EATING DISORDERS TREATMENT: AREAS OF FOCUS IN THE INITIAL ASSESSMENT
After basic demographic questions-age, family status, and so on – I ask about eating behaviors. I also explore her social life, sexual history and attitudes, and her use of illicit drugs or alcohol. In later conversations we take a closer look at her answers.
Weight: One important area to explore is the patient’s weight history. I ask patients about their “desired weight.” When a patient who weighs 150 pounds says her ideal weight is 110, I will pursue the matter, asking how realistic she thinks that goal is. Often she responds, “Well, I’d like to hit one hundred and ten, but probably the best I could hope for is one hundred and twenty-five. I did get down to one hundred and twenty once, but only for three days. I felt miserable when I started gaining again.”
Patients often recount their weight history in enormous detail, which is not surprising considering they focus on eating every waking moment. Actually, the ability to recall weight history often provides me with a vital number for anorexics: the weight at which they stopped menstruating. In restoring weight, the target weight needs to be above this level if patients are to overcome their phobia about resuming menses.
I also want to learn about her attitudes toward weight. Does her family comment frequently on weight and appearance? One patient traced her disorder to the fact that whenever her father saw a fat woman he said, “Look at that tub of lard!” She was so concerned he would say that about her-and thus stop loving her- that she began to starve herself.
And what about mealtime behavior? What is dinnertime like? Who is present? What turns does the conversation-if any-take?
I also explore her attitude about her body. What is her body image? Is it accurate or distorted? Does she focus on a particular area? Is there a clash between perception and reality?
Behavior: Next I’ll look at the patient’s behavior related to food and eating. What about dieting? Are certain foods “forbidden”? What are her attitudes about weighing herself and looking in the mirror?
Historical context: In family therapy, it is sometimes said that the calendar tells the story. I look to see how the problem evolved over time, and to find events that might have triggered the disorder. These events may include a loss (death of a relative), change (divorce, relocation), or rejection (breakup of a romance). Some details may emerge in conversations with parents. This isn’t to say that the adults’ perspective is better or more accurate than the patient’s. Both points of view are often needed.
Family: I also want to know the patient’s family background. Does she view her parents as strict or uninvolved? Is she starving for attention? Have there been traumatic events-death, separation, loss of a parent’s job?
Thinking patterns: People with eating disorders often display black-and-white thinking: Everything is all one way or the other, with no room for subtle shadings. During the assessment, I listen for such clues so I can orient therapy to correct distorted ways of thinking.
Social milieu: How well does the patient function outside the family? Does she get along at school or on the job? Does she have friends? A lover? What else is there in her life besides the eating disorder? Obviously, if there is nothing else, giving up her behavior will be that much harder.
Substance abuse: Use of illicit drugs and alcohol severely complicates an eating disorder. I will always ask: Do you use alcohol or drugs? How often? How much? I try to avoid sounding like a prosecutor, but I have to know the facts if I am to be of any help. Detoxification is a critical element in managing eating disorders.
Suicidal feelings: As with substance abuse, if a troubled patient doesn’t bring up the subject of suicidal thoughts, then I will make a point of asking about them directly.
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