be
planned or impulsive. Potential binge “triggers,” such as emotional pre-
cipitants (e.g., stress, anxiety, depression, sadness), particular settings
(e.g., restaurants, buffets, bakeries, supermarkets, social gatherings), and
food cravings, should also be explored.

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

Rumination
Patients with eating disorders may engage in rumination behavior—that is,
regurgitating, re-chewing, and re-swallowing or spitting out of food. This
behavior should be specifically queried. If the rumination behavior occurs
exclusive of another eating disorder (i.e., AN, BN, BED, ARFID) or a
medical condition and the severity of the behavior necessitates clinical at-
Eating Problems in Adults 31

tention, then a DSM-5 diagnosis of rumination disorder is warranted

(American Psychiatric Association 2013).

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

Assessment of Shape and Weight Concerns

In addition to obtaining detailed information about the patient’s current
eating habits and the development of restricting, binge-eating, and purg-
ing behaviors, it is essential to the proper characterization of eating prob-
lems for the clinician to assess the patient’s experience of his or her body
shape and weight. Regardless of the patient’s likely diagnosis, any assess-
ment of eating-related pathology should include documentation of
changes in weight and body size, including lifetime highest and lowest
weights and any significant weight fluctuations. The clinician should also
inquire about the patient’s ideal weight, the patient’s view of his or her
current weight (e.g., too high, too low, tolerable, unacceptable), and the
importance of shape or weight in the patient’s self-evaluation.
Shape and weight concerns are important to both the onset and main-
tenance of eating-disordered thoughts and behaviors, and they play an es-
sential role in differential diagnosis. Pica, rumination disorder, and
ARFID are not associated with significant disturbances in the perception
or evaluation of body shape and weight (American Psychiatric Association
2013). Individuals whose restrictive eating behaviors lead to significantly
low body weight may meet DSM-5 diagnostic criteria for either AN or
ARFID; shape and weight concerns distinguish these diagnoses from one
another. Shape and weight concerns are a salient distinguishing feature of
these diagnoses. Disturbances in the experience of body shape or weight,
undue influence of body weight or shape on self-evaluation, and persistent
lack of recognition of the seriousness of the current low body weight are
characteristic of individuals with AN, whereas there is no evidence of a
32 Handbook of Assessment and Treatment of Eating Disorders

disturbance in the way in which one’s body weight or shape is experienced

among individuals with ARFID.
Furthermore, many individuals with AN report an intense fear of gain-
ing weight or becoming fat. Explicit endorsement of this fear was a diag-
nostic requirement for AN in DSM-IV, but the criterion has been
expanded in DSM-5 to include persistent behavior that interferes with
weight gain despite the patient being at a significantly low weight. Focused
inquiry regarding what foods the patient actually consumes and his or her
emotional reaction to weight gain may elucidate the patient’s level of con-
cern about body shape and weight. Family members and treatment pro-
viders familiar with the patient’s eating attitudes and behaviors may offer
additional evidence to support or refute strong fears of weight gain.
DSM-5 also requires that individuals with BN endorse overconcern
with body shape and weight. Although it is normal for body image to play
a role in the regulation of self-esteem, individuals with BN overvalue
shape and weight compared to individuals without eating disorders. Indi-
viduals with BED also typically endorse shape and weight concerns to a
higher degree than individuals of a similar body size who do not binge eat,
but such concern is not required for the diagnosis of BED according to
DSM-5 criteria. Notably, overvaluation of shape and weight plays a key
role in the transdiagnostic model of AN, BN, and BED and informs cog-
nitive-behavioral therapy for eating disorders (Fairburn et al. 2003).

Assessment of Medical and Psychological

Features Associated With Eating Problems
Physical Assessments
An essential component of the assessment of adults with eating problems
is obtaining objective measures of current physical health status. Measur-
ing height and weight, taking vital signs (e.g., pulse, blood pressure), per-
forming a general physical examination, and obtaining laboratory tests are
all important and can be done either by the clinician assessing the history,
if he or she has the requisite training and experience, or by a physician
who serves a general medical role. The nature of the presenting problem
and the clinician’s observations of the patient should inform the necessity
for and extensiveness of the physical examination. For example, a patient
with a history of substantial weight loss or of frequent purging is in more
urgent need of a full medical workup than one with a normal, stable
weight whose main presenting problem is psychological overconcern with
body size.
Eating Problems in Adults 33

Medical Complications
In addition to conducting an extensive assessment of the patient’s current
physical health status, the clinician should ask whether the patient has ex-
perienced any physical problems as a consequence of his or her eating dis-
turbance. Specific inquiry should be made about emergency room visits,
less acute medical and dental care, and the existence of physical or medi-
cal complications such as changes to skin, hair, or nails; dental complica-
tions, including dental caries and/or enamel erosion; and stress fractures
or other evidence of osteoporosis. Medical complications associated with
AN and BN are listed in Table 2–2. The medical complications associated
with BED are those associated with overweight and obesity, including hy-
pertension, cardiovascular disease, and diabetes.
Laboratory assessments, including blood tests for hemoglobin, white
blood cell count, and a chemistry panel, should be included in a compre-
hensive physical assessment, because blood cell counts may be low in the
context of undernutrition, and metabolic and electrolyte disturbances are
common. One of the most dangerous electrolyte disturbances is low po-
tassium, or hypokalemia, which often is a result of recurrent vomiting but
may also occur secondary to severe and prolonged food restriction. Hypo-
kalemia can result in cardiac arrhythmias and therefore must be regularly
monitored, especially in high-risk cases (e.g., individuals with purging be-
haviors). Prolongation of QT and QTc (rate corrected) intervals is also
possible, even in the absence of electrolyte abnormalities, and this risk
may rise with decreasing weight (Takimoto et al. 2004). Electrocardio-
grams are essential to further evaluate the acuity of the hypokalemia and
assess for signs of arrhythmias. Hypomagnesemia may also occur with hy-
pokalemia and if left untreated will prevent sustained normalization of po-
tassium.
Low sodium, or hyponatremia, may be present and is commonly ac-
companied by low chloride levels, or hypochloremia. The hyponatremia
associated with eating disorders generally results from one of two possible
mechanisms (Bahia et al. 2011). The more common is that related to in-
creased water intake. Through normal homeostatic processes, patients
lose sodium and water through sweat and urine. Drinking water alone is
insufficient to replace these losses, and the sodium concentration in the
blood is ultimately diluted. A second potential etiology of hyponatremia
is the development of the syndrome of inappropriate antidiuretic hor-
mone secretion (SIADH). In both cases, water restriction is usually the
treatment of choice for clinically significant hyponatremia. If fluid restric-
tion is insufficient to fully restore electrolyte balance (sodium levels), med-
ical consultation should be obtained. Although the low sodium in patients
34 Handbook of Assessment and Treatment of Eating Disorders

TABLE 2–2. Some physical and laboratory findings associated

with anorexia nervosa and bulimia nervosa
Anorexia nervosaa Bulimia nervosa

Skin/extremities Lanugo (fine hair on trunk/ Callus on back of hand

face)
Red/blue fingers
Edema
Cardiovascular Low pulse rate
Low blood pressure
Gastrointestinal Salivary gland enlargement Salivary gland
Slow stomach emptying enlargement
Constipation Dental erosion
Liver abnormalities
Hematopoietic Anemia
Low white blood cell count
Fluid/electrolyte Decreased kidney function Low blood potassium
Low blood potassium Low blood sodium
Low blood sodium Reduced blood acidity
Low blood phosphate
Endocrine Low blood sugar
Low estrogen or testosterone
Low-normal thyroid
hormone levels
Increased cortisol
Bone Decreased bone density
aPatients with the binge-eating/purging subtype of anorexia nervosa are at risk for the

physical and laboratory findings associated with bulimia nervosa in the context of frequent
purging.
Source. Adapted from Walsh and Attia 2011.

with AN is often the result of a gradual and chronic state, acute hypona-
tremia can precipitate seizures, and thus regular monitoring of electrolytes
is indicated.
Signs of dehydration are common and can include tachycardia, ortho-
static hypotension, and laboratory abnormalities suggestive of prerenal
azotemia, including elevated creatinine and blood urea nitrogen levels.
These issues generally resolve with resumption of regular food and fluid
intake. However, the patient with symptoms of dehydration (e.g., light-
headedness, syncope) may require intravenous hydration, which will nor-
malize these physical and laboratory abnormalities more quickly.
Eating Problems in Adults 35

Refeeding syndrome, which can occur during the initial stages of

weight recovery, is marked by metabolic disturbances and volume over-
load manifesting as edema (pedal and/or pulmonary) and cardiac failure.
Reports indicate that early hypophosphatemia is a harbinger of refeeding
syndrome (Ornstein et al. 2003; Trent et al. 2013). The mechanism of
refeeding syndrome is thought to be related to changes in insulin-glucose
functioning and the requirements for phosphorus, magnesium, and other
elements in the catabolic process. Despite normal serum levels of phos-
phorus on initial evaluation, phosphorus levels may fall upon initiation of
refeeding, with the nadir often occurring 3–4 days following the initiation
of refeeding. Thus, phosphate levels should be monitored regularly during
initial resumption of regular food intake and repleted as necessary.
In cases of significant food restriction, specific nutrient or vitamin de-
ficiencies may be present, even if absolute weight is close to normal. For
example, individuals who avoid fruits and vegetables or who eat a limited
range of foods may need vitamin supplements. Those who refuse to swal-
low a recommended multivitamin supplement because of its feel or smell
should be monitored for vitamin deficiencies.
Almost all of these medical complications are reversible with adequate
nutrition. Supportive measures such as careful monitoring of cardiac func-
tion or electrolyte levels may be necessary for successful and safe refeed-
ing. Slowed gastric motility becomes important during nutritional
rehabilitation (see Chapter 13, “Treatment of Restrictive Eating and Low-
Weight Conditions, Including Anorexia Nervosa and Avoidant/Restrictive
Food Intake Disorder”); fullness and possible constipation may cause the
refeeding process to be physically uncomfortable.

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

present prior to the onset of eating disorder symptoms or if mood distur-

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

Differential Diagnosis
Before concluding that a patient’s difficulties are best attributed to the ex-
istence of an eating disorder, the clinician should consider whether the eat-
ing disturbances are better accounted for by another psychiatric disorder
or whether the symptoms may be secondary to a general medical condi-
tion. For example, binge-eating episodes may occur in association with
major depressive disorder, and many medical illnesses can lead to sub-
stantial weight loss. Clinicians should consider the possibility that another
medical or psychological issue accounts for the patient’s eating or weight
symptoms, particularly when the history is unclear or the features are un-
usual.
Differential diagnosis when the primary symptoms are restrictive eating
and/or low weight involves assessment of the underlying assumptions and
motivations for the abnormal eating behavior. Mood, anxiety, and psychotic
disorders may occasionally be associated with weight loss and disturbances
in eating behavior, but the concerns about shape and weight that are char-
acteristic of AN are not present in these illnesses. Similarly, some of the psy-
chological characteristics of individuals with social anxiety disorder,
obsessive-compulsive disorder, or body dysmorphic disorder resemble
those of patients with AN; however, individuals with these disorders do not
exhibit the unrelenting drive for thinness seen in patients with AN.
Overeating with loss of control, a defining feature of BN and BED,
may sometimes occur in association with major depressive disorder with
atypical features and with borderline personality disorder. These disorders
may be comorbid with BN or BED, and if a patient meets criteria for both
BN or BED and another mental disorder, both diagnoses should be given.
However, if the patient does not endorse overconcern with body shape
Eating Problems in Adults 37

and weight, a diagnosis of BN should not be given. Also, if binge eating

does not occur at an average frequency of at least one episode a week, an
alternative diagnosis should be considered. In this case, if no other psycho-
logical disorder is warranted and the eating symptoms are significant
enough to cause distress or impairment, the diagnosis should be other
specified feeding or eating disorder (e.g., BN or BED of low frequency
and/or limited duration).
Many serious medical illnesses are associated with substantial weight
loss, including gastrointestinal illnesses such as Crohn’s disease and celiac
disease, brain tumors and other malignancies, and AIDS. Some medical
and neurological conditions, such as Kleine-Levin syndrome, are associ-
ated with binge eating. These and other medical illnesses should be con-
sidered in the differential diagnosis. Occasionally, an eating disorder and
a medical illness occur together and multiple diagnoses are warranted.
Key features are the intense psychological reward associated with losing
weight and the fear of weight gain in AN and the use of compensatory be-
haviors to control weight and the overconcern with shape and weight that
characterize BN.

Assessment of Family History and Social

and Occupational Functioning
Two other areas warranting attention are the familial history of eating dis-
orders and the patient’s occupational and social history. Regardless of
whether other family members have been formally diagnosed with eating
disorder, the family’s attitudes toward eating and accompanying behav-
iors (e.g., dieting), especially if taken to an extreme, can play a significant
role in the formation of patients’ attitudes and behaviors. The clinician
should inquire about these family patterns, if not already volunteered by
the patient, and the effect on his or her relationship to food. Similarly, the
emphasis on shape and weight within the family structure and its influence
on the patient’s perceptions of shape and weight should be discussed.
A standard assessment of social, interpersonal, and occupational diffi-
culties should be conducted, specifically noting the impact of the eating
problem on the formation and maintenance of interpersonal relationships
(e.g., loss of friendships due to avoidance of social eating) and on work or
academic performance. Individuals with eating disturbances frequently
engage in occupations in which shape and weight are highly emphasized
(e.g., personal trainer) or food is the focal point (e.g., waitress). Whether
the pursuit of such careers is a contributing factor to or a by-product of the
eating disturbance undoubtedly varies, but the relationship of these occu-
38 Handbook of Assessment and Treatment of Eating Disorders

pations to the chronology of changes in eating and dieting practices should

be reviewed. Such information may prove valuable in treatment planning
when a consideration of career plans can be more thoroughly evaluated.

Assessment of Treatment Needs

The final step in the clinical evaluation of eating problems in adults is the
assessment of treatment needs and the formulation of a plan for follow-up
care. Various treatment settings (e.g., inpatient, partial hospitalization, out-
patient), modalities (e.g., behavioral, cognitive, interpersonal, family ori-
ented, psychopharmacological, medical), and intensities are currently
employed in the treatment of eating disorders (see Part 4, “Treatment,” in
this volume). The nature of the patient’s past treatments should be as-
sessed, with the caveat that these treatments may be difficult for the patient
(or clinician) to characterize accurately. Furthermore, for a patient with a
long history of illness, a complete history of treatment may be too lengthy
to obtain in a single assessment. The clinician should strongly consider,
with the patient’s permission, speaking with past treatment providers and
obtaining a copy of important historical documents (e.g., hospital dis-
charge summaries). It is important to ascertain whether and how often the
patient has been hospitalized for treatment of an eating disorder or its
complications, what psychological strategies and medication interventions
have been attempted, and what the patient has found to be most and least
helpful. It is also useful to determine the reason for termination of past
treatment (e.g., expiration of insurance coverage, the patient’s leaving
treatment against medical advice).
The severity of the patient’s current eating problems is the most im-
portant factor to consider in determining a recommended level of care.
Medical instability, including such disturbances as low heart rate (e.g.,
<40 beats per minute), low blood pressure (e.g., <90/60 mmHg), electro-
lyte imbalance, dehydration, and organ failure requiring acute treatment,
requires inpatient hospitalization. In addition, suicidal ideation with a spe-
cific plan or intent is a clear indicator of a need for hospitalization and
should be assessed during the clinical interview. Maintenance of a body
weight below 80% of expected weight for age, sex, and height or acute
weight loss in the context of food refusal also suggests that a higher level
of care (e.g., inpatient, residential) may be warranted. If a high degree of
structure seems necessary for the patient to eat and gain weight, partial or
full hospitalization should be considered. Success or failure in less inten-
sive treatments may be the best indicator of this necessity (Yager et al.
2006).
Eating Problems in Adults 39

A patient’s motivation for change, cooperativeness, insight, and ability

to control obsessive thoughts about food and eating should be at least fair
if outpatient treatment is to be considered. Patients with severe symptoms
but poor insight, little motivation, and constant preoccupation with eating-
related obsessions require a higher level of care. In addition, any comorbid
psychiatric illness requiring hospitalization (e.g., psychotic illness, severe
obsessive-compulsive disorder) precludes the recommendation of outpa-
tient or day programs. Finally, severe environmental stress, including fam-
ily conflict, absent or inadequate social support, or unstable living
arrangements, may influence clinical decision making about the proper
level of care (Yager et al. 2006).
Patients for whom highly structured treatment programs are recom-
mended should be aware that such programs represent only the beginning
step in what is likely to be a lengthy process of treatment and recovery.
The least restrictive environment that provides adequate support for the
patient to practice making healthier eating choices should always be rec-
ommended, because practicing new behaviors in a familiar environment
has the greatest potential to effect substantive and lasting change.

Challenges and Obstacles in

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

Patient Reluctance to Provide Information

For a variety of reasons, patients may be reluctant to provide accurate in-
formation about their difficulties. In some instances, patients are ashamed
40 Handbook of Assessment and Treatment of Eating Disorders

of beliefs or behaviors that they recognize as abnormal but feel unable to

control. Patients may deny that they purge, may overreport their daily cal-
orie consumption, or may consume excessive amounts of liquids or carry
concealed objects when they are weighed. No approach to such denial and
subterfuge is universally effective; however, it may be useful for the clini-
cian to note that individuals with eating problems commonly have diffi-
culties being open about all aspects of their disorder and therefore to ask,
in a nonconfrontational manner, whether there are symptoms the patient
has difficulty admitting. The clinician should avoid criticizing the patient
for not being open, because such maneuvers are unlikely to yield more ac-
curate information and will undermine the development of a therapeutic
alliance.

Minimization of Symptom Severity

and/or Need for Treatment
The final challenge in obtaining information from patients with eating dis-
orders is their difficulty admitting that their behaviors are problematic or
potentially harmful (Vitousek et al. 1990). Many deny that they have a
psychiatric illness and decline offers for help. Individuals with AN, in par-
ticular, often vehemently deny that their weight is dangerously low or that
their eating behaviors are not healthy, and many report extreme distor-
tions in body image, often using words such as “obese,” “enormous,” and
“whalelike” to describe their perception of their emaciated bodies. Indi-
viduals with BN and BED, particularly those seeking treatment, typically
do not describe such drastic differences between their internal experience
and the observations of others, but they may minimize the severity of as-
pects of their eating disorder they consider shameful or embarrassing,
such as binge eating, purging, or laxative misuse. Furthermore, patients of
any diagnosis who tend toward perfectionism and agreeableness may
show overcompliance during the interview, answering questions in the
way that he or she interprets as being “right.”
We reiterate that there is no one way to deal with minimization, denial,
or distortion in a clinical interview. The clinician can reflect back inconsis-
tencies and discrepancies in the information provided by the patient in an
open, curious manner, without assuming that the patient is deliberately
trying to mislead. Efforts to normalize symptoms may increase patients’
willingness to disclose information; for example, the clinician might ask,
“Some people who try to keep their weight down do so by cutting out cer-
tain food groups—have you ever done that?” or “How many times would
you say you binge eat in a given day or week?” By assuming a relatively
high degree of symptom frequency or severity, the clinician can commu-
Eating Problems in Adults 41

nicate to the patient that the symptoms are within the realm of what is typ-
ically encountered and may also engender the patient’s trust in the
clinician as someone who has experienced other individuals with similar
struggles.

Conclusion
In this chapter, we have attempted to summarize the essential components
of a thorough clinical assessment of individuals with suspected eating dis-
orders. The clinician should obtain a comprehensive description of the pa-
tient’s eating behavior and the psychological and emotional concomitants
of that behavior. The clinician should also attempt to understand how these
disturbances began and how they have evolved over time and should as-
sess the patient’s commitment to change. Physical assessments should be
conducted to identify any medical complications of the disordered eating
behavior. Other psychiatric disorders and general medical conditions that
involve disturbances in eating and weight should be considered as alterna-
tive explanations of the presenting concern. Although the assessment of
eating pathology in adults can be challenging because of the shame and se-
crecy typically involved in these disorders, carrying out the assessment in
a thorough but empathic fashion should facilitate the formation of a strong
therapeutic alliance with the patient.
Finally, it should be noted that the assessment approach described in
this chapter is a semistructured method that can be used in most general
clinical settings. A range of more structured assessment methods are avail-
able, including the Eating Disorder Assessment for DSM-5 (EDA-5; Sysko
et al. 2015), as discussed in Part 3 (“Assessment Tools”) of this volume.
Such structured and semistructured assessments are routinely used in re-
search settings, and they may also be usefully employed in routine clinical
practice to obtain objective measures of the patient’s symptoms.

Key Clinical Points

• The overarching goal of the clinical assessment of eating problems
in adults is to elicit sufficiently detailed information from the patient
to facilitate the accurate description of his or her presenting symp-
toms and to guide appropriate treatment recommendations.
• The assessment approach described in this chapter is a method
that can be used in most general clinical settings. A range of more
structured assessment methods are also available.
42 Handbook of Assessment and Treatment of Eating Disorders

• The assessment of eating problems should begin with a thorough

evaluation of eating behaviors. Once the nature of the eating prob-
lem has been established, further information should be obtained to
contextualize the eating problem in terms of medical complications,
comorbid conditions, social and occupational functioning, and
treatment history and needs.
• Physical assessments, including measurement of height and
weight, physical examination, and laboratory assessments as indi-
cated, should be routinely included in the assessment of eating dis-
orders in adults.
• The assessment of eating pathology in adults can be challenging
because of the shame, secrecy, and ambivalence about change
that are often involved in these disorders. A collaborative, nonjudg-
mental stance will facilitate the collection of accurate information
and strengthen patients’ motivation for change.

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3 Eating Problems in
Children and Adolescents
Neville H. Golden, M.D.
Rollyn M. Ornstein, M.D.

Medical professionals, including pediatricians, adolescent

medicine specialists, and primary care practitioners, are uniquely suited for
the early identification of eating problems in children and adolescents because
patients in this age group are usually seen at regular intervals. However, the
diagnosis of an eating disorder in this age group can be particularly challeng-
ing because these patients frequently fail to endorse cognitions typically asso-
ciated with eating disorders (e.g., feeling fat, fearing weight gain, concern
about body shape or weight) but may instead present with vague physical
complaints such as nausea, difficulty swallowing, or abdominal pain after eat-
ing. Physicians working with youths would therefore benefit from additional
information about the unique presentation of children and adolescents with
feeding and eating problems. In particular, physicians would be helped by un-
derstanding the changing nosology of feeding and eating disorders as de-
scribed in DSM-5 (American Psychiatric Association 2013) that may affect
the diagnostic labels applied to eating problems in youths. Especially notable
in DSM-5 is the development of a revised diagnostic category now entitled
avoidant/restrictive food intake disorder (ARFID) and the inclusion of rumi-
nation disorder and pica in feeding and eating disorders in DSM-5.
The aim of this chapter is to provide a practical approach for pediatri-
cians, adolescent medicine physicians, primary care practitioners, and

45
46 Handbook of Assessment and Treatment of Eating Disorders

other professionals who may need to assess children and adolescents with
potential feeding or eating disorders. Given the aforementioned chal-
lenges of differing presentations in youths and the recently updated diag-
nostic scheme, this chapter provides assistance in the assignment of the
diagnosis of a feeding or eating disorder in a child or adolescent. Guidance
is offered for conducting a careful history and physical examination, and
suggestions are offered for the exclusion of other medical and psychiatric
conditions as part of this evaluation. The reader is encouraged to view
Video 2, “Assessing eating problems in the primary care setting.”

Epidemiology and Nosology

of Eating Disorders
Although eating disorders have historically been considered diseases of af-
fluent white adolescent females, data on epidemiology suggest changes
over the past few decades (Pike et al. 2013). Increased prevalence rates
have been identified among ethnic and racial minorities (Alegria et al.
2007; Marques et al. 2011; Nicdao et al. 2007; Taylor et al. 2007) and in
countries where eating disorders were traditionally not reported (Chandra
et al. 2012; Chisuwa and O’Dea 2010; Eddy et al. 2007; Jackson and Chen
2010; Lee et al. 2010). Although the onset of eating disorders was previ-
ously more common during middle to late adolescence, more recent stud-
ies indicate that the age at onset for both anorexia nervosa (AN) and
bulimia nervosa (BN) has been decreasing (Favaro et al. 2009; van Son et
al. 2006), with a significant increase in the numbers of individuals under
age 12 presenting for treatment (Madden et al. 2009; Nicholls et al. 2011;
Pinhas et al. 2011) and a notable increase in females ages 15–19 presenting
with AN (van Son et al. 2006). Data also suggest an increase in the identi-
fication of males with eating disorders (Swanson et al. 2011) and a reduced
female-to-male ratio in younger patients with restrictive eating disorders
(Madden et al. 2009; Nicholls et al. 2011; Pinhas et al. 2011), highlighting
the importance of broadening perceptions with relation to the sex and the
presentation of individuals with feeding and eating disorders.
Under the DSM-IV diagnostic classification scheme, more than 50%
of children and adolescents with eating disorders were assigned the diag-
nosis of eating disorder not otherwise specified (EDNOS), because they
did not meet full criteria for either AN or BN, or they had an entirely dif-
ferent disorder (Eddy et al. 2008; Peebles et al. 2010). A goal of DSM-5
was to improve the clinical utility of the eating disorder diagnostic catego-
ries and decrease the need to employ the EDNOS category. Early studies
demonstrated that application of the DSM-5 criteria leads to significant
Eating Problems in Children and Adolescents 47

decreases in the proportion of EDNOS diagnoses and modest increases in

both AN and BN diagnoses in children, adolescents, and young adults
(Machado et al. 2013; Ornstein et al. 2013; Stice et al. 2013). In clinical
samples of younger patients referred to specialized eating disorder pro-
grams, 5%–23% meet criteria for ARFID (Fisher et al. 2014; Nicely et al.
2014; Norris et al. 2014; Ornstein et al. 2013).

Basic Screening for a Feeding

or Eating Disorder
Physicians can play a key role in identifying early eating problems among
children and adolescents during health maintenance visits or preparticipa-
tion sports physical examinations. A critical element in screening for a
feeding or eating disorder is the measurement of height and weight to plot
body mass index (BMI; weight in kilograms divided by height in meters
squared [kg/m2]), which should be examined at each visit, with close at-
tention paid to any significant change in percentiles for height, weight, or
BMI. The degree of change and current status are important in determin-
ing level of concern. Children and adolescents who fail to make expected
weight gain during a period of growth, even if they have not lost any
weight, should be assessed further. Parents of a preteen or adolescent
should be asked specific questions about concerns they may have regard-
ing their child’s dietary intake (e.g., limited consumption, greatly de-
creased range of foods eaten), physical activity, excessive weight concerns,
or inappropriate dieting. In girls, primary or secondary amenorrhea in the
context of dieting or excessive exercise should be a red flag. Any suspicion
of a possible eating disorder requires a more comprehensive assessment,
which may or may not be possible given the time and resource constraints
of the physician’s practice and the patient’s insurance plan. If additional
time cannot be spent on evaluation, the clinician should refer the patient
to an eating disorder specialist.

Initial Medical Assessment for a Suspected

Eating Disorder in a Child or Adolescent
The initial medical assessment of the child or adolescent who may have an
eating disorder may be performed by a pediatrician, adolescent medicine
specialist, or primary care practitioner. This evaluation aims to establish
current eating disorder symptoms, develop a preliminary diagnosis, ex-
clude other causes of weight loss or vomiting, evaluate for any associated
48 Handbook of Assessment and Treatment of Eating Disorders

medical complications, and, as appropriate, initiate a plan for treatment

and ongoing monitoring. A mental health professional may be needed to
perform a psychological assessment to evaluate for common comorbid
psychiatric illnesses such as affective or anxiety disorders.

History
When a child or adolescent initially presents for an evaluation of a possible
feeding or eating disorder, the health care provider should usually start by
obtaining a history with both parent and patient together. Observing the
interaction between child and parent(s) can be informative. Subsequently,
the physician should speak individually with the child or adolescent and
the parent(s) to ask each party about specific related disordered behaviors,
such as purging, compulsive exercising, and other habits. Skilled inter-
viewing can reveal any “hidden agenda” and clarify any discrepancies in
perspective between parent(s) and child. For example, the clinician can ask
the child or adolescent what he or she has been told about the reason for
the appointment; the physician can then observe whether the parent auto-
matically answers for the child or interrupts and whether the child speaks
freely or looks to the parent to answer. With regard to the presented prob-
lem, the chief complaint may be weight loss, but it also may be amenor-
rhea, weakness, dizziness, fatigue, abdominal pain, nausea, vomiting, or a
combination of complaints. A detailed history can usually differentiate an
eating disorder from another etiology for symptoms. Sample questions that
might be asked in this interview are provided in Table 3–1 and illustrated
in Video 2.

Video Illustration 2: Assessing eating problems in the primary

care setting (3:24)

Physical Examination
A thorough physical examination is an essential component of the assess-
ment of a child or adolescent suspected of having an eating disorder.
Height should be obtained using a wall-mounted stadiometer, and post-
voiding weight should be measured with the patient wearing only a hospi-
tal gown. The physician should calculate BMI, plot it on the Centers for
Disease Control and Prevention charts (www.cdc.gov/growthcharts/
clinical_charts.htm), and determine the percentage of median BMI (pa-
tient’s BMI/median BMI100). It is important to review the patient’s pre-
vious weights and heights on the growth chart to determine whether
growth arrest has occurred. Particular attention should be paid to obtain-
ing vital signs, including oral temperature and orthostatic measurements
Eating Problems in Children and Adolescents 49

TABLE 3–1. Eating disorders evaluation: sample questions and

issues to explore in obtaining history
History of present illness
When did your eating habits change? Why did they change?
What is the most you ever weighed? How tall were you then? When was that?
What is the least you ever weighed in the past year? How tall were you then?
When was that?
What would you like to weigh? Are there specific body parts you would wish to
change?
What have you eaten in the last 24 hours?
Calorie counting? Fat-gram counting? Carbohydrate counting?
Food restrictions? Recent vegetarianism? Excessive noncaloric fluid intake?
Do you eat with others? Do you eat outside of your home?
Do you exercise? How much, how often, and what level of intensity? How do you
feel if you miss exercising?
Have you engaged in binge eating? Frequency?
Have you purged by self-induced vomiting? Frequency?
Do you use laxatives, diuretics, or diet pills?
Have you ever had any previous treatment for an eating disorder or other mental
health issue?
If there is a suspicion of avoidant/restrictive food intake disorder, may add these questions:
Do you have any fears about vomiting or choking? Have you ever experienced
or witnessed episodes where someone choked on food?
Have you ever used oral nutritional supplementation or tube feedings? When?
Would you describe yourself/your child as a picky eater?
Are you bothered by characteristics of food related to smell, taste, texture, or color?
Past medical history
Birth history, neonatal course, feeding history, episodes of gagging or other
intolerances to food, and texture/sensory issues
Medical or mental health problems, hospitalizations, and surgeries
Menstrual history (girls)
At what age did you have your first period (if applicable)?
Were your menstrual cycles regular prior to the eating disorder?
When was your last menstrual period?
Family history
Medical problems, recent illnesses, or deaths (e.g., obesity, diabetes,
cardiovascular disease)
Family members with weight loss efforts, possible eating disorder
Mental health history, alcoholism, and/or substance abuse
50 Handbook of Assessment and Treatment of Eating Disorders

TABLE 3–1. Eating disorders evaluation: sample questions and

issues to explore in obtaining history (continued)
Review of systems
General: weight changes, sleep habits, fevers, night sweats, heat/cold intolerance,
hair loss
Cardiovascular: chest pain, heart palpitations
Respiratory: shortness of breath, cough with or without exertion
Gastrointestinal: abdominal pain, fullness/bloating, early satiety, nausea,
dyspepsia, reflux symptoms, vomiting, diarrhea, constipation
Musculoskeletal: weakness, numbness/tingling, pain, swelling
Neurological: headaches, dizziness, syncope
Psychiatric: symptoms of depression, anxiety, obsessive-compulsive disorder,
substance abuse, physical and/or sexual abuse

of heart rate and blood pressure (measured when the patient is lying down
and again 2 minutes after standing). It is not uncommon for significant
bradycardia, hypotension, and hypothermia to be present. Physical ex-
amination may reveal loss of subcutaneous fat, prominence of bony pro-
tuberances, and lanugo hair on the back, trunk, and arms. Dental enamel
erosion and enlargement of the parotid and salivary glands may be pres-
ent in those who purge. Russell’s sign, or calluses on the dorsum of the
hand that are caused by the central incisors when the fingers are used to
induce vomiting, may be evident. Examination of the heart may reveal a
midsystolic click or murmur from mitral valve prolapse. Assessment of
sexual maturity rating (Tanner staging for development of breasts and pu-
bic hair for girls or for genitals and pubic hair for boys) is important to
evaluate for pubertal delay or arrest. Common physical signs noted in chil-
dren and adolescents with eating disorders are listed in Table 3–2, and
conditions that would suggest a need for inpatient medical hospitalization
are listed in Table 3–3.

Laboratory Investigations
Recommended laboratory tests are shown in Table 3–4. Laboratory tests
are not diagnostic per se, but they may help confirm an eating disorder di-
agnosis by excluding other causes of weight loss or vomiting. Despite a pa-
tient’s significant weight loss and severe dietary restriction, laboratory tests
are usually normal.
Eating Problems in Children and Adolescents 51

TABLE 3–2. Physical findings associated with anorexia

nervosa and bulimia nervosa in children and
adolescents
Anorexia nervosa Bulimia nervosa

General Low weight Weight usually normal

Loss of subcutaneous fat
Proximal and intercostal
muscle wasting
Prominence of bony
protuberances
Hypothermia
Skin Dry skin with hyperkeratotic Russell’s sign (calluses on
areas dorsum of hand caused by
Yellowish discoloration self-induced vomiting)
(carotenemia)
Lanugo
Acrocyanosis
Hair loss or thinning
Pitting and ridging of nails
Cardiovascular Bradycardia Electrocardiographic
Hypotension abnormalities, particularly
Orthostasis QTc prolongation
Peripheral edema
Systolic murmur sometimes
associated with mitral valve
prolapse
Electrocardiographic
abnormalities—bradycardia,
low voltages, prolonged
QTc
Gastrointestinal Scaphoid abdomen with stool Parotid and salivary gland
palpable in left-lower enlargement
quadrant Dental enamel erosion
Elevated transaminases Loss of gag reflex
Dental caries, gingivitis,
stomatitis, glossitis
Abdominal distension after
meals
52 Handbook of Assessment and Treatment of Eating Disorders

TABLE 3–2. Physical findings associated with anorexia

nervosa and bulimia nervosa in children and
adolescents (continued) (continued)
Anorexia nervosa Bulimia nervosa
Metabolic/ Amenorrhea Oligomenorrhea or normal
endocrine Cold intolerance, menses; amenorrhea also
hypothermia possible
Growth retardation
Delayed puberty
Musculoskeletal Muscle wasting Usually normal weight
Low bone mineral density Usually normal bone mineral
with pathological fractures density
Neurological Cognitive and memory Cognitive and memory
dysfunction dysfunction
Depression Depression
Anxiety Anxiety
Hematological Easy bruising, petechiae
Thrombocytopenia
Leukopenia
Anemia

Medical Complications
Many of the medical complications of eating disorders are secondary to
the effects of malnutrition and/or purging behavior. As described in the
following subsections, almost every organ system may be involved.

Fluid and Electrolytes

Patients with eating disorders may present with dehydration and abnor-
mal serum levels of sodium, potassium, chloride, phosphorus, magnesium,
carbon dioxide, and blood urea nitrogen. Electrolyte disturbances, most
commonly hypokalemia, are more likely in those patients who are vomit-
ing and/or abusing laxatives or diuretics. Hyponatremia can occur in
those who “water load” (i.e., consume large amounts of water to temporar-
ily appear to weigh more) and can lead to seizures, coma, and death. Se-
rum phosphorus levels may be normal on presentation but can drop
during the process of refeeding, and careful monitoring is needed if phy-
sicians are overseeing an outpatient weight gain regimen for patients who
are underweight. Hypophosphatemia may play a role in the development
Eating Problems in Children and Adolescents 53

TABLE 3–3. Indications for hospitalization in a child or adolescent

with an eating disorder
75% median body mass index for age and sex
Dehydration
Electrolyte disturbance (hypokalemia, hyponatremia, hypophosphatemia)
Electrocardiographic abnormalities (e.g., prolonged QTc or severe bradycardia)
Physiological instability
Severe bradycardia (heart rate <50 beats/minute daytime; <45 beats/minute at
night)
Hypotension (<90/45 mmHg)
Hypothermia (body temperature <96°F or 35.6°C)
Orthostatic increase in pulse (>20 beats/minute) or drop in blood pressure
(>20 mmHg systolic or >10 mmHg diastolic)
Arrested growth and development
Failure of outpatient treatment
Acute food refusal
Uncontrollable bingeing or purging
Acute medical complications of malnutrition (e.g., syncope, seizures, cardiac
failure, pancreatitis)
Comorbid psychiatric or medical condition that prohibits or limits appropriate
outpatient treatment (e.g., severe depression, suicidal ideation, obsessive-
compulsive disorder, type 1 diabetes mellitus)
Note. One or more of the indications justifies hospitalization.
Source. Adapted from Golden et al. 2015.

of cardiac arrhythmias and sudden unexpected death seen during refeed-

ing (Katzman et al. 2014). Hypomagnesemia is more common among pa-
tients who purge (Raj et al. 2012).

Cardiovascular System
In patients with eating disorders, resting heart rates may be as low as 30–40
beats per minute, both systolic and diastolic blood pressures may be low,
and there may be orthostatic changes in both pulse and blood pressure.
These changes reflect an adaptive response to reduced energy intake and
are generally seen in the restrictive eating disorders. Heart size is reduced
and exercise capacity is diminished, but cardiac output and left ventricular
function are usually preserved. A silent pericardial effusion may be present
(Ramacciotti et al. 2003). Electrocardiographic abnormalities include sinus
bradycardia, low voltage complexes, a prolonged QTc interval, increased
QT interval dispersion, first- and second-degree heart block, and various
54 Handbook of Assessment and Treatment of Eating Disorders

TABLE 3–4. Recommended laboratory and ancillary tests for the

evaluation of a child or adolescent with a suspected
eating disorder
Complete blood count and erythrocyte sedimentation rate
Urinalysis
Chemistry profile including blood urea nitrogen, creatinine, albumin, and
electrolytes (sodium, potassium, calcium, phosphorus, and magnesium) and
liver function tests
Serum amylase level (if patient is vomiting)
Triiodothyronine (T3), thyroxine (T4), and thyroid-stimulating hormone levels
Serum luteinizing hormone, follicle-stimulating hormone, estradiol, and
prolactin (if patient is amenorrheic)
Serum 25-hydroxyvitamin D level
Electrocardiogram
Dual-energy X-ray absorptiometry (DXA)
Optional laboratory tests include
Celiac screen
Upper gastrointestinal tract series and small-bowel series
Magnetic resonance imaging of the head

atrial and ventricular arrhythmias. Congestive heart failure does not usually
occur in the starvation phase but can occur during refeeding.

Gastrointestinal System
Among patients with eating disorders, bloating and constipation are fre-
quent complaints and reflect delayed gastric emptying and decreased in-
testinal motility. Liver aminotransferases are elevated in 4%–38% of
patients with AN and improve with nutritional rehabilitation (Narayanan
et al. 2010). Weight loss can lead to the superior mesenteric artery syndrome, a
condition that is characterized by pain and vomiting after eating and is
caused by extrinsic compression of the duodenum by the superior mesen-
teric artery where it originates from the aorta. Rapid weight loss can also
be associated with gallstone formation.
Recurrent vomiting results in erosion of dental enamel, esophagitis,
Mallory-Weiss tears, and possibly esophageal or gastric rupture. Prolonged
recurrent vomiting may cause Barrett’s esophagus, which is a precancer-
ous condition. Laxative abuse can be accompanied by bloody diarrhea.
Serum amylase may be elevated in individuals who are bingeing or purg-
Eating Problems in Children and Adolescents 55

ing. Acute pancreatitis occasionally occurs. Total protein and serum albu-
min levels are usually normal in patients with eating disorders, in contrast
to patients with other forms of malnutrition.

Endocrine System
Growth retardation and short stature can occur in children and adolescents
who develop an eating disorder prior to completion of growth (Lantzouni
et al. 2002; Modan-Moses et al. 2003). This is more likely to occur in ado-
lescent boys with AN because they grow, on average, for 2 years longer
than girls. Catch-up growth can occur with nutritional rehabilitation; how-
ever, even with intervention, these adolescents may not reach their genetic
height potential (Lantzouni et al. 2002). Pubertal delay can occur in those
who develop AN prior to completion of puberty. In girls, primary or sec-
ondary amenorrhea is common and usually follows weight loss but has
been shown to precede weight loss in 20% of cases (Golden et al. 1997).
Levels of luteinizing hormone, follicle-stimulating hormone, and estradiol
are low, often in the prepubertal range. In males, testosterone levels can be
low. In addition to suppression of the hypothalamic-pituitary-gonadal axis,
hypothalamic dysfunction is evidenced by disturbances in satiety, difficul-
ties with temperature regulation, and inability to concentrate urine. There
is activation of the hypothalamic-adrenal axis with high levels of serum
cortisol. The low T3 (triiodothyronine) syndrome or sick euthyroid syn-
drome, is caused by an adaptive response to malnutrition or chronic illness
and is frequently seen. Disturbances in thyroid function resolve with nutri-
tional rehabilitation and should not be treated with thyroid replacement
hormone. A serum 25-hydroxyvitamin D level that is below 30 ng/mL in-
dicates vitamin D insufficiency and requires treatment to replenish vita-
min D stores.

Musculoskeletal System
Because adolescence is a critical time for accrual of peak bone mass, re-
duced bone mineral density for age is a serious long-term complication of
AN. It occurs in both boys and girls (Misra et al. 2008) and is associated
with increased fracture risk even after patients recover from the eating dis-
order (Lucas et al. 1999; Vestergaard et al. 2002).

Hematological System
In patients with eating disorders, suppression of the bone marrow leads to
leukopenia, anemia, and thrombocytopenia (Misra et al. 2004). Anemia is
56 Handbook of Assessment and Treatment of Eating Disorders

usually secondary to bone marrow suppression but may also be due to di-
etary deficiency of vitamin B12, folate, or iron. The erythrocyte sedimen-
tation rate is usually low secondary to decreased hepatic production of
fibrinogen. The presence of an elevated sedimentation rate should arouse
suspicion for another diagnosis.

Neurological System
The major neurological complications of eating disorders are syncope, sei-
zures (secondary to electrolyte disturbances), and structural brain changes
noted on imaging studies (Golden et al. 1996; Katzman et al. 1996). Mus-
cle weakness and a peripheral neuropathy can also occur. Volume deficits
of both gray and white matter have been identified in low-weight patients
with AN, and neuropsychological testing has demonstrated impairment of
attention, concentration, and memory, with deficits in visuospatial ability.
These abnormalities improve substantially or disappear entirely with
weight restoration.

Differential Diagnosis
The differential diagnosis of an eating disorder in a child or adolescent in-
cludes a variety of medical and psychiatric conditions that can be respon-
sible for the presented symptoms. An outline of the differential diagnosis
is shown in Table 3–5. It is important to exclude any other gastrointestinal
conditions, such as inflammatory bowel disease or celiac disease, that can
lead to pain and discomfort related to eating, weight loss, and growth re-
tardation. However, it is also possible for an eating disorder to coexist with
another condition.

Specific Eating Disorder Diagnosis and

Associated Problems in Children
and Adolescents
Anorexia Nervosa
Peak age at onset for AN is during mid-adolescence (ages 13–15 years), but
children as young as 6–7 years may present with the classic syndrome. In
older age groups, approximately 10% of patients with AN are male, but in
those younger than age 14 years, one in six is male (Pinhas et al. 2011).
Eating Problems in Children and Adolescents 57

TABLE 3–5. Differential diagnosis for eating disorders

Medical conditions
Inflammatory bowel disease
Malabsorption: cystic fibrosis, celiac disease
Endocrine conditions: hyperthyroidism, Addison’s disease, diabetes mellitus
Collagen vascular disease
Central nervous system lesions: hypothalamic or pituitary tumors
Malignancies
Chronic infections: tuberculosis, HIV
Immunodeficiency
Psychiatric conditions
Mood disorders
Anxiety disorders
Somatization disorder
Substance use disorders
Psychosis

Core features of AN include restriction of energy intake, leading to low

body weight for age, sex, and development; fear of gaining weight or of be-
coming fat; and disturbance in the way in which one’s body weight or shape
is perceived. Children and younger adolescents frequently do not endorse
fear of gaining weight or body image dissatisfaction, but with revisions to
DSM-5, reliance on identifying behaviors that interfere with weight gain im-
proves diagnostic utility in younger patients. In DSM-5, amenorrhea has
been eliminated as one of the required diagnostic criteria for AN.
The medical findings associated with AN in children and adolescents are
similar to those in adults, with a couple of exceptions. First, children and ado-
lescents may become medically compromised much more rapidly than adults
because of reduced nutritional reserves and increased metabolic demands for
growth and development. Thus, significant medical complications can occur
with a smaller relative amount of weight change or in the context of rapid
weight loss. Second, certain complications such as growth retardation, inter-
ruption of puberty, and interference with peak bone mass acquisition and
brain development have a greater impact in children and adolescents and are
potentially irreversible. For children and adolescents with AN, ongoing med-
ical monitoring in the primary care practitioner’s office every 1–2 weeks is es-
sential to ensure continued weight gain and to monitor for medical stability.
58 Handbook of Assessment and Treatment of Eating Disorders

Bulimia Nervosa
Peak age at onset of BN is in late adolescence or early adulthood; how-
ever, BN does occur in children younger than age 14 years, and there is
evidence that the age at onset for BN is decreasing (Favaro et al. 2009; van
Son et al. 2006). Comorbidity of BN with affective disorders, anxiety dis-
orders, personality disorders, and substance use disorders is high. The
core features of BN include recurrent episodes of binge eating and recur-
rent compensatory behaviors (vomiting, laxatives, diuretics, fasting, exer-
cising) to prevent weight gain, both occurring on average at least once a
week for 3 months. The diagnosis of BN should be considered for any ad-
olescent with weight and body image concerns and marked fluctuations
in weight. On physical examination, particular attention should be paid
to the three objective physical signs of BN: parotid hypertrophy, dental
enamel erosion, and Russell’s sign. Similar to AN, a multidisciplinary
treatment approach is recommended. The role of the medical provider is
to ensure medical stability and monitor for electrolyte disturbances asso-
ciated with unhealthy weight-control practices.

Avoidant/Restrictive Food Intake Disorder

ARFID in DSM-5 is a revision and significant expansion of the DSM-IV
diagnosis called “feeding disorder of infancy or early childhood.”
ARFID describes some individuals who previously were given a diagno-
sis of EDNOS and is frequently seen in younger patients but can occur
at any age. The preponderance of males with ARFID is higher than with
AN. Patients with ARFID may present with clinically significant restric-
tive eating, leading to weight loss or lack of weight gain, growth retarda-
tion, nutritional deficiencies, reliance on tube feeding or oral nutritional
supplements, and/or disturbances in psychosocial functioning. Individu-
als with ARFID may have sensory problems related to the taste, smell,
color, or texture of food, resulting in a limited variety of food consumed.
Some have a fear of swallowing or an inability to swallow food, especially
solid or lumpy foods, which often follows either a personal or witnessed
choking episode. Others have a fear of vomiting, with resultant food re-
fusal. Some patients with ARFID have symptoms of depression and/or
anxiety and may offer somatic complaints as to why they are not eating
(e.g., “my belly hurts”). To make a diagnosis of ARFID, avoidance or re-
striction of food cannot be better justified by another medical condition
or psychiatric disorder; however, these disorders can coexist with the eat-
ing disorder, as long as the severity of abnormal eating behaviors neces-
sitates further clinical attention (American Psychiatric Association 2013).
Eating Problems in Children and Adolescents 59

Because the criteria for ARFID are new in DSM-5, there is no validated
assessment tool or formalized evaluation to aid clinicians in this diagnosis.1
Recent studies have shown that the prevalence of ARFID in newly diagnosed
patients presenting to adolescent medicine eating disorder programs ranges
from 5% to 14% (Fisher et al. 2014; Ornstein et al. 2013; Norris et al. 2014).

Rumination Disorder
Rumination disorder is the repeated, unforced regurgitation of recently eaten
food over at least a 1-month period, occurring multiple times per week and
often daily. It is not associated with nausea or part of any medical illness (e.g.,
gastroesophageal reflux disease), but the diagnosis can be made concurrently
with a medical condition, as long as the other condition is not the only reason
for the behavior. Although rumination has been believed to occur most com-
monly in infants and individuals with developmental disabilities, it also occurs
in children, adolescents, and adults of normal intelligence. It may be difficult
to differentiate between regurgitation and self-induced vomiting; however,
the behavior is effortless and does not serve as a method of weight control. Ru-
mination may help to self-soothe or self-stimulate, especially in those with
mental disabilities, whereas in others, it seems to be related to anxiety. The be-
havior can often be witnessed by clinicians (Chial et al. 2003).

Pica
The distinguishing feature of pica is the ingestion of one or more nonnu-
tritive, nonfood substances on a continual basis for at least 1 month. The
diagnosis of pica cannot be made before age 2, and the behavior cannot
denote an endorsed cultural, religious, or social practice. Pica can be ob-
served with other mental disorders (e.g., developmental disabilities, au-
tism spectrum disorder, schizophrenia); it is only given as a separate
diagnosis if the eating behavior is serious enough to warrant additional
clinical management (American Psychiatric Association 2013).

Conclusion
Because eating disorders have recently become more prevalent among
younger patients, it is incumbent upon pediatric health care providers to

1The Eating Disorder Assessment for DSM-5 (EDA-5; Sysko et al. 2015) does
provide an assessment guide for ARFID, but no information about its perfor-
mance is yet available. Refer to Part 3, “Assessment Tools,” in this volume for
additional information.
60 Handbook of Assessment and Treatment of Eating Disorders

recognize the signs and symptoms and to make prompt diagnoses or refer
to specialists as necessary. DSM-5 has the potential to improve clinical
utility via more specific diagnostic categories.

Key Clinical Points

• When evaluating a child or adolescent with a possible eating disor-
der, the clinician needs to take a history from the patient and par-
ents together, as well as from each individually.
• Skeletal growth retardation or growth in a prepubertal or early pu-
bertal child without concomitant weight gain should be recognized
as significant and akin to weight loss.
• Children and adolescents with eating disorders can become medi-
cally compromised much more rapidly than adults, and frequent
monitoring for medical safety is recommended. Although amenor-
rhea has been removed as a diagnostic criterion for anorexia ner-
vosa in DSM-5, it can still serve as a useful indicator of malnutrition
and clinical severity.
• Although bulimia nervosa was often thought to occur primarily in
older adolescents, younger patients are presenting with significant
clinical symptomatology, which may represent a diagnostic contin-
uum. The DSM-5 change in the minimum frequency criterion for
binge eating and inappropriate compensatory behaviors to once
weekly should help to include more patients in this category.
• Avoidant/restrictive food intake disorder is a newly articulated dis-
order in DSM-5 that is seen typically in younger patients, with a
higher preponderance of males. More research is needed to eluci-
date its diagnosis, complications, and treatment.

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This page intentionally left blank
4 Eating Problems in
Individuals With
Overweight and
Obesity
Marsha D. Marcus, Ph.D.
Jennifer E. Wildes, Ph.D.

Individuals with overweight or obesity constitute the

majority of people in the United States. In general, the assessment of dis-
ordered eating in overweight or obese people does not differ from that in
individuals at a healthy weight, but the presence of obesity requires clini-
cal consideration. Therefore, we focus in this chapter on the clinical ap-
proach to the assessment of overweight and obese people with disordered
eating; specifically, we discuss differential diagnosis, associated problems,
physical assessment, and implications for treatment. Video 3, “Assessing
eating problems in overweight adults,” depicts the issues pertinent to over-
weight or obese patients.

Clinical Approach
It is crucial to define overweight and obesity to provide a context for the
assessment of disordered eating and to provide some background for the
perspective taken in this chapter. Simply stated, obesity refers to excess ad-

65
66 Handbook of Assessment and Treatment of Eating Disorders

iposity, but there is no specific threshold. Currently, the terms overweight

and obese are defined using ranges of body mass index (BMI), a measure
calculated using this formula: weight in kilograms divided by height in me-
ters squared (kg/m2). Specifically, a person with a BMI of 25–30 kg/m2 is
considered overweight, and one with a BMI of at least 30 kg/m2 is consid-
ered obese (National Institutes of Health 1998). On the basis of BMI,
33.4% of U.S. adults currently are overweight and 34.9% are obese (Ogden
et al. 2014); however, it is important to remember that BMI is a proxy for
relative adiposity, and although BMI has been shown to correlate strongly
with obesity-related health problems, it is an imperfect measure of body
fat. Although it appears that the prevalence of overweight and obesity has
stabilized in the United States, the overall prevalence remains high (Ogden
et al. 2014).
The causes of excess adiposity are manifold, but there is little contro-
versy about the fact that increases in obesity prevalence are associated
with the widespread availability of highly palatable foods with high energy
density as well as decreases in levels of physical activity. Indeed, available
data from dietary surveys have documented that calorie intake in the
United States has increased in a fashion parallel to the increased preva-
lence of obesity (Jeffery and Harnack 2007). However, the development
of obesity is not simply a matter of persistent overeating. Rather, obesity
develops in genetically vulnerable individuals as a consequence of an in-
tricate cascade of interacting biological, psychological, family, commu-
nity, and cultural factors. Thus, disordered eating in a given person must
be evaluated in the context of the complex etiology of obesity in the cur-
rent cultural milieu.
An issue of particular salience for clinicians working with obese indi-
viduals is weight bias or stigma. There is considerable evidence that nega-
tive appraisals of obese individuals are ubiquitous (Puhl and Heuer 2010)
and are based on derisive stereotypes about the causes and correlates of
obesity, which include gluttony, laziness, lack of discipline, self-indulgence,
and slovenliness. Weight stigma leads to discrimination against obese indi-
viduals in social contexts, in the workplace, and, importantly, among
health professionals, including those who specialize in the treatment of
obesity (Schwartz et al. 2003). An increasing body of evidence indicates
that stigma and discrimination are associated with significant negative
health consequences, which may include promoting weight gain and the
onset of obesity (Jackson et al. 2014).
Negative weight biases appear especially relevant for obese individuals
with aberrant eating, because obesity-related stigma is complicated further
by awareness that problematic eating behavior may contribute to un-
wanted weight gain. For example, Barnes et al. (2014) compared obese in-
Eating Problems in Individuals With Overweight and Obesity 67

dividuals with and without binge-eating disorder (BED) who sought

treatment for weight and eating problems. Although all study participants
had negative attitudes toward obesity, weight bias was significantly higher
among individuals with BED and was associated with more depression and
eating disorder psychopathology. It is not surprising that blame heaped on
obese individuals may lead them to have intense feelings of shame, which,
in turn, perpetuate a cycle of behaviors that promotes binge eating and ex-
cess weight gain. Given compelling evidence that the presence of weight
bias and stigmatization among care providers and patients may pose signif-
icant barriers to effective treatment, it is imperative that clinicians treating
eating disorders maintain awareness of their own attitudes and beliefs and
that they ensure that patients’ feelings about being larger than average size
are recognized and validated during the assessment process.
Given the high levels of body shame and body dissatisfaction reported
by obese people with disordered eating, clinicians need to appreciate that
these individuals often are desperate to lose weight. As noted by Bulik et
al. (2012), a mismatch between the patient’s expectations (i.e., help for dis-
ordered eating and weight loss) and the goals of clinicians that focus on eat-
ing disorder treatment (mitigation of disordered eating) may lead to
treatment dropout or failure. To enhance the likelihood of achieving con-
gruence between the goals of patients and those of treating clinicians, the
overall eating disorder assessment should include evaluation of both
weight history and disordered eating. Optimally, a thorough assessment
will validate patients’ concerns regarding body weight, create a shared un-
derstanding, and establish a firm basis for treatment recommendations.
A list of assessment topics to guide the clinician in the evaluation of a
patient’s weight and eating behavior history appears in Table 4–1. The sug-
gestions are not exhaustive but are presented to illustrate the interconnec-
tedness of body weight, diet history, and eating behavior. For example,
given that 40%–70% of the variance in body size is explained by genetic
factors that affect obesity proneness (Barsh et al. 2000), it is important for
the assessment clinician and the patient to understand personal obesity
vulnerability by discussing family and personal weight history. Similarly,
because duration of obesity is associated with the development of comor-
bidities, information about age at onset may provide some insight into the
likelihood of the presence of obesity-related conditions that require inde-
pendent medical attention.
Questions related to variation in body weight during adulthood allow
for assessment of weight suppression or significant diet-induced weight
loss that is sustained for a year or more (Lowe 1993). Weight suppression,
which is calculated as the difference between the highest previous adult
body weight (when not pregnant) and current weight, has been shown to
68 Handbook of Assessment and Treatment of Eating Disorders

TABLE 4–1. Weight history assessment

Assessment topic Rationale

Family and personal history of obesity Obesity runs in families.

