Developing a Multidisciplinary
Eating Disorder Treatment Team
in a University Setting
Aimee Daigle, FNP | Jennifer Gilkes, MD
Vanessa Richard, RD, LDN | Rachel Stokes, PsyD
Objectives
1. Define the role, function and value of a
multidisciplinary eating disorder treatment team in a
university setting.
2. Discuss “how-to” skills for developing and
implementing an eating disorder treatment program
within a university setting.
3. Identify the key components of a multidisciplinary
eating disorder treatment team.
4. Discuss ways to increase treatment effectiveness and
measure treatment outcomes.
ROLE, FUNCTION, AND VALUE
Role, Function, and Value
• Evaluate and Assess
– Students are often identified in various
departments on campus and referred to the
treatment team
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Administration
Faculty/Staff
Residential Life
Sorority/Fraternity
– Self-referrals
Role, Function, and Value
• Provide Treatment and Referrals
– Provide outpatient treatment services
– Provide referrals for community care
– Provide support for clients navigating the
university and/or healthcare system
• Ex. withdrawing from classes, leaving housing,
enrollment, disability services, health
insurance/reimbursement assistance
Role, Function, and Value
• Financial Value of Treatment
– Estimated Treatment Cost
• 1 year of community outpatient treatment
– Out of Pocket: $7,000-10,000
– With Insurance: $1,400-2,000
» Assuming 80% coverage
• 1 year of LSU Student Health Fees
– $390 (Fall, Spring, Summer fees combined)
HOW TO DEVELOP A TREATMENT
TEAM
“How-to” Skills
1. Solicit Administrative Support from Key
Departments
• Ex. counseling center, medical clinic, health promotion
2. Determine which Treatment Components will be
Provided
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Individual /Group Therapy
Nutrition Counseling
Medical Treatment
Psychiatric Treatment
Case Management
Exercise Monitoring
“How-to” Skills
3. Find and Establish Working Relationships with
Providers
– Creating a working relationship between core
treatment providers is vital in successfully building a
treatment team
• Within a Student Health Center
• Across campus
• Community providers/resources
– Establish a strong, frequent communication pattern
between providers
“How-to” Skills
4. Schedule Time for Interdisciplinary Meetings
– Treatment Team Meetings
• Weekly consultation/review for providers participating
in the team
• Weekly to biweekly phone /email consultation with
community providers
• Documentation of review for charting purposes
“How-to” Skills
4. Schedule Time for Interdisciplinary Meetings
– Client Staffing Meetings
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All providers and client in attendance
Held once per semester or as needed
Aids in multifaceted treatment planning
Provides continuity of care
Additional way to track progress
Gives the client a voice in treatment
Opportunity for family and/or partner to attend
“How-to” Skills
5. Determine Types of Documentation
– Treatment Contract
– Evaluation/Assessment Forms
– Staffing Reviews/Reports
– Treatment Team Meeting Reviews
– Assessment Measure
– Treatment Plan
“How-to” Skills
“How-to” Skills
“How-to” Skills
6. Create a Policies and Procedures Manual
– Purpose:
• Establishes the scope of practice of the treatment
program/boundaries
• Rely on policies/procedures when higher level of care is
needed and/or noncompliance issues
• Helpful for risk management purposes
“How-to” Skills
6. Create a Policy and Procedures Manual
– Essential Components
• Establish the central goal of the treatment program
• Identify core procedures to meet identified goals
• Identify type of documentation and where
documentation will be stored (EMR vs. paper chart)
– Helpful Hints
• Consult with peer institutions with established teams
• Adapt to meet the needs and constraints of your
resources
“How-to” Skills
7. Designate Case Management Services
– For individuals with complex needs
– Can be provided by existing team members or
dedicated case manager
– Examples:
• Client is without health insurance
• Referral to community providers or higher level of care
• Intensive medical services
“How-to” Skills
8. Advertise the Treatment Program
– Freshman orientation
– Campus-wide outreach
– Brochures/literature stands
– Student Health Center website
9. Develop Campus Wide Relationships
– Communication with campus partners,
administrators, faculty and staff
“How-to” Skills
10. Create a Referral Base
– Self referrals
– Parent, partner, family and friend referrals
– Administrative referrals (mandated)
• Expectations must be clear about ongoing
communication with administrative referrals
• Ex-residence hall disturbances
– Faculty/Staff referrals
“How-to” Skills
11. Define the Community Referral Process
– Partial treatment by community provider
– Referral for higher level of care or alternative
treatment
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Outpatient Treatment Providers
Intensive Outpatient Program
Partial Hospitalization Program
Residential Treatment Program
Medical Stabilization/Inpatient Hospitalization
KEY COMPONENTS OF A
TREATMENT TEAM
Key Components of a Treatment Team
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Psychological Evaluation and Treatment
Nutritional Evaluation and Treatment
Medical Evaluation and Treatment
Psychiatric Evaluation and Treatment
Psychological Evaluation and Treatment
• Evaluation
• Severity of symptoms (outpatient vs. residential
treatment)
• Emotional functioning and comorbidity
• Empirically Supported Treatment Approaches
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Cognitive Behavioral Therapy
Interpersonal Therapy
Dialectical Behavior Therapy
Short-term Psychodynamic Therapy
Integrative Approaches
Psychological Evaluation and Treatment
• Beginning Stage: Building trust, providing
psychoeducation, and establishing treatment
parameters
• Weekly /biweekly therapy
• Building a positive therapeutic relationship
• Assessing key features of the eating disorder and
individual needs
• Providing education about the effects of disordered
eating patterns
• Enhancing motivation for change
Psychological Evaluation and Treatment
• Mid Stage: Changing beliefs related to
food/weight/body and broadening the scope
of therapy
• Identifying dysfunctional thoughts, schemes, and
thinking patterns and developing cognitive
restructuring skills
• Developing a sense of self without the ED
• Focus on interpersonal relationship patterns
• Reframing relapses
Psychological Evaluation and Treatment
• Ending Stage: Preventing relapse and
preparing for termination
• Summarizing progress
• Summarizing areas of continued vulnerability
• Clarifying when to return to treatment
Nutritional Evaluation and Treatment
• Role of the Registered Dietitian
– Provide nutrition education and counseling
• Bridges therapeutic and medical components
– Addresses the “surface” issues
• Eating and exercise behaviors, symptom usage
• Expertise in disordered eating is preferred
– Strong counseling skills
– Often met with resistance
Nutritional Evaluation and Treatment
• Appointment Frequency
– Weekly to biweekly follow up
• less frequent over time
• Primary Goals
– Weight stabilization
– Nutrition restoration
– Reducing symptom usage
– Improvement in relationship with food and body
Nutritional Evaluation and Treatment
Nutrition
Education
Nutrition
Counseling
• Meal planning
• Restoring nutrition
status
• Debunking myths
• Reducing
symptoms
• Addressing
food fears
• Rolling with
resistance
Maintenance
• Practicing
mindfulness
• Managing
triggers
• Elimination of
symptoms
Medical Evaluation and Treatment
• Role of Medical Clinician
– Assess and treat any medical complications that
result from eating disorder
– May or may not be first point of contact
– Educate medical staff on early recognition
of/screening for EDs
– Liaison between medical clinic, treatment team
and involved outside providers (if indicated)
– Educate the patient/client
Medical Evaluation and Treatment
• Initial History and Physical
– Schedule adequate time—trust, rapport building
– Establish documentation/templates— to assure
comprehensive exam, “queue questions” for essential
information
– Rule out other physical causes for symptoms
• GI disorders, infectious/autoimmune disease, primary endocrine
disorders, neurological disorder/disease
– Determine physical impact/severity of disorder to date
– Determine necessitation for immediate medical
intervention/hospitalization for medical stabilization
– Establish if specialty referrals are indicated
– Develop medical goals, treatment plan, follow-up schedule
– Educate patient regarding medical needs/complications
Medical Evaluation and Treatment
• Eating Disorder History
• Age of onset, longevity of ED
• Weight history --loss/change/amount
• “Typical day”—eating habits, hydration, exercise, caffeine
use, supplements, alcohol/tobacco use, sleep, bowel
habits/patterns
• Compensatory behavior history--such as restriction, binge,
purge, laxatives, diet pills, supplements, substance
use/abuse, exercise
• Family history and psychosocial history—FMH EDs,
substance abuse, support systems
• Medical /surgical /psychiatric history—medications,
hospitalizations/dates
• Known medical co morbidities
Medical Evaluation and Treatment
Review of Systems
General
-fatigue, malaise
Neuro/Psychological
-seizures
-decreased
