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Multidisciplinary Management of Complicated Eating Disorder Patients on University and College Campuses

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Title: Multidisciplinary Management of Complicated Eating Disorder Patients on University and College Campuses


1
Multidisciplinary Management of Complicated
Eating Disorder Patients on University and
College Campuses
  • American College Health Association Annual
    Meeting
  • June 4, 2010
  • Marni Greenwald, MD and Elizabeth Wettick, MD
  • University of Pittsburgh Student Health Service

2
Disclosure
  • We have no financial relationship with a
    commercial entity producing health-care related
    products and/or services

3
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7
Eating Disorders and the Internet
  • On pro-eating disorder websites, anyone can find
  • Crash dieting techniques and recipes
  • People competing with each other to lose weight
    and people who fast together
  • People commiserating with one another after
    breaking a fast or binging
  • Advice on how to best induce vomiting and on
    using laxatives and emetics
  • Tips on hiding weight loss from parents and
    healthcare providers
  • Information on reducing the side-effects of
    anorexia
  • People posting their weight, body measurements,
    details of their dietary regimen, or pictures of
    themselves to solicit acceptance and affirmation
  • Suggested ways to ignore or suppress hunger

8
Objectives
  1. Define the three categories of eating disorders
    delineated in the diagnostic and statistical
    manual of mental disorders fourth edition
    (DSM-IV)
  2. Review the history and physical examination
    findings presented by patients with eating
    disorders
  3. Recognize the medical and psychological
    complications of eating disorders
  4. Describe a multidisciplinary model that can be
    used to effectively manage eating disorder
    patients on university and college campuses
  5. Discuss legal and ethical dimensions of
    challenging eating disorder cases on university
    and college campuses
  6. Identify potential triggers necessitating the
    need for referral to a higher level of care

9
Background Facts and Stats
  • Lifetime prevalence
  • Anorexia nervosa 0.6
  • Bulimia nervosa 1
  • Eating disorder not otherwise specified 3-5
  • Approximately 10 of eating disordered
    individuals coming to the attention of mental
    health professionals are male
  • Eating disorders are among the most common
    psychiatric problems that affect young women and
    are a significant cause of morbidity and
    mortality among adolescents and young adults
  • Although eating disorders can begin in adulthood,
    the highest incidence is between 10 and 19 years
    of age
  • Eating disorders affect people of all ages,
    genders, races, socioeconomic statuses and
    ethnicities most common among whites in
    industrialized nations

10
  • The average American woman is 54 tall and
    weighs 140 pounds
  • The average American model is 511 tall and
    weighs 117 pounds

11
Americans spend more than 40 billion dollars a
year on dieting and diet-related products
12
Background Facts and Stats
  • Anorexia has the highest mortality rate of any
    mental illness
  • The mortality rate among people with anorexia has
    been estimated at 0.56 percent per year, or
    approximately 5.6 percent per decade, which is
    about 12 times higher than the annual death rate
    due to all causes of death among females ages
    15-24 in the general population
  • Research dollars spent on eating disorders
    averaged 1.20 per affected individual, compared
    to over 159.00 per affected individual for
    schizophrenia
  • Four out of ten Americans either suffered from or
    have known someone who has suffered from an
    eating disorder
  • Eating disorders are common among college students

13
Background National Eating Disorders Association
(NEDA) 2006 Data
  • NEDA polled 1,002 male and female undergraduate
    and graduate students of various ethnicities on
    private and public campuses
  • Poll Results
  • More than half of those polled (55.3) said they
    know at least one person who has struggled with
    an eating disorder
  • Only 37.8 felt their lives were not personally
    impacted by an eating disorder
  • Of the 19.6 who admit to having personally had
    an eating disorder at some time, nearly 75 of
    those had never received or sought treatment
  • Students who have dieted and avoided or skipped
    meals (80.9 and 74.7, respectively)
  • Students who know someone who compulsively
    exercises more than two hours at a time, more
    days of the week than not (44.4), purges by
    vomiting (38.8), uses laxatives to lose weight
    (26)

14
Background American College Health Association
National College Health Assessment
  • Fall 2009 Data
  • 34,208 students 57 schools
  • Within the last 12 months, diagnosed or treated
    by a professional for the following ()
  • Anorexia (Valid responses 33,563 or 98.1)
  • Male 0.6
  • Female 1.0
  • Bulimia (Valid responses 33,526 or 98)
  • Male 0.5
  • Female 1.0

15
Background 2005 Youth Risk Behavior Survey
  • These are the students matriculating onto our
    campuses
  • 32 of adolescent girls believed that they were
    overweight and 61 were attempting to lose weight
  • 6 reported that they had tried vomiting or had
    taken laxatives to help control their weight in
    the 30 days before questioning

16
Background Etiology
  • Unknown
  • Multifactorial
  • Risk Factors
  • Certain personality traits
  • Low self-esteem
  • Difficulty expressing negative emotions
  • Difficulty resolving conflict
  • Being a perfectionist
  • Participation in activities that promote thinness
  • Ballet dancing
  • Modeling
  • Athletics (e.g. gymnastics, swimming)

17
Background Psychiatric Comorbidity
  • Psychiatric comorbidity is extremely common and
    must be considered in eating disorder patients
  • Major depression is the most common comorbid
    condition among patients with anorexia with a
    lifetime prevalence of as high as 80
  • Anxiety disorders are also common
  • Obsessive compulsive disorder has a prevalence of
    30 among patients with eating disorders
  • Substance abuse prevalence is estimated at 12-18
    in patients with anorexia and 30-70 in patients
    with bulimia
  • Personality disorders are also common
  • Bulimia nervosa Cluster B (dramatic/erratic)
  • Anorexia nervosa Cluster C (avoidant/anxious)

18
Background Factors Specific to the College
Population
  • Transition to college
  • Finding healthy eating choices
  • Difficulty developing and/or maintaining healthy
    meal patterns
  • Influence of others body image concerns
  • Increase in feelings of lack of control and
    overwhelmed
  • Unrealistic about ability to manage both symptoms
    and college