Duration of obesity/pediatric obesity Medical comorbidity increases with
duration of obesity.
Weight suppression (difference Weight suppression predicts increases
between the highest previous adult in body mass index, eating disorder
body weight [when not pregnant] and psychopathology, and poorer
current weight) treatment outcome.
History of weight loss efforts It is crucial to identify history of
significant dietary restriction, history
of low weight, and contraindications
for weight loss.
Personal ideal body weight It is important to identify and discuss
patient expectations.
Current weight loss goals Understanding current expectations is
salient for intervention
recommendations.
Weight change during previous year Many individuals gain weight in the
period prior to seeking treatment.
Age at onset of disordered eating Individuals who report loss-of-control
or binge eating prior to their first diet
may have different course.

predict increases in BMI (Stice et al. 2011), poor response to eating disor-
der treatment (Butryn et al. 2006), and increases in bulimic pathology
(Thomas et al. 2011). Understanding the temporal relationship among di-
eting history, weight, and aberrant eating also may yield information that
will help guide treatment planning. Evidence indicates that a significant
proportion (38.7%–55%) of overweight and obese individuals report the
onset of binge eating before the initiation of dieting (Abbott et al. 1998;
Spurrell et al. 1997). This developmental pattern is associated with more
eating disorder psychopathology and other psychiatric symptoms (Marcus
et al. 1995; Spurrell et al. 1997) and suggests that dieting behavior may be
a consequence rather than a cause of binge eating for a substantial propor-
tion of individuals with binge-eating problems. Given the potential clinical
implications, it is important for clinicians to include the discussion of
weight history as part of a comprehensive assessment.
Video 3 illustrates the special considerations in the assessment and
treatment of overweight patients.
Eating Problems in Individuals With Overweight and Obesity 69

Video Illustration 3: Assessing eating problems in overweight

adults (5:52)

Differential Diagnosis
The differential diagnosis of disordered eating in individuals who are over-
weight or obese includes consideration of any DSM-5 (American Psychi-
atric Association 2013) feeding or eating disorder except anorexia nervosa
(AN), which requires a significantly low body weight. In this section, we
first discuss the assessment of disorders characterized by binge eating—that
is, BED and bulimia nervosa (BN)—and then the assessment of other spec-
ified eating disorders. Finally, we describe avoidant/restrictive food intake
disorder (ARFID), a new feeding disorder in DSM-5.
Before discussing BED and BN, it is important to note that binge eating
is defined identically in both disorders as the intake of an unusually large
amount of food given the circumstances (i.e., more than others would eat
in a similar situation), accompanied by a sense of a lack of control during
the episode (see also Chapter 10, “Use of the Eating Disorder Assessment
for DSM-5”). Because BED is strongly associated with obesity (Marcus
and Wildes 2009), much of the available data on aberrant eating among
obese individuals is from the population with BED. Indeed, data from the
National Comorbidity Survey Replication (Hudson et al. 2007), a popula-
tion-based study of U.S. men and women, showed that 81.1% of individu-
als with a 12-month prevalence of BED were overweight or obese.
The DSM-5 diagnostic criteria for BED include persistent binge eat-
ing in the absence of the regular compensatory behaviors to prevent
weight gain that are a cardinal feature of BN. For a BED diagnosis, binge-
eating episodes must be associated with marked distress and three or
more of the following correlates: eating much more quickly than normal;
eating until feeling uncomfortably full; eating large amounts of food when
not physically hungry; eating alone because of feeling embarrassed by the
quantity that one is eating; and feeling disgusted with oneself, depressed,
or very guilty afterward. Finally, the binge eating must occur at least once
per week, on average, for 3 months (see the DSM-5 diagnostic criteria in
Box 1–3 in Chapter 1, “Classification of Eating Disorders”).
Although the cognitive correlates of disordered eating required for a
diagnosis of AN or BN are not required for a BED diagnosis, there is evi-
dence that the presence of an undue influence of body shape or weight on
self-evaluation has prognostic significance. For example, Grilo et al. (2013)
found that overvaluation of shape and weight in individuals with BED was
70 Handbook of Assessment and Treatment of Eating Disorders

strongly related to distress and eating-related psychopathology and nega-

tively associated with treatment outcome. Therefore, clinicians should ask
obese individuals routinely about overvaluation of weight and shape and
other cognitive symptoms of disordered eating.
BN also should be included as a differential diagnosis in the assessment
of individuals who are obese. BN is characterized by recurrent binge eat-
ing, accompanied by regular inappropriate compensatory behaviors (i.e.,
self-induced vomiting; misuse of laxatives, diuretics, or other medications;
fasting; or excessive exercise) to prevent weight gain. The binge eating and
inappropriate compensatory behaviors must occur, on average, at least
once a week for a minimum of 3 months. A diagnosis of BN also requires
that an individual’s self-evaluation be unduly influenced by shape and
weight (see the DSM-5 diagnostic criteria in Box 1–2 in Chapter 1).
Although long considered to be primarily a disorder of nonobese indi-
viduals, BN is also associated with adiposity. For example, Hudson et al.
(2007) found that 84.2% of individuals with a 12-month diagnosis of BN
were overweight or obese. Similarly, recent data from the World Health
Organization World Mental Health Surveys, a population-based study of
more than 24,000 men and women in 14 countries, documented the prev-
alence and correlates of BED using BN as a comparator (Kessler et al.
2013). Individuals with BN and BED both had higher BMIs than those
without a history of eating disorders; 32.8% of individuals with BN and
41.7% of individuals with BED were obese. Moreover, there were no sig-
nificant differences between BN and BED in proportions of underweight,
healthy weight, overweight, or obese individuals, confirming the impor-
tance of considering both diagnoses in overweight and obese individuals
who present with recurrent binge eating.
In DSM-5, individuals who have symptoms of disordered eating asso-
ciated with distress and dysfunction but do not meet full criteria for a spe-
cific feeding or eating disorder may be diagnosed with other specified
feeding or eating disorder (OSFED). One example provided in DSM-5 is
atypical AN, in which the individual’s body weight is normal or above
normal despite persistent dietary restriction and significant weight loss but
the person meets all of the other criteria for AN. Therefore, a previously
obese individual who loses a significant amount of weight and develops all
of the signs and symptoms of AN except a markedly low body weight may
be given the diagnosis of atypical AN. Although this presentation is not
uncommon in eating disorder specialty care settings, little is known about
how or whether the course and outcome of atypical AN differ from those
of full-syndrome AN.
Another example of OSFED is night eating syndrome, which is charac-
terized by recurrent episodes of night eating (eating after awakening from
Eating Problems in Individuals With Overweight and Obesity 71

sleep or excessive food consumption after the evening meal) with aware-
ness and recall of the eating. This pattern of eating is not better explained
by BED or another mental disorder and is not due to another medical dis-
order or the effects of medication. Criteria for night eating syndrome have
evolved over time, and many studies have failed to control for the overlap
between night eating syndrome and BED. Consequently, there has been
uncertainty as to whether night eating syndrome is a distinct clinical entity
(Runfola et al. 2014). Nevertheless, night eating syndrome appears to be
more common in overweight and obese individuals and may lead to
weight gain in vulnerable people (Gallant et al. 2012). Although a com-
plete evaluation of disordered eating in overweight and obese individuals
should include consideration of night eating syndrome, there is only pre-
liminary evidence to suggest that a form of cognitive-behavioral therapy
(CBT) adapted to incorporate sleep hygiene, relaxation, and consideration
of either bright light or medication treatments may be helpful for these pa-
tients (Allison et al. 2010).
DSM-5 feeding and eating disorders also include pica, rumination dis-
order, and ARFID, any of which may be diagnosed in overweight and
obese individuals. Pica (the persistent ingestion of nonnutritive food sub-
stances) and rumination disorder (the repeated regurgitation of food that is
then re-chewed, re-swallowed, or spit out) have been studied in special popu-
lations, such as pregnant women and individuals with developmental disabil-
ities, but, in general, they are poorly understood. A recent study of individuals
in a residential program for eating disorders and an outpatient weight man-
agement program found that diagnosable pica and rumination disorder were
rare, but reports of pica-like behaviors (e.g., eating uncooked pasta, chewing
ice) and rumination were more common (Delaney et al. 2015). The authors
suggested that questions regarding behaviors associated with pica and ru-
mination should be included routinely in eating disorder assessment.
ARFID is a new feeding disorder in DSM-5. The criteria for feeding
disorder of infancy or early childhood in DSM-IV (American Psychiatric
Association 1994) were expanded and renamed in recognition that in ad-
dition to young children, there are older children, adolescents, and adults
who habitually restrict food intake to a degree that they develop medical
or psychosocial consequences (Attia et al. 2013). ARFID is characterized
by a persistent failure to meet nutritional and/or energy needs associated
with one or more of the following: significant weight loss (or failure to gain
expected weight or faltering growth in children), significant nutritional de-
ficiency, dependence on enteral feeding, or marked interference with psy-
chosocial functioning. The food restriction cannot be due to a lack of
available food or associated with a culturally sanctioned practice, and
there is no disturbance in the experience of body shape or weight (i.e.,
72 Handbook of Assessment and Treatment of Eating Disorders

ARFID is not diagnosed in addition to AN or BN). Finally, the eating dis-

turbance cannot be better explained by a concurrent medical condition or
another mental disorder (see the DSM-5 diagnostic criteria for ARFID in
Box 1–4 in Chapter 1). Very little is known about ARFID, in general, and
about the disorder in adults, in particular. Research is needed to determine
the course, prognosis, and outcome of the disorder (Kreipe and Palomaki
2012). Nevertheless, given initial reports about preferences among highly
selective eaters for highly palatable, nutrient-dense foods and indications
that overweight and obesity rates in these individuals are comparable with
those in the general population (Wildes et al. 2012), clinicians evaluating
aberrant eating in obese individuals should assess significant dietary re-
striction associated with distress, dysfunction, or nutritional deficiency.
Finally, although not included in DSM-5 as a diagnosis, individuals who
are overweight or obese may seek treatment for food addiction. The con-
cept of food addiction has been the focus of extensive attention in the scien-
tific literature and the lay press, and the notion that certain foods,
particularly those that are highly palatable and high in calories, are addict-
ing has considerable face validity. Briefly, the addiction model of obesity
posits that substance use disorders and persistent overeating of highly palat-
able foods share a common phenomenology (e.g., escalation of use over
time and continued misuse of the substance despite negative consequences).
These observations are bolstered by animal studies and a growing number
of human studies that have shown that repeated consumption of palatable
foods results in behavioral and neurochemical changes analogous to those
seen in chronic substance use (Marcus and Wildes 2014). The notion that
the reinforcement from highly palatable food can override homeostatic
eating and co-opt the dopaminergic neurocircuitry involved in reward
sensitivity and incentive motivation has both research support (Volkow et
al. 2013) and prominent critics (Ziauddeen and Fletcher 2013), and the
topic continues to be controversial. Indeed, given mixed findings from
studies comparing obese and lean individuals, there have been investiga-
tions focusing on binge eaters as the obesity phenotype characterized by
food addiction (Dalton et al. 2013). As noted by Gearhardt et al. (2011),
understanding the relationship between food addiction and BED may help
explicate the etiology of aberrant eating or may offer neurobiological targets
for treatment. At this point in time, however, the implications of food addic-
tion for treatment, course, and outcome of disordered eating are unknown.

Associated Problems
Eating disorders and obesity are associated with other psychiatric comor-
bidities, suggesting that individuals with both conditions may have an in-
Eating Problems in Individuals With Overweight and Obesity 73

creased mental health burden. There is robust evidence that BED and BN
are associated with psychiatric comorbidity; data from the National Co-
morbidity Replication Study (Hudson et al. 2007) documented that 78.9%
of individuals with BED and 94.5% of those with BN met criteria for at
least one additional DSM-IV psychiatric disorder. Odds ratios indicated
that the risk of a comorbid lifetime psychiatric disorder was higher in BN
than in BED, but comorbid mood and anxiety disorders, in particular,
were highly prevalent in both groups (e.g., 46.4% of individuals with BED
and 70.7% of individuals with BN had a lifetime history of comorbid mood
disorder). A population-based study of BED and BN in 14 countries (Kes-
sler et al. 2013) mirrored findings from the United States (Hudson et al.
2007); that is, the majority of individuals with BED (79%) and BN (84.8%)
met lifetime criteria for an additional DSM-IV psychiatric disorder. More-
over, BED and BN were associated with comparable levels of impairment
in social and occupational functioning across countries, demonstrating the
clinical significance of both disorders.
Obese individuals also are at elevated risk for psychiatric comorbidity.
For example, in an analysis of data from 177,047 participants in the 2006
Behavioral Risk Factor Surveillance System (Zhao et al. 2009), rates of self-
reported diagnoses of current depression, lifetime diagnosed depression,
and anxiety were higher in women who were overweight or obese than
among nonoverweight women and were higher in men with severe obe-
sity than among nonoverweight men, after the authors controlled for mul-
tiple potential confounders, including medical illness and psychosocial
factors. Similarly, a meta-analysis of longitudinal studies examining the as-
sociation between obesity and depression confirmed a reciprocal link be-
tween depression and obesity, such that obesity increased the risk for
depression and, to a lesser extent, depression predicted the development
of obesity (Luppino et al. 2010). Finally, the risk of mood disorders, but
not anxiety or substance use disorders, is markedly higher among individ-
uals with severe obesity compared with overweight or moderately obese
individuals (Petry et al. 2008).
Given the risk of psychiatric comorbidity in individuals with eating dis-
orders and obesity, and the potential of an additive or interactive effect for
individuals who are obese and have disordered eating, clinicians should
conduct a complete psychiatric assessment and consider the role of psy-
chiatric comorbidity in treatment planning.

Physical Assessment
The medical consequences of obesity are indisputable and affect virtually
all aspects of human functioning (Hill and Wyatt 2013). Obesity is associ-
74 Handbook of Assessment and Treatment of Eating Disorders

ated with cardiovascular and metabolic risk, kidney disease, several types
of cancer, osteoarthritis, sleep apnea, and reduced quality of life (Eckel
2008; Vucenik and Stains 2012; Wang et al. 2011). Binge eating also may
contribute to medical morbidity over and above that associated with obe-
sity alone. For example, in a prospective 5-year study of individuals with
and without BED matched for baseline BMI, investigators documented
that BED conferred an increased risk for self-reported dyslipidemia and
two or more components of the metabolic syndrome (Hudson et al. 2010).
Another investigation documented that overweight and obese individuals
with BED, when compared with those without BED, were significantly
more likely to have irritable bowel syndrome and fibromyalgia (Javaras et
al. 2008). Although additional research is needed to confirm that BED is
an independent contributor to obesity-related medical comorbidity, as-
sessment and management of obesity-related comorbidities are necessary
for all overweight individuals.
It is likely that patients who are obese who do receive regular medical
care have been advised to lose weight to mitigate the risk of developing
comorbidities, particularly cardiovascular disease and diabetes. In this
context, it is appropriate for mental health clinicians to communicate with
primary care providers regarding the presence of disordered eating to en-
hance the likelihood that medical recommendations are consistent with
the treatment of disordered eating (Bulik et al. 2012).
Mental health clinicians need to keep in mind that eating disorders in
individuals of any body size are associated with medical sequelae that
might require attention. Purging behaviors, especially self-induced vomit-
ing and misuse of laxatives, and to a lesser extent binge eating, are associ-
ated with multiple medical complications (see Mehler et al. 2011 for
review). Medical assessment prior to treatment is advisable, and depend-
ing on the severity of the eating disorder behaviors, routine medical mon-
itoring may be indicated.

Implications for Treatment

Research on the treatment of overweight and obese individuals with dis-
ordered eating has focused primarily on BED. Although both disordered
eating and excess adiposity may serve as the focus of treatment for over-
weight and obese individuals with BED, we recommend that the eating
disorder should be the initial focus of intervention. Some studies have
shown that behavioral weight loss interventions are effective in reducing
binge eating and promoting modest weight loss in obese BED patients in
the short term, but there now is solid evidence that addressing binge eating
is more effective than behavioral weight loss in the treatment of BED. In
Eating Problems in Individuals With Overweight and Obesity 75

the most compelling study to date, Wilson et al. (2010) randomly assigned
more than 200 overweight or obese men and women with BED to 20 ses-
sions of a behavioral weight loss program, interpersonal therapy (IPT), or
CBT guided self-help (CBTgsh). Two-year follow-up data showed that
both IPT and CBTgsh were more effective than behavioral weight loss in
achieving remission from binge eating. Although weight loss was limited
and similar across intervention conditions, remission from binge eating
was associated with a greater likelihood of weight losses that were at least
5% of initial body weight.
Bolstering the recommendation for a primary focus on disordered eat-
ing, a study that examined patterns of weight change among treatment-
seeking obese individuals with BED found that a significant minority
(35.4%) had gained 10% of body weight or more in the year preceding
treatment. Thus, although treatment focusing on disordered eating may
not lead to weight loss, especially in the short term, findings suggest that
eating disorder intervention may serve to stabilize weight and prevent in-
creases in obesity severity (Masheb et al. 2013). In summary, clinicians are
in a strong position to advise that the treatment of disordered eating
should be the focus: successful intervention may stabilize weight, and
long-term abstinence from binge eating may be associated with decreases
in body weight.
Much less is known about the treatment of obese individuals with BN
or other feeding or eating disorders. To our knowledge, there are no inves-
tigations comparing the treatment outcome of overweight and nonover-
weight individuals with BN. Furthermore, it is not currently known
whether the apparent increase in obesity among patients with BN is ex-
plained by demographic trends or if obese and nonobese individuals differ
in salient clinical characteristics. Some evidence suggests that individuals
with BN who report binge eating before the onset of dieting behavior,
when compared with those who dieted before the onset of binge eating,
have an earlier onset of aberrant eating, higher weights, and a lower fre-
quency of vomiting in relation to binge eating; that is, they tend to resem-
ble individuals with BED (Haiman and Devlin 1999). Future research is
needed to clarify how obesity may affect treatment outcome of BN; how-
ever, at this point, CBT is the treatment of choice for BN and BED (Wil-
son et al. 2007). Finally, because the evidence base for the treatment of
DSM-5 feeding disorders or other specified feeding and eating disorders
is small, there is little to guide clinicians on the management of obese in-
dividuals presenting with these problems.
Although we recommend a primary focus on disordered eating for in-
dividuals with BED or BN, questions remain for clinicians and treatment-
seeking obese individuals with binge-eating problems—whether and when
76 Handbook of Assessment and Treatment of Eating Disorders

patients can or should pursue weight loss. Although stabilization of eating

behaviors through the successful treatment of BED may provide a better
foundation for subsequent weight loss interventions, there also is substan-
tial evidence that behavioral weight loss programs focusing on the
achievement of even 3%–5% sustained decreases in initial body weight are
associated with significant improvements in cardiometabolic risk factors,
psychiatric symptoms, and quality of life. Indeed, guidelines for the man-
agement of adults who are overweight or obese (Jensen et al. 2014) advise
that all patients with a BMI over 30 kg/m2 and those with a BMI greater
than or equal to 25 kg/m2 with one or more additional risk factors (e.g.,
hypertension) should be referred for comprehensive behavioral lifestyle
intervention. Furthermore, there is evidence that a significant percentage
of participants in comprehensive behavioral weight loss programs are able
to sustain at least some weight loss and associated decreases in cardiomet-
abolic risk over a several-year period when there is continued contact with
interventionists (Knowler et al. 2009).
Nevertheless, there are important caveats when considering behav-
ioral weight management for obese individuals with binge-eating prob-
lems. First, many individuals with BED will not be satisfied with modest
weight losses, and individual weight loss goals for those entering obesity
treatment programs have been shown to be significantly greater than the
reasonable weight losses suggested by health guidelines (Foster et al.
1997). Second, weight loss programs may not lead to sustained weight
losses for most individuals, and data from a study by Gorin et al. (2008)
suggest that long-term weight loss maintenance is more problematic for in-
dividuals with BED than for those without.
Despite these concerns, it also is important to note that there is little
evidence showing that comprehensive behavioral weight management
programs are associated with the exacerbation of eating-related psycho-
pathology. For example, although Wilson et al. (2010) found that inter-
ventions that targeted binge eating were superior to behavioral weight
management in achieving remission from binge eating, there was no evi-
dence that comprehensive behavioral weight management was associ-
ated with exacerbation of eating-related psychopathology at any
assessment point. Thus, consideration of weight management for obese
individuals with BED should involve a detailed discussion of the pros and
cons of pursuing weight loss at a given point in time.
Finally, in the context of considering the management of obesity, dis-
cussion of Health at Every Size (HAES; Miller and Jacob 2001) is war-
ranted because this movement has gained increased traction in the eating
disorders community. Briefly stated, the philosophy of HAES emphasizes
shifting the focus from weight loss to promotion of healthy behaviors as a
Eating Problems in Individuals With Overweight and Obesity 77

goal for people of all sizes. Proponents argue that weight loss programs do
not lead to sustained improvements in health or weight and are associated
with negative consequences such as increased body and food preoccupa-
tion, reduced self-esteem, disordered eating, and weight stigmatization
(Bacon and Aphramor 2011; Miller and Jacob 2001). The effects of tradi-
tional weight loss programs are indeed modest, but the evidence offers
meager justification for the proposition that HAES leads to superior out-
comes. There have been few controlled trials of HAES interventions. In
one randomized controlled trial comparing a 4-month HAES intervention
with a social support intervention and a wait-list control group
(Provencher et al. 2009), no differences were observed between the HAES
and social support groups at 1-year follow-up, and neither of the interven-
tion conditions was associated with improvements in weight, lipoproteins,
blood pressure, self-reported energy intake, or physical activity.
In a second trial, Bacon et al. (2002, 2005) evaluated the relative effi-
cacy of a behavioral weight management program and a HAES program.
Weekly group sessions were offered for 6 months, and an additional six
monthly sessions followed. Participants also were evaluated 1 year after
completion of the 1-year intervention. There was a high rate of attrition in
both groups (nearly 50%) at follow-up, and no significant between-group
differences were observed in weight-related parameters or cardiovascular
risk factors. Nevertheless, those in the HAES group, compared to the be-
havioral weight control participants, showed significant improvements in
subscale scores on the Eating Disorder Inventory (Garner 1991). HAES
also was associated with greater improvements in self-esteem, but both
groups showed significant improvement over the 2-year period of obser-
vation.
In summary, results of the few extant studies provide initial evidence
that HAES may have psychosocial benefits for some patients, but support
for the idea that HAES improves weight-related or cardiovascular risk
profiles is scant. Conversely, and consistent with other data about the ef-
fects of weight management on aspects of disordered eating, the one
HAES study that used a behavioral weight management comparison con-
dition (Bacon et al. 2002, 2005) did not document negative effects of the
program on any measured variable, raising questions regarding the oft-
stated HAES proposition that unsuccessful weight management is associ-
ated with significant harms.
In addition to a lack of evidence for the utility of HAES interventions,
HAES advocates have argued that the strong associations between obesity
and multiple medical comorbidities do not prove causality and that many
studies fail to control for salient covariables that explain the obesity and
medical illness relationship (Bacon and Aphramor 2011). Imperfect re-
78 Handbook of Assessment and Treatment of Eating Disorders

search may abound, but the contention that obesity-related health risks are
overstated and unproven is inconsistent with an enormous amount of ev-
idence and scientific consensus. Furthermore, the notion of metabolically
healthy obesity (Lavie et al. 2015) has been questioned. Recent analyses
have shown that individuals who are obese are at increased risk for unfa-
vorable outcomes even when they have no current metabolic abnormali-
ties and indicate that increased adiposity is not a benign condition
(Kramer et al. 2013). Thus, although additional research may substantiate
the utility of HAES interventions, there is no current justification for state-
ments averring its efficacy.

Conclusion
In this chapter, we have outlined multiple and often interacting factors that
are salient for the assessment of individuals who are obese and who have
disordered eating. This population requires special consideration, espe-
cially in light of data suggesting that weight stigma and weight discrimina-
tion exist among health professionals, including specialists in the
treatment of obesity (Schwartz et al. 2003). Available evidence indicates
that binge eating should be treated first, but behavioral weight manage-
ment may mitigate obesity-related risk and does not appear to be associ-
ated with eating disorder symptoms.

Key Clinical Points

• The majority of individuals in the United States are overweight or
obese.
• The etiology of obesity is multifactorial, and most obese individuals
do not report disordered eating.
• It is important for clinicians to understand how shaming and stigma
affect treatment-seeking individuals and that body shame and body
dissatisfaction often are associated with an intense desire to lose
weight as well as to stop disordered eating.
• Overweight and obese individuals may be diagnosed with any
DSM-5 feeding or eating disorder except anorexia nervosa, and
thus the full range of feeding and eating disorders should be con-
sidered.
• Disordered eating among individuals who are obese is associated
with marked psychiatric comorbidity and impairments.
• Obesity is associated with significant nonpsychiatric medical co-
morbidity, and the presence of binge eating may confer additional
Eating Problems in Individuals With Overweight and Obesity 79

risks. Thus, referral for comprehensive health assessments is rec-

ommended prior to the initiation of treatment.
• Eating disorder treatment, particularly cognitive-behavioral therapy,
should be the first-line intervention for obese individuals with binge-
eating problems, although cognitive-behavioral therapy is not usu-
ally associated with short-term weight loss.
• The pros and cons of behavioral weight management interventions
for obese individuals should be considered carefully, but modest
weight losses may improve cardiometabolic health without psycho-
social harms, and therefore these interventions can be considered
for selected individuals.

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5 Assessment of
Eating Disorders
and Problematic Eating
Behavior in Bariatric
Surgery Patients
Eva M. Conceição, Ph.D.
James E. Mitchell, M.D.

Bariatric surgery procedures substantially alter the

normal anatomy of the gastrointestinal (GI) tract, leading to significant
changes in eating behavior. However, a number of bariatric surgery pa-
tients report problematic eating behaviors, as well as full and subthreshold
eating disorders, both preoperatively and postoperatively, which have
been associated with poor weight treatment outcomes (Conceição et al.
2013a, 2014). The notable heterogeneity in eating pathology documented
in the literature and the lack of an identified nomenclature for these prob-
lems are serious challenges, and understanding disordered eating in can-
didates for bariatric surgery is important for clinicians attempting to devise
and implement an effective therapeutic approach.
Currently, no diagnostic terms have been specifically developed to de-
scribe eating disorders and problematic eating in individuals before or af-
ter bariatric surgery. The criteria used for diagnosis in these populations
have been the standard Diagnostic and Statistical Manual criteria, but impor-

83
84 Handbook of Assessment and Treatment of Eating Disorders

tant differences should be considered when assessing eating disorders and

problematic eating behaviors in bariatric surgery patients, both preopera-
tively and in the postoperative period. In this chapter, we focus on the as-
sessment of eating disorders before and after surgery and in the
application of DSM-5 criteria for eating disorders in bariatric surgery pa-
tients (American Psychiatric Association 2013). We also address problem-
atic eating behaviors and GI syndromes that play an important role in
bariatric surgery outcomes, such as grazing, emotional eating, and dump-
ing syndrome. Finally, we provide specific guidelines for the clinical as-
sessment of eating disorders and problematic eating behaviors.

Special Considerations
for the Clinical Assessment
It is strongly recommended that mental health professionals assessing in-
dividuals before and after bariatric surgery possess specialized interest in
and knowledge about obesity, weight control, and weight loss surgery. The
clinical assessment of eating disorders and problematic eating behaviors
in bariatric surgery patients requires not only specific knowledge of the
different surgical procedures, the associated nutritional requirements, and
the variations in eating that these patients must implement over time, but
also attention to subsyndromal presentation of symptoms and atypical be-
haviors not often seen in nonbariatric surgery patients with eating disor-
ders. Additionally, clinicians need to have open communication with the
rest of the multidisciplinary bariatric team to exchange information partic-
ularly regarding adherence to nutritional requirements, as well as other
factors affecting surgical outcomes. These factors may result in less weight
loss or greater weight regain and also may dictate the need for additional
clinical attention. The remainder of this chapter focuses on the specific
types of information relevant to the assessment of eating disorders and
problematic eating among individuals having bariatric surgery.
When a bariatric surgery candidate or postoperative patient is referred
for evaluation, standard assessments for the DSM-5 diagnostic criteria for
eating disorders should be used. The assessment of eating pathology is of-
ten intended to identify patients who are engaging in behaviors that may
increase the risk for poor outcomes, including attenuated weight loss, ex-
cessive regain, or impaired psychological functioning. Because interviews
typically occur during what is often a mandatory psychiatric assessment,
there is a risk that participants will deny problematic behaviors to avoid
delay or denial of surgery. With postsurgery patients, assessment should
take place at critical postoperative time points, particularly after the weight
Assessment of Bariatric Surgery Patients 85

loss nadir is reached at about 1–2 years after surgery, when eating behav-
ior may potentially deteriorate (Magro et al. 2008). Like other individuals
with symptoms of an eating disorder, post–bariatric surgery patients with
anorexia- or bulimia-like symptoms may deny their problematic behaviors
in the hope of achieving unrealistic weight goals. They may justify these be-
haviors as common sequelae of surgery, including the need to limit the
amounts and types of foods ingested, and may attribute the occurrence of
vomiting and/or dumping to the surgery even if those behaviors are self-
induced. In such cases, the patients’ low level of commitment to change may
be particularly challenging, and an empathic, nonjudgmental but firm ap-
proach will be needed to address the underlying motivation for these prob-
lematic behaviors. At all times, educating patients about the risks of certain
eating behaviors or eating disorders and about how early detection of prob-
lematic symptoms may improve outcome of surgery and enhance psycho-
logical functioning will facilitate cooperation and openness.
Binge-eating disorder (BED), binge eating, and so-called loss-of-control
eating are the most commonly reported eating disorder problems in pa-
tients before and after bariatric surgery. However, in bariatric surgery can-
didates, little is known about the prevalence of either full or subthreshold
bulimia nervosa (BN), and anorexia nervosa (AN) is excluded because
these patients do not meet the low-weight criteria. The development of
classic eating disorders after bariatric surgery is now recognized, and al-
though incidence rates are not well established, they appear to be very low.
Nonetheless, in rare cases inpatient eating disorder treatment may be re-
quired (Conceição et al. 2013a). Presentations following surgery may be
atypical because of age at onset (bariatric surgery patients are usually
older), the difficulties in deciding what should be considered a normal or
low body mass index (BMI), dissatisfaction with body image after massive
weight loss, and some of the specific compensatory behaviors that are
unique to this population.
Clinicians must distinguish between symptoms of an eating disorder
and changes in behavior necessitated by alterations to the GI tract. After
surgery, patients require a very restrictive diet and are instructed to limit
meal size, to systematically follow an eating schedule, to weigh their food,
and often to cut food into small pieces. They are also told to avoid certain
foods that may be intolerable (e.g., red meat), to chew food extensively, and
to monitor and control their weight. In fact, some level of patient self-
responsibility and self-control regarding food intake is strongly encouraged
by professionals caring for these patients to facilitate weight loss. These self-
responsibility and self-control behaviors may resemble those expected in
treatment of individuals with eating disorders. Thus, in evaluating such be-
haviors, the clinician needs to determine whether the patient’s behaviors
86 Handbook of Assessment and Treatment of Eating Disorders

result from excessive concerns about weight and shape or from the desire
to strictly adhere to recommendations to avoid complications following
surgery.
Similarly, episodic vomiting is frequent among patients following bar-
iatric surgery (de Zwaan et al. 2010) and usually occurs in response to the
ingestion of intolerable foods (e.g., red meat), eating too quickly, or chew-
ing food insufficiently. At times, vomiting is used to reduce physical dis-
comfort from plugging symptoms (problems with the small opening of the
stomach becoming plugged with food) or from having eaten too much at
one time. However, a minority of patients (12% in the study by de Zwaan
et al. [2010]) also utilize vomiting as a means to control their weight.
Atypical compensatory behaviors also may emerge in patients follow-
ing bariatric surgery. Dumping syndrome—the rapid movement of undi-
gested food into the small bowel, causing abdominal cramps, nausea, and
diarrhea—is a common GI event after surgery. Dumping syndrome has
typically been described as an involuntary event, but dumping also is in-
duced purposefully with the ingestion of specific foods by some patients to
compensate for overeating or to enhance weight loss.
Additional concerns emerge when assessing low weight in post–bariatric
surgery patients. It has not yet been determined what constitutes a low BMI
for patients who were formerly severely obese and have lost massive
amounts of weight following surgery. A BMI of 25 kg/m2 has been recom-
mended as a useful line between overweight and so-called normal weight in
the general population; however, there is little agreement on what should
be regarded as a low or normal BMI in patients following bariatric surgery
(Dixon et al. 2005). In reality, the majority of those who successfully lose
weight postsurgery do not reach a BMI lower than 25 kg/m2, which would
be difficult to achieve outside of severely restricting their food intake and
risking malnutrition (Dixon et al. 2005). Moreover, postsurgery BMI is also
affected by patients’ excess skin, which averages 4.8 kg but can account for
up to 15 kg of weight following massive weight loss (Ortega et al. 2010). A
detailed weight history and exploration of the patient’s expectations re-
garding weight may facilitate the evaluation of BMI in this population.
Among patients being assessed after surgery, the clinician should also
assess the age at onset and duration of obesity, past history of weight loss
and weight loss attempts, the patient’s view about his or her current
weight, the patient’s ideal weight and desired weight after surgery, weight
loss since surgery, and recent weight fluctuations and their impact on self-
esteem and mood. Patients’ perspectives about their ideal weight, the
weight they think they can achieve and maintain in a healthy way, fear of
weight regain, coping strategies for weight stabilization, and behaviors to
facilitate weight loss may help in deciding whether the weight goal is ap-
Assessment of Bariatric Surgery Patients 87

propriate and whether it is being pursued or maintained with problematic

or inappropriate eating behaviors.
Addressing weight or shape concerns in individuals who are undergo-
ing massive changes in weight poses additional challenges. When address-
ing the role of body weight and body image in self-evaluation, the clinician
should consider the fact that substantial weight loss facilitates many activ-
ities of daily living, improves perceived quality of life and social function-
ing, and is usually reinforced by others, which naturally results in weight
being a salient aspect of self-evaluation (van Hout et al. 2006). Following
surgery, individuals not only may have a realistic fear of weight regain, but
excess loose skin, skin envelopes, and fat deposits also have a great impact
on body image and may contribute to severe body dissatisfaction, as well
as social embarrassment, despite weight loss (Odom et al. 2010). Weight
concerns appear to peak when much of the expected weight loss has been
achieved and patients reach a plateau in their rate of weight change (Con-
ceição et al. 2013b). The slower weight loss rate at this time may trigger
increased fears of weight regain (Conceição et al. 2013b) and greater ef-
forts to control weight, resulting in overly restrictive eating behaviors that
may result in malnutrition.
Special considerations and specific probe questions for the assess-
ment eating disorder criteria in bariatric surgery patients are summarized
in Table 5–1.

Binge Eating and Loss-of-Control Eating

An objective binge-eating episode, as defined by DSM-5, is determined by two
characteristics: 1) a sense of loss of control over eating, or not being able
to resist eating or stop eating once started, and 2) ingestion of an exces-
sively large amount of food in a discrete period of time (see Chapter 10,
“Use of the Eating Disorder Assessment for DSM-5”). Assessing binge eat-
ing prior to bariatric surgery poses challenges similar to those faced in the
assessment of this behavior in any overweight individual (see Chapter 4,
“Eating Problems in Individuals With Overweight and Obesity”). Consid-
erations include 1) evaluating the presence of loss of control, which is often
not as distinct among obese individuals as among individuals with BN, be-
cause feelings of loss of control may not be as intense and disorganizing
for severely obese individuals and for BN patients and many of these pa-
tients may feel that they “gave up” trying to control or limit the amount of
food they eat because of unsuccessful previous attempts; 2) deciding what
constitutes a large amount of food in the context of eating episodes may
be challenging because it may not be as distinctively different from other
non-binge meals as it is in BN patients; and 3) the absence of inappropriate
 88
TABLE 5–1. Summary of special considerations when assessing eating-disordered criteria after bariatric surgery and
specific probe questions

Handbook of Assessment and Treatment of Eating Disorders

Required for Special considerations Specific probe questions (to be used in addition to the
DSM-5 diagnosis Criterion after surgery questions concerning formal eating disorder diagnosis)

AN Restriction of energy A highly restrictive diet is Could you describe your regular eating patterns for me?
intake relative to prescribed in the initial months What is the prescribed nutritional plan for your follow-up?
requirements leading after surgery. Do you avoid any foods, not because of the physical
to a significantly low The amount of food tolerated is discomfort they may cause you but because you believe
body weight in the limited. they will have an impact on your weight?
context of age, sex, There are no clear rules for defining Have you experienced any symptoms of starvation (e.g.,
developmental underweight in postoperative cold intolerance, hypotension)?
trajectory, and patients. Considering the weight Do you have a problem with excess hanging skin?
physical health loss trajectory and physical health
are particularly important.
Intense fear of gaining Fear of weight gain is to some extent What strategies do you use to control your weight?
weight or becoming fat realistic and based on past Do you count calories?
and persistent experience. Do you avoid any food or nutritional supplements that
behaviors to control were recommended to you?
weight Do you limit the amount of food you eat at each meal?
How often do you weigh yourself?
How would you feel if you regained 5 pounds? 10 pounds?
 Assessment of Bariatric Surgery Patients
TABLE 5–1. Summary of special considerations when assessing eating-disordered criteria after bariatric surgery and
specific probe questions (continued)

Required for Special considerations Specific probe questions (to be used in addition to the
DSM-5 diagnosis Criterion after surgery questions concerning formal eating disorder diagnosis)

AN, BN, BED Undue influence of Aesthetic alterations characterized What areas of your body are affected by extra hanging
body weight or shape by loose skin, skin envelopes, and skin?
on self-evaluation fat deposits have important What activities do you avoid because of excess skin?
impacts on body image, causing What types of clothing do you avoid?
dissatisfaction and social
embarrassment.
BN, BED Recurrent episodes of Assessing the amount of food How is the amount of food eaten in a binge-eating episode
binge eating requires knowledge about the different from the regular amount of food you eat in your
nutritional needs of each patient in typical meals?
their stage of treatment, the gastric Do you often have the feeling of plugging from the food in
capacity, and the type of surgery. your stomach?
Loss of control may be the only Do you experience dumping syndrome?
feature present in postoperative Do you keep eating even though you know food will feel
bariatric patients. plugged, you will vomit, or you will experience
dumping?

89
 90
TABLE 5–1. Summary of special considerations when assessing eating-disordered criteria after bariatric surgery and
specific probe questions (continued)

Handbook of Assessment and Treatment of Eating Disorders

Required for Special considerations Specific probe questions (to be used in addition to the
DSM-5 diagnosis Criterion after surgery questions concerning formal eating disorder diagnosis)

BN Recurrent inappropriate Spontaneous or voluntary vomiting What are your motives for vomiting and/or dumping?
compensatory is commonly associated with the Does episodic vomiting happen because you feel plugged
behaviors in order to ingestion of intolerable foods or or physically uncomfortable with the food eaten?
prevent weight gain with eating too rapidly, or is Did you overeat because you knew you would easily vomit
secondary to physical discomfort or compensate through dumping?
after eating, and is not necessarily
influenced by body weight or
shape concerns.
Atypical compensatory behaviors
such as dumping may emerge.
Note. AN=anorexia nervosa; BED=binge-eating disorder; BN=bulimia nervosa.
Assessment of Bariatric Surgery Patients 91

compensatory behaviors, such as vomiting at the termination of an eating

episode, as is seen in BN, possibly making occurrences more difficult to
recognize as episodes of binge eating.
After surgery, physical restriction greatly limits the amount of food that
can fit into a small gastric pouch/stomach created by bariatric surgery.
However, it is still possible for individuals to report feeling a loss of control
over eating, although the amount of food eaten is not objectively large
(Colles et al. 2008). Therefore, the decision as to what constitutes a large
amount of food eaten by individuals following bariatric surgery is not
always straightforward, and emerging data suggest that this distinction
may not be as important as the feature of loss of control over eating
(Fitzsimmons-Craft et al. 2014; Niego et al. 1997). In fact, research with
different patient samples showed that those presenting with subjective binge
eating (loss of control over amounts of food not “large” but viewed by the
individual as excessive) were similar to those reporting objective binge
eating on eating disorder features, general psychopathology, and negative
affect (Brownstone et al. 2013; Palavras et al. 2013). Additionally, subjec-
tive binge eating seems to be associated with depressive symptoms, anxi-
ety, social avoidance, insecure attachment, and cognitive distortion
(Brownstone et al. 2013; Fitzsimmons-Craft et al. 2014).
A number of studies have evaluated the presence of binge eating prior
to bariatric surgery in an attempt to identify eating behaviors that might
be predictive of attenuated weight loss after surgery, but research has
failed to consistently demonstrate a significant relationship between pre-
operative binge eating and outcome. Some studies have found an associa-
tion with poorer weight outcomes, whereas other studies have found no
association or even greater weight loss (Livhits et al. 2012; Meany et al.
2014). However, the presence of binge eating prior to surgery can be as-
sociated with the risk of postsurgical binge eating or loss-of-control eating,
both of which have been more consistently associated with less weight loss
and/or increased weight regain over time (Meany et al. 2014; White et al.
2010). Binge eating prior to surgery has been related to increased psycho-
logical distress and other eating-disordered symptoms (Colles et al. 2008).
Therefore, assessing binge eating prior to surgery plays an important role
in screening for a subgroup of patients who may pose additional chal-
lenges following surgery.
Other problematic eating behaviors, such as grazing and emotional
eating, have also been associated with loss-of-control eating (Allison et al.
2010; Conceição et al. 2014) and ultimately with risk of increased weight
regain (Colles et al. 2008). See Table 5-1 for the special considerations
that must be taken into account when assessing eating disorders in post–
bariatric surgery patients.
92 Handbook of Assessment and Treatment of Eating Disorders

Night Eating Syndrome

Night eating syndrome, listed in DSM-5 as one of the other specified feed-
ing or eating disorders, is characterized by evening/nocturnal hyperpha-
gia and associated emotional distress (Allison et al. 2010). With a wide
range of prevalence rates reported, the prevalence of night eating syn-
drome is estimated to be as high as 55% among obese patients seeking sur-
gical treatment (Colles and Dixon 2006). No consistent relationship has
been observed between presurgery night eating syndrome and presurgery
psychological distress or postsurgery weight loss, loss-of-control eating,
grazing, or night eating syndrome (Colles and Dixon 2006). However, pre-
operative night eating syndrome has been associated with BED, lower
cognitive restraint, increased social eating, eating when tired, and less con-
sumption of protein, which can be highly problematic for patients follow-
ing bariatric surgery (Colles and Dixon 2006; Colles et al. 2008). Thus,
night eating syndrome seems to be part of a disorganized, high-risk eating
pattern that may require treatment before or after bariatric surgery. Night
eating syndrome should be distinguished from sleep-related eating disor-
der, a rare condition often related to the use of certain sedatives or hyp-
notics and associated with other sleep disorders such as restless legs
syndrome (Colles and Dixon 2006). Sleep-related eating disorder is char-
acterized by partial arousal from sleep, reduced levels of awareness, and
impaired recall.

Grazing
Different definitions of the term grazing have been employed in the liter-
ature, which has led to some confusion. Recently, with our colleagues, we
proposed that grazing be defined as the repetitive eating (more than twice
in the same period of time without prolonged gaps between) of small or
modest amounts of food in an unplanned manner and/or not in response
to sensations of hunger or satiety (Conceição et al. 2014). Two subtypes
were also suggested: 1) compulsive grazing—trying to resist but not being able
to, returning repetitively to snack on food, and 2) noncompulsive grazing—
repetitively eating in a distracted and mindless way (Conceição et al.
2014). Constructs similar to grazing that have been described in the litera-
ture include picking, nibbling, and repetitive snack eating; however, there
is little research regarding the extent to which these behaviors overlap.
After surgery, owing to reduced gastric capacity, most patients must
eat multiple small meals in order to consume a sufficient amount of food.
This behavior should not be considered grazing, because this eating pat-
tern demonstrates appropriate control. Grazing should also be distin-
Assessment of Bariatric Surgery Patients 93

TABLE 5–2. Summary of and differentiation between different

eating behaviors found in postoperative bariatric
patients and their associated level of control
over eating
Sense of
Episode control Description

Normal 0 Eating behavior that is planned, controlled, and

mindful of hunger and satiety.
Repetitive eating of small amounts of food in order
to accommodate the required daily amounts.
Deliberate 0 Plan to fractionate and repeatedly eat small
overeating amounts to intentionally overeat and
accommodate the amount of food desired (e.g.,
dessert). No sense of loss of control.
Grazing, 1 “Mindless” and distracted eating of whatever is
noncompulsive available. Not planned.
subtype
Grazing, 2 Attempting to resist but returning repeatedly to eat
compulsive small/modest portions of tempting foods;
subtype associated with cravings for food.
Binge eating; loss 3 Eating in a circumscribed period of time with a
of control sense that one cannot resist eating or stop eating.
Source. Adapted from Conceição et al. 2014.

guished from intentional overeating, a behavior in which individuals

fractionate and eat smaller portions of a large amount over an extended
time in order to purposefully overeat. The planned nature of intentional
overeating distinguishes it from grazing. Grazing should also be differen-
tiated from binge eating with moderate amounts of food (subjective binge
eating), because grazing does not involve the sense that one cannot stop or
resist eating in a circumscribed period of time.
Grazing may be characterized by some level of lack of control that is
clinically different from the loss of control experienced in binge-eating ep-
isodes and that might be captured with a more flexible rating scheme.
Some have advocated the use of a continuous rating scale for loss of con-
trol (see example in Table 5–2) instead of the more typical dichotomous
(present/absent) nomenclature (Conceição et al. 2014; Mitchell et al.
2012).
Little is known about the clinical importance or prevalence of grazing
prior to surgery, but the emergence of grazing postoperatively has been
94 Handbook of Assessment and Treatment of Eating Disorders

the focus of some research. Postoperative grazing has been suggested to

serve the same function as presurgery binge eating, which is no longer pos-
sible because of the anatomical changes (Saunders 2004). Also, the un-
planned, repetitive nature of the behavior may result in excessive caloric
intake and ultimately less weight loss and/or greater weight regain. Graz-
ing behavior after bariatric surgery may also be associated with binge eat-
ing and/or loss-of-control eating, and the overall combined pattern may
lead to increased weight regain (Conceição et al. 2014). Although incon-
sistent, initial evidence points to an association between grazing and de-
pressive symptoms, emotional eating, mindless eating, and poorer mental
health and quality of life (Colles et al. 2008; Kofman et al. 2010). Although
there is no clear evidence to argue that grazing is necessarily a psycho-
pathological eating behavior in the general population, it does seem that
grazing may compromise weight outcomes after bariatric surgery.

Emotional Eating
Although a standardized definition of emotional eating is lacking, the
phenomenon has been described as “the tendency to eat in response to
emotional distress and during stressful life situations” (Canetti et al. 2009,
p. 109). Before surgery, emotional eating has been associated with higher
levels of depression and binge eating and with more frequent eating in re-
sponse to external cues (Fischer et al. 2007). Emotional eating is thought
to be common among bariatric surgery candidates and postoperative pa-
tients and has been associated with binge eating (Pinaquy et al. 2003), graz-
ing, uncontrolled eating, and snack eating (Chesler 2012). Additionally,
some authors have considered emotional eating to be a risk factor for
poorer outcomes after surgery, although data addressing this issue are
quite limited (e.g., Canetti et al. 2009; Chesler 2012). Although emotional
eating has been suggested to play a mediating role in treatment outcomes,
including weight loss and quality of life (Canetti et al. 2009), contradictory
results have been reported about the impact of emotional eating on weight
outcomes after surgery (Fischer et al. 2007).

Dumping Syndrome
Dumping syndrome refers to a constellation of GI and vasomotor symptoms
associated with the consumption of foods containing high concentrations
of carbohydrates or sugar and/or with eating excessively following bariat-
ric surgery (Deitel 2008). Dumping syndrome is estimated to occur in
about three-quarters of patients undergoing malabsorptive bariatric proce-
dures (Mechanick et al. 2013), typically develops 10–30 minutes postpran-
Assessment of Bariatric Surgery Patients 95

dially, and has been referred to as early dumping by some authors. The
syndrome occurs following rapid gastric emptying, leading to a hyperos-
molar load in the intestine and subsequent fluid shifts (Deitel 2008), which
are accompanied by an autonomic vasomotor response.
Dumping usually involves diarrhea, and there are anecdotal reports of
patients using dumping as a compensatory behavior, relying on this GI
consequence to compensate for overeating or binge eating. Thus, clini-
cians need to be aware that dumping is not only a frequent problem in the
initial months after surgery, particularly until patients learn to eat slowly
and to avoid foods that trigger these symptoms, but also an inappropriate
method to compensate for eating and to regulate weight. Uncontrolled se-
vere dumping can also result in a fear of certain foods or of eating, result-
ing in accentuated weight loss and even malnutrition (Lin and Hasler
1995).
Some patients have reported another condition similar to dumping
that has been termed by some authors late dumping, as opposed to the
early dumping that corresponds to dumping syndrome. Despite the simi-
larity of symptoms reported by patients (dizziness, fatigue, diaphoresis,
and weakness), the physiological mechanism underlying these conditions
is not the same, and they should be considered distinct conditions. Late
dumping occurs about 1–3 hours after a meal because of an exaggerated
insulin response to hyperglycemia, resulting in subsequent reactive hypo-
glycemia (Ceppa et al. 2012; Deitel 2008); when intense and recurrent,
this may result in blackouts, seizures, and other severe complications, in-
cluding death as a rare outcome (Ceppa et al. 2012). Whereas early dump-
ing usually develops shortly after surgery, late dumping typically develops
a year to several years later. Clinicians should assess for dumping syn-
dromes and educate patients about common triggers and consequences.
Patients who experience late dumping may require dietary modifications
to reduce carbohydrate intake, may need to take medications, or, in rare
treatment-resistant cases, may require pancreatic resection.

Assessment of Current Eating Behaviors

To perform a comprehensive evaluation of a patient’s current eating be-
haviors, the clinician should inquire about the frequency and content of
meals and snacks, problematic eating behaviors, and GI problems. Impor-
tant concerns include the following:

1. Level of restriction and avoidance of certain foods. The amount of food

ingested by patients following bariatric surgery is naturally limited, and
96 Handbook of Assessment and Treatment of Eating Disorders

some foods (e.g., meat and pasta) are best avoided because of intoler-
ance and physical discomfort. The motives underlying restrictive be-
haviors should be probed, along with expectations about the influence
of restriction on weight. Recurrent thinking about calories; establish-
ment or maintenance of a very low calorie plan; and frequent weigh-
ing, body pinching, or body checking may be of concern.
2. Presence, frequency, and duration of binge-eating and/or loss-of-control
episodes, including the amounts and the types of food ingested during
these episodes.
3. Presence, frequency and duration of any purging behaviors. Besides
those behaviors typically reported by individuals with AN and BN, the
occurrence of dumping should be assessed. Clinicians should differen-
tiate vomiting related to the ingestion of intolerable foods or to exces-
sively rapid eating from vomiting related to weight or shape concerns.
4. Frequency and intensity of exercise.
5. Presence, frequency, and duration of grazing (Conceição et al. 2014).
6. Presence and frequency of overeating by intentionally fractionating large
amounts of food into smaller portions to be eaten over an extended time.
7. Emotional eating, which has two subtypes (Chesler 2012): 1) a conscious
behavior to cope with emotional distress and 2) an automatic/reflexive
reaction to misidentified feelings and emotions or alexithymia, which
is common among bariatric surgery candidates and postoperative pa-
tients (Noli et al. 2010).
8. Presence, frequency, and duration of night eating symptoms (Allison et al.
2010).

Assessment of Prior Eating Disturbances

In addition to assessing current eating behaviors and related symptoms,
the clinician needs to assess whether a patient has had prior clinically sig-
nificant eating problems. For example, a history of intensive dietary re-
striction and low weight because of AN may indicate that a patient is more
likely to subscribe to rigid, inflexible attitudes regarding eating and weight
and to have these attitudes reinforced by the extreme weight loss and the
facilitation of control over eating that surgery permits. A past history of
BN, BED, or night eating may be informative regarding the potential for
loss-of-control eating and the prior use of compensatory behaviors (e.g.,
vomiting, dumping) that may reemerge because they are facilitated by the
surgery. Finally, information about past treatments and responses to them
may be useful in anticipating what may be most helpful in the future.
Assessment of Bariatric Surgery Patients 97

Structured Clinical Interviews

and Self-Report Measures
Providers may use the general guidelines provided in this chapter in con-
ducting clinical interviews but may also consider the use of structured di-
agnostic assessment instruments. Table 5–3 provides a brief summary of
clinical interviews and self-report measures to assess disordered eating
behavior among individuals following bariatric surgery (see also Part 3,
“Assessment Tools,” in this volume).

Clinical Interview:
Additional Considerations
As part of the clinical interview, in addition to soliciting the information
relevant to eating disorders, providers should also assess other past and co-
occurring psychiatric conditions of particular relevance for bariatric sur-
gery patients.

Mood and Anxiety Disorders

Among bariatric surgery candidates, the presence of BED has been asso-
ciated with current or past history of both mood and anxiety disorders. Al-
though significant improvement often occurs after surgery, postoperative
BED or loss of control has also been associated with continued anxiety
and depression and ultimately poorer outcomes (de Zwaan et al. 2011).

Impulse-Control Disorders
Impulse-control disorders such as skin-picking disorder, compulsive buy-
ing, or intermittent explosive disorder have been estimated to occur in up
to 19% of bariatric surgery candidates (Schmidt et al. 2012).

Alcohol Use Disorder

Although presurgery binge eating has not been found to be a significant
predictor of postsurgery alcohol abuse (King et al. 2012), individuals with
eating disorders are at increased risk of alcohol abuse (Ferriter and Ray
2011). Extant evidence suggests that bariatric surgery patients have a
greater sensitivity to the intoxicating effects of alcohol after surgery and
are vulnerable to the development of alcohol use disorder, particularly fol-
lowing gastric bypass (King et al. 2012).
 98
TABLE 5–3. Clinical interviews and self-report measures for eating-disordered behaviors and associated features in
bariatric surgery patients

Handbook of Assessment and Treatment of Eating Disorders

Examples of studies
Type of on bariatric surgery
Measure (authors) measure Description patients

Eating EDQ (Mitchell 2005) Self-report Designed to collect comprehensive data about disordered NA
disorders eating symptoms (current and lifetime); psychosocial,
medical, and psychiatric history; and weight history.
EDE—Bariatric Semistructured 45- to 75-minute interview. Assesses eating-disordered Kalarchian et al. 2000
Surgery Version interview behaviors and symptomatology and gastrointestinal
(Fairburn et al. 2008; problems. Generates global score and four subscores:
modified by Restraint, Eating Concerns, Shape Concern, and Weight
de Zwaan et al. 2010) Concern. Also addresses behaviors specific to bariatric
surgery patients.
EDE-Q (Fairburn and Self-report Self-report version of EDE. Assesses eating-disordered Grilo et al. 2013;
Beglin 2008) behaviors and symptomatology. Generates global score Kalarchian et al.
and four subscores: Restraint, Eating Concern, Shape 2000
Concern, and Weight Concern.
BES (Gormally et al. Self-report 16-item questionnaire with a total score reflecting severity of Grupski et al. 2013;
1982) binge-eating behaviors. Hood et al. 2013
DEBQ (van Strien et Self-report 33-item questionnaire assessing three patterns of eating, van Hout et al. 2007
al. 1986) resulting in three subscores: Restrained Eating, Emotional
Eating, and External Eating.
 Assessment of Bariatric Surgery Patients
TABLE 5–3. Clinical interviews and self-report measures for eating-disordered behaviors and associated features in
bariatric surgery patients (continued)

Examples of studies
Type of on bariatric surgery
Measure (authors) measure Description patients

Grazing Rep(eat) (Conceição Semistructured 15- to 45-minute interview. Assesses eating behaviors (Conceição et al.,
et al. 2014) interview including grazing and allows decision on the presence/ work in progress)
absence and characterization of grazing behavior.
Rep(eat)-Q Self-report 15-item questionnaire. Assesses grazing and generates a total (Conceição et al.,
(Conceição et al. score reflecting levels of associated symptomatology. work in progress)
2014)
Night eating NEQ (Allison et al. Self -report 14-item questionnaire. Assesses behavioral and psychological Rand et al. 1997
syndrome 2008) symptoms of night eating syndrome. Generates a total score
reflecting levels of associated symptomatology.
Emotional EES (Arnow et al. Self-report 25-item scale. Assesses tendency to eat in response to Castellini et al. 2014
eating 1995) emotional triggers. Generates three subscores: Depression,
Anxiety, and Anger.
Dumping Sigstad’s Clinical Self-report Generates an index score based on the weight of 16 Kalarchian et al. 2014
Diagnostic Index symptoms of dumping. A score of 7 or more points is
(Sigstad 1970) suggestive of dumping.
Note. BES=Binge-Eating Scale; DEBQ=Dutch Eating Behavior Questionnaire; EDE—Bariatric Surgery Version=Eating Disorder Examination—Bariatric
Surgery Version; EDE-Q=Eating Disorder Examination Questionnaire; EDQ=Eating Disorder Questionnaire; EES=Emotional Eating Scale; NA=none
available; NEQ=Night Eating Questionnaire; Rep(eat)=Repetitive Eating Interview; Rep(eat)-Q=Repetitive Eating Questionnaire.

99
100 Handbook of Assessment and Treatment of Eating Disorders

Medical Complications
and Physical Assessment
Disordered eating behaviors in patients who have undergone bariatric sur-
gery may have physical consequences that require medical attention. Dis-
ordered eating behaviors may be associated with compromised intake of
vitamins and minerals, such as vitamin B12, calcium, vitamin D, thiamine,
folic acid, iron, zinc, and magnesium (Malone 2008). Deficiency second-
ary to surgery and/or due to lack of compliance with replacement regi-
mens should be addressed, as should dumping syndrome and recurrent
vomiting.

Conclusion
Assessment of eating disorders and problematic eating behaviors in bar-
iatric candidates poses challenges to both clinicians and researchers at-
tempting to improve the support provided to these patients and to
enhance weight outcomes. Particularly in the postoperative period, the
subsyndromal presentations of eating disorders and the fact that some
compensatory behaviors may be facilitated by the surgical procedures
make the line between normative and problematic behaviors difficult to
establish. Further, problematic eating behaviors that do not constitute
DSM diagnoses should also be assessed as they may compromise weight
maintenance in the long term.
Research has been proliferating in the development and validation of
assessment instruments, and there are a variety of semistructured inter-
views and self-report measures validated to assess eating behaviors and
problematic eating in both preoperative and postoperative bariatric sur-
gery patients. However, despite the growing evidence that eating behaviors
are predictors of outcomes, it seems that it is the long-term presentation of
problematic eating that best predicts poor weight loss or weight regain,
shedding light on the importance of longitudinal assessment of these pa-
tients.

Key Clinical Points

• The presence of problematic eating behaviors and subsyndromal
presentations of eating disorders are common in bariatric surgery
patients, but no diagnostic terms have been specifically developed
for these patients.
Assessment of Bariatric Surgery Patients 101

• Restriction of energy intake in patients following bariatric surgery

must be assessed in light of the highly restrictive diet initially pre-
scribed for these patients and the limitations on the amount of food
that can be physically tolerated following surgery.
• There is no clear definition of what constitutes being underweight
among patients following bariatric surgery.
• On the basis of previous experience, patients’ fear of weight gain
following bariatric surgery is, at least to some extent, realistic.
• Excessive loose skin, skin envelopes, and fat deposits following
surgery can have a major negative impact on body image, causing
body dissatisfaction and social embarrassment.
• The experience of loss of control may be the only feature of binge
eating following surgery.
• Spontaneous, involuntary vomiting is commonly associated with
physical discomfort and may not be related to excessive concern
about body weight or shape. Atypical compensatory behaviors
such as dumping may emerge following surgery.
• Grazing, night eating, and emotional eating have been related to
loss-of-control eating, increased psychopathology, and adverse
bariatric surgery weight outcomes.

References
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6 Eating-Related
Pathology in
Men and Boys
Thomas Hildebrandt, Psy.D.
Katherine Craigen, Ph.D.

The clinical assessment of males with eating problems

requires several important conceptual considerations. First, such problems
have a very diverse presentation among men and boys. Second, the moti-
vations that drive such problems may differ from those typically cited
among females. Finally, male body image disturbances often differ in their
quality and content from female equivalents. These conceptual distinc-
tions may assist with the assessment and diagnosis of men and boys with
eating disorders, particularly when uncertainty exists about whether an
eating disorder is even present. This guidance, however, should not re-
place existing validated methods, because men and boys can also present
with classic syndromes identical to those of women and girls. Video 4,
“Assessing eating problems in men,” addresses specific issues related to as-
sessment and treatment of male patients.

Conceptual Overview of Assessing Men

and Boys With Eating-Related Pathology
A number of diffuse conditions (e.g., reverse anorexia, bigorexia, muscle
dysmorphia, anabolic-androgenic steroid use) with links to traditional eat-

105
106 Handbook of Assessment and Treatment of Eating Disorders

ing disorders potentially have a higher prevalence among males than fe-
males (Grieve et al. 2009; Hildebrandt et al. 2011a). Several studies have
demonstrated superficial overlap of clinical features between traditionally
recognized eating disorders and these other presentations. The most nota-
ble symptom cluster in males is a subtype of body dysmorphic disorder
termed muscle dysmorphia (Pope et al. 1997). Muscle dysmorphia is charac-
terized by obsessional and compulsive behaviors intended to achieve a
lean and muscular physique. Men with anorexia nervosa (AN) and men
with muscle dysmorphia display similar severity levels of compulsive ex-
ercise, body image disturbance, and disordered eating (Murray et al.
2012). Core psychological constructs associated with eating disorders (per-
fectionism, difficulty tolerating negative moods, and low self-esteem) also
correlate with muscle dysmorphia symptoms (Murray et al. 2013) and act
as antecedents to symptom onset (McFarland and Kaminski 2009).
Empirical classification studies suggest that symptoms of obsessive-
compulsive disorder and bulimia nervosa (BN) cluster with symptoms of
muscle dysmorphia (Hildebrandt et al. 2006), leading to the suggestion
that muscle dysmorphia should be considered an eating disorder in the
Diagnostic and Statistical Manual of Mental Disorders (Murray et al. 2010). De-
spite these suggestions, as well as the superficial overlap in symptoms, a
core distinction between muscle dysmorphia and AN remains: the primary
importance of eating pathology. Although patients with muscle dysmor-
phia report engaging in a number of weight-regulating behaviors, includ-
ing some forms of disordered eating (Contesini et al. 2013), their primary
disturbance relates to body image, whereas AN and other eating disorders
are primarily defined by a core disturbance in eating. Consequently, any
clinical assessment of men and boys may require differentiating distress
and impairment related primarily to eating from that related to concerns
about body image. Should the latter be primary, we recommend following
clinical guidelines for men and boys with body dysmorphic disorder (see
Hartmann et al. 2013).
The core motivations for men and boys to control or influence their
appearance through eating and weight control often differ from those of
their female counterparts. One approach to understanding this potential
divergence is to consider how shape and appearance serve different func-
tions for each sex. For instance, the functional (as contrasted to appear-
ance) demands of the male body are often the primary source of
evaluation, meaning that men or boys will have greater investment in how
fast they run or how well they fight. Consequently, male body dissatisfac-
tion may more likely be triggered by some actual or perceived failure to
perform physically in an athletic or similar setting where physical perfor-
mance rather than appearance is the primary focus of evaluation (Edman
Eating-Related Pathology in Men and Boys 107

et al. 2014). This difference yields a qualitatively distinct experience for

many men and boys and contributes to the clinical heterogeneity found in
treatment-seeking populations. For instance, a boy who idealizes an
Olympic swimmer may express a desire for leanness and endurance,
choosing a range of behaviors designed to keep weight and body fat down
while maintaining a high level of fitness. Alternatively, a boy who idealizes
an American professional football player may express a desire for muscu-
larity, choosing weight-control methods that favor muscle development
and raw strength.
Body image disturbances among males can be conceptually defined
along two orthogonal dimensions of muscularity and body fat. Depending
on an individual’s current placement along these dimensions (e.g., high
muscularity and low body fat) and the desired change (e.g., larger or
smaller), the types of weight- and shape-controlling behavior can be pre-
dicted (Hildebrandt et al. 2010). Men and boys who desire leanness but
have little concern for muscularity may be more likely to present with clas-
sic eating disorder concerns about thinness. Conversely, men and boys
who present with greater desire for muscularity but little concern for lean-
ness may be more likely to present with symptoms of muscle dysmorphia.
Males who have a high degree of concern about both leanness and mus-
cularity may have elements of both muscle dysmorphia and an eating dis-
order and may engage in distinct behaviors linked to these motivations.
Notably, it is also the latter group that is most likely to abuse performance-
enhancing drugs (Pope et al. 2012).
Illicit substances used to control one’s outward appearance or level of
physical fitness are termed appearance- and performance-enhancing drugs
(APEDs). These drugs encompass an evolving market of synthetic chem-
icals designed to target and enhance the natural breakdown and repair of
energy stores and muscle (Hildebrandt et al. 2007). Not surprisingly, men
who use these substances are generally at risk for eating or body image pa-
thology and tend to evaluate the functional aspects of their bodies and tra-
ditionally masculine body parts (e.g., shoulders, biceps) (Walker et al.
2009). These males are also more likely to be concerned with aspects of
body hair, head hair, physical height, and penis size (Tiggemann et al.
2008), each of which is associated with its own set of behavioral checking
and avoidance strategies.
In summary, assessing men and boys for eating disorder symptoms re-
quires an understanding of what symptoms (eating, body image, or drug
use) drive the primary distress and impairment. To make such distinctions,
the assessment strategy used by clinicians working with men and boys re-
quires an understanding of the unique motivations for the weight- and
shape-controlling behaviors. These motivations may involve traditional
108 Handbook of Assessment and Treatment of Eating Disorders

investment in thinness but also may involve scrutiny of specific functional

components of body image (e.g., strength, speed). In addition, the assess-
ment strategy requires a thorough evaluation of APED use, because this
may be a more common approach to dealing with body image distur-
bances in men and boys than in women and girls.

Challenges in the Assessment of

Eating-Related Pathology in Men and Boys
The role of gender in the assessment and diagnosis of eating disorders
should not be underestimated. Increasing knowledge of the unique clinical
presentations of men and boys with disordered eating behaviors and atti-
tudes has increased understanding of important considerations for clinical
assessment.
Video 4 demonstrates special issues that may arise in the assessment
and treatment of male patients.