LOC/memory/concentration
-fainting/syncope
-anxiety/depression/insomnia
-suicidal ideation
HEENT
-oral/dental concerns/hoarseness
-swollen glands
Respiratory/Cardiovascular
-SOB/activity intolerance
-CP/palpitations
-swelling
G/I
-epigastric/abdominal pain/reflux
-bloating/fullness
-vomiting/hematemesis
-constipation/diarrhea
-rectal bleeding/hemorrhoids
Endocrine
-menstrual irregularities
-libido changes
Musculoskeletal/Dermatological
-back/limb pain
-bruising
-slow healing
-hair loss/lanugo
Medical Evaluation and Treatment
Physical Exam
Weight/BMI
-assure accuracy/consistency
-consider patient concerns
Vitals
-bradycardia
-orthostatic changes HR/BP
Temperature
-hypothermia
HEENT
-cachexia/facial wasting
-hoarseness
-dental/oral erosions
-stomatitis
-inflamed/infected salivary glands
Cardiovascular
-murmur
-MVP
-poor perfusion
Gastrointestinal
-decreased bowel sounds/tenderness
-hemorrhoids
Musculoskeletal/Dermatological
-bruising/skin discoloration
-muscle wasting
-lanugo (downy hair)
-”Russell Sign”
Neurological/Psychological
-flat affect
-anxious/depressed affect
-decreased LOC
Medical Evaluation and Treatment
LABS /Findings
CBC
-anemia, pancytopenia,leukopenia
Metabolic Profile/Magnesium/Phos
-hyper/hypoglycemia, hypokalemia,
hypophophatemia, hyponatremia
Other Tests
DEXA SCAN
-decreased bone mineral density
-indicated for longstanding ED or
amenorrhea > 6 months
Thyroid function studies
-normal to low TSH, low T4
EKG (ECHO if indicated)
-arrhythmias
-prolonged QT interval
-bradycardia
Estrogen/Testosterone
-low estrogen/testosterone
MRI/CT
-neuro symptoms
Vitamin D
-hypovitaminosis D
Amylase, lipase, FSH/LH, fasting insulin
GTT, 24 Urine CC
U/A
-low SG
Note:
-lipids elevated in malnutrition
-use care in discussing with patient
Medical Evaluation and Treatment
• Medically Unstable/Requiring Immediate Hospitalization
– Establish guidelines/criteria for your institution
– Key indications
– Cardiac problems/compromise
– Unstable/abnormal symptomatic vitals signs
» CP, HR < 40, abnormal EKG/arrhythmias of concern
– Symptomatic/marked electrolyte imbalances/lab abnormalities
» Hypokalemia, hypophosphatemia, marked hypoglycemia
– GI bleed, obstruction, other GI concerns
– Renal/hepatic compromise
– EKG abnormalities
– Dehydration
– Severe malnutrition
– Altered mental status
– Suicidality
– < 70% IBW, low BMI
– Use good clinical judgment (safety/do parents need to be
contacted?)
Medical Evaluation and Treatment
• Key Reminders
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Eating disorders affect every system in the body
Weight is NOT the only clinical marker of an ED
An ED can occur with NO obvious physical signs or symptoms
Underweight, normal, and overweight patients can still have
nutritional deficiencies
Labs are generally normal, don’t be fooled—however, abnormal labs
can assist with residential admission criteria
Medical consequences of EDs can go unrecognized even by
experienced clinicians
Medications should be targeted on treatment of comorbid conditions
Medications should NOT be used as a substitute for
nutritional/behavioral recovery
Keep medical visits to the minimum required to reduce blame of
symptoms on a physical cause if ruled out
Medical Evaluation and Treatment
• Useful Links for Medical Providers
– Diagnosis of Eating Disorders in Primary Care
http://www.aafp.org/afp/2003/0115/p297.html
– Clinical Report—Identification and management of Eating Disorders in
Children and Adolescents—American Academy of Pediatrics
http://pediatrics.aappublications.org/content/126/6/1240.full.pdf+html
– Critical Points for Early Recognition and Medical Risk management in
the Care of Individuals with Eating Disorders
http://www.aedweb.org/AM/Template.cfm?Section=Medical_Care_Standards
&Template=/CM/ContentDisplay.cfm&ContentID=2413
Psychiatry and College EDTT
• First Evaluation
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Establish therapeutic alliance
Diagnose and treat co-occurring illness
Make predictions about illness
Psycho-education
Determine best treatment setting
• Subsequent Appointments
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Monitor response to medication
Monitor eating disorder symptoms and behaviors
Collaborate with other providers
Assess/monitor psychiatric status and safety
Therapeutic Alliance for Eating Disorders
• Reduces drop out risk
• The clinician should:
– Be curious
– Welcome the client
– Give assurance/support
– Praise/validate (hard work and courage)
Determine Appropriate Treatment Setting
• Anorexia
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Outpatient
Intensive outpatient (part-day outpatient care)
Partial hospitalization (full-day outpatient care)
Residential treatment center
