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 Disclosure • We have no financial relationship with a commercial entity producing health-care related products and/or services 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 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 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 • The average American woman is 5’4” tall and weighs 140 pounds • The average American model is 5’11” tall and weighs 117 pounds Americans spend more than $40 billion dollars a year on dieting and diet-related products 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 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%) 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 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 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) 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) 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 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) Anorexia Nervosa 1. 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) 2. Intense fear of gaining weight or becoming fat, even though underweight 3. 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 4. Amenorrhea (at least three consecutive cycles) in postmenarchal girls and women Anorexia Nervosa • The DSM-IV specifies two subtypes: – Restricting Type: during the current episode of anorexia nervosa, the person has not regularly engaged in bingeeating 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, selfinduced vomiting, or the misuse of laxatives, diuretics, or enemas) Bulimia Nervosa 1. 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. 2. Recurrent inappropriate compensatory behavior to prevent weight gain, such as: self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; excessive exercise. 3. The binge eating and inappropriate compensatory behaviors occur, on average, at least twice a week for three months. 4. Self-evaluation is unduly influenced by body shape and weight 5. The disturbance does not occur exclusively during episodes of anorexia nervosa. 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. 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 DSM-V: Proposed Diagnostic Criteria for BED A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: 1. 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 2. 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) B. The binge-eating episodes are associated with three or more of the following: 1. Eating much more rapidly than normal 2. Eating until feeling uncomfortable full 3. Eating large amounts of food when not feeling physically hungry 4. Eating alone because of being embarrassed by how much one is eating 5. Feeling disgusted with oneself, depressed, or very guilty after overeating DSM-V: Proposed Diagnostic Criteria for BED Continued C. Marked distress regarding binge eating is present D. 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 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 1. Do you make yourself Sick because you feel uncomfortably full? 2. Do you worry you have lost Control over how much you eat? 3. Have you recently lost more than One stone (14 pounds or 6.35 kg) in a three month period? 4. Do you believe yourself to be Fat when others say you are too thin? 5. Would you say that Food dominates your life? Screening • the Eating disorder Screen for Primary care (ESP) 1. Are you satisfied with your eating patterns? (No is abnormal) 2. Do you ever eat in secret? (Yes is abnormal) 3. Does your weight affect the way you feel about yourself? (Yes is abnormal) 4. Have any members of your family suffered with an eating disorder? (Yes is abnormal) 5. 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 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 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 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), Russell’s sign (calluses on the dorsum of the dominant hand), loss of subcutaneous fat, nail changes, edema (Refeeding Syndrome), hair changes, acrocyanosis • Neuromuscular: Trousseau’s sign (hypocalcemia) • GU: Hypoestrogenized vaginal mucosa 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 Levels Usually Associated with Purging Method of Purging Serum Levels Urine Levels Sodium Potassium Chloride Bicarbonate pH Sodium Potassium Chloride Vomiting ↑↓↔ ↓ ↓ ↑ ↑ ↓ ↓ ↓ Laxatives ↑↔ ↓ ↑↓ ↑↓ ↑↓ ↓ ↓ ↓↔ Diuretics ↓↔ ↓ ↓ ↑ ↑ ↑ ↑ ↑ Mehler PS. Bulimia Nervosa. NEJM 2003; 349: 875-881 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 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 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 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 Addison’s 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 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) 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 Refeeding Syndrome • Potentially fatal • Caused by rapid changes in fluids and electrolytes • Especially at risk: severely underweight (<75% 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 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 • Wernicke’s encephalopathy (delirium) due to thiamine deficiency 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 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 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: 1. Restoring the person to a healthy weight 2. Treating the psychological issues related to the eating disorder 3. Reducing or eliminating behaviors or thoughts that lead to disordered eating 4. 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 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 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 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 Treatment: Bulimia Nervosa – Medication • Various classes of antidepressants have been demonstrated in short-term, double-blind, placebocontrolled 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) 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 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 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 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 15;67(2):297-304. 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 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 Authorization for Release of Information 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 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 student’s relationship with food and eating – Nutrient and caloric requirements are individualized Dietitian: Two Page Initial Assessment for Eating Disorder Patients 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 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) 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 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 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) 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 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 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 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 Counseling Center: Treat or Refer? • Refer – Client is actively suicidal – There is an urgent need to stabilize the client’s 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 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) 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 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 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 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 nearsyncope, fatigue, dizziness, sore throat, seizures, chest pain, palpitations, stomach pain, heartburn, constipation, diarrhea, gas/bloating, dry skin, hair loss, and cold intolerance 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, Russell’s 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 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 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 patient’s 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 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 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 Cases 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 >3 times/day and running 6-7 times/week approximately 3 miles Case Physical Examination: CC • • • • • • • • • • Vital signs: Temp 97.5°F; 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 Russell’s sign Extremities: No edema or acrocyanosis 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 Case Course: CC • Multiple communications between the clinician and the patient occurred regarding the patient’s 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 Case Discussion: CC • When is it appropriate to refer to a higher level of care? 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 Medically stable to the extent that more extensive Medically medical monitoring, as defined in levels 4 and 5, is stable to the not required. extent that IVF, NG tube feedings, or multiple daily laboratory tests are not needed. Level 5: Inpatient For adults: HR<43bpm; BP<90/60mmHg; Glucose<60mg/dl; Potassium<3mEq/L; Electrolyte imbalance; Temperature<97°F; Dehydration; Hepatic, renal, or cardiovascular organ compromise requiring acute treatment; poorly controlled diabetes Level of Care Guidelines Continued Level 1: . Outpatient Level 2: Intensive Outpatient Level 3: Partial Hospitalization Level 5: Inpatient Generally < 85 percent <85% or acute weight decline with food refusal Weight as percentage of healthy body weight Generally > 85 percent Co-occurring disorders Presence of co-morbid condition may influence choice of level of care. Structure Self-sufficient needed for eating/gaining weight Generally > 80 percent Level 4: Residential Treatment Center Needs some structure to gain weight Needs supervision at all meals or will restrict eating Existing psychiatric disorder requiring hospitalization Needs supervision during and after all meals or NG/special feedings Level of Care Guidelines Continued Level 1: Outpatient Suicidality Purging Behavior Level 2: Intensive Outpatient Level 3: Level 4: Partial Residential Hospitalization Treatment Center If suicidality is present, inpatient monitoring and treatment may be needed depending on the estimated level of risk. 