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The Critical Role of Primary Care Providers in the Evaluation, Management, and Referral of Eating Disorders February 26, 2007 Mary Tantillo PhD RN CS Director, Eating Disorders Recovery Center of Western NY Director, Eating Disorders Program, Unity Health System Richard Kreipe MD Medical Director, Eating Disorders Recovery Center of WNY Director, Child and Adolescent Eating Disorder Program, Golisano Children’s Hospital Learning Objectives Evaluate adolescents/young adults with eating disorders as they present in Primary Care Manage common health problems associated with eating disorders (metabolism, heart, gyn, bones) Avoid pitfalls commonly encountered when interacting with patients/families with eating disorders Enhance the effectiveness of referrals to specialists Overview Screening and assessment in primary care Principles of early recognition and treatment Management of Common Problems – Malnutrition and Metabolism – Cardiovascular – Reproductive – Musculoskeletal Engaging Patients and Parents Role play Referral to EDRC – Principles of comprehensive treatment – Elements of treatment Discussion 12 year old self-portrait 1) Library: 5 Minute Exercises, Recipes for Health, Calories Do Count, Secrets of Staying Thin 2) Exercise rope 3) Clock always at mealtime 4) Plate with vegetables, fruit, no meat or fat. Most food uneaten 5) Forbidden foods beyond arm’s reach 6) Externally: Superwoman 7) Internally: An empty skeleton DSM-PC Wolraich ML, et al. The Classification of Child and Adolescent Mental Diagnoses in Primary Care: Diagnostic and Statistical Manual for Primary Care (DSM-PC), Child and Adolescent Version. AAP, 1996 Variation Problem Disorder V65.49 Dieting/Body Image Variation Dieting may occur if the child is overweight but it should be a realistic program. The child does not completely eliminate any food group, but generally decreases intake of food, especially of sweets and fats or is on an appropriate diet. The child favors a thin appearance but has a realistic image. The individual can stop dieting voluntarily. DSM-PC, Child and Adolescent Version, AAP, 1996 V69.1 Dieting/Body Image Problem More intense dieting/food restrictions resulting in weight loss or failure to gain weight as expected, but not enough to qualify for A.N. or E.D. NOS Obsessed with the pursuit of thinness and develops systematic fears of gaining weight Consistent disturbance in body perception and starts to deny that weight loss or dieting is a problem. DSM-PC, Child and Adolescent Version, AAP, 1996 ANOREXIA NERVOSA (pursuit of thinness) Insufficient energy intake Wasting of the body Delusion of being fat Obsession to be thinner Does not diminish with weight loss Denial BULIMIA NERVOSA (avoidance of obesity) Recurrent, secretive binge-eating Fear of not being able to stop eating Awareness that eating pattern is abnormal Depressed moods and self-deprecating thoughts Temporary relief via avoidance of weight gain by – – – – Fasting Self-induced vomiting Catharsis or diuresis Exercise Guidelines for Adolescent Preventive Services (G.A.P.S.) http://www.ama-assn.org/ama/pub/category/1980.html Eating Disorders: Caveats in Primary Care Negative “Classic” presentation less likely in younger patients and/or shorter duration of illness No single “cause” to this final common pathway No diagnostic lab (blood, urine, ECG, imaging, etc) studies Opinions are less important than facts Initial goal is not to diagnose an eating disorder, but to determine the cause of weight loss Eating Disorders: Caveats in Primary Care Positive Physical findings are the result of weight control habits Mental status is part of the physical examination Laboratory studies for baseline, or to reinforce physical examination finding Motivational interviewing avoids many pitfalls in management Parents are part of the solution to, not the cause of, the eating disorder Diagnostic Algorithm for Weight Loss Is weight loss intentional and/or desired? – – – – Unrecognized illness Increased energy needs due to exercise or growth Efforts to “get in shape” Energy restriction (intake) or output (exercise) Excessive dieting or exercise – Symptoms, signs, body image distortion Pursuit of thinness/avoidance of obesity major issue – “Healthy” habits directed toward sport, dance, etc – Unhealthy habits Determine level of care needed – Outpatient / Intensive Outpatient – Partial Hospitalization – Inpatient / Residential Principles of Motivational Interviewing (Miller & Rollnick) 1. Express empathy with patient’s perceptions 2. Develop discrepancy between present behavior & personal goals 3. Avoid argumentation and defensiveness 4. Redefine, rather than confront, resistance 5. Support self-efficacy through autonomy support Dr. Kreepie Major Systems Affected Metabolic – Hypometabolism Cardiovascular – Functional compensation Reproductive – Amenorrhea Musculoskeletal – Osteoporosis Keys, et al The Biology of Human Starvation U Minnesota Press 1950 Bonus question: What was Ancel Keys’ claim to fame? Affected Biological Systems Neurologic (CNS and PNS) Skin and Hair Cardiovascular Hematologic Hepatic GI: motility, absorption Endocrine (hypothalamic) – Thyroid – Growth hormone – Adrenal – Gonads Musculoskeletal Kreipe RE. Assessment of Weight Loss in the Adolescent. Ross Labs. Columbus, OH 1988. Drawing by C. Lyons, MD Salivary gland enlargement Parotid Submandibular Dental Enamel Erosion www.maxillofacialcenter.com/bulimia.html - Dentin (yellow) visible beneath eroded enamel (white) - Worse on lingual than buccal surfaces www.thejcdp.com/issue001/gandara/ introgan.htm A: Less enamel loss on buccal surfaces B: Enamel sparing in gingival crevices Erosion of enamel (white) and dentin (yellow) from persistent vomiting, resulting in tooth decay, fracture, and loss Malnutrition and Hypometabolism Muscle wasting Lanugo Energy intake results in wasting of lean (muscle) > fat Metabolism occurs in the lean body mass>>>>>fat Energy conservation: BMR; Temp.; HR; Peripheral blood flow; Physical activity ~70% of regained weight is lean body mass Week 1: •Wt 91#; •S.G. 1.018; •HR: 62 70; •36.9°C Weekly visits Week 5: •Wt 91#; •S.G. 1.020; •HR: 4482 •35.3°Cl Recheck Wt. (observed) and physical exam Cardiovascular: Physiologic v Pathologic Physiologic – Bradycardia (low energy intake) – Cold hands/feet (energy conservation) – Slow capillary refill (low cardiac output) – Acrocyanosis (deoxygenated hgb) – Orthostatic pulse ∆ >25 BPM: (compensatory) Pathologic – ECG: Non-specific changes (voltage ↓, R QRS axis, ST ↓, T flat or inverted, U waves) – Echo: Normal contractility; C.O. ↓; effusion? – Dysrhythmia: Ventricular tachyarrhythmia – Surveillance depends on findings and symptoms Edema Slow Capillary Refill Acrocyanosis Carotenemia Livedo Reticularis Bluish discoloration of skin Reticular (“lacy”) pattern Asymptomatic, but often associated with low core temperature and metabolism www.pediatrics.wisc.edu/education/ derm/tutc/69.html Cardiovascular Changes Symptoms respond to adequate nutrition Adequate energy intake needed to gain weight Moderate exercise, after intake exceeds output Limiting exercise is possible, but difficult Gynecologic Status Amenorrhea and infertility are related to weight and exercise Menstrual weight: 90% ABW for height Prolonged amenorrhea does not preclude childbearing With adequate weight gain, fertility should return to normal, but ovulation weight may exceed menstrual weight Gynecologic Changes Birth control pills preclude using menses as sign of physical health recovery Birth control pills and other hormonal therapy results in withdrawal bleeding, NOT menses Progesterone challenge does NOT “kick start” normal menstrual periods Return of menses related to gain of lean, as well as fat, body mass Musculoskeletal Status Reduced skeletal muscle mass Causes of osteopenia/osteoporosis – Low weight – Ineffective load-bearing exercise – Low estrogen – High cortisol N=48 with AN RCT: E/P vs Placebo F-U: 1.5 years Results 1) HRT does not prevent bone loss overall 2) If <70% ABW, BMD : E/P +4.0% Pla -20.1% 3) If >70% ABW, BMD : E/P +2.2% Pla +4.3% 4) Resumption of menses leads to normalized BMD Estrogen/Progestin Placebo Klibanski et al. JCEM 1995;80:898-904 Annual BMD ∆ Relative to Menses and Wt Gain Resumed menses & Improved weight: Spine ↑ 3.1%; Hip ↑ 1.8% No menses and No weight gain: Spine ↓ 2.6%; Hip ↓ 2.4% Resumed menses: Spine* ↑ 2.7%; Hip N.S. ↑ Improved weight: Spine ↓ 0.2%; Hip* ↑ 0.15% Lean body mass: Stronger determinant of BMD than either weight ↑ or fat mass ↑ On OCP: No BMD ↑ at any site, despite a mean 11.7% weight increase Miller et al. Determinants of skeletal loss and recovery in A.N. J Clin Endo Metab 2006;91:2931 Treatment Of Osteopenia / porosis Prevention is the only cure! Weight gain and resuming menses is the MOST effective method of increasing BMD