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Eating Disorders

When Does a Diet Become an Eating Disorder?

Twitter CEO Jack Dorsey's interview sparked discussion about eating disorders.

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Twitter CEO Jack Dorsey recently appeared on a fitness podcast to talk about his eating and exercise habits, which include weekend fasting, restricting weekday food intake to one meal per day, and walking five miles to work on a regular basis. Dorsey claimed that his routine led to greater focus and efficiency (and also feeling like he was hallucinating). His eating patterns were inspired by intermittent fasting diets, which have gained popularity in recent years and should be further researched. After news of Dorsey's interview spread, people responded with concern about whether he has an eating disorder.

In most cases, mental health professionals lack the detailed information needed to answer diagnostic questions about public figures. Moreover, speculating without adequate knowledge is typically considered unethical. While I can't speak to the specifics of Dorsey’s diagnostic status, it is worth demystifying the process that mental health professionals generally use to make that kind of determination with the people they treat.

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What information do mental health professionals use to diagnose an eating disorder?

The Diagnostic and Statistical Manual of Mental Disorder, Fifth Edition defines an eating disorder as “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.” There are several different eating disorder diagnoses, including anorexia nervosa, bulimia nervosa, and binge-eating disorder.

1. Presence

What types of eating disorder symptoms, if any, is the person experiencing? The kinds of symptoms mental health professionals are looking for include dietary restriction (e.g., limiting to certain calorie amounts), binge eating (i.e., eating large quantities of food while experiencing a sense of loss of control), inappropriate compensatory behaviors (e.g., self-induced vomiting, laxative abuse), preoccupation with weight (e.g., thinking about it so much that it interferes with concentration), and others (e.g., basing one’s sense of worth on their body shape).

2. Frequency

How often do the symptoms occur? If someone binge eats three times a year, that would not, in itself, constitute an eating disorder. Meanwhile, binge eating three times per week would exceed the frequency criterion for binge-eating disorder or bulimia nervosa.

3. Persistence

How long have the symptoms lasted? If someone has been excessively exercising (e.g., when sick or seriously injured), it matters whether it’s been a matter of weeks or months.

4. Negative effects

Do the symptoms impair physical health, cause substantial distress, and/or impact functioning? In order to be diagnosed with an eating disorder, the eating-related behaviors must interfere in a significant way, such as the ability to do well in school or have meaningful relationships.

5. Other explanations ruled out

Can the symptoms be better explained by another medical or mental health condition (e.g., decreased appetite due to depression, substance abuse, or gastrointestinal issues) or a cultural/religious explanation (e.g., fasting during Ramadan)? If so, it would be inaccurate to call it an eating disorder.

If a mental health professional finds that someone is experiencing multiple symptoms that are frequent, persistent, cause impairment, and cannot be explained by alternative causes, then an eating disorder is typically diagnosed.

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How do mental health professionals gather diagnostic information?

1. Screening

Assessments for eating disorders often start with a screening tool, which is a brief way to see if someone has symptoms that need more in-depth exploration.

2. Questionnaires

If a screening reveals the presence of eating disorder symptoms, a more in-depth measure should be employed. After the completion of a more comprehensive questionnaire, such as the Eating Disorder Examination-Questionnaire (EDE-Q), the responses are totaled and scored to determine whether the symptoms fall within a typical range compared to the general population, or if they fall within a clinical range that's closer to people who have eating disorders.

3. Interviews

Structured interviews like the Eating Disorder Examination (EDE; the interview version of the EDE-Q) are another method for gathering diagnostic information. Interviews involve the therapist asking questions and following up to make sure that there's a clear understanding of the person's experiences. Interviewing other people (e.g., partners, parents, friends) about the person’s eating behaviors can be helpful for gaining a fuller picture.

4. Medical examinations

Eating disorders can cause serious physical health problems. Physicians are the most appropriate people to evaluate whether there have been negative effects on the body (e.g., electrolyte imbalances, heart rate changes, organ functioning).

If you're struggling with issues that don't quite cross the disorder threshold, you still may want to seek a formal evaluation from a mental health professional. There are effective treatments for eating disorder symptoms available for people with different levels of severity and early intervention can be lifesaving.

To find a therapist near you, visit the Psychology Today Therapy Directory.

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