Assessing & Treating
Eating Disorders
Kayj Nash Okine, Ph.D.
Chrysalis Center for
Counseling & Eating Disorder
Treatment
The Continuum Model of
Eating Disorders
NORMAL EATING
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WEIGHT PREOCCUPATION
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CHRONIC DIETING
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BINGE EATING
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PURGING
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SUBCLINICAL EATING DISORDER
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CLINICAL EATING DISORDER
When Does An
Eating Disorder Exist?
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ED behaviors satisfy psychological needs.
One’s food intake & weight affect one’s
feelings about work, school, relationships, self.
Body image & desire to lose weight affects,
and becomes the basis for, decisions.
Desire to lose weight & engage in ED
behaviors becomes more important than
anything else.
ED behaviors & weight preoccupation give
meaning to one’s life.
Anorexia Nervosa:
Diagnostic Criteria
A.
B.
C.
D.
E.
Refusal to maintain a minimally healthy,
normal body weight (85% weight criteria)
Intense fear of weight gain, despite being
underweight
Body image distortion & denial of seriousness
of condition
Amenorrhea for at least 3 consecutive cycles
Weight loss is not due to a general medical
condition or the effects of medication
Anorexia Nervosa:
Diagnostic Criteria for Subtypes
Restricting Type: does not engage in
binge eating or purging behaviors (e.g.
vomiting, use of laxatives, diuretics,
enemas)
 Binge-Eating/Purging Type: regularly
engages in binge-eating or purging
behavior
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Anorexia Nervosa:
Behavioral Indicators
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Restrictive eating
Odd food rituals
Significant weight loss
Preoccupation with food, weight, body size
Dressing in baggy clothes or layers
Excessive exercising
Frequent weighing
Denial of hunger
Lack of interoceptive awareness
Anorexia Nervosa:
Physical Indicators
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Noticeably thin
Hormonal imbalances
& menstrual
irregularities
Sallow complexion
Dry, brittle hair
Lanugo
Weakness, dizziness,
fainting
Muscle atrophy
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Premature bone loss
Dehydration
Low body temperature,
cold intolerance
Increased
susceptibility to
infections
Low pulse rate, low
blood pressure
GI complaints
Anorexia Nervosa:
Psychological Indicators
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Body image distortion
Perfectionism
Obsessive-compulsive traits
Mood lability
Depression
Social withdrawal, isolation
Anhedonia
Lack of assertiveness
People pleasing, care-giving, self-sacrificing
Anorexia Nervosa: Facts & Figures
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Common comorbid psychological disorders: anxiety
disorders, depression, OCD, cluster C personality disorders
Gender: 90-95% female
Age of onset: mid to late adolescence
Prevalence: .5%-1.0% for women; 0.05%-0.1% for men
Highest prevalence: adolescence & young adulthood
Course: chronic or intermittent; may require hospitalization
Prognosis: poor, particularly without treatment
Racial & cultural factors: primarily white, but increasing
among other cultures
Highest mortality of any mental illness: 10-20%
Bulimia Nervosa:
Diagnostic Criteria
A.
B.
C.
D.
Recurrent episodes of binge eating:
1) eating an excessive amount of food
2) feeling out of control during episode
Recurrent compensatory behaviors
Frequency of at least 2x/week for 3+ months
Self evaluation is unduly influenced by body
image and weight
Bulimia Nervosa:
Diagnostic Criteria for Subtypes
Purging Type: regularly engages in selfinduced vomiting or the use of laxatives,
diuretics, or enemas
 Nonpurging Type: uses other
compensatory behaviors such as fasting
or excessive exercise
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Bulimia Nervosa:
Behavioral Indicators
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Compulsive eating, emotional eating
Secretive eating, hiding or hoarding food
Visiting bathroom after meals
Compensatory behaviors
Avoiding social engagements involving food
Preoccupation with food, weight, body image
Bulimia Nervosa:
Physical Indicators
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Average or above
average weight
Frequent weight
fluctuations
Swollen glands, puffy
cheeks, broken eye
blood vessels
Dental erosion
Calluses on back of
hands and fingers
Ulcers in mouth
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Cycling between bloating
& dehydration
Sore throat
Acid reflux
Inflammation of
esophagus
Electrolyte imbalances:
depleted potassium,
sodium, chloride
GI complaints
Irregular heartbeat
Bulimia Nervosa:
Psychological Indicators
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Disparaging self for eating too much
Usually aware that behavior is abnormal
Seeking others’ approval and reassurance
Engaging in other self-destructive and
impulsive behaviors
Mood lability, irritability
High comorbidity with personality disorders
Bulimia Nervosa: Facts & Figures
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Common comorbid psychological disorders: anxiety
disorders, mood disorders, substance abuse, cluster C
personality disorders (particularly borderline)
Gender: 90-95% female
Age of onset: late adolescence to early adulthood
Prevalence: 1-3% for women; 0.1-0.3% for men
Highest prevalence: adolescence & young adulthood
Course: chronic or intermittent
Prognosis: poor, particularly without treatment
Racial & cultural factors: primarily white, but increasing
among other cultures
Eating Disorder Not Otherwise
Specified: Diagnostic Criteria
Eating disorder symptoms that do not meet
the criteria for Anorexia or Bulimia:
• Meets criteria for Anorexia except for body
weight or absence of menses
• Meets criteria for Bulimia except for
frequency or amount of food consumed
• Chewing and spitting
• Meets criteria for Binge Eating Disorder
Binge Eating Disorder:
Research Criteria
A.
B.
Recurrent episodes of binge eating:
1) eating an excessive amount of food
2) feeling out of control while eating
Binge eating episodes are characterized by 3+ of
the following:
1) rapid eating
2) eating until uncomfortably full
3) eating large amounts of food when not hungry
4) solitary eating due to embarrassment
5) feeling disgust, depression, guilt after eating
Binge Eating Disorder:
Research Criteria
C.
D.
E.
F.
Marked distress regarding binge eating
Frequency of at least 2 days/week for
6+ months
Does not engage in compensatory
behaviors
Eating is not due to a general medical
condition or the effects of medication
Binge Eating Disorder:
Behavioral Indicators
Eating when not hungry
 Secretive eating, eating little in public
 Emotional eating, compulsive eating
 Constantly dieting
 Restricting activities due to
embarrassment about weight and body
size
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Binge Eating Disorder:
Physical Indicators
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Weight gain, weight fluctuations
GI complaints
Bloating
Fatigue
High blood pressure
High cholesterol
Type II Diabetes
Heart disease
Binge Eating Disorder:
Psychological Indicators
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Feeling out of control over eating
Likened to an addiction
Mood lability, depression
Intense self-hatred/self-criticism
Attributes all perceived failures to weight or
body size
History of trauma is common
Binge Eating Disorder:
Facts & Figures
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Prevalence: 20% of obese people in weight
loss program; 50% among candidates for
gastric bypass surgery
Prognosis: relatively good
Onset: ½ start with dieting and ½ start with
binging
Gender: more equally distributed among men
& women
Eating Disorders:
Contributing Factors
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History of emotional, physical, sexual abuse
History of being teased or ridiculed,
particularly about size or weight
Dysfunctional dynamics & relationships with
family & others
Difficulty identifying & expressing one’s needs
& feelings
Difficulty asserting oneself
Eating Disorders:
Contributing Factors
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Control issues
Low self-esteem
Underlying problems, such as depression,
anxiety, anger, loneliness, insecurity
Cultural emphasis on thinness, beauty, &
physical appearance, particularly for women
Biochemical or hormonal imbalances
Genetic factors
TREATING EATING DISORDERS
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Need for an Integrated,
Multidisciplinary Approach
Psychological Counseling
Nutritional Counseling
Medical Evaluation & Monitoring
Psychiatric Evaluation & Medication
Management
Psychological Counseling
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Thorough assessment
Individual counseling
Involving significant others in treatment
Group counseling
Therapeutic approach: empathic,
nonjudgmental, relational, functional
Empirically validated treatments: Cognitive
Behavioral & Interpersonal
Nutritional Counseling
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Thorough evaluation
Psychoeducation
Individualized eating and exercise plan
Monitoring weight
Ongoing support & encouragement
Medical Care
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Comprehensive medical evaluation
Monitoring weight and vitals
Bloodwork as indicated
Education regarding effects of behaviors
Ongoing medical stabilization, monitoring, and
support
Referral to specialists as indicated
Medical clearance for inpatient treatment
programs
Psychiatric Care
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Comprehensive psychiatric evaluation,
including diagnostic impressions and treatment
recommendations
Medication management: SSRI’s, Wellbutrin,
Effexor, Cymbalta, Atypical Antipsychotics,
Antianxiety
Need for close collaboration with primary
therapist