Calcium and vitamin D supplementation (if low dairy intake) Hormone therapy: NO evidence of effectiveness in improving BMD Bisphosphonates, DHEA, IGF-I? What Do I Do Until “Treatment Begins”? Don’t waste time on “why” Focus on symptoms, signs and health Use motivational interviewing techniques Plan to gradually improve weight control habits Enlist support from family Regular health check visits Plan follow-up visit(s) after treatment begins to reinforce importance and acknowledge challenge Stages of Change Precontemplation Contemplation Preparing for Action Action Maintenance Termination (Prochaska, Norcross, & Diclemente, 1994) Support for Change in Primary Care Provide information about –Illness –Recovery process –How we get in our own way Therapeutic relationship (alliance) Awareness of influence of language, environment and social norms (Prochaska, Norcross, & DiClemente, 1994) Principles of Motivational Interviewing (Miller & Rollnick) 1. Express empathy with adolescent’s perceptions 2. Develop discrepancy between present behavior & personal goals 3. Avoid argumentation and defensiveness 4. Redefine, rather than confront, resistance 5. Support self-efficacy through autonomy support Engaging Patients In Treatment Symptoms/Signs related to weight control habits: “What your body is telling me” Focus on health, rather than weight Nurturant-authoritative approach – Acknowledge conflict explicitly – Emphasis on will-power, self-determination – Avoid blame, fault, guilt – Consultant, advisor, health expert (after Levenkron S: Treating and Overcoming AN, 1990) Engaging Parents in Treatment Developmental framework (child adult) Discuss blame, fault, guilt openly Realignment of roles in family Positive framing of family attributes Future orientation Authority to treat, and empowerment of, professionals comes from parents Problems Addressed In Mental Health Treatment Low Self-esteem Distorted body-image Dysfunctional coping behaviors and habits Depression – SSRIs only for BN or weight recovered AN Ineffective communication Conflict resolution Lack of assertiveness Post-trauma recovery (sexual abuse, etc) PCP Approach for Patients with Eating Disorders Validation Direct/specific questions Don’t assume, clarify Anticipate cognitive distortions and reasoning errors Be genuine/real (not opaque/distant) Use warmth, humor, consistency and persuasiveness Educate Team approach and good communication decreases splitting Role Play Referral to, and Collaboration with, Mental Health Care Providers (1 of 4) Be confident about the referral with the patient and family Emphasize the need for consultation for you, the patient, and the family Reinforce the patient is not “crazy.” Focus on the interplay between mind and body Educate the patient/family re: a mental health evaluation—worries, sadness, anxiety, fears, conflict, alternative coping Referral to, and Collaboration with, Mental Health Care Providers (2 of 4) Externalize the illness. Use an empowering and non-blaming/nonshaming approach with the family. Decrease isolation and refer families to Eating Disorders Network Support Meetings Encourage parents to work as a team and remain unified Referral to, and Collaboration with, Mental Health Care Providers (3 of 4) Say why you have chosen a particular therapist or consultant. Frame therapist as a specialist who is helpful Negotiate the kind of collaborative relationship and communication you would like to have on the treatment team. Specify roles and responsibilities (weekly weigh-ins, lab work, lunch supervision, etc.). Referral to, and Collaboration with, Mental Health Care Providers: It’s All about Relationships (4 of 4) Avoid Splitting. Do not make changes in treatment plan without discussing them with team: unified front.= Do not assume therapy is failing if the patient complains about the therapist. Communication is essential (schedule calls) Use case review to provide concrete examples of management challenges and helpful strategies Referral to and Collaboration with Mental Health Care Providers Help parents get respite and support for themselves. Monitor for strain on all family members, e.g., siblings. Validate the burden incurred by the illness. Encourage family to connect in ways that don’t involve eating disorder. Engaging with Patients in the Dental Office Be empathic and non-judgmental and adopt a more normalizing attitude during history taking. “I noticed today that your enamel looