As a dietitian who specializes in eating disorder recovery nutrition. I often hear therapists outside the eating disorder field say “I don’t work with eating disorders”. I totally understand. You identify with a certain niche and are most often seeing clients within that niche. But, did you know that at least 50% of clients who are diagnosed with a mental illness also struggle with disordered eating? This means a decent portion of the clients you are seeing could be struggling with an eating disorder. Or their relationship with their body. Regardless of whether or not they disclose this to you. Understanding how therapists can screen for an eating disorder may be more important than you think.
The Therapist Role
How therapists can screen for an eating disorder is an integral part of identifying and supporting people with eating disorders. The average time to diagnose an eating disorder is 4 years. However, it can be 10+ years for some individuals to get a diagnosis. Since eating disorders can have many mental and physical symptoms and impacts. It is important that you can recognize the signs of an eating disorder. Then, clients can get the help they need sooner rather than later.
I believe one reason why eating disorders often go unnoticed is because we grow up with a stereotypical understanding of what eating disorders “look like.” For insatnce, white, malnourished, young female. However, eating disorders do NOT discriminate. Just like all other mental health diagnoses. Eating disorders can affect any human from any background, race, gender, ethnicity, age, weight/size and socioeconomic status. Therefore, we need to be screening ALL individuals for eating disorders. With a better understanding of how therapists can screen for an eating disorder, more cases could be diagnosed.
Please consider asking your client the following questions during an initial session. If a client answers yes to any of these questions, please consider referring to an eating disorder dietitian.
1. Is my client exhibiting rigidity with their routines, especially around food?
Ask your client about their eating routine. Determine whether or not they feel flexible with their food choices.
Clients who have rigid schedules or rituals surrounding food may be struggling with their relationship with food. Rigidity around food includes what they eat, how much they eat, who they eat with, and when they eat. This could mean a client arranges their day around their rituals. Conversely, clients may have a rigid exercise regimen that they follow. Regardless of energy, time, or injury. They may avoid or fear disruptions that would interrupt their routines. And continue these habits at the expense of their relationships or sleep.
While many people have preferred routines, the difference is in the individual’s reaction when these rituals are disrupted. A disruption in routine presents an inconvenience to many, but individuals with eating disorders may become agitated and experience intense feelings of anxiety.
2. Does my client feel their self-worth and self-esteem is dependent on body size?
Eating/not eating certain foods? Or how much physical activity they do in a day?
People who struggle with eating disorders may tie their self-esteem to their perception of their body. This perception may be based on how “good” or “bad” they were about eating or avoiding certain foods. It could also depend on the physical activity they do or don’t do. Their ability to act in the way they feel they “should” be acting can directly impact how they view themselves and their daily mood.
This can be especially difficult to navigate. Certain changes in diet or exercise habits may be considered “healthy” in our society. Your client may get positive feedback from friends or family about weight loss or behavior changes. The desire to receive positive feedback may create a cycle in your client’s daily life. They may make more drastic changes to their diet. For insstance, cutting out whole food groups or exercising for excessive amounts of time. If they are unable to maintain the habit, whether for one day or a longer period of time, it can lead to negative feelings and low self-worth.
3. Is my client socially withdrawing, showing decreased interest in activities, irritable, or having mood swings?
Eating disorders, like other mental health illnesses, may lead to social withdrawal or exhibit mood changes.
Restricting food intake can lead to body changes such as low blood sugar. Low blood sugar can cause irritability, poor concentration, and mood swings. Hunger has a similar impact on the body. For instance, if you miss a meal, your head may feel cloudy, you may be more quick to snap at a colleague, or you might not be able to concentrate on important tasks. This is the body’s way of signaling that it needs food. Long-term inadequate food intake can lead to chronic irritability, apathy, and social withdrawal. On the other hand, restriction may lead to binging behaviors and overeating. These contribute to an emotional rollercoaster response.
Of course, social withdrawal doesn’t always indicate disordered eating. This along with other symptoms could be indicative that your client needs more support from not only you, but also a dietitian.
4. Does my client complain of feeling cold, tired, apathetic, or lethargic?
People with eating disorders, especially those that involve severely restricting food consumption, may feel cold, tired, and lethargic. These symptoms even occur in the summer and with adequate amounts of sleep.
Reminder: our clients can be severely restricting even if they do not “look” malnourished.
When the body is deprived of energy, it saves energy any way it can. This includes turning down the internal thermostat. Even in the summer, clients may wear large, warm, baggy clothing. This is done to hide weight loss if weight loss is a consequence of their disorder. Or to stay warm.
Tiredness, apathy, and lethargy may stem from restricted food intake. If your client is limiting their food intake. They may not be eating enough to give them energy to complete daily tasks. Again, continue to screen for any changes.
5. Do you find your conversations are revolving around food or GI distress?
Clients may not always identify “food thoughts” as eating disorder behaviors. Therefore, you may be finding yourself reading between the lines. However, you may find in your sessions there are frequent conversations about food or body image.
Research suggests that food restriction causes increased food preoccupation. Individuals may develop food rituals or spend non-eating time thinking about food. These thoughts may spill over into your sessions. This could look like clients spending (a lot of) time searching for recipes on Pinterest. Or cooking for other people but not themselves. They may also talk about wanting to eat certain foods. But not actually eating them. You can ask questions about their cooking/food habits in your sessions to get a gauge.
Additionally, GI distress may stem from eating disorder behaviors. Or it may influence eating disorder behaviors. These behaviors disrupt normal digestion. Behaviors such as severe restriction, consuming large amounts of food at one time, vomiting, or the use of laxatives can cause disruption. Common GI complaints may be constipation, gastrointestinal reflux or burning sensation in the chest area, bloating, and abdominal pain. On the other hand, GI distress stemming from irritable bowel syndrome, Crohn’s disease, or other GI condition, may serve as a basis for over restricting the variety or quantity of food consumed. A client can develop fears over eating certain foods due to how those foods could potentially impact their GI system.
6. Does your client report concerns about their weight, shape or size?
Clients may have concerns or preoccupation with their weight or how their body looks. The client may feel that their body does not align with their desired ideal. Their desired ideal is influenced by their background and identity. To them, the ideal body may be thinner, more muscular, more masculine, more feminine, more curvaceous, or larger. Other times, the number on the scale may be more important than body shape.
You can simply say to your client: “I’d like to hear a bit more about how you feel in your body and about your body image.”
7. Have you noticed significant weight gain/loss in a short period of time?
Once again: please remember, eating disorders are a mental health illness. They do not always manifest physically! And also, a very small percentage of people with an eating disorder are “underweight.”
In some cases, changes in weight may signify eating disorder behaviors. I’m not talking about slight changes. Rather, significant changes in a relatively short period of time. Generally speaking, I would be more concerned about weight loss than weight gain.
I would also encourage you to be very careful with language when discussing weight/numbers. Instead of commenting on body size, I would recommend probing with other questions about food thoughts, body image and exercise habits. You can reference the questions above! Referring to an eating disorder dietitian in many of these cases might be the best next step.
Eating Disorder Treatment for your Clients
How therapists can screen for an eating disorder plays an important role in recovery. As well as identifying and encouraging clients to seek help for their eating disorders. If you notice some of these behaviors or thought patterns in your clients. Or would like general guidance regarding eating disorders, reach out to us at Courage to Nourish. We offer a variety of resources and expertise in working with individuals with eating disorders.
Eating disorder recovery is possible. We will work closely with you and your client to explore their beliefs and emotions surrounding food and body image. As well as tailor interventions to their specific needs. And support patients through interventions and situations as they arise.
Courage to Nourish is a group of eating disorder specialized dietitians. We have in person locations in Alexandria, Virginia, Columbia, Maryland. and College Park, Maryland. We offer virtual services across the state of Virginia, Washington DC, Pennsylvania, and Colorado. We offer individual nutrition therapy. As well as support groups. We would love to guide you in building a better relationship with food.
Helping my clients cultivate meaningful connections and interests outside of their eating disorder is a true passion of mine. I like to think my clients and I are on a team to navigate recovery. I love working with high school and college students as well as athletes seeking to have a better relationship with exercise. I am a proud anti-diet dietitian and work with my clients through a Health At Every Size © and intuitive eating framework.