Video Illustration 4: Assessing eating problems in men (5:32)

Table 6–1 describes the key areas of assessment for men and boys who
present for treatment with likely eating and related psychopathology. Gen-
erally, querying about these domains should involve a professional non-
judgmental style. The questions should be direct and reflect some
knowledge of the domain. This approach is particularly important for
questions pertaining to APED use, because the patient may assume that
the clinician is ignorant about the nature of these drugs, their effects, and
the relative risks associated with their use. The interviewer’s demonstration
of some understanding of street use (e.g., how drugs are sourced or used)
or brands of these substances will increase the likelihood of the patient’s
disclosure. Similarly, questions about body image or disturbances in eating
should be direct and begin with the goal of generating a general under-
standing of how a patient experiences his body (appearance and function)
as well as what approach(es) he takes to influencing his body (appearance
and function) and in what context. Many body image–controlling behav-
iors can be healthy or normative in the appropriate context (e.g., heavy ex-
ercising or weight change for athletic competition). The interviewer,
however, must determine whether these behaviors are functionally impair-
ing given the specific context provided by the patient.
The following is a review of additional common challenges and impor-
tant features that the clinician should consider for the successful assess-
ment of males struggling with eating and body image issues.
Eating-Related Pathology in Men and Boys 109

TABLE 6–1. Relevant questions in the assessment of eating-

related problems in men and boys
Information relevant to
Topic eating disorder Sample inquiries

Weight history Recent weight change What is your current weight?

What has been your highest and
lowest weight?
Have you experienced any
recent weight loss or weight
gain?
Body checking Excessive in quantity or How do you evaluate your
compulsive/ritualistic outward appearance?
How do you evaluate yourself
physically?
Exercise Compulsive and Do you feel compelled to
patterns compensatory in nature exercise?
How bad do you feel if you miss
or have to limit your amount or
intensity of exercise?
Eating habits Evidence of restriction, How would you describe a
dietary rules typical day’s eating?
What influences your day-to-day
decisions about eating?
Binge eating Overeating with loss of Have you ever consumed what
control others might consider an
unusually large amount of
food?
Supplement/ Steroids, muscle-building Have you ever taken a fitness
illicit drug use supplements, fat-burning supplement, weight-control
supplements, hormones drug, or synthetic hormone
such as an anabolic steroid?
How would you describe your
pattern of fitness supplement
use?

Diagnosis Bias
Males suffering from body image and eating issues have a significant
stigma to overcome, because U.S. culture typically considers eating disor-
ders and obsession with appearance to be “women’s issues.” Although AN
and BN continue to be more common among women than men, the gap
is narrowing. Prevalence rates suggest that binge-eating disorder is about
as common in men as in women (Lewinsohn et al. 2002; Mond and Hay
110 Handbook of Assessment and Treatment of Eating Disorders

2007; Striegel-Moore et al. 2009). Recent data suggest that for both AN
and BN, the ratio of women to men is approximately 3:1 (Hudson et al.
2007). It is difficult to determine whether the rising prevalence rates of
males with AN and BN represent an increasing number of actual cases, a
greater awareness of this problem in men and boys, or an improvement in
diagnostic criteria that are less gender biased. For example, the amenor-
rhea criterion for AN in DSM-IV (American Psychiatric Association
1994) may have primed clinicians to be more likely to consider girls and
women for that diagnosis. Clinicians should be sensitive to their own gen-
der biases regarding eating disorder diagnoses. Men may be more likely
to be misdiagnosed and less likely to receive treatment or be referred to
specialized eating disorder programs (Currin et al. 2007).

Shame and Gender Roles

Cultural stereotypes about women and eating disorders may also present
challenges for male patients seeking help for their eating-disordered be-
haviors and attitudes. Men often experience shame about their eating-
disordered behaviors and about reporting those behaviors, which can lead
to total avoidance of help seeking for these issues or underreporting of
symptom severity (Robinson et al. 2013). Adherence to traditional gender
role norms that encourage men to exercise emotional control may inter-
fere with help-seeking behavior (Good et al. 2005; Mahalik et al. 2003). It
is therefore important for clinicians to consider the experience of shame
within the context of cultural gender role norms for men and boys.
Data on the relationship between body and muscle dissatisfaction and
gender roles among men are mixed. Research suggests that only certain as-
pects of masculinity are associated with dissatisfaction. Specifically, placing
an emphasis on winning, emotional control, risk taking, violence, domi-
nance, power over women, and pursuit of status seems to place men at risk
for higher levels of dissatisfaction with their muscularity and muscularity-
oriented disordered eating (Blashill 2011; Griffiths et al. 2015).

Sexual Orientation
Research has demonstrated that sexual orientation is a risk factor for dis-
ordered eating and that bisexual and gay men, compared with heterosex-
ual men, report significantly greater disordered eating and higher body
dissatisfaction (Carlat et al. 1997; Feldman and Meyer 2007; Jones and
Morgan 2010; Russell and Keel 2002). Although the reason for this re-
mains uncertain, it has been suggested that gay culture places a heightened
emphasis on physical appearance and that certain subcultures may there-
Eating-Related Pathology in Men and Boys 111

fore be at greater risk when trying to attract other men as romantic part-
ners (Siever 1994). Supporting this theory, several studies have found that
both heterosexual and gay men tend to place more emphasis on appear-
ance when looking for a romantic partner than do heterosexual and gay
women (Legenbauer et al. 2009; Tiggemann et al. 2007; Yelland and
Tiggemann 2003). Cultural pressures and aesthetic ideals therefore appear
to be more salient for gay and bisexual men.

Eating Disorder Measures

in the Assessment of Males
Eating disorder research has begun to recognize that it may be inappropri-
ate to draw conclusions about males with eating disorders based on their
responses to questionnaires designed for females. Such measures have
demonstrated lower rates of reliability for men than for women (Boerner
et al. 2004), which may be due to the intention for these instruments to as-
sess symptoms that are more relevant to the presentation of eating disor-
ders in women than in men. The following measures are recommended
for the assessment of eating-disordered behaviors and attitudes in men and
boys because they have been specifically designed for or normed with
males.

Eating Disorder Examination Questionnaire

The Eating Disorder Examination Questionnaire (EDE-Q; Fairburn and
Beglin 1994, 2008) is a self-report version of the Eating Disorder Exami-
nation (EDE) interview (Cooper and Fairburn 1987) (for details, see
Chapter 9, “Self-Report Assessments of Eating Pathology”). The EDE-Q
is used for both research and clinical purposes, and normative data are
now available for adolescent boys (Mond et al. 2014) and undergraduate
men (Lavender et al. 2010).

Eating Disorder Inventory

The Eating Disorder Inventory (EDI; Garner et al. 1983) is a six-point,
forced-choice, self-report measure. The three subscales (Drive for Thin-
ness, Bulimia, and Body Dissatisfaction) assess levels of eating-disordered
behaviors and attitudes (for details, see Chapter 9). The EDI is a com-
monly used measure; however, studies have found that men and boys
score lower on the three core subscales and that the scale is somewhat less
reliable for males than females.
112 Handbook of Assessment and Treatment of Eating Disorders

Male Body Checking Questionnaire

The Male Body Checking Questionnaire (MBCQ; Hildebrandt et al.
2010) is a 19-item measure that assesses the frequency of body checking
behaviors and results in scores on four subscales: Global Muscle Check-
ing, Chest and Shoulder Checking, Other Comparative Body Checking,
and Body Testing. The questionnaire has demonstrated good reliability
and discriminant validity with a young adult male population.

Muscle Dysmorphia Disorder Inventory

The Muscle Dysmorphia Disorder Inventory (MDDI; Hildebrandt et al.
2004) is a 13-item self-report measure of muscle dysmorphia symptomatol-
ogy with three subscales (Drive for Size, Appearance Impairment, and
Functional Impairment) that map onto the DSM-5 (American Psychiatric
Association 2013) criteria for body dysmorphic disorder with muscle dys-
morphia specifier. Higher scores represent greater likelihood of having
muscle dysmorphia, with the Functional Impairment subscale having the
greatest discriminative validity.

Body Change Inventory

The Body Change Inventory (BCI; Ricciardelli and McCabe 2002) is an
18-item self-report tool designed for adolescent boys and girls that evalu-
ates three body change strategies: Strategies to Decrease Body Size, Strat-
egies to Increase Body Size, and Strategies to Increase Muscle Size. This
scale has demonstrated good internal consistency and discriminant valid-
ity (Ricciardelli and McCabe 2002) for adolescents up to age 17.

Male Eating Behavior and Body Image Evaluation

The Male Eating Behavior and Body Image Evaluation (MEBBIE; Kamin-
ski et al. 2002; P.L. Kaminski and J. Caster, The Male Eating Behaviors and
Body Image Evaluation, unpublished test, 1994, available from P.L. Kamin-
ski [[email protected]]) is a 57-item self-report scale designed to assess
men’s attitudes and behaviors regarding eating, exercise, and body image.
The MEBBIE yields scores on seven subscales: Body Dissatisfaction, Drive
for Muscularity, Emotional Eating, Drive for Thinness, Overexercise, Fear
of Fatness, and Distorted Cognitions.

Drive for Muscularity Scale

The Drive for Muscularity Scale (DMS; McCreary and Sasse 2000) is a 14-
item self-report measure of muscularity-oriented attitudes and behaviors.
Eating-Related Pathology in Men and Boys 113

Each item is scored on a six-point scale, ranging from “always” to “never.”

The internal reliability has been shown to be 0.84 for adolescent boys and
0.87 in a combined high school and college male sample. This measure
has been widely used to examine body image issues in gay men.

Appearance and Performance Enhancing

Drug Use Schedule
The Appearance and Performance Enhancing Drug Use Schedule
(APEDUS; Hildebrandt et al. 2011b) is a semistructured interview that as-
sesses the use of substances (e.g., anabolic-androgenic steroids) to effect
change in appearance, as well as assessing associated behaviors such as in-
tense exercise and dietary control. For the assessment of eating-disordered
behaviors in men, the clinician would use only the sections pertaining to
subscales addressing the associated features (Compulsive Exercise, Dietary
Control, and Body Image Disturbance). This measure has demonstrated
interrater agreement and reliability as well as convergent validity with
adult men.

Physical Assessment
Chapter 2, “Eating Problems in Adults,” and Chapter 3, “Eating Problems in
Children and Adolescents,” provide comprehensive descriptions of the types
of physical assessments needed for the evaluation of eating disorders. There
are no data to suggest that specific gender-appropriate modifications are
needed other than ensuring assessment of male gonadal hormone function.
The assessment of physical signs and complications related to APED use is
beyond the scope of this chapter; see Langenbucher et al. 2008 for a com-
prehensive discussion of the physical complications of this type of drug use.

Conclusion
The assessment of men and boys with eating problems reflects diagnostic
heterogeneity associated with body image disturbance. Special attention to
the differential diagnosis of muscle dysmorphia, eating disorders, and sub-
stance use disorders is required, and the symptom assessments suggested
in this chapter may assist in the evaluation. It is also essential to recognize
challenges (e.g., diagnosis bias, impact of shame and gender roles, sexual
orientation) related to help seeking in this population. A well-informed cli-
nician should adapt his or her assessment approach to incorporate these is-
sues effectively.
114 Handbook of Assessment and Treatment of Eating Disorders

Key Clinical Points

• Men and boys who desire leanness but have little concern for mus-
cularity may be more likely to present with classic eating disorder
concerns about thinness.
• Conversely, men and boys who present with greater desire for mus-
cularity or both leanness and muscularity may be more likely to
present with symptoms of muscle dysmorphia.
• The assessment strategy for clinicians working with men and boys
requires an understanding of the unique motivations for the weight-
and shape-controlling behaviors.
• Men who use appearance- and performance-enhancing drugs are
generally at risk for eating or body image pathology and tend to
evaluate the functional aspects of their bodies and traditionally
masculine body parts.
• Gender biases in the diagnosis of eating disorders are important to
understand. Although anorexia nervosa and bulimia nervosa con-
tinue to be more common among women than men, the gap is
smaller in the general population than in clinical populations, and
binge-eating disorder is about as common in men as women.
• Shame related to gender role biases in help-seeking behavior may
lead to underreporting of severity.
• Sexual orientation is a risk factor for disordered eating; bisexual and
gay men report significantly greater disordered eating and higher
body dissatisfaction than heterosexual men.

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7 Eating Problems in
Special Populations
Cultural Considerations
Anne E. Becker, M.D., Ph.D., S.M.

Clinical effectiveness in multicultural and cross-cultural

settings in general warrants sensitivity to variations in illness experience
and symptom reporting as well as expectations, values, and preferences that
drive risk, presentation, help seeking, and therapeutic engagement in health
care delivery. Attunement to culturally and socially patterned characteris-
tics of clinical presentation is essential to an informed and accurate mental
health assessment, given the importance of the psychiatric interview and
patient report of experiential symptoms to the diagnostic formulation. Un-
derstanding cultural variation is especially germane to identifying, evaluat-
ing, and managing feeding and eating disorders, given the dimensional
nature of many core symptoms, the salience of cultural contextual factors
in ascertaining diagnostic criteria, and the critical importance of decisions
to seek help and disclose symptoms. Video 5, “Cultural considerations in
the assessment of eating problems,” highlights cultural factors.

Epidemiology of Eating Disorders

Across Social Contexts
Historical and cross-cultural data support that anorexia nervosa (AN) and
bulimia nervosa (BN) are mental disorders associated with the sociocul-

119
120 Handbook of Assessment and Treatment of Eating Disorders

tural contexts of modernization. After sentinel case reports of AN in the

nineteenth century, aesthetic ideals and valuation of thinness emerged in
the United States and other historically Western cultural regions in the
twentieth century, and the documented prevalence of AN rose concomi-
tantly (Brumberg 1988). By the late twentieth century, the presence of AN
and BN was recognized in North America, Europe, Australia, and New
Zealand, whereas eating disorders were viewed as relatively rare outside
postindustrialized, Westernized societies. In this respect, the argument that
eating disorders are “culture bound” to the West or to Western cultures has
been made (e.g., Keel and Klump 2003; Swartz 1985).
The Global Burden of Disease Study demonstrates, however, that the
health burdens associated with eating disorders, as measured both in dis-
ability-adjusted life years and in years lived with disability, have shown
steep percentage increases globally over the past two decades (Murray et al.
2012; Vos et al. 2012). Given that the prevalence of AN and BN does not
appear have increased in Europe, the United States, and other high-income
regions over the past few decades (Smink et al. 2012), these data support the
possibility that eating disorders may be increasingly prevalent in low- and
middle-income countries. Transnational migration and widespread partici-
pation in the global economy have resulted in similarly widespread expo-
sure to ideas, values, and products originating in historically Western
societies. Cross-cultural epidemiological data, moreover, support the asso-
ciation of eating disorders with some of these Western cultural exposures,
even across socially diverse populations. These exposures occur, for exam-
ple, through acculturation associated with both migration and in-country
rapid social and economic development (e.g., Becker 2004; Becker et al.
2002, 2010a; Nasser et al. 2001). Furthermore, emerging communication
platforms—including televised and other media—that enable the rapid and
broad global distribution of ideas, images, and products may foster acceler-
ated distribution of cultural exposures that elevate risk for disordered eating
(Becker et al. 2011; Gerbasi et al. 2014; Grabe et al. 2008; Levine and
Murnen 2009).
Within the United States, eating disorders are also more broadly dis-
tributed across sociodemographic strata than previously understood. Epi-
demiological data collected in representative community-based samples
of the U.S. population indicate that eating disorders occur across each ma-
jor census group residing in the United States (Alegria et al. 2007; Nicdao
et al. 2007; Striegel-Moore et al. 2011; Taylor et al. 2013). Although clini-
cians should be aware of sociodemographic variation in patterns of eating
disorder presentation, they should also understand that it is neither possi-
ble nor advisable to summarize clinical features that “typify” eating disor-
ders within a particular ethnic, racial, or social group. For example, there
Eating Problems in Special Populations: Cultural Considerations 121

is substantial heterogeneity within any one of the major census groups, re-
lating to country of origin and postmigration generation. In addition, cul-
tural exposures arise not only from the family’s country or ethnic heritage
of origin but also from the so-called host or dominant culture, global cul-
ture (accessed through the media and Internet), and other immigrant com-
munities.
It may be that the only valid assumption relating ethnicity to eating dis-
orders for clinical assessment is that any individual could be at risk, re-
gardless of ethnic, racial, or social background. Clinicians should be aware
that although eating disorders may present in conventional ways across di-
verse populations (Shaw et al. 2004), disclosure and presentation of symp-
toms may vary across sociodemographic groups. For this reason,
implementation of the DSM-5 Cultural Formulation Interview (American
Psychiatric Association 2013a) and its additional supplementary modules
(American Psychiatric Association 2013b) can be especially helpful in elic-
iting the patient’s understanding and experience of symptoms as well as
his or her preferences and expectations about treatment. Because of lay
and clinical stereotyping of AN as a disease associated with affluence and
white ethnicity, ethnic minority patients are at risk of a double stigma at-
tached to having an eating disorder (Becker et al. 2010b). Stigma, more-
over, may have different kinds of impact for different health care
consumers. For example, in China, Tong et al. (2014) reported a 39% re-
fusal rate for an interview among study participants who were likely to
meet diagnostic criteria on the basis of screening; they suggested that this
may have been driven by concerns about stigma and shame (Tong et al.
2014).

Cultural Patterning and Other Contextual

Influences on Diagnostic Assessment
Evidence of culture-specific phenotypes and patterning of symptoms
(Franko et al. 2007; Lee et al. 2010; Pike and Mizushima 2005; Striegel-
Moore et al. 2011; Thomas et al. 2011) suggests that cultural factors may
have more of a dimensional than categorical role in influencing the kind
and presentation of symptoms. For example, in Fiji, the use of traditional
herbal purgatives has been identified as a weight management behavior
among adolescent girls. Individuals with this behavior—along with those
reporting more familiar and conventional purging behaviors—have greater
eating psychopathology than individuals who do not engage in purging; in
addition, and perhaps more unexpectedly, the use of traditional herbal
purgatives appears to be associated with greater distress and impairment
122 Handbook of Assessment and Treatment of Eating Disorders

than is the more familiar and conventional bulimia-like purging behavior

(Thomas et al. 2011).
Lee and colleagues have extensively documented another example of
a culture-specific phenotype of AN. They described a variant of AN
among the Hong Kong Chinese distinguished by an absence of “fear of fat-
ness,” a characteristic that has been regarded as a core diagnostic feature
of AN. This presentation, termed non-fat-phobic AN, characterized a sizable
proportion of individuals presenting to a tertiary psychiatric clinic in this
Hong Kong setting in the mid-1980s (Lee et al. 2010). Notably, these pa-
tients provided a different—but culturally salient—rationale for their dietary
restriction and failure to gain weight (Lee 1995, 1996; Lee et al. 2001). Ad-
ditional studies identified non-fat-phobic AN in other Asian study popula-
tions, including in Japan, Singapore, and China (e.g., Pike and Borovoy
2004). Non-fat-phobic AN has also been documented in the United States
(Becker et al. 2009b).
The phenomenological diversity of feeding and eating disorders is re-
flected in the substantial proportion of cases that are assigned to the resid-
ual category even after the publication of revised criteria in DSM-5
(Machado et al. 2013; Nakai et al. 2013). Wide cultural variability in di-
etary patterns and variability in body size and weight ideals and their sa-
lience across the life course (Becker 1995) amplify this diversity further
and may contribute to the absence of clinical detection of an eating disor-
der, which is frequent in primary care settings. Other major challenges in
the diagnostic assessment of feeding and eating disorders include the di-
mensionality of key symptoms that lie on a continuum with socially nor-
mative dietary patterns and weight concerns. Intrinsic to several of these
criteria is their relativity to cultural context. For instance, ascertainment of
Criterion D for BN requires a judgment about whether the influence of
shape and weight on an individual’s self-evaluation is “undue.” Likewise,
Criterion A for both BN and binge-eating disorder operationalizes a binge
episode in relation to an amount that most individuals “would eat in a sim-
ilar period of time under similar circumstances” (American Psychiatric As-
sociation 2013a, pp. 345, 350). As a result, clinical assessment requires
understanding of the prevailing social norms within the patient’s cultural
milieu. In the absence of observable behaviors or collateral history that
can inform ascertainment of cognitive symptoms intrinsic to the feeding
and eating disorders, their assessment relies on patient report, which can
be affected by maturity, insight, and willingness to disclose (Becker et al.
2005, 2009a). Furthermore, whether a patient is able or willing to formu-
late or provide information about the departure from these norms may
also be governed by cultural style. Additional related symptoms such as
“marked distress” or “feeling uncomfortably full” (American Psychiatric
Eating Problems in Special Populations: Cultural Considerations 123

Association 2013a, p. 350) also require interpretation of subjective experi-

ence, which may be informed by socialization to culturally grounded stan-
dards and expectations. Collateral information from other sources is also
likely filtered through a cultural lens.

A Clinical Approach to Eating Problems

Across Culturally and Socially Diverse
Patient Populations
DSM-5 has replaced the older term “culture-bound syndrome” with sev-
eral new terms that better frame and capture the multiple cultural dimen-
sions that influence experience, presentation, and help seeking
(American Psychiatric Association 2013a, p. 758). Definitions are summa-
rized in Table 7–1 with some corresponding examples. A culturally in-
formed approach to assessment of feeding and eating disorders in
multicultural clinical settings will benefit from referencing relevant cul-
tural syndromes, idioms of distress, and cultural explanations with regard
to the disordered eating and comorbid psychiatric symptoms and disor-
ders, including anxiety and depressive disorders. However, because these
cultural influences are neither temporally fixed nor uniform within any
particular social group, a process-based approach to cross-cultural diag-
nostic formulation—such as is set forth in the Cultural Formulation Inter-
view (CFI) in DSM-5—has optimal clinical utility. The CFI can also be
accessed at www.psychiatry.org/practice/dsm/dsm5/online-assessment-
measures#Cultural.
Video 5 demonstrates cultural factors in the assessment of individuals
with eating problems.

Video Illustration 5: Cultural considerations in the assessment of

eating problems (6:10)

Overcoming Social and

Cultural Barriers to Treatment
Eating disorders are serious mental disorders, yet nearly half of individuals
with an eating disorder in the United States do not receive specialty care
for this problem (Hudson et al. 2007). Available evidence, moreover,
points to ethnic disparities in care access for an eating disorder in the
United States (Marques et al. 2011). Factors associated with both clinicians
and health consumers likely contribute to suboptimal care access. For ex-
124 Handbook of Assessment and Treatment of Eating Disorders

TABLE 7–1. Cultural dimensions of illness experience, expression,

and expectations relevant to mental health
assessment
Cultural Examples relevant to
concept DSM-5 definition disordered eating

Cultural “[C]lusters of symptoms and Macake (Fijian)—a loss of

syndromes attributions that tend to co- appetite associated with
occur among individuals in rhinorrhea, fever, oral
specific cultural groups, candidiasis, which can cause
communities, or contexts and dangerous weight loss
that are recognized locally as (Becker 1995)
coherent patterns of
experience”
Cultural “[W]ays of expressing distress Non-fat-phobic anorexia
idioms of that may not involve specific nervosa among Hong Kong
distress symptoms or syndromes, but Chinese—in lieu of concerns
that provide collective, shared about fatness or weight gain,
ways of experiencing and patients provide an
talking about personal or alternative rationale for
social concerns” dietary restriction, such as
fullness or other
gastrointestinal symptoms,
which is culturally salient
(Lee et al. 2001)
Cultural “[L]abels, attributions, or Macake (Fijian)—often
explanations features of an explanatory perceived to be caused by
or perceived model that indicate culturally social neglect that leads to a
causes recognized meaning or diet that is of poor quality or
etiology for symptoms, illness, otherwise inadequate
or distress” (Becker 1995)
Note. Definitions are excerpted from American Psychiatric Association 2013a, p. 758.
Used with permission. Copyright © 2013 American Psychiatric Association.

ample, consumer demand for care may be low in certain ethnic groups,
and clinician recognition of and response to patients with a feeding or eat-
ing disorder may also vary across patient ethnicity. Community-based epi-
demiological survey data demonstrate that service utilization for an eating
disorder is significantly lower among African Americans, Latinos, and
Asian Americans than among non-Hispanic white populations in the
United States (Marques et al. 2011). One study, controlling for severity of
symptoms, found that clinicians in a college-based screening program were
less likely to refer Latino participants than non-Latino white participants,
when controlling for severity of symptoms (Becker et al. 2003). A qualita-
Eating Problems in Special Populations: Cultural Considerations 125

tive study showed that some health consumers experience ethnicity-based

stereotyping by clinicians specific to their eating or weight complaints
(Becker et al. 2010b). Clinician bias related to other psychiatric diagnoses
has also been reported (Good 1992–1993). Unfortunately, these clinician
and health consumer factors can both reinforce reluctance to seek care and
reify the impression that feeding and eating disorders are uncommon
among ethnic minorities. It is advisable, therefore, for clinicians to consider
whether patient distrust may adversely affect a patient’s willingness to en-
gage in care. The CFI includes a probe question (question 16) that clini-
cians can use to address this sensitive issue in a respectful way along with
other social and cultural barriers to help seeking. The CFI Supplementary
Module 8 (“Patient-Clinician Relationship”) provides additional guidance
for addressing factors in the patient-clinician relationship that might under-
mine care. This module can be accessed in its entirety online (see Ameri-
can Psychiatric Association 2013b). Table 7–2 excerpts five relevant
questions that clinicians can ask a patient to expand on CFI question 16.
A variety of additional cultural and social factors influence patterns of
help seeking for mental disorders. For example, the stigma frequently as-
sociated with mental disorders may present a barrier to care if there are
perceived intolerable social costs to the patient or family. Likewise, pa-
tients and their caregivers may experience the therapeutic benefits of care
in nonclinical settings as superior or preferable. Family and social factors
that either enable or undermine adherence can be elicited using the CFI
Supplementary Module 3 (“Social Network”). Example questions from this
module are included in Table 7–2, and the module can be accessed in its
entirety online (see American Psychiatric Association 2013b).
Many individuals with an eating disorder are initially reluctant to dis-
close their symptoms to a clinician but may be willing to admit to symp-
toms when asked directly (Becker et al. 2005). Self-report assessments,
such as the Eating Disorder Examination Questionnaire (EDE-Q; Fair-
burn and Beglin 1994) and the SCOFF questionnaire (Morgan et al. 1999),
which have demonstrated validity in several languages and study popula-
tions, may be useful in promoting case identification when used alongside
clinician-based assessment. For example, they can augment a clinical in-
terview or prime a conversation about disordered eating symptoms. Be-
cause the item content in these measures may not tap all relevant domains
in all cultural settings, clinicians working with populations in multiethnic
settings or regions outside of Europe, North America, Australia, and New
Zealand should consider supplementing these screeners—as well as clinical
interviews—with questions assessing local dietary and weight management
behaviors. In addition to inquiring about conventional symptoms, clini-
cians should consider asking patients about use of complementary and al-
126 Handbook of Assessment and Treatment of Eating Disorders

TABLE 7–2. Excerpted questions from Cultural Formulation Interview

(CFI) supplementary modules addressing the patient-
clinician relationship and the patient’s social network
Patient-Clinician Relationship (related to CFI question 16)
QUESTIONS FOR THE PATIENT:
1. What kind of experiences have you had with clinicians in the past? What was
most helpful to you?
2. Have you had difficulties with clinicians in the past? What did you find difficult
or unhelpful?
3. Now let’s talk about the help that you would like to get here. Some people
prefer clinicians of a similar background (for example, age, race, religion, or
some other characteristic) because they think it may be easier to understand
each other. Do you have any preference or ideas about what kind of clinician
might understand you best?
4. Sometimes differences among patients and clinicians make it difficult for them
to understand each other. Do you have any concerns about this? If so, in what
way? [RELATED TO CFI Q#16.]
5. What patients expect from their clinicians is important. As we move forward in
your care, how can we best work together?
Social Network (related to CFI questions 5, 6, 12, 15)
INTRODUCTION FOR THE INDIVIDUAL BEING INTERVIEWED: I
would like to know more about how your family, friends, colleagues, co-workers,
and other important people in your life have had an impact on your [PROBLEM].
Composition of the individual’s social network
2. Is there anyone in particular whom you trust and can talk with about your
[PROBLEM]? Who? Anyone else?
Social network understanding of problem
4. What ideas do your family and friends have about the nature of your
[PROBLEM]? How do they understand your [PROBLEM]?
Social network response to problem
6. What advice have family members and friends given you about your
[PROBLEM]?
Social network as a stress/buffer
9. What have your family, friends, and other people in your life done to make
your [PROBLEM] better or easier for you to deal with? (IF UNCLEAR: How
has that made your [PROBLEM] better?)
11. What have your family, friends, and other people in your life done to make
your [PROBLEM] worse or harder for you to deal with? (IF UNCLEAR: How
has that made your [PROBLEM] worse?)
Social network in treatment
15. How would involving family or friends make a difference in your treatment?
Source. Excerpted from American Psychiatric Association 2013b. Used with permission.
Copyright © 2013 American Psychiatric Association.
Eating Problems in Special Populations: Cultural Considerations 127

ternative medicines and products, including over-the-counter natural

supplements. Because use of natural supplements and traditional purga-
tives varies across ethnicities (Kelly et al. 2006) and may be regarded as nor-
mative in some social milieus, and may also be common among individuals
with BN (Roerig et al. 2003), clinicians should inquire directly about usage
and probe further for misuse that reflects eating disorder psychopathology.
Although little is known about the global epidemiology of the feeding
and eating disorders, avoidant/restrictive food intake disorder and rumi-
nation disorder, there are numerous prevalence studies of pica eating. For
example, in some African regions, geophagia is prevalent among school-
children (e.g., near or exceeding 75% in Zambia [Nchito et al. 2004] and
Western Kenya [Geissler et al. 1998a]) as well as among women attending
antenatal clinics (e.g., approximately half of women sampled in Kenya
[Geissler et al. 1998b]). Pica eating in these regions often falls within local
social norms (e.g., in Western Kenya, Zambia, and Dar es Salaam [Geissler
et al. 1999; Kawai et al. 2009; Nchito et al. 2004]). For example, in some
regions, local vendors sometimes sell earth for consumption. Conse-
quently, clinicians not only should consider assessing for pica eating in mi-
grant populations in which pica eating is prevalent but also should
evaluate whether or not it is socially normative if intervention is indicated.
In assessing AN, clinicians should probe for persistent dietary restric-
tion or compensatory behaviors that prevent weight gain even if the pres-
ence of intense fear of weight gain or fatness is not apparent. When these
behaviors are present, the patient’s rationale should be evaluated. If pres-
ent, unconventional rationales for dietary restriction, such as gastrointesti-
nal (GI) discomfort, which are commonly seen in Chinese patients (Lee et
al. 2012) and which persist in undermining weight gain despite appropri-
ate intervention, should be considered and assessed.
Clinicians should be aware that social structural barriers, such as pov-
erty or limited knowledge of English, may impede access to treatment set-
tings and also influence clinical presentation. The differential diagnosis for
AN should encompass nutritional deficits due to food insecurity. The U.S.
Department of Agriculture reports that 14.5% of U.S. households were
food insecure in 2012. In addition, 7 million American households (5.7%)
experienced very low food security (operationalized by disruption of eat-
ing patterns and reduction of food intake by at least one household mem-
ber because of poverty). Nearly half of these households with very low
food security reported weight loss due to inadequate money for food
(Coleman-Jensen et al. 2013). Clinicians may find the questions used to as-
sess household food security as part of the Current Population Survey
(item content available at www.ers.usda.gov/media/1183208/err-155.pdf;
Coleman-Jensen et al. 2013) to be a useful guide for assessing food insecu-
128 Handbook of Assessment and Treatment of Eating Disorders

rity; they should also ask about the specific impact of food insecurity, if
any, on the identified patient. Household characteristics associated with
food insecurity in the United States include those with children and
headed by a single adult, those at or below the poverty line, and those with
identified as black or Hispanic (Coleman-Jensen et al. 2013). Although the
relationship between food insecurity and disordered eating is not yet well
understood, neither poverty nor presence of hunger excludes the possibil-
ity of an eating disorder, because both can be simultaneously present.

Physical Assessment
Physical examination is crucial to excluding medical causes of signs and
symptoms and planning nutritional, medical, pharmacological, and psy-
chosocial management. Psychoeducation for the patient and his or her
family, when appropriate, about the physical health impacts of disordered
eating may be especially helpful if they are unfamiliar with eating disor-
ders and their associated risks. In addition to a comprehensive physical
and laboratory examination to evaluate general health, clinicians should
consider and evaluate additional possible health and psychosocial expo-
sures among patients who have recently emigrated from or traveled to
their country of origin. A patient’s weight and height should be measured
and assessed against international standards for body mass index (BMI)
and BMI centiles, as well as in the context of population-specific bench-
marks, growth history, and family history. For example, clinicians should
be aware that the relationship among BMI, adiposity, and health risk var-
ies across some Asian, white, and Pacific Islander populations (Duncan et
al. 2009; Rush et al. 2009; WHO Expert Consultation 2004).
Although GI symptoms are common complaints among patients with
feeding or eating disorders, these symptoms may have no discernible
physiological correlate. Moreover, if a GI symptom or another somatic
complaint is a culturally preferred idiom for distress, then some patient
populations may present with these complaints with greater frequency
than others. In addition to considering and ruling out GI disorders and
conditions (Becker and Baker 2010), clinicians should consider and ex-
clude helminthic and other parasitic infections that can affect appetite and
weight (Stephenson 1994) and that differentially affect certain populations
in the United States (Hotez 2008).

Conclusion
Eating disorders have broad global distribution and occur across diverse
social and cultural contexts. Given sociocultural variation in help seeking
Eating Problems in Special Populations: Cultural Considerations 129

for, and the presentation and experience of, mental disorders, it is impor-
tant for clinicians to consider the potential influence of the cultural and so-
cial contexts in which symptoms have developed in the diagnostic
assessment of an eating disorder. Clinicians, moreover, should be mindful
of social barriers to treatment in framing recommendations and formulat-
ing a care management plan. The DSM-5 Cultural Formulation Interview
can be a helpful supplemental tool in evaluating social and cultural factors
germane to the diagnosis and treatment of an eating disorder.

Key Clinical Points

• Eating disorders occur across all of the major U.S. census groups
as well as around the world. The measurable global health burdens
associated with eating disorders increased substantially over the
past few decades.
• Service utilization for eating disorders varies substantially across
major ethnic groups, and thus certain ethnic groups are at higher
risk for lack of access to care; social barriers to care for an eating
disorder include clinician stereotyping and stigma. Ethnic variation
in service utilization for feeding disorders is unknown.
• Cultural variation has been observed in eating disorder symptom
presentation. However, cultural influences on prevalence and phe-
nomenology of disordered eating are fluid and dynamic and there-
fore cannot be generalized for application in any particular ethnically
or culturally defined population.
• Clinicians should include food insecurity in their differential diagno-
sis of anorexia nervosa, particularly among high-risk households.
• Clinicians should inquire about use of herbal, indigenous, or tradi-
tional supplements that affect appetite, weight, or gastrointestinal
function.
• Clinicians should reference dietary behaviors against local social
norms, using collateral history from the patient’s family, when ap-
propriate.
• Clinicians should consider conducting a patient-centered interview,
using the DSM-5 Cultural Formulation Interview and supplementary
modules, to elicit symptoms or terms with salience for the patient
that might not otherwise emerge when using questions with con-
ventional medical or psychiatric ideas or terms.
130 Handbook of Assessment and Treatment of Eating Disorders

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PA RT I I I
Assessment Tools
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8 Assessment Measures,
Then and Now
A Look Back at Seminal
Measures and a Look Forward
to the Brave New World
Jennifer J. Thomas, Ph.D.
Christina A. Roberto, Ph.D.
Kelly C. Berg, Ph.D., LP

Assessment is perceived by some people to be pedantic

and boring. One may envision a group of research assistants sitting around
a conference table quibbling over whether a sleeve of crackers counts as a
“binge.” However, accurate and reliable diagnostic evaluation is the foun-
dation for everything we do as clinicians and researchers. The way data
are captured and recorded informs diagnoses, treatment plans, insurance
requests, research results, and public policy.
Eating disorder assessment has come a long way over the last quarter
century. Just over 25 years ago, no structured interviews for assessing eat-
ing psychopathology existed, and eating disorders were rarely evaluated
in large-scale epidemiological studies. Since then, a plethora of interview
measures have emerged, each with its own advantages and disadvan-
tages. Seminal measures, most notably the Eating Disorder Examination
(EDE; Cooper and Fairburn 1987), have irrevocably shaped understand-
ing of the core psychopathology of eating disorders. Newer measures,
137
138 Handbook of Assessment and Treatment of Eating Disorders

such as the Eating Disorder Assessment for DSM-5 (EDA-5; Sysko et al.
2015), have pioneered the assessment of novel constructs of feeding psy-
chopathology. Recently, synergistic factors, including the publication of
DSM-5 (American Psychiatric Association 2013) criteria that incorporate
feeding disorders into a combined diagnostic scheme with eating disor-
ders, improvements in the understanding of psychometrics, and advances
in mobile technology, have converged to create a brave new world of
feeding and eating disorder assessment that will shape the next quarter
century of research and clinical care. Video 1, “Diagnostic issues in the
age of DSM-5,” presents a discussion of the changes in DSM-5.

A Look Back at Seminal Measures

Eating disorders have historically been assessed with either eating disor-
der–specific or general psychiatric interviews. Both types of measures
have strengths and weaknesses. In general, these measures were not de-
signed to incorporate the measurement of feeding disorders; however, ex-
ceptions are noted in the descriptions of the interviews in this chapter. The
currently available instruments are summarized in Table 8–1.

Eating Disorder–Specific Interviews

The first and most widely used eating disorder–specific interview has un-
doubtedly been the EDE (Cooper and Fairburn 1987). Other specialty in-
terviews that help in diagnosing eating disorders include the Structured
Interview for Anorexic and Bulimic Disorders (SIAB; Fichter et al. 1990),
the Interview for the Diagnosis of Eating Disorders (IDED; Williamson
1990), and an eating disorder–focused adaptation of the Longitudinal In-
terval Follow-up Evaluation (LIFE-EAT-3; K. T. Eddy, H. B. Murray, J. J.
Thomas, unpublished work, July 2015).1 These measures differ with respect to
the specific diagnoses derived, the constructs assessed, the generation of
dimensional severity ratings, and the assessment of current versus lifetime
symptoms.

Eating Disorder Examination

The EDE was the first structured interview to assess current eating disor-
der psychopathology. This widely used instrument has long been consid-

1 Other eating disorder–specific interviews, such as the Yale-Brown-Cornell Eating

Disorder Scale (Sunday et al. 1995) and the Clinical Eating Disorder Rating Instru-
ment (Palmer et al. 1987), can also be used to assess the severity of eating disorder
psychopathology and associated features. However, they are not discussed in this
chapter because neither can be used to make eating disorder diagnoses.
 Assessment Measures, Then and Now
TABLE 8–1. Characteristics of currently available structured interviews for eating disorder diagnosis
Clinical Current
expertise Age range Administration Feeding and eating disorder or lifetime Updated
Measure required (years) time diagnoses assessed diagnoses for DSM-5
Eating disorder–specific interviews
EDE-17.0D Yes 14 and up 1 hour AN, BN, BED, OSFED Current Yes
(Fairburn et al. 2014)
Child EDE Yes 8–14 1 hour AN, BN, OSFED Current No
(Bryant-Waugh et al. 1996)
SIAB-EX (Fichter et al. 1998) Yes 12–65 30–60 minutes AN, BN, BED Both No
IDED (Williamson 1990) Yes Adolescents 30 minutes AN, BN, BED Current No
and adults
LIFE-EAT-3 (K.T. Eddy, H.B. Yes 10 and up 15–20 minutes AN, BN, BED, ARFID, pica, Both Yes
Murray, J.J. Thomas, rumination disorder, OSFED
unpublished work, July 2015)
EDA-5 (Sysko et al. 2015) Some Adult 15 minutes AN, BN, BED, ARFID, pica, Current Yes
rumination disorder, OSFED
General psychiatric interviews
SCID-5 (First et al. 2015) Yes Adult 1–2 hoursa AN, BN, BED, OSFED Both Yes
(ARFID optional)

139
 140
TABLE 8–1. Characteristics of currently available structured interviews for eating disorder diagnosis (continued)
Clinical Current
expertise Age range Administration Feeding and eating disorder or lifetime Updated

Handbook of Assessment and Treatment of Eating Disorders

Measure required (years) time diagnoses assessed diagnoses for DSM-5
KSADS-PL Yes 6–18 1.25 hoursa AN, BN, BED Both Yes
(J. Kaufman, B. Birmaher, D.
Axelson, F. Perepletchikova,
D. Brent, Neal Ryan, working
draft, 2013)
CIDI (Robins et al. 1988) No Adult 1.5 hoursa AN, BN, BED Both No
DISC-IV No 6–17 1.5 hoursa AN, BN, pica Both No
(Shaffer et al. 2000)
Note. AN = anorexia nervosa; ARFID =avoidant/restrictive food intake disorder; BED = binge-eating disorder; BN = bulimia nervosa; CIDI = Composite
International Diagnostic Interview; DISC-IV = Diagnostic Interview Schedule for Children Version IV; EDA-5 = Eating Disorder Assessment for DSM-5;
EDE-17.0D = Eating Disorder Examination Version 17; IDED = Interview for the Diagnosis of Eating Disorders; KSADS-PL = Schedule for Affective Disor-
ders and Schizophrenia for School-Age Children—Present and Lifetime version; LIFE-EAT-3 =Longitudinal Interval Follow-up Evaluation eating disorder
adaptation; OSFED = other specified feeding or eating disorder; SCID-5 = Structured Clinical Interview for DSM-5; SIAB = Structured Interview for An-
orexic and Bulimic Disorders.
aReflects administration time for full interview, not just eating disorder section.
Assessment Measures, Then and Now 141

ered the gold standard for eating disorder assessment (for review, see
Thomas et al. 2014). The EDE was created primarily as a research tool for
studies of psychopathology and treatment response; it requires specialized
training to administer. To minimize recall bias (e.g., Teasdale and Fogarty
1979), the interview begins by orienting the respondent to the 28-day time
frame that is the focus of most of the interview, with the exception of di-
agnostic questions, which assess the frequency of behaviors over the past
3 months. Respondents are provided at the outset with a calendar and
asked to describe any events (e.g., holidays, days off work) that would help
them remember the time period; the calendar is then referenced through-
out the interview. This type of timeline follow-back procedure, which was
originally developed for the retrospective recall of alcohol consumption
(Sobell et al. 1979), helps orient respondents to the time period for the as-
sessment and provides contextual information during the interview. Each
interview item includes a mandatory probe and optional additional ques-
tions designed to elicit the necessary information for the assessor to make
a rating. The EDE generates scores for four subscales: Restraint, Eating
Concern, Weight Concern, and Shape Concern. These scores are aver-
aged to produce a global score. Constructs originally introduced in the
EDE (e.g., overvaluation of shape and weight) later became central to re-
vised diagnostic criteria for bulimia nervosa (BN). Items are coded based
on either the frequency of a behavior or cognition (e.g., present every day)
or the severity (e.g., to an extreme amount) using a seven-point Likert
scale with unequal spacing and an absolute zero point (Fairburn et al.
2008). The EDE also assesses key behavioral features of eating disorders,
including three forms of overeating (objective overeating, objective bu-
limic episodes, and subjective bulimic episodes) based on the amount of
food consumed and the degree of loss of control over eating. The fre-
quency scores generated from these questions (e.g., number of objective
bulimic episodes in the past 28 days) can be analyzed dimensionally or
used categorically to derive a diagnosis of anorexia nervosa (AN), BN, or
binge-eating disorder (BED). The EDE has recently been updated to ver-
sion 17 (i.e., EDE-17.0D; Fairburn et al. 2014; available for free from
www.credo-oxford.com/6.2.html) to better reflect diagnostic algorithms
for DSM-5 criteria; however, the interview itself was not altered from the
prior version (EDE-16.0D). To facilitate the assessment of youths, both
parent (Couturier et al. 2007) and child (Bryant-Waugh et al. 1996) ver-
sions of the EDE are available.
The EDE-17.0D has several strengths, including 1) the lack of skip logic
(i.e., every respondent answers every question, regardless of previous re-
sponses), which ensures that subthreshold eating disorder symptoms are
captured rather than overlooked (e.g., Swanson et al. 2011); 2) empirical
142 Handbook of Assessment and Treatment of Eating Disorders

support for aspects of its reliability and validity (for review, see Berg et al.
2012); 3) free availability; and 4) inclusion of items that enable the as-
sessment of some—but not all—other specified feeding or eating disorder
(OSFED) example presentations (i.e., subthreshold BN, subthreshold BED,
and purging disorder). In addition, as the most widely used interview assess-
ment of eating disorders, it has provided a consistent measure of clinical re-
sponse across treatment outcome studies (Fairburn et al. 2009; le Grange et
al. 2007) and is ideal for capturing clinically significant change, even over
brief time periods (e.g., 4 weeks).
The EDE also has a number of limitations. Perhaps the most impor-
tant are theoretical in nature and include 1) a bias toward assessing the
psychopathology of BN; 2) a focus on concepts most relevant to cognitive-
behavioral therapy; and 3) a lack of empirical support for the proposed
factor structure (Thomas et al. 2014). There are also a number of logistical
and functional limitations, including 1) the lack of empirical support for
the clinical or research value of specific items (e.g., picking and nibbling,
concern over body composition); 2) unnecessary item redundancy
throughout the interview (Berg 2010) and some overly complex ques-
tions; 3) limited accessibility of the specialized training needed to admin-
ister the interview; 4) rating scales with unequal intervals that limit the
statistical utility of certain items; 5) a diagnostic algorithm that does not
fully represent DSM-5 criteria; 6) a lack of items assessing feeding disor-
ders or concepts relevant to avoidant/restrictive food intake disorder
(ARFID), pica, and rumination disorder; and 7) the length of time re-
quired to conduct the interview (usually an hour or more).

Structured Interview for Anorexic and Bulimic Disorders

The SIAB (Fichter et al. 1990) was originally developed as both a self-
report questionnaire (SIAB-S) and a semistructured interview or expert
rating scale (SIAB-EX). The SIAB-EX (Fichter et al. 1998) was subse-
quently revised to be compatible with DSM-IV (American Psychiatric As-
sociation 1994) and the International Classification of Diseases (ICD-10;
World Health Organization 1992) and can be used to derive eating disor-
der diagnoses.2 Additionally, the SIAB-EX includes subscales that pro-
vide dimensional measures of eating disorder–specific psychopathology
as well as additional symptoms and characteristics that are commonly as-

2The SIAB-EX is freely available online for research purposes (www.klinikum.uni-

muenchen.de/Klinik-und-Poliklinik-fuer-Psychiatrie-und-Psychotherapie/en/forsc-
hung/epidemiologie). Alternatively, it can be obtained by contacting the primary
author, Manfred Fichter, at [email protected] or at the Department of
Psychiatry, University of Munich, Nussbaumstrasse 7, 80336 Munich, Germany.
Assessment Measures, Then and Now 143

sociated with eating disorder diagnoses (Body Image and Slimness Ideal,
General Psychopathology, Sexuality and Social Integration, Bulimic
Symptoms, Measures to Counteract Weight Gain, Fasting, Substance
Abuse, and Atypical Binges). The strengths of the SIAB-EX include the
following: 1) it is the only eating disorder–specific interview that was de-
signed to measure both current and lifetime symptoms, making it ideal for
use in genetic studies (e.g., the Price Foundation Collaborative Group
[2001] used the SIAB to evaluate lifetime eating disorder phenotypes in a
large multisite genetics collaboration); 2) it is currently the only eating dis-
order interview that can be used to derive both DSM and ICD diagnoses;
3) it was designed to be used both dimensionally and categorically, a fea-
ture that broadens the utility of the instrument; and 4) the manual and cod-
ing forms include detailed descriptions of each construct being assessed as
well as additional probes, which may enhance the validity with which
these constructs are assessed as well as the reliability of ratings between as-
sessors. Limitations of the SIAB-EX include the following: 1) although
there are plans to update the instrument,3 it has not yet been modified to
reflect changes in DSM-5 criteria for AN, BN, and BED4; 2) it does not as-
sess symptoms associated with ARFID, pica, or rumination disorder; 3) it
is a long interview (87 items), which may be prohibitive in terms of time
and cost; 4) it is meant to be administered by someone who has expertise
in the field of eating disorders, and untrained clinicians require substantial
training prior to administering the interview; and 5) some of the items as-
sess constructs that may not be a priority in some settings (e.g., internal
achievement motivation, grazing, substance use).

Interview for the Diagnosis of Eating Disorders

The IDED (Williamson 1990) was originally developed to derive descrip-
tive and diagnostic information about AN, BN, compulsive overeating,
and obesity. The interview begins with general assessment and history to
elicit descriptive information about the onset and course of eating- and
weight-related problems, weight history, and associated medical prob-
lems. Three additional sections are devoted to the psychopathology of
AN, BN, and compulsive overeating, with a focus on questions related to
diagnostic criteria. The IDED has been subsequently revised, most re-

3 There are plans to update the SIAB-EX for both ICD-11 and DSM-5 once
ICD-11 is finalized and released (M. Fichter, personal communication, Septem-
ber 2014).
4 The current version of SIAB-EX is incompatible with DSM-5 because frequen-

cies of binge eating and compensatory behaviors are measured on a Likert scale
that does not include a frequency anchor for one episode per week.
144 Handbook of Assessment and Treatment of Eating Disorders

cently to ensure compatibility with DSM-IV criteria for AN, BN, and
BED (IDED-IV; Kutlesic et al. 1998).5 Strengths of the IDED-IV include
the following: 1) it can be used either categorically to derive diagnoses or
dimensionally to describe eating disorder psychopathology; 2) diagnostic
coding is relatively straightforward; and 3) research has demonstrated pre-
liminary support for interrater reliability and for the content, concurrent,
and discriminant validity of the instrument to assess and derive diagnostic
data on eating disorders (Kutlesic et al. 1998). Limitations of the IDED-IV
include the following: 1) there are no plans to update the instrument for
DSM-5 (e.g., changes to the diagnostic criteria for AN, BN, and BED will
not be reflected; V. Kutlesic, personal communication, September 2014);
2) it does not assess ARFID, pica, and rumination disorder; 3) it does not
assess specific symptom frequencies (e.g., binge eating, vomiting), which
decreases its utility for certain types of analyses and increases the likeli-
hood of ceiling and/or floor effects; and 4) its focus on the diagnostic cri-
teria necessarily precludes a rich and detailed assessment of specific facets
of eating disorder psychopathology (e.g., weight/shape concern, cognitive
restraint) or the assessment of constructs relevant to eating disorders that
are not reflected in diagnostic criteria. Owing in part to these limitations,
the IDED has been used much less frequently in eating disorder research
than the EDE or the SIAB.

Longitudinal Interval Follow-up Evaluation

The LIFE (Keller et al. 1987) was developed for use in longitudinal stud-
ies, and the eating disorder adaptation (LIFE-EAT) was created for one of
the longest-running longitudinal studies of eating disorders, ongoing since
1987 (Eddy et al. 2008). LIFE-EAT-3 was recently updated to reflect
DSM-5 criteria (K. Eddy, personal communication, June 2015). The
LIFE-EAT-3 assesses the relative severity of diagnostic features of AN, BN,
BED, ARFID, pica, rumination disorder, and OSFED over a prespecified
length of time determined by the study purpose. The assessor uses a calen-
dar to collect detailed weekly data to track longitudinal fluctuations in eat-
ing disorder symptoms. On the basis of these findings, the assessor confers
a transdiagnostic psychiatric status rating (PSR) on a six-point severity
scale, ranging from “definite criteria severe” to “complete recovery.”

5 The IDED-IV can be obtained by contacting the primary author, Vesna Kutle-
sic, at [email protected] or at 6100 Executive Boulevard, Room 2A01B,
MSC 7510, Bethesda, MD 20892-7510.
Assessment Measures, Then and Now 145

Strengths include 1) the free availability of the measure6; 2) the collection

of weekly symptom data that can be used to ascertain clinically significant
change, persistence, recurrence, time to recovery, or diagnostic crossover
over time; and 3) the recent update to reflect DSM-5 criteria. The primary
limitation of the LIFE-EAT-3 is the lack of reliability and validity data for
the most recent version.

General Psychiatric Interviews

Because eating disorder–specific interviews are typically time-consuming
and require specialized training to administer, general psychiatric inter-
views provide a viable alternative that allows eating disorders to be as-
sessed alongside other potentially comorbid disorders. The clear standard
in patient-oriented research is the semistructured assessment that requires
some degree of clinical expertise to administer. These instruments include
the Structured Clinical Interview for DSM Axis I disorders (SCID; First
et al. 2002b), which is used to assess adults, and the Schedule for Affective
Disorders and Schizophrenia for School-Age Children (KSADS; Ambro-
sini 2000), which is used to assess both children and adolescents. In con-
trast, epidemiological studies typically employ highly structured
interviews that can be delivered by nonclinicians. These interviews in-
clude the Composite International Diagnostic Interview (CIDI; Robins et
al. 1988), used with adults, and the Diagnostic Interview Schedule for Chil-
dren Version IV (DISC-IV; Shaffer et al. 2000), used with children and ad-
olescents.

Structured Clinical Interview for DSM Axis I Disorders

The SCID is a widely used semistructured interview designed to assess
DSM diagnostic criteria for psychiatric disorders. It includes modules that
cover a range of psychiatric diagnoses, including eating disorders. The
SCID is published by the American Psychiatric Association, which also
publishes DSM. Prior to the 2013 publication of DSM-5, the SCID-IV,
based on DSM-IV criteria, was most widely used, with different versions
for researchers (First et al. 2002b), for clinicians (First et al. 1996), and for
use with community samples (First et al. 2002a). (A version for children,
called the KID-SCID [Matzner et al. 1997], is freely available but does not

6 To obtain a copy of LIFE-EAT-3, please contact Kamryn T. Eddy at

[email protected] or at the Massachusetts General Hospital Eating Disorders
Clinical and Research Program, 2 Longfellow Place, Suite 200, Boston, MA 02114.
146 Handbook of Assessment and Treatment of Eating Disorders

have published reliability and validity data and, more importantly, does
not have a module for eating disorders.) The recently available SCID-5
(First et al. 2015) assesses the DSM-5 diagnostic criteria for AN, BN, and
BED and also covers some OSFED presentations and contains an op-
tional module to assess ARFID.
To conduct the SCID, assessors read mandatory probe questions that
include suggested follow-up items designed to evaluate a specific diagnos-
tic criterion. The SCID uses extensive skip logic that prompts the assessor
to skip subsequent questions when sufficient diagnostic criteria are not met
to warrant further questioning. The SCID assesses both current and life-
time diagnoses, with criteria for partial or full remission, and prompts the
assessor to capture age at illness onset and to rate current illness severity.
Scoring the SCID for an eating disorder diagnosis can be done in a few
minutes by the assessor after administration of the module. Ideally, the
SCID is completed by an assessor who has enough clinical knowledge that
he or she could conduct a diagnostic interview in the absence of a struc-
tured interview (First et al. 2008), but those with less knowledge or expe-
rience can administer the SCID provided they receive appropriate
training and have been observed by an experienced assessor. The SCID
and training DVDs can be ordered online (www.scid4.org). In a major
multisite study of SCID-III-R test-retest reliability, good to excellent reli-
ability was obtained for AN and BN diagnoses in patient samples (Wil-
liams et al. 1992). Another study found substantial interrater reliability for
eating disorder diagnoses ascertained through an unstructured clinical in-
terview versus the SCID-IV (Thomas et al. 2010).
The SCID-5 has several strengths, including 1) generating diagnoses
based on DSM-5 criteria, although probes remain largely consistent with
DSM-IV queries; 2) empirical support for the reliability and validity of
prior versions, although additional data will be needed to support the
SCID-5 itself; and 3) an eating disorder module that can be administered
and scored relatively quickly. There are also two key improvements from
the SCID-IV, including the addition of specific questions (under OSFED)
to establish impairment, helping the assessor to distinguish between an
eating disorder or non–eating disorder diagnosis, and specific guidance on
assigning severity categories for AN (based on a table of adult heights and
weights for each severity category) and BN (based on frequency of com-
pensatory behaviors). The SCID-5 also has several limitations: 1) pica and
rumination disorder are excluded; 2) the ARFID module is optional, which
likely means that limited data will be collected to further the understand-
ing of this new diagnostic category; 3) the extensive use of skip logic cre-
ates missed opportunities to capture useful diagnostic information that
might be of interest to researchers or clinicians; 4) options for assigning
Assessment Measures, Then and Now 147

OSFED diagnoses include a list of OSFED presentations but no interview

prompts to guide their identification; and 5) it must be purchased.

Schedule for Affective Disorders and Schizophrenia for

School-Age Children
The KSADS is a semistructured interview that generates psychiatric diag-
noses for youths ages 6–18 (Ambrosini 2000). The KSADS was adapted
from the Schedule for Affective Disorders and Schizophrenia (SADS) for
adults (Endicott and Spitzer 1978), with the “K” standing for kiddie. Par-
allel versions of the KSADS include options to interview the child alone
and/or both the child and parent separately and subsequently to create a
summary score from the child and all collateral sources (e.g., parent, child,
teacher, medical record). The KSADS—Present and Lifetime (PL) version
2013 Working Draft (J. Kaufman, B. Birmaher, D. Axelson, F. Pereplet-
chikova, D. Brent, Neal Ryan) has been updated to reflect DSM-5 criteria,
including both severity and remission specifiers. The KSADS eating dis-
order screen begins with 2–3 minutes of open-ended questions to gather
information about typical eating habits and feelings about shape and
weight, followed by items keyed to specific DSM-5 diagnostic criteria,
which can be assessed as present, subthreshold, or threshold. If the respon-
dent meets any key criteria, the assessor then asks additional diagnostic
questions from the eating disorder supplement. The KSADS produces
current and lifetime diagnoses of AN, BN, and BED.
Strengths of the KSADS include 1) the flexibility of the semistructured
style that allows assessors to ask additional unscripted questions and apply
their own clinical judgment; 2) the lengthy screen with queries about a va-
riety of eating disorder symptoms (e.g., fear of weight gain, low weight,
binge eating, purging), which trigger application of the supplement if an-
swered affirmatively, thereby reducing the probability of missing clini-
cally significant presentations; 3) a recent update to reflect DSM-5
criteria; and 4) free availability.7 In contrast, the weaknesses include 1) the
lack of ARFID, pica, and rumination disorder items; 2) the necessity for
a trained clinician to administer the interview, thus reducing ease of dis-
semination; and 3) the length of time required for assessment (approxi-
mately 1.25 hours) (Ambrosini 2000).

7 To obtain a copy of the KSADS-PL, please contact the primary author, Joan
Kaufman, at [email protected] or at the Department of Psychiatry, Yale
School of Medicine, Congress Place, 301 Cedar Street, P.O. Box 208098, New
Haven, CT 06520.
148 Handbook of Assessment and Treatment of Eating Disorders

Composite International Diagnostic Interview

The CIDI was developed by the World Health Organization to be relevant
cross-culturally and reflective of both DSM and ICD criteria (Robins et al.
1988). A unique feature of the CIDI is its cross-cultural applicability (e.g.,
items assessing the criteria for alcohol use disorders query not just about ab-
senteeism from salaried employment but also about failure to complete
chores, which may be more relevant to rural subsistence farmers in devel-
oping countries). The CIDI assesses both current and lifetime AN, BN, and
BED. Of special note for the eating disorders field, the CIDI was the instru-
ment used to establish the widely cited eating disorder prevalence rates
from the United States–based National Comorbidity Survey Replication
(Hudson et al. 2007). Because administration is fully computerized and
questions are close-ended, trained lay assessors can administer the inter-
view without a formal clinical degree.
Strengths of the CIDI include 1) enhanced cross-cultural validity in com-
parison to other interviews; 2) ease of use by lay assessors after brief training;
and 3) free accessibility online (www.hcp.med.harvard.edu/wmhcidi).
Weaknesses include the following: 1) because eating disorders are consid-
ered “non-core” disorders, they are not assessed on the abridged “core” ver-
sion of the measure; 2) OSFED, ARFID, pica, and rumination disorder are
not assessed; 3) skip logic requires that respondents who do not endorse
twice-weekly binge eating will not be asked about purging, meaning that
clinically significant presentations (e.g., purging disorder) may be missed;
and 4) it has not yet been updated to reflect DSM-5, likely because the up-
date will need to wait until the publication of ICD-11, anticipated in 2017.

Diagnostic Interview Schedule for Children Version IV

The DISC-IV (Shaffer et al. 2000) is a highly structured psychiatric inter-
view, originally based on the adult Diagnostic Interview Schedule (Robins
et al. 1981) and developed by the National Institute of Mental Health
(NIMH). The DISC-IV features options for direct administration to youths
ages 9–17 and parallel administration versions for parents/caretakers and
youths ages 6–17. The youth (DISC-IV-Y) and parent (DISC-IV-P) versions
are nearly identical except for pronoun usage (i.e., “you” vs. “him” or
“her”). Now in its fourth revision, the DISC-IV generates current and op-
tional lifetime diagnoses adhering very strictly to DSM-IV and ICD-10 cri-
teria. In addition to assessing AN and BN, the DISC-IV is one of the few
currently available psychiatric interviews—either general or eating disor-
der–specific—that assesses the diagnostic criteria for pica (i.e., “eating
things that aren’t food, like peeling paint...or ashes...or dirt...or pebbles”
for at least 4 weeks with associated impairment).
Assessment Measures, Then and Now 149

The DISC-IV has many pros: 1) it can be administered by lay asses-

sors after brief training, thereby making it an ideal measure for large-
scale epidemiological studies; 2) questions are read verbatim and are
never open-ended, so administration is extremely straightforward; 3) as-
sessors are encouraged to use the computer-assisted version, which stan-
dardizes administration, reduces data entry burden, and identifies
positive diagnoses based on a computer algorithm; and 4) it assesses
pica.8 Cons include the following: 1) it does not assess BED, ARFID, ru-
mination disorder, or OSFED; 2) it employs a very strict skip-out struc-
ture and scoring algorithm that may miss clinically significant diagnoses,
especially atypical presentations; and 3) it has not yet been updated for
DSM-5.

A Look Forward to the Brave New World

Despite their seminal role in defining the field, existing measures—both
eating disorder–specific and general psychiatric—have limitations, particu-
larly in the assessment of DSM-5 constructs, most notably feeding disor-
ders. A newly published interview, the EDA-5 (Sysko et al. 2015),
overcomes many of these limitations, although it is not without its own
drawbacks. The combination of feeding and eating disorders into a single
DSM-5 chapter introduces new challenges but ultimately presents a
unique opportunity to shape the field by developing new assessments that
will better define these emerging phenotypes.
See Video 1, which features a roundtable discussion with B. Timothy
Walsh, M.D., and colleagues involved in changes to feeding and eating dis-
order diagnoses in DSM-5.

Video Illustration 1: Diagnostic issues in the age of DSM-5 (8:11)

Eating Disorder Assessment for DSM-5

The EDA-5 (Sysko et al. 2015) is a brief, semistructured interview specifi-
cally developed to derive feeding and eating disorder diagnoses using
DSM-5 criteria (see Chapter 10, “Use of the Eating Disorder Assessment
for DSM-5”). Originally developed as a paper-and-pencil instrument, it
has been modified for use as a Web-based application (“app”) for comput-

8To obtain a copy of the DISC-IV, please e-mail [email protected]

or write to DISC Development Group, Columbia University, 1051 Riverside
Drive, Unit 78, New York, NY 10032.
150 Handbook of Assessment and Treatment of Eating Disorders

ers and mobile devices (freely available at www.eda5.org). The app allows
the assessor to enter information provided by the respondent directly into
the app’s answer fields. The app then moves the assessor through the in-
terview (and diagnostic criteria) based on the information being provided
by the respondent. At the end of the interview, the app provides the diag-
nosis that best fits the respondent’s reported symptoms as well as key
symptoms associated with the diagnostic criteria (e.g., current body mass
index [BMI], frequency of binge eating, frequency of compensatory be-
haviors). The EDA-5 is relatively brief to administer (i.e., approximately
15 minutes; Sysko et al. 2015), which can be attributed to its primary focus
on feeding and eating disorder diagnostic criteria and its use of skip rules.
Research comparing the EDA-5 to the diagnostic items of the EDE and
unstructured clinical interviews has demonstrated preliminary evidence of
the validity of the EDA-5 to determine diagnoses and the test-retest reli-
ability of derived diagnoses (Sysko et al. 2015).
There are several advantages of the EDA-5, particularly in comparison
with other currently available interviews. First, the EDA-5 is the first—and
currently the only—comprehensive interview that assesses all symptoms of
feeding and eating disorders described in DSM-5, which, at least concep-
tually, would enhance one’s ability to derive accurate diagnoses. Second,
it can be administered by individuals with limited training, is available as
a Web-based application, and is compatible with mobile devices, which
enhances its portability and ease of use (e.g., it automatically follows skip
rules, calculates BMI, and runs diagnostic algorithms that derive diagno-
ses). Finally, it is a brief instrument, which minimizes the burden on both
the respondent and the assessor. Minimizing assessment burden can en-
hance the validity of the information gathered during an assessment, re-
duce costs associated with the assessment (e.g., salary/wages for assessor,
payment for research participation), and allow time for the assessment of
other relevant symptoms or constructs.
Although the instrument’s specificity as a diagnostic measure of
DSM-5 feeding and eating disorders has inherent strengths, it also has
limitations. For example, symptoms or features that are often associated
with eating disorders but are not included in the DSM-5 criteria (e.g., per-
fectionism, impulsivity) are not assessed by the EDA-5. Additionally, be-
cause the EDA-5 was developed as a diagnostic tool, the data provided
are primarily categorical; the tool provides only minimal dimensional
data. These features of the EDA-5 mean that if assessors are interested in
gathering information above and beyond diagnosis and frequency of dis-
ordered behaviors, the inclusion of other assessment instruments (e.g., a
dimensional self-report measure of eating psychopathology) is likely to be
necessary. In the age of the NIMH Research Domain Criteria (Insel et al.
Assessment Measures, Then and Now 151

2010), which are based on dimensional assessment, the focus on categor-

ical diagnoses could negate the strengths of the EDA-5 as a brief measure
for use in research settings.
Additionally, although the use of skip rules does minimize the time
needed to complete the instrument, skip rules can result in failure to cap-
ture clinically significant symptoms. Indeed, prior research on skip rules
suggests that this loss of information can lead to an underestimation of the
prevalence and severity of symptoms (Swanson et al. 2014). For example,
the first three items of the EDA-5, which function to determine whether a
feeding or eating disorder might be present, are skip-out items. Unless the
respondent endorses at least two of these items,9 the interview ends with-
out an assigned diagnosis. Given that inadvertent or deliberate minimiza-
tion of symptoms is common among individuals with eating disorders
(Becker et al. 2009), the use of skip rules so early in the interview may be
problematic. Another consideration is that data entered into the app ver-
sion of the EDA-5 are not saved and must later be entered by hand. Fi-
nally, the EDA-5 is relatively new and its psychometric properties have
not been thoroughly tested or replicated.

Feeding Disorder Assessment

Few currently available interviews assess the specific psychopathology of
feeding disorders. ARFID is assessed only on the EDA-5 and in an op-
tional SCID module, pica is assessed only on the EDA-5 and DISC-IV,
and rumination disorder is assessed only on the EDA-5. Importantly, all
existing interviews that assess feeding disorders are purely diagnostic, and
none of them feature dimensional measures of feeding disorder severity.
Current knowledge of feeding disorders is scattered across disciplines, in-
cluding not only psychiatry but also speech pathology, occupational ther-
apy, and gastroenterology. Indeed, apart from the EDA-5, the only other
structured interview to assess rumination behavior is the Rome-III Diag-

9 A curiosity of the EDA-5 is that of the first three items, the only one that respon-
dents must endorse to move forward in the interview is the item that assesses
impairment/distress, a symptom that is not required for DSM-5 diagnoses of AN,
BN, BED, pica, rumination disorder, and ARFID. Even if the respondent
answers affirmatively to the other two items, the interview will end and the
respondent will receive a diagnosis of no feeding or eating disorder if the respon-
dent does not endorse impairment/distress. The EDA-5 does specify that the
assessor can use additional sources of information such as clinical observation,
treatment providers, and family members to help determine whether impair-
ment/distress is present. However, these sources of information may not always
be available.
152 Handbook of Assessment and Treatment of Eating Disorders

nostic Questionnaire for Functional Gastrointestinal Disorders (Walker et

al. 2006). The Rome-III items may be instructive to feeding disorder re-
searchers because they differentiate “adolescent rumination syndrome”
from gastroesophageal reflux disease, in part by querying about pain and
nausea associated with regurgitation.
Just as the development of structured interviews played a major role in
refining eating disorder phenotypes over the last quarter century, so too
could the development of structured assessments for feeding disorders
over the next 25 years. Owing to the overlapping nature of feeding and
eating symptoms, the two will likely need to be evaluated side by side. In-
deed, rumination can be challenging to separate from frank purging in the
context of shape and weight concerns (Delaney et al. 2015), and the con-
sumption of nonfood items to suppress appetite (sometimes observed in
patients with AN; Delaney et al. 2015) would not meet DSM-5 criteria for
pica. Thus, there is currently a critical need for specialized interviews and
self-report questionnaires on feeding pathology; we cannot study what we
do not measure.

Conclusion
The last quarter century of eating disorder assessment has demonstrated
that the development of structured interviews was vital to the advance-
ment of the field. However, these historical measures, including the gold
standard EDE, are not without limitations. The newly published EDA-5 is
currently the only measure that captures all DSM-5 feeding and eating dis-
order diagnoses, but it may not be suitable for all clinical and research ap-
plications. The addition of feeding disorders in a joint DSM-5 category
with eating disorders poses a diagnostic challenge but will ultimately pre-
sent an opportunity for further refining phenotypes over the next quarter
century.

Key Clinical Points

• Accurate and reliable assessment is the foundation for clinical and
research efforts. The way in which data are captured and recorded
informs diagnoses, treatment plans, insurance requests, research
results, and public policy. Structured interviews fall into two catego-
ries: eating disorder–specific and general psychiatric.
• The Eating Disorder Examination (EDE-17) is the most widely used
eating disorder–specific interview, and its seminal value to the field
is reflected in the current understanding of the core psychopathol-
Assessment Measures, Then and Now 153

ogy of anorexia nervosa and bulimia nervosa. This instrument has a

number of strengths, including comprehensive assessment of eat-
ing disorder psychopathology, empirical support for aspects of its
reliability and validity, and free availability. However, it is limited by
a bias toward assessing bulimia nervosa, a focus on concepts spe-
cific to cognitive-behavioral therapy, a lack of feeding disorder cov-
erage, and minimal support for the proposed factor structure.
• The Structured Clinical Interview for DSM (SCID) disorders is the
most widely used general psychiatric interview applicable for eating
disorders, and the SCID-5 is the most recent version. It captures
DSM-5 diagnostic criteria, and it can be scored easily and quickly.
Prior versions have shown good to excellent reliability. However, the
SCID-5 is limited by the use of skip rules, minimal coverage of feed-
ing disorders, and a lack of prompts to help assessors assign spe-
cific examples of other specified feeding or eating disorders.
• The Eating Disorder Assessment for DSM-5 (EDA-5) is a promising
new diagnostic interview for eating disorders. Benefits include its
brevity, compatibility with DSM-5 criteria, and use of technology
(i.e., a mobile app). However, limitations include its specificity, use
of skip rules, minimal dimensional assessment, and limited psycho-
metric data.
• Few currently available interviews assess the specific psychopa-
thology of feeding disorders. This poses a challenge for establish-
ing prevalence, severity, and treatment response but also presents
a unique opportunity to shape the field by creating new assess-
ments that more clearly define feeding disorder phenotypes.

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9 Self-Report Assessments
of Eating Pathology
Kelsie T. Forbush, Ph.D., LP
Kelly C. Berg, Ph.D., LP

Self-report measures of eating psychopathology are

important tools for understanding disordered eating behaviors across a
wide variety of contexts, ranging from routine clinical care to large-scale
epidemiological research studies. In the era of managed health care, the
selection of self-report measures with evidence to support their reliability
and validity has become increasingly important within clinical settings. In-
deed, managers of mental health organizations face pressures to reduce or
eliminate unnecessary costs, while maintaining strong quality of care,
which has led to an increased emphasis on the need for tracking of clinical
outcomes (Burlingame et al. 1995).
Tracking clinical outcomes is important not only from the perspective of
managed care but also because results from randomized studies have shown
that when therapists are provided with objective feedback from assessments
of clients’ progress, a variety of improved client outcomes, including in-
creased therapy attendance, greater achievement of clinically significant or re-
liable change, and reduced deterioration of therapeutic gains after treatment
termination, occur (Hatfield et al. 2010; Lambert and Shimokawa 2011;
Lambert et al. 2002; Reese et al. 2010). For patients who were predicted
to have a good prognosis at the beginning of therapy, assessment feedback
has been shown to result in a reduced number of therapy sessions without
reducing positive therapeutic outcomes (Lambert et al. 2002).

157
158 Handbook of Assessment and Treatment of Eating Disorders

Although the assessment of eating disorder behaviors provides an impor-

tant foundation for empirical research studies and is a crucial component of
clinical care, few resources summarize the psychometric properties and clin-
ical utility of available self-report measures. The current chapter aims to offer
a useful resource for clinicians and researchers alike. We provide information
on the development, reliability, and validity of commonly used self-report
measures of eating pathology. We also mention issues in the assessment of
disordered eating behaviors and cognitions among specific demographic
populations, such as men, overweight or obese persons, and individuals in
ethnic or racial minorities, as a complement to the descriptions in other chap-
ters of the book (e.g., Chapter 6, “Eating-Related Pathology in Men and
Boys,” and Chapter 7, “Eating Problems in Special Populations”). Given the
large number of available eating disorder measures, we limit the chapter to
popular “all-in-one” self-report assessments of eating pathology that assess
multiple dimensions of eating disorder psychopathology within a single mea-
sure. The measures we have chosen have strong psychometric properties, are
easily available to clinicians, and/or have a substantial research base. An-
other reason we focus on multidimensional measures is because they repre-
sent an efficient way for busy clinicians to assess their clients for eating
psychopathology (i.e., the all-in-one measures can be used instead of a battery
of several self-report measures to assess the same thoughts and behaviors).
We conclude with a discussion of the strengths and limitations of self-report
assessments of eating disorders and suggestions for future research.

Scale Development Methods

Although the initial development and validation of eating disorder self-
report measures are crucial considerations in instrument selection, the
busy eating disorder professional may overlook their importance. Many
of the issues with reliability and validity subsequently discussed in this
chapter stem from outdated scale development and testing, and we are
not aware of any published articles or chapters in the field of eating dis-
orders that describe optimal methods for scale construction. Given that
tracking client outcomes and interpreting research findings often hinge
on the psychometric properties of the selected test battery, it is important
to have at least a cursory knowledge of scale development procedures.

Rationally and Empirically Based Methods

At one end of the scale development spectrum are rationally based methods,
which are based primarily (or exclusively) on theory and in which empirical
(statistical) methods are not used to eliminate questions from the initial item
pool (although statistics may be used after the measure is finalized to test the
Self-Report Assessments of Eating Pathology 159

reliability and validity of the measure). At the extreme other end are purely
empirically based methods, which use statistical approaches in the absence of
theory to identify a set of questionnaire items that best distinguish among cri-
terion groups (e.g., items may be selected that best distinguish individuals with
anorexia nervosa [AN] from those with bulimia nervosa [BN]). Each of these
approaches has a serious problem: rational measures tend to have a large
number of psychometric issues that hamper their reliability and validity; em-
pirical measures are limited to the samples in which they were developed
(Clark and Watson 1995; Comrey 1988). As an example of the latter, if an
eating disorder measure was designed to distinguish patients with AN from
those with BN, it would not be appropriate to use that measure with persons
with binge-eating disorder (BED) without additional validation. The need to
validate an empirically based measure to each population in which it could be
used (e.g., diagnostic group, age group, racial/ethnic group) has the potential
to significantly limit the usefulness of these types of measures.

Hybrid-Based Methods
Modern scale development recommendations highlight the importance of
hybrid-based methods (Clark and Watson 1995; Comrey 1988). These ap-
proaches incorporate both a heavy emphasis on using theory to develop the
initial item pool and the use of empirical analyses to remove poorly perform-
ing items from the scale by employing exploratory and confirmatory factor
analyses. These factor analytic techniques are designed to identify latent un-
observed dimensions (or “factors”) based on the pattern of correlations among
items in the item pool. Myriad data in other areas of psychopathology suggest
that hybrid-based approaches are more likely to result in the development of
measures with strong psychometric properties, such as good convergent va-
lidity (the measure or scale is correlated moderately to strongly with other
measures or scales of the same construct) and discriminant validity (the mea-
sure or scale is not correlated substantially with measures or scales assessing
different constructs). We direct the interested reader to classic papers by
Clark and Watson (1995), Loevinger (1957), and Smith et al. (2000) for ad-
ditional information on best practices for scale development and testing.

Overview of Multidimensional
Eating Disorder Self-Report Assessments
Eating Disorder Inventory
The Eating Disorder Inventory (EDI; Garner et al. 1983), now in its third
edition (EDI-3; Garner 2004), is a widely used measure designed to assess
cognitive and behavioral features that underlie AN and BN. Expert clini-
160 Handbook of Assessment and Treatment of Eating Disorders

cians who were familiar with the research literature on AN and had treated
patients with eating disorders developed the initial item pool. The items
were administered to independent samples of individuals (males and fe-
males) with AN (n =113) and female control subjects without AN (n =577).
The authors retained items only if they were able to significantly differen-
tiate between individuals with AN and control subjects without AN and
only if they were more highly correlated with the scale to which they were
hypothesized to belong than with other scales.
In the second phase of development, additional items were written; the
scale was administered to independent samples of individuals with AN and
female control subjects; and criterion validity (the ability of a measure or scale
to predict a criterion, such as psychiatric diagnosis, either concurrently or in
the future) was tested in a variety of samples that included men (n =166) and
participants with BN (n =195), obesity (n =44), past history of obesity (n =52),
or past history of AN (n=17). The results of these analyses led to the develop-
ment of eight scales: Drive for Thinness (excessive concern with dieting,
weight preoccupation, and the pursuit of thinness), Bulimia (“uncontrollable”
overeating episodes and the desire to engage in self-induced vomiting), Body
Dissatisfaction (the belief that body parts that are generally associated with
shape change or weight gain during puberty are too large), Ineffectiveness
(feelings of inadequacy, insecurity, and lack of control over one’s life), Perfec-
tionism (excessively high personal and achievement standards), Interpersonal
Distrust (disinclination to form close relationships and feelings of alienation),
Interoceptive Awareness (lack of ability to identify emotions, satiety, and hun-
ger), and Maturity Fears (desire to retreat to the security of preadolescence be-
cause of the stressors and demands of adulthood). Scores from the three eating
disorder–specific scales (Drive for Thinness, Bulimia, and Body Dissatisfac-
tion) can be summed to create the Eating Disorder Risk Composite score.
In 1991, a second version of the EDI was developed (EDI-2; Garner
1991), which retains the original EDI format and adds 27 new items in three
additional subscales: Asceticism, Impulse Regulation, and Social Insecurity.
The EDI was revised again in 2004 (EDI-3; Garner 2004) to provide a new
0- to 4-point scoring system and the calculation of age- and diagnosis-
adjusted T scores. Although new scales were introduced, including Low
Self-Esteem, Personal Alienation, Interpersonal Insecurity, Interpersonal
Alienation, and Emotion Dysregulation, the eating disorder–specific scale
content was not changed from the EDI-2 to the EDI-3.

Eating Disorder Examination Questionnaire

The Eating Disorder Examination Questionnaire (EDE-Q; Fairburn and
Beglin 1994) is a self-report version of the Eating Disorder Examination
Self-Report Assessments of Eating Pathology 161

(EDE) interview (Cooper and Fairburn 1987), which is considered by

many in the field to represent the gold standard of eating disorder psycho-
pathology assessment (see Chapter 8, “Assessment Measures, Then and
Now”). The EDE was developed based on 1) comprehensive literature re-
views, in which the authors identified key elements of eating disorder psy-
chopathology, and 2) unstructured interviews with patients with AN or
BN to elicit detailed descriptions of their behaviors and attitudes. Items
were written to assess the hypothesized key elements of eating disorders,
and the interview was administered to patients with eating disorders and
matched control subjects (sample sizes not published) to test the EDE’s in-
terrater reliability. From published articles (Cooper and Fairburn 1987;
Fairburn and Beglin 1994), it appears that no statistical analyses were con-
ducted to remove items from the EDE during the initial scale develop-
ment and validation process, suggesting that the EDE and EDE-Q were
developed using rational methods.
The EDE and EDE-Q contain four rationally derived subscales: Re-
straint, Eating Concern, Shape Concern, and Weight Concern. The most
recent version of the EDE interview (Fairburn 2008) contains an item as-
sessing night eating, but this content is not included in the EDE-Q. Al-
though the EDE interview is able to generate diagnoses for AN, BN, BED,
and a variety of other specified feeding or eating disorders, such as purging
disorder (Keel et al. 2005), the questionnaire is intended to obtain infor-
mation regarding dimensions of eating disorder psychopathology and was
not developed as a self-report diagnostic measure. In addition to scores for
the four subscales listed above, the EDE-Q provides a global score that
represents the composite (sum) of scores from the four subscales and in-
cludes specific items that assess binge eating, driven exercise, and purging
behaviors. (For information on the child version of the EDE-Q, please re-
fer to Chapter 11, “Diagnosis of Feeding and Eating Disorders in Children
and Adolescents.”)

Eating Pathology Symptoms Inventory

The Eating Pathology Symptoms Inventory (EPSI; Forbush et al. 2013)
was developed using a hybrid scale development approach in an effort to
comprehensively assess a broad range of eating disorder dimensions. The
initial item pool, developed on the basis of theoretical and empirical mod-
els of eating disorders, included 160 items designed to assess 20 potential
dimensions of eating pathology and included items to assess all of the
DSM-IV-TR (American Psychiatric Association 2000) criteria for eating
disorders. The initial item pool was administered to large independent sam-
ples of college students (N =433) and community adults (N =407). Explor-
162 Handbook of Assessment and Treatment of Eating Disorders

atory, confirmatory, and multiple-group factor analyses (which test to

determine whether the structure of the measure is different across different
groups of people) were used to eliminate poorly performing items from
the pool. An 88-item revised measure was then administered to additional
independent samples of patients with eating disorders (N =158) and gen-
eral psychiatric outpatients (N =303). On the basis of the results of addi-
tional multivariate statistical analyses, the measure was revised a second
time, which resulted in the final 45-item measure.
The EPSI contains eight scales: Body Dissatisfaction (dissatisfaction
with body weight and/or shape), Binge Eating (ingestion of large amounts
of food and accompanying cognitive symptoms), Cognitive Restraint (cog-
nitive efforts to limit or avoid eating, whether or not such attempts are suc-
cessful), Purging (self-induced vomiting, laxative use, diuretic use, and diet
pill use), Muscle Building (desire for increased muscularity and muscle
building supplement use), Restricting (concrete efforts to avoid or reduce
food consumption), Excessive Exercise (physical exercise that is intense
and/or compulsive), and Negative Attitudes Toward Obesity (negative at-
titudes toward individuals who are overweight or obese).

Reliability and Stability

Reliability refers to the consistency or precision of a measure. The critical
question when evaluating reliability is whether test scores are sufficiently
consistent and free from error to be useful.
Test-retest reliability measures the consistency of scores on an assessment
over relatively short time intervals (e.g., several days to a month), during
which time it would be highly unlikely that true change would have oc-
curred. Correlations among test scores that are below 1.00 (indicating per-
fect agreement) are assumed to indicate the presence of time sampling
error. Scores of at least 0.70 typically indicate evidence for good retest re-
liability (Joiner et al. 2005).
A related concept is stability, which is defined as the consistency of test
scores over more extended time periods (e.g., months to years between as-
sessments). Stability estimates are expected to be lower than test-retest re-
liability estimates because in addition to time sampling error, true change
may have occurred (e.g., the patient may have experienced symptom im-
provement [Watson 2004]).
Finally, internal consistency refers to error in scores that results from fluc-
tuations in items across a test scale. Low internal consistency manifests as
low correlations among test items and is typically measured by coefficient
or the average inter-item correlation (Urbina 2011). In general, coeffi-
cient values of at least 0.80 and average inter-item correlation values be-
Self-Report Assessments of Eating Pathology 163

tween 0.20 and 0.50 represent strong evidence for internal consistency
(Clark and Watson 1995).

Eating Disorder Inventory

Coefficient for the EDI-2 and EDI-3 appears to be good to excellent, with
values generally exceeding 0.80. Nevertheless, in a large, well-conducted
study by Clausen et al. (2011), Perfectionism, Asceticism, and several of the
newer nonspecific EDI-3 scales (Personal Alienation, Interpersonal Alien-
ation, and Emotion Dysregulation) had low coefficient values in a sample
of 561 patients with eating disorders. The coefficient for the EDI-3 Ascet-
icism scale was also very low (r =0.59) among control participants without
eating disorders. Tasca et al. (2003) evaluated average inter-item correla-
tion values for the EDI in a large sample of individuals seeking treatment
for BED or BN. The results of their study indicated that except for the As-
ceticism scale, all scales had average inter-item correlation values within
the 0.15–0.50 range, suggesting that high coefficient values for the EDI-3
do not appear to be due to redundant item content.
As indicated in Table 9–1, studies evaluating the retest reliability of the
EDI suggest that this measure is highly reliable over short time intervals,
and these findings have been replicated across both patients with eating
disorders and general psychiatric patients who did not have an eating dis-
order diagnosis, as well as in nonclinical samples of college students. Sta-
bility estimates for the EDI are generally good across nonclinical samples
of college females and in clinical eating disorder samples (Crowther et al.
1992; Tasca et al. 2003); however, very low stability was observed for the
Bulimia scale (r =0.22) and Maturity Fears scale (r =0.26) among a sub-
sample of college females at risk for an eating disorder (Crowther et al.
1992). Overall, the EDI has strong test-retest reliability over short time pe-
riods and good stability (with the exception of the Bulimia and Maturity
Fears scales), and the eating disorder–specific EDI-3 scales demonstrate
evidence for high internal consistency.

Eating Disorder Examination Questionnaire

Table 9-1 presents reliability and stability data for the EDE-Q. Internal con-
sistency for the EDE-Q is generally good, with correlations close to or
above 0.80 among female college undergraduates and community women
(Luce and Crowther 1999; Mond et al. 2004a). However, other research
has found that the Restraint, Eating Concern, and Weight Concern scales
have lower internal consistency among individuals with bulimic syn-
dromes (r ranged from 0.70 to 0.73 [Peterson et al. 2007]). We are not aware
of published studies reporting average inter-item correlation values for the
164 Handbook of Assessment and Treatment of Eating Disorders

TABLE 9–1. Reliability for multidimensional eating disorder self-

report measures
Test-retest
Measure Study sample reliability Stability

EDI
Crowther et 282 female undergraduate – 0.41–0.75
al. 1992 students (31 participants (total sample);
were deemed at risk for the 0.26–0.81
development of an eating (at-risk sample)
disorder)
Tasca et al. 40 women seeking treatment – 0.67–0.82
2003 for binge-eating disorder
Thiel and 327 female inpatients with 0.81–0.89 –
Paul 2006 eating disorders and 209 (eating disorder
general psychiatric patients patients);
(without eating disorders) 0.75–0.94
(general
psychiatric
patients)
Wear and 70 undergraduates (75.7% 0.90–0.97 –
Pratz 1987 female)
EDE-Q
Luce and 139 female undergraduate 0.81–0.92 –
Crowther students (subscalesa);
1999 0.54–0.92
(behavioral
itemsb)
Mond et al. 802 community adult – 0.57–0.77
2004a females (subscales)
Reas et al. 86 adults with binge-eating 0.66–0.77 –
2006 disorder (79.1% female) (subscales)
EPSI
Forbush et al. 233 undergraduate students 0.61–0.85 –
2013 (58.15% female)
Note. Dash indicates that data are not available for the specific type of reliability that is
listed in the column headings. EDE-Q = Eating Disorder Examination Questionnaire;
EDI = Eating Disorder Inventory; EPSI = Eating Pathology Symptoms Inventory.
aThe subscales on the EDE-Q are Weight Concern, Shape Concern, Eating Concern, and

Dietary Restraint.
bBehavioral items on the EDE-Q include self-induced vomiting, binge eating, excessive

exercise, diuretic misuse, and laxative misuse.

Self-Report Assessments of Eating Pathology 165

EDE-Q, so it is unclear whether high internal consistency was achieved, in

part, because of item redundancy within scales.
Apart from self-induced vomiting, the behavioral features of the EDE-Q
(i.e., binge eating, laxative misuse, diuretic misuse, excessive exercise) have
lower than desirable test-retest reliability, ranging from 0.54 to 0.68 in fe-
male undergraduate students (Luce and Crowther 1999). Reas et al. (2006)
found that the retest reliability for objective binge episodes in the EDE-Q
was excellent; however, retest reliabilities were low for subjective binge ep-
isodes (r =0.51) and objective overeating episodes (r =0.39) in a sample of
adults with BED. Finally, Mond et al. (2004a) conducted a stability study of
the EDE-Q in a nationally representative sample of community women
from Australia. Results indicated that subscale scores showed evidence of
reasonable stability over an 11-month period, yet objective binge eating
(r =0.44), subjective binge eating (r =0.24), and excessive exercise (r =0.31)
had quite poor stability over time. Taken together, EDE-Q scores show ev-
idence for high internal consistency among female college students and
community women, and several scales possess good test-retest reliability
and stability. However, concerns related to the reliability and stability of the
EDE-Q behavioral items (e.g., self-induced vomiting, binge eating) have
been documented in previous research studies.

Eating Pathology Symptoms Inventory

The EPSI has been shown to have good to excellent internal consistency
across a range of samples, including men, women, obese participants, and
psychiatric patients with and without eating disorders (Forbush et al. 2013,
2014). The majority of EPSI scales, except Negative Attitudes Toward
Obesity (which showed some evidence of redundant item content), had
average inter-item correlation values within the recommended range. To-
gether, these findings indicate that the majority of EPSI scales are highly
internally reliable across multiple populations.
Only one published study has evaluated the test-retest reliability of the
EPSI (see Table 9–1). Most scales had excellent retest reliability, exceeding
the recommended benchmark of 0.70. However, the retest reliability of the
Cognitive Restraint scale was 0.61, indicating that this scale may not be as re-
liable or stable over time. These findings may reflect difficulties in measuring
cognitive restraint using self-report measures, given that Forbush et al. (2013)
found that the EDE-Q Restraint scale had an identical retest reliability of
0.61 in the same sample. Rigorous studies that have sought to evaluate the
predictive validity of cognitive restraint (vs. more concrete efforts to restrict
dietary intake) imply that the lowered reliability for restraint may also trans-
late into poor validity for assessing dietary intake (Stice et al. 2004, 2007).
166 Handbook of Assessment and Treatment of Eating Disorders

Comparison of Measures
Taken together, the results from reliability studies of multidimensional
self-report assessments of eating disorders indicate evidence for good in-
ternal consistency and acceptable to excellent test-retest reliability and
stability. Some caveats to this statement include the following: 1) certain
EDI-3 scales that measure more general psychopathology (i.e., Maturity
Fears, Perfectionism, Asceticism, Personal Alienation, Interpersonal
Alienation, Emotion Dysregulation) show evidence for poor internal con-
sistency and/or test-retest reliability; 2) EDE-Q behavioral items have
lower test-retest reliability compared with scale scores; and 3) few data
exist to describe the reliability of the EPSI. Despite these limitations, it is
important to note that in many ways, the reduced reliability of EDE-Q
behavioral items is to be expected because the majority of these EDE-Q
behavioral items are assessed with only one or two items (compared with
the EDE-Q subscales, which have several items). As a result of having
fewer items, the EDE-Q behavioral items are inherently more susceptible
to time sampling error. The EPSI includes scales that assess much of the
behavioral content of the EDE-Q, but with more items, and these scales
appear to be more reliable over time. Finally, despite the clear need for
additional research to support the reliability of the EPSI, it is notable that
Forbush et al. (2013) included men in the test-retest reliability sample,
given that few reliability studies of eating disorder measures have in-
cluded males (see Chapter 6, “Eating-Related Pathology in Men and
Boys,” for more information about self-report measures developed for
males).

Validity
Eating Disorder Inventory
Comprehensive validity data for the first and second versions of the EDI
are available; however, far less information is available about the validity
of the EDI-3 as a multifactorial measure of eating disorder symptomatol-
ogy. Although the EDI-3 includes the same item content as the EDI-2,
changes to the factor structure, response indicators, and scoring necessi-
tated a reexamination of the validity of the instrument. Independent inves-
tigations (Clausen et al. 2011; Stanford and Lemberg 2012) found that in
both female and male samples, the EDI-3 successfully differentiated be-
tween eating disorder and control groups, with the eating disorder group
scoring significantly higher on all subscales (thus providing evidence for
criterion validity). The theorized factor structure of the EDI-3, which in-
Self-Report Assessments of Eating Pathology 167

cludes 12 subscales and 2 higher-order subscales representing eating dis-

order–specific pathology and general psychological disturbance, has also
been replicated (Clausen et al. 2011). However, the authors noted that the
model fit was minimally acceptable and suggested that this might be due
to poor psychometric properties of several individual items on the EDI-3.
In sum, early psychometric data on the EDI-3 are consistent with the psy-
chometric data on the EDI-2; however, these conclusions must be tem-
pered in light of the relative lack of information.

Eating Disorder Examination Questionnaire

The validity of the EDE-Q for the assessment of eating pathology has been
investigated in several ways. First, research has consistently demonstrated
that compared with control samples, individuals with eating disorders
score higher on the EDE-Q (Aardoom et al. 2012; Engelsen and Laberg
2001; Mond et al. 2004b; Wilson et al. 1993), findings that support the cri-
terion validity of the EDE-Q to distinguish between individuals with and
without eating disorders. Second, with regard to convergent and discrim-
inant validity, research has demonstrated that scores on the EDE-Q sub-
scales are significantly and positively correlated with scores on the
corresponding EDE subscales (for review, see Berg et al. 2012). The Re-
straint subscale, specifically, has been found to correlate more strongly
with measures of similar constructs than with measures of dissimilar con-
structs (Bardone-Cone and Boyd 2007; Grilo et al. 2013). Finally, two
studies have demonstrated that the frequencies of objective bulimic epi-
sodes reported on the EDE-Q were significantly correlated with the fre-
quencies of these eating episodes recorded in daily food intake records
(Grilo et al. 2001a, 2001b).
The factor structure of the EDE-Q has also been examined to deter-
mine the structural validity of the four EDE-Q subscales. Numerous fac-
tor analytic studies have failed to replicate the original, rationally derived
subscales (Aardoom et al. 2012; Friborg et al. 2013; Grilo et al. 2013;
Hrabosky et al. 2008; Peterson et al. 2007); interestingly, all of the analy-
ses derived different factor structures. Two of the more recent factor anal-
yses have suggested that there may be one general underlying dimension
(Aardoom et al. 2012) or a nested general factor (Friborg et al. 2013),
which could explain the inconsistent findings in previous studies.
Finally, given that the EDE-Q can also be used as a diagnostic mea-
sure, the validity of diagnoses derived from the EDE-Q has been investi-
gated. When eating disorder diagnoses derived from the EDE-Q were
compared with those derived from another self-report questionnaire, there
was low diagnostic agreement between the two measures (Elder et al.
168 Handbook of Assessment and Treatment of Eating Disorders

2006). However, moderate diagnostic agreement and similar latent struc-

tures have been found when comparing the EDE-Q with the EDE (Berg
et al. 2012, 2013). In sum, there is support for the validity of the EDE-Q as a
measure of eating disorder pathology; however, there is no empirical support
for the original four subscales of the EDE-Q. Furthermore, additional data are
needed on the validity of the EDE-Q as a diagnostic instrument.

Eating Pathology Symptoms Inventory

The EPSI subscale scores have been shown to successfully discriminate
between eating disorder and general psychiatric outpatient samples (For-
bush et al. 2013), between eating disorder and college student samples
(Forbush et al. 2013, 2014), and between individuals with AN and individ-
uals with BN (Forbush et al. 2013). Interestingly, the EPSI differentiated
between nonpatient college males and females but not between male and
female eating disorder patients (with the exception that males with eating
disorders scored significantly higher on the EPSI Muscle Building sub-
scale [Forbush et al. 2014]). Additionally, analyses in college samples have
demonstrated evidence for convergent and discriminant validity, with
EPSI scale scores correlating more strongly with scores on measures of
theoretically similar constructs than with scores on theoretically dissimilar
constructs (e.g., EPSI Cognitive Restraint and EDE-Q Restraint vs. EPSI
Cognitive Restraint and positive affect). Finally, the eight-factor structure
of the EPSI has been replicated across patient and nonpatient samples
(Forbush et al. 2013), as well as in male and female samples (Forbush et al.
2014). In sum, the existing data provide promising preliminary support for
the validity of the EPSI as a measure of a wide range of eating disorder
pathology.

Special Populations and Issues

Given the preponderance of data suggesting that individuals with eating
disorders are heterogeneous with regard to gender, race/ethnicity, age,
body mass index, and so forth, it seems obvious that the psychometric
properties of eating disorder assessments need to be examined in similarly
heterogeneous samples. However, the vast majority of eating disorder as-
sessments have been developed and validated in samples of young white
females. This most likely reflects the outdated stereotype that eating disor-
ders are problems confined to young, affluent, white women (see also
Chapter 7, “Eating Problems in Special Populations”). Unfortunately,
without psychometric data on eating disorder measures in more diverse
samples, it is impossible to know whether the gathered data are accurate
Self-Report Assessments of Eating Pathology 169

or useful in assessing symptom levels or assigning diagnoses among males

and ethnic and racial minorities. Without psychometric data characteriz-
ing eating disorder pathology among diverse samples, it is challenging to
make appropriate recommendations for treatment planning, insurance re-
imbursement, and research funding.
There is evidence to suggest that fundamental differences between
groups could impact response patterns on eating disorder assessments. For
example, evidence suggests that there may be differences between males
and females with regard to body ideals, which subsequently may translate
into different symptom presentations (Darcy and Lin 2012). As a result,
males have been found to score lower than females on measures of “tradi-
tional” eating disorder constructs (e.g., EDI Drive for Thinness, EPSI
Body Dissatisfaction) but to score higher on measures of “nontraditional”
eating disorder constructs (e.g., EPSI Muscle Building [Forbush et al.
2014; Stanford and Lemberg 2012]; see also Chapter 6). Similarly, re-
search suggests that individuals from diverse cultures may not endorse ste-
reotypic eating disorder pathology (e.g., fat phobia) but may engage in
alternative forms of eating disorder pathology (e.g., use of herbal purga-
tives) that are not typically included in current eating disorder assessments
(see also Chapter 7). The addition of culturally relevant constructs to the
EDE-Q has been found to substantially increase the accuracy with which
eating disorder cases are identified (Becker et al. 2010).
Additional considerations may need to be made when assessing chil-
dren, adolescents, and young adults (see also Chapter 11, “Diagnosis of
Feeding and Eating Disorders in Children and Adolescents”). For exam-
ple, several common eating disorder symptoms are fairly abstract con-
structs (e.g., overvaluation of shape and weight, loss of control over
eating), and assessments of these constructs may require cognitive skills
(e.g., abstract reasoning, metacognition) that may not be fully developed
in younger respondents (Bravender et al. 2011). Consistent, blanket denial
of all symptoms on eating disorder assessments appears to be more com-
mon in younger samples (e.g., Berg et al. 2012), and it is possible that this
finding may be due, in part, to the advanced cognitive requirements of in-
struments described in this chapter.
Finally, some constructs may be more difficult to assess in particular
samples. For example, given the physiological changes associated with
bariatric surgery, the assessment of binge eating in postoperative bariatric
surgery patients often needs to be modified (see also Chapter 5, “Assess-
ment of Eating Disorders and Problematic Eating Behavior in Bariatric
Surgery Patients”). In sum, given these considerations, current eating dis-
order assessments may overestimate, underestimate, or misrepresent eat-
ing disorder pathology in heterogeneous samples.
170 Handbook of Assessment and Treatment of Eating Disorders

Conclusion
Given certain limitations of reliability and validity, additional psychometric
data on the EDE-Q, EDI-3, and EPSI are needed. Very few reliability or
stability studies have been conducted on any of the multidimensional eat-
ing disorder measures, and the majority of research has been conducted us-
ing nonclinical samples of women. With regard to the EDE-Q, the inability
to replicate the original (or any) factor model must be addressed, with par-
ticular attention given to the possibility that a general, underlying dimen-
sion exists. Additionally, given the mixed findings, further research is
needed on the validity of the EDE-Q as a diagnostic instrument. With re-
gard to the EDI, additional research is needed to both replicate and expand
on the psychometric data that currently exist. Despite substantive changes
to the EDI-3, little research has examined the psychometric properties of
the revised measure. As a result, few conclusions can be made about the
replicability or validity of the EDI-3 as a measure of eating disorder pathol-
ogy. With regard to the EPSI, given that the majority of the control samples
have been college students, it may be useful for future research to examine
the psychometric properties of this instrument in the general population.
Sensitivity, specificity, and receiver operator characteristic analyses could
also be conducted to determine whether the EPSI could be used to identify
cases of eating disorders. The psychometric properties of all three of these
instruments need to be examined in more heterogeneous populations and
also should be compared across gender, race/ethnicity, age, and other pop-
ulations, such as in bariatric surgery patients.
So which “all-in-one” measures should the busy eating disorder pro-
fessional use? On the basis of our review of the literature, we believe that
each of the three measures has numerous advantages as well as certain
limitations. We have three main recommendations to help guide clini-
cians in selecting self-report tools in their practice. First, in the context of
tracking client symptom change over time, it is beneficial to select a self-
report measure that has strong test-retest reliability, stability, and a repli-
cable factor structure (otherwise, change in the clients’ scale scores could
reflect the instability of the measure rather than true change). The EDI-3
and EPSI demonstrated good evidence for test-retest reliability and are
excellent tools for measuring changes in response to behavioral and phar-
macological interventions (although readers should be cautioned that few
data on long-term stability are currently available for the EPSI). Notably,
an advantage of the EPSI for tracking symptom change is that it possesses
well-defined scales and a replicable factor structure relative to the EDI-3.
For example, the EPSI assesses purging and binge eating separately,
Self-Report Assessments of Eating Pathology 171

rather than combined together on the same scale, and thereby provides a
more nuanced measure of change in specific eating disorder symptom-
atology.
Second, if one is primarily interested in assessing core constructs delin-
eated in the transdiagnostic model of eating disorders (Fairburn 2008), we
recommend the EDE-Q because its scales are well aligned with the six
core maintaining features of eating disorders that are targeted in Fair-
burn’s cognitive-behavior therapy for eating disorders. (We refer the inter-
ested reader to Chapter 15, “Treatment of Other Eating Problems,
Including Pica and Rumination,” for more information on Fairburn's
transdiagnostic cognitive-behavior therapy approach.) Finally, given that
the EPSI has a male-specific Muscle Building scale and was developed
and validated in male populations, we recommend using the EPSI to as-
sess eating disorder psychopathology with male clients.
Regardless of their individual choices, clinicians have a number of ex-
cellent self-report tools from which to select, and our main recommenda-
tion is that eating disorder professionals use one or more of the measures
that we have described to assess client outcomes rather than omit assess-
ment altogether. As we mentioned in the introduction of this chapter, as-
sessment can significantly improve client outcomes, which we believe is
well worth the time and effort.

Key Clinical Points

• Regular assessment of clients’ mental health symptoms has been
shown to improve therapeutic outcomes across a range of thera-
peutic modalities and client types.
• There is support for the validity of all three self-report question-
naires—the Eating Disorder Inventory (EDI), the Eating Disorder Ex-
amination Questionnaire (EDE-Q), and the Eating Pathology
Symptoms Inventory (EPSI)—to distinguish between cases and
noncases of eating disorders. However, the extent to which there is
support for the factor structure of these three questionnaires varies
substantially.
• The EPSI is a recently developed self-report measure of eating dis-
order symptoms that has shown good reliability and validity in pre-
liminary studies.
• The EDE-Q is the only one of the three questionnaires that can be
used diagnostically; however, empirical support for the validity of
the EDE-Q as a diagnostic measure is mixed.
172 Handbook of Assessment and Treatment of Eating Disorders

• The majority of research on the psychometric properties of self-

report questionnaires has been conducted in heterogeneous sam-
ples; therefore, little data are available to support the validity of
these three questionnaires in specific populations, such as males,
adolescents, or ethnic and racial minorities.

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10 Use of the Eating Disorder
Assessment for DSM-5
Deborah R. Glasofer, Ph.D.
Robyn Sysko, Ph.D.
B. Timothy Walsh, M.D.

This chapter provides an overview of the Eating Disorder

Assessment for DSM-5 (EDA-5; Sysko et al. 2015), a novel semistruc-
tured interview for the diagnosis of feeding and eating disorders de-
scribed in DSM-5 (American Psychiatric Association 2013). The chapter
includes information relevant to researchers—namely, a review of the de-
velopment and the psychometrics of the EDA-5 and essential principles
of the instrument’s administration—and, beginning with the section “In-
strument Structure and Content,” a step-by-step guide for clinicians in-
tending to use the measure as part of routine practice. The EDA-5 is an
electronic assessment (available freely at www.eda5.org), and we recom-
mend that readers access the application while reviewing this chapter as
an aid for learning about the instrument’s structure and content.

Excerpts from the Eating Disorder Assessment for DSM-5 (EDA-5) interview in-
cluded in this chapter are reprinted with permission. Copyright © 2013 American
Psychiatric Association. We gratefully acknowledge Jonathan Cohen (Rivington
Digital) and Alim Razak for their assistance in the development of the EDA-5 Web
site and electronic application.

175
176 Handbook of Assessment and Treatment of Eating Disorders

Eating Disorder Assessment

for DSM-5 Overview
With the publication of DSM-5, the category of feeding and eating disor-
ders was revised from the DSM-IV (American Psychiatric Association
1994) disorders. As described in Chapter 1, “Classification of Eating Dis-
orders,” some of the changes from DSM-IV were modest (e.g., reducing
the frequency of binge eating and/or purging behaviors for the diagnosis
of bulimia nervosa [BN]) and others were major (e.g., merging feeding and
eating disorders into one category, recognizing binge-eating disorder
[BED]). Given the differences between DSM-IV and DSM-5 criteria for
feeding and eating disorders, the utility of existing diagnostic assessment
tools is quite limited. Thus, as described in detail by Sysko et al. (2015), we
chose to develop and validate the EDA-5 as an interview guide to assess
for current DSM-5 feeding and eating disorders in adults.
The EDA-5 was designed to focus specifically on assessment of the
DSM-5 criteria and was not aimed at a broader assessment of other psycho-
pathological features associated with eating disorders, such as the intensity
of concerns over shape or weight. As described in Chapter 9, “Self-Report
Assessments of Eating Pathology,” such facets of eating problems can be
conveniently evaluated through the use of self-report measures. There-
fore, the EDA-5 differs significantly from some other interview-based
measures, such as the Eating Disorder Examination (EDE; Fairburn et al.
2008), which assesses both the DSM criteria for eating disorders and a
range of psychopathological features characteristic of individuals with
these problems (see also Chapter 8, “Assessment Measures, Then and
Now”). The EDE requires extensive training and an extended amount of
time to administer; thus, its use has largely been relegated to specialized
care settings (e.g., eating disorders clinics). The Structured Clinical Inter-
view for DSM-5 (SCID-5), another interview-based measure, is intended
to determine whether an individual meets criteria for any DSM-5 disorder
(First et al. 2015). Although it assesses the presence of an eating disorder,
it does not ask about pica or rumination disorder and does not attempt to
determine with precision the individual’s body mass index (BMI) or the
particular frequencies of a range of behavioral disturbances such as objec-
tive and subjective binge-eating episodes. Although the SCID-5 includes
a module on avoidant/restrictive food intake disorder (ARFID), this sec-
tion is optional and therefore may not be routinely administered. The
EDA-5, in contrast, 1) provides a comprehensive assessment of DSM-5
feeding and eating disorder criteria, 2) requires minimal interviewer train-
ing, and 3) reduces participant burden. We hope that this instrument will
Use of the Eating Disorder Assessment for DSM-5 177

be helpful to practitioners ranging broadly in professional degree, spe-

cialty, and experience and will be useful across a range of general clinical
settings (e.g., primary care, community mental health centers) to deter-
mine when an individual’s symptoms are sufficient to suggest the need for
a referral to specialist services.

Development and Psychometrics

To date, two studies have evaluated the utility of the EDA-5 in treatment-
seeking adults across multiple sites (for details, see Sysko et al. 2015). The
first study compared the diagnostic validity of a paper-and-pencil version of
the EDA-5 to the EDE and evaluated the test-retest reliability of diagnoses
from the EDA-5. High rates of agreement were found between diagnoses
using the EDA-5 and the EDE (=0.74 across diagnoses, n =64), with 
ranging from 0.65 for other specified feeding or eating disorder/unspecified
feeding or eating disorder (OSFED/USFED) to 0.90 for BED. For a ran-
domly selected subgroup of study participants, the EDA-5 was readminis-
tered by a new interviewer 7–14 days following the initial assessment. The
test-retest  coefficient was 0.87 across diagnoses, which would be consid-
ered excellent to almost perfect; diagnostic agreement was achieved in 19
of 21 cases (90.5%).
In light of feedback from interviewers about the complexity of the in-
terview’s skip rules, an electronic application (“app”) of the EDA-5, with
automated skip rules, was created. The second study compared the diag-
nostic validity of the EDA-5 app to an interview by an experienced clini-
cian. A high rate of agreement was observed between diagnosis by EDA-5
and experienced clinician (=0.83 across diagnoses, n =71). Across indi-
vidual diagnostic categories,  ranged from 0.56 for OSFED/USFED to
0.94 for BED.
In both studies, information was collected on interview duration (i.e.,
participant and interviewer burden) and acceptability of the new measure.
The EDA-5 required significantly less time to complete than the EDE. The
electronic application of the EDA-5 significantly shortened the length of
time needed to administer the interview from the first to the second study,
from an average of 19.3±5.6 minutes (range of 5–34 minutes) in the for-
mer study to 14.0±6.2 minutes (range of 5–30 minutes) in the latter inves-
tigation. Among those who reported a preference for the EDA-5 or the
EDE, a larger proportion of individuals preferred the EDA-5 (54.1%) over
the EDE (31.1%) [2(2)=14.3, P =0.001].
The results of these preliminary investigations are encouraging. How-
ever, these studies, despite their strengths (e.g., the successful administra-
178 Handbook of Assessment and Treatment of Eating Disorders

tion of the EDA-5 by interviewers with varying degrees of clinical

experience), also had several limitations (see Sysko et al. 2015), including
a lack of data on the assessment of the feeding disorders (i.e., ARFID, ru-
mination disorder, pica). Thus, additional validation (and replication)
studies are warranted.

Principles of Administration
The EDA-5 assesses feeding and eating disorders in adults according to
the DSM-5 criteria. It is intended for use by clinicians and researchers in
a variety of disciplines (e.g., nursing, psychology, social work), and it as-
sumes familiarity with the feeding and eating disorder diagnoses. The
questions are posed to assess a current problem—that is, a problem within
the last 3 months rather than a problem that may have existed in the past.
EDA-5 questions closely mirror the DSM-5 feeding and eating disor-
der criteria but are worded to aid the assessment process. The interviewer
must exercise clinical judgment in answering all questions. It is appropri-
ate to use whatever clinical information is available, including the individ-
ual’s answers to questions, the interviewer’s observations of the individual,
and ancillary sources of information such as other treatment providers,
close family members, and, as appropriate, people within the individual’s
community. Interviewers are strongly advised to obtain objective informa-
tion (i.e., clinician-measured height and weight) whenever possible.

Instrument Structure and Content

The EDA-5 was designed as a semistructured assessment tool. During the
administration of the EDA-5 app, each screen adheres to a similar format:
section name, symptom being assessed (i.e., individual DSM-5 criterion),
example probe to query patient, and answers (Figure 10–1).
Instructions to the interviewer, and clarifications when necessary, are
indicated on screen in italics. The individual DSM-5 criterion or portions
of the criterion to be assessed are provided in the symptom portion of the
screen. The probe section provides suggested questions the interviewer
may use in determining the presence or absence of the symptom. Inter-
viewers begin by using the probes provided, but clinical judgment should
be employed to determine whether follow-up questions are needed to clar-
ify responses. Suggested follow-up questions are sometimes included to
enhance standardization and assist those interviewers who are less familiar
with the assessment of feeding and eating disorders. In some cases, items
Use of the Eating Disorder Assessment for DSM-5 179

Back Restart Save EDA-5 Notes

Section Anorexia Nervosa

SYMPTOM:
Interviewer
DSM-5 • Is there an intense, irrational fear of weight gain or of
Notes
Criterion becoming fat?
PROBE:
Question
• Are you afraid of gaining weight?
to Ask
If No: Are you worried that if you start to gain weight, you
will continue to gain weight and will become fat?
5.1
A NSWERS:

Answer Yes: there is intense fear of weight gain

to Input No: NOT afraid of gaining weight

FIGURE 10–1. EDA-5 screen structure.

contain text boxes for data entry (e.g., frequency/type of purging behav-
iors). The answers section at the bottom of each screen contains a button
or buttons with the available options for answers. Following a logical flow
diagram based on the DSM-5 criteria, the EDA-5 chooses the next screen
to present based on the answer provided. At the top right-hand corner of
each screen, there is a “Notes” button. By pressing this button, the inter-
viewer may add comments. Additional comments can be added to those
previously entered, and all comments will be available to print in the final
report at the conclusion of the interview.
The interview is divided into the following sections, which are more
completely described in subsequent subsections: Introduction, Anorexia
Nervosa (AN), Binge Eating and Compensatory Behaviors, Bulimia Ner-
vosa (BN), Binge-Eating Disorder (BED), Avoidant/Restrictive Food In-
take Disorder (ARFID), Rumination Disorder, Pica, and Other Specified
Feeding or Eating Disorder (OSFED). Consistent with DSM-5, the EDA-5
adheres to diagnostic “trumping” rules. Thus, although the electronic ver-
sion includes content to diagnose all feeding and eating disorders, once cri-
teria for a condition are met, the criteria for other disorders will, in general,
not be assessed. For example, if an individual meets criteria for AN, the BN
180 Handbook of Assessment and Treatment of Eating Disorders

section will be skipped because a diagnosis of AN supersedes that of BN.

Questions in the Binge Eating and Compensatory Behaviors and the Pica
sections are included for all interviewees. Symptom information from the
Binge Eating and Compensatory Behaviors section is required in order to
rule in or out several diagnoses. A diagnosis of pica can be assigned in the
presence of another feeding or eating disorder.

Introduction
Following the first screen, which contains an abbreviated overview of the
EDA-5, the interview proceeds to a page where the interviewer is cued to
input basic identifying information, including date of interview, inter-
viewer identification, subject identification, and subject’s age. This is the
only place in the EDA-5 where identifying information is contained. The
EDA-5 does not transmit the information obtained over the Internet and
is capable of saving only an encrypted copy of the final summary report
on the device being used. Nonetheless, to provide even greater assurance
of confidentiality, the interviewer may choose to use only initials (or a
code name) to identify the individual being interviewed.
In the introduction, the EDA-5 next aims to determine whether a clin-
ically significant disturbance in eating is, in fact, present. Interviewers are
guided first to ask about any problems with eating and then to obtain an
overview of the individual’s pattern of eating. In the presence of a feeding
or eating disturbance (indicated by a positive response to either of the first
two symptoms), the interviewer next determines whether the feeding or
eating problem is clinically significant (i.e., functionally impairing or dis-
tressing). If the disturbance in feeding or eating has resulted in functional
impairment or in significant distress (a nearly universal feature outlined in
DSM-5 for all mental conditions), the interview continues; otherwise, the
EDA-5 ends because it has been determined that a clinically significant
eating problem is not present. Of particular importance within the realm
of feeding and eating disorders, some individuals may minimize their
symptoms, and therefore the EDA-5 reminds interviewers that in assess-
ing such individuals, it may be particularly useful to obtain information
from others knowledgeable about the individual’s symptoms.
The interviewer is asked to input the individual’s height and weight,
from which the EDA-5 calculates current BMI (kg/m2). Wherever possi-
ble, interviewers should obtain objective measurements, ideally by
weighing the individual and measuring his or her height. If the inter-
viewer indicates that the individual is currently underweight, the inter-
viewer will be directed to complete additional questions as part of the AN
section. For responses that indicate the individual is currently normal
Use of the Eating Disorder Assessment for DSM-5 181

weight, overweight, or obese, interviewers are asked to provide the indi-

vidual’s lowest weight in the past 3 months. If the individual has been un-
derweight within this time frame, the EDA-5 will proceed to the other
questions in the AN section. Although DSM-5 does not specify the
amount of time an individual should be at a normal weight to be consid-
ered recovered from AN or to be assigned another feeding or eating dis-
order, the EDA-5 uses a 3-month time frame, because this time frame is
also used to assess the average frequencies of binge eating and purging. If
the interviewer indicates that the individual is not currently and has not
been underweight in the last 3 months, the EDA-5 proceeds to the Binge
Eating and Compensatory Behaviors section.

Anorexia Nervosa
If the individual endorses current or recent (prior 3 months) low weight, in-
terviewers will be directed to the AN section of the EDA-5. Because restric-
tion of energy intake leading to significantly low body weight (Criterion A
for AN in DSM-5) is assessed prior to entering this section, the first question
assesses fear of weight gain or becoming fat (Criterion B) (Figure 10–1).
Next, all individuals are asked about the presence of behaviors that might
interfere with efforts to gain weight (Criterion B). Such behaviors include
cutting back on calories or amounts or types of food, exercising, and vom-
iting after eating. If the individual endorses any of these behaviors, the in-
terviewer may select “Yes: there is persistent behavior to avoid weight gain”
(Figure 10–2) and proceed to the next item. This question is aimed solely at
determining whether Criterion B is satisfied. More detailed questions about
such behaviors are reviewed in the Binge Eating and Compensatory Behav-
iors section of the EDA-5.
If the individual does not endorse a specific behavior, the interviewer
probes in a more open-ended manner: “Do you do anything else that
might make it hard for you to gain or maintain weight?” Examples of clin-
ically significant behaviors that might reasonably interfere with weight
gain include spitting out food and inappropriate use of stimulants (e.g., as
appetite suppressants). If the individual denies both a fear of weight gain
and persistent actions that might interfere with weight gain, Criterion B is
not satisfied, and the interviewer is guided to the Binge Eating and Com-
pensatory Behaviors section. If the individual endorses either of these
items, the interview continues with the remainder of the AN section.
The AN section concludes with items assessing 1) body image distor-
tion, 2) an overemphasis on weight or shape in self-evaluation, and 3) de-
nial of the seriousness of current or recent low weight status. If the
individual views his or her body realistically (e.g., does not consider being
182 Handbook of Assessment and Treatment of Eating Disorders

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Anorexia Nervosa
SYMPTOM:
• Are persistent behaviors (e.g., dietary restriction,
excessive exercise, purging, fasting) interfering with
weight gain?

Other clinically significant behavior that interferes with

weight gain might include spitting out food or
inappropriate stimulant use.

PROBE:
• Once any of the interfering behaviors below is endorsed,
press YES and proceed.

Do you try to cut back on calories or amounts or types of

food? What do you try to do?

Do you exercise? What do you do and how often?

Do you vomit or use any types of pills (such as diet pills,

diuretics, or laxatives)?

Do you do anything else that might make it hard for you

to gain or maintain weight?
5.2
A NSWERS:

Yes: there is persistent behavior to avoid weight gain

No: NO persistent behavior to avoid weight gain

FIGURE 10–2. EDA-5 anorexia nervosa sample item.

significantly underweight as the way he or she should look), does not feel
that his or her self-worth is unduly influenced by weight or body shape,
and is aware of the seriousness of being underweight, an AN diagnosis is
not assigned. Alternatively, if one or more of these symptoms are en-
dorsed, the individual meets criteria for AN diagnosis. Once the individual
meets criteria for this disorder, or for any of the other disorders subse-
quently assessed, a pop-up window visible to the interviewer indicates that
a diagnosis has been assigned (Figure 10–3). After the AN section, the in-
terviewer will be guided into the Binge Eating and Compensatory Behav-
iors section.

Binge Eating and Compensatory Behaviors

The Binge Eating and Compensatory Behaviors section poses questions
about the presence, type, and frequency of aberrant eating episodes and of
Use of the Eating Disorder Assessment for DSM-5 183


Back The page
Restart
st art Saveat interview.eda5.org
EDA-5 says: Notes
Critera for Anorexia Nervosa met
Anorexia Nervosa Diagnosis Pop-Up
SYMPTOM: OK
Window
• Does the
th individual
i di id l recognizei or acknowledge
k l d the
th
seriousness of his or her low body weight?

If individual initially acknowledges seriousness of the

problem, are the efforts taken consistent with this
recognition?

PROBE:
• Do you think that your current or recent low weight presents
a significant problem for you and your overall health? Why or
why not?

If Yes: What efforts have you made in the past 3 months to

deal with this problem? Have your feelings about the
significance of the problem fluctuated? How so?

A NSWERS:

Individual recognizes seriousness of current weight

Individual does NOT recognize seriousness of current weight

FIGURE 10–3. Example of EDA-5 diagnosis pop-up window.

abnormal behaviors to compensate for eating. Consistent with Criterion A

for both BN and BED, the questions in this EDA-5 section focus first on
the assessment of objective binge episodes (OBEs); these are referred to as
binge-eating episodes in DSM-5, which are defined as discrete eating epi-
sodes characterized by a loss of control in which an amount of food is con-
sumed that is definitely larger than most individuals would eat in a similar
period of time under similar circumstances. DSM-5 is silent on whether
OBEs are required for individuals with AN to be designated as having the
binge-eating/purging subtype of AN. In constructing the EDA-5, we de-
cided that the presence of recurrent OBEs and/or purging within the last
3 months, operationalized as occurring at least once per month on aver-
age, would satisfy the requirements of this subtype. In the service of col-
lecting information of clinical utility in assessing other individuals with
eating disorders, the EDA-5 also assesses the frequency of subjective binge
episodes (SBEs), defined as aberrant eating episodes in which the individual
describes eating a normal, for the context, or small amount of food (for ex-
amples, see Table 10–1) but experiences a sense of loss of control over eat-
ing. SBEs are not specifically referred to in DSM-5 but may be of clinical
significance.
184 Handbook of Assessment and Treatment of Eating Disorders

TABLE 10–1. Examples of objectively and subjectively large

amounts of food
Objectively large Subjectively large

2 pints of ice cream ½ pint of ice cream, 2 (1 inch1 inch)

brownies
10 apples 5 carrot sticks, 2 tablespoons of peanut
butter, ½ cup of nuts, 1 individual
yogurt
2 boxes of waffles, 1 pound of pasta, 2 bowls of cereal
8 ounces of cheese, 1 box of chocolate
donuts
1 family-size bag of chips 2 individual yogurts, ½ grapefruit,
3 waffles
4 peanut butter sandwiches, 2 bananas 6-inch sub sandwich, 2 snack-size bags
of chips
10 muffins, 10 bagels, 20 pats of butter, 2 muffins
20 pats of jelly, 20 pats of cream
cheese, 1 piece of fruit
>2 bags of frozen vegetables 1 bag of frozen vegetables
4 slices of pizza, 1 calzone 3 slices of pizza
2 Big Macs, 2 orders of large fries, milk 2 Big Macs
shake
½ of an 8-inch two-layer cake with 1 piece of pie, 10 Oreo cookies
frosting
Note. This table provides examples of objectively large versus subjectively large amounts
of food. It is therefore possible that a smaller amount of food than delineated might be con-
sidered an objective binge episode or that a larger amount of food than delineated might
be considered a subjective binge episode. If a determination of size is ambiguous, consul-
tation with other interviewers is recommended.

The Binge Eating and Compensatory Behaviors section concludes by

evaluating purging behaviors and excessive exercise. Frequent purging
behavior or excessive exercise satisfies Criterion B of BN and excludes a
diagnosis of BED (BED Criterion E). Purging behavior (but not excessive
exercise) also satisfies the criterion for the binge-eating/purging subtype of
AN. The intended function of purging and excessive exercise behaviors
(e.g., weight control, compensation for binge eating) is evaluated in this
section. Binge-eating and/or purging subtype and frequency are stored by
the EDA-5 and, at the conclusion of the interview, summarized in a report
that can be printed or saved on the device in encrypted form. (For more
details, see “Notes and Results” section later in this chapter.)
Use of the Eating Disorder Assessment for DSM-5 185

Loss of Control: Is It a Binge?

OBEs and SBEs both require that individuals endorse a sense of loss of con-
trol during the episode of eating. Although loss of control must be present for
an eating episode to be characterized as a binge, assessing loss of control can
be challenging for a variety of reasons (Blomquist et al. 2014; Fairburn et al.
2008; Latner et al. 2014). For example, some individuals describe a dissocia-
tive or “numbing” quality during or following the binge episodes that may
make it difficult to recall or evaluate their psychological experience when they
were eating. After binge eating has persisted for some time, individuals may
report that their binge-eating episodes are no longer characterized by an acute
feeling of loss of control (and that sometimes these episodes are even planned
in advance) but rather by behavioral indicators of impaired control, such as
difficulty resisting binge eating or difficulty stopping a binge once it has begun.
The impairment in control associated with binge eating is not absolute; for ex-
ample, an individual may continue binge eating while the telephone is ringing
but cease eating if a roommate or spouse unexpectedly enters the room. An
episode may or may not be planned in advance and is usually (but not always)
characterized by rapid consumption. The binge eating often continues until
the individual is uncomfortably, or even painfully, full.
The EDA-5 Binge Eating and Compensatory Behaviors section be-
gins with a series of probes to help the interviewer ascertain the presence
of the psychological experience of feeling out of control while eating
(Figure 10–4).
Because loss of control while eating can be difficult to assess, the inter-
viewer may need to present illustrative metaphors or examples to confirm
that the individual understands the construct being assessed. Potentially
useful probes include the following:

1. Another way of thinking about this is to imagine a ball sitting atop a hill.
Once it starts rolling, it keeps going and going. In the past 3 months,
have you had an experience of eating and feeling like you could not
stop, like you just kept going and going? (This is adapted from the child
version of the EDE [Bryant-Waugh et al. 1996, per Tanofsky-Kraff et al.
2004].)
2. Think of a car parked on a steep incline with no emergency brake; it
starts going slowly down the hill and then picks up speed and does not
stop. In the past 3 months, have you ever felt like this while eating?
3. In the past 3 months, have you ever been interrupted during an epi-
sode of eating and felt like you could not stop thinking about going
back to eating? What happened when the interruption ended (e.g., did
you return to eating)?
186 Handbook of Assessment and Treatment of Eating Disorders

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Binge Eating & Compensatory Behaviors

SYMPTOM:
• Has the individual experienced a lack of control while
eating?
PROBE:
• In the past 3 months, were there times when you
felt a sense of loss of control over eating?
Or times when you felt that you could not stop eating?
Or times when you felt unable to control what or
how much you were eating?

If No: Have there been times when you felt you could not
prevent yourself from eating?
7.01
A NSWERS:

Yes: experiences loss of control

No: does NOT experience loss of control

FIGURE 10–4. EDA-5 probes assessing loss of control while eating.

If the individual denies loss of control in the past 3 months, the inter-
viewer will proceed next to a series of questions regarding purging behav-
ior. If loss of control is endorsed, the interviewer will then be guided to
assess the size of the binge episodes during which the loss of control is ex-
perienced.

It’s a Binge! Is It Large or Small?

The EDA-5 next queries about OBEs, episodes in which the individual de-
scribes feeling out of control and eating what would clearly be a large
amount of food (Figure 10–5). If OBEs are endorsed, the interviewer is
asked to note, in the text box provided, the type and amount of food typ-
ically consumed during a binge episode.
The context in which the eating occurred must be evaluated; for exam-
ple, what would be regarded as excessive consumption at a typical meal
might be considered normal during a meal eaten for a celebration or hol-
iday (e.g., Thanksgiving, Fourth of July). Examples of amounts of food that
would meet the threshold of objectively large, developed on the basis of
ratings from our clinical staff, are provided in Table 10–1 as a guideline for
EDA-5 interviewers.
If the first example provided by the individual is not a clearly large
amount of food, the interviewer might ask for a second example of “the
Use of the Eating Disorder Assessment for DSM-5 187

Back Restart Save EDA-5 Notes

Binge Eating & Compensatory Behaviors

Back to SYMPTOM:
Previous
• Objective Binge Episode (OBE): Has the individual eaten
Screen an objectively large amount of food in a discrete period of
time, while experiencing a loss of control?

PROBE:
• Were there times in the last 3 months when you
felt out of control and consumed what was clearly a large
amount of food?

Can you give me an example of what you typically ate?

And the context?

If Yes: Enter typical binge below:

Text Box

7.02
A NSWERS:

Yes: describes OBEs

No: does NOT describe OBEs

FIGURE 10–5. EDA-5 objective binge episode assessment.

largest amount of food that you recall eating in the last 3 months, while ex-
periencing a loss of control.” If the individual denies OBEs, the inter-
viewer is guided next to a series of questions about smaller binge episodes.
However, if OBEs are endorsed, the frequency of such episodes must be
obtained before proceeding.
The EDA-5 Binge Eating and Compensatory Behaviors section next
asks about SBEs. As with OBEs, if SBEs are described, the interviewer is
asked to note the type and amount of food in a typical episode. If this type
of eating episode is not described as having occurred in the past 3 months,
the interviewer is guided to a series of questions about purging behaviors.
However, if SBEs are endorsed, the frequency of such episodes must be
obtained before proceeding.

Other Common Challenges in Assessing Binge Eating

Because some individuals have difficulty recalling or distinguishing
among different binge episodes, information gathered about typical epi-
188 Handbook of Assessment and Treatment of Eating Disorders

sodes does not always occur in the sequence with which the EDA-5 pro-
ceeds. In such cases, the interviewer may want to take notes and input the
information into the EDA-5 only once it is clear whether the episode is
better characterized as an OBE or an SBE. It is also possible to move back
and forth between questions without losing data by selecting the “Back”
button on the top left of each screen (see Figure 10–5).
In general, if an individual is struggling to answer EDA-5 items related
to distinguishing OBEs and SBEs, it may be useful to ask about the most
recent episode of loss-of-control eating, determine episode size, and then
inquire about typicality. Also of note, although a single episode of binge
eating need not be restricted to one setting, these episodes should occur
within a “discrete period of time” (i.e., a limited period, usually less than
2 hours). Continual snacking on small amounts of food throughout the
day would not be considered an episode of binge eating.
When the interviewer is uncertain whether an amount of food de-
scribed is objectively large, he or she should 1) use the examples provided
in Table 10–1 as guidelines, 2) confer with colleagues to reach consensus,
or 3) conservatively code an episode as subjectively large. It is important
to recall that OBEs are characterized by the consumption of an unambigu-
ously large amount of food.

Probing About Compensatory Behaviors

Following the assessment of binge eating, the interviewer is directed to ask
about the use of inappropriate purging behaviors, including self-inducted
vomiting or misuse of laxatives, diuretics, or other medications (e.g., diet
pills, stimulants) (Figure 10–6). Indicators of misuse include 1) using the
purging behavior explicitly to compensate for binge eating, 2) using a pre-
scription medicine without medical supervision, 3) using greater quanti-
ties of the medicine than recommended, and 4) using the medicine more
frequently than recommended. If purging is endorsed, information will
next be collected on the frequency and types of behaviors present in the
3 months prior to assessment. If the individual denies use of purging be-
haviors, the interviewer proceeds to ask about excessive exercise.
The EDA-5 guides the interviewer to determine whether exercise is
excessive or inappropriate by asking about several possible concerns
(Figure 10–7). Exercise may be viewed as excessive if it interferes with
daily functioning (e.g., the individual avoids family responsibilities), per-
sists despite significant injury or other medical complications, becomes
overly compulsive (e.g., the individual feels excessive guilt if unable to
exercise), or is clearly an inappropriate level of physical activity given
Use of the Eating Disorder Assessment for DSM-5 189

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Binge Eating & Compensatory Behaviors

SYMPTOM:
• Average number of episodes per WEEK over last 3
months. Has inappropriate behavior occurred at least
once a week, on average, for the last 3 months?

PROBE:
• Can you estimate how many times per WEEK over the
last 3 months, on average, you have made yourself
vomit, or misused laxatives, diuretics or other
medications?

Average weekly frequency over past 3 months:

Vomiting:
Laxatives:
Diuretics:
If other method used, describe below and enter
frequency per week
Description
7.0505
A NSWERS:

Proceed

FIGURE 10–6. EDA-5 assessment of purging behaviors.

weight status (i.e., the individual is underweight). In instances in which in-

dicators of misuse are not clear, additional potentially useful probes in-
clude the following:

1. Do you (or would you) continue to exercise if you are (were) ill or in-
jured?
2. Have you canceled or missed important social plans because you could
not tolerate skipping the exercise?
3. Is your exercise routine the primary determinant of how you arrange
your work or school schedule?
4. How easy or difficult is it for you to take days off from your exercise
regimen?
5. How much do you vary the routine in type or duration of exercise? How
easy or difficult would varying the routine have been in the past 3 months?
190 Handbook of Assessment and Treatment of Eating Disorders

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Binge Eating & Compensatory Behaviors

SYMPTOM:
• Does the individual use exercise inappropriately (i.e.,
excessively)?

Indicators of excessive exercise include exercising

despite illness or injury, exercising to an extent that it
interferes with daily responsibilities (e.g., being late for
work or school), or feeling highly distressed when unable
to exercise.

PROBE:
• Do you exercise? What type of exercise do you do and
for how long?

Type of Exercise:
Average # of minutes per
episode:

Does the amount of exercise you do interfere with your

health or get in the way of meeting your daily
responsibilities?
7.06
A NSWERS:

Yes: exercises excessively

No: does NOT exercise excessively

FIGURE 10–7. EDA-5 questions on inappropriate exercise.

Data fields are provided for the interviewer to note the individual’s
preferred type(s) of exercise and the average duration of a typical exercise
session (Figure 10–7). If the behavior described is determined to be exces-
sive by the interviewer, he or she asks questions about the frequency of the
behavior.
If the individual endorses purging behavior, excessive exercise, or both,
the interviewer is guided to assess the purpose of these behaviors—that is,
whether they are intended to control weight or to compensate specifically
for binge-eating episodes. If neither purging behavior nor excessive exer-
cise is noted, then the end of the Binge Eating and Compensatory Behav-
iors section has been reached.

Assessing Frequency of Behaviors

Each series of questions about the frequency of OBEs, SBEs, purging be-
haviors, and excessive exercise follows the same structure (see example in
Figure 10–8). The interviewer is first guided to obtain a weekly frequency
Use of the Eating Disorder Assessment for DSM-5 191

estimate for the 3 months prior to assessment (Figure 10–8A). Because

DSM-5 employs a threshold of at least once a week to meet the criteria for
binge eating in BN and BED, and for purging behavior in BN, the EDA-5
focuses on determining whether the frequencies of the behaviors endorsed
early in the interview are at or below this threshold. However, the EDA-5
obtains information on frequency even if it is less than once weekly, be-
cause this information may be of clinical importance and may suggest the
presence of a subthreshold disorder (e.g., OSFED). If a threshold of at least
once per week is met, the interviewer will be asked to note the average
weekly frequency in a text box on the following screen (Figure 10–8B). If
the threshold of at least once per week is not met, the interviewer will be
guided to ask about monthly frequency. If a threshold of at least once per
month is met, then the interviewer will be asked to note the average
monthly frequency in a text box on the following screen. If the threshold of
at least once per month is not met, the EDA-5 will retain the information
regarding the presence of particular behaviors but will not probe for addi-
tional frequency information.
As previously noted, information collected in the Binge Eating and
Compensatory Behaviors section determines subtyping of AN cases as
well as the next appropriate section to which the interviewer should be
guided (e.g., BN, ARFID). If a diagnosis of AN has been met and the sub-
type determined, the next section to be accessed is the Pica section. If
symptoms consistent with BN (i.e., OBEs and purging behaviors of at least
once per week) or BED (i.e., OBEs of at least once per week) are endorsed
in this section, the interviewer will be guided accordingly. In all other in-
stances, the next section to be accessed is the ARFID section.

Bulimia Nervosa
Assuming that the individual is not underweight (either currently or in the
past 3 months) and has endorsed at least one OBE per week on average and
at least one episode of inappropriate compensatory behavior (e.g., vomit-
ing, laxatives, excessive exercise) per week on average in the last 3 months,
the interviewer is directed to the BN section of the EDA-5. This section con-
tains one item assessing overreliance on weight or shape for self-evaluation
(Figure 10–9).
If this symptom is endorsed, the individual meets criteria for a BN di-
agnosis, and a pop-up window indicates to the interviewer that a diagnosis
has been reached. The EDA-5 then proceeds to the Pica section. If the in-
dividual does not meet criteria for BN, the interviewer is guided to the
ARFID section.
 192
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Binge Eating & Compensatory Behaviors Binge Eating & Compensatory Behaviors

Handbook of Assessment and Treatment of Eating Disorders

SYMPTOM: SYMPTOM:
• Has objective binge eating occurred at least once a • Average number of OBEs per WEEK over the last 3
week, on average, for the last 3 months? months
PROBE: PROBE:
• How many times in the last WEEK have you had an • Can you estimate how many times per WEEK, on
eating episode like what you have just described, when average, over the last 3 months, you have had episodes
you ate a large amount of food and felt a lack of control? like this?

Is this consistent with how frequently this behavior has

occurred for the past 3 months? # of OBEs per week:

If No: How was frequency of episodes different? 7.0203

7.0201 A NSWERS:
A NSWERS:
Proceed
Yes: at least 1 OBE/WEEK, on average
No: less than 1 0BE/WEEK, on average

A B
FIGURE 10–8. Sequence for behavior frequency items on EDA-5.
Interviewer determines whether or not the frequency meets threshold of at least once per week, on average (A). Estimated weekly frequency is
entered (B).
Use of the Eating Disorder Assessment for DSM-5 193

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Bulimia Nervosa
SYMPTOM:
• Does body shape or weight exert undue influence on
sense of self-worth or on self-evaluation?
PROBE:
• Does your body shape or weight impact how you
feel about yourself?

For example, if you were to have a day when you did not
like the number on the scale, or the way your clothes fit,
or how your body shape felt in general, how much would
that impact you? Would it make you feel very badly about
yourself? Please tell me a little about this.

8
A NSWERS:

Yes: shape and weight exert undue influence

No: shape and weight do NOT exert undue influence

FIGURE 10–9. EDA-5 questions on overvaluation of shape and weight.

Binge-Eating Disorder
Assuming that the individual is not underweight (either currently or in the
past 3 months), has endorsed at least one OBE per week on average, and
denies frequent inappropriate compensatory behavior in the 3 months
prior to assessment, the interviewer is directed to the BED section of the
EDA-5. The next several items assess features typically associated with
OBEs (e.g., eating more rapidly than normal, eating in the absence of hun-
ger). For each probe, the interviewer is encouraged to anchor the individ-
ual to the OBE example described in the Binge Eating and Compensatory
Behaviors section (see Figures 10–5 and 10–10). Per the DSM-5 criteria, if
the individual endorses at least three of the five features and endorses sig-
nificant distress about the binge episodes, the individual meets criteria for
a BED diagnosis; a pop-up window indicates that a diagnosis has been
reached. Regardless of whether or not a diagnosis of BED is assigned, the
interviewer is guided next into the ARFID section of the EDA-5.
It may be surprising that the EDA-5 assesses for the presence of
ARFID even after an individual’s symptoms have satisfied the criteria for
BED. A brief description of the trumping rules embedded in the feeding
and eating disorders section of DSM-5 is required in order to explain the
194 Handbook of Assessment and Treatment of Eating Disorders

Back Restart Save EDA-5 Notes

Binge Eating Disorder

SYMPTOM:
• During OBEs, eating more rapidly than usual?

PROBE:
• Keeping in mind the type of episode you described just a
moment ago, when you ate a large amount of food and
felt that loss of control...
Refer to example of OBE provided.

9a. ...did you eat faster than usual?

9.1
A NSWERS:

Yes: ate faster than usual

No: did NOT eat faster than usual

FIGURE 10–10. Feature(s) associated with objective binge episodes in

EDA-5.

rationale. In DSM-5, a current diagnosis of AN excludes a diagnosis of

any other feeding or eating disorder except pica (in the DSM-5 scheme,
individuals with any other disorder can also receive a diagnosis of pica).
Similarly, if criteria for AN are not met but criteria for BN are satisfied,
the diagnosis of BN excludes all other disorders except pica. A diagnosis
of AN, BN, BED, or ARFID excludes a diagnosis of rumination disorder.
However, DSM-5 does not provide explicit guidance on whether a diag-
nosis of ARFID should exclude a diagnosis of BED or vice versa. In real-
ity, it is difficult to imagine that an individual’s symptoms would
simultaneously involve both frequent binge eating and the level of clini-
cally significant restriction of food intake required for ARFID. Nonethe-
less, because the DSM-5 criteria do not exclude this possibility, the
criteria for ARFID are assessed in the EDA-5 even after a diagnosis of
BED has been made; if the criteria for ARFID are satisfied, the EDA-5
will also assign that diagnosis.

Avoidant/Restrictive Food Intake Disorder

The EDA-5 gateway item for the ARFID section is the presence of severe
food restriction or avoidance that has resulted in nutritional problems
Use of the Eating Disorder Assessment for DSM-5 195

Back Restart Save EDA-5 Notes

Avoidant/Restrictive
/ Food Intake Disorder (ARFID)
( )
SYMPTOM:
• Has severe food restriction or avoidance resulted in
serious nutritional problems?

PLEASE NOTE: Sufficient information may already be

available to answer this without additional questions.

Restriction that occurs only in the context of a binge

eating episode does not satisfy this criterion.

PROBE:
• In the last 3 months, have you had a serious nutritional
problem because you severely restricted or avoided
eating some foods?
11
A NSWERS:

Yes: serious nutritional problems from restricted eating

No: NO serious nutritional problems

FIGURE 10–11. EDA-5 gateway item for avoidant/restrictive food in-

take disorder (ARFID).

(Figure 10–11). At this juncture, a note reminds the interviewer that “suffi-
cient information may already be available to answer this without addi-
tional questions.” This reminder is included because, as described in the
previous paragraph, depending on the symptoms that have thus far been
endorsed by the individual (i.e., subthreshold BN or BED symptoms), the
transition into the ARFID section can be awkward.
If the first ARFID symptom is denied (or not met on the basis of infor-
mation already obtained) and neither a BN nor BED diagnosis was previ-
ously assigned, then the interviewer is guided into the Rumination
Disorder section. If serious nutritional problems as a result of highly re-
strictive eating are present, the interviewer is guided to ask four additional
probes to assess 1) significant weight loss, 2) related significant medical
problems, 3) need for nutritional supplements (e.g., Ensure, Sustacal,
Boost) or enteral feeding (e.g., the use of a tube inserted into the stomach),
and 4) resultant psychosocial impairment. If one or more of these symp-
toms are endorsed, the interviewer continues with the remainder of the
ARFID items. If all of these symptoms are denied, the interviewer is
guided to the Rumination Disorder section.
196 Handbook of Assessment and Treatment of Eating Disorders

Back Restart Save EDA-5 Notes

Rumination Disorder
SYMPTOM:
• Does the individual repeatedly regurgitate food?

PROBE:
• In the past month, have you re-chewed, re-swallowed, or
spit out your food? How often has this happened?
15
A NSWERS:

Yes: repeatedly regurgitates food

No: does NOT repeatedly regurgitate food

FIGURE 10–12. EDA-5 gateway item for rumination disorder.

To meet criteria for a diagnosis of ARFID, the individual’s eating dis-

turbance must not be better explained by a lack of available resources, by
culturally sanctioned eating practices, or by a concurrent medical or men-
tal condition. It should be noted that many individuals with ARFID have
(or have had) a problem that contributes to the restrictive eating, such as
medical illnesses affecting the gastrointestinal tract (e.g., regional enteritis,
gluten intolerance, food allergies) or other mental disorders (e.g., autism
spectrum disorder). An important question is whether the restrictive eat-
ing problem is so severe that it requires clinical attention in addition to that
routinely needed to address the other disorder.
If ARFID is diagnosed, a pop-up window indicates to the interviewer
that a diagnosis has been reached, and the EDA-5 directs the interviewer
to the Pica section. If ARFID criteria are not met, the interviewer is di-
rected to the Rumination Disorder section.

Rumination Disorder
The Rumination Disorder section of the EDA-5 requires an initial assess-
ment of the presence of repeated regurgitation of food via re-chewing, re-
swallowing, or spitting out of food (Figure 10–12). If this behavior is absent,
the interviewer proceeds to the Pica section. If such behavior is present, the
interviewer is guided to determine if it is best accounted for by another
medical or mental condition, such as esophageal reflux or intellectual dis-
ability. Rumination disorder frequently occurs in association with medical
problems such as esophageal reflux; the critical question, in this instance,
Use of the Eating Disorder Assessment for DSM-5 197

Back Restart Save EDA-5 Notes

Pica
SYMPTOM:
• Has there been persistent ingestion of non-nutritive, non-
food substances?

PROBE:
• Have you eaten any non-food materials (e.g., dirt,
paint) in the last month? What have you eaten? How
often?
19
A NSWERS:

Yes: eats non-food substances

No: does NOT eat non-food substances

FIGURE 10–13. EDA-5 gateway item for pica.

is whether or not the reflux is sufficient to explain the symptoms of rumi-

nation.
If there is no alternate problem associated with this behavior (or if the al-
ternate is not a sufficient explanation of the symptoms described) and if the
severity of the behavior warrants specialized clinical attention (e.g., nutritional
counseling, targeted psychotherapy), a diagnosis of rumination disorder is in-
dicated by a pop-up window. Whether or not a diagnosis of rumination disor-
der is assigned, the next section presented is the Pica section.

Pica
Pica, characterized by the repeated ingestion of nonnutritive substances,
can occur with any of the other feeding and eating disorders. Thus, all in-
dividuals are asked about at least the gateway item for this section of the
EDA-5 (Figure 10–13). Because the EDA-5, in its current form, is an adult
assessment, the eating of nonnutritive substances is assumed to be inappro-
priate to the individual’s developmental level. When individuals endorse
this behavior, interviewers must confirm 1) that this is not part of a cultur-
ally sanctioned or normative practice and 2) that if the behavior occurs in
the setting of an associated medical or mental condition (e.g., pregnancy,
intellectual disability), it is severe enough to merit specialized clinical atten-
tion. In these cases, a diagnosis of pica is assigned and is indicated in a pop-
up window.
At this juncture in the interview, if a feeding and eating disorder diag-
nosis has been made, the interviewer will be provided with a summary
198 Handbook of Assessment and Treatment of Eating Disorders

form of EDA-5 results (see “Notes and Results” section below). If no feed-
ing or eating disorder diagnosis has thus far been assigned, the interviewer
will be guided into the OSFED section.

Other Specified Feeding or Eating Disorder

The OSFED section of the EDA-5 is intended to capture residual feeding
and eating disorder diagnoses. A brief introduction to the section advises in-
terviewers to take into account the information collected thus far and to de-
cide whether the cluster of symptoms endorsed fits into an OSFED
category (Figure 10–14A). To make this determination, interviewers will
likely need to ask additional questions, possibly about the individual’s
weight history or eating patterns. In these instances, probes might include
the following:

1. What has your highest weight been within the last 3 months?
2. How much weight, if any, have you lost in the last 3 months? 6 months?
Year?
3. Do you eat at night, long after dinner or after you have slept for a
while? How often has this occurred in the last 3 months? What do you
remember about these types of eating episodes?

On the following screen, the interviewer will be asked to choose the

most appropriate diagnosis based on the data and the interviewer’s clinical
impression (Figure 10–14B). Because DSM-5 does not provide diagnostic
criteria for any of these disorders and because an individual may have
symptoms consistent with more than one OSFED, the clinician must use
his or her judgment to decide which category is most appropriate.
One option in the OSFED section of the EDA-5 is “other (unspecified)
feeding or eating disorder.” The interviewer assigns this diagnosis when an
individual has an unspecified but clinically significant constellation of
feeding and eating disorder symptoms that do not meet either the criteria
for any of the formally recognized feeding and eating disorders or the de-
scriptions provided in the OSFED section of the EDA-5.

Notes and Results

Interviewer Notes
The EDA-5 allows for the interviewer to take notes as needed by using the
“Notes” button at the top right-hand corner of each screen (see Figure 10–1).
New comments are added to those previously entered, and all comments are
 Use of the Eating Disorder Assessment for DSM-5
Back Restart Save EDA-5 Notes Back Restart Save EDA-5 Notes

Other Feeding and Eating Disorders Other Feeding and Eating Disorders
SYMPTOM: SYMPTOM:
• Brief descriptions are provided below. Proceed to the
• Choose the disorder that most closely matches the
next page to indicate the most appropriate diagnosis.
presenting problem.
Choose the one that most closely matches the
presenting problem. PROBE:
PROBE:
• The conditions below are other eating disorders noted in
• The conditions very briefly described below are other DSM-5, but not formally recognized.
feeding and eating disorders noted in DSM-5, but not
formally recognized. 32
A NSWERS:
Atypical Anorexia Nervosa: meets all criteria for
Anorexia Nervosa, but, despite significant weight loss,
weight is within or above normal range. Atypical Anorexia Nervosa
Subthreshold Bulimia Nervosa: meets all criteria for Subthreshold Bulimia Nervosa
Bulimia Nervosa, but low in frequency or of limited
duration. Subthreshold Binge Eating Disorder
Subthreshold Binge Eating Disorder: meets all criteria
for Binge Eating Disorder, but low in frequency or of Purging Disorder
limited duration. Night Eating Syndrome
Purging Disorder: Recurrent purging to influence shape
or weight, but no binge eating. Other (unspecified) Feeding or Eating Disorder
Night Eating Syndrome: Recurrent episodes of night
eating (after falling asleep or after evening meal)
Other (unspecified) Eating Disorder 31
A NSWERS:

A Proceed to choose most appropriate diagnosis. B

199
FIGURE 10–14. Other specified feeding and eating disorders.
Brief descriptions of other feeding and eating disorders are provided to guide the interviewer (A). The diagnosis is selected on the following screen (B).
200 Handbook of Assessment and Treatment of Eating Disorders

printed in the final report at the conclusion of the interview (see “Output”
section below). The notes area is meant to be used by the interviewer
throughout the interview to make notes about symptoms that are either sub-
threshold or not clearly diagnostic but are, nonetheless, highly relevant to
the individual’s clinical presentation. To return to the interview from the
Notes page, the interviewer presses the “Save” button at the top left-hand
corner of the screen.
Upon completion of the EDA-5, the interviewer is guided to a final
comments screen, in which the interviewer is reminded to enter additional
notes as desired. The notes space can be used to remark on salient features
of the particular case (e.g., if the individual is a bariatric surgery candidate
or postoperative patient) or interview process (e.g., if the individual had dif-
ficulty with comprehension of items or recall of symptoms). If an individual
has been diagnosed with an OSFED, the interviewer might use this space
to clarify the rationale for his or her diagnostic decision. If the individual
has been diagnosed with USFED, a description of the condition’s symp-
toms can be noted in this space. All notes will be included in the output.

Data Collection
The following data are collected and stored by the EDA-5 for output on
the Results screen (Figure 10–15): Interview (demographics), BMI, Binge
Eating (typical OBE items and OBEs per week), specific compensatory
behaviors (frequency of vomiting; laxative and diuretic use; type and fre-
quency of other weight-control methods; and exercise type, duration, and
frequency), Diagnosis, and Notes. Interviewers should remember that this
information is not electronically transferred anywhere and item-by-item
responses are not stored by the interview. Once the interviewer exits the
EDA-5, the data collected are no longer retained. However, the report it-
self may be stored on the device.

Output
Output from the interview can be recorded in one of two ways. If the inter-
viewer selects “print” on the Results screen (Figure 10–15), the interviewer
will be guided to a reformatted EDA-5 Results screen (Figure 10–16) that
can be printed if a printer is accessible to the device. Alternatively, if the
interviewer selects “Save,” he or she is asked to log in to an account previ-
ously established on the device, and the report will be encrypted and stored
on the device. It can later be retrieved but only after the interviewer logs in
with the username and password he or she previously entered.
 Use of the Eating Disorder Assessment for DSM-5
Back Restart Save EDA-5 Notes Back Restart Save EDA-5 Notes

Results print
L AXATIVES
INTERVIEW
Date 12/31/14 Average number per week 0
InterviewerID AB For Printable
DIURETICS
SubjectID BC Results Screen
SubjectAge 32 Average number per week 0
OTHERMETHOD
BMI
Name n/a
Weight 135
Average number per week 0
Height 65
BMI 22.5 E XERCISE
RecentWeight 130
RecentHeight 65 Type Running, swimming
RecentLowBMI 21.6 Average number mins per 90 min
episode
BINGEE ATING Average number episodes 7
per week
typical OBE items 1 large mushroom pizza, 4
cupcakes, 1 1/2 pints of DIAGNOSIS
chocolate ice cream
Bulimia Nervosa
OBEs per week 7
NOTES
VOMITING
Feels better about body shape than she did at a higher weight, but
Average number per week 9
still finds that it is the primary way she evaluates herself.

201
FIGURE 10–15. EDA-5 initial results screen.
 202
Interview
EDA-5 Results
Date 12/31/14
InterviewerID AB
SubjectID BC

Handbook of Assessment and Treatment of Eating Disorders

SubjectAge 32
BMI
Weight 135
Height 65
BMI 22.5
RecentWeight 130
RecentHeight 65
RecentLowBMI 21.6
BingeEating
typical OBE items 1 large mushroom pizza, 4 cupcakes, 1 1/2 pints of chocolate ice cream
OBEs per week 7
Vomiting
Average number per week 9
Laxatives
Average number per week 0
Diuretics
Average number per week 0
OtherMethod
Name n/a
Average number per week 0
Exercise
Type Running, swimming
Average number mins per episode 90 min
Average number episodes per week 7
Diagnosis
Bulimia Nervosa
Notes
Feels better about body shape than she did at a higher weight, but still finds that it is the primary way she evaluates herself.

FIGURE 10–16. EDA-5 printable results form.

Use of the Eating Disorder Assessment for DSM-5 203

Future Directions
We hope that the first version of the EDA-5 provides an acceptable, accu-
rate tool for the diagnosis of DSM-5 feeding and eating disorders. We are
well aware that in this original form, the EDA-5 does not fit all profession-
als’ needs. Depending on the setting, for example, interviewers may prefer
a long-form version of the measure (i.e., without trumping rules) or a mea-
sure that assesses past feeding and eating disorder diagnoses (such as tools
described in Chapter 8, “Assessment Measures, Then and Now”).
It is also apparent that several more substantial adaptations of the orig-
inal EDA-5 warrant development and rigorous study. For example, a
broad categories system of diagnosis (i.e., focusing on shared features or
symptom clusters of feeding and eating conditions) was proposed as a po-
tentially useful diagnostic scheme to reduce the number of cases classified
as eating disorder not otherwise specified using DSM-IV (Sysko and
Walsh 2011a, 2011b; Walsh and Sysko 2009). This type of classification
system appears to virtually eliminate the need for a residual diagnostic cat-
egory (Machado et al. 2013; Nakai et al. 2013; Sysko and Walsh 2011a,
2011b). The utility of this system in reducing the number of cases desig-
nated as DSM-5 OSFED and USFED could be evaluated if the EDA-5 is
adapted for broad categories assessment.
To be used across a variety of different populations, the EDA-5 must
also undergo adaptation. Perhaps the most straightforward of these
changes would be translation of the measure into other languages so that
it can be used across cultures and countries to enhance accuracy and stan-
dardization of feeding and eating disorder diagnoses. In addition, the
EDA-5 would benefit from modest changes to make it more palatable to
and appropriate for younger populations, akin to adjustments made to the
EDE for use with children (Bryant-Waugh et al. 1996) (see Chapter 11,
“Diagnosis of Feeding and Eating Disorders in Children and Adoles-
cents”).

Conclusion
The EDA-5 is a novel measure providing comprehensive assessment of
DSM-5 feeding and eating disorder criteria while reducing participant
burden and requiring minimal interviewer training. It is our hope that this
semistructured interview will address some of the limitations of prior as-
sessments and will prove helpful to practitioners ranging broadly in pro-
fessional background, specialty, and experience across a variety of clinical
and research settings.
204 Handbook of Assessment and Treatment of Eating Disorders

Key Clinical Points

• The Eating Disorder Assessment for DSM-5 (EDA-5) assesses cur-
rent feeding and eating disorders in adults according to the DSM-5
criteria. It is intended for use by clinicians and researchers in a va-
riety of disciplines (e.g., nursing, psychology, social work), and it as-
sumes familiarity with the DSM-5 feeding and eating disorder
diagnoses.
• In contrast to other available semistructured diagnostic interviews,
the EDA-5 requires minimal interviewer training and reduces partic-
ipant burden.
• In its current electronic application form, the EDA-5 uses automated
skip rules to mirror DSM-5’s diagnostic “trumping” rules.
• The EDA-5 collects and retains information about frequency of be-
havioral symptoms of feeding and eating conditions; however, it is
not aimed at a broader assessment of associated psychopatholog-
ical features, such as the intensity of concerns over shape or
weight.
• In initial psychometric studies, the EDA-5 demonstrated high rates
of diagnostic agreement with the Eating Disorder Examination
(EDE) and with clinician interview. In addition, test-retest reliability
of the EDA-5 was excellent. The EDA-5 required significantly less
time to complete than the EDE.
• Although further study of the measure’s ability to diagnose feeding
disorders is warranted and further development of the measure so
that it might be used across a variety of populations is needed, the
EDA-5 is a promising new diagnostic instrument for the assessment
of DSM-5 feeding and eating disorders.

References
American Psychiatric Association: Diagnostic and Statistical Manual of Mental
Disorders, 4th Edition. Washington, DC, American Psychiatric Association,
1994
American Psychiatric Association: Diagnostic and Statistical Manual of Mental
Disorders, 5th Edition. Arlington, VA, American Psychiatric Association,
2013
Blomquist KK, Roberto CA, Barnes RD, et al: Development and validation of the
Eating Loss of Control Scale. Psychol Assess 26(1):77–89, 2014 24219700
Bryant-Waugh RJ, Cooper PJ, Taylor CL, et al: The use of the Eating Disorder Ex-
amination with children: a pilot study. Int J Eat Disord 19(4):391–397, 1996
8859397
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Fairburn CG, Cooper Z, O’Connor M: Eating Disorder Examination, Edition 16.0D,

in Cognitive Behavior Therapy and Eating Disorders. Edited by Fairburn CG.
New York, Guilford, 2008, pp 265–308
First MB, Williams JBW, Karg RS, et al: Structured Clinical Interview for DSM-5
Disorders, Research Version (SCID-5-RV). Arlington, VA, American Psychi-
atric Association, 2015
Latner JD, Mond JM, Kelly MC, et al: The Loss of Control over Eating Scale: de-
velopment and psychometric evaluation. Int J Eat Disord 47(6):647–659, 2014
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Machado PP, Gonçalves S, Hoek HW: DSM-5 reduces the proportion of EDNOS
cases: evidence from community samples. Int J Eat Disord 46(1):60–65, 2013
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Nakai Y, Nin K, Teramukai S, et al: Comparison of DSM-IV diagnostic criteria
versus the Broad Categories for the Diagnosis of Eating Disorders scheme in
a Japanese sample. Eat Behav 14(3):330–335, 2013 23910776
Sysko R, Walsh BT: Does the Broad Categories for the Diagnosis of Eating Disor-
ders (BCD-ED) scheme reduce the frequency of eating disorder not otherwise
specified? Int J Eat Disord 44(7):625–629, 2011a 21997426
Sysko R, Walsh BT: Rethinking the nosology of eating disorders, in Developing an
Evidence-Based Classification of Eating Disorders: Scientific Findings for
DSM-5. Edited by Striegel-Moore RH, Wonderlich SA, Walsh T, et al. Arling-
ton, VA, American Psychiatric Association, 2011b, pp 3–17
Sysko R, Glasofer DR, Hildebrandt T, et al: The Eating Disorder Assessment for
DSM-5 (EDA-5): development and validation of a structured interview for
feeding and eating disorders. Int J Eat Disord 48(5):452–463, 2015 25639562
Tanofsky-Kraff M, Yanovski SZ, Wilfley DE, et al: Eating-disordered behaviors, body
fat, and psychopathology in overweight and normal-weight children. J Consult
Clin Psychol 72(1):53–61, 2004 14756614
Walsh BT, Sysko R: Broad Categories for the Diagnosis of Eating Disorders (BCD-
ED): an alternative system for classification. Int J Eat Disord 42(8):754–764,
2009 19650083
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11 Diagnosis of Feeding
and Eating Disorders
in Children and
Adolescents
Natasha A. Schvey, Ph.D.
Kamryn T. Eddy, Ph.D.
Marian Tanofsky-Kraff, Ph.D.

Eating disorders affect nearly 3% of adolescents in the

United States (Swanson et al. 2011), whereas associated psychopathology,
such as undue influence of shape and weight (Neumark-Sztainer et al.
2002), loss of control over eating (Tanofsky-Kraff et al. 2008a), unhealthy
weight-control practices (Neumark-Sztainer et al. 2012), and compensa-
tory behaviors (Solmi et al. 2014), is increasingly common among both
male and female youths (Ackard et al. 2007; Field et al. 2014). Disordered
eating attitudes and behaviors are associated with numerous physical and
psychological consequences, including depression, substance use, and

The opinions or assertions contained herein are the private ones of the authors and
are not to be construed as official or reflecting the views of the Department of De-
fense, the Henry M. Jackson Foundation, or the Uniformed Services University of
the Health Sciences.

207
208 Handbook of Assessment and Treatment of Eating Disorders

poorer overall health (Field et al. 2012). Furthermore, unhealthy weight-

control behaviors in youths are significant risk factors for the development
of full-threshold eating disorders, and binge eating and loss-of-control eat-
ing in youth predict weight gain and excess adiposity (Goldschmidt et al.
2013), placing children at risk for a host of psychological and physical co-
morbidities (Dixon 2010). Importantly, research has consistently shown
that eating disturbances tend to begin in childhood and adolescence
(Tanofsky-Kraff et al. 2004); therefore, early detection of aberrant eating
behaviors and cognitions is crucial for both prevention and treatment. Be-
cause childhood and adolescent eating symptoms commonly persist into
adulthood (Goldschmidt et al. 2014; Kotler et al. 2001) and overweight
youths are up to 20 times more likely to be overweight adults (Field et al.
2005), the assessment and diagnosis of feeding and eating disorders in
youths and adolescents are critical (see also Chapter 3, “Eating Problems
in Children and Adolescents”).
The assessment of eating disorder symptoms in youths presents unique
challenges, such as the child’s or adolescent’s unfamiliarity with key con-
structs (Bravender et al. 2007; Neumark-Sztainer and Story 1998); the lack
of concordance between self-report, parent-report, and interview assess-
ments (Field et al. 2004; Shomaker et al. 2013; Tanofsky-Kraff et al. 2003);
the need for clarification of certain terms, such as dieting, which may be
subject to interpretation (Neumark-Sztainer and Story 1998); and the se-
lection of developmentally appropriate definitions and criteria (e.g., deter-
mination of what constitutes an “objectively large amount of food” for a
growing child). Although measures of eating disorder symptoms and asso-
ciated features developed for adults have been used unaltered with pedi-
atric and adolescent samples, we focus in this chapter exclusively on
measures that have been specifically developed or adapted for use in
youths. We assembled our list, which is not exhaustive, by searching schol-
arly databases for terms related to child and adolescent feeding and eating
disorders, diagnostic assessment, and eating pathology. We have included
measures that assess eating disorders and eating-related psychopathology
specifically in children and adolescents under age 18 years.
DSM-5 (American Psychiatric Association 2013), the most recent edi-
tion of the Diagnostic and Statistical Manual, was published in 2013. Conse-
quently, at the time this chapter was written, few measures had been
developed to assess the diagnostic criteria for feeding and eating disorders,
which have undergone changes since DSM-IV (American Psychiatric As-
sociation 1994). Moreover, there is a paucity of measures that assess pica
(the persistent ingestion of nonnutritive items such as dirt and chalk), ru-
mination disorder (repeated regurgitation of food), or avoidant/restrictive
food intake disorder (ARFID), a reformulation of the DSM-IV diagnosis,
Diagnosis in Children and Adolescents 209

“feeding disorder of infancy or early childhood” (see also Chapter 8, “As-

sessment Measures, Then and Now”). The development of assessment
tools to detect these aberrant behaviors in youths is critical for both re-
search and clinical practice. If youths and/or their parents are not queried
and assessed for specific symptoms, it is unlikely that the behavior(s) will
be detected within clinical or research settings, and thus intervention and
treatment may be thwarted and research efforts hindered. At the conclu-
sion of this chapter in the section “Proposed Eating Disorder Assessment
for DSM-5 Adaptation for Youths,” we propose and discuss a novel assess-
ment tool to address these gaps.

Tools to Assess Eating Disorder Symptoms

Interview Versus Self-Report Methodology
Interview methodology is often considered the optimal means of assessing
eating-related psychopathology (Fairburn and Beglin 1994). This is largely
because interviews allow for explanation and clarification of complex core
features germane to feeding and eating disorders. Additionally, interviews
are often considered preferable because of the methodological limitations
inherent in self-report measures, such as selection of socially acceptable re-
sponses, nonresponse, and lack of clarification for ambiguous terms (e.g.,
dieting, loss of control). Although concordance between interview and
self-report measures is high for unambiguous behaviors, such as laxative
misuse, much lower concordance is observed for those behaviors whose
definitions are more abstract, such as binge eating and overvaluation of
shape (Fairburn and Beglin 1994). Other factors such as literacy level,
speaking English as a second language, and cultural differences might im-
pede an individual’s comprehension and valid completion of question-
naire measures. In the assessment of children, semistructured interview
methods are not reliant on literacy and thus may be appropriate for a
wider range of ages and socioeconomic backgrounds. (For more interview
methodology, see Chapter 8.)
Despite the advantages of interview methodology, there are also con-
siderable disadvantages, especially among pediatric samples. Interview
methods may be costly, because of the extensive training required for as-
sessors as well as the significant amount of time the administration may re-
quire (30–60 minutes on average, and potentially longer for children who
have difficulty comprehending abstract concepts) (Fairburn and Beglin
1994). In contrast, self-report measures are often brief and require little
training or qualification for assessors. Also, interview methods are not fea-
sible in the collection of nationally representative data and therefore may
210 Handbook of Assessment and Treatment of Eating Disorders

be less practical for large-scale research samples. Furthermore, certain be-

haviors, such as purging and binge eating, may be considered shameful by
the respondent, who may be less likely to endorse such behaviors in a face-
to-face interview (Lavender and Anderson 2009); this potential issue is es-
pecially salient for adolescents, who may be particularly self-conscious
and sensitive to the perceived judgment of others. As a result, the assessor
must take into account the purpose of the assessment, characteristics of the
respondent, and practical considerations when selecting the most appro-
priate measure. The use of more than one type of assessment is typically
recommended to best capture complex eating pathology and associated
features (Tanofsky-Kraff 2008).

Interview Measures
Eating Disorder Examination Adapted for Children
To date, the most commonly used interview measure for the assessment of
eating pathology in youths is the Eating Disorder Examination adapted for
children (ChEDE; Bryant-Waugh et al. 1996). Adapted from the 61-item
Eating Disorder Examination (EDE; Fairburn and Cooper 1993), the
ChEDE was first piloted in a sample of children ages 7–14 seeking treat-
ment in an eating disorders clinic. The ChEDE, like the EDE, is a semi-
structured interview, a format that facilitates an interactive assessment
wherein a child’s questions can be answered, age-related differences may
be addressed, and key concepts (e.g., loss of control) can be explained in
full until the child demonstrates comprehension. Additionally, follow-up
queries can be posed to the child for improved specificity and accuracy.
The ChEDE yields four subscale scores—Dietary Restraint, Eating Con-
cern, Shape Concern, and Weight Concern—and a global score, all of
which range from 1 to 6 (with higher scores indicative of greater pathol-
ogy). The ChEDE may be used diagnostically to determine the presence
of anorexia nervosa (AN), bulimia nervosa (BN), binge-eating disorder
(BED), or other specified feeding or eating disorder (OSFED), as well as
to further elucidate subthreshold eating pathology, such as undue influ-
ence of shape or weight or compensatory behaviors.
Training for administration of the ChEDE is ideally conducted by
trained postgraduates in the field of pediatric eating disorders and entails
reviewing the criteria for eating disorders and discussing each item on the
interview. Audiotaped interviews are listened to and co-rated by trainees.
Trainees then practice administering the ChEDE with simulated patients,
observe an actual ChEDE administration, and ultimately administer the
ChEDE under observation and supervision. Training continues until inter-
rater reliability between trainee and trainer reaches 95%. To ensure fidel-
Diagnosis in Children and Adolescents 211

ity, ongoing supervision is provided and all ChEDE administrations are

audiotaped so that ambiguous responses may be reviewed in regular meet-
ings. Additional information on training for the ChEDE is described else-
where (Tanofsky-Kraff et al. 2004, 2007a).
One primary adaptation that differentiates the ChEDE from the EDE
is the use of a card sort task to assess overvaluation of shape and weight,
which may be an abstract and difficult concept for children to grasp. In the
card sort task, children are asked to write down “those things that are im-
portant to you in how you see yourself or think about yourself” and sort
the items in order of importance. The child is then asked to indicate where
on this list shape and weight would fit. Additionally, for the ChEDE, cer-
tain items have been rephrased to better assess intent as opposed to behav-
ior. For instance, although a child may wish to abstain from food for a
period of 8 hours or more, he or she may be unable to do so because of
parental supervision. To assess this possibility, the original ChEDE asks,
“Would you have done ____ if you could have?” (Bryant-Waugh et al.
1996). Recent iterations of the ChEDE, however, have opted out of this
modification (Tanofsky-Kraff et al. 2007a). The interviewer should use his
or her discretion in determining whether to assess both behavior and in-
tent.
The ChEDE queries respondents primarily regarding the 4 weeks pre-
ceding administration to assess present functioning. Because DSM-5 diag-
nostic criteria for both BN and BED require a duration of 3 months, the
respondent is also asked to recall certain feelings and behaviors (e.g., meal
skipping, binge episodes) during this time span. Owing to difficulty in re-
call for children, parents may be enlisted to help with this task. Specifi-
cally, a parent or guardian may fill in a 3-month calendar with significant
events and scheduled activities (e.g., holidays, birthdays, after-school
clubs) to cue the child’s memory.
The ChEDE enables the categorization of eating episodes into four dif-
ferent types: objective bulimic episodes, subjective bulimic episodes, ob-
jective overeating without the experience of loss of control, and no
episode. To ascertain the presence of an eating episode, the interviewer
asks respondents about the “largest” amount of food they have consumed
within the past 28 days. To assist respondents with recollecting types and
amounts of food consumed in a given episode, a book of photographed
food portions may be employed as a visual aid (Hess 1997). It is recom-
mended that determination of whether an ambiguously large amount of
food is “objectively large” be made by consensus of the research team.
Whereas DSM-5 diagnostic criteria for BED in adults specify that
binge-eating episodes must be objectively large, extant research indicates
that the presence of loss of control, rather than amount of food consumed,
212 Handbook of Assessment and Treatment of Eating Disorders

may be the more salient feature of a binge episode in youths (Shomaker et

al. 2010). Furthermore, because it may be difficult to determine what con-
stitutes an objectively large amount of food in children and adolescents
who reach puberty and physical maturation at different rates, the presence
of loss of control is often a more accurate proxy for a binge-eating episode
in youths. Therefore, it is critical to assess both objective binge-eating ep-
isodes and subjective binge-eating episodes; in the latter, the child experi-
ences loss of control while consuming a subjectively large amount of food.
The ChEDE has been used to assess children as young as age 6 years
(Tanofsky-Kraff et al. 2003) and may be used through late adolescence.
The ChEDE has demonstrated excellent psychometric properties, includ-
ing interrater reliability, internal consistency, and discriminant validity in
both clinical and research samples (Bryant-Waugh et al. 1996; Tanofsky-
Kraff et al. 2004). Administration typically takes 1 hour, although 1½ hours
may be more realistic for younger children, youths with attention deficits,
or youths who struggle to comprehend abstract concepts. At the onset of
the interview, youths are informed that they may take breaks as needed
(e.g., to use a restroom or stretch). Breaks may also be suggested at the in-
terviewer’s discretion if a child begins to lose focus.

Supplemental Sections to the Eating Disorder Examination

Adapted for Children
To bolster the ChEDE’s specificity and utility, two supplemental sections
have been added: the Standard Pediatric Eating Episode Interview
(SPEEI) (Tanofsky-Kraff et al. 2007a) and the Age of Onset of any Eating-
Disordered Behavior, Overweight, and Dieting (Tanofsky-Kraff et al.
2005). Both have demonstrated feasibility in pediatric and adolescent sam-
ples.
Administered following the overeating section of the ChEDE, the
SPEEI queries respondents about the behavioral, physical, emotional,
and contextual aspects of a specified eating episode. The SPEEI is used to
assess critical features of a binge episode, such as negative affect, prior ca-
loric restriction, and shame following eating. If a child endorses more than
one aberrant eating episode, only one is selected as the target for the
SPEEI (Tanofsky-Kraff et al. 2007a). The SPEEI is a useful clinical and
research tool to further assess antecedents to, subjective experience dur-
ing, and emotional and physical consequences of a binge episode.
The Age of Onset of any Eating-Disordered Behavior, Overweight,
and Dieting supplement to the ChEDE (Tanofsky-Kraff et al. 2005) pro-
vides additional temporal information pertaining to loss of control over
eating, dieting, and overweight onset. Children are queried regarding the
onset, duration, and nature of dieting attempts and weight-control behav-
Diagnosis in Children and Adolescents 213

iors; the age at which they became overweight; and the age at which they
first experienced loss of control, regardless of the amount of food con-
sumed.

Children’s Binge Eating Disorder Scale

The Children’s Binge Eating Disorder Scale (C-BEDS; Shapiro et al.
2007) is a brief seven-item interview assessment of BED and subthreshold
binge behaviors, such as eating in response to negative affect. This mea-
sure may be a useful instrument for assessing both threshold and subsyn-
dromal binge eating in youths. Additionally, the child-friendly
terminology and brevity make it a viable screening tool for the presence
of binge behaviors in youths. Because the C-BEDS employs provisional
diagnostic criteria and has not yet been validated in large, diverse samples,
it would benefit from additional psychometric testing and validation. This
measure is useful in assessing specific behaviors and cognitions associated
with binge eating in a brief interview format wherein difficult concepts
may be explained and elaborated upon.

Self-Report Measures
Although semistructured interviews are often considered the gold standard
method of assessment in youths (Tanofsky-Kraff et al. 2003), existing re-
search indicates that methods of assessment, such as self-report question-
naires, that do not involve direct questioning by an interviewer may yield
higher and potentially more valid rates of eating pathology, the open ex-
pression of which may be blunted during face-to-face interviews (Lavender
and Anderson 2009). Although self-report measures have utility in clinical
and research settings, they may require supplemental objective and/or
parent-report data. Selection of measures may vary depending on the pur-
pose of assessment; for instance, some assessments are diagnostic, whereas
others may be more useful in elucidating accompanying symptoms and
subsyndromal behaviors (see also Chapter 9, “Self-Report Assessments of
Eating Pathology”).

Diagnostic Measures
To diagnostically assess eating disorders in youths, well-validated adult
measures, such as the Eating Disorder Examination Questionnaire
(EDE-Q; Fairburn and Beglin 1994) and the Questionnaire on Eating and
Weight Patterns (QEWP; Spitzer et al. 1993), have been adapted and vali-
dated for use in pediatric populations to determine the presence of AN, BN,
BED, and OSFED. The EDE-Q has not yet been adapted for DSM-5; the
QEWP adaptation for DSM-5 was recently published (Yanovski et al.
2015).
214 Handbook of Assessment and Treatment of Eating Disorders

The Youth Eating Disorder Examination Questionnaire (YEDE-Q;

Goldschmidt et al. 2007), adapted from the EDE-Q (Fairburn and Beglin
1994), was designed for diagnostic use with child and adolescent samples.
The specific modifications were modeled after those used in the ChEDE
(Bryant-Waugh et al. 1996), wording was adapted for a third-grade reading
level, and examples and pictures are provided. The YEDE-Q, which was
piloted in a sample of overweight youths ages 12–17 years, demonstrated
agreement with the ChEDE on subscale scores and assessment of binge
episodes (Goldschmidt et al. 2007). The YEDE-Q may be used diagnosti-
cally to determine presence of AN, BN, BED, and OSFED, as well as to
assess subthreshold disordered thoughts and behaviors. The YEDE-Q
may be effectively used in place of more cumbersome and time-intensive
assessment methods.
The Questionnaire on Eating and Weight Patterns—Adolescent Version
(QEWP-A; Johnson et al. 1999) is an adaptation of the QEWP that may
be used diagnostically to assesses the presence of BED and BN in youths.
It assesses both behavioral and cognitive features and may also be accu-
rate in detecting subthreshold or prodromal BED and BN. The measure,
piloted in a sample of individuals ages 10–18 years, demonstrated concur-
rent validity and stability. See Yanovski et al. (2015) for the QEWP-A
DSM-5 adaptation. Table 11–1 summarizes details about diagnostic mea-
sures of feeding and eating disorders in youths.

Nondiagnostic Measures
Several adult measures have also been adapted for use with children to as-
sess nondiagnostic markers of eating pathology, such as dieting, food pre-
occupation, compensatory behaviors, and concerns about becoming
overweight. The Children’s Eating Attitudes Test (ChEAT; Maloney et al.
1988), adapted from the Eating Attitudes Test (EAT; Garner and Garfinkel
1979), reliably assesses food preoccupation, dieting, eating-related atti-
tudes, and fear of becoming overweight in youths age 8 or older. The mea-
sure has demonstrated strong test-retest and internal reliability, and
administration takes approximately 35 minutes. Scores are comparable to
those observed in adult samples (Maloney et al. 1988).
The Eating Disorder Inventory—Child (EDI-C; Garner 1991) is an ad-
aptation of the Eating Disorder Inventory (EDI; Garner et al. 1983), a non-
diagnostic, multiscale assessment of symptoms commonly associated with
AN and BN. The measure consists of 91 forced-choice items, which form
11 subscales: three assess thoughts and behaviors related to eating, shape,
and weight; five capture psychological traits associated with eating pathol-
ogy (e.g., perfectionism, interoceptive awareness); and the rest assess traits
commonly observed in eating disorder patients (e.g., impulse regulation).
 Diagnosis in Children and Adolescents
TABLE 11–1. Tools to assess eating disorder symptoms: child assessments
Type of Age Number of
Measure assessment Symptoms assessed (years) items/duration Citation

Diagnostic measures
Children’s Binge Eating Interview Binge-eating disorder and subthreshold binge 5–13 7 Shapiro et al.
Disorder Scale (C-BEDS) behaviors 2007
Eating Disorder Examination Interview Anorexia nervosa, bulimia nervosa, binge-eating 7–14 36/1 hour Bryant-Waugh
Adapted for Children disorder, other specified feeding or eating et al. 1996
(ChEDE) disorders
Questionnaire on Eating and Questionnaire Binge-eating disorder, bulimia nervosa 10–18 12 Johnson et al.
Weight Patterns—Adolescent 1999
Version (QEWP-A)
Youth Eating Disorder Questionnaire Anorexia nervosa, bulimia nervosa, binge-eating 12–17 39 Goldschmidt
Examination Questionnaire disorder, other specified feeding or eating et al. 2007
(YEDE-Q) disorders
Nondiagnostic measures
Children’s Eating Attitudes Questionnaire Food preoccupation, dieting, eating-related 8–13 35 minutes Maloney et al.
Test (ChEAT) attitudes 1988
Dutch Eating Behavior Scale Questionnaire Eating in response to negative affect, eating in 7–12 37 van Strien et
(DEBQ) response to external cues, restraint al. 1986
Eating Disorder Inventory— Questionnaire Associated symptoms of anorexia nervosa and 9–16 91 Garner 1991
Child (EDI-C) bulimia nervosa
Kids’ Eating Disorders Survey Questionnaire Body dissatisfaction, restriction, binge eating, 9–16 14 Childress et al.

215
(KEDS) compensatory behaviors 1992
 216
TABLE 11–1. Tools to assess eating disorder symptoms: child assessments (continued)
Type of Age Number of
Measure assessment Symptoms assessed (years) items/duration Citation

Handbook of Assessment and Treatment of Eating Disorders

Tools to assess associated features
Eating in the Absence of Questionnaire Eating in response to emotional and 6–19 14 Tanofsky-
Hunger for children and environmental cues Kraff et al.
adolescents (EAH-C) 2008b
Emotional Eating Scale for Questionnaire Eating in response to emotional cues 8–18 25 Tanofsky-
children and adolescents Kraff et al.
(EES-C) 2007c
Perception of Teasing Scale Questionnaire Weight- and appearance-based teasing 10–18 49 Thompson et
(POTS) al. 1995
Yale Food Addiction Scale for Questionnaire Food addiction 4–16 25 Gearhardt et
Children (YFAS) al. 2013
Diagnosis in Children and Adolescents 217

The primary factors derived from the EDI-C are drive for thinness, affec-
tive instability, self-esteem, overeating, and maturity fears. The EDI-C has
been administered to child and adolescent samples (Eklund et al. 2005),
although the scale’s length may pose a challenge for younger respondents.
The Kids’ Eating Disorders Survey (KEDS; Childress et al. 1992) is a
self-report nondiagnostic measure that assesses body dissatisfaction, restric-
tion, binge eating, and compensatory behaviors. The KEDS was piloted
among respondents ages 9–16 and has demonstrated adequate test-retest
reliability (Childress et al. 1993). For an assessment of body dissatisfaction,
youths are provided with eight figure drawings and asked to indicate which
most resembles their current shape or weight and which resembles what
they “would most want to look like.” Children are also provided with de-
scriptions of sample binge episodes and asked to indicate whether they
have consumed a similar or greater amount in a period of 2 hours. This
item, designed to measure binge eating, does not assess loss of control, the
hallmark feature of binge eating (Shomaker et al. 2010). Therefore, deter-
mination of a binge cannot be made from this measure alone. Furthermore,
the sample binge episodes provided may prove difficult for children to ex-
trapolate from in the event that dissimilar foods were consumed during an
eating episode. This measure may be most appropriate for assessment of
body dissatisfaction, dieting, and compensatory behaviors among school-
age children. (See Table 11–1 for a summary of nondiagnostic measures of
eating-related psychopathology.)

Tools to Assess Associated Features

of Eating Disorder Symptoms
Children and adolescents presenting with disordered eating are a hetero-
geneous population; therefore, additional indices of eating-related cogni-
tions and behaviors are warranted. Furthermore, certain pathological
behaviors and features (e.g., eating in response to negative affect) may pre-
cede full-threshold eating disorders and weight problems; therefore, it is
critical to assess for aberrant eating attitudes and behaviors in youths. To
further elucidate the associated features commonly observed among
youths presenting with eating pathology, several measures have been
adapted and developed. Four measures that assess associated features spe-
cifically pertaining to eating and weight pathology are listed in Table 11–1.
Indices (e.g., Children’s Depression Inventory) that assess more general
psychopathology are beyond the scope of this chapter.
218 Handbook of Assessment and Treatment of Eating Disorders

Eating in Response to External and Affective Cues

Environmental cues and affective states can precipitate eating, even in the
absence of physiological hunger. Eating in the absence of hunger has been
well documented among children and adolescents (Tanofsky-Kraff et al.
2008b) and is associated with loss-of-control eating, dysregulation of hun-
ger and satiety cues, and excess body weight. Questionnaires have been
developed for use with children and adolescents to specifically assess eat-
ing in the absence of hunger (Tanofsky-Kraff et al. 2008b), eating in re-
sponse to affective states (Tanofsky-Kraff et al. 2008b)and environmental
cues (Tanofsky-Kraff et al. 2007c), and food addiction (Gearhardt et al.
2013) (see details in Table 11–1).

Weight-Based Teasing
The experience of weight-related teasing in youth predicts poor body im-
age, unhealthy eating behaviors, binge eating, and disordered eating cog-
nitions (Puhl and Latner 2007). Therefore, it is critical to assess the
experience of weight-based victimization among overweight youths, who
are particularly vulnerable to both weight-based teasing and the onset of
aberrant eating behaviors. Overweight and obese youths face pervasive
stigmatization by peers, teachers, health care providers, and parents. As a
result, overweight youths may suffer psychological, interpersonal, and
physical health consequences. To measure weight-based and physical ap-
pearance–based teasing in youths, the Perception of Teasing Scale (POTS;
Thompson et al. 1995) was developed to retrospectively assess teasing that
occurred between ages 5 and 16 years.
An additional measure of weight-based victimization, Experiences of
Weight-Based Victimization, has been developed for research purposes in
adolescent populations (Puhl and Luedicke 2012). This measure identifies
the perpetrator, nature, and duration of weight-based teasing, as well as
the target’s response. Weight-based teasing is useful to assess in both clin-
ical and research settings because it is common among youths of all weight
strata (Puhl and Luedicke 2012) and is significantly predictive of un-
healthy weight-control practices, binge eating, and disordered eating
thoughts and behaviors (Puhl and Latner 2007).

Parent-Report Measures
Because some youths, particularly younger children, may struggle to con-
ceptualize and describe complex emotions and behaviors (e.g., eating in
response to negative affect) and may need assistance with the recall and
Diagnosis in Children and Adolescents 219

chronology of eating behaviors, parent-report measures may be particu-

larly valuable when assessing disordered eating. Consequently, a number
of parent-report measures have been developed to assess feeding and eat-
ing disturbances in youths (Table 11–2).
Despite the utility of parent report in providing information that may
be beyond the scope of a child’s understanding, memory, or insight, infor-
mant discrepancies are common among various clinical assessments of
psychopathology in youths (De Los Reyes and Kazdin 2005). For instance,
parent and child reports of disordered eating demonstrate greatest concor-
dance when no eating pathology is present; the two reports have been
shown to lack concordance in the presence of eating pathology (Johnson
et al. 1999).
In a large cross-sectional study of nearly 8,000 adolescent-parent dy-
ads, parents and children were generally discordant in symptom reports
(Swanson et al. 2014). As in prior studies, parents were less likely than
their children to report the children’s bulimic behaviors. Additionally, de-
spite pronounced sex differences in self-report measures (adolescent girls
are two to four times more likely than male age-mates to report binge eat-
ing), parent-report measures did not differ according to the sex of the child
(Swanson et al. 2014). Parent-report measures were, however, predictive
of body mass index and were also more likely than child measures to ac-
curately report thinness (Swanson et al. 2014). Additionally, parent report
may be more reliable for abstract concepts, such as eating in the absence
of hunger (Shomaker et al. 2013). Thus, parent-report measures may be
useful in identifying youths at risk for low weight, as well as inappropriate
weight gain over time. Objective measurement of a child’s weight is opti-
mal, although if it is not feasible, parent report is probably preferable to
child self-report, because children’s estimates of their own weight are fre-
quently inaccurate (Sarafrazi et al. 2014). It is likely, however, that parent-
report measures grossly underestimate the presence of secretive binge and
compensatory behaviors; therefore, caution should be used when relying
solely on parent-report measures.

Parent-Report Interview Measures

Several parent-report interview measures exist to assess general psychopa-
thology in youths. Table 11–2 lists these measures, including the Diagnos-
tic Interview Schedule for Children—Parent Version (DISC-P; Shaffer et al.
1993), the Schedule for Affective Disorders and Schizophrenia for School-
Age Children (KSADS; Kaufman et al. 1997), the Development and Well-
Being Assessment (DAWBA) parent interview (Goodman et al. 2000), and
the Composite International Diagnostic Interview parent interview
 220
TABLE 11–2. Tools to assess eating disorder symptoms: parent reports
Type of Age
Measure assessment Symptoms assessed (years) Citation(s)

Handbook of Assessment and Treatment of Eating Disorders

Parent-report measures for children and adolescents
Diagnostic Interview Schedule for Interview Comprehensive psychiatric evaluation (with 8–19 Fisher et al. 1993;
Children—Parent Version (DISC-P) Eating Disorder subsection) Shaffer et al. 1993
Schedule for Affective Disorders and Interview Comprehensive psychiatric evaluation (with 7–17 Kaufman et al. 1997
Schizophrenia for School-Age Children Eating Disorder subsection)
(KSADS)
Development and Well-Being Assessment Interview Comprehensive psychiatric evaluation (with 5–16 Goodman et al.
(DAWBA) parent interview Eating Disorder subsection) 2000
Composite International Diagnostic Interview Comprehensive psychiatric evaluation (with Robins et al. 1988
Interview (CIDI) parent interview Eating Disorder subsection)
Questionnaire on Eating and Weight Questionnaire Binge eating and purging 10–18 Johnson et al. 1999
Patterns—Parent Version (QEWP-P)
Eating in the Absence of Hunger (EAH-P) Questionnaire Eating in response to emotional and 6–19 Shomaker et al.
environmental cues 2013; Tanofsky-
Kraff et al. 2008b
Parent-report measures for younger pediatric samples
Children’s Eating Behaviour Questionnaire Eating style 2+ Wardle et al. 2001
Questionnaire (CEBQ)
Child Feeding Questionnaire (CFQ) Questionnaire Feeding practices, food acceptance, proneness to 2–11 Birch et al. 2001
obesity
Diagnosis in Children and Adolescents 221

(CIDI; Robins et al. 1988). To date, these measures have not generally
been adapted to reflect DSM-5 diagnostic criteria. These measures may be
used in full for a comprehensive psychiatric evaluation, or only the “Eat-
ing Disorder” subsection may be administered. Of note, however, certain
parent-report measures of eating pathology have demonstrated lack of
sensitivity (Fisher et al. 1993), which may reflect parents’ inability to infer
children’s emotions (e.g., fear of gaining weight) or may be the result of se-
crecy surrounding certain behaviors. This discordance is consistent with
other parent-report measures (Swanson et al. 2014) and underscores the
need for both child and parent report (or child report alone) for the diag-
nosis and classification of eating pathology.

Parent-Report Questionnaire Measures

Additional parent-report measures include parent versions of the Ques-
tionnaire on Eating and Weight Patterns (QEWP-P; Spitzer et al. 1993) and
of the Eating in the Absence of Hunger questionnaire (EAH-P; Tanofsky-
Kraff et al. 2008b). Notably, the QEWP demonstrates high concordance
between child self-report and parent report in the presence of no diagnosis
(82% agreement); however, concordance is significantly reduced when the
child reports subthreshold binge eating (15.5%) or BED (25%) (Johnson et
al. 1999). This difference may be due to the secrecy and shame associated
with binge eating and suggests that parents’ reporting of sensitive behav-
iors may be insufficient in the assessment of adolescent eating and weight
pathology. In contrast, the parent version of the EAH demonstrated signif-
icantly greater construct validity than the child report, perhaps because of
the abstract nature of the construct of interest (Shomaker et al. 2013).

Parent-Report Measures
for Younger Pediatric Samples
Although the utility of parent-report measures in the assessment of adoles-
cents is unclear (Johnson et al. 1999; Swanson et al. 2014), parent reports
are necessary in the evaluation of younger pediatric samples. Parent-report
measures that assess eating and feeding behaviors in children as young as
age 2 years have been developed. These include the Children’s Eating Be-
haviour Questionnaire (CEBQ; Wardle et al. 2001), which assesses dimen-
sions of eating style (e.g., satiety responsiveness, fussiness, emotional
overeating), and the Child Feeding Questionnaire (CFQ; Birch et al. 2001),
which measures feeding practices, food acceptance, and proneness to obe-
sity in youths ages 2–11 years (see Table 11–2). These scales may have im-
portant predictive utility because problematic eating in early childhood is
a risk factor for the onset of eating disorders (Jacobi et al. 2004).
222 Handbook of Assessment and Treatment of Eating Disorders

Alternative Methods of Assessing Eating

Pathology and Associated Features in Youths
Given the myriad challenges facing clinicians and researchers assessing
aberrant eating in youths—for instance, limited recollection of foods con-
sumed, lack of insight regarding affective states, and the discordance of
parent-report measures—several novel methods have been developed for
more thorough and ecologically valid assessments. Although these meth-
ods may be more cumbersome and costly, they provide objective data that
may contribute substantially to the understanding of eating behaviors in
youths.

Feeding Paradigms
Retrospective dietary recall may pose a challenge even for adult respon-
dents and recall may be unreliable or invalid among youths (McPherson
et al. 2000); laboratory feeding paradigms enable researchers to examine
eating behavior in a controlled setting. Using well-established paradigms
and test meals, energy intake and macronutrient content of both binge and
regular meals can be ascertained in the laboratory (Tanofsky-Kraff et al.
2007b). Additionally, researchers can precisely assess both premeal and
postmeal affect, rather than relying on retrospective report. Laboratory
feeding studies have been adapted for youths and have been critical in the
investigation of binge and eating behaviors in youths who are lean and
those who are overweight (Mirch et al. 2006; Tanofsky-Kraff et al. 2009).

Ecological Momentary Assessment

Ecological momentary assessment (EMA) has been used in adult popula-
tions to gather random and event sampling of food intake, food-related
cognitions, and affect in natural settings and shows promise for use in pe-
diatric and adolescent samples (Hilbert et al. 2009; Ranzenhofer et al.
2014; Shingleton et al. 2013) (see Chapter 12, “Application of Modern
Technology in Eating Disorder Assessment and Intervention”). Feasibility
of EMA has been demonstrated in children as young as age 7 years (Silk
et al. 2011). When EMA is conducted with children, child-specific cellular
phones or personal digital assistants are provided and participants are
trained in their use. Notably, EMA may detect individuals who denied
presence of loss of control in clinical interviews and thereby may serve as
an important method of detecting false-negative loss-of-control eaters (Hil-
bert et al. 2009). The data garnered from this method may elucidate the
antecedents to binge-eating and aberrant eating episodes and help to es-
Diagnosis in Children and Adolescents 223

tablish the temporal relationship among mood (Hilbert et al. 2009), inter-
personal difficulties (Ranzenhofer et al. 2014), and eating behaviors.

Neuropsychological Assessments
Neuropsychological and neurobiological tools may have utility in identi-
fying neural markers and correlates of eating disorders in youths (Eddy
and Rauch 2011). Additionally, neuropsychological methods may be used
to identify children who are at risk for binge eating and obesity. Because
neural response to food-related stimuli develops in youth, functional mag-
netic resonance imaging and neuropsychological assessments may be
helpful in determining neural mechanisms involved in the development
and maintenance of eating and weight disorders (e.g., Lock et al. 2011;
Marsh et al. 2011). Review of the literature pertaining to the neurobiology
of adolescent eating disorders is beyond the scope of this chapter.

Proposed Eating Disorder Assessment

for DSM-5 Adaptation for Youth
To date, the only comprehensive diagnostic tools developed for the detec-
tion of DSM-5 feeding and eating disorders are the EDE Version 17.0D
(Fairburn et al. 2014) and the Eating Disorder Assessment for DSM-5
(EDA-5; Sysko et al. 2015). The EDA-5 (described in Chapter 10, “Use of
the Eating Disorder Assessment for DSM-5”) lends itself well to a child-
specific adaptation. An adaptation of the EDA-5 for use with child and ad-
olescent populations could be disseminated in both clinical and research
settings and would provide diagnostic information pertaining to binge eat-
ing, compensatory behaviors, dietary restraint, ARFID, pica, and rumina-
tion disorder, in addition to the range of OSFED subtypes, such as night
eating syndrome and purging disorder. This computerized assessment, ad-
ministered by an interviewer via computer or mobile device, has been
shown to minimize participant burden (Sysko et al. 2015). This format
may be particularly useful with children and adolescents, in whom sus-
tained attention can vary widely. For use of the EDA-5 with youths, the
language should be modified in accordance with prior measures (e.g., the
ChEDE [see subsection “Interview Measures” within this chapter]), to aid
in comprehension. Additional information and elaboration should be pro-
vided pertaining to abstract constructs; for instance, “loss of control”
should be described in more detail with the use of metaphor (e.g., “the ex-
ample of a ball rolling down a hill, going faster and faster” [Tanofsky-Kraff
et al. 2004]). As described in Chapter 10, the adult version of the EDA-5
224 Handbook of Assessment and Treatment of Eating Disorders

employs the DSM-5 trumping rules (e.g., a current diagnosis of AN ex-

cludes any other feeding or eating disorder, with the exception of pica);
however, in pediatric and adolescent samples, it will be important to ad-
minister the full battery so that every category of feeding and eating disor-
der is assessed. In the assessment of younger children, it is also important
to obtain supplemental information from parents. For instance, parental
report may be necessary to document any medical problems or nutritional
deficiencies resulting from low energy intake. Although the digitized for-
mat of the assessment will likely reduce time and burden for respondents,
it does require that a member of the clinical or research team administer
the interview.

Conclusion
The assessment and diagnosis of feeding and eating disorders in youths are
complex and merit a holistic approach. Although the prevalence of full-
threshold eating disorders among youths is estimated at approximately 3%
(Swanson et al. 2011), subthreshold eating behaviors and cognitions, such
as binge and loss-of-control eating, dietary restriction, and preoccupation
with shape and weight, are quite common among child and adolescent
samples (Ackard et al. 2007; Eddy et al. 2010; Tanofsky-Kraff et al. 2004).
Therefore, the early detection and diagnosis of disordered eating and re-
lated psychopathology are vital in preventing the onset of full-threshold
eating disorders and obesity during child and adolescent development. To
better assess feeding and eating pathology in youths, several measures,
both interviews and self-reports, have been developed or adapted from
adult measures.
Relatively few children meet full DSM-5 criteria for eating and feeding
disorders; however, many endorse problematic eating behaviors and cog-
nitions that may be prodromal or increase risk for full-syndrome eating
disorders. Therefore, it is strongly recommended that children be assessed
both for the diagnostic criteria and for subthreshold features of feeding
and eating disorders, such as loss-of-control eating and hyperresponsivity
to food cues; where feasible, interview assessments and self-report mea-
sures should be administered in tandem. Alternative methods, such as
feeding paradigms or EMA, may prove useful in assessing in vivo eating
behaviors and affect.
Although the utility of parent-report measures remains indeterminate,
and some argue that diagnosis can be made based on child report alone
(Johnson et al. 1999; Swanson et al. 2014), parents can play a crucial role
in assisting their child with recall and providing relevant information such
Diagnosis in Children and Adolescents 225

as weight status and medical sequelae. Parent report may be less reliable,
however, for the assessment of potentially shameful behaviors, such as
binge eating and purging. Because self-reported weight may not be an ac-
curate proxy for measured weight in youths (Sarafrazi et al. 2014) and di-
etary recall may pose a challenge for younger respondents (McPherson et
al. 2000), objective measures of eating behavior and weight should be col-
lected whenever feasible.
Owing to the relatively recent release of DSM-5, few measures exist
that assess the revised diagnostic criteria and newly added categories. In
fact, the EDA-5 is the only available tool to assess pica, rumination disor-
der, and ARFID, in addition to AN, BN, and BED. Therefore, this is an
area in need of future research and clinical effort. More specifically, re-
search should focus on measurement development to assess DSM-5 diag-
nostic criteria and categories of feeding and eating disorders in both
youths and adults.

Key Clinical Points

• Well-validated interview and questionnaire assessments of eating
disorder symptoms have been adapted for pediatric populations.
• Clinicians and researchers are advised to assess diagnostic criteria
as well as associated behaviors, cognitions, and risk factors.
• Interview methods are considered the optimal means of assessing
eating-related psychopathology, although training and administra-
tion may be cumbersome.
• Self-report measures may augment respondent candor and incur
less participant burden.
• Data on the utility of parent-report measures are mixed, although
parent report may be necessary for younger children and for esti-
mates of weight and medical sequelae.
• The administration of multiple assessments (e.g., interview and self-
report) is recommended.
• Adaptations of measures to assess DSM-5 diagnostic criteria are
warranted.
• Objective measures of eating behavior and weight should be col-
lected whenever feasible.
226 Handbook of Assessment and Treatment of Eating Disorders

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12 Application of Modern
Technology in Eating
Disorder Assessment
and Intervention
Jo M. Ellison, Ph.D.
Stephen A. Wonderlich, Ph.D.
Scott G. Engel, Ph.D.

Technology is becoming ubiquitous in daily life. Statistics

regarding the infiltration of mobile devices and Internet access into soci-
ety are staggering. In the United States, 90% of adults report owning a mo-
bile phone, and 58% of this group own a smartphone (Pew Research
Internet Project 2014). These rates are similar to those of other nations,
such as South Korea, Japan, Australia, Norway, Sweden, Denmark, the
United Kingdom, and the Netherlands, where smartphone ownership
rates passed the 50% threshold by 2014. The worldwide smartphone own-
ership rate is, in fact, still growing, and eMarketer (2014) predicted that
the rate would reach 25% in 2015. Home Internet access statistics vary
based on the type of Internet subscription surveyed. The U.S. govern-
ment census suggests that 74.4% of Americans had Internet service in
their homes in 2013 (File and Ryan 2014). Approximately 79% of Euro-
pean Union households report having high-speed Internet service (Euro-
stat 2013). American ownership of smartphones and home Internet

231
232 Handbook of Assessment and Treatment of Eating Disorders

connections crosses demographic groups, including those defined by gen-

der, race, ethnicity, and urban versus rural settings. However, certain
groups, including young adults and those with more education or higher
household income, report greater utilization of such technology (File and
Ryan 2014; Pew Research Internet Project 2014).
The evident popularity of technology makes it important for clinicians
to consider how they might incorporate it into professional practice. In
fact, the health care industry is already capitalizing on the ease of access to
technology. In 2013, of the 60% of U.S. adults who reported tracking their
weight, diet, or exercise regimen, 21% reported that they used technology
to track these data (Fox 2013). The purpose of this chapter is to provide
clinicians with information about the practical application of technology
in both the assessment and treatment of eating disorders. Several areas of
recent technological development and empirical study fall under this large
umbrella; however, our focus in this chapter is on those areas most rele-
vant to clinical practice with individuals with eating disorders. We discuss
ecological momentary assessment (EMA) in terms of its use in the scien-
tific study of these conditions and as a possible clinical tool for data collec-
tion. We review ecological momentary intervention (EMI), another
portable strategy that has emerged in conjunction with EMA and that can
be useful in delivering interventions to individuals as they go about daily
routines. We then discuss the utility and effectiveness of Web-based and
telemedicine treatments. Finally, we offer a practical examination of how
clinicians can integrate portable technology into practice.

Ecological Momentary Assessment

Largely due to the limitations of retrospective self-report, including mem-
ory limitations and cognitive biases, researchers are increasingly relying
on innovative real-time approaches to data collection to improve the va-
lidity of their data (Smyth et al. 2001). EMA involves the use of portable
devices, including personal digital assistants (PDAs) and mobile phones,
that enable intensive assessment of an individual’s states and behaviors in
naturalistic settings and in close approximations of real time.
EMA has been used successfully in the study of depression (aan het
Rot et al. 2012), substance use disorders (Shiffman 2009), psychotic disor-
ders (Oorschot et al. 2009), borderline personality disorder (Ebner-
Priemer et al. 2006), and eating disorders (Smyth et al. 2001). In addition to
reducing retrospective recall bias, EMA is advantageous in that it collects data
in the natural environment and thus avoids the artificiality of laboratory set-
tings (Smyth et al. 2001). Furthermore, intensive and repeated assessment of
Application of Modern Technology in Assessment and Intervention 233

FIGURE 12–1. Example ecological momentary assessment mood rating

and eating episode rating.
Source. Reprinted with permission from Real Time Assessment in the Natural
Environment (ReTAINE), http://retaine.org.

clinical variables, over hours, days, and weeks, allows for the examination of
relationships among various environmental or psychological factors and ob-
jective behaviors. For example, EMA can examine theoretically meaningful
causal variables (e.g., stressful events, emotional states) and various behavioral
outcome variables (e.g., alcohol consumption, binge eating, exercising) in a
manner that carefully accounts for the temporal order of events, thus poten-
tially clarifying cause and effect. Figure 12–1 provides two screen shots of an
EMA questionnaire that could be viewed and completed on a mobile device.
There has been a dramatic increase in the use of EMA for the study of
eating disorders in the past decade (Wonderlich 2010). This body of re-
search has improved understanding of various causal factors (e.g., ecolog-
ical factors, stress, emotion) involved in eating disorders. For example, an
early EMA study of bulimia nervosa (BN) revealed that bulimic symptoms
are most likely to occur on weekends and between the hours of 7 and 9 P.M.
(Smyth et al. 2009). EMA studies have also shown that negative emotional
234 Handbook of Assessment and Treatment of Eating Disorders

states increase while positive emotional states decrease before various eat-
ing disorder behaviors in anorexia nervosa (AN; Engel et al. 2013), BN
(Smyth et al. 2007), and binge-eating disorder (BED; Goldschmidt et al.
2012). Other data suggest that individuals with AN and BN experience a
marked variety of “emotional days,” but that eating disorder symptoms
occur most often on days when negative affect is heightened, specifically
in the later part of such days (Crosby et al. 2009; Lavender et al. 2013).
These and other EMA findings have been further supported by meta-
analytic research (Haedt-Matt and Keel 2011). Taken together, EMA find-
ings confirm that emotional states may serve as a momentary risk factor
for binge eating and associated behaviors (e.g., purging).
EMA studies have also fruitfully examined eating disorder behaviors
and emotional processes across different subgroups of individuals with
eating disorders, including those with comorbid borderline personality
disorder (Selby et al. 2012), posttraumatic stress disorder (Karr et al.
2013), a history of child abuse (Wonderlich et al. 2007), or multi-impulsive
BN (Myers et al. 2006). As expected, individuals with these co-occurring
psychiatric conditions experience heightened emotional reactivity and, at
times, differ from other eating-disordered individuals in terms of affect
and eating disorder behavior.
In summary, EMA has been used to make significant contributions to
the empirical study of eating disorders in the last decade. Existing studies
highlight the momentary relationship of emotional states and eating disor-
der behavior and have implications for maintenance models of eating dis-
orders. Furthermore, these data suggest that clinicians may benefit from
examining momentary processes surrounding eating disorder behaviors,
in terms of both conceptualizing individual cases and devising clinical in-
terventions to interrupt decision making in affect-laden moments preced-
ing and following a given behavior. In line with this recommendation, a
new treatment for BN (i.e., integrative cognitive-affective therapy) is based
on momentary models of bulimic behavior derived from EMA studies
and has been shown to effectively reduce bulimic symptoms in a random-
ized controlled trial (RCT) (Wonderlich et al. 2014). Future EMA studies
are needed to further elucidate the temporal nature of eating disorder be-
haviors in ways that can inform effective clinical applications of the results.

Ecological Momentary Intervention

Heron and Smyth (2010) refer to ecological momentary interventions as
the delivery of interventions to people as they go about their daily lives.
This definition suggests that EMI may be relatively unstructured (e.g., an
individual is reminded to complete food logs) or highly structured (e.g., a
Application of Modern Technology in Assessment and Intervention 235

smoker receives explicit instructions at times of day that have been empir-
ically demonstrated to be high risk). EMI may include response-contingent
interventions (e.g., delivering a text message with explicit instructions after a
patient reports increasing levels of negative affect via EMA) or non-
response-contingent interventions (e.g., delivering a text message at previ-
ously determined times of day, such as at mealtimes in weight loss protocols).
EMI has been implemented in several areas of psychology and behavioral
medicine, including smoking cessation (Rodgers et al. 2005), physical activ-
ity promotion (King et al. 2008), and substance use treatment (Weitzel et
al. 2007). It has been successfully used by a wide range of individuals (from
teenagers to the elderly) who have significantly different levels of techno-
logical sophistication (Heron and Smyth 2010).
The study of EMI in eating disorder samples has been relatively lim-
ited. Early noncontrolled pilot studies (Bauer et al. 2003; Shapiro et al.
2010) suggested that text message interventions may have small effects on
reducing eating disorder symptoms in posthospitalization aftercare stud-
ies, particularly for individuals with less severe forms of eating disorders.
In an RCT comparing a text message–based EMI with treatment as usual
in adults with BN, patients in the text messaging condition provided
weekly symptom reports over 16 weeks following hospital discharge and
received tailored feedback based on their symptom status (Bauer et al.
2012). Individuals in the treatment-as-usual condition were discharged
from inpatient treatment and received no follow-up contact beyond addi-
tional outpatient care sought on their own. Those in the text messaging
condition were significantly more likely to achieve remission of eating dis-
order symptoms than individuals in the treatment-as-usual condition.
Although the empirical database for EMI and eating disorders remains
undeveloped, obesity researchers have more extensively evaluated the
utility of this modality of intervention. Findings suggest that EMI is a
promising strategy to produce clinically significant weight loss in over-
weight and obese adults (e.g., Coons et al. 2012; Rao et al. 2011). The in-
clusion of handheld technology, in particular, has been associated with
significantly more weight loss among obese individuals than more tradi-
tional programs that rely on behavioral weight loss strategies without EMI
(e.g., Burke et al. 2011; Haapala et al. 2009; Patrick et al. 2009). For exam-
ple, in an RCT involving overweight individuals seeking weight loss,
Burke et al. (2011) compared three self-monitoring and recording systems:
1) paper record, 2) a PDA with dietary and exercise software, and 3) a
PDA with the same software plus a daily message delivered on the PDA.
In this 2-year investigation, participants who received information on their
PDA plus a daily message were the most likely to have achieved a 5%
weight loss when assessed at 6-month follow-up.
236 Handbook of Assessment and Treatment of Eating Disorders

Overall, it seems that EMI confers more benefit if it includes a more

comprehensive intervention or is offered as an adjunct to an in-person
treatment. This pattern was recently replicated in a study comparing an in-
person group-based weight loss intervention with a treatment that offered
the same intervention plus a PDA to record food consumption, record ac-
tivity level, and provide decision-support strategies (i.e., 15-minute coach-
ing calls from a paraprofessional every 2 weeks to review data and assist
the individual in establishing calorie and activity goals; Spring et al. 2013).
The group receiving the intervention plus the PDA lost more weight than
the group receiving the in-person intervention as a stand-alone treatment;
this pattern was maintained at each of several follow-up assessments. The
authors highlight that the delivery of EMI was shown to be effective while
using relatively minimal amounts of paraprofessional time, supporting the
utility of EMI as an adjunctive strategy. Furthermore, this study was
conducted in a primary care facility through the Veterans Affairs system,
suggesting that such interventions can be delivered effectively in non-
specialty-based settings.
It may yet be premature to draw conclusions about the effectiveness of
mobile phones and similar devices as weight loss tools (Rao et al. 2011),
and more research is certainly warranted in feeding and eating disorder
populations. However, existing applications of EMI (e.g., Spring et al.
2013) suggest that the intervention holds promise in comprehensive pri-
mary care–based weight management programs and possibly in improv-
ing dissemination and implementation of evidence-based interventions.

Web-Based Prevention and

Treatment of Eating Disorders
In eating disorders, the effectiveness and feasibility of technology-based
interventions that do not rely on momentary transactions between a pa-
tient (providing data) and a computer (processing the patient’s data) have
also been of interest. These Web-based platforms, focusing on prevention
and/or treatment, allow individuals to log on to a standardized and often
comprehensive program that includes assessment, education, and provi-
sion of various interventions.

Web-Based Prevention and Intervention Programs

A clear benefit of online platforms for eating disorder prevention is the rel-
ative ease with which larger numbers of young people can be targeted
(Bauer 2014). This area of study is changing rapidly, and scientifically
based conclusions may lag behind technological advances. Consequently,
Application of Modern Technology in Assessment and Intervention 237

the following study review serves as a general discussion of online preven-

tion and intervention programs available at the time of publication. At this
time, most studies focus exclusively on prevention in female populations.
The Web-based format of prevention and treatment programs changes
slightly depending on the specific intervention. Some provide stand-alone
materials and activities without clinician interaction, some offer asynchro-
nous message boards for group or individual clinical contact, and others
provide synchronous discussions and messaging for group and individual
clinical contact.
Several programs focus on prevention by enrolling females who may
be at risk for developing an eating disorder because they have elevated
shape and weight concerns. How a given program works with respect to
prevention varies. Student Bodies, for example, is a Web-based prevention
program developed and studied by Taylor et al. (2006) that presents psy-
choeducational materials and involves brief e-mail–based interactions be-
tween clinicians and participants. This intervention, compared with no
intervention, has been shown to significantly reduce weight and shape
concerns, and subsequent analyses suggest that improvements are main-
tained (Beintner et al. 2012). Other prevention programs, including the
Body Project and its online version, eBody Project (Stice et al. 2012), use
an approach based on cognitive-dissonance theory. Namely, these pro-
grams aim to help individuals reduce their drive to pursue a thin body
type by engaging in a variety of activities in which the thin ideal is cri-
tiqued. The online version of the program did not significantly differ from
the in-person version on major outcome variables, including body dissat-
isfaction, thin-ideal internalization, eating disorder symptoms, and nega-
tive affect (Stice et al. 2012). The effects of the eBody Project on eating
disorder pathology faded more quickly than those of the Body Project, but
the online version still produced greater and more enduring reduction in
risk for large weight gain at 1- and 2-year follow-ups (Stice et al. 2014).
Taken together, these studies indicate that online prevention programs can
have an impact, even when their scope is limited to psychoeducation or
reduction of thin-ideal internalization.
More comprehensive online treatment programs are also available.
Set Your Body Free (Paxton et al. 2007) is one such program; it employs
multiple modalities and has been used with individuals reporting signifi-
cant body dissatisfaction as well as those reporting current disordered
eating behaviors. It has been shown to reduce problematic eating atti-
tudes and behaviors, body dissatisfaction, avoidant tendencies, body
comparison, and internalization of the thin ideal (Paxton et al. 2007). An-
other program, adapted for adolescent girls and titled My Body, My Life:
Body Image Program for Adolescent Girls, appears similarly effective for
238 Handbook of Assessment and Treatment of Eating Disorders

this population (Heinicke et al. 2007). Finally, ProYouth is a Web-based

prevention/intervention program that helps to find the appropriate level
of treatment for the individual depending on the severity of his or her
symptoms. This program operates in seven European Union countries
and delivers treatment content through a variety of modalities, at varying
levels of intensity, essentially personalizing the intervention based on
each individual’s unique symptom pattern. For example, online, synchro-
nous chat sessions are offered to participants either in group or individual
format (ProYouth 2013). Initial investigations indicated that, as the devel-
opers intended, participants at high risk for an eating disorder generally
used more intensive modules than did those participants at “moderate
risk” (Lindenberg et al. 2011). ProYouth is currently operational and open
to public enrollment in the participating countries (Bauer 2014).
Overall, such online prevention and intervention programs appear to
be comparable in effectiveness to traditional face-to-face options and cer-
tainly more effective than no intervention. Retention for these platforms
appears high, suggesting that this modality is appealing to program partic-
ipants who may not have sought other treatments (Bauer 2014). Addition-
ally, Web-based treatments may show promise as cost-effective methods
of reducing the rate of onset of eating disorders. One limitation related to
online prevention programs is their current state of limited availability to
the general public. Although manuals for many traditional face-to-face
prevention programs have been published, the online versions are not
readily available to those outside specific academic research settings. As
the technology and empirical support for these interventions increase, it
seems reasonable to assume that greater access will follow.

Web-Based Individual Therapy

The use of technology in the active treatment of individuals with eating
disorder diagnoses has been attempted in different ways. Web-based treat-
ment delivered to individual patients differs from traditional face-to-face
treatment and from telemedicine in that Web-based treatment does not in-
clude an audiovisual interaction between clinician and patient. Web-based
individual treatment involves communicating via electronic messages and
viewing online materials (e.g., information modules, videos).
Web-based individual therapy for eating disorders has been studied
in multiple countries with generally positive results. To date, cognitive-
behavioral therapy (CBT) is the most widely studied Web-based individ-
ual treatment approach (Aardoom et al. 2013; Dölemeyer et al. 2013).
The amount of actual therapist contact time in such treatments is similar
to that in face-to-face treatments, averaging once a week, although the
Application of Modern Technology in Assessment and Intervention 239

amount of time interacting with the patient each week may differ based
on mode of delivery (e.g., e-mail vs. synchronous chat; Dölemeyer et al.
2013). In three studies evaluating Web-based CBT—guided self-help in-
terventions (Carrard et al. 2011; Ljotsson et al. 2007; Sánchez-Ortiz et al.
2011), treatment targeted individuals with binge eating for a duration
varying from 12 weeks to 6 months. Treatment content was presented in
sequential online modules, with additional weekly electronic communi-
cation with a clinician. All three studies reported significant symptom re-
duction in treatment subjects compared with wait-list control subjects at
rates comparable to those of previous face-to-face guided self-help trials
(Carrard et al. 2011; Ljotsson et al. 2007; Sánchez-Ortiz et al. 2011).
Overall, patients in Web-based CBT trials appear to improve over
time, report notable reductions in global eating disorder symptoms (e.g.,
concerns over eating, restraint, weight, and shape) and binge-eating be-
haviors, and tend to maintain these improvements after treatment ends
(Dölemeyer et al. 2013; Shingleton et al. 2013). Symptom improvement
extends to comorbid depression and anxiety, as well as to overall quality
of life (Dölemeyer et al. 2013).
Individuals who are likely to respond best to Web-based treatment in-
clude those who struggle with binge eating (rather than simple food restric-
tion; Aardoom et al. 2013) and those who are willing to engage maximally
with the technology (i.e., adhere to the modules and engage in more “ses-
sions”). Higher levels of online contact with a therapist yield higher rates
of symptom reduction (Shingleton et al. 2013).
Although Web-based CBT appears promising, with initial studies indi-
cating benefits roughly comparable to the effects of face-to-face treatments
(e.g., Wagner et al. 2013), more studies comparing Web-based treatments
with other active treatments (i.e., not simply using a wait-list control com-
parison) are required to better appreciate how robust the effects of this mo-
dality of intervention might be (Aardoom et al. 2013).

Web-Based Relapse Prevention Following

Intensive Treatment
Given the high relapse rates among patients with eating disorders (Stein-
hausen 2002; Steinhausen and Weber 2009), the possibility of using Web-
based interventions in aftercare to reduce the risk of recurrence of these
conditions is appealing. As described in the section “Ecological Momen-
tary Intervention,” Bauer et al. (2012) found that treatment as usual with
added text message–based EMI, provided to individuals with BN following
completion of an inpatient treatment, was associated with sustained and sig-
nificantly improved remission of eating disorder symptoms compared with
240 Handbook of Assessment and Treatment of Eating Disorders

treatment as usual without EMI. To date, however, little other research has
been done in this area. In Germany, one research group has developed a
Web-based relapse prevention program, VIA, and studied its use in indi-
viduals following completion of inpatient AN treatment (Fichter et al.
2012). VIA includes nine monthly sessions of CBT-informed content pro-
vided through self-monitoring, monthly real-time chat sessions hosted by
a clinician, and the possibility of e-mail with a readily available therapist.
Compared with participants receiving treatment as usual, those receiving
the online intervention demonstrated a greater increase in body mass in-
dex and improvements in eating disorder behaviors, suggesting a more fa-
vorable course of the disorder over time (Fichter et al. 2012). Compared
with control subjects and partial completers, participants who completed
all sessions of VIA reported significantly better continued health improve-
ment throughout the intervention and during follow-up periods; com-
pleters were also significantly less likely to be readmitted for inpatient
treatment during the follow-up period (Fichter et al. 2013). VIA is now
available to hospital systems that have a German-speaking population and
a specialized eating disorder treatment unit for any patients with AN or
BN as their level of care steps down following discharge from the inpatient
program (M. Fichter, personal communication, August 2014). In light of
these promising results, future studies of Web-based relapse prevention
programs are warranted.

Patient Acceptability of Web-Based

Eating Disorder Treatment
Many clinicians are concerned about how Web-based treatments might
impact the therapeutic relationship. Evidence suggests that the association
between the therapist-client relationship and outcomes is not as strong in
online-only treatments as it is in traditional face-to-face treatments (Cava-
nagh and Millings 2013). In other words, the mechanism of change in
Web-based treatments, while likely still involving aspects of relational fac-
tors, may differ from that in traditional therapy. Research suggests that to
improve outcomes in Web-based psychological treatments, the clinician
must encourage active engagement in the treatment and provide a sup-
portive yet accountable environment for the patient. Additionally, the
technology itself is often built with therapeutic relationships in mind, with
technology-based messages and reminders that are designed to be sup-
portive and motivational (Cavanagh and Millings 2013).
As one might expect, some patients report liking the flexibility and
convenience of Web-based treatments, whereas other patients describe
negative impressions of the impersonal nature of online eating disorder
Application of Modern Technology in Assessment and Intervention 241

treatment interactions. It seems important to balance concerns about the

therapeutic relationship in Web-based treatments with the potential for
such treatments to assist patients who 1) experience barriers to treatment
access (e.g., lack of transportation), 2) learn material well when it is pre-
sented in a variety of formats (e.g., visual and verbal information com-
bined), and/or 3) are reluctant to seek help due to shame about their eating
disorder symptoms (Paxton and Franko 2010). In a study of opinions
about prevention programs, potential participation in a face-to-face,
group-based eating disorder prevention program was offered to a sample
of undergraduate women. Individuals scoring higher on weight concerns
were likely to report that the group format was a deterrent to participation,
suggesting that an online intervention might be more appealing to those
with greater weight and shape concerns (Atkinson and Wade 2013). Drop-
out rates in Web-based CBT interventions for eating disorder behavior ap-
pear similar to those in Web-based treatments studied in other fields,
suggesting average levels of acceptability for individuals with eating disor-
ders (Aardoom et al. 2013; Dölemeyer et al. 2013). Carrard et al. (2011)
reported that the dropout rate from their Internet-guided self-help treat-
ment for BED was similar to rates from other face-to-face guided self-help
treatments for BED but also reported a higher dropout rate among those
participants who had higher levels of shape concern and a higher drive for
thinness. Overall, studies that have examined patient views of Web-based
treatments report mixed findings; however, there is evidence that these
treatments can be effective with no suggestion of harm when implemented
properly (Robinson and Serfaty 2003). Thus, it appears that continued
study of these interventions is warranted, not only using symptom-based
outcome measures but also using metrics of patient perception of the treat-
ment and its outcomes.

Telemedicine
Telemedicine refers to face-to-face treatment between an individual patient
and a clinician that is delivered via camera and/or audiovisual technology.
According to the American Telemedicine Association (ATA), over 12,000
citations can be found in PubMed (the freely accessible U.S. National Li-
brary of Medicine MEDLINE database) regarding telemedicine. Broadly,
the ATA reports that telemedicine is cost-effective, improves the health
care provided, and is generally well liked by patients (American Telemed-
icine Association 2013). In a review of 65 studies looking at live videocon-
ferencing psychotherapy for a variety of mental health concerns and a
variety of patients, evidence revealed similar outcomes to traditional face-
242 Handbook of Assessment and Treatment of Eating Disorders

to-face treatments and good acceptability ratings by patients. The studies

included in the review were predominantly using individual therapy ses-
sions (71%) with adults (86%), and the treatments were largely cognitive-
behavioral in nature (45%). The highest percentage of studies focused on
the treatment of psychological trauma disorders (21%). The conclusions of
the review suggest a great need for continued study of telemedicine and a
need to improve the measures used to assess patient experience and out-
come in order to obtain more information about how telemedicine is
viewed by patients (Backhaus et al. 2012). One of the largest bodies of lit-
erature on telemedicine exists within the field of psychiatry. Broad findings
from literature reviews suggest that consultation, diagnosis, medication
management, assessment, and therapeutic treatments for psychological
conditions have not been found to be significantly different when done via
videoconferencing versus face-to-face contacts. Additionally, the benefits
to rural, elderly, prisoner, military, and other hard-to-reach populations
have been great, often with reduced cost to clinics. Also, few differences
were found in adherence to treatment, attendance, and overall patient re-
sponses, suggesting that telemedicine is seen as acceptable and satisfactory
to patients (Monnier et al. 2003; O’Reilly et al. 2007).
Findings from the limited amount of eating disorder telemedicine
treatment research replicate the findings described above. Mitchell et al.
(2008) found that CBT provided via telemedicine is as effective as face-to-
face CBT and also provides the added benefit to rural populations of in-
tervention without the need for transportation. Additional analyses of this
data set suggest that telemedicine can be delivered at a substantial cost sav-
ings when compared with having therapists or patients travel, frequently
across long distances, for face-to-face treatment (Crow et al. 2009). Of
note, although therapists demonstrated a preference for face-to-face treat-
ment over telemedicine, in that they were more critical of the quality of
therapeutic relationships in telemedicine-based treatment, patients had no
significant preference for one type of treatment over the other (Ertelt et al.
2011).
It has been several years since telemedicine has been actively com-
pared with a traditional face-to-face intervention in the eating disorder
field. The findings likely would be even more robust currently, because
the ease of access to teleconferencing software and facilities has greatly im-
proved, as have Internet connection speeds and clarity of webcam images,
making the experience more seamless and lifelike (Shingleton et al. 2013).
Additionally, the young adult and adolescent populations that are poten-
tial recipients of such care are more familiar with such technology and
have wider access to it than ever before, making it likely a more feasible
care option.
Application of Modern Technology in Assessment and Intervention 243

Technological Innovation and the Treatment

of Eating Disorders: A Practical Discussion
Given the preponderance of mobile technologies and the ease of Internet
access, it makes sense that clinicians treating eating disorders would want
to integrate technology into their practices. This sentiment may be espe-
cially true of clinicians working with young adult and adolescent patients,
who are already heavily invested in and excited about technology. There
are a number of different ways to integrate technology into practice,
whether it is through interventions that take place completely over the In-
ternet, that use technology as an adjunct to face-to-face treatment, or that
rely on some combination of different traditional interventions with tech-
nology. Incorporating different types of technology into practice can be
difficult in terms of feasibility, knowledge and comfort with technology, li-
censure and liability coverage, and other legal concerns. While the re-
search discussed previously highlights the potential value of using mobile
technologies, the Internet, and telemedicine in clinical practice, it is im-
portant to address a number of practical issues and concerns relevant to
the practicing eating disorder clinician.

Integrating Mobile Technology and Practice

Mobile technologies (e.g., EMA, EMI) represent important contributions
to the field of mental health and have been important in eating disorder
research through improving models of disorder onset and maintenance;
however, incorporating the technology itself into clinical practice can be
challenging because of its complexity. Collecting large amounts of mo-
mentary data without the technical and statistical assistance available at re-
search facilities is not likely feasible or useful for the typical clinician.
However, using technology to collect the data for treatment seems to be
the most obvious way for a clinician to integrate clinical treatments and
mobile health technologies. For example, the clinician can simply replace
elements of interventions or homework (e.g., meal planning, food records,
relaxation exercises) with appropriate smartphone applications. Another
example of a simple integration of technology into clinical interventions
would be taking photographs of handouts or capturing information dis-
cussed in session on a mobile device so that the participant can have ac-
cess to this information during difficult moments between sessions. Web
sites that provide this type of information in formats that are easy to view
on mobile devices would also be helpful. Patients could bookmark or cre-
ate icons for these Web sites and easily access the information when
needed.
244 Handbook of Assessment and Treatment of Eating Disorders

Applications, or apps, are programs available for download or pur-

chase on a number of different types of mobile devices, including mobile
phones and tablets. The content and purpose of such apps vary widely,
and a number of different apps are currently available that attempt to
modify various types of behavior relevant to an eating disorder clinician.
The most common apps in this category focus on simple monitoring of
eating behavior and meal planning. Many apps encourage restrictive eat-
ing and emphasize weight loss; consequently, such apps may be contrain-
dicated for most patients with eating disorders. Some apps allow for goals
of weight gain or weight maintenance and may be more applicable to pa-
tients with eating disorders. SparkPeople and MyFitnessPal are among the
more popular producers of these types of applications. Some more sophis-
ticated apps may collect data about other elements of eating, such as food
micronutrient content, timing of meals, and speed of eating meals. Among
these types of apps, there are many free options, and some that require a
purchase fee.
We discuss two apps that seem particularly relevant for possible inte-
gration into eating disorder treatment, largely because they allow individ-
uals to set behavioral goals and then compare actual outcome with the
goals. Recovery Record and Rise Up+Recover are specifically produced
for use by eating disorder patients and are meant to be used in conjunction
with face-to-face treatment. Both apps are free to download onto a mobile
device.
Recovery Record describes itself as useful in the treatment of full and
subthreshold eating disorders and body image disturbances (Recovery
Record 2014). Patients using Recovery Record can use templates to create
a meal plan and set goals for eating and other behaviors (e.g., weighing,
body checking, coping strategies); individuals can also personalize their
goals, timelines, and reminders. Messages are sent to the user if planned
meals appear to have been skipped, to remind the individual to record cer-
tain data, or to remind him or her of a particular goal. To tailor questions
and messages, patients indicate which types of behaviors or emotional
states are most relevant to them. The app also allows for connection with
a treatment team by syncing a clinician app with the patient app, enabling
meal plans and other information to be viewed by the treatment provider.
The clinician can also send messages and feedback to the patient through
the app. The app’s Web site is very user friendly and meant to help orient
patients and clinicians (Recovery Record 2014).
Rise Up+Recover allows for logging of meals, emotional states, vari-
ous behaviors (including substance use), and coping skills. The app en-
ables patients to export PDF summaries of their logged information,
which can then be sent to a clinician. This app has been recently translated
Application of Modern Technology in Assessment and Intervention 245

into German and Spanish, and there is also a podcast, Recovery Warriors,
that is produced weekly by the makers of the app. The podcast and discus-
sion boards are easily accessible through the app and focus on sharing the
experiences of others struggling with eating disorders and the presentation
of scientific findings from the eating disorder field. The focus of the app is
toward patients, and the Web site is a source for accessing podcasts, music,
book recommendations, and more; however, there is less emphasis on
how to help clinicians use the app (Recovery Warriors 2014).
Recommending apps for patient use in conjunction with eating disor-
der treatment implies that from a legal perspective, such apps are part of
the clinician’s therapeutic intervention. Thus, it behooves the clinician to
be very familiar with the apps (both the way they work and the research
behind them) before recommending their use (Kramer et al. 2015).
Additionally, wearable ambulatory devices that capture movement,
sleep, and other physiological data may be useful in eating disorder treat-
ment. A variety of types of ambulatory devices can be found at health and
recreation retailers or larger online retailers, often listed under keywords
such as “fitness tracker” or “activity tracker.” Popular makers of these types
of wearable devices include Fitbit, Misfit, Jawbone, and Nike, among
many others. These types of devices monitor biometric data, generally
limited to movement (walking/exercise), movement during sleep, and
heart rate. The devices also transfer collected data via wireless Internet or
Bluetooth to a companion app for the device; some of the apps allow one
to set goals and monitor progress toward those goals (Taylor 2014).
Although these technologies might not be as easily applicable for pa-
tients with AN and BN diagnoses because of the potential for misuse in
driven/compelled exercising or caloric restriction, treatment of BED may
be well served by the addition of a behavioral-activation component of-
fered by these products. A meta-analysis evaluating the efficacy of mobile
health technology in increasing physical activity found generally positive
results, suggesting the potential clinical utility of such technologies in
achieving behavioral change (Fanning et al. 2012). Kim and Park (2012)
created a model containing several factors that predict perceived useful-
ness of mobile health technologies; perceived usefulness, in turn, is
thought to influence actual use of such devices and, ultimately, behavioral
change. The most potent factors that were found to predict perceived use-
fulness of mobile health devices were the individual’s sense of his or her
potential for health deterioration, his or her engagement in social compe-
tition, and his or her perceived sense of self-efficacy with the technological
system. Despite the lack of specific studies examining the efficacy of ad-
junctive use of mobile health technology in eating disorder treatments,
broad results from behavioral change literature suggest that if properly
246 Handbook of Assessment and Treatment of Eating Disorders

motivated to use such technology, individuals can successfully use such

devices or apps to change behaviors.

Ethical and Professional Issues

Kramer et al. (2015) present a thorough discussion of legal and regulatory
concerns related to the use of technology in clinical practice. They suggest
that an important issue related to apps is data storage among those apps
that allow for transmission of information between patient and clinician.
The same data storage issues are relevant to clinicians using e-mails or text
messages to communicate with clients. When data are transmitted, even if
the clinician was not expecting or did not endorse the information trans-
fer, the burden is placed on the “entity” that is covered by the Health In-
surance Portability and Accountability Act (HIPAA) to ensure that data
are handled appropriately (i.e., the clinician is responsible). Once the cli-
nician receives electronic patient data, the data should be moved into the
patient record and then deleted from the mobile device or e-mail so that
the data are no longer stored on virtual databases or other servers. Mobile
technology tends to use less secure networks that are more susceptible to
third-party interception, and although higher levels of security are avail-
able for use, one cannot be sure that the patient is using such security mea-
sures. Although there are no specific guidelines set for HIPAA compliance
in terms of mobile phone data management, it is best for clinicians to thor-
oughly review these issues and find encryption apps or virtual private net-
work (VPN) systems that are HIPAA compliant and provide secure
transfer and storage of information. Additionally, it is important for clini-
cians to draw boundaries in terms of length or frequency of such electronic
communications with patients in order to create consistent expectations
and to avoid a dramatic increase in clinician demand and burden. Confi-
dentiality may also be boosted by suggesting that patients use pseudonyms
or nondescript e-mail addresses separate from work or home e-mail ac-
counts to reduce the risk of an accidental information breach (Paxton and
Franko 2010).
Extensive forethought is required to create risk-management policies
for situations in which patients indicate imminent risk to themselves or
others via electronic communications. For example, with e-mails, the cli-
nician can set an automatic reply to all e-mails reminding the individual to
call 911 in the case of emergency and stating that e-mail is monitored at a
particular and limited frequency. However, text messaging or synchro-
nized apps do not necessarily have the same automatic-reply features, and
therefore, both written and verbal consent procedures may need to be
more comprehensive and documentation more thorough (Kramer et al.
(2015). There is some benefit to electronic communication in that the con-
Application of Modern Technology in Assessment and Intervention 247

versations between patient and clinician are already documented verba-

tim. For example, in chat rooms used for synchronous individual or group
therapy sessions, a full transcript is typically available. Full transcripts and
digital, time-stamped records can also be helpful to clinicians. In the case
of eating disorder treatment, there is added risk of patient medical deteri-
oration of which clinicians using Web-based treatment may not be aware.
Clinicians may want to add elements to consent procedures that include
releases to communicate with a local health care provider or family mem-
ber in the case of geographically isolated patients (Paxton and Franko
2010). Telemedicine also has the added complication of duty-to-warn laws
when there may not be clinical supervision of the patient wherever he or
she is located at the time of the telemedicine intervention. Therefore, it is
important to create risk-management plans that reflect the laws of the
states in which the telemedicine is being practiced. To address these laws,
the clinician needs to be thorough when providing informed consent to
patients, highlighting differences between states when using telemedicine
as well as discussing potential differences in the risk of confidentiality
breaches in telemedicine and in traditional face-to-face treatment (Kramer
et al. 2015). Overall, it is important to have thorough risk-management
protocols when engaging in electronic communication with patients and
to continually remind patients of the policies of the practice.
Telemedicine, despite being well supported in scientific literature, has
not been standardized in many health care and legal systems. Therefore,
when considering the incorporation of telemedicine into clinical practice,
the clinician needs to recognize the lack of standardized procedures,
equipment, and ethical guidelines (Valdagno et al. 2014). One issue to
think about is whether the clinician and patient will be within the geo-
graphical boundaries of the clinician’s licensing body. In the United States,
state licensure boards exist to protect the interests of their citizens, and
thus they prefer that all clinicians who provide services to their citizens be
licensed in their state. Obtaining multiple state licensures can become
problematic because of increased financial and administrative strain on
the providers (Kramer et al. 2015). Some states are moving toward chang-
ing licensing laws to increase ease of use of telemedicine; such legal
changes would be especially important in states with large rural popula-
tions. If U.S. clinicians are interested in getting state or neighboring-state
licensure boards and legislatures to discuss these issues, the ATA provides
a great deal of information about political precedent and strategies for cli-
nicians to use in communication with their representatives and legislators
about these issues (American Telemedicine Association 2013).
Different state laws pertaining to issues of clinical practice and mental
health also may be significant to clinicians incorporating technology into
248 Handbook of Assessment and Treatment of Eating Disorders

practice. Kramer et al. (2015) caution clinicians to be very familiar with

HIPAA guidelines as well as state privacy laws that might apply to use of
different technologies. They also suggest that clinicians take the time to get
basic training in the use of these technologies to help troubleshoot and to
cut down on mistakes that might cause breaches in confidentiality
(Kramer et al. 2015). Often clinics and a patient’s home will differ in ver-
sions of software, Internet browsers, webcam and microphone accessories,
and Internet speeds, which can increase the potential for technical difficul-
ties and frustrations for both patient and clinician. Thus, the more the cli-
nician can be helpful in mitigating these problems, the more therapy can
be successfully conducted.
Liability insurance is a rapidly changing issue and a potential area of
concern for clinicians practicing telemedicine or other technology-based
treatment. It is important for clinicians to ask their liability insurance pro-
viders about the level of coverage provided through a policy and to run
through potential scenarios with them to ensure adequate protection. It
may be advisable to obtain written clarification on coverage areas in lia-
bility insurance when existing policy language is not written to clarify tele-
medicine applications (Kramer et al. 2015). Medicare recently created
standards related to credentialing and privileging providers in the use of
telemedicine, and it is hoped that these policies will continue to improve
federal standards for technology-based treatment over time (American
Telemedicine Association 2013). It can be helpful both legally and profes-
sionally for clinicians to create relationships with other clinicians who are
providing telemedicine or other technology-based treatments as a re-
source for ongoing consultation (Kramer et al. (2015).

Conclusion
To date, a variety of different technologies have been employed in eating
disorder assessment and practice; these include EMA, EMI, Web-based
prevention programs, Web-based individual treatment, Web-based re-
lapse prevention programs, and telemedicine. Some technologies have
been used primarily in areas of research (e.g., EMA), and their clinical ap-
plicability is not well developed. Many technologies are on the cusp of
broader application yet are still in the stage of development and efficacy
trials; therefore, although they may be available for research participants,
they are not widely available to clinicians in practice (e.g., prevention pro-
grams or online versions of individual treatment). Other technologies are
ready for implementation, to be used as adjuncts to traditional interven-
tions (e.g., apps) or as new methods of implementing existing treatments
(e.g., Web-based or telemedicine-based implementation of individual ther-
Application of Modern Technology in Assessment and Intervention 249

apy). A clear area in need of additional research is telemedicine-based in-

tervention in eating disorders; additionally, technology exists that would
allow clinicians to begin to use this method of treatment, after addressing
potential administrative and licensing concerns.
The findings on efficacy of technology-based interventions for eating
disorders lag behind the access to such technology. A major problem in
researching technology and clinical practice is the rapid rate of technology
development compared with the slower rate of research validation and
dissemination. The average amount of time it takes for RCTs to be con-
ducted and the evidence to be published is 5.5 years (Kumar et al. 2013).
This lag time is too great to keep up with technology; the programs or de-
vices being tested in such trials will be obsolete by the time the evidence
supporting their use is established. Additionally, in the world of apps and
Web-based content, frequent updates and minor changes are often neces-
sary for such programs to remain competitive or even usable. Thus, the ex-
act versions of apps and devices that have gone through rigorous research
are likely not the same apps and devices that were used at the start of the
research process. Although the rate of technological innovation and the
rate of the research process appear to be diametrically opposed, solutions
are being proposed to improve the compatibility of these systems.
One proposed solution involves the use of new research designs, such
as repeated measures designs, that allow for greater statistical power using
smaller participant numbers so that studies may be completed more
quickly and efficiently. Another avenue would be to reduce the research
and development on the front end of RCTs. The National Institutes of
Health hopes to increase the effectiveness of mobile health research in this
way by sharing resources and data collection. The solution involves a net-
work that gives researchers access to the underlying structure of these tech-
nologies and to databases already collected. Thus, new mobile health
technologies may be built more quickly, will not need to be created from
scratch, and instead will build on existing, previously studied platforms.
Also, data could be combined with or supplemented by existing data-
bases, so that these types of studies and developments are not conducted
in isolation, taking years to disseminate and apply in the clinic (Kumar et
al. 2013). Open mHealth is a nonprofit group that advertises its “open ar-
chitecture” to help jump-start creative ideas and implementation. By pro-
viding information and resources on how to create mobile apps and other
ambulatory assessment programs, Open mHealth seeks to reduce produc-
tion time and get research started quickly, building on the past success of
other researchers (Open mHealth 2014). Additionally, the National Insti-
tutes of Health funds the Patient Reported Outcomes Measurement Infor-
mation System (PROMIS), which provides clinicians with Internet access
250 Handbook of Assessment and Treatment of Eating Disorders

to previously established and tested self-report health measures for adults

and children. The purpose is to create stronger networks of data that use
the same outcome measures to make results more comparable and appli-
cation to clinical settings easier. The measures and scoring information are
provided at their Web site (PROMIS Network 2011).
It is important to note that as technology rapidly changes and evolves,
empirical studies documenting the utility and effectiveness of technology-
enhanced eating disorder treatment will be a step behind newer, emerging
technologies. For example, many more technologies are available to you,
the reader, than were available at the time this chapter was written. Overall,
utilizing technology in clinical practice is appealing to clinicians and pa-
tients and can help to enhance treatment, overcome barriers to treatment,
and increase the scope of interventions. Using technology in clinical prac-
tice also comes with unique challenges and requires careful planning and
documentation in order to protect clinicians and patients. The future of the
integration of technology and psychological treatment is exciting and full of
promise, with increasing opportunities to involve clinicians and patients in
improving research and to apply research findings.

Key Clinical Points

• Ecological momentary assessment has been used extensively in
empirical research on eating disorders, but its clinical application
remains largely undeveloped.
• Increasing numbers of clinicians and researchers are developing
ecological momentary intervention strategies for the treatment of
obesity; these types of interventions for use in the treatment of eat-
ing disorders are still in early stages of development.
• Prevention-oriented technologies have been shown to be some-
what effective in reducing the risk of eating disorder onset, but
translating these into everyday clinical practice is rare.
• Web-based individual treatments of eating disorders can effectively
target eating disorder symptoms; however, availability of such pro-
grams to the general public is still somewhat limited outside of sev-
eral countries in the European Union. Similarly, technology-based
aftercare strategies to reduce the risk of relapse have been shown
to be effective but are not yet readily available to clinicians.
• Although “apps” that may complement clinical practice are increas-
ingly available, typically these have not been empirically studied.
Application of Modern Technology in Assessment and Intervention 251

• Telemedicine is expanding dramatically in psychiatry and psychol-

ogy in general, and it has been shown to be potentially effective in
eating disorder treatment. This technology has significant, immedi-
ate implications for eating disorder treatment.

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PA RT I V
Treatment
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13 Treatment of Restrictive
Eating and Low-Weight
Conditions, Including
Anorexia Nervosa and
Avoidant/Restrictive
Food Intake Disorder
Joanna Steinglass, M.D.
Laurel Mayer, M.D.
Evelyn Attia, M.D.

A salient feature at the core of anorexia nervosa (AN) is

energy intake that is inadequate with respect to caloric requirements, re-
sulting in significantly low body weight. Restrictive eating may be charac-
terized by food rules, some of which are remarkably similar across
individuals (e.g., recurrent selection of low-fat foods) and some of which
are idiosyncratic (e.g., eating only at 10 minutes after the hour). Although
present across eating disorders, restrictive eating poses particular chal-
lenges when it leads to undernourishment, nutrient deficiencies, or frank
starvation, as in the cases of AN and avoidant/restrictive food intake dis-
order (ARFID). Restrictive eating behaviors in these disorders warrant
particular attention because they contribute to the severity of illness, in-
cluding medical morbidity, the need for hospitalization or other intensive
treatment, and mortality.

259
260 Handbook of Assessment and Treatment of Eating Disorders

Restrictive intake by individuals with AN has been documented in ob-

jective studies of eating behavior, showing caloric intake below caloric
needs and a significantly reduced intake of fat specifically (Hadigan et al.
2000; Mayer et al. 2012). In a study of hospitalized patients with AN, mea-
surement of eating in a laboratory setting revealed significantly reduced
intake compared with that of healthy control subjects at the time of hospi-
tal admission. Although intake increased after normalization of weight, it
remained significantly reduced compared with that observed in the con-
trol subjects. In addition to their restricted energy intake, patients with AN
showed a specific reduction in calories from fat. Patterns of restriction
have been shown to be related to longer-term outcome (Schebendach et
al. 2008); these patterns include rigid rules, repetitive intake of the same
few foods with little variety, and intake of low-energy foods and noncaloric
beverages. Ecological momentary assessment studies and laboratory meal
studies among individuals who restrict food have demonstrated a relation-
ship between affective state and restriction (Lavender et al. 2013; Stein-
glass et al. 2010).
AN and ARFID differ in the psychological features that motivate food
restriction, and fewer studies have been done of eating behavior in
ARFID specifically. Nevertheless, treatments for both have similar com-
ponents because the common goal is normalization of weight and eating
behavior. In this chapter, we outline principles for treating feeding and eat-
ing disorders that are characterized by low weight and restrictive eating,
including AN and ARFID. The principles of treatment in this chapter are
derived from the treatment of AN, with applicability to ARFID. We con-
sider features specific to ARFID at the end of the chapter.

Principles of Treatment for

Restrictive Eating and Low Weight
Low-weight disorders are challenging to treat for two notable reasons:
First, no treatment has emerged as the clear, empirically supported treat-
ment of choice for all patients. Second, for many individuals, there is a re-
luctance to utilize treatment, including aspects that emphasize improved
eating behavior and improved weight status.
AN and ARFID are different illnesses in their initiating and sustaining
factors. AN is characterized by inadequate intake relative to requirements
associated with fear of fatness or behavioral interference with weight gain,
together with body weight or shape concerns. ARFID is an eating or feed-
ing disturbance that is manifested by failure to meet appropriate nutri-
tional and/or energy needs that is not associated with body weight or shape
Treatment of Restrictive Eating and Low-Weight Conditions 261

concern but may be associated with anxiety about eating and associated
features (e.g., fear of vomiting, fear of choking) or with food avoidance due
to the sensory characteristics of food.
Because ARFID is a newly described disorder in DSM-5 (American
Psychiatric Association 2013), very little has been written about its treatment.
In contrast, much has been described about approaches for AN, but small
study sample sizes, high dropout rates, negative findings in randomized clini-
cal trials using particular treatment strategies, and tiny numbers of studies ex-
amining more comprehensive, multimodal treatment approaches have
limited the evidence base for treatments for AN. Most treatment information
regarding AN appears in professional guideline and expert consensus docu-
ments, and this information suggests that behavioral management is a core
strategy for the achievement of behavioral change in the treatment of AN
(American Psychiatric Association 2006; Wilson and Shafran 2005).
Both AN and ARFID are psychiatric conditions with medical as well as
psychological features; therefore, treatment needs to include a comprehen-
sive assessment of medical and psychiatric symptoms and a specific assess-
ment of the acute medical and psychiatric risks. This assessment will inform
treatment goals and the selection of an appropriate treatment setting. Selec-
tion of treatment setting usually includes consideration of the least restric-
tive setting that is appropriate for the identified goals (Table 13–1).
Treatment goals for individuals with restrictive eating and low weight in-
clude medical stabilization as needed, nutritional rehabilitation (reversal of
nutritional deficiencies and restoration of normal weight), and interruption
of eating-disordered behaviors. Strategies for achieving these goals are de-
scribed in the remainder of this chapter.

Medical Stabilization
Both AN and ARFID are associated with nutritional compromise and
physiological changes, many of them severe and some potentially life-
threatening. Height and weight assessments are a first step in assessing
nutritional status. A clinician’s determination of underweight commonly
includes assessment of weight in the context of an individual’s baseline
or highest weight, as well as assessment of physiological disturbances that
may be associated with weight status (see Chapter 2, “Eating Problems in
Adults”). According to the National Heart, Lung, and Blood Institute
(2000) and the World Health Organization (1995), the lower limit of a
normal body mass index (BMI) is 18.5 kg/m2. Notably, the World Health
Organization defines moderate thinness as BMI less than 17.0 kg/m2, se-
vere thinness as BMI less than 16.0 kg/m2, and extreme thinness as less
than 15.0 kg/m2.
262 Handbook of Assessment and Treatment of Eating Disorders

TABLE 13–1. Treatment settings for individuals with

eating disorders
Setting Description Indications

Outpatient Individual or group-based An outpatient program is the most

sessions are available, and commonly used setting for
patients often select or are eating disorder treatment. Many
recommended for several patients utilize outpatient
treatment components, often treatment as they begin
offered by clinicians from engagement in eating disorder
different clinical disciplines treatment or because they are
(e.g., psychology, nutrition, unable to access higher levels of
medicine). Outpatient care because of geographic or
treatment is optimized when other resource limitations.
providers communicate Outpatient treatment is most
regularly in order to appropriate for individuals who
coordinate care, creating a are medically stable and are
treatment “team.” achieving or maintaining
behavioral goals using this level
of care.
Intensive IOP refers to a routine of An IOP is appropriate for
outpatient outpatient sessions in which individuals who are medically
program visits include several hours of stable and require small amounts
(IOP) treatment per visit offered at of meal instruction or meal
a frequency of several visits supervision without additional
(e.g., three) each week. daily programmatic structure.
Supervised meals are often An IOP is often used as a step-
available as part of an IOP down from higher levels of care.
visit.
Partial Also known as day treatment A PHP is appropriate when meal
hospital programs, PHPs offer more supervision is needed without
program hours of weekly treatment requirement for 24-hour
(PHP) than do IOPs. A PHP may supervision. PHP admission
serve as a transition from generally requires that patients
inpatient to outpatient care or be at or above a minimally
may help some individuals acceptable weight (e.g., 80%
avoid the need for ideal body weight) and maintain
hospitalization. PHPs other evidence of medical
generally include 4–7 days of stability. A PHP is often used as
treatment with two or three a step-down from a higher level
supervised meals each of care, or as a step-up from a
treatment day. lower level of care.
Treatment of Restrictive Eating and Low-Weight Conditions 263

TABLE 13–1. Treatment settings for individuals with

eating disorders (continued)
Setting Description Indications

Residential RTCs offer specialized An RTC is appropriate for

treatment treatment delivered in a full- patients with low weight (e.g.,
center time setting; however, they <85% ideal body weight) and/or
(RTC) are less structured than evidence of eating disorder
hospital programs. They behaviors who are in need of
include less medical close supervision but not in need
monitoring and less staffing of daily medical attention.
at night than do hospital- Patients in an RTC must
based programs. demonstrate motivation needed
for voluntary treatment.
Inpatient Psychiatric hospitalization An inpatient program is
program represents the highest level of appropriate for patients with
care and may be necessary significantly low weight (e.g.,
for some individuals with <75% ideal body weight) and/or
eating disorders, especially the presence of other signs of
those at low weights and medical or psychiatric instability
those with comorbidities. (e.g., vital sign or electrolyte
Specialized inpatient disturbance; comorbidity,
programs include medical including behavioral dyscontrol
personnel, such as and/or suicidality). Inpatient
psychiatrists and nurses. treatment is also appropriate for
individuals who have failed to
respond to treatment at an RTC.

For children and adolescents, assessments of weight and height require

comparison to reference standard data for age and sex. BMI varies greatly
in growing children, and BMI-for-age reference standards are important
for evaluating healthy and expected growth. BMI assessment for children
should be examined in the context of individual growth curves (see Chap-
ter 3, “Eating Problems in Children and Adolescents”). Failure to gain as
expected may be as serious an indication of nutritional compromise in a
child or adolescent as weight loss is for an adult with a restrictive eating
disorder.
Many of the physical consequences of malnourishment that are com-
monly manifested in AN may be manifested in ARFID as well. Almost ev-
ery system in the body is affected as part of the physiological responses of
the body to being underweight, including cardiac, metabolic, endocrine,
skeletal, hematopoietic, gastrointestinal, and dermatological (including
skin and hair). Physiological responses to low weight commonly include
bradycardia, decreased respiration rates, and low body temperature. Lab-
264 Handbook of Assessment and Treatment of Eating Disorders

oratory assessments commonly reflect abnormalities consistent with nutri-

tional deficiencies, dehydration, and purging behaviors (see Chapters 2
and 3 for additional information about medical complications of low
weight). Although many of these complications are chronic consequences
of starvation and weight loss, others present acute management issues
(Trent et al. 2013). As refeeding is initiated, vital signs and laboratory test
results should be monitored closely and should improve as energy intake
and hydration reach daily requirements.

Nutritional Rehabilitation
Successful treatment of restrictive eating associated with AN or ARFID re-
quires nutritional rehabilitation. Resumption of energy intake adequate
for gaining weight to and then maintaining weight within a healthy range
is essential. Psychological support can help with motivation to eat and
making specific behavioral changes, but formal psychotherapy and other
psychosocial interventions may be of limited utility in underweight and
nutritionally deficient individuals. Patients are encouraged to restore
weight fully (e.g., BMI=20–22 kg/m2; weight consistent with pre-illness
weight range or growth curve, if patient had healthy baseline; or weight
consistent with return of normal menstruation for the amenorrheic pa-
tient). Better long-term outcomes have been shown to be associated with
full weight restoration (Baran et al. 1995; Kaplan et al. 2009).

Initial Refeeding
Nutritional plans for initial weight gain involve reintroducing foods at
modest caloric levels (e.g., 1,500–1,800 kcal/day); providing supervision,
psychological support, and psychoeducation (Table 13–2); and medical
monitoring. Macronutrient composition is prescribed consistent with the
standard daily macronutrient requirements per the Institute of Medicine
to ensure adequate dietary fat in particular (Marzola et al. 2013). Liver
function should be monitored because abnormalities, including paradoxi-
cally elevated cholesterol, are common. In addition to the medical moni-
toring described above, patients may benefit from the nutritional
information that their cholesterol will improve with a normal diet. Low-fat
diets are not indicated.
Caloric prescription should increase steadily (e.g., by 400 kcal every
48–72 hours), with ongoing monitoring, until a weight gain rate of 1–2 kg
per week is consistently achieved. Weight restoration at this rate com-
monly requires consumption of 3,500–4,000 kcal/day. In addition to food,
meals and snacks, nutritional supplements are often needed during weight
Treatment of Restrictive Eating and Low-Weight Conditions 265

TABLE 13–2. Guidelines for engagement of underweight patients

Low-weight patients may benefit from information about the physiological and
psychological consequences of low weight and restrictive eating.
For some low-weight individuals, it may be useful to emphasize the identified
diagnosis (e.g., anorexia nervosa or avoidant/restrictive food intake disorder),
whereas for others, especially those who insist that their eating disturbance has
atypical features, it is preferable to begin with the identified risk of low weight
or restrictive eating and the need for nutritional change, without one particular
diagnostic label.
Individuals with low weight should be informed that many of their symptoms
(e.g., anxiety, depression, preoccupation with food) would be expected to
improve with weight gain, despite their often strong beliefs that weight gain or
changed eating behaviors would worsen their mood or anxiety symptoms.
Obtaining a careful history of cognitive and psychological functioning prior to
the onset of restrictive eating may identify baseline strengths that may be used
as treatment targets and possible motivators for embarking on weight and
eating change.
For individuals with avoidant/restrictive food intake disorder, obtaining a careful
history from patient and/or family of symptoms that interfere with normal
eating and inform specific food choices is essential. Treatment needs to include
individualized goals appropriate for specific symptoms. Discomfort with food
sensations may require graded exposure to novel foods; restrictive eating due
to fear of choking or vomiting may require exercises that target these concerns.

gain. Vitamin supplements (e.g., daily multivitamin, thiamine, folate) are

commonly prescribed. Supportive acknowledgment of the physical dis-
comfort associated with the gastrointestinal sequelae of starvation, includ-
ing decreased motility and constipation, which may contribute to early
fullness and related discomfort after eating, and the sequelae related to lax-
ative use discontinuation (e.g., edema and constipation) is needed. Re-
peated reassurance that continued intake will lead to improvement in
these physical symptoms is often required. Stool softeners (e.g., docusate
sodium) and nonstimulant bulking agents (e.g., polyethylene glycol) may
also be considered.
Nutritional rehabilitation emphasizes normative eating, with struc-
tured meals and snacks that include adequate dietary variety and energy
density. Feeding via nasogastric tube may be necessary for individuals re-
sistant to eating voluntarily or for those prescribed exceptionally large
doses of liquid intake. Individuals with ARFID may need meal plans that
target specific nutrient deficiencies that have developed in the context of
the eating disturbance.
Therapeutic meal plans should be designed to improve diet variety
and increase energy density. For example, they should include items with
266 Handbook of Assessment and Treatment of Eating Disorders

higher kilocalories per gram, meals that moderate water consumption,

and minimal noncaloric foods and beverages. Although meal plans ini-
tially may not offer patients much preference or choice, greater autonomy
in food selection is given as patients improve in medical status, weight, and
eating behavior. Following weight restoration, nutritional plans should ad-
just to help patients stay within a healthy weight range.

Nutritional Rehabilitation and

Psychological Change
It is important to understand that while nutritional rehabilitation targets
weight and physiological change, it also improves psychological symp-
toms associated with AN and ARFID. Many of the psychological features
attributed to these conditions are, in fact, part of the natural sequelae of
starvation and being underweight. In their landmark study of semistarva-
tion in previously healthy male subjects who were given restrictive diets,
Keys et al. (1950) described depressed mood, restricted affect, heightened
anxiety, poor concentration, perfectionism, and obsessionality associated
with the underweight and malnourished state. Even in these subjects with-
out an eating disorder, the authors observed increased preoccupation with
food, as well as unusual patterns of eating (e.g., eating quickly or dawdling
over eating) in the setting of significant weight loss. These historical find-
ings suggest that the psychological symptoms present in low-weight re-
strictive eaters with AN or ARFID may have developed or intensified as
a result of the state of undernutrition.
Other common psychological sequelae of the underweight state in in-
dividuals with AN or ARFID include poor sleep, sadness, hopelessness,
and anxiety. Anxiety symptoms may include social fears, generalized
worry, and physical symptoms of anxiety, as well as eating-related and
non-eating-related obsessions and compulsions. Cognitive disturbances,
including poor attention, visuospatial deficits, and executive functioning
deficits, have been well described in the underweight state among individ-
uals with AN (Steinglass and Glasofer 2011). It is recommended that indi-
viduals with AN or ARFID receive psychoeducation about both the
physical and psychological consequences of low weight as they are sup-
ported through nutritional rehabilitation (see Table 13–2).

Psychiatric Comorbidities
In addition to experiencing psychological change secondary to nutritional
depletion, patients with AN or ARFID may have co-occurring psychiatric
diagnoses, most commonly mood and anxiety disorders, and these may
Treatment of Restrictive Eating and Low-Weight Conditions 267

not resolve with refeeding. In a sample of 172 individuals with AN present-

ing for treatment, 35% met criteria for comorbid mood disorders and 11%
for anxiety disorders (Bühren et al. 2014). In their retrospective study of
173 children and adolescents receiving day treatment for a feeding or eat-
ing disorder, Nicely et al. (2014) reported that 72% of the 39 individuals
with ARFID met criteria for an anxiety disorder, in contrast to the lower
rate of 37% of the 93 individuals with AN. Additionally, the investigators
found that 13% of those with ARFID and none of those with AN met cri-
teria for autism spectrum disorder. Also, across many studies, suicidal ide-
ation, suicide attempts and self-injury, and rates of completed suicides
were consistently reported to be high in samples of patients with AN
(Berkman et al. 2007).
Significant improvement in psychological symptoms is seen with nu-
tritional rehabilitation and weight restoration (Attia et al. 1998; Sysko et
al. 2005). Psychological improvement may lag behind physiological
change, which can be a challenging situation for patients who seek relief
of symptoms. Mood and anxiety symptoms, in particular, may continue to
be outside the normal range at the time of acute weight normalization.
These symptoms show continued improvement with long-term mainte-
nance of healthy eating and healthy weight (Pollice et al. 1997).

Behavioral Management
Because both AN and ARFID may be associated with reluctance to nor-
malize eating behaviors, behavioral management treatment is commonly
employed to reverse or reduce many of the most worrisome features of
these eating disorders (Attia and Walsh 2009). Behavioral management
programs are those that encourage the achievement of normal weight and
eating behavior through the use of reinforcements for healthy behavioral
choices. Behavioral management may be delivered as part of inpatient or
outpatient treatment; if it is offered as part of outpatient treatment, a fre-
quency of more than once weekly is generally required. Commonly, these
treatments include supervised meals and snacks, use multiple treatment
modalities, and include clinicians across disciplines. The aim of the meal
supervision is to address behaviors at meals that contribute to the perpet-
uation of eating restriction. Supervision is additionally included after
meals to support “having eaten” and to prevent compensatory behaviors,
including vomiting, standing, and exercising.
Behavioral programs reinforce healthy eating by offering privileges or
activities following the successful completion of eating goals. As an exam-
ple, the specialty eating disorders treatment program at Columbia Univer-
268 Handbook of Assessment and Treatment of Eating Disorders

sity offers off-unit privileges to patients who consume all of prescribed

food, offers additional groups and activities for those at healthier weight
ranges, and offers opportunities for brief unaccompanied passes to pa-
tients once weight gain goals have been achieved. Part of the power of the
behavioral treatment comes from the consistency of the program, which
sets standards that all participants can achieve. The expectation that all
program participants will aim to eat 100% of prescribed food contributes
to the likelihood that the goal will be met and to the overall therapeutic
effect. Additionally, the treatment milieu provides group reinforcement
for healthy choices. Participants often report that they meet their treat-
ment goals to avoid disappointing their peers as much as for any other mo-
tivation for change. In addition to the standard reinforcements of the
program, individually tailored reinforcements can be introduced. For ex-
ample, if an individual demonstrates lack of motivation for the privilege of
an off-unit pass, contingencies may be adjusted to reinforce healthy eating
and weight with opportunities on the unit (e.g., opportunities for food
preparation and cooking on the unit).
Behavioral management for ARFID may require more attention to the
individualized assessment of restrictive behaviors and a plan that specifi-
cally reinforces successful eating of the restricted foods or reversal of some
of the avoidant or restrictive behaviors. Patients who avoid foods because
of their sensory characteristics (e.g., smells, textures) may need treatments
that expose patients to the specific sensations that are associated with their
restrictive eating. Treatments for ARFID need to reinforce reversal of spe-
cific eating disturbances in addition to generally reinforcing any required
increase in food intake, weight restoration, and improvements in identi-
fied nutritional deficiencies.
Behavioral management is incorporated into most intensive treat-
ment programs for individuals with low weight and restrictive eating (see
Table 13–1). Intensive treatment programs include inpatient, residential,
day treatment, and other intensive outpatient programs that generally re-
quire several visits weekly. Less intensive outpatient treatment for indi-
viduals with these disorders should similarly include firm behavioral
goals. Outpatient treatment may be offered by a team of clinicians, in-
cluding an internist or pediatrician, a therapist, and a nutritionist. Patients
in outpatient treatment—and sometimes their families—should participate
in setting treatment goals that reinforce healthy and improved eating be-
haviors and weight change.

Psychotherapeutic Approaches
Several specific psychotherapeutic approaches that emphasize behavioral
change, including family-based treatment, cognitive-behavioral therapy
Treatment of Restrictive Eating and Low-Weight Conditions 269

(CBT), and exposure and response-prevention treatment, have been stud-

ied in the treatment of AN and are commonly used in outpatient settings.
There are no published treatment studies of ARFID, but behavioral strat-
egies used in other eating disorders are commonly applied to the treat-
ment of ARFID and other conditions that include avoidant or restrictive
eating.
Also known as the Maudsley approach, family-based treatment for ad-
olescents with AN is a psychological treatment with solid empirical support
(Agras et al. 2014; Lock et al. 2010). Family-based treatment emphasizes
participation by all family members and empowers parents to refeed their
undernourished child. This outpatient approach aims to help adolescents
achieve full weight restoration with normal eating behaviors. When suc-
cessful, the 6- to 12-month treatment terminates with a transition back to
developmentally appropriate autonomy regarding eating and food choice
for the weight-restored adolescent.
With stronger support for its effectiveness for the treatment of BN than
for AN, CBT is, nevertheless, used by eating disorder clinicians treating
low-weight conditions (Fairburn 2008). CBT generally begins with educa-
tion about the medical and psychological effects of being underweight
(see Table 13–2). With attention to treatment alliance and goal setting, the
clinician encourages the patient to examine and change behaviors that
contribute to the restrictive state and to create a plan for regular, healthier
eating. As behavioral change is made and nutritional status improves, the
treatment examines and addresses the cognitive distortions that contrib-
ute to the individual’s illness. Food monitoring records are a mainstay of
treatment, and close attention is paid to actual eating behavior. Over time,
thought records and methods for challenging problematic beliefs (i.e.,
cognitive distortions) are introduced. These techniques have shown mod-
est benefit, although they are not empirically superior to other outpatient
psychotherapies that pay close attention to weight and eating behavior
(McIntosh et al. 2005). For individuals who have already achieved full
weight restoration, CBT has been shown to be more successful than nu-
tritional counseling alone in preventing relapse of AN (Pike et al. 2003).
Exposure and response prevention is the cornerstone of treatment for
many anxiety disorders and obsessive-compulsive disorder and is a be-
havioral treatment strategy that has shown some promise for individuals
with AN. The premise of the technique is that individuals need to confront
rather than avoid the anxiety-producing stimuli. With incremental expo-
sure to feared stimuli, patients learn that anxiety dissipates over time and
that feared consequences do not occur. With this behavioral learning as
the mechanism of change, patients practice resisting avoidance behaviors
(i.e., response prevention). In treatment of eating disorders specifically, ex-
270 Handbook of Assessment and Treatment of Eating Disorders

posure and response prevention targets eating-related anxiety and aims to

support patients in confronting rather than avoiding eating-related fears.
In inpatient settings, these techniques successfully supported healthier eat-
ing behavior and clinical improvement (Simpson et al. 2013; Steinglass et
al. 2014a).

Management of ARFID
Because ARFID is newly described as a distinct diagnosis in DSM-5, no
data specific to ARFID are yet available to provide empirical support for
treatment. Clinical guidelines suggest that behavioral treatment ap-
proaches are likely to be beneficial, because the primary concern is the
need to alter behavior. CBT principles are likely to be applicable and suc-
cessful. CBT, however, is a general therapeutic approach that often needs
to be specifically tailored to diagnoses with different features. For exam-
ple, the CBT manuals for depression differ significantly from those for
anxiety disorders. Even within the anxiety disorders category, each diag-
nosis has its own emphasis for helpful interventions. ARFID is likely a het-
erogeneous category, and behavioral strategies will need to be tailored
differently, depending on the type of illness. The features specific to
ARFID, however, suggest particular directions for the development of
useful CBT interventions. For example, those individuals whose ARFID
symptoms occur within the context of autism spectrum disorder will differ
from those whose symptoms are more strongly associated with an anxious
temperament or anxiety spectrum. For the anxious patient, interventions
may focus on exposure to sensations, whereas for the individual with au-
tism, interventions may focus on consistent meal schedules and positive
reinforcement of adequate intake.
Exposure and response prevention, as described in the subsection
“Psychotherapeutic Approaches,” may be particularly relevant for treating
ARFID. Among some individuals with ARFID, symptoms develop as a
conditioned negative response to an experience of eating. These cases of
ARFID share many features with specific phobias; however, among indi-
viduals with ARFID, the avoidant or restrictive eating behavior has be-
come the primary focus of treatment. Principles of exposure therapy
suggest that for each individual, a hierarchy of feared situations can be cre-
ated. Similar to individuals treated for fear of heights who are gradually
exposed to higher and higher floors of a building, individuals with ARFID
would begin treatment with eating-related activities that generate low lev-
els of anxiety. As the individual becomes increasingly able to engage in
these behaviors, the assignments move toward increasingly higher levels
of anxiety. When ARFID includes avoidant or restrictive intake associated
Treatment of Restrictive Eating and Low-Weight Conditions 271

with heightened sensory awareness or sensitivity around aspects of eating,

exposure to various eating sensations may be necessary. Additionally,
techniques that promote awareness of internal bodily sensations may be
useful for exposure.

Psychopharmacology
Pharmacological trials in patients with AN are few in number. Owing to
the lack of information about the neurobiological mechanisms underlying
AN, approaches to medication management in patients with AN have by
necessity relied on shared features with other psychiatric illnesses. The
high levels of depressive and anxiety symptoms that accompany starva-
tion led to consideration of antidepressants, in particular, as potentially
helpful for weight restoration treatment. Many medications appeared
promising in case reports or case series, only to prove disappointing when
compared with placebo treatment in randomized controlled trials (Hay
and Claudino 2012). Meta-analyses have attempted to use the available
data from small studies to advance understanding of which strategies may
or may not hold promise, and these have similarly shown limited utility of
medications (de Vos et al. 2014). These studies highlight the need for rig-
orous testing of medications, including comparison with placebo, for both
AN and ARFID. Although current treatment guidelines have emphasized
the lack of utility of medications for AN (Aigner et al. 2011; Watson and
Bulik 2013), medications continue to be frequently prescribed, contribut-
ing to the cost of treatment and the potential for unwanted complications
from medication.

Antidepressants
Individuals with AN often present with significant depressive symptoms, in-
cluding sad mood, hopelessness, and/or anhedonia. Furthermore, early anti-
depressants were also associated with weight gain as an unwelcome side effect
in non–eating disorder populations. Together, these data suggested the poten-
tial utility of antidepressant medications for the treatment of AN. Unfortu-
nately, these strategies proved disappointing. Early trials of tricyclic
antidepressants showed no benefit for weight gain (indicating no significant
impact on eating behavior) (Biederman et al. 1985; Halmi et al. 1986; Lacey
and Crisp 1980), and these medications are associated with cardiac side ef-
fects that preclude their use in underweight individuals with AN.
Some of the most influential data have come from a study comparing
fluoxetine with placebo in patients with AN receiving behavioral treat-
272 Handbook of Assessment and Treatment of Eating Disorders

ment for weight restoration (Attia et al. 1998). This study clearly indicated
that fluoxetine offered no benefit over placebo when offered together with
a comprehensive weight restoration program. Although all study partici-
pants showed improvement in weight as well as in mood and anxiety
symptoms during the study period, there were no differences between the
fluoxetine-treated and placebo-treated groups.
Underweight individuals with AN are associated with profoundly al-
tered physiology. Therefore, the possibility that antidepressants may con-
fer benefit only after nutritional rehabilitation has been accomplished has
been studied separately. Unfortunately, these data have been similarly dis-
appointing. The largest randomized clinical trial among weight-restored in-
dividuals with AN showed no benefit of fluoxetine compared with placebo
(Walsh et al. 2006). These patients were studied for 1 year after hospital
discharge, while receiving CBT aimed at relapse prevention. Fluoxetine
again conferred no benefit in rate of relapse or in improvement of psycho-
logical symptoms.
Together, these data are very convincing that antidepressants do not
significantly improve the treatment of AN.

Anxiolytics
Individuals with AN commonly struggle with anxiety, specifically around
mealtimes. This may be a prominent feature of ARFID as well (Nicely et
al. 2014). Because anxiety has been shown to be related to actual food in-
take (Engel et al. 2013; Steinglass et al. 2010), medications that may reduce
anxiety acutely seem worth consideration, such as for individuals during
structured treatment. Benzodiazepines are commonly considered as an
option to relieve premeal anxiety, yet there are no randomized controlled
trials of the clinical utility of benzodiazepines in restrictive eating. The
only available data show no benefit of alprazolam compared with placebo
in reducing premeal anxiety among a small group of hospitalized patients
with AN or in improving their intake in a laboratory meal (Steinglass et al.
2014b). Similarly, in the treatment of obsessive-compulsive disorder, ben-
zodiazepines have not been shown to reduce symptoms (Hollander et al.
2003).

Antipsychotics
Antipsychotic medications have been considered for the treatment of AN,
both for the potential psychological benefits and to capitalize on the
weight gain side effects seen in other populations. The concrete, rigid, and
near-delusional thought processes seen in AN make this class of medica-
Treatment of Restrictive Eating and Low-Weight Conditions 273

tions a compelling possibility for treatment. Early trials were uninforma-

tive, because the complications from these medications precluded their
use (i.e., seizures, binge and purge symptoms) (Dally and Sargant 1960;
Vandereycken 1984; Vandereycken and Pierloot 1982). With the innova-
tion of second-generation antipsychotics and their broad-ranging pharma-
cology and improved side-effect profile, a new treatment possibility
emerged. Initial studies have shown some weight gain benefit of olanza-
pine among adults with AN (Attia et al. 2011; Bissada et al. 2008), al-
though not in adolescents (Kafantaris et al. 2011). Additionally, it may be
that olanzapine relieves some of the obsessionality around eating seen in
individuals with AN (Bissada et al. 2008) and thereby may contribute to
improved eating. Larger trials will be informative as to whether olanza-
pine may be a useful treatment for outpatients with AN.

Hormonal Treatments
Bone health issues, osteopenia and osteoporosis, are well documented in
individuals with AN, and reduced bone density may be the single medical
complication that may not fully normalize with complete weight restora-
tion. Bone issues occur in the context of a low-estrogen state, leading to in-
creased bone resorption and poor nutrition, which, in turn, lead to
decreased bone formation. Reductions in bone mineral density can be
seen on dual-energy X-ray absorptiometry (DXA) as early as 6–12 months
after onset of illness (Castro et al. 2000). Results from a more recent study
(Faje et al. 2014) suggest that patients with AN carry an increased fracture
risk, even in the absence of identifiable areal bone mineral density deficits.
A number of pharmacological interventions have been studied, including
oral and transdermal hormone replacement, growth factors (i.e., insulin-
like growth factor 1), and bisphosphonates. Only one study in adolescents
of transdermal estrogen with cyclic progesterone has shown significant
promise (Misra et al. 2011). Studies of bisphosphonates suggest that these
drugs may offer modest improvement; however, their long half-life and
potential impact on a developing fetus make them inappropriate for use in
women of reproductive potential.

Medications for ARFID

No medication trials have been done specifically for the treatment of
ARFID. Given the similarities in malnourishment between AN and
ARFID, it is certainly plausible that medications will be similarly disap-
pointing for ARFID as they have been for AN. However, there may be sig-
nificant differences in the underlying psychological and neurobiological
274 Handbook of Assessment and Treatment of Eating Disorders

mechanisms that differentiate these illnesses. Pharmacological treatment

studies for ARFID are needed. The prominence of anxiety symptoms and
phobic-like traits among individuals with ARFID suggests that anxiolytic
medications—and possibly selective serotonin reuptake inhibitors—may be
more useful in this population than they have been for individuals with AN.
Given the potential promise of second-generation antipsychotics in treating
AN, these are worth studying for the treatment of ARFID as well.

Conclusion
Restrictive eating and low weight, associated with eating disorders such as
AN and ARFID, require careful clinical evaluation and management.
Low weight is associated with many physiological disturbances and sub-
stantial medical risk. Low weight is also associated with psychological
symptoms that may worsen in the context of nutritional deficiencies. Nu-
tritional rehabilitation and behavioral management, requiring multimodal
treatment, are the core components for reversing low weight and normal-
izing disturbances in eating behavior. Empirical support for specific treat-
ments is limited for AN and entirely absent for ARFID. Novel treatment
approaches need to be developed for AN. Descriptive data as well as pre-
liminary data regarding treatment efforts are sorely needed for the re-
cently identified ARFID category.

Key Clinical Points

• Anorexia nervosa (AN) and avoidant/restrictive food intake disorder
(ARFID) differ in identified motivation for restrictive eating, but indi-
viduals with either disorder may develop significant psychological
and medical symptoms associated with low weight and undernutri-
tion and may benefit from structured, behaviorally focused treat-
ment that reinforces healthy eating and weight.
• Treatment for low weight and restrictive eating commonly includes
supervision during meals and snacks, together with a nutritional
plan that ensures consistent weight restoration.
• In AN, as nutritional status improves, treatment includes targeting
the problematic beliefs that underlie the behaviors. Cognitive inter-
ventions ask patients to acknowledge and challenge problematic
thoughts about food and about shape and weight.
• For younger patients with AN, family-based treatment engages the
family to provide the structure and behavioral interventions that
help nourish adolescents back to normal weight.
Treatment of Restrictive Eating and Low-Weight Conditions 275

• In AN and ARFID, restrictive eating may be associated with anxiety.

Helpful interventions can include exposure to specific foods, food
groups, or somatic experiences (e.g., swallowing exercises in indi-
viduals with ARFID with choking fears). These strategies may be
helpful in diminishing food-related anxiety symptoms.
• Unfortunately, no medication has emerged as an evidence-based
approach to restrictive eating and undernourishment.

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14 Treatment of Binge Eating,
Including Bulimia Nervosa
and Binge-Eating Disorder
Loren Gianini, Ph.D.
Allegra Broft, M.D.
Michael Devlin, M.D.

In this chapter, we provide an overview of the general

approach to treating binge eating that is typically seen in the context of bu-
limia nervosa (BN) or binge-eating disorder (BED). We discuss evidence-
based psychotherapeutic and pharmacological treatments for BN and BED,
as well as other promising treatment approaches. The reader is encouraged
to view Video 2 for sample questions regarding the preliminary assessment
of binge eating and compensatory behaviors by a general practitioner.

Video Illustration 2: Assessing eating problems in the primary

care setting (3:24)

General Approach to the Treatment of

Binge Eating
Normalization of Eating
The primary goal of treatment for individuals with either BN or BED is
the normalization of eating behavior. The common behavior shared by

279
280 Handbook of Assessment and Treatment of Eating Disorders

these conditions is binge eating, and an important focus of interventions

for BN and BED is to eliminate both objective binge episodes (i.e., episodes
during which abnormally large amounts of food are consumed with a
sense of loss of control) and subjective binge episodes (i.e., episodes in which
a normal amount is consumed with a sense of loss of control) (see also
Chapter 2, “Eating Problems in Adults” and Chapter 5, “Assessment of
Eating Disorders and Problematic Eating Behavior in Bariatric Surgery
Patients”). For individuals with BN, an additional goal is to eliminate inap-
propriate behaviors undertaken to compensate for binge episodes or for
other forms of eating; these behaviors include vomiting, use of laxatives or
diuretics, and excessive or compulsive exercise. Some individuals with
BED and the majority with BN engage in some type of dietary restraint or
rigid dietary rules, although success in adhering to these rules may be spo-
radic, especially for those with BED (Carrard et al. 2012). Restriction may
consist of attempts to eat very little throughout the day or strict rules about
what can and cannot be eaten (e.g., no sweets, no high-fat foods), and it
has been linked to the maintenance of binge eating. Thus, a common goal
of treatment is to increase dietary flexibility and ensure that individuals eat
on a regular basis and in a manner that meets their daily caloric needs.

Overvaluation of Shape and Weight

In addition to targeting maladaptive eating behaviors, another common
goal in treating binge eating is reducing the overvaluation of body shape and
weight. This overvaluation is typically defined as self-evaluation that is un-
duly influenced by an individual’s perception of his or her body shape or
weight. Body shape may refer to the overall shape and size of the body or of
a particular body area (e.g., stomach, buttocks), whereas body weight refers to
the number on the scale. The self-evaluation of individuals with BN, by def-
inition, is influenced by shape and weight to an impairing degree; however,
this presentation is also seen in a significant portion of individuals with
BED, and it is associated with heightened eating pathology, depression, and
worsened treatment outcomes (Grilo et al. 2012b). Overvaluation of shape
and weight is often entrenched and difficult to change during the course of
treatment, although significant inroads can be made in this area. Treatment
follow-up studies in BN have also demonstrated that when body image dis-
turbance is high following treatment, individuals are at heightened risk of
poor outcomes and relapse (Keel et al. 2005).

Weight Management
Many individuals with BED, and a smaller subset of individuals with BN,
who present for treatment in clinical settings have a body mass index
Treatment of Binge Eating 281

(BMI) in the overweight or obese range (25 kg/m2; Bulik and Reichborn-
Kjennerud 2003; Masheb and White 2012). These individuals are at in-
creased risk for presenting with obesity-related medical complications
such as hypertension and type 2 diabetes. Furthermore, some evidence
suggests that in the 12 months prior to entering treatment, a significant
portion of individuals with BED report gaining upward of 15 pounds
(Blomquist et al. 2011). Therefore, weight management may be included
as a component of treatment for binge eating; however, caution should be
observed so as not to reinforce preoccupation with shape or weight.

Evidence-Based Treatments for

Bulimia Nervosa and Binge-Eating Disorder
Cognitive-Behavioral Therapy
Cognitive-behavioral therapy (CBT) is a brief, present-focused treatment
with a strong evidence base for both BN and BED. CBT is considered the
treatment of choice for BN, with a Cochrane Review demonstrating the
superiority of CBT over no treatment, wait-list control, and other psycho-
therapies with regard to reductions in binge eating, purging, and depres-
sion (Hay et al. 2009). CBT can effectively eliminate binge eating and
purging behaviors in 30%–50% of patients with BN. A large portion of pa-
tients who are not abstinent from binge eating or vomiting experience
meaningful reductions in symptoms, including improvements in dietary
restraint, eating, and weight and shape concerns, at the end of treatment
and in long-term follow-up (Fairburn et al. 1995). Similarly, CBT reduces
or eliminates binge eating in 50%–60% of patients with BED, and it is su-
perior to behavioral weight loss treatment and pharmacological interven-
tions (Grilo et al. 2005, 2012a).
CBT for BN and BED, as manualized by Fairburn (2008), is rooted in
the hypothesis that individuals’ eating disorders are maintained by mal-
adaptive thoughts and beliefs (i.e., overvaluation of shape and weight) that
lead to maladaptive behaviors (i.e., binge eating, compensatory behav-
iors, restrictive eating) and vice versa. An important first step in treatment
is creating an individualized “formulation” in which the clinician and pa-
tient work together to visually diagram the reinforcing relationship be-
tween the eating-disordered thoughts and behaviors experienced by the
patient (Figure 14–1). Creation of this formulation is intended to increase
the patient’s interest in and understanding of the mechanisms maintaining
the disorder. It can also help direct the patient to what thoughts and be-
haviors will be targeted in the treatment and why.
282 Handbook of Assessment and Treatment of Eating Disorders

Feel like I fail at everything/hate myself

Hate the way I look and wish I could lose weight

Cut calories, set rules about what I’ll allow myself to eat

Feel upset or numb Binge eat

Vomit

FIGURE 14–1. Individualized cognitive-behavioral therapy formulation

of bulimia nervosa (patient’s wording).

Self-monitoring of eating behavior is a cornerstone of CBT for BN

and BED. Traditionally, clinicians provide patients with preprinted self-
monitoring forms that allow for tracking of food consumed; the presence
of binge eating, purging, or other eating-disordered behaviors; and the
context (time, place, thoughts) of the eating episode. Electronic applica-
tions with self-monitoring capabilities for smartphones and/or computers
are also now available (see Chapter 12, “Application of Modern Technol-
ogy in Eating Disorder Assessment and Intervention”). Patients are en-
couraged to monitor for the duration of treatment in real time and to
record what they have eaten as closely to the eating episode as possible
(Figure 14–2). Self-monitoring has two purposes: First, it allows the clini-
cian and patient to work together to identify and effectively target mal-
adaptive eating patterns; they can also use monitoring logs to track
progress and identify what is going well for the patient. Second, the act of
monitoring eating behavior in real time may have the effect of reducing
eating-disordered behaviors. It is thought that having to write down and
share details of eating-disordered episodes may dissuade patients from
engaging in these behaviors in the moment. It is also possible that real-
time monitoring leads to heightened self-awareness of one’s actions, and
patients may feel they have more agency over their decisions in the mo-
ment and may opt out of eating-disordered behaviors.
Treatment of Binge Eating 283

Time Food & Drink Location Binge Vomit Comments

6:45 Orange juice Kitchen Very hungry from
Oatmeal with restricting yesterday. Trying
blueberries to get back on track today.

1:00 1 small container Desk at work Brought lunch from home.

Greek yogurt I know it’s small, but I
Salad: lettuce, tomato, worry that if I eat more,
cucumber, carrot, I won’t be able to stop
chickpeas, crushed and I’ll have a binge.
walnuts, 1 tablespoon
nonfat dressing
Seltzer water

3:00 2 seltzer waters Break room I am getting hungry, and

at work it’s hard to concentrate on
work. Hoping these seltzers
will fill me up so that I don’t
eat more.

6:00 Bagel with Walking to Went into different shops

cream cheese the bus on my way to the bus,
Twix bar after work buying food. Feel like I
can’t stop myself.
Bag of potato chips
Ice cream sandwich X V

Macaroni and cheese Living room After getting off the bus
Medium pizza near home, I went into the
deli and bought the rest of
Pint of ice cream X V my binge food. I’m so
ashamed of myself. I
promised myself I wouldn’t
do this today.

10:00 Glass of water Kitchen Today was awful. I’m

exhausted and just want to
go to bed. I’m worried I
haven’t gotten rid of all the
calories from my binges.

FIGURE 14–2. Example of eating behavior self-monitoring form.

284 Handbook of Assessment and Treatment of Eating Disorders

Following successful self-monitoring, patients are typically prescribed

a pattern of “regular eating,” or three meals and two to three snacks per
day. Patients are encouraged to eat every few hours and to let no more
than 4 hours elapse between eating episodes. Regular, frequent meals and
snacks reduce disordered eating behaviors because significant dietary re-
striction (e.g., going more than 4 hours without eating) increases food crav-
ing and binge eating. Aberrant eating patterns among individuals with BN
and BED may result in abnormal sensations of hunger and satiety, along
with other physiological signals that would typically help initiate or termi-
nate eating (e.g., slowed gastric emptying in BN; Devlin et al. 1997). Often,
the maintenance of a pattern of regular eating will greatly reduce the fre-
quency of binge episodes. For residual binges, techniques such as stimulus
control, urge surfing (a strategy for systematic delay of disordered behavior
such as binge eating or purging), or use of distraction are often implemented.
Patients are asked to weigh themselves once weekly at treatment ses-
sions. Those weighing themselves more often are educated about the del-
eterious effects of frequent weighing, namely, the manner by which this
behavior reinforces preoccupation with weight, and about normative fluc-
tuations in weight even while weight is stable. Weighing provides both the
patient and the clinician with objective information about the effect of reg-
ular eating on the patient’s weight. CBT clinicians also provide patients
with psychoeducation regarding the typical nature of dieting, binge eating,
and compensatory behaviors (and their relative ineffectiveness as weight-
control strategies) within the context of BN and BED.
The initial focus of CBT for BN and BED is behavioral, and after the
disordered eating behaviors are better managed, the treatment shifts to ad-
dressing thoughts. To start, the cognitive distortions that are targeted are
those that relate to eating behavior and dietary rules (e.g., “Eating carbo-
hydrates will make me fat”). Next, thoughts (and related behaviors) that
maintain an overvaluation of shape and weight are tackled. The clinician
may target beliefs, such as “If I feel fat, it means that I am fat,” or behaviors,
such as body checking and body comparisons, that reinforce maladaptive
shape- and weight-related thoughts. Patients are encouraged to increase
participation in activities not focused on shape and weight to expand the
number of options the patients have for self-evaluation and ultimately to
detract from the prominence of body weight and shape in determining self-
worth.
CBT typically concludes with a progress-maintenance/relapse-
prevention phase focused on short-term and long-term maintenance
plans. This phase includes 1) steps to minimize the likelihood that a re-
lapse will occur, 2) identification of warning signs that the patient is be-
ginning to slip back into eating-disordered thoughts and behaviors, and
Treatment of Binge Eating 285

3) development of specific, actionable plans for what the patient can do

if this occurs.
Fairburn (2008) also developed an enhanced version of CBT (CBT-E)
that can be applied transdiagnostically across eating disorders. CBT-E al-
lows for broad and focused treatment courses. The focused treatment
strictly addresses reducing core eating disorder psychopathology, whereas
the broad treatment addresses other issues that may help maintain eating
pathology, such as perfectionism, low self-esteem, and interpersonal diffi-
culties. Interpersonal difficulties are addressed through the simultaneous
implementation of CBT and an abbreviated version of interpersonal psy-
chotherapy (IPT; discussed in more detail in the section “Interpersonal
Psychotherapy”). Studies assessing the efficacy of CBT-E in treating BN
and BED are limited. For individuals with binge-eating behavior, one ran-
domized controlled trial (RCT) found significant improvements in eating
pathology with both the broad and focused versions of CBT-E in a sample
of patients with BN and eating disorder not otherwise specified, with the
broad version potentially being more effective for individuals with com-
plex psychopathology (Fairburn et al. 2009).
CBT for BN and BED can be delivered in either pure or guided self-
help formats. In the pure version, patients typically follow a treatment
book without clinical interaction, whereas patients receiving guided self-
help typically have at least brief meetings with a clinician to implement the
treatment. Evidence suggests that self-help treatments are significantly
more effective than wait-list control conditions in reducing binge-eating
and purging behaviors; however, it is unclear whether pure self-help and
guided self-help are equally efficacious, and evidence suggests that self-
help interventions may be less potent than more intensive face-to-face
treatments (Sysko and Walsh 2008).

Interpersonal Psychotherapy
IPT was originally developed as a brief, time-limited intervention for the
treatment of depression and was subsequently modified for the treatment
of both BN and BED (Murphy et al. 2012). IPT focuses primarily on help-
ing patients identify and address current interpersonal problems that are
hypothesized to maintain and perpetuate their eating disorders; healthy
interpersonal functioning is posited as necessary for psychological well-
being. Because individuals with BN and BED report a significant number
of interpersonal difficulties, including deficits in social problem solving,
loneliness, and poor self-esteem (Ansell et al. 2012), this approach may be
particularly appealing to patients. Within the IPT framework, binge eat-
ing is theorized to occur as a response to interpersonal disturbances (e.g.,
social isolation) and consequent negative mood (Fairburn et al. 1993).
286 Handbook of Assessment and Treatment of Eating Disorders

A distinguishing feature of IPT is the assignment of the “sick role” to

the patient. This process involves presenting patients with a formal diag-
nosis of an eating disorder and emphasizing the importance of focusing
their efforts on treatment and recovery, as one would with any medical ill-
ness, even if this means that other responsibilities take a backseat during
the duration of treatment. In contrast to CBT, IPT does not so overtly fo-
cus on the modification of disturbed eating behaviors or overvaluation of
shape and weight.
During the course of IPT, clinicians work with patients to identify typical
types of interpersonal problems and determine what the patient can do to
effectively address these issues. As a first step toward identifying interper-
sonal difficulties, the clinician takes an extensive interpersonal history, in-
cluding an inventory of the patient’s significant relationships. The patient is
requested to reflect on how the development of eating disorder symptoms
interacted with relationships in the past. The clinician also assesses current
interpersonal functioning and the effect of the eating disorder on current re-
lationships. Through this assessment process, one or more primary problem
areas are identified and become an area of focus in treatment; these areas
include role transitions, interpersonal role disputes, grief, and interpersonal
deficits. Role transitions frequently include such situations as beginning new
employment, graduation, marriage, or the dissolution of an intimate rela-
tionship; role disputes might include conflicts an individual has about what is
expected given a particular role (e.g., at work, as a family member); grief
may be related to the loss of a person, relationship, or an important piece of
one’s identity; and interpersonal deficits usually refers to instances when an in-
dividual lacks significant relationships, which may be due to poor social
skills. Clinicians encourage mastery of current social roles as well as adjust-
ment to evolving interpersonal situations (Wilfley et al. 2002). A primary
goal of treatment is to help mitigate or resolve these interpersonal difficul-
ties in a way that in turn promotes the abstinence from eating-disordered
behaviors. To this end, eating disorder symptoms can be linked consis-
tently back to their role in the perpetuation or maintenance of the patient’s
interpersonal domain of focus (Tanofsky-Kraff and Wilfley 2010).
IPT is effective in the reduction and elimination of binge eating and
purging in BN, although it is somewhat less effective than CBT (Agras et
al. 2000). In a multisite trial comparing CBT with IPT in 220 individuals
with BN, 45% of individuals in the CBT treatment condition had attained
abstinence from binge eating and purging at the end of treatment, com-
pared with 8% of individuals in the IPT treatment arm (Agras et al. 2000).
At 12-month follow-up assessment, 40% of the individuals who had com-
pleted CBT had achieved abstinence, compared with 27% of those com-
pleting IPT, a difference that was not statistically significant.
Treatment of Binge Eating 287

Although the existing evidence indicates that CBT is superior to IPT in

the treatment of BN, CBT and IPT appear to be equally efficacious in the
treatment of BED, both immediately following treatment and in longer-
term follow-up (Wilfley et al. 2002; Wilson et al. 2010). For example, a
large study comparing CBT and IPT in the treatment of patients with BED
found that 73% of individuals in the IPT condition achieved remission
from binge eating at the end of treatment, compared with 79% of individ-
uals in the CBT condition (Wilfley et al. 2002). At the time of a 12-month
follow-up, 62% of individuals in the IPT condition reported abstinence
from binge eating, compared with 59% in the CBT condition. Subgroup
analyses suggest that individuals with BED are heterogeneous, which may
affect overall treatment outcome. Patients with BED experiencing the most
mood symptoms and high shape and weight concerns appeared to derive
more benefit from IPT, and patients with increased eating disorder pathol-
ogy experienced greater improvements from CBT (Sysko et al. 2010).

Pharmacotherapy
Bulimia Nervosa
Although several medications are efficacious for the treatment of BN, the
role of pharmacotherapy is often best viewed as adjunctive. Some evi-
dence suggests that the combination of pharmacotherapy and psychother-
apy may be more efficacious than either intervention alone, but
pharmacotherapy alone may be inferior to psychotherapy alone (Hay et
al. 2001). Therefore, pharmacotherapy should be considered as a stand-
alone treatment for BN primarily when evidence-based psychotherapy is
not feasible or has not been successful. The mechanism by which pharma-
cological interventions produce clinical improvement in BN is unknown.
Antidepressant medications, including selective serotonin reuptake in-
hibitors (SSRIs), tricyclic antidepressants (TCAs), and monoamine oxi-
dase inhibitors (MAOIs), are the most commonly studied classes of
medications for the treatment of BN. Comprehensive reviews of placebo-
controlled RCTs indicate that each of these classes of medications is signif-
icantly more effective than placebo in reducing binge eating, purging, and
depression (Flament et al. 2012). Although MAOIs and TCAs alleviate
symptoms in BN, both classes of medication have a number of problem-
atic side effects and the potential for fatal overdose; therefore, they are not
recommended as first-line treatments for BN and are not typically used.
Furthermore, use of MAOIs involves maintaining a tyramine-free diet,
which places several restrictions on types of foods that can be safely con-
sumed, and thus may be especially problematic for individuals with disor-
dered eating (Schatzberg et al. 2010).
288 Handbook of Assessment and Treatment of Eating Disorders

The SSRI fluoxetine is the most widely studied medication for BN and
was approved by the U.S. Food and Drug Administration (FDA) for this di-
agnosis. Therefore, it is considered to be the pharmacological intervention
of choice for individuals with BN. Fluoxetine is typically prescribed at a dos-
age of 20 mg/day for the treatment of depression; however, a 60-mg/day
dosage is significantly more effective in reducing binge eating, purging,
weight and shape concerns, and depression among patients with BN. There-
fore, this higher dosage is typically recommended (Fluoxetine Bulimia Ner-
vosa Collaborative Study Group 1992; Romano et al. 2002). The common
side effects of fluoxetine and other SSRIs are milder and better tolerated by
patients than those of MAOIs and TCAs. Other SSRIs that produce mean-
ingful reductions in symptoms (albeit in fewer trials than with fluoxetine) in-
clude citalopram (Leombruni et al. 2006), fluvoxamine (Fichter et al. 1997),
and sertraline (Milano et al. 2004). One additional non-antidepressant med-
ication option for BN is the anticonvulsant topiramate. Topiramate acts as a
-aminobutyric acid (GABA) receptor agonist and glutamate receptor antag-
onist and may alleviate symptoms by improving regulation of appetite and
impulsive behaviors. In placebo-controlled RCTs, frequency of binge eating
and purging decreased significantly more in the topiramate condition than
in the placebo condition (Nickel et al. 2005). Furthermore, individuals in
the topiramate condition experienced significant reductions in weight com-
pared with individuals in the placebo group. Therefore, before prescribing
topiramate for BN, it may be important to consider the BMI of a patient and
the potential implications (both positive and negative) of weight loss.
Most RCTs examining the efficacy of medications in the treatment of
BN have been relatively short in duration (e.g., approximately 8 weeks).
Of the few trials that have followed patients for significantly longer periods
of time, dropout rates have been high (Romano et al. 2002), and therefore
the ideal length of pharmacotherapy for BN is unknown. (A minimum of
6–12 months of treatment is consistent with evidence-based recommenda-
tions for the pharmacological treatment of depression and is often recom-
mended for patients with BN in the absence of other clarifying data.)
Of note, there has been one placebo-controlled RCT using the antide-
pressant bupropion, and this trial was discontinued prematurely after 4 of
55 patients taking bupropion experienced grand mal seizures (Horne et al.
1988). As a result, use of bupropion is currently contraindicated in the
treatment of BN.

Binge-Eating Disorder
Lisdexamfetamine dimesylate, a dextroamphetamine prodrug, has re-
cently received FDA approval for the treatment of BED (McElroy et al.
2015). Long-term efficacy of this medication has not yet been assessed.
Treatment of Binge Eating 289

Whereas several antidepressant medications have been associated with

short-term reduction in binge eating, no particular antidepressant medica-
tion has been found to be superior to others. A 2008 meta-analysis analyz-
ing seven studies of SSRIs (i.e., citalopram, fluoxetine, fluvoxamine,
sertraline) and a TCA (imipramine) in short-term trials indicated that sig-
nificantly more participants experienced remission from binge eating in
the active medication conditions than in the placebo condition (40.5% vs.
22.2%; Stefano et al. 2008). Although these results are promising, no long-
term studies of the efficacy of antidepressants in BED have been con-
ducted, and the durability of these short-term improvements remains un-
tested.
Many individuals with BED have BMIs in the overweight or obese
range, and most seeking treatment for their binge eating identify weight
loss as a goal of treatment. For this reason, the efficacy of the anticonvul-
sants topiramate and zonisamide, both of which can have the side effect of
weight loss, has been examined in the treatment of BED. Topiramate has
been studied in three trials (Claudino et al. 2007; McElroy et al. 2003,
2007). When topiramate was employed in the absence of psychotherapy,
intent-to-treat analyses showed superior rates of binge-eating remission in
the topiramate groups (58%–64%) compared with the placebo groups
(29%–30%; McElroy et al. 2003, 2007). Furthermore, the active medica-
tion groups experienced significantly greater reductions in weight than did
the placebo groups (5.9 kg vs. 1.2 kg). In a study comparing topiramate
and CBT with placebo and CBT, 83.3% of those in the topiramate group
and 61.1% of those in the placebo group achieved binge-eating remission
during the 21-week trial (Claudino et al. 2007). Despite these benefits, the
side effects associated with topiramate can be difficult to tolerate, and
treatment adherence can be a problem with this medication. In an open-
label extension trial of topiramate lasting 42 weeks, McElroy et al. (2004)
found that 68% of study participants failed to complete the trial, with ad-
verse events and nonadherence to treatment being among the primary
reasons cited for discontinuation. Similarly, one RCT used zonisamide
and found it to be associated with significant reductions in both binge eat-
ing and weight. Side effects were similar to those seen with topiramate and
were not well tolerated by study participants (McElroy et al. 2006).
Currently, there are four FDA-approved medications for weight loss:
lorcaserin, naltrexone-bupropion, orlistat, and phentermine-topiramate.
Of these, only orlistat, a pancreatic lipase inhibitor, has been studied in in-
dividuals with BED; in these studies, the medication was combined with
either a guided self-help version of CBT (Grilo et al. 2005) or a very low
calorie diet (Golay et al. 2005). Orlistat does not appear more effective
than placebo in achieving remission from binge eating, but there is some
290 Handbook of Assessment and Treatment of Eating Disorders

evidence that compared with placebo, it causes greater weight loss and
that the loss is better maintained after a 3-month follow-up period (Golay
et al. 2005; Grilo et al. 2005).

Other Promising Psychotherapies

Dialectical Behavior Therapy
Dialectical behavior therapy (DBT) is a behaviorally focused outpatient
intervention that is efficacious in the treatment of borderline personality
disorder (Linehan 1993). DBT is based on a model that views maladap-
tive behaviors, such as self-injury, as attempts to regulate distressing emo-
tions. Because negative affect often precedes binge eating and other
eating-disordered behaviors, affect regulation has been hypothesized as a
maintaining mechanism, and therefore a treatment such as DBT may be
indicated (Haedt-Matt and Keel 2011). DBT was adapted for BED and BN
by Safer et al. (2009), and it directly targets binge eating, purging, mindless
eating, and any other behaviors that appear to interfere with progress in
psychotherapy. As currently manualized, DBT for BED and BN includes
modules devoted to teaching and developing mindfulness skills, including
eating mindfully, distress tolerance, and emotion regulation skills. A strong
emphasis is placed on daily monitoring of eating-disordered behaviors,
concurrent mood states, and use of skills taught during sessions via diary
cards.
Although there have been few trials of DBT in treating BN and BED,
the results of extant studies have been promising. In a small trial compar-
ing DBT with a wait-list control condition for patients with BED, 89% (16
of 18) of those in the DBT group experienced remission from binge eating
and improvements in general eating pathology, compared with 12% (2 of
16) of those on the wait list (Telch et al. 2001). In a larger trial, 101 adults
with BED were randomly assigned to 20 group sessions of either DBT or
supportive psychotherapy (Safer et al. 2010). At posttreatment, 64% of pa-
tients in the DBT group had achieved abstinence from binge eating, com-
pared with 36% in the supportive psychotherapy group, which was a
significant difference. At 12-month follow-up, this significant difference
had disappeared, with 64% of DBT patients and 56% of supportive psy-
chotherapy patients maintaining abstinence. Notably, attrition for DBT
was lower, in that only 4% of those receiving DBT dropped out of treat-
ment, whereas 33.3% of patients in the supportive psychotherapy condi-
tion prematurely discontinued treatment. In patients with BN, a smaller
trial comparing 20 weeks of individual DBT to a wait-list control condi-
tion found that by the end of treatment, 29% of participants (4 of 14) in
Treatment of Binge Eating 291

the DBT condition had achieved abstinence from bingeing and purging,
whereas none of the 15 patients in the wait-list control condition experi-
enced remission, representing a statistically significant difference (Safer et
al. 2001).

Integrative Cognitive-Affective Therapy

Integrative cognitive-affective therapy (ICAT) is a brief, present-focused
therapy developed for the outpatient treatment of BN (Wonderlich et al.
2008). ICAT is similar in many ways to other therapies such as CBT and
DBT; for example, patients are instructed to engage in a regular pattern of
eating meals and snacks throughout the day and to track this behavior for
analysis during sessions, although meal planning may be more prescrip-
tive and detailed in nature than in these other therapies. In addition, ICAT
emphasizes the role of interpersonal patterns in the maintenance of disor-
dered eating, especially through the activation of negative affective states,
which may, in turn, lead to emotionally driven disordered eating behav-
iors. Maladaptive interpersonal styles and negative emotions are first iden-
tified and then addressed through the use of targeted interventions. The
use of electronic technologies, such as personal digital assistants, is inte-
grated into treatment so that patients can track their emotions and use of
skills taught during treatment sessions.
In the first RCT studying ICAT for patients with BN, Wonderlich et
al. (2014) compared 21 sessions of ICAT with CBT-E among 80 adults
with BN. At the end of treatment, 37.5% of individuals randomly assigned
to the ICAT condition and 22.5% of those in the CBT-E condition had
achieved abstinence from binge eating and purging; the difference was
not statistically significant. At the 4-month follow-up assessment, 32.5% of
individuals randomly assigned to ICAT and 22.5% of individuals ran-
domly assigned to CBT-E reported abstinence from these behaviors;
again, this was not a statistically significant difference. These results are
promising and suggest that ICAT is an intervention worthy of further
study.

Conclusion
The primary objective of the treatment of BN and BED is the normaliza-
tion of eating. Reduction of overvaluation of shape and weight is often an
additional target of treatment. Weight management is sometimes an addi-
tional treatment target. Because of the strong evidence base for the use of
CBT in the treatment of BN, CBT should be considered the treatment of
choice. IPT and pharmacotherapy (SSRIs, fluoxetine in particular) should
292 Handbook of Assessment and Treatment of Eating Disorders

be considered as viable alternatives when CBT is not available. CBT and

IPT both have very strong evidence supporting their efficacy in the treat-
ment of BED, and although no individual medication has emerged as su-
perior, pharmacotherapy may also confer significant benefit and
reductions in binge eating in this group.

Key Clinical Points

• The primary goal of treatment for binge eating is to normalize eating
behavior and eliminate objective and subjective binge episodes.
Additional goals may include the reduction of overvaluation of
shape and weight and weight management.
• Cognitive-behavioral therapy (CBT) is considered the treatment of
choice for bulimia nervosa (BN). CBT has also demonstrated signif-
icant effectiveness in eliminating binge eating in binge-eating disor-
der (BED) and has demonstrated superiority to behavioral weight
loss treatment and pharmacological interventions.
• Interpersonal psychotherapy (IPT) is effective in the reduction and
elimination of binge eating and purging in BN, although it is less ef-
fective than CBT and slower to produce improvements. CBT and
IPT appear to be equally efficacious in the treatment of BED.
• Fluoxetine, at a dosage of 60 mg/day, is the pharmacological inter-
vention of choice for BN. Use of other selective serotonin reuptake
inhibitors also results in meaningful reductions in symptoms. The
combination of pharmacotherapy and psychotherapy may be more
efficacious than either intervention alone; however, pharmacother-
apy alone may be inferior to psychotherapy alone. Use of bupropion
is contraindicated in the treatment of BN.
• Antidepressant medications may be effective for reducing binge
eating in BED, although no one medication has emerged as supe-
rior to others. For those patients who can tolerate its side effects,
topiramate may also be effective in the treatment of BED.
• Two promising psychotherapeutic interventions worthy of further
study include dialectical behavior therapy, which has been adapted
for BN and BED, and integrative cognitive-affective therapy, devel-
oped for the treatment of BN.
Treatment of Binge Eating 293

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15 Treatment of Other Eating
Problems, Including Pica
and Rumination
Eve Khlyavich Freidl, M.D.
Evelyn Attia, M.D.

In this chapter, we describe the evidence-based and

evidence-informed treatments of several of the feeding and eating disor-
ders about which there has been limited research and clinical description:
pica, rumination disorder, night eating syndrome, purging disorder, and
atypical anorexia nervosa (AN). With the publication in 2013 of DSM-5
(American Psychiatric Association 2013), pica and rumination disorder
have joined the more commonly recognized eating disorders in the feed-
ing and eating disorders diagnostic classification, and several other condi-
tions, including night eating syndrome, purging disorder, and atypical
AN, have been categorized under “other specified feeding or eating disor-
der.” We briefly review diagnosis, prevalence, associated symptoms, and
assessment for pica, rumination disorder, night eating syndrome, and
purging disorder in order to provide context to the therapeutic approaches
reviewed. We also briefly discuss therapeutic approaches for atypical AN.

Pica
Pica is defined in DSM-5 as persistent eating of nonnutritive, nonfood sub-
stances inappropriate to developmental level and not in the context of cul-

297
298 Handbook of Assessment and Treatment of Eating Disorders

turally or socially normative practice. The term originated from the Latin
word for magpie, a bird thought to have a diet of edible and nonedible
items, and medical case reports date back to the sixteenth century (Parry-
Jones and Parry-Jones 1992). Despite the behavior’s long history, epidem-
iological studies of pica are limited and its prevalence remains unclear,
perhaps in part because cases may only reach clinical attention when com-
plications require medical or surgical treatment. Pica is seen across all ages
and genders but most commonly in individuals with developmental dis-
abilities, in pregnant women, and in children at lower socioeconomic lev-
els (Rose et al. 2000). Geophagia, or dirt and clay ingestion, is believed to
have medicinal purposes in some cultures, in which case it does not meet
criteria for a diagnosis of pica.
Pica has been described in the context of nutritional deficiency, espe-
cially iron deficiency, although it remains unclear if the nutritional defi-
ciency is a cause or a result of pica. Pica is associated with many serious
complications, including toxicity; intestinal obstruction from foreign body
ingestion, as well as from bezoars that develop from hair ingestion; exces-
sive calorie intake; nutritional deprivation; parasitic infections; and dental
injury (Rose et al. 2000). Physical examination and clinical assessments
with attention to these complications are important in the clinical evalua-
tion of pica. Laboratory tests for pica commonly include complete blood
count with peripheral smear; iron, ferritin, and lead levels; general chem-
istry panel (including electrolytes and liver function tests); stool studies for
ova and parasites; and an abdominal radiograph to evaluate for foreign
objects, bezoars, and parasites.
Because pica is most prevalent among individuals with developmental
disabilities, much of the empirical evidence for behavioral treatment for
pica has focused on this population (Matson et al. 2013). Behavioral treat-
ments, especially those combining reinforcement and response reduction
procedures, are well-established treatments for pica (Hagopian et al.
2011).
Earlier treatments relied on behavioral techniques that limited oppor-
tunities to engage in the eating disturbances that characterize pica and of-
ten applied punitive measures. Although some of the older research
utilized methods that may not be considered socially or ethically appropri-
ate at this time, we review these techniques, including aversive or noxious
stimuli, restraint, overcorrection, and response blocking and interruption.
Because the risk of serious physical harm due to pica may be quite high in
certain populations, the consideration of procedures with aversive ele-
ments may be warranted.
Aversive stimuli that have been studied in case reports include lemon
juice, aromatic ammonia, and water mist; taste aversion; and auditory
Treatment of Other Eating Problems 299

stimulation. In these studies, the aversive stimuli were employed when

pica behaviors were attempted, and the technique resulted in pica suppres-
sion (Bell and Stein 1992). Restraint, including mechanical restraint and
physical restraint, has been shown to be effective both when applied con-
tingently to target behavior and when used protectively in a noncontin-
gent manner. Mechanical restraints include mittens, arm splints, helmets
with mouth coverings, and fencing masks. Physical restraint has been used
contingently, with brief holds used after attempted or actual ingestions
(Paniagua et al. 1986). In more dangerous situations, longer-duration re-
straints have been required. Restraint is usually considered justified only
when the risk of serious physical harm is high, when lesser restrictions are
unsuccessful, and when restraint is used as one of the strategies in a com-
prehensive treatment plan (Hagopian et al. 2011).
Overcorrection is a technique considered to have high validity because
it requires restitution and then engages the individual in practicing a new,
more appropriate behavior. For example, when an individual who ingests
feces is discovered to have feces or the traces of feces on his or her mouth
or hand, a trainer guides the patient to the toilet and encourages him or
her to spit the feces into the toilet bowl. Then the patient is given oral hy-
giene training that includes brushing the mouth, teeth, and gums with a
toothbrush soaked in a mild antiseptic; is directed to wash hands and scrub
fingernails with a nailbrush in warm soapy water for 10 minutes; and is re-
quired to clean his or her anal area and repeat brief hand washing. Finally,
the patient is guided to the area where he or she was discovered to be en-
gaged in pica and is required to mop the floor with disinfectant. When
used with two cognitively impaired young adults, this 30-minute overcor-
rection procedure reduced target behaviors to zero (Singh and Bakker
1984).
Response blocking and interruption, a commonly used intervention
for challenging behaviors in persons with developmental disabilities, may
be promising in pica. However, there is limited research regarding its spe-
cific use in pica. Response blocking alone has been shown to produce ag-
gression, but when paired with an interruption with alternatively preferred
foods, it has been shown to reduce pica. This technique involves training
in which the patient is offered the inedible objects typically ingested and
is blocked from ingesting these but simultaneously given an alternative
preferred food item (Hagopian and Adelinis 2001).
More contemporary behavioral procedures, including reinforcement,
habit reversal, stimulus control, and environmental changes, are consid-
ered preferred methods to the older techniques just discussed. These
newer, less restrictive methods allow individuals to have a more normal-
ized routine and stimulating environment.
300 Handbook of Assessment and Treatment of Eating Disorders

Differential reinforcement techniques include reinforcing lower rates

of pica, reinforcing behavior other than pica, and reinforcing habits in-
compatible with pica. Several studies using these techniques with small
numbers of individuals had positive results (Donnelly and Olczak 1990;
Smith 1987). Habit reversal includes awareness training, competing re-
sponse training, and social support. Awareness training, also called dis-
crimination training, involves teaching the patient to differentiate between
food and nonfood times (e.g., “What is this?” “Should you eat it?”). Then,
the patient is instructed to do a competing behavior that is incompatible
with eating, such as pursing lips, and is praised for doing this alternative
behavior (Madden et al. 1981). Stimulus control, by definition, is any
method used to increase the amount of effort required to do the undesired
behavior. For pica, this includes placement of desired inedible objects in
more difficult to reach places or in containers that require time to open.
Environmental changes, including the creation of a safe and enriched
environment, also have an important role in treating pica. Safety measures
may include special attention to garbage collection systems, such as safe
containers for disposal of latex gloves, especially in an institutional setting
(Williams and McAdam 2012). Other safety measures may include ensur-
ing that nuts and bolts are tightly fastened in furniture, securing of cleaning
and medical materials in locked cabinets, and maintaining clean areas.
The rationale for an enriched environment is informed by high rates of
lead poisoning and mouthing of objects observed in impoverished set-
tings. The environment may be enriched with toys (Madden et al. 1981)
and the intervention further strengthened by reinforcement or praise for
play with toys (rather than engaging in pica). Increases in leisure activities
and time for special attention from a caregiver are other techniques for en-
richment.
In practical terms, functional behavioral analysis of the pica is an appro-
priate first step to determine which behavioral components should be part
of an individual’s treatment plan. Functional behavioral analysis aims to de-
fine variables that maintain a target behavior. This assessment includes op-
erationalizing the target behavior by describing its mode (e.g., cognitive,
affective, motor components) and defining the parameters of frequency, du-
ration, and intensity. A clear definition of the pica allows for the identifica-
tion of an objectively measurable behavior and then allows for examination
of the contextual variables that are related to the behavior, including social
contingencies and internal reinforcement. Pica appears predominantly to be
a motor behavior that is reinforced by an individual’s sensory responses.
Specific details of this process allow for the development of a unique treat-
ment plan that is likely to combine stimulus control, training in alternative
or incompatible behaviors, and reinforcement.
Treatment of Other Eating Problems 301

Nutritional supplementation has limited support for the treatment of

pica. Even in cases in which a specific nutritional deficiency is identified
by laboratory examination, results have been variable. Iron supplementa-
tion seems to have the most benefit for individuals with iron deficiency
who ingest ice, whereas in other cases of pica associated with iron defi-
ciency, iron repletion has had limited effect on the behavior (Khan and
Tisman 2010).
Psychopharmacological interventions should target comorbid condi-
tions that may exacerbate pica. No studies to date support the use of psy-
chopharmacological agents specifically for pica (Matson et al. 2013).

Rumination Disorder
DSM-5 defines rumination as a disorder of repeated regurgitation in which
the regurgitated food may be re-chewed, re-swallowed, or spit out. Rumi-
nation disorder has been observed across the age span for many centuries,
but in earlier editions of DSM, it was defined as an illness only of infancy
or early childhood (Olden 2001). Epidemiological studies indicate that in-
fants, children, and adults with developmental delay, as well as individuals
with normal cognitive abilities, may have rumination disorder. Prevalence
rates are uncertain, and they are difficult to ascertain because care provid-
ers do not often screen for this disorder, even in the context of other feed-
ing or eating problems, and because many affected individuals consider
this an embarrassing problem that they are reluctant to disclose.
Rumination disorder has been associated with weight loss, malnutri-
tion, dental erosion, halitosis, electrolyte abnormalities, and gastroesopha-
geal reflux disease (GERD), and it may be associated with high morbidity
in pediatric patients (O’Brien et al. 1995).
Rumination as a symptom may occur in association with eating disor-
ders, including AN and bulimia nervosa (BN). According to the DSM-5
definition for rumination disorder, individuals with AN or BN do not meet
criteria for rumination disorder because they have another disorder, but
they may, nonetheless, warrant specific treatments to target this behavior.
The diagnosis of rumination disorder is made on the basis of patient
history and physical examination by a clinician; however, some authors
suggest that supporting diagnostic tests are indicated. Because rumina-
tion occurs via the relaxation of the lower esophageal sphincter accom-
panied by increased intra-abdominal pressures, a characteristic pattern is
seen on upper gastrointestinal manometry. Kessing et al. (2014) suggest
that this testing, which reveals a different profile from GERD, is indi-
cated because behavioral treatments for rumination disorder are costly
and time-consuming. In contrast, Chial et al. (2003) reviewed medical
302 Handbook of Assessment and Treatment of Eating Disorders

records of pediatric patients and found that only 40% had the character-
istic pattern on manometry, and therefore they do not recommend the
monitoring because it is invasive and is typically performed only at ter-
tiary care centers. Furthermore, Chial et al. (2003) suggest that invasive
tests have often led to misdiagnosis of GERD or gastroparesis. Other
groups have also recommended against diagnostic testing to rule out
medical conditions such as GERD or gastroesophageal motility disor-
ders, because these procedures are invasive and the diagnosis can be
made based on clinical observation alone (O’Brien et al. 1995).
Behavioral approaches for treatment of rumination disorder are sup-
ported by a number of case reports; however, no controlled trials have
been reported to date. A brief review of the proposed physiological mech-
anism of rumination is helpful to understand the most common treatment
interventions. Although animals that ruminate as part of their digestive
process use reverse peristalsis, this mechanism is not observed in the hu-
man esophagus. It appears that regurgitation in humans is made possible
by an increase in intragastric pressure (voluntary or otherwise) at the same
time as a lowering of lower esophageal sphincter tone (again, voluntary or
otherwise), which seems to occur by tonic contraction of the diaphragm
(via contracting abdominal muscles). Thus, diaphragmatic breathing has
been shown to be an effective treatment for rumination to disrupt this
mechanism (Chitkara et al. 2006).
Diaphragmatic breathing is described as both a relaxation technique
and a strategy of simple habit reversal; however, this distinction is mostly
semantic because the implementation of the technique varies minimally.
Diaphragmatic breathing is taught by asking a patient to place one hand
on the upper chest and one hand on the abdomen and to take a deep in-
spiration and allow only the hand on the abdomen to move while the hand
on the chest stays still (Chial et al. 2003). Patients are trained to breathe
diaphragmatically throughout a meal, with the goal that they will begin to
unconsciously breathe diaphragmatically during events that precipitate re-
gurgitation (Chitkara et al. 2006). Diaphragmatic breathing as a habit re-
versal technique is considered to be a behavior incompatible with
regurgitation, and training includes awareness training of regurgitation,
practice of the incompatible behavior, and social support (Wagaman et al.
1998).
Some case reports note the importance of education about regurgita-
tion and its consequences as part of the treatment plan (Khan et al. 2000).
Levine et al. (1983) described several patients who experienced relief of
symptoms when they learned that their habit was typically harmless. Bio-
feedback and gum chewing have also been reported as useful techniques
(Fredericks et al. 1998; Weakley et al. 1997). Operant conditioning, in
Treatment of Other Eating Problems 303

which attention is withdrawn in response to rumination and additional at-

tention is demonstrated in response to appropriate feeding behavior, has
been reported to be helpful for infants and for individuals with develop-
mental disabilities (Olden 2001).
As mentioned earlier in this section, studies have shown a relationship
between eating disorders and rumination symptoms (Blinder 1986; Fair-
burn and Cooper 1984). There are special considerations for treatment of
patients who ruminate following recovery from an eating disorder and pa-
tients who ruminate in the context of AN or BN because these symptoms
may go unnoticed or may not be assessed by the clinician. In these pa-
tients, it may be more common that regurgitated food is spit out in an at-
tempt to avoid absorbing calories, consistent with the fear of gaining
weight or becoming fat. For these patients, psychoeducation about rumi-
nation and its possible medical sequelae, as well as about the physiology
of digestion, may be important to emphasize. Additionally, strategies
aimed at vomiting prevention may be useful in prevention of spitting out
regurgitated food.
Pharmacological strategies have limited utility for rumination disorder.
Proton pump inhibitors may be considered to protect the esophagus, oro-
pharynx, and teeth. Gastric motility agents should be considered only if a
specific motility disorder is identified. Antidepressant or anxiolytic medi-
cations may be considered to target comorbid disorders that may contrib-
ute to rumination disorder. In the past, surgical procedures that targeted
the lower esophageal sphincters were used, but there is little evidence to
support these interventions; although rumination reportedly resolved fol-
lowing surgery, complications, including gas bloat syndrome and gastro-
paresis secondary to vagal nerve damage, were reported (Olden 2001).

Night Eating Syndrome

Night eating syndrome is one of the DSM-5 other specified feeding or eat-
ing disorders. Night eating syndrome is described in DSM-5 as “recurrent
episodes of night eating, as manifested by eating after awakening from
sleep or by excessive food consumption after the evening meal” (p. 354).
A key feature of this disorder is that the individual has awareness and re-
call of the eating; in contrast, in sleep-related eating disorder, the individ-
ual has no conscious awareness of the nocturnal behavior (Winkelman
1998).
Prevalence of night eating syndrome is estimated at 1.5% of the general
population, with a higher prevalence among obese patients seeking weight
loss treatment, including bariatric surgery, and among patients with other
eating disorders, especially binge-eating disorder (Colles et al. 2007). Al-
304 Handbook of Assessment and Treatment of Eating Disorders

though the prevalence of night eating syndrome increases with body mass
index in patient populations, several studies have demonstrated that night
eating syndrome is not correlated with obesity in the general population
(Rand et al. 1997; Striegel-Moore et al. 2006). Night eating syndrome af-
fects men and women in comparable proportions, although more women
seek weight loss treatment, which may contribute to the impression that
the disorder predominantly affects women.
Screening for night eating syndrome should be part of the diagnostic
assessment when evaluating disordered eating behavior. In addition, be-
cause night eating may interfere with weight loss and with glucose man-
agement in patients with diabetes, clinicians should also assess for the
presence of this behavior in overweight and obese individuals and patients
with diabetes (Vander Wal 2012). Night eating syndrome is associated
with morning anorexia, insomnia, and other sleep disturbances.
Studies support both psychotherapy and pharmacotherapy as effec-
tive treatment strategies for night eating syndrome (Allison et al. 2010;
O’Reardon et al. 2006; Pawlow et al. 2003). Abbreviated progressive mus-
cle relaxation and cognitive-behavioral therapy (CBT) have shown prom-
ise as treatment approaches for night eating syndrome. In a randomized
controlled trial comparing abbreviated progressive muscle relaxation
with sitting quietly, Pawlow et al. (2003) found that patients trained in ab-
breviated progressive muscle relaxation showed significant improvement
in anxiety, relaxation, and morning and evening hunger patterns. Nonsig-
nificant improvements in the number of breakfasts eaten, awakenings
from sleep, and weight were also demonstrated. In the abbreviated pro-
gressive muscle relaxation used in this trial, subjects were instructed to es-
tablish a consistent bedtime routine, listen to a soothing tape, and monitor
mood and food intake, indicating that sleep hygiene instruction and self-
monitoring may be important elements of an effective treatment. In an
uncontrolled pilot study, Allison et al. (2010) demonstrated that patients
who received CBT specifically developed for night eating syndrome had
significant decreases in caloric intake after dinner, number of nocturnal
ingestions, weight, and scores on the Night Eating Symptom Scale (NESS;
O’Reardon et al. 2004). The core components of this CBT treatment in-
cluded psychoeducation, self-monitoring, relaxation strategies, sleep hy-
giene, cognitive restructuring, and implementation of a regular eating
schedule of structured meals. Case reports also support the use of addi-
tional daytime calories (Aronoff et al. 1994) and of bright light therapy for
night eating syndrome that presents together with comorbid depression
(Friedman et al. 2004). Several studies support the use of selective sero-
tonin reuptake inhibitors for night eating syndrome. In one double-blind
placebo-controlled trial, sertraline was associated with significant im-
Treatment of Other Eating Problems 305

provements in the number of nighttime awakenings, nocturnal ingestions,

and post-evening-meal caloric intake (O’Reardon et al. 2006). Further-
more, overweight patients in the sertraline group lost more weight than
those in the control group.

Purging Disorder
Purging disorder is described in DSM-5 as a disorder of “recurrent purg-
ing behavior to influence weight or shape...in the absence of binge eating”
(p. 353). Purging behaviors include self-induced vomiting and misuse of
laxatives, diuretics, and other medications.
Lifetime prevalence rates for purging disorder ranged from 1% to 5%
in several epidemiological studies (Favaro et al. 2003; Machado et al.
2007; Wade et al. 2006). Patients with purging disorder are within a nor-
mal weight range. This disorder differs from BN, which requires recurrent
episodes of objective binge eating, although patients with purging disorder
may report subjective binge episodes in which they experience loss of con-
trol but do not consume more food than what most people would eat un-
der similar circumstances. Purging disorder is associated with dietary
restraint, depression, and anxiety (Keel et al. 2005).
Assessment of individuals with purging disorder should include phys-
ical examination and laboratory studies recommended for patients with
BN. Patients should be assessed for parotid gland enlargement, gastro-
esophageal reflux symptoms, dental erosion, and electrolyte imbalance,
because individuals who engage in self-induced vomiting are at risk for
esophageal damage and electrolyte abnormalities (e.g., hypokalemia, hy-
pochloremic metabolic acidosis).
No treatment trials have been reported for purging disorder; therefore,
treatment strategies are best informed by evidence-based approaches for
other eating disorders, especially BN, because of the overlap of some treat-
ment targets, such as purging, dietary restraint, and overvaluation of shape
and weight. Evidence-based treatments for BN include psychotherapy
(CBT, interpersonal psychotherapy) and pharmacotherapy (Shapiro et al.
2007) (for details, see Chapter 14, “Treatment of Binge Eating, Including
Bulimia Nervosa and Binge-Eating Disorder”).
Very strong evidence supports the use of CBT for the reduction and re-
mission of purging episodes in BN. In multiple comparison trials, CBT has
been shown to be more effective than behavioral treatment alone, expo-
sure with response prevention, supportive therapy, nutritional counseling,
and wait list (Shapiro et al. 2007). Interpersonal psychotherapy has been
shown to be as effective as CBT at 1-year follow-up, but CBT has much
more rapid symptom relief (Fairburn et al. 1991).
306 Handbook of Assessment and Treatment of Eating Disorders

A transdiagnostic CBT approach that was evaluated in a longitudinal

trial showed similar benefit to that associated with CBT for BN (Fairburn
et al. 2009). Transdiagnostic CBT, also called enhanced CBT (CBT-E), uti-
lizes a dimensional approach to treatment and focuses on the shared clin-
ical features of several eating disorders and the common mechanisms that
are involved in the persistence of disordered eating behavior. In addition
to the core elements of CBT for BN (e.g., attempts to normalize eating,
prevention strategies to decrease binge and purge episodes, techniques to
address overvaluation of shape and weight), CBT-E has specific models to
address clinical perfectionism, core self-esteem issues (e.g., negative self-
evaluation that extends beyond body image), mood intolerance, and inter-
personal difficulties. The transdiagnostic approach may be particularly
well suited for purging disorder, with the rationale that a dimensional view
of eating disorders places purging disorder somewhere in the middle of
the continuum, so a broader strategy may be more helpful than one aimed
specifically at BN.

Atypical Anorexia Nervosa

DSM-5 suggests that the term atypical anorexia nervosa be used if an indi-
vidual meets all criteria for AN, except that despite a significant weight
loss, his or her weight is within or above the normal range. Although this
presentation has been recognized for some time, minimal research data
are available regarding its prevalence, presentation, or course to inform
clinical care. Patients with atypical AN may present for treatment because
of clear functional impairment and may benefit from strategies used in the
treatment of other eating disorders (Wade and O’Shea 2014). In addition,
this eating disorder profile has been described in patients who have under-
gone bariatric surgery (Conceição et al. 2013).
The primary treatment goals for typical AN patients are refeeding and
restoring normal weight. In patients in a malnourished state, specific psy-
chotherapeutic interventions have little empirical support (Bulik et al.
2007), but in weight-restored patients, CBT has more promising results,
especially for relapse prevention (Pike et al. 2003). Furthermore, as de-
scribed in the section on purging disorder, there is very strong evidence
that CBT is effective in treating BN. Thus, for normal-weight or over-
weight patients with restricted diet, intense fear of gaining weight, and dis-
turbance in body image, CBT is an obvious first choice for therapeutic
approach. The behavioral management must be targeted at normalizing
eating, because these individuals often fast, restrict food variety, and
avoid forbidden foods. Stimulus control and coping strategies may need
Treatment of Other Eating Problems 307

to be aimed at excessive exercise behavior, which appears to be common

in individuals with atypical AN. Strategies to prevent vomiting and other
purging behaviors may also be necessary. Finally, cognitive and exposure
work focused on body image distortion are crucial. For adolescent pa-
tients with atypical AN, family-based treatment should also be considered
(Le Grange et al. 2005).
Although psychopharmacological interventions have not been shown
to be helpful in weight gain for patients with AN (Bulik et al. 2007), med-
ication has been shown to reduce target eating disorder symptoms in BN
(Levine 1992). Therefore, a trial of fluoxetine may be a reasonable ap-
proach for atypical AN, especially if binge and/or purge symptoms are
present.
Rapid weight loss has been associated with medical complications, pos-
sibly including hormonal changes similar to those seen in AN (Pi-Sunyer
1993). Therefore, even though patients with atypical AN have normal or
above-normal weights, medical assessment and monitoring remain impor-
tant for this group of patients.

Conclusion
Patients with pica, rumination disorder, and other specified feeding or eat-
ing disorder, including purging disorder, night eating syndrome, and atyp-
ical AN, may benefit from treatment approaches that have been better
studied in the formally classified feeding and eating disorders. The inclu-
sion in DSM-5 of these specified categories of subthreshold and other con-
ditions hopefully will encourage clinicians and researchers to collect and
report data about these groups and thereby create a useful evidence base.

Key Clinical Points

• Pica is best treated with a combination of stimulus control, habit re-
versal, and reinforcement.
• Environmental safety and enrichment are important components of
a successful treatment plan for pica.
• Diaphragmatic breathing (as a relaxation strategy or simple habit re-
versal technique) is a promising treatment approach for rumination
disorder.
• Clinical trials support the use of abbreviated progressive muscle re-
laxation, cognitive-behavioral therapy, and selective serotonin
reuptake inhibitors for night eating syndrome.
308 Handbook of Assessment and Treatment of Eating Disorders

• Treatments for purging disorder should be based on treatments of

known effectiveness for bulimia nervosa.
• Although patients with atypical anorexia nervosa have normal or
above-normal weight, medical assessment and monitoring are im-
portant.

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Index
Page numbers printed in boldface type refer to figures and tables.

Adiposity, binge-eating disorder and, questionnaire measures, 221

70 for younger pediatric sam-
Adolescents, eating problems in, 45–63. ples, 220, 221
See also Boys, eating problems in proposed assessment for DSM-5
delay in puberty, 55 adaptation for youth,
diagnosis of feeding and eating dis- 223–224
orders in, 207–230 differential diagnosis, 56, 57
alternative methods of assessing epidemiology and nosology of,
eating pathology and asso- 46–47
ciated features, 222–223 medical assessment, 47–50
ecological momentary family history, 49
assessment, 222–223 history of, 48
feeding paradigms, 222 indications for hospitalization,
neuropsychological assess- 53
ments, 223 interview sample questions and
assessment tools for associated issues, 49–50
features of symptoms, laboratory investigations, 50, 54
217–218 physical examination, 48, 50
eating in response to exter- physical findings associated
nal and affective cues, with anorexia nervosa and
218 bulimia nervosa, 51–52
weight-based teasing, 218 medical complications in
assessment tools for symptoms cardiovascular system, 53–54
of, 209–217 endocrine system, 55
interview measures, 210–213 fluid and electrolytes, 52–53
interview versus self-report gastrointestinal system, 54–55
methodology, 209–210 hematological system, 55–56
self-report measures, 213–214, musculoskeletal system, 55
215–216, 217 neurological system, 56
overview, 207–209 overview, 45–46
parent-report measures, screening, 47
218–221, 220 Adults, eating problems in, 23–43.
interview measures, 219, 221 See also Boys; Men

311
312 Handbook of Assessment and Treatment of Eating Disorders

Adults (continued) Age of Onset of any Eating-Disordered

assessment of eating behaviors, Behavior, Overweight, and Diet-
25–31 ing, 212–213
binge eating, 29–30 AIDS, 37
development of eating prob- Alcohol use disorder, clinical inter-
lems, 25–26 view and, 97
energy and macronutrient Amenorrhea, 12
restriction, 26, 28–29 in girls, 47
pica, 31 American Telemedicine Association
purging behaviors, 30 (ATA), 241, 247
rumination, 30–31 AN. See Anorexia nervosa
sample questions to assess diet Anabolic-androgenic steroid use,
and eating behaviors, 27–28 105–106
assessment of family history and Anemia, 55–56
social and occupational func- Anorexia nervosa (AN), 9–12
tioning, 37–38 in adolescents, diagnosis, 56–57
assessment of medical and psycho- in adults, physical and laboratory
logical features associated with findings associated with, 34
eating problems, 32–37 assessment after bariatric surgery,
comorbid conditions, 35–36 88–89
differential diagnosis, 36–37 assessment for DSM-5, 181–182,
medical complications and, 182
33–35 atypical, treatment of, 306–307
physical and laboratory findings characteristics of
associated with anorexia amenorrhea, 12
nervosa and bulimia ner- distortion of body image, 12
vosa, 34 fear of gaining weight, 12
physical assessments, 32 low body weight, 11–12
assessment of shape and weight in children, diagnosis, 56–57
concerns, 31–32 clinical assessment of, 85
assessment of treatment needs, cognitive-behavioral therapy for
38–39 treatment of, 269
challenges and obstacles in assess- differential diagnosis of, 127
ment of, 39–41 DSM-5 criteria for, 10–11
cognitive impairment, 39 DSM-IV to DSM-5, 10–11
patient minimization of symp- energy and macronutrient restric-
tom severity and/or need tions, 28
for treatment, 40–41 history of, 9–10
patient reluctance to provide Maudsley approach to treatment
information, 39–40 of, 269
clinical interview with, 24–25 medical stabilization of, 261,
with obesity, 65–82 263–264
overview, 23–24 in men, 106
with overweight, 65–82 non-fat-phobic, 122
Index 313

patient assessment of shape and energy and macronutrient restric-

weight concerns, 32 tions with, 29
principles of treatment for, 260–261 medical stabilization of, 261,
reverse, 105–106 263–264
Antidepressants. See also Tricyclic medications for, 273–274
antidepressants nutritional rehabilitation and, 265
for treatment of restrictive eating patient assessment of shape and
and low-weight conditions, weight concerns, 32
271–272 principles of treatment for, 260–261
Antipsychotics, for treatment of psychiatric comorbidities with,
restrictive eating and low-weight 266–267
conditions, 272–273 psychological change during reha-
Anxiety disorders, 36, 73 bilitation, 266
clinical interview and, 97
Anxiolytics, for treatment of restric- Bariatric surgery. See also Gastrointes-
tive eating and low-weight condi- tinal system; Obesity
tions, 272 assessment
APEDS (appearance- and performance- after surgery, 86–87
enhancing drugs), 107 of problematic eating behavior
APEDUS (Appearance and Perfor- in patients, 83–104
mance Enhancing Drug Use special considerations for, 88–90
Schedule), 113 binge eating and, 87, 91
Appearance- and performance- clinical assessment of patients, 84–87
enhancing drugs (APEDS), 107 dumping syndrome and, 94–95
Appearance and Performance eating behaviors in postoperative
Enhancing Drug Use Schedule patients, 93
(APEDUS), 113 emotional eating and, 94
ARFID. See Avoidant/restrictive food grazing and, 92–94
intake disorder loss-of-control eating and, 87, 91
ATA (American Telemedicine Associ- medical complications and physical
ation), 241, 247 assessment, 100
Atypical anorexia nervosa, treatment night eating syndrome and, 92
of, 306–307 overview, 83–84
Avoidant/restrictive food intake disor- physical restrictions after surgery, 91
der (ARFID), 16–17, 208–209 structured clinical interviews and
in adolescents, diagnosis, 58–59 self-report measures, 97, 98–99
assessment for DSM-5, 194–196, Barrett’s esophagus, 54
195 BCI (Body Change Inventory), 112
assessment of, 151–152 BED. See Binge-eating disorder
behavioral management of, 268, Behavioral management, 267–271
270–271 management of ARFID, 270–271
in children, diagnosis, 58–59 overview, 267–268
differential diagnosis and, 71–72 psychotherapeutic approaches to,
DSM-5 criteria for, 16–17 268–270
314 Handbook of Assessment and Treatment of Eating Disorders

BES (Binge-Eating Scale), 98 general approach to treatment of,

Bigorexia, 105–106 279–281
Binge-eating disorder (BED), 14–15, normalization of eating, 279–280
29–30, 67, 96 overvaluation of shape and
adiposity and, 70 weight, 280
in adults, 29–30, 69–72 weight management, 280–281
assessment after bariatric surgery, 89 history of, 14
subjective binge episodes, 183, implications for treatment of, 74–75
184 large versus small assessment,
assessment for DSM-5, 182–191, 186–187, 187
187, 193–194, 194 loss of control and, 185–186, 186
objective binge episodes, 183, physical assessment of, 74
184, 186 prior to bariatric surgery, 91
bariatric surgery and, 87, 91 subjective, 91
challenges in assessing, 187–188, treatment, 279–295
187 Binge-Eating Scale (BES), 98
characteristics of, 30 BMI (body mass index), 47, 48, 66,
clinical assessment of, 85 76, 86, 128, 261, 263
comorbidity and, 73 BN. See Bulimia nervosa
compensatory behaviors and, Body Change Inventory (BCI), 112
182–191 Body image, 11
definition of, 69 in adults, assessment of shape and
description of, 69 weight concerns, 31–3
differential diagnosis and, 69–70 after bariatric surgery, 87
DSM-5 criteria for, 15 denial of, 12
DSM-IV to DSM-5, 14–15 distortion of, 12
evidence-based treatments for, in men, 107
281–291 My Body, My Life: Image Pro-
cognitive-behavioral therapy, gram for Adolescent Girls,
281–282, 284–285 237–238
example of eating behavior overvaluation of shape and weight,
self-monitoring form, 280
283 shame and, 67
individualized therapy for- Body mass index (BMI), 47, 48, 66,
mulation, 282 76, 86, 128, 261, 263
interpersonal psychotherapy, Body Project, 237
285–287 Boys, eating problems in, 105–117. See
pharmacotherapy, 288–291 also Adolescents, eating problems
dialectical behavior therapy, in; Children, eating problems in
290–291 body image in, 107
integrative cognitive-affective challenges in assessment of eating-
therapy, 291 related pathology of, 108–111
examples of objectively and sub- diagnosis bias, 109–110
jectively large amounts of sexual orientation, 110–111
food, 184 shame and gender roles, 110
Index 315

eating disorder measures in assess- integrative cognitive-affective

ment of, 111–113 therapy, 291
Appearance and Performance interpersonal psychotherapy,
Enhancing Drug Use 285–287
Schedule, 113 pharmacotherapy, 288–291
Drive for Muscularity Scale, general approach to treatment of,
112–113 279–281
Eating Disorder Inventory, 111 normalization of eating, 279–280
Examination Questionnaire, overvaluation of shape and
111 weight, 280
Male Body Checking Question- weight management, 280–281
naire, 112 history of, 12–13
Male Eating Behavior and implications for treatment, 75
Body Image Evaluation, patient assessment of shape and
112 weight concerns, 32
Muscle Dysmorphia Disorder treatment, 279–295
Inventory, 112 Bupropion, 288
overview, 105–108
physical assessment, 113 Calcium, 100
relevant questions in assessment of, Carbohydrates, 28
109 Cardiovascular disease, 74
Bulimia nervosa (BN), 12–14 Cardiovascular system, in children
in adolescents, diagnosis, 58 and adolescents, 53–54
in adults, physical and laboratory C-BEDS (Children’s Binge Eating
findings associated with, 34 Disorder Scale), 213, 215
assessment CBT. See Cognitive-behavioral ther-
after bariatric surgery, 89, 90 apy
for DSM-5, 191, 193 CBTgsh. See Cognitive-behavioral
in children, diagnosis, 58 therapy, with guided self-help,
clinical assessment of, 85 75
comorbidity and, 73 CEBQ (Children’s Eating Behaviour
differential diagnosis and, 70 Questionnaire), 220, 221
DSM-5 criteria for, 13 Celiac disease, 37
DSM-IV to DSM-5, 13–14 CFI (Cultural Formulation Interview),
evidence-based treatments for, 121, 125
281–291 excerpted questions from, 126
cognitive-behavioral therapy, CFQ (Child Feeding Questionnaire),
281–282, 284–285 220, 221
example of eating behavior ChEAT (Children’s Eating Attitudes
self-monitoring form, Test), 214, 215
283 ChEDE (Eating Disorder Examina-
individualized therapy for- tion adapted for children),
mulation, 282 210–212, 215
dialectical behavior therapy, Child Feeding Questionnaire (CFQ),
290–291 220, 221
316 Handbook of Assessment and Treatment of Eating Disorders

Children, eating problems in, 45–63. physical findings associated

See also Boys, eating problems in with anorexia nervosa and
amenorrhea and, 47 bulimia nervosa, 51–52
diagnosis of feeding and eating dis- medical complications in, 52–56
orders in, 207–230 cardiovascular system, 53–54
alternative methods of assessing endocrine system, 55
eating pathology and asso- fluid and electrolytes, 52–53
ciated features, 222–223 gastrointestinal system, 54–55
ecological momentary hematological system, 55–56
assessment, 222–223 musculoskeletal system, 55
feeding paradigms, 222 neurological system, 56
neuropsychological assess- overview, 45–46
ments, 223 screening, 47
assessment tools for associated Children’s Binge Eating Disorder
features of symptoms, Scale (C-BEDS), 213, 215
217–218 Children’s Eating Attitudes Test
eating in response to exter- (ChEAT), 214, 215
nal and affective cues, Children’s Eating Behaviour Ques-
218 tionnaire (CEBQ), 220, 221
weight-based teasing, 218 CIDI (Composite International Diag-
assessment tools for symptoms nostic Interview), 140, 148, 219,
of, 209–217 220, 221
interview measures, 210–213 Clinical Eating Disorder Rating
interview versus self-report Instrument, 138
methodology, 209–210 Clinical interview
self-report measures, with adults, 24–25
213–214, 215–216, 217 alcohol use disorder and, 97
parent-report measures, 218– anxiety disorders and, 97
221, 220 for bariatric surgery patients, 97,
interview measures, 219, 221 98–99
questionnaire measures, 221 impulse-control disorders and, 97
for younger pediatric sam- literacy and, 209
ples, 220, 221 measures, 210–213
differential diagnosis, 56, 57 mood disorders and, 97
epidemiology and nosology of, sample questions to assess diet and
46–47 eating behaviors, 27–28
medical assessment for, 47–50 versus self-reporting methodology,
family history, 49 209–210
history of, 48 Cognitive-behavioral therapy (CBT)
indications for hospitalization, 53 with guided self-help, 75
interview sample questions and for night eating syndrome, 71, 304
issues, 49–50 for purging disorder, 305–306
laboratory investigations, 50, 54 for treatment of anorexia nervosa,
physical examination, 48, 50 269
Index 317

for treatment of binge-eating disor- Diagnostic Interview Schedule for

der, 281–282, 284–285 Children Version IV (DISC-IV),
for treatment of bulimia nervosa, 140, 148–149
281–282, 284–285 Dialectical behavior therapy (DBT),
Web-based, 238–239 290–291
Cognitive impairment, in adults, 39 Diaphragmatic breathing, 302
Compensatory behaviors, 86 Dietary guidelines, 26, 28, 208
assessment for DSM-5, 188–189, DISC-IV (Diagnostic Interview Sched-
190 ule for Children Version IV), 140,
Composite International Diagnostic 148–149
Interview (CIDI), 140, 148, 219, DISC-P (Diagnostic Interview Sched-
220, 221 ule for Children—Parent Ver-
Crohn’s disease, 37 sion), 219, 220
Cultural explanations or perceived Diuretics, misuse of, 30
causes, DSM-5 definition of, 124 DMS (Drive for Muscularity Scale),
Cultural Formulation Interview (CFI), 112–113
121, 125 Drive for Muscularity Scale (DMS),
excerpted questions from, 126 112–113
Cultural idioms of distress, DSM-5 DSM-III, 5–6
definition of, 124 DSM-III-R, 7
Cultural syndromes, DSM-5 defini- DSM-IV
tion of, 124 to DSM-5, 7–9
Culture approach and process leading
eating problem considerations in to DSM-5, 8–9
special populations, 119–133 history of, 7–8
in Fiji, 121, 124 not otherwise specified diagnosis, 6
in Hong Kong Chinese, 122, 124 DSM-5
transnational migration, 120 advantages of, 6
Current Population Survey, 127–128 approach to diagnosis, 3–4
criteria
DAWBA (Development and Well- for anorexia nervosa, 10–11
Being Assessment), 219, 220 for avoidant/restrictive food
DBT (dialectical behavior therapy), intake disorder, 16–17
290–291 for binge-eating disorder, 15, 69
DEBQ (Dutch Eating Behavior Ques- for bulimia nervosa, 13
tionnaire), 98, 215 for eating disorders, 84
Dehydration, 34 for pica, 18
Depression, 36, 73 for rumination disorder, 18–19
Development and Well-Being Assess- definitions
ment (DAWBA), 219, 220 of cultural explanations or per-
Diabetes, 74 ceived causes, 124
Diagnostic Interview Schedule for of cultural idioms of distress,
Children—Parent Version 124
(DISC-P), 219, 220 of cultural syndromes, 124
318 Handbook of Assessment and Treatment of Eating Disorders

DSM-5 (continued) development of, 25–26

description of, xvii–xviii differential diagnosis of, 36–37
diagnostic categories, 19 energy and macronutrient restric-
from DSM-IV, 7–9 tions, 26, 28–29
eating disorder assessment for, 138, in individuals with overweight and
175–205 obesity, 65–82
problems with, 5–6 medical complications and, 33–35
proposed assessment for adapta- in postoperative bariatric surgery
tion for youth, 223–224 patients, 93
video illustration, 9 self-report assessment of eating
Dual-energy X-ray absorptiometry pathology, 157–174
(DXA), 273 Eating Disorder Assessment for DSM-5
Dumping syndrome, 86 (EDA-5), 138, 139, 149–152,
bariatric syndrome and, 94–95 223–224
clinical interviews and self-measures, anorexia nervosa, 181–182, 182
99 avoidant/restrictive food intake
description of, 94–95 disorder, 194–196, 195
Dutch Eating Behavior Questionnaire binge eating and compensatory
(DEBQ), 98, 215 behaviors, 182–191
DXA (dual-energy X-ray absorptiom- challenges in assessing, 187–188,
etry), 273 187
examples of objectively and
EAH-C (Eating in the Absence of subjectively large amounts
Hunger for children and adoles- of food, 184
cents), 216 large versus small assessment,
EAH-P (Eating in the Absence of 186–187, 187
Hunger), 220, 221 loss of control and, 185–186,
EAT (Eating Attitudes Test), 214 186
Eating Attitudes Test (EAT), 214 objective binge episodes, 183,
Eating behaviors 184, 186
assessment of, 25–31 subjective binge episodes, 183,
binge-eating episodes, 96 184
current, 95–96 binge-eating disorder, 187, 193–194,
emotional eating, 96 194
grazing, 96 bulimia nervosa, 191, 193
loss-of-control episodes, 96 compensatory behaviors, 188–189,
night eating symptoms, 96 189, 190
overeating, 96 development and psychometrics,
prior, 96 177–178
purging behaviors, 96 example of diagnosis pop-up win-
restriction and avoidance of cer- dow, 183
tain foods, 95–96 frequency of behaviors, 190–191,
clinical interview, 24–25, 27–28 192
cultural considerations and, future directions, 203
119–133 inappropriate exercise, 190, 190
Index 319

instrument structure and content, Feeding Disorder Assessment,

178–198 151–152
introduction, 180–181 general psychiatric interviews,
screen structure, 178, 179 145–149
notes and results, 179, 198–200 Composite International
data collection, 200, 201 Diagnostic Interview,
output, 200, 202 148
other specified feeding or eating Diagnostic Interview Sched-
disorder, 198, 199 ule for Children Ver-
overview, 175–177 sion IV, 148–149
pica, 197–198, 197 overview, 145
principles of administration, 178 Schedule for Affective Disor-
purging behaviors, 188, 189 ders and Schizophrenia
rumination disorder, 196–197, 196 for School-Age Children,
screen structure, 178, 179 147
use of, 175–205 Structured Clinical Inter-
Eating Disorder Examination (EDE), view for DSM Axis I
137–138, 139, 141–142 Disorders, 145–147
Eating Disorder Examination adapted Interview for the Diagnosis of
for children (ChEDE), 210–212, Eating Disorders, 143–144
215 Longitudinal Interval Follow-up
Eating Disorder Examination Ques- Evaluation, 144–145
tionnaire (EDE-Q), 111, 125, 213 overview, 137–138
reliability and stability of, 163, 164, seminal measures, 138–149
165 specific interviews, 138–145,
self-reporting, 160–161 139–140
validity of, 167–168 Structured Interview for
Eating Disorder Inventory (EDI), 111 Anorexic and Bulimic Dis-
reliability and stability of, 163, 164 orders, 142–143
self-reporting, 159–160 assessment of problematic eating
validity of, 166–167 behavior in bariatric surgery
Eating Disorder Inventory—Child patients, 83–104
(EDI-C), 214, 215 classification of, 3–20
Eating Disorder Questionnaire clinical approach across culturally
(EDQ), 98 and socially diverse patient
Eating disorders. See also Anorexia ner- populations, 123
vosa; Avoidant/restrictive food clinical interviews and self-measures,
intake disorder; Binge-eating dis- 98
order; Bulimia nervosa; Mental comorbid conditions with, 35–36
illness; Pica; Rumination disorder cultural patterning and other con-
assessment measures, 137–156 textual influences on diagnos-
Eating Disorder Assessment for tic assessment of, 121–123
DSM-5, 149–151 diagnosis in children and adoles-
Eating Disorder Examination, cents, 207–230
138–142 DSM-5 diagnostic criteria, 84
320 Handbook of Assessment and Treatment of Eating Disorders

Eating Disorders (continued) medications for ARFID,

epidemiology across social con- 273–274
texts, 119–121 overview, 271
global epidemiology of, 127 treatment settings, 262–263
health consequences of, xviii inpatient program, 263
in men and boys, 105–117 intensive outpatient program,
not otherwise specified, 6, 8, 13, 46 262
other specified feeding or eating outpatient, 262
disorder, 70, 142 partial hospital program, 262
overcoming social and cultural bar- residential treatment center, 263
riers to treatment of, 123–128 Eating Disorders Work Group, 8
physical assessment of, 128 Eating in the Absence of Hunger
relapse prevention following inten- (EAH-P), 220, 221
sive treatment, 239–240 Eating in the Absence of Hunger for
sleep-related, 92 children and adolescents (EAH-C),
technology in assessment and 216
intervention, 231–255 Eating Pathology Symptoms Inven-
treatment of restrictive eating and tory (EPSI)
low-weight conditions, 259–277 reliability and stability of, 164, 165
behavioral management, self-reporting, 161–162
267–271 validity of, 168
management of ARFID, eBody Project, 237
270–271 Ecological assessment, 222–223,
overview, 267–268 232–234
psychotherapeutic example of, 233
approaches to, 268–270 Ecological intervention, 234–236
guidelines for engagement of Ecological momentary assessment
underweight patients, (EMA), 222–223
265 Ecological momentary intervention
medical stabilization, 261 (EMI), 234–236
nutritional rehabilitation, EDA-5. See Eating Disorder Assess-
264–267 ment for DSM-5
initial refeeding, 264–266 EDE (Eating Disorder Examination),
overview, 264 137–138, 139, 141–142
psychiatric comorbidities, EDE—Bariatric Surgery Version, 98
266–267 EDE-Q. See Eating Disorder Examina-
psychological change and, tion Questionnaire
266 EDI. See Eating Disorder Inventory
overview, 259–260 EDI-C (Eating Disorder Inventory—
principles of, 260–261 Child), 214, 215
psychopharmacology, 271–274 EDNOS (eating disorder not other-
antidepressants, 271–272 wise specified), 6, 13
antipsychotics, 272–273 EDQ (Eating Disorder Question-
anxiolytics, 272 naire), 98
hormonal treatments, 273 EES (Emotional Eating Scale), 99
Index 321

EES-C (Emotional Eating Scale for Food triggers, 30

children and adolescents), 216
EMA (ecological momentary assess- GABA (-aminobutyric acid), 288
ment), 222–223 -aminobutyric acid (GABA), 288
EMI (ecological momentary interven- Gastroesophageal reflux disease
tion), 234–236 (GERD), 301
Emotional eating, 91, 96 Gastrointestinal system. See also Bar-
bariatric surgery and, 94 iatric surgery
clinical interviews and self-measures, in children and adolescents, 54–55
99 Gender, roles in men, 110
Emotional Eating Scale (EES), 99 Geophagia, 127, 298
Emotional Eating Scale for children GERD (gastroesophageal reflux dis-
and adolescents (EES-C), 216 ease), 301
Endocrine system, in children and Global Burden of Disease Study, xviii,
adolescents, 55 120
Energy intake, 11 Gluten, restriction of, 28
restrictions, 26, 28–29 Grazing, 91, 96
EPSI. See Eating Pathology Symptoms bariatric surgery and, 92–94
Inventory clinical interviews and self-measures,
Ethics, 246–248 99
Exercise, 96 compulsive, 92, 93
inappropriate, 190, 190 following bariatric surgery, 94
Experiences of Weight-Based Victim- noncompulsive, 92, 93
ization, 218 overeating, 92–93
Grief, 286
Family history
assessment HAES (Health at Every Size), 76–78
in adults, 37–38 Health at Every Size (HAES), 76–78
in children and adolescents, 49 Health Insurance Portability and
weight, 68 Accountability Act (HIPAA), 246
FDA (U.S. Food and Drug Adminis- Hematological system, in children
tration), 288 and adolescents, 55–56
Feeding disorders HIPAA (Health Insurance Portability
assessment of, 151–152 and Accountability Act), 246
diagnosis in children and adoles- Hormones
cents, 207–230 in children and adolescents, 55
Fluoxetine for treatment of restrictive eating
for treatment of anorexia nervosa, and low-weight conditions, 273
271–272 Hyperglycemia, 95
for treatment of bulimia nervosa, Hypokalemia, in adults, 33
288 Hypomagnesemia, in adults, 33
Folic acid, 100 Hyponatremia, 33–34
Food addiction, 72 in children and adolescents, 52
Food allergies, 29 Hypophosphatemia, in children and
Food intake, 11 adolescents, 52–53
322 Handbook of Assessment and Treatment of Eating Disorders

ICAT (integrative cognitive-affective Laxatives, 74

therapy), 291 abuse of, 54–55
IDED (Interview for the Diagnosis of misuse of, 30
Eating Disorders), 139, 143–144 Leukopenia, 55
Imipramine, 289 LIFE-EAT-3 (Longitudinal Interval
Impulse-control disorders, clinical Follow-up Evaluating eating dis-
interview and, 97 order adaptation), 139, 144–145
Inpatient program, 263 Linnaeus, Carl, 4
Integrative cognitive-affective ther- Lisdexamfetamine dimesylate, for
apy (ICAT), 291 treatment of binge-eating disor-
Intensive outpatient program (IOP), der, 288
262 Literacy, 209
Internet, 231–232. See also Technol- Longitudinal Interval Follow-up Eval-
ogy, in eating disorder assess- uating eating disorder adaptation
ment and intervention (LIFE-EAT-3), 139, 144–145
Interpersonal deficits, 286 Lorcaserin, for weight loss, 289
Interpersonal therapy (IPT) Loss-of-control eating, 96
for treatment of binge-eating disor- bariatric surgery and, 87, 91
der, 285–287
for treatment of bulimia nervosa, Macake (Fijian), 124
285–287 Macronutrients, restrictions of, 26,
for weight loss, 75 28–29
Interview for the Diagnosis of Eating Magnesium, 100
Disorders (IDED), 139, 143–144 Major depressive disorder, 36
IOP (intensive outpatient program), Male Body Checking Questionnaire
262 (MBCQ), 112
IPT. See Interpersonal therapy Male Eating Behavior and Body
Iron, 100 Image Evaluation (MEBBIE), 112
Males. See Boys, eating problems in;
KEDS (Kids’ Eating Disorders Sur- Men, eating problems in
vey), 215, 217 Malignancies, 37
Kids’ Eating Disorders Survey Mallory-Weiss tears, 54
(KEDS), 215, 217 MAOIs (monoamine oxidase inhibi-
Kleine-Levin syndrome, 37 tors), 287
KSADS-PL (Schedule for Affective Maudsley approach, 269
Disorders and Schizophrenia for MBCQ (Male Body Checking Ques-
School-Age Children—Present tionnaire), 112
and Lifetime version), 140, 147, MDDI (Muscle Dysmorphia Disor-
219, 220 der Inventory), 112
MEBBIE (Male Eating Behavior and
Laboratory findings Body Image Evaluation), 112
associated with anorexia nervosa, 34 MEDLINE, 241
associated with bulimia nervosa, 34 Men, eating problems in, 105–117. See
in medical assessment, 50, 51–52, also Adults, eating problems in
54 anorexia nervosa in, 106
Index 323

body image and, 107 Musculoskeletal system, in children

challenges in assessment of eating- and adolescents, 55
related pathology of, 108–111 My Body, My Life: Body Image Pro-
diagnosis bias, 109–110 gram for Adolescent Girls,
sexual orientation, 110–111 237–238
shame and gender roles, 110 MyFitnessPal, 244
eating disorder measures in assess-
ment of, 111–113 Naltrexone-bupropion, for weight
Appearance and Performance loss, 289
Enhancing Drug Use National Comorbidity Replication
Schedule, 113 Study, 73
Body Change Inventory, 112 NEQ (Night Eating Questionnaire), 99
Drive for Muscularity Scale, Neurological system, in children and
112–113 adolescents, 56
Eating Disorder Inventory, 111 Neuropsychological assessments, 223
Examination Questionnaire, 111 Night Eating Questionnaire (NEQ), 99
Male Body Checking Question- Night eating syndrome, 96
naire, 112 bariatric surgery and, 92
Male Eating Behavior and Body clinical interviews and self-measures,
Image Evaluation 99
(MEBBIE), 112 description of, 303
Muscle Dysmorphia Disorder differential diagnosis and, 70–71
Inventory, 112 prevalence of, 303–304
overview, 105–108 screening, 304
physical assessment, 113 treatment of, 303–305
relevant questions in assessment of, cognitive-behavior therapy, 304
109 pharmacotherapy, 304
Menstruation, assessment in children psychotherapy, 304
and adolescents, 49 Non-fat-phobic anorexia nervosa, 122
Mental health, cultural dimensions of NOS (not otherwise specified), 6
illness experience, expression, Not otherwise specified (NOS), 6
and expectations of assessment Nutrients, deficiency in, 35
of, 124 Nutritional rehabilitation, 264–267
Mental illness initial refeeding, 264–266
definition of, 4–5 overview, 264
diagnosis of, 4–5 psychiatric comorbidities, 266–267
Monoamine oxidase inhibitors psychological change and, 266
(MAOIs), 287
Mood disorders, 73 Obesity. See also Bariatric surgery
clinical interview and, 97 associated problems with, 72–73
Mood disturbance, 35 clinical approach to, 65–68
Morton, Richard, 10 description of, 65–66
Muscle dysmorphia, 105–106 differential diagnosis, 69–72
Muscle Dysmorphia Disorder Inven- eating problems with, 65–82
tory (MDDI), 112 implications for treatment, 74–78
324 Handbook of Assessment and Treatment of Eating Disorders

Obesity (continued) guidelines for engagement of

overview, 65 underweight, 265
physical assessment of, 73–74 minimization of symptom severity
weight history assessment, 68 and/or need for treatment,
Obsessive-compulsive disorder, 36 40–41
Occupational functioning, 37–38 motivation for change, 39
Orlistat, for weight loss, 289–290 refusal to consume, 11
OSFED. See Eating disorders, other reluctance to provide information,
specified feeding or eating disorder 39–40
Overeating, 92–93, 96 “sick role” of, 286
Over-the-counter natural supplements, Perception of Teasing Scale (POTS),
127 216, 218
Overweight. See also Bariatric surgery Pharmacotherapy. See also Psycho-
associated problems with, 72–73 pharmacology
clinical approach to, 65–68 for treatment of binge-eating disor-
description of, 66 der, 288–291
differential diagnosis, 69–72 for treatment of bulimia nervosa,
eating problems with, 65–82 288–291
implications for treatment, 74–78 Phentermine-topiramate, for weight
overview, 65 loss, 289
physical assessment of, 73–74 PHP (partial hospital program), 262
weight history assessment, 68 Pica, 17–18, 127, 208
in adolescents, diagnosis of, 59
Pancreatitis, 55 in adults, 31
Parents assessment for DSM-5, 197–198,
parent-report measures for assess- 197
ment of eating problems, in children, diagnosis of, 59
218–221, 220 description of, 17–18, 297–298
interview measures, 219, 221 differential diagnosis and, 71
questionnaire measures, 221 DSM-5 criteria for, 18
for younger pediatric samples, during pregnancy, 17
220, 221 treatment of, 297–301
Partial hospital program (PHP), awareness training, 300
262 differential reinforcement, 300
Patient Reported Outcomes Measure- environmental changes, 300
ment Information System habit reversal, 299
(PROMIS), 249–250 nutritional supplementation, 301
Patients overcorrection, 299
acceptability of technology in treat- response blocking and interrup-
ment, 240–241 tion, 299
assessment of problematic eating restraints, 299
behavior in bariatric surgery POTS (Perception of Teasing Scale),
patients, 83–104 216, 218
energy intake, 11 Pregnancy, pica during, 17
Index 325

Professional issues, 246–248 Questionnaire on Eating and Weight

PROMIS (Patient Reported Out- Patterns—Parent Version
comes Measurement Informa- (QEWP-P), 220, 221
tion System), 249–250 Questionnaires, for parents, 220, 221
Protein, intake of, 29
ProYouth, 238 Recovery Warriors, 245
Psychopharmacology. See also Phar- Recovery Record, 244
macotherapy Refeeding syndrome, 35
for treatment of restrictive eating in children and adolescents, 53
and low-weight conditions, Refusal, 11
271–274 Rep(eat)-Q (Repetitive Eating Ques-
antidepressants, 271–272 tionnaire), 99
antipsychotics, 272–273 Repetitive Eating Questionnaire
anxiolytics, 272 (Rep(eat)-Q), 99
hormonal treatments, 273 Residential treatment center (RTC),
medications for ARFID, 263
273–274 Reverse anorexia, 105–106
overview, 271 Rise Up+Recover, 244–245
Puberty, delay in, 55 Roles
PubMed, 241 disputes, 286
Purging behaviors, 74, 96 transitions, 286
in adults, 30 Rome-III Diagnostic Questionnaire
assessment for DSM-5, 188, 189 for Functional Gastrointestinal
EDA-5 assessment of, 188, 189 Disorders, 151–152
Purging disorder RTC (residential treatment center),
assessment of, 305 263
prevalence of, 305 Rumination disorder, 18–19, 208
treatment, 305–306 in adolescents, diagnosis, 59
cognitive-behavioral therapy, in adults, diagnosis, 30–31
305–306 assessment for DSM-5, 196–197,
196
QEWP (Questionnaire on Eating and in children, diagnosis, 59
Weight Patterns), 213 description of, 18
QEWP-A (Questionnaire on Eating diagnosis of, 301–302
and Weight Patterns—Adolescent differential diagnosis and, 71
Version), 214, 215 DSM-5 criteria for, 18–19, 301
QEWP-P (Questionnaire on Eating treatment of, 301–303
and Weight Patterns—Parent behavioral approaches for,
Version), 220, 221 302
Questionnaire on Eating and Weight diaphragmatic breathing, 302
Patterns (QEWP), 213 pharmacological strategies for,
Questionnaire on Eating and Weight 303
Patterns—Adolescent Version Russell, Professor Gerald, 12–13
(QEWP-A), 214, 215 Russell’s sign, 30
326 Handbook of Assessment and Treatment of Eating Disorders

Schedule for Affective Disorders and reliability and stability of, 162–166,
Schizophrenia for School-Age 164
Children—Present and Lifetime scale development methods,
version (KSADS-PL), 140, 147, 158–159
219, 220 hybrid-based methods, 159
SCID-5 (Structured Clinical Inter- rationally and empirically based
view for DSM-5), 140, 145–147 methods, 158–159
SCOFF questionnaire, 125 in special populations and issues,
Selective serotonin reuptake inhibitors 168–169
(SSRIs), 287 Web-based, 239
Self-reporting measures, 213–214, Sensory problems, 58
215–216, 217 Set Your Body Free, 237
assessment of eating pathology, Sexual orientation, 110–111
157–174 Shame, 67, 110, 241
for bariatric surgery patients, 97, in males, 110
98–99 SIAB (Structured Interview for
clinical outcomes of, 157 Anorexic and Bulimic Disorders),
comparison of measures, 166 139, 142–143
for diagnosis in children and ado- SIADH (syndrome of inappropriate
lescents, 213–214, 214, 217 antidiuretic hormone secretion),
diagnostic measures, 213–214 33–34
nondiagnostic measures, 214, Sick euthyroid syndrome, 55
217 Sigstad’s Clinical Diagnostic Index, 99
Eating Disorder Examination Sleep-related eating disorder, 92
Questionnaire, 160–161 Social functioning, in adults, 37–38
reliability and stability of, 163, SparkPeople, 244
164, 165 SPEEI (Standard Pediatric Eating Epi-
validity of, 167–168 sode Interview), 212–213
Eating Disorder Inventory, Spitzer, Robert, 14
159–160 SSRIs (selective serotonin reuptake
reliability and stability of, 164, inhibitors), 287
165 Standard Pediatric Eating Episode
validity of, 166–167 Interview (SPEEI), 212–213
Eating Pathology Symptoms Stimulus control, 284
Inventory, 161–162 Structured Clinical Interview for
reliability and stability of, 164, DSM-5 (SCID-5), 140, 145–147
165 Structured Interview for Anorexic and
validity of, 168 Bulimic Disorders (SIAB), 139,
example of eating behavior self- 142–143
monitoring form, 283 Student Bodies, 237
versus interview methodology, Stunkard, Albert, 14
209–210 Subjective binge eating, 91
multidimensional eating disorder Substance abuse, 35
assessments, 159–162 Superior mesenteric artery syndrome,
overview, 157–158 54
Index 327

Syndrome of inappropriate antidiuretic Urge surfing, 284

hormone secretion (SIADH), U.S. Food and Drug Administration
33–34 (FDA), 288
Syrup of ipecac, 30
VIA, 240
TCAs (tricyclic antidepressants), 287 Videoconferencing, 241–242
Technology, in eating disorder assess- Videos
ment and intervention, 231–255 assessing eating problems
applications, 244–245 in men, 108
ecological momentary assessment, in overweight adults, 69
232–234 in the primary care setting, 25,
example of, 233 48
ecological momentary intervention, cultural considerations in the
234–236 assessment of eating prob-
innovation and treatment, lems, 123
243–248 description of, xxv–xxvi
ethical and professional issues, diagnostic issues in DSM-5, 9, 149
246–248 guide to, xxv–xxviii
integrating mobile technology Virtual private network (VPN), 246
and practice, 243–246 Vitamin B12, 100
overview, 243 Vitamin D, 100
Internet, 231–232 Vitamins, 265
liability insurance for providers, deficiency in, 35
248 disordered eating and, 100
overview, 231–232 Vomiting, 74
telemedicine, 241–242 episodic, 86
videoconferencing, 241–242 self-induced in adults, 30
Web-based prevention and treat- VPN (virtual private network), 246
ment, 236–241
individual therapy, 238–239 Web-based platforms. See Technol-
patient acceptability of, ogy, in eating disorder assess-
240–241 ment and intervention
prevention and intervention Weight. See also Obesity; Overweight
programs, 236–238 in adults, assessment of, 31–32
relapse prevention following after bariatric surgery, 87
intensive treatment, assessment topics, 68
239–240 -based teasing, 218
Telemedicine, 241–242, 247 bias and, 66–67
Thiamine, 100 energy intake, 11
Thrombocytopenia, 55 fear of gaining, 12, 221
Topiramate, 288, 289 goals, 86–87
Trauma disorders, 36 low, 10, 11–12
Treatise of Consumptions (Morton), 10 maintenance of, 38
Tricyclic antidepressants (TCAs), management, 280–281
287 overvaluation of, 280
328 Handbook of Assessment and Treatment of Eating Disorders

Weight (continued) YEDE-Q (Youth Eating Disorder

plateaus in, 87 Examination Questionnaire),
refusal to consume, 11 214, 215
treatment of low-weight condi- YFAS (Yale Food Addiction Scale for
tions, 259–277 Children), 216
Weight loss programs, 75, 76 Youth Eating Disorder Examination
Questionnaire (YEDE-Q),
Yale-Brown-Cornell Eating Disorder 214, 215
Scale, 138
Yale Food Addiction Scale for Chil- Zinc, 100
dren (YFAS), 216 Zonisamide, 289