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 Level 5: Inpatient Specific plan with high lethality or intent; consider in patients with suicidal ideas or after a suicide attempt Needs supervision during and after meals and in the bathroom Level of Care Guidelines Continued Level 1: Outpatient Level 2: Intensive Outpatient Level 3: Partial Level 4: Hospitalization 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 Ability to control compulsive exercise Can manage through selfcontrol 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 Treatment program is too distant for patient to participate from home Level of Care Guidelines Continued Level 1: . Outpatient Motivation to Fair-torecover, good including motivation cooperativeness, insight, and ability to control obsessive thoughts Level 2: Level 3: Partial Intensive Hospitalization Outpatient Fair motivation Partial motivation; cooperative; patient preoccupied with intrusive repetitive thoughts > 3 hours/day Level 4: Residential Treatment Center Level 5: Inpatient 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 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 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? Case History: LB • Chief Complaint: “I’m 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 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 < 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 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 Case Physical Examination: LB • Physical Examination: – – – – – – – – – – Vital Signs: Temp 98.1°F; 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 Case Management : LB • Data: – Labs: Glucose 42 (70-99); AST 46 (NL<40); ALT 57 (NL<40); 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 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 medical needs necessitated a higher level of care • Patient agreed to withdraw from all classes • Care transferred to tertiary eating disorder center Case Course: LB • Patient returned to school 6 weeks later having gained only 4 pounds • Due to continued concerns, a contract in consultation with the dietitian, counseling center, and legal department was written • The contract explicitly stated the following: – “You agree to the following guidelines. Please know that should any of the conditions below not be met, you may be terminated from enrollment at the University in the interest of your own well-being.” Case Course: LB • The contract went on to outline the following guidelines: 1. Weekly visits with clinician (gowned weigh-ins), dietitian, and psychologist 2. Steady weight gain to specified goal weight 3. No exercise 4. Acquisition of discharge summary from outside treatment facility Case Course: LB • Throughout the following semester the patient was compliant with all aspects of the contract except weight gain LB Weight Over Semester 116 114 Weight (lbs) 112 110 108 106 104 Actual Weight 102 Goal Weight 100 1/7 1/14 1/21 1/28 2/4 2/11 2/18 2/25 3/4 Date 3/11 3/18 3/25 4/1 4/8 4/15 4/22 Case Course: LB • Care was transferred to outside facility over the summer and patient never returned to see any members of treatment team • Patient was seen the following semester running on campus and appeared emaciated Case Discussion: LB • Readmission process – Judicial hold – Student Code of Conduct University of Pittsburgh Student Code of Conduct and Judicial Procedures Effective August 24, 2009 Division of Student Affairs http://www.studentaffairs.pitt.edu/conduct Offenses Related to Person(s) An offense related to a person is committed when a student: “Abuses or injures oneself or another person physically.” Case Discussion Continued: LB • Proposed policy Argument for Proposed Policy • Policy addresses issues that do not cleanly or clearly fall within the Student Code of Conduct • It gives providers at the counseling center and student health a way to address the student whose needs exceed the care that the University can provide and who is non-compliant with treatment recommendations, for example: – Eating disorder patients who are too ill for us to be able to take care of who are referred to a higher level of care. If the student refuses to comply with the treatment recommendations made by the outside facility and returns to our care, we do not have an effective mechanism to address this situation – This becomes even more challenging when the parents know our concerns and recommendations but do not partner with us to get the recommended treatment – Having an established policy clearly demonstrates the University’s commitment to recognizing the importance of physical and mental health for our students • When we have had to press the issue in the past, we invoke the harm to self concept within the Student Code of Conduct Argument for Proposed Policy Continued • Policy establishes a “medical hold” for high risk students who voluntarily or involuntarily withdraw for certain medical/psychological reasons • This creates a process of re-admission whereby a student who has had a “medical hold” placed must submit a written request for readmission clearance at least four weeks prior to the first day of classes of the semester in which the student wishes to enroll • This allows the University to fully evaluate whether a student is appropriate to return to campus • If it was an involuntary withdrawal, the University can verify that the student has fulfilled the requirements that were given to him/her when the withdrawal was mandated Case Discussion: LB • Readmission process – Judicial hold – Student Code of Conduct • Proposed Policy • Contracts Case History: AW • Chief Complaint: “I am here for my weekly weight check” • HPI: 18 year-old WF with 10-year history of eating disorder requiring two inpatient hospitalizations presented to student health for weekly weight check • Denies history of laxatives, diet pills, diuretics, excessive exercise • PMH/PSH: Anorexia nervosa • Medications: OCP, multivitamin • SH: Freshman; denies tobacco, alcohol, drugs Case Physical Examination: AW • Vital Signs: Temp 96°F; HR 75; RR 12; BP could not be obtained due to size • Height 61"; weight 80.4 lbs (66% IBW) • General: Pleasant, very thin WF • HEENT: Thinning hair • Thyroid: No thyromegaly or masses • CV: RRR without ectopy • Chest: Clear • Abdomen: Scaphoid, soft, NT/ND, positive BS • Skin: Without rash • Lower extremity: No edema, palpable pedal pulses Case Course: AW • Clinician immediately called patient’s parents regarding low body weight and expressed concerns over both immediate and long-term health consequences • Mother requested clinician speak to primary care doctor • Unwilling to be referred to Counseling Center as mother states “she has had enough counseling” • Phone call with primary care doctor: – AW weighed 82-86 lbs over past year – Goal weight: 90 lbs to safely come to college – Offered higher level of care in order achieve goal weight; patient refused – Weight 86 lbs two weeks prior to visit (i.e. ~6 lb weight loss) – Agrees with clinician regarding the need for a higher level of care to achieve weight gain and need for psychotherapy Case Course: AW • Mother and patient asked for the opportunity to demonstrate weight gain • Mother and patient agreed to the following: – Weekly visits with dietitian and clinician alternating weeks – Counseling Center assessment • Patient exhibited minimal weight gain and in consultation with the EDTT and the legal department, a contract was crafted Case Contract: AW Dear AW: As you are aware, we are concerned about your physical health due to your diagnosis of Anorexia Nervosa. We initially recommended that you withdraw from school, and you still have that option. I realize that you and your mother strongly oppose a withdrawal because of a lessening of beginning of the year stressors, your being weighed on a different scale in early September, your willingness to comply with treatment and counseling, and you felt that your recent weight gain demonstrates improvement. We are willing to work with you to help you attain and maintain a healthy body weight which will enable you to achieve your academic goals and fully participate in any extracurricular activities that you choose. However, working with you will require effort on your part. If you and your parents choose for you to continue your studies here we need you to agree to the following guidelines: 1. I will see Dr. W and the dietitian on alternating weeks so that I am weighed weekly for one year. I will not skip appointments; 2. I agree to gain weight and understand that I need to demonstrate steady weight gain with a goal of one pound per week to my goal weight of 94 pounds; this is defined as a healthy weight for a female of your age and height by the Centers for Disease Control and Prevention. 3. I will schedule an appointment to be seen at the Counseling Center and will follow their recommendations for treatment. 4. My goals are to weigh 90 pounds as of November 8 and 94 pounds at the beginning of Spring term . 5. I will immediately convey any adverse health conditions I may be experiencing to the Student Health Center so appropriate treatment may be advised. Please review this with your parents and understand that non-compliance with any of these will require a review for potential medical withdrawal, to which you also agree, subject to you being readmitted in a future semester upon attainment of your goals. Please understand it is our of concern for your welfare that these measures are being or would be undertaken. If you are in agreement with these terms, and after you have discussed this with your parents, please sign below and return this letter to me no later that 10-12-07. Sincerely, Case Course: AW • Patient failed to meet contractual requirement of expected weight gain • Patient claimed weight loss due to “heavy backpack” and “walking around campus” • Mother contacted and agreed reluctantly to daughter’s withdrawal from the university • During final conversation with mother, she expressed frustration over the fact that her daughter was permitted to matriculate, but deemed too ill to finish the semester Case Discussion: AW • Pre-matriculation physical exam requirement • Parents reluctance to acknowledge severity of illness Conclusion • Eating disorders are common among college students and can affect people of all ages, races, genders and ethnicities • Eating disorders are potentially life threatening and can cause both considerable psychological distress and major physical complications • A detailed history and physical examination is paramount • Patients with eating disorders may have normal labs and/or a normal physical examination • Treatment should encompass a multidisciplinary approach • There are many challenges to treating patients with eating disorders and despite an increase in eating disorders in the past two decades, eating disorders research continues to be underfunded, insurance coverage for treatment is inadequate, and societal pressures to be thin remain rampant Cases from the Audience Special Thanks • Meg Mayer-Costa, MS, RD, LDN • Kathleen Whittaker, PhD “Each individual woman's body demands to be accepted on its own terms.” - Gloria Steinem QUIZ B.S., a junior in college, is a 21 y.o. WF who presents to SHS as a referral from the Counseling Center. Her height is 64 ¾ inches and her weight is 105.5 lbs (78% IBW). Her desired weight is 100-103 lbs. She states that the only reason she is seeking help is because her boyfriend demanded it. Per the dietitian, B.S. endorses fear of weight gain and anxiety upon being advised to eat 3 meals and 3 snacks daily. She has been amenorrheic for 2 months. Does this patient meet criteria for anorexia nervosa? a. YES b. NO B.S., a junior in college, is a 21 y.o. WF who presents to SHS as a referral from the Counseling Center. Her height is 64 ¾ inches and her weight is 105.5 lbs (78% IBW). Her desired weight is 100-103 lbs. She states that the only reason she is seeking help is because her boyfriend demanded it. Per the dietitian, B.S. endorses fear of weight gain and anxiety upon being advised to eat 3 meals and 3 snacks daily. She has been amenorrheic for 2 months. Does this patient meet criteria for anorexia nervosa? b. NO – The patient has been amenorrheic for only 2 months J.S., a senior in college, is a 22 y.o. WF who presents to SHS as a self referral. She reports binging and purging daily for the past two years. Her binges consist of, for example, at least a pint of ice cream and packages of chips and/or cookies. She reports a lack of control when binging and eats quickly to the point of feeling physically ill. She also exercises excessively in an attempt to both improve her body image and achieve her ideal body shape. She has regular menses and is of normal weight. Which of the following is true? a. b. c. d. The patient meets criteria for anorexia nervosa The patient meets criteria for bulimia nervosa The patient meets criteria for EDNOS The patient meets criteria for binge eating disorder J.S., a senior in college, is a 22 y.o. WF who presents to SHS as a self referral. She reports binging and purging daily for the past two years. Her binges consist of, for example, at least a pint of ice cream and packages of chips and/or cookies. She reports a lack of control when binging and eats quickly to the point of feeling physically ill. She also exercises excessively in an attempt to both improve her body image and achieve her ideal body shape. She has regular menses and is of normal weight. Which of the following is true? b. The patient meets criteria for bulimia nervosa Which of the following IS NOT an example of EDNOS? a. For females, all of the criteria for AN are met except that the individual has regular menses b. All of the criteria for AN are met except that, despite substantial weight loss, the individual's current weight is in the normal range c. All of the criteria for bulimia are met except that binge eating and inappropriate compensatory mechanisms occur at a frequency of three times a week for a duration 6 months d. 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) e. Repeatedly chewing and spitting out, but not swallowing, large amounts of food Which of the following IS NOT an example of EDNOS? c. All of the criteria for bulimia are met except that binge eating and inappropriate compensatory mechanisms occur at a frequency of three times a week for a duration of 6 months Patients with eating disorders may present with which of the following physical examination findings? a. Loss of tooth enamel b. Parotid gland hypertrophy c. Bradycardia d. Russell’s sign e. All of the above Patients with eating disorders may present with which of the following physical examination findings? e. All of the above Which of the following statements about the treatment of eating disorders is true? a. According to a 2007 systematic review of randomized controlled trials published in the International Journal of Eating Disorders, evidence for AN treatment is strong b. Several medications have shown to be effective in restoring a patient to a healthy weight c. Unfortunately, no specific psychotherapy appears to be consistently effective for treating adults with anorexia d. The efficacy of CBT has not been convincingly demonstrated in randomized, controlled trials e. Fluoxetine is the only medication approved by the FDA for treating bulimia; recommended in a dose that is smaller than is typically used for depression Which of the following statements about the treatment of eating disorders is true? c. Unfortunately, no specific psychotherapy appears to be consistently effective for treating adults with anorexia References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. http://cdc.gov/ http://www.nih.gov/ www.nationaleatingdisorders.org/ American Psychiatric Association. 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Treating Eating Disorders in Primary Care. Am Fam Physician. 2008;77(2):187-195. Yager J, et al. Anorexia Nervosa. NEJM. 2005;353:1481-1488.