Are You Missing Eating Disorders in Your Practice?

Many therapists don’t get adequate training on how to identify and treat eating disorders. If I hadn’t decided to do an extra two-year specializing in eating disorders after I finished graduate school, I never would’ve learned a thing about them. And because so few of us get this type of formalized training, eating disorders can often go unnoticed and undiagnosed in private practice. 

Although this is understandable given the widespread failing of many training programs, it can be dangerous for our clients. Eating disorders are one of the deadliest mental illnesses, second only to opioid addiction. So even if clinicians don’t specialize in treating eating disorders, knowing the right screening questions to ask and when it’s time to make a referral will be critical to helping their clients get the care they need. 

Screening Questions to Identify Eating Disorders

Eating disorders don’t discriminate. Anyone—and I mean anyone—can have an eating disorder. People of all ages, races, genders, sexualties, and socioeconomic status can have eating disorders, but they may present differently in different groups. It only takes a few screening questions to determine whether or not there’s cause for concern, and what your next course of action should be. 

Regardless of what stage of treatment we’re in, whether it’s intake or wrapping up, here are two questions I ask all my clients. 

1. On a scale from 0 to 10—with 10 being the highest—how afraid are you of gaining weight? (If the person is a body builder, I might ask, how afraid are you of “being fat”?) 
2. What do you eat on an average day? Describe to me the type and amount of foods that you eat. 

While these two simple questions don’t address every aspect of every eating disorder, they’re a good place to start. The answers to these questions can point you in the right direction when considering treatment options or referrals. 

Question 1: Determining Fear of Fatness

The first screening question asks about your client’s emotional experience (how afraid they are of gaining weight or “being fat”). In asking this question, we can indirectly assess pathology. This is important for two reasons—people with eating disorders can often lack insight into the problem, and often wish to continue their behaviors in an effort to lose weight. If you ask them something direct like, “Do you struggle with your eating patterns?” they might earnestly tell you no—when in fact they do struggle. As such, inquiring about your clients’ fear levels is a way for you to gain more clear insight into their disorder. 

In general, if a person reports intensely fearing weight gain—at about a seven or higher on the zero to ten scale—it’s very likely they have significant eating and body image pathologies. In these cases, it’s worth some more probing to discover whether the eating pathology is primary, and how urgently it needs to be addressed. 

Question 2: Understanding Feeding Disorders

It’s important to note that not all eating pathology is directly tied to fear of weight gain or “fatness.” Like people with anorexia nervosa, people with the feeding disorder Avoidant and Restrictive Food Intake Disorder (ARFID) have malnourished bodies secondary to a mental illness. 

However, the difference is people with ARFID typically don’t have a fear of weight gain. Instead, they may fear another negative consequence from eating food such as choking, having an allergic reaction, vomiting, or having an aversive sensory experience (like having mushy, gritty, or crunchy foods in their mouth). 

Because fear of weight gain or “fatness” isn’t part of ARFID, asking the second screening question about diet is helpful to screen for this disorder. With this line of questioning, you might discover that your client is only eating foods with a certain quality. For instance, perhaps your client is only consuming liquids as a maladaptive way to manage their fear of choking. Gathering information about the amount and type of food eating in a given day can be helpful in forming a diagnosis, regardless of the level of fear your client reports in the first question.

Daily Food Consumption 

The second screening question is also looking for specific patterns in a client’s food intake. Keep an eye out for these patterns in their responses. 

1. Food restriction: eating too little throughout the day (e.g., 1,000 calories in a day or only a few small snacks.)
2. Food avoidance: eating a limited variety of foods (e.g., avoiding all carbs or crunchy foods.)
3. Binge eating: eating a large amount in one sitting. This can often present as eating nothing (or very little) in the morning and afternoon, and then eating a lot at night.  

To help determine these patterns, you might want to ask follow-up questions like: 

• Do you count calories or try to limit your food intake? 
• Do you avoid specific foods for any reason?
• Do you feel out of control when you eat?
• Do you ever do anything to “make up” for eating such as exercise, take laxatives, take diet pills, or intentionally vomit? 

We can start to identify potential eating disorders when we get a sense of what our clients eat on a typical day. Although this is by no means an assessment for all eating disorder pathology, it’s a start. And you can use the information you gather with these questions to help you decide if you need to screen further. 

Further Screening

If you detect eating and body image pathology during this screening process, you may need to collect further information. If you think your client might be at risk, a good option is to ask them to fill out an EAT-26. This is a simple, 26-item questionnaire that’s available for free on the internet. It can be helpful in gathering more information and choosing the best course of action. 

Next Steps for You to Take

Eating disorders like anorexia nervosa, bulimia nervosa, ARFID, or other specified feeding or eating disorder (OSFED) are typically considered primary disorders—given the life-threatening nature of those illnesses. It’s worth noting that although binge-eating disorder is typically considered to be the least concerning of the disorders, it’s usually still helpful to make a referral. Binge-eating can easily morph into bingeing and purging behavior. 

If you don’t feel properly equipped to treat eating disorders directly, you can still help your client by making an appropriate referral. Check sites like the Academy for Eating Disorders (AED) or the International Association for Eating Disorder Professionals (IAEDP) to find licensed providers in your area. And if you’re interested in getting more training on treating eating disorders yourself, I recommend getting involved with those same organizations as well. 

Additionally, I recommend Overcoming Binge Eating and Cognitive Behavior Therapy and Eating Disorders, both by Christopher Fairburn, MD, for more information on treating eating disorders in adults, and my book Treating Eating Disorders in Adolescents for younger clients. 

It can be overwhelming to notice a pattern or a disorder in your clients and not feel prepared to adequately treat it. By preparing yourself with these two simple questions and a network to lean on and refer out to, you can ensure you’re offering your clients the best care possible.