19
DEFINITIONS
  • The criteria for diagnosing a patient with an
    eating disorder according to the Diagnostic and
    Statistical Manual of Mental Disorders (DSM-IV)
    published by the American Psychiatric Association
    in 1994
  • Anorexia Nervosa (AN)
  • Bulimia Nervosa (BN)
  • Eating Disorder Not Otherwise Specified (EDNOS)
  • Binge Eating Disorder (BED)

20
Anorexia Nervosa
  • Refusal to maintain body weight at or above a
    minimally normal weight for age and height (e.g.
    weight loss leading to maintenance of body weight
    less than 85 of that expected or failure to
    make expected weight gain during period of
    growth, leading to body weight less than 85 of
    that expected)
  • Intense fear of gaining weight or becoming fat,
    even though underweight
  • Disturbance in the way in which one's body weight
    or shape is experienced, undue influence of body
    weight or shape on self-evaluation, or denial of
    the seriousness of the current low body weight
  • Amenorrhea (at least three consecutive cycles) in
    postmenarchal girls and women

21
Anorexia Nervosa
  • The DSM-IV specifies two subtypes
  • Restricting Type during the current episode of
    anorexia nervosa, the person has not regularly
    engaged in binge-eating or purging behavior (that
    is, self-induced vomiting, or the misuse of
    laxatives, diuretics, or enemas). Weight loss is
    accomplished primarily through dieting, fasting,
    or excessive exercise
  • Binge-Eating Type or Purging Type during the
    current episode of anorexia nervosa, the person
    has regularly engaged in binge-eating OR purging
    behavior (that is, self-induced vomiting, or the
    misuse of laxatives, diuretics, or enemas)

22
Bulimia Nervosa
  • Recurrent episodes of binge eating. An episode of
    binge eating is characterized by both of the
    following
  • Eating, in a fixed period of time, an amount of
    food that is definitely larger than most people
    would eat under similar circumstances. Mainly
    eating binge foods.
  • A lack of control over eating during the episode
    a feeling that one cannot stop eating or control
    what or how much one is eating.
  • Recurrent inappropriate compensatory behavior to
    prevent weight gain, such as self-induced
    vomiting misuse of laxatives, diuretics, or
    other medications fasting excessive exercise.
  • The binge eating and inappropriate compensatory
    behaviors occur, on average, at least twice a
    week for three months.
  • Self-evaluation is unduly influenced by body
    shape and weight
  • The disturbance does not occur exclusively during
    episodes of anorexia nervosa.

23
Bulimia Nervosa
  • There are two sub-types of bulimia nervosa
  • Purging type bulimics self-induce vomiting
    (usually by triggering the gag reflex or
    ingesting emetics such as syrup of ipecac) to
    rapidly remove food from the body before it can
    be digested, or use laxatives, diuretics, or
    enemas.
  • Non-purging type bulimics (approximately 6-8
    of cases) exercise or fast excessively after a
    binge to offset the caloric intake after eating.
    Purging-type bulimics may also exercise or fast,
    but as a secondary form of weight control.

24
Eating Disorder Not Otherwise Specified
  • More than 50 of eating disorder cases in the
    community
  • Include disorders that do not meet the criteria
    for a specific eating disorder, for example
  • For females, all of the criteria for AN are met
    except that the individual has regular menses
  • All of the criteria for AN are met except that,
    despite substantial weight loss, the individual's
    current weight is in the normal range
  • All of the criteria for BN are met except that
    binge eating and inappropriate compensatory
    mechanisms occur at a frequency of less than
    twice a week or for a duration of less than 3
    months
  • The regular use of inappropriate compensatory
    behavior by an individual of normal body weight
    after eating small amounts of food (i.e.
    self-induced vomiting after the consumption of
    two cookies)
  • Repeatedly chewing and spitting out, but not
    swallowing, large amounts of food

25
DSM-V Proposed Diagnostic Criteria for BED
  • Recurrent episodes of binge eating. An episode of
    binge eating is characterized by both of the
    following
  • Eating, in a discrete period of time (e.g. within
    any 2-hour period), an amount of food that is
    definitely larger than most people would eat in a
    similar period of time under similar
    circumstances
  • A sense of lack of control over eating during the
    episode (e.g. a feeling that one cannot stop
    eating or control what or how much one is eating)
  • The binge-eating episodes are associated with
    three or more of the following
  • Eating much more rapidly than normal
  • Eating until feeling uncomfortable full
  • Eating large amounts of food when not feeling
    physically hungry
  • Eating alone because of being embarrassed by how
    much one is eating
  • Feeling disgusted with oneself, depressed, or
    very guilty after overeating

26
DSM-V Proposed Diagnostic Criteria for BED
Continued
  • C. Marked distress regarding binge eating is
    present
  • The binge eating occurs, on average, at least
    once a week for three months
  • E. The binge eating is not associated with the
    recurrent use of inappropriate compensatory
    behavior (i.e. purging) and does not occur
    exclusively during the course of bulimia nervosa
    or anorexia nervosa

27
Screening
  • A number of tools to identify patients with
    eating disorders have been developed
  • The diagnosis of eating disorders can be elusive
    and more than one half of all cases go undetected
  • SCOFF Questionnaire
  • Do you make yourself Sick because you feel
    uncomfortably full?
  • Do you worry you have lost Control over how much
    you eat?
  • Have you recently lost more than One stone (14
    pounds or 6.35 kg) in a three month period?
  • Do you believe yourself to be Fat when others say
    you are too thin?
  • Would you say that Food dominates your life?

28
Screening
  • the Eating disorder Screen for Primary care (ESP)
  • Are you satisfied with your eating patterns? (No
    is abnormal)
  • Do you ever eat in secret? (Yes is abnormal)
  • Does your weight affect the way you feel about
    yourself? (Yes is abnormal)
  • Have any members of your family suffered with an
    eating disorder? (Yes is abnormal)
  • Do you currently suffer with or have you ever
    suffered in the past with an eating disorder?
    (Yes is abnormal)
  • Eating Attitude Test (EAT-26) is a self-report
    instrument available free online

29
Eating Disorder Patient Assessment History
  • Patients with eating disorders may present with a
    wide range of symptoms, for example, those with
    milder illness may have nonspecific complaints
    like fatigue or dizziness
  • Other presenting symptoms may include
    amenorrhea, sore throat, abdominal pain,
    constipation, palpitations
  • History
  • Past medical history
  • Family history, including eating disorders,
    obesity, depression
  • Psychiatric history, including prior eating
    disorder diagnosis and treatment and psychiatric
    co-morbidities
  • Medications, including diet pills, laxatives and
    diuretics
  • Social history, including substance use and
    living arrangement
  • Menstrual history
  • Review of systems
  • Other exercise, caffeine, self-harm behaviors,
    weight history, binge/purge behaviors, support

30
Eating Disorder Patient Assessment Physical
Examination
  • Many patients may have a completely normal
    physical exam, which does not rule out an eating
    disorder
  • Accurate height and weight assessment
  • Consider the following with respect to obtaining
    weight
  • Post-void
  • Gowned
  • Back to the scale
  • Example University of Pittsburgh Student Health
    Service (sticker on chart)
  • Vital Signs Temperature, pulse, blood pressure,
    consider orthostatic blood pressure and pulse
  • Bradycardia
  • Tachycardia
  • Hypotension
  • Hypothermia
  • Orthostasis

31
Eating Disorder Patient Assessment Physical
Examination
  • General appearance Emaciated, sunken cheeks,
    sallow skin, flat affect
  • HEENT Sunken eyes, dry mucous membranes, loss of
    tooth enamel, parotid gland hypertrophy,
    subconjunctival hemorrhage, cavities
  • Breasts Atrophy
  • Cardiac examination Bradycardia, arrhythmia
  • Abdominal examination Scaphoid, masses, tender
    epigastrium, bloating, palpable stool
  • Skin and extremity evaluation Dryness, bruising,
    cutting, lanugo (fine body hair), Russells sign
    (calluses on the dorsum of the dominant hand),
    loss of subcutaneous fat, nail changes, edema
    (Refeeding Syndrome), hair changes, acrocyanosis
  • Neuromuscular Trousseaus sign (hypocalcemia)
  • GU Hypoestrogenized vaginal mucosa

32
Eating Disorder Patient Assessment Labs
  • Complete blood count
  • Leukopenia is not uncommon
  • In severe cases, pancytopenia may be present
  • Anemia
  • Glucose
  • Electrolytes (e.g. sodium, potassium, magnesium,
    phosphorous)
  • Hypokalemia as a result of vomiting, laxative
    and/or diuretic use
  • Metabolic alkalosis from vomiting
  • Hyponatremia from excessive water intake
  • Blood urea nitrogen and creatinine
  • Thyroid function tests
  • Liver function tests, which may be elevated

33
Levels Usually Associated with Purging
Method of Purging Serum Levels Serum Levels Serum Levels Serum Levels Serum Levels Urine Levels Urine Levels Urine Levels
Sodium Potassium Chloride Bicarbonate pH Sodium Potassium Chloride
Vomiting ??? ? ? ? ? ? ? ?
Laxatives ?? ? ?? ?? ?? ? ? ??
Diuretics ?? ? ? ? ? ? ? ?
Mehler PS. Bulimia Nervosa. NEJM 2003 349
875-881
34
Eating Disorder Patient Assessment Labs
  • Amenorrhea
  • Pregnancy test (urine or blood)
  • Consider the following blood tests
  • Thyroid stimulating hormone (TSH)
    Hyper/hypothyroidism
  • Prolactin Prolactinoma
  • Follicle stimulation hormone (FSH) Premature
    ovarian failure
  • Dehydroepiandrosterone sulfate (DHEAS) Adrenal
    tumor
  • Free testosterone Polycystic ovary syndrome
    (PCOS)/hyperandrogenism
  • Estradiol Hypothalamic amenorrhea/progestin
    challenge

35
Eating Disorder Patient Assessment Labs
  • Most laboratory values will be within normal
    limits in anorectic patients who restrict until
    the late stages of the illness

36
Eating Disorder Patient Assessment Other
  • Urinalysis specific gravity (rule out water
    loading) and ketones
  • Dual energy X-ray absorptiometry (DEXA) to
    measure bone mineral density (BMD)
  • The International Society for Clinical
    Densitometry recommends that BMD in premenopausal
    women be expressed as Z-scores to compare to age-
    and sex-matched controls
  • To evaluate for bone loss, a DEXA scan should be
    obtained in patients who have had amenorrhea for
    longer than six months
  • EKG arrhythmia, bradycardia, U-waves, prolonged
    QT
  • Echocardiogram
  • Holter Monitor
  • Celiac Panel

37
Differential Diagnosis
  • Other causes of weight loss and/or vomiting must
    be considered, for example
  • Hyperthyroidism
  • Malignancy
  • Inflammatory Bowel Disease
  • Immunodeficiency
  • Celiac Disease
  • Chronic infections
  • Addisons Disease
  • Diabetes
  • Primary Depression
  • Most patients with a medical condition that leads
    to eating problems and weight loss express
    concern over their weight loss however, eating
    disorder patients have a disordered body image
    and express a desire to be underweight

38
Medical Complications of Eating Disorders
  • Complications of eating disorders can affect
    nearly every organ system
  • Most pathophysiological complications are
    reversible with improved nutritional status or
    remittance of abnormal eating and purging
    behaviors
  • Some medical complications are irreversible or
    have later repercussions on health, especially
    those affecting the skeleton, reproductive
    system, and brain
  • Dental problems, growth retardation, and
    osteoporosis are some of the long-term problems
  • Cardiac EKG abnormalities (prolonged QT),
    arrhythmias, sudden death, mitral valve prolapse,
    congestive heart failure, diet pill toxicity
    (palpitations, hypertension), cardiomyopathy
    (ipecac syrup)

39
Medical Complications of Eating Disorders
  • Endocrine Amenorrhea, hypoglycemia, infertility,
    thyroid abnormalities
  • Neurologic Cognitive changes, seizures,
    peripheral neuropathy
  • GI Bloating/fullness, constipation, delayed
    gastric emptying, dental erosions in bulimic
    patients, esophageal rupture, esophagitis
  • Pulmonary/mediastinal Pneumothorax, aspiration
    pneumonitis, pneumomediastinum
  • Metabolic Refeeding syndrome, electrolyte
    abnormalities

40
Refeeding Syndrome
  • Potentially fatal
  • Caused by rapid changes in fluids and
    electrolytes
  • Especially at risk severely underweight (lt75
    IBW) and/or recent rapid weight loss
  • Occurs when patients are fed orally, enterally
    (tube feedings), or parenterally (intravenously
    TPN)
  • At risk during the first 2-3 weeks of refeeding,
    especially first 4 days
  • Defined primarily by manifestations of
    hypophosphatemia
  • Cardiovascular collapse
  • Rhabomyolysis
  • Seizures
  • Delirium

41
Refeeding Syndrome
  • Hypophosphatemia
  • Depleted intracellular phosphate stores
  • Results in impaired energy stores (adenosine
    triphosphate) and tissue hypoxia (erythrocyte 2,
    3 diphosphoglycerate)
  • Heart failure due to an increased circulatory
    volume and depressed myocardial function
    (decreased myocardial mass and hypophosphatemia)
  • Hypokalemia (insulin secretion) and
    hypomagnesemia (unknown etiology) can lead to
    cardiac arrhythmias
  • Wernickes encephalopathy (delirium) due to
    thiamine deficiency

42
Osteoporosis/Osteopenia
  • One of the most severe complications of anorexia
    and one of the more difficult to reverse
  • The pathogenesis of bone loss in anorexia is not
    entirely clear
  • Osteopenia is marked by increased bone resorption
    and decreased bone formation
  • To evaluate for bone loss, a DEXA scan should be
    obtained in patients who have had amenorrhea for
    longer than six months
  • Bone loss can be detected within a year of
    illness and may progress to produce fractures
  • Long-term follow-up of adolescents with anorexia
    suggests that catch up of bone density is
    possible if overall health improves

43
Osteoporosis/Osteopenia
  • The primary treatment for bone loss is WEIGHT
    GAIN
  • Menses typically resume within 6 months of
    achieving 90 of IBW
  • Bisphosphonates should not be used in young women
  • Recommend calcium and vitamin D
  • Controversial efficacy of hormones, exercise,
    insulin-like growth factor, antiresorptive
    agents, estrogen and DHEA combined

44
Treatment Anorexia Nervosa
  • According to a 2007 systematic review of
    randomized controlled trials published in the
    International Journal of Eating Disorders,
    evidence for the effectiveness of anorexia
    treatment is weak
  • Treatment guidelines largely rely on expert
    recommendations
  • Treating AN involves the following
  • Restoring the person to a healthy weight
  • Treating the psychological issues related to the
    eating disorder
  • Reducing or eliminating behaviors or thoughts
    that lead to disordered eating
  • Preventing relapse
  • Expected rate of weight gain
  • 2-3 pounds/week (inpatient) 0.5-1 pound/week
    (outpatient)
  • Early in the refeeding process, despite low
    calorie intake, patients may gain weight due to
    fluid retention and a low metabolic rate
  • The number of calories required for weight gain
    rapidly increases as body weight increases

45
Treatment Anorexia Nervosa
  • Some research suggests that the use of
    medications, such as antidepressants,
    antipsychotics, or mood stabilizers, may be
    modestly effective in treating patients with
    anorexia by helping with mood and anxiety
    symptoms that often co-exist with anorexia
  • No medication has shown to be effective in
    restoring a patient to a healthy weight
  • No strong evidence supports drug treatment either
    in the acute or maintenance phases of the illness

46
Treatment Anorexia Nervosa
  • Different forms of psychotherapy, including
    individual, group, and family-based, can help
    address the psychological reasons for the illness
  • Unfortunately, no specific psychotherapy appears
    to be consistently effective for treating adults
    with anorexia
  • For adolescents, family psychotherapy as
    practiced according to the Maudsley method is
    recommended (moderate evidence and beneficial
    effect)
  • Parents are placed in charge of refeeding the
    affected child in the home

47
Treatment Bulimia Nervosa
  • Treating bulimia involves reducing or
    eliminating binge and purge behavior by the
    following
  • Nutritional counseling
  • Psychotherapy
  • Cognitive behavioral therapy (CBT), which
    emphasizes the relationship of thoughts and
    feelings to behavior, is the most effective
    psychotherapy for patients with bulimia and has
    demonstrated efficacy in changing binging and
    purging behaviors
  • The efficacy of CBT has been convincingly
    demonstrated in randomized, controlled trials
  • CBT has been found to be effective for
    non-specified eating disorder(s) similar to
    bulimia nervosa
  • Alternative psychotherapy Interpersonal therapy
  • Therapy may be individual or group-based

48
Treatment Bulimia Nervosa
  • Medication
  • Various classes of antidepressants have been
    demonstrated in short-term, double-blind,
    placebo-controlled trials, to be effective in
    reducing the severity of symptoms of bulimia
  • Some antidepressants may help patients who also
    have depression and/or anxiety
  • Fluoxetine, a selective serotonin reuptake
    inhibitor (SSRI), is the only medication
    approved by the Food and Drug Administration
    (FDA) for treating bulimia recommended in a dose
    that is higher than is typically used for
    depression (60 mg)

49
Treatment Bulimia Nervosa
  • Medication
  • There is less evidence of efficacy for other
    SSRIs
  • A combination of an antidepressant and CBT
    appears to be more effective in reducing the
    frequency of binging and purging behaviors than
    either treatment alone
  • SSRIs are recommended as first line because of
    their effectiveness and safety profile
  • Bupropion is contraindicated because of the risk
    of seizures in patients who purge
  • Further studies required Topiramate and
    Ondansetron

50
Treatment Eating Disorders
  • One study suggests that an online intervention
    program may prevent some at-risk college women
    from developing an eating disorder
  • Taylor CB, et al. Prevention of Eating Disorders
    in At-risk College-age Women. Archives of General
    Psychiatry. August 2006
  • A long-term, large-scale NIH funded study has
    found that an Internet-based intervention program
    may prevent some high risk, college-age women
    from developing an eating disorder
    (http//www.nimh.nih.gov/publicat/eatingdisorders.
    cfm)
  • There is currently an on-line intervention study
    for treatment of bulimia being conducted at our
    tertiary care referral center several of our
    students are enrolled

51
Treatment Multidisciplinary Approach
  • Clinician
  • Assess medical complications
  • Monitor weight and studies (i.e. labs, DEXA, EKG)
  • Dietitian
  • Assessment of current diet
  • Provide information on a healthy diet and meal
    planning
  • Assist the team in identifying appropriate weight
    goals
  • Behavioral health care professional
  • Provide psychotherapy, including cognitive
    behavioral therapy
  • Assist with pharmacotherapy

52
Prognosis and Outcomes
  • The prognosis of patients with eating disorders
    is variable
  • Anorexia Nervosa
  • General consensus 50 good 30 intermediate
    20 poor
  • Associated with a good outcome short duration of
    illness
  • Associated with a poor outcome presence of
    psychiatric comorbidity(ies)
  • Mortality rate six times that of peers without
    anorexia
  • Bulimia Nervosa
  • The percentages are similar in bulimic patients
    45 good 18 intermediate 21 poor
  • Factors that predict improved outcomes for eating
    disorders include early age at diagnosis, brief
    interval before initiation of treatment, good
    parent-child relationships, and having other
    healthy relationships with friends or therapists
  • American Family Physician. 2003 Jan 1567(2)297-3
    04.

53
University of Pittsburgh
  • Eating Disorder Treatment Team (EDTT)
  • Student Health Service Eating Disorder Protocol
  • Current withdrawal process
  • University of Pittsburgh Course Withdrawal
    Procedure
  • Case presentations

54
Multidisciplinary Model Eating Disorder
Treatment Team (EDTT)
  • EDTT
  • Counseling Center
  • Student Health Service
  • Physician (opt-in)
  • Dietitian
  • Referral process
  • Meets monthly
  • Collaborative model
  • Craft the following for higher risk students
  • Individualized Treatment Plan
  • Contracts in consultation with legal
  • Authorization for Release of Information

55
Authorization for Release of Information
56
EDTT Multidisciplinary Approach
  • Clinician
  • Assess medical complications
  • Monitor weight and studies (i.e. labs, DEXA, EKG)
  • Dietitian
  • Assessment of current diet
  • Provide information on a healthful diet and meal
    planning
  • Assist the team in identifying appropriate weight
    goals
  • Behavioral health care professional
  • Provide psychotherapy, including cognitive
    behavioral therapy
  • Assist with pharmacotherapy

57
Dietitian Background
  • University of Pittsburgh employs a full-time
    Registered Dietitian, trained in motivation
    interviewing, within the Office of Health
    Education and Promotion
  • Able to see students year round within 7-10 days
    for assessment
  • Initial assessment appointment is 45 minutes
  • Sees patients with all nutritional questions,
    concerns, and conditions
  • Vegetarian or vegan, irritable bowel syndrome,
    anemia, hypercholesterolemia, weight loss, sports
    nutrition, diabetes, hypertension
  • The ultimate goal is to improve the students
    relationship with food and eating
  • Nutrient and caloric requirements are
    individualized

58
Dietitian Two Page Initial Assessment for Eating
Disorder Patients
59
Dietitian Areas of Emphasis on Eating Disorders
Nutritional Assessment
  • Weight history
  • Behavior history
  • Restriction, purging, pills, binging, exercise,
    smoking, alcohol, spitting, caffeine, gum,
    supplements
  • Past diet instruction, nutrition knowledge, and
    sources
  • Functional habits and past medical history
  • Menses, bowel function, appetite, medications
  • Assessment of living situation
  • On or off campus, shopping, transportation, meal
    plan, finances, single living, support, family
    awareness, relationship with food, social eating
  • 24-hour dietary recall
  • Timing, location, satiety and hunger cues,
    bedtime, availability
  • Plans/Goals/Individualized Recommendations

60
Dietitian Follow-Up
  • Length of visit 15-20 minutes
  • Frequency
  • Very individualized
  • Weekly (initially, concerning patients) or
    biweekly depending on other members of the EDTT
  • With length of treatment, may decrease
    appointment frequency for encouragement and
    support rather than nutrition education
  • May see until graduation (undergraduate and
    graduate students)
  • No cap on number of appointments
  • Student health fee (flat 85.00/semester fee, no
    third party billing)

61
Dietitian Individual Recommendations
  • Very individualized based on the following
  • Motivation to change
  • Stages of Change Model, Prochaska and DiClemente
  • Tolerance to change
  • Accepting the ramifications of change (e.g.
    grocery bill and jean size)
  • Focus on reducing negative aspects of the
    disorder
  • Hunger, fatigue, constipation
  • Collaboration with the student
  • Nutrient versus caloric need

62
Dietitian Campus Education
  • Bulletin boards in clinic for National Eating
    Disorder Awareness (NEDA) week in February
  • Body image programs across campus, especially
    residence halls, sororities, and teams
  • Peer health educators provide campus educational
    programs
  • Collaboration with food services
  • University of Pittsburgh Tray free
  • Other Posted nutritional information, including
    calories and fat grams, and set meal times

63
Counseling Center Background
  • Personnel
  • 20 full-time and part-time staff, including
    psychologists, social workers, psychiatrists, and
    trainees
  • Hours of Operation
  • Open five days a week, including two evenings
    until 9 PM
  • Services
  • Individual counseling
  • Couples counseling
  • Group Counseling (average 10 groups per semester)
  • Consultation with faculty, residence life,
    parents and staff
  • Outreach
  • Crisis intervention (24 hour on-call system)

64
Counseling Center Facts
  • All intakes are 50 minutes
  • Triage system during busy times of the year to
    assess needs and safety
  • No waiting list
  • Try to get students in within 10 days
  • Daily urgency/emergency slots available for
    crisis situations

65
Counseling Center Assessment and Follow-Up
  • Initial Assessment
  • Identifying Information
  • Presenting problems
  • History of psychological concerns
  • Academic functioning
  • Family history
  • Relationship and social history
  • Substance use
  • Medical history
  • Behavioral observations and suicidality
    assessment
  • Summary and recommendations
  • Follow-up depends on the needs and risk of the
    student typically 2-3 weeks

66
Counseling Center Indicators for Prognosis
  • Correlates with a good prognosis
  • Early intervention
  • Student is motivated, open, and ready to make
    changes
  • Good support system
  • Other internal strengths (e.g. maturity,
    well-rounded, social skills)
  • Eating disorder is ego-dystonic for student
  • Correlates with a poor prognosis
  • Early onset and long-standing eating disorder
  • Prior inpatient or intensive treatment with
    little change
  • Poor support system
  • Under-developed identity
  • Psychological impediments, including psychiatric
    comorbidities

67
Counseling Center Treat or Refer?
  • Treat
  • Symptoms are not life threatening and are a match
    for individual counseling
  • Client is already making changes and is motivated
    to work
  • Client can be helped even if seen bi-weekly or
    with longer increments between sessions client
    understands and agrees to the limitations of
    availability
  • Client is willing to work with the EDTT as deemed
    necessary by the treating psychologist

68
Counseling Center Treat or Refer?
  • Refer
  • Client is actively suicidal
  • There is an urgent need to stabilize the clients
    symptoms
  • Disturbed thinking, harmful behaviors, and/or
    psychiatric comorbidities are too severe to be
    managed by the Counseling Center
  • Shows minimal or no motivation
  • Has insurance and/or financial resources

69
Counseling Center Recommendations
  • Get parents involved
  • Agree to treatment with all disciplines of the
    EDTT
  • Choose friends and living situation carefully
  • Break rigid rules as soon as possible
  • If constant weighing is occurring, do not be
    around a scale
  • Modify harmful behaviors as quickly as possible
  • Redirect focus outside of self (e.g.
    volunteering, trying new things, being social)

70
Counseling Center Treatment
  • Address the most urgent symptoms
  • Assess the appropriate level of care
  • Individualized treatment encompasses an
    integrative approach and may include behavioral
    interventions, cognitive behavioral therapy, and
    interpersonal psychotherapy

71
Eating Disorder Clinical Protocol
  • Eating Disorders, Medical Evaluation and
    Treatment of
  •  
  • Objective
  • To perform an initial history, medical, and
    laboratory evaluation and either refer or
    initiate outpatient management by the University
    of Pittsburgh Eating Disorder Treatment Team when
    appropriate for patients suspected of having an
    eating disorder
  • To recognize that anorexia nervosa, bulimia
    nervosa and eating disorder not otherwise
    specified affect university students
  • To determine which patients need to be referred
    and which can be managed on campus
  • To recognize potentially life-threatening
    complications

72
Eating Disorder Clinical Protocol Evaluation
  • History
  • How/why/by whom was the patient referred for
    evaluation?
  • Does the patient acknowledge possibility of an
    eating disorder or voice denial? Duration of
    symptoms/behaviors/concern?
  • Previous medical and psychological
    history/treatment?
  • Tobacco, alcohol, and drug (illicit or
    prescription) use?
  • Weight history including high/low/desired and
    changes over preceding months. General eating
    habits and 24-hour dietary recall
  • Menstrual history, sexual history, including
    birth control method
  • Intensity and quantity of exercise

73
Eating Disorder Clinical Protocol Evaluation
  • History Continued
  • Family history
  • Direct questions about binging, purging, use of
    medications (prescription and OTC), including
    laxatives, diuretics, diet pills, thyroid
    medication and amphetamines
  • Often related behaviors (i.e. self-mutilation,
    high-risk sexual behavior) and co-morbidities
    (depression, anxiety, and OCD)
  • Degree to which activities of daily living are
    impaired/quality of life (i.e. time, money,
    relationships, academics)
  • Current medical symptoms including, but not
    limited to, blood in vomit or stool, muscle
    weakness, syncope or recurrent near-syncope,
    fatigue, dizziness, sore throat, seizures, chest
    pain, palpitations, stomach pain, heartburn,
    constipation, diarrhea, gas/bloating, dry skin,
    hair loss, and cold intolerance

74
Eating Disorder Clinical Protocol Evaluation
  • Physical Examination
  • Vital signs, including orthostatic blood
    pressure and pulse
  • Height and weight without shoes and gowned per
    clinician
  • General appearance
  • Skin changes including evidence of cutting,
    Russells sign
  • Head and neck for thyromegaly, dental erosions,
    parotid enlargement, pharyngeal irritation
  • Cardiovascular for rate, rhythm, murmur
  • Abdomen for bowel sounds, tenderness,
    distention, masses
  • Neurologic with attention to paresthesias,
    mental status and tremor

75
Eating Disorder Clinical Protocol Diagnosis
  • Labs (may be normal though may still be at risk)
  • CBC with differential (anemia)
  • Complete Metabolic Panel (electrolyte
    abnormality, alkalosis in bulimia, dehydration)
  • TSH
  • Urinalysis (specific gravity, ketones)
  • Consider amenorrhea (primary or secondary)
    work-up, EKG, DEXA, other studies if diagnosis in
    question (for example, colonoscopy)
  • Diagnosis
  • Differential Diagnosis Malignancy, IBD,
    malabsorption, endocrine disorders, CNS tumors,
    IBS, psychiatric illness
  • Diagnostic Criteria for anorexia nervosa,
    bulimia, and eating disorder not otherwise
    specified per the DSM-IV

76
Eating Disorder Clinical Protocol Plan
  • Make decision regarding need for
    referral/hospitalization
  • If emergent
  • If urgent medical treatment required, refer and
    transport to local emergency department
  • If urgent psychiatric evaluation required, refer
    and transport to local psychiatric hospital
  • Depending on the patients willingness to accept
    acute treatment, involuntary commitment may be
    required
  • If non-emergent
  • Consider outpatient treatment options, including
    medical, psychological/psychiatric and
    nutritional therapy. Depending on severity of
    disease, insurance, and patient preference,
    patient may be followed at student health clinic
    in coordination with the counseling center and
    the dietitian (EDTT)
  • Community resources as per referral sheet

77
Eating Disorder Clinical Protocol Treatment
  • Restore healthy eating patterns
  • Choose weight gain goals. Initial goal of 90 of
    normal body weight and/or restoration of menses,
    expecting 0.5-2 lb gain per week
  • Monitor behaviors and symptoms through frequent
    follow-up and refer if appropriate
  • Strongly encourage involvement of parents
  • Request that the student sign a EDTT release
  • Consider psychotropic medications
  • SSRIs have been shown to be helpful in the
    treatment of bulimia. Fluoxetine has been most
    studied (60mg)
  • For anorexia, no single drug is clearly
    effective, though patients with co-morbid
    psychiatric illness(es) may benefit from
    medication
  • Bupropion may be contraindicated due to
    increased risk of seizure

78
University of Pittsburgh Course Withdrawal
Policy and Procedure
  • All students may resign up to the 60 point in
    time of the term or session
  • After that deadline, a student may withdraw from
    all classes only with the permission of their
    academic dean
  • If the reason for the withdrawal is medical or
    psychological in nature the student must supply
    support documentation to the dean for approval
  • Financial Repercussion

79
Cases
80
Case History CC
  • Date January 26, 2009
  • Chief Complaint I think I lost a bunch of
    weight and I am not doing well with eating. I
    feel depressed and lightheaded
  • HPI 20 y.o. WF originally presented Spring 2008
    as a referral from the CC for evaluation of
    eating disorder. She was followed for 2 months
    and was then lost to follow-up
  • PMH/PSH Depression, eating disorder status post
    intensive outpatient treatment, wisdom teeth
    extraction
  • Medications Self-discontinued fluoxetine May
    2008
  • SH Senior year, occasional ETOH, denied tobacco
    and drugs
  • Interim History
  • Summer 2008 B/P 1-2 times/day
  • November 2008 B/P escalated to gt3 times/day and
    running 6-7 times/week approximately 3 miles

81
Case Physical Examination CC
  • Vital signs Temp 97.5F Pulse 56 RR 12 BP
    118/76
  • Height 62" Weight 103 lbs (4/2008 129 lbs)
    82.4 IBW
  • General Tearful, thin appearing WF
  • HEENT No parotid hypertrophy, slightly dry MM,
    no visible erosions
  • Thyroid No thyromegaly or masses
  • Cardiovascular Irregular rhythm, bradycardic
  • Chest Clear to auscultation bilaterally
  • Abdomen Midepigastric tenderness with palpation
  • Skin No Russells sign
  • Extremities No edema or acrocyanosis

82
Case Management/Course CC
  • EKG Bradycardia, ectopic beats, and ? U-waves
  • Transferred to ER
  • ER management Abnormal electrolytes repleted and
    IV hydration
  • Patient communication Informed clinician she
    told her parents eating disorder behaviors
    persist
  • Re-evaluated at SHS one week later and deemed to
    need a higher level of care
  • Patient referred to the Western Psychiatric
    Institute and Clinic Center for Overcoming
    Problem Eating (COPE)
  • Recommendation Partial hospitalization
    consisting of 29 treatment hours per week

83
Case Course CC
  • Multiple communications between the clinician and
    the patient occurred regarding the patients
    concerns with her inability to fulfill the
    recommendation and graduate on time
  • Collaboration with COPE allowed patient to
    participate in their intensive outpatient program
    (IOP) consisting of 9.5 hours/week with a
    contract for weight gain of one pound per week,
    attendance, and maintenance of normal labs
  • Patient failed to meet her contractual agreement
    with COPE and a higher level of care was
    recommended, which patient refused due to
    imminent graduation
  • Patient graduated May 2009

84
Case Discussion CC
  • When is it appropriate to refer to a higher level
    of care?

85
Level of Care Guidelines Medical Status
Level 1 Outpatient Level 2 Intensive Outpatient Level 3 Partial Hospitalization (full-day outpatient care) Level 4 Residential Treatment Center Level 5 Inpatient
Medically stable to the extent that more extensive medical monitoring, as defined in levels 4 and 5, is not required. Medically stable to the extent that more extensive medical monitoring, as defined in levels 4 and 5, is not required. Medically stable to the extent that more extensive medical monitoring, as defined in levels 4 and 5, is not required. Medically stable to the extent that IVF, NG tube feedings, or multiple daily laboratory tests are not needed. For adults HRlt43bpm BPlt90/60mmHg Glucoselt60mg/dl Potassiumlt3mEq/L Electrolyte imbalance Temperaturelt97F Dehydration Hepatic, renal, or cardiovascular organ compromise requiring acute treatment poorly controlled diabetes
86
Level of Care Guidelines Continued
Level 1 . Outpatient Level 2 Intensive Outpatient Level 3 Partial Hospitalization Level 4 Residential Treatment Center Level 5 Inpatient
Weight as percentage of healthy body weight Generally gt 85 percent Generally gt 80 percent Generally gt 80 percent Generally lt 85 percent lt85 or acute weight decline with food refusal
Co-occurring disorders Presence of co-morbid condition may influence choice of level of care. Presence of co-morbid condition may influence choice of level of care. Presence of co-morbid condition may influence choice of level of care. Presence of co-morbid condition may influence choice of level of care. Existing psychiatric disorder requiring hospitalization
Structure needed for eating/gaining weight Self-sufficient Self-sufficient Needs some structure to gain weight Needs supervision at all meals or will restrict eating Needs supervision during and after all meals or NG/special feedings
87
Level of Care Guidelines Continued
Level 1 Outpatient Level 2 Intensive Outpatient Level 3 Partial Hospitalization Level 4 Residential Treatment Center Level 5 Inpatient
Suicidality If suicidality is present, inpatient monitoring and treatment may be needed depending on the estimated level of risk. If suicidality is present, inpatient monitoring and treatment may be needed depending on the estimated level of risk. If suicidality is present, inpatient monitoring and treatment may be needed depending on the estimated level of risk. If suicidality is present, inpatient monitoring and treatment may be needed depending on the estimated level of risk. Specific plan with high lethality or intent consider in patients with suicidal ideas or after a suicide attempt
Purging Behavior Can greatly reduce incidents in an unstructured setting no significant medical complications, such as electrocardiographic or other abnormalities, suggesting the need for hospitalization Can greatly reduce incidents in an unstructured setting no significant medical complications, such as electrocardiographic or other abnormalities, suggesting the need for hospitalization Can greatly reduce incidents in an unstructured setting no significant medical complications, such as electrocardiographic or other abnormalities, suggesting the need for hospitalization Can ask for and use support from others or use cognitive and behavioral skills to inhibit purging Needs supervision during and after meals and in the bathroom
88
Level of Care Guidelines Continued
Level 1 Outpatient Level 2 Intensive Outpatient Level 3 Partial Hospitalization Level 3 Partial Hospitalization Level 4 Residential Treatment Center Level 5 Inpatient
Environmental Stress Others able to provide adequate emotional and practical support and structure Others able to provide at least limited support and structure Severe family conflict or problems or absence of family so patient is unable to receive structured treatment in home patient lives alone without adequate support system Severe family conflict or problems or absence of family so patient is unable to receive structured treatment in home patient lives alone without adequate support system Severe family conflict or problems or absence of family so patient is unable to receive structured treatment in home patient lives alone without adequate support system Severe family conflict or problems or absence of family so patient is unable to receive structured treatment in home patient lives alone without adequate support system
Ability to control compulsive exercise Can manage through self-control Some degree of external structure beyond self-control required to prevent patient from compulsive exercising rarely a sole indication for increasing the level of care Some degree of external structure beyond self-control required to prevent patient from compulsive exercising rarely a sole indication for increasing the level of care Some degree of external structure beyond self-control required to prevent patient from compulsive exercising rarely a sole indication for increasing the level of care Some degree of external structure beyond self-control required to prevent patient from compulsive exercising rarely a sole indication for increasing the level of care Some degree of external structure beyond self-control required to prevent patient from compulsive exercising rarely a sole indication for increasing the level of care
Geographic availability of treatment program Patient lives near treatment center Patient lives near treatment center Patient lives near treatment center Treatment program is too distant for patient to participate from home Treatment program is too distant for patient to participate from home Treatment program is too distant for patient to participate from home
89
Level of Care Guidelines Continued
Level 1 . Outpatient Level 2 Intensive Outpatient Level 3 Partial Hospitalization Level 4 Residential Treatment Center Level 5 Inpatient
Motivation to recover, including cooperativeness, insight, and ability to control obsessive thoughts Fair-to-good motivation Fair motivation Partial motivation cooperative patient preoccupied with intrusive repetitive thoughts gt 3 hours/day Poor-to-fair motivation patient preoccupied with intrusive repetitive thoughts 4-6 hours a day patient cooperative with highly structured treatment Very poor to poor motivation patient preoccupied with intrusive repetitive thoughts patient not cooperative with treatment or cooperative only in highly structured environment
90
Indications for Hospitalization in an Adolescent
With an Eating Disorder
  • One or more of the following justify
    hospitalization
  • Severe malnutrition
  • Dehydration
  • Electrolyte disturbances
  • Cardiac dysrhythmia
  • Physiologic instability
  • Arrested growth and development
  • Failure of outpatient treatment
  • Acute food refusal
  • Uncontrollable binging and purging
  • Acute medical complications of malnutrition
  • Acute psychiatric emergencies
  • Comorbid diagnosis that interferes with the
    treatment of the eating disorder
  • Position Paper of the Society of Adolescent
    Medicine 2003

91
Case Discussion Continued CC
  • What is our responsibility as staff at a
    university with regard to liability and loss of
    patient follow-up?
  • Break (e.g. summer and holiday) during semester
  • How aggressively do we pursue these patients?
  • When does our responsibility to the patient
    terminate?
  • Balancing the needs of a graduating senior with
    the treatment recommendations
  • For example, parental expectations, leases,
    financial ramifications, pending future plans
  • As college health providers we are entrusted to
    ensure that the students graduate with a healthy
    mind and body
  • Are our stringent practices deterring students
    from seeking treatment?

92
Case History LB
  • Chief Complaint Im bleeding all the time
  • HPI 18 y.o. WF never sexually active on oral
    contraceptive pills to regulate cycle for 2 years
    presented with a complaint of no withdrawal bleed
    during placebo week and breakthrough bleeding
    during weeks 2 and 3 of her current pill pack
  • PMH/PSH Stress fracture, ACL repair, Female
    Athlete Triad

93
Female Athlete Triad
  • Identified and defined by the ACSM in the early
    1990s
  • Increasingly prevalent, especially among college
    freshman
  • Participation in college sports 2 in 1972 to
    43 in 2002
  • All athletes are at risk higher prevalence in
    sports that have an aesthetic component or sports
    tied to a weight class
  • 3 components disordered eating, amenorrhea,
    osteoporosis
  • Diagnosis largely clinical no test enables
    definitive diagnosis
  • Screening and education for prevention are
    paramount
  • The pre-participation physical examination
    presents an ideal opportunity to screen female
    athletes
  • Modest exercise reductions (10-20 per week) if
    weight lt 80 IBW, more aggressive cessation or
    higher level of care may be required
  • Treatment should involve a team approach
  • Primary emphasis is on optimizing energy
    availability

94
Case History Continued LB
  • Medications OCP, MVI, calcium
  • SH Competitive high school gymnast, college
    freshman, denies tobacco, ETOH, illicit drugs
  • Other Denied laxatives, diuretics, diet pills,
    vomiting

95
Case Physical Examination LB
  • Physical Examination
  • Vital Signs Temp 98.1F HR 60 RR 12 BP 100/72
  • Height 67 weight 104.5 lbs (75 IBW)
  • General Pleasant WF, thin-appearing
  • HEENT Thinning hair
  • Thyroid No thyromegaly or masses
  • Cardiovascular RRR
  • Chest CTAB
  • Abdomen Soft, NT/ND, positive BS
  • Skin Normal
  • LE No edema

96
Case Management LB
  • Data
  • Labs Glucose 42 (70-99) AST 46 (NLlt40) ALT 57
    (NLlt40) otherwise, normal
  • EKG NSR rate 61bpm NL axis/intervals
  • Plan
  • Referred to dietitian
  • Referred to counseling center
  • Consent to speak to mother
  • Calcium
  • No exercise/increase caloric intake
  • Dexa-Scan ordered
  • Follow-up 1 week

97
Case Course LB
  • Patient followed for 2 weeks and failed to
    demonstrate ability to gain weight in the
    outpatient setting
  • In collaboration with parents, the EDTT
    determined that her medic
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