Inpatient hospitalization (either on a medical unit
for acute stability of physical concerns or on a
psychiatric ward)
• Bulimia, Binge Eating and EDNOS
– Outpatient treatment services
Co-occurring Illnesses in Eating Disorders
• Diagnose and treat co-occurring illness
– Many with bulimia or anorexia suffer from clinical
depression, anxiety, obsessive-compulsive disorder,
substance abuse, and other psychiatric illnesses
– Bulimia is associated with Diabetes I
– Binge eating disorder is associated with Diabetes II
Psychiatric Evaluation and Treatment
• Make predictions about illness
– Poor Outcomes: Anorexia
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Very low BMI
Family conflict or dysfunction
Long duration of illness
Comorbid psychiatric or personality disorders
Vomiting or laxative abuse
– Good Outcomes: Anorexia
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Absence of severe weight loss
Absence of serious medical complications
Good social support
Absence of drug abuse
Psychotropic Medication
• SSRI’s
– Fluoxetine
• Serotonin-norepinephrine re-uptake inhibitors
– Venlafaxine
– Desvenlafaxine
– Duloxetine
• Bupropion (FDA black box warning for use in ED due to
increased risks of seizures)
• TCA’s and MAOI’s (generally avoided)
• Mood Stabilizers
– Anti-seizure meds
– Second Generation Antipsychotics
– Lithium (generally avoided in bulimia)
• Benzodiazepines (generally avoided)
FDA Approved Medications for Anorexia
• There are NONE!
– Use medication with caution for comorbid
conditions such as depressive or obsessive–
compulsive features
• Depression, anxiety and obsessions may resolve with
weight gain alone
• Students with anorexia may be more sensitive to side
effects
Psychiatric Evaluation and Treatment
• Why medications may not work with this
population
– Anorexia as a self perpetuating illness:
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Severe weight loss
Leads to loss of white and grey matter of the brain
Decreased neurotransmitters and proteins
Decreased metabolic rate
Abnormalities in cognitive dysfunction
GI abnormalities that lead to early fullness, decreased
gastric motility, constipation, and abdominal distention
Psychiatric Evaluation and Treatment
• FDA approved medications for Bulimia, Binge
Eating and EDNOS
– Fluoxetine (60mg) is FDA approved for Bulimia
Nervosa
– No medications are FDA approved for Binge Eating
Disorder or EDNOS
TREATMENT EFFECTIVENESS AND
OUTCOME MEASUREMENT
Treatment Effectiveness and Outcome
Measurement
• Objective Measures
– Physical
• Vitals
• Labs
• Weight/BMI
– Psychological and Behavioral Measures
• Nutrition Analysis of Food Intake
• Psychological Measures
– Eating Disorder Inventory – 3 (EDI-3);
– Eating Disorders Examination (EDE);
– Eating Disorders Examination-Questionnaire (EDE-Q)
Treatment Effectiveness and Outcome
Measurement
• Subjective Measures
– Client self-report and food journals
– Provider report and observation
– Treatment team meetings
– Client staffing meetings
Treatment Effectiveness and Outcome
Measurement
LSU Data
Female 96%
Male 4%
Treatment Effectiveness and Outcome
Measurement
Treatment Effectiveness and Outcome
Measurement
Treatment Effectiveness and Outcome
Measurement
Treatment Effectiveness and Outcome
Measurement
Initial EDI-3 Assessment (M=46.74, SD=10.69) and Final EDI-3 Assessment
(M=36.06, SD=9.47); t(31)=5.47, p <.001
Challenges
Administrative Challenges
• Gaining administrative support
• Limited sessions or services
through the team
• Limited community referral
options
• Cohesiveness within the
treatment team
• Communication with
community providers
• Confidentiality vs. university
notification
• Record keeping
• Absent treatment team
member
Client Challenges
• Clients with limited
resources needing a higher
level of care
– Lacking insurance, family
support, financial resources
• Clients noncompliant with
recommendations
• Autonomy vs.
communication with family
members
– Family out of town
– Family involvement
Conclusion
• Recovery from an eating disorder is life
changing for the student
• Participation in an interdisciplinary treatment
program offers
– Increased graduation rates
– Increased treatment compliance
– Provides a support system
– Reduced burnout for clinicians
Helpful Websites
• National Eating Disorders Association
www.nationaleatingdisorders.org
• National Institute of Mental Health
www.nimh.nih.gov/health/topics/eating-disorders/index.shtml
• Academy for Eating Disorders
www.aedweb.org
• International Association of Eating Disorder Professionals
www.iadep.com
• GURZE Books
www.gurze.com
• Something Fishy-Website on Eating Disorders
www.something-fishy.org
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