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Assessment and Conceptualization: What to Expect in Clients With Eating Disorders Not Otherwise Specified

Counseling professionals use assessment and conceptualization skills to evaluate, understand, organize, and make sense of the client's needs (Hinkle, 1994; Seligman, 2004). To paint a conceptual picture that will be useful during the course of therapy, practitioners must routinely first gain a comprehensive understanding of their client's presenting concerns and reason for referral. To be most effective, they must next cast a wider net to collect all of the clinically significant client data they can about such factors as additional issues pertaining to major life roles (including school, work, and additional major life roles), other relevant aspects of social and personal emotional adjustment, and developmental and family history such as current and past family and parental relationships and previous peer and social experiences. Moreover, they should make observations about the person's help seeking and previous history with counseling during the session and collect relevant medical, psychiatric, substance use, suicidal- ity, and other psychological assessment data (Schwitzer & Rubin, 2012).

To assist counseling professionals in knowing what to anticipate in an intake session, we discuss a comprehensive conceptual picture of clients with EDNOS. This conceptual model is drawn from a series of studies conducted as part of an ongoing clinical research program investigating EDNOS (Schwitzer et al., 1998, 2001, 2008; Schwitzer & Rodriguez, 2002). The model is consistent with the findings of other recent researchers (Peck & Eightsey, 2008).

Eating Disorder Diagnostic Features

First and foremost, assessing for EDNOS means recognizing – and not overlooking – subthreshold eating syndromes when they are present. Counselors should take the lead, engaging clients in clinical exploration during screening, intake, and early sessions. Diagnostically, women with these problems present with combinations of anorexic and bulimic symptoms characterized by restrictive dieting, binging, or purging that occur at levels below minimum DSM-IV- TR requirements for a major ED. In other words, they might at times engage in severe dieting, but not often enough or for a long enough duration to cause severely low body weights; they might binge eat, characterized by discrete time periods of focused, excessive eating that feels out of control, but less frequently than twice per week or for a duration of less than 3 months; and they might compensate inappropriately with self-induced vomiting, misuse of laxatives, or excessive exercise but, once again, less frequently than twice per week or for duration of less than 3 months (APA, 2000a).

In fact, Schwitzer et al. (2001) found that more than 80% of college women in their ED treatment program had symptoms meeting these criteria. Regarding eating behavior, on the basis of two different studies with women in treatment and women not in treatment, about 80% of women with EDs reported occasionally bingeing, and their frequency was in the range of one to three times per month, compared with a mean of zero times per month for women without EDs (Schwitzer et al., 2001, 2008). Regarding anorexic behavior, although these women did report avoiding eating when hungry and engaging in dieting at greater rates than women without EDs, only a modest portion, 13%, reported the severely restrictive dieting often associated with a major ED diagnosis (Schwitzer et al., 2001, 2008). Instead, girls and women with EDNOS were more likely to use a mix of excessive exercise (or weekly exercise with ongoing rumination about the need to exercise more often), vomiting (at rates less than once per month), and laxative use (at rates less than once per month; Fairburn & Bohn, 2005; Shisslak et al., 1995; Wilson et al., 2007; Wonderlich et al., 2007). Taken together, the primary symptoms among those with EDNOS include

• eating binges in which one feels unable to stop;

• avoiding eating, and engaging in dieting and food intake control methods, at greater rates than peers without EDs; and

• managing weight, when it occurs, mostly through exercise augmented by occasional purging via vomiting, laxative use, and the like.

Characteristically, along with overt primary symptoms pertaining to eating and compensating, diagnosable EDs also consist of additional problematic cognitive, behavioral, and psychoemotional features. These features can include intense fears of gaining weight or becoming fat; undue negative influence of body appearance on self-evaluation; and misperceptions of body size, weight, or shape (APA, 2000a). These features are especially salient, and troubling, for girls and women with EDNOS. Here again, counselors should take the lead in inquiring about these symptoms. According to the evidence (Schwitzer et al., 2001, 2008), typical cognitive features of clients with EDNOS might include

• rumination about body appearance, thinness, and eating and weight management;

• preoccupation with food, becoming thinner, burning calories, and having body fat; and

• devotion of excessive amounts of time and thought to eating.

Looking at behavioral features beyond primary symptoms, clients

• are likely to be knowledgeable calorie, fat, and nutritional intake counters;

• might engage in food strategies such as secretive eating or eating meals unusually slowly; and

• are likely to have common fluctuations in their weight.

Looking at closely related psychoemotional features, these individuals generally feel tyrannized by their body and food preoccupations: They

• fear gaining weight;

• feel food controls their life;

• struggle to resist eating and compensatory urges; and

• work to stifle the effects of their preoccupations on their mood, stress levels, and sense of self.

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