Eating disorders are more commonly discussed in our culture, however, much of what people believe they understand about eating disorders is false. Identifying, diagnosing, and treating these disorders is much more complicated than many assume.

What is an Eating Disorder?

An eating disorder sounds self-explanatory and, in some ways, they are. They are disorders related to the way an individual engages with food and eating. More specifically, “feeding and eating disorders are characterized by a persistent disturbance of eating or eating-related behavior that results in the altered consumption or absorption of food and that significantly impairs physical health or psychosocial functioning [1].”

These disorders are all-consuming in that they impact the individual’s physical, psychological, and social well-being.

How do Doctors Diagnose Eating Disorders?

Recognizing signs of an eating disorder is important, however, diagnosis cannot be confirmed based on observation alone. To diagnose eating disorders, doctors, therapists, and psychiatrists must consider specific criteria that are identified and can be measured using psychological assessments as well as physical examinations.

Physical Evaluations

Doctors can utilize physical examinations to determine the presence of eating disorder behaviors as well as their severity. An individual’s labs and vital signs can indicate that an individual is malnourished or engaging in binge/purge behaviors. Other physical signs of eating disorders that a Doctor may consider in their diagnosis include:

Any severe weight gain/loss/fluctuations.
Gastrointestinal complaints.
Menstrual irregularities in females.
Fainting/dizziness.
Problems falling or staying asleep.
Feeling cold all the time.
Soft, downey, hair on the body.
Difficulty regulating body temperature.
Dental problems.
Calluses on tops of knuckles.
Dry brittle nails/hair/skin.
Muscle weakness
Yellow skin
Impaired immune functioning.

Psychological Evaluations

Psychological evaluations can go beyond diagnostic criteria to learn more about the specific beliefs regarding food, body, weight, and self-worth and how these relate to eating disorder behaviors. The most common psychological assessments for eating disorder behaviors include the following:

EAT-26 (Eating Attitudes Test): A 26-item test asking questions related to attitudes, beliefs, feelings, and behaviors on eating.
EDE (Eating Disorder Examination): Viewed as the “gold standard” for assessing eating disorder behaviors, the EDE “provides a measure of the range and severity of eating disorder features. It can also generate operational eating disorder diagnoses [2].”
EDE-Q (Eating Disorder Examination – Questionnaire): Based off of the EDE, the EDE-Q is intended for situations when the interview is not clinically recommended or possible. The EDE-Q “designed to assess eating disorder psychopathology [3].”
CET (Compulsive Exercise Test): a 24-item test intended to measure compulsive exercise behaviors.

Eating Disorder Diagnostic Criteria

While symptoms indicative of an eating disorder may be present in an individual, this does not necessarily mean that they meet criteria required for an official diagnosis. This diagnostic criteria is specified by the American Psychological Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) and identifies not only the behaviors that must be present but the frequency and duration these must have been occurring at as well as psychology behind the behaviors [1].

The DSM-5 does provide diagnostic criteria to specify severity as well, which differs depending on the specific disorder. The criteria one must meet for the three most common eating disorder diagnoses are specified below.

Related Reading

Anorexia Nervosa

The National Institute of Mental Health specifies that Anorexia Nervosa involves “a significant and persistent reduction in food intake leading to extremely low body weight; a relentless pursuit of thinness; a distortion of body image and intense fear of gaining weight; and extremely disturbed eating behavior [4].”

To meet full criteria for an eating disorder, an individual must meet the following criteria:

Restriction of energy intake relative to requirements, leading to significantly low body weight in the context of age, sex, developmental trajectory, and physical health,
Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight,
Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight [1].

Further, Anorexia Nervosa criteria specifies identification of the subtypes “Restricting Type” Anorexia Nervosa and “Binge-eating/Purging Type” Anorexia Nervosa [1].”

The severity specifiers for Anorexia Nervosa depend on the Body Mass Index (BMI) of the individual [1].

Bulimia Nervosa

Bulimia Nervosa is an eating disorder characterized by binge eating episodes followed by compensatory behaviors to “purge” the food consumed during the episode.

The DSM-5 specifies that the following criteria must be met for a full Bulimia Nervosa diagnosis:

Recurrent episodes of binge eating, which are characterized by BOTH of the following
- “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.
- 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).
Recurrent, inappropriate compensatory behaviors in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise.
The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months.
Self-evaluation is unduly influenced by body shape and weight.
The disturbance does not occur exclusively during episodes of anorexia nervosa [1].

Severity of Bulimia Nervosa is determined by the average episodes of inappropriate compensatory behaviors an individual engages in per week [1].

Binge Eating Disorder

Individuals struggling with Binge Eating Disorder (BED) engage in binge eating episodes that negatively impact their daily life. Binge eating episodes involve eating an atypically large amount of food in a short period of time with the individual reporting feelings of loss of control during the episode and immense shame and guilt afterward. These individuals do not engage in compensatory behaviors to purge the food consumed as in Bulimia Nervosa.

The DSM-5 provides the following criteria for BED:

Recurrent episodes of binge eating, which are characterized by BOTH of the following
- “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.
- 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).
The binge-eating episodes are associated with three (or more) of the following:
Eating much more rapidly than normal.
Eating until feeling uncomfortably full..
Eating large amounts of food when not feeling physically hungry.
Eating alone because of feeling embarrassed by how much one is eating.
Feeling disgusted with oneself, depressed, or very guilty afterward.
Marked distress regarding binge eating is present.
The binge eating occurs, on average, at least once a week for 3 months.
The binge eating is not associated with the recurrent use of inappropriate compensatory behavior as in bulimia nervosa and does not occur exclusively during the course of bulimia nervosa or anorexia nervosa [1].”

Severity of BED diagnosis is related to the number of binge episodes one engages in per week [1].

What to do After an Eating Disorder Diagnosis

Once diagnosed, it is important to seek out the assistance of eating disorder professionals to determine next steps. Your Primary Care Doctor or Outpatient Therapist may be well-qualified in their field, however, eating disorder expertise is required in order to give appropriate treatment recommendations.

Your doctor or therapist may be able to refer you. If this is not possible, call your insurance company to learn about eating disorder professionals in your area. You might also use directories from trusted eating disorder organizations, such as Eating Disorder Hope, to learn about eating disorders, resources, treatment, and more.

References

[1] American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).

[2] Unknown (2021). Measures. Enhanced Cognitive Behavior Therapy. Retrieved from https://www.cbte.co/for-professionals/measures/#ede.

[3] Jennings, K., Phillips, K. E. (2018). Eating Disorder Examination – Questionnaire (EDE-q): norms for a clinical sample of males. Archives of Psychiatric Nursing.

[4] Unknown (2017). Eating disorders. National Institute of Mental Health. Retrieved from https://www.nimh.nih.gov/health/statistics/eating-disorders#part_155057.

Author: Margot Rittenhouse, MS, LPC, NCC
Page Last Reviewed and Approved By: Jacquelyn Ekern, MS, LPC / 12.6.21

Testing and Assessments for Eating Disorders

What is an Eating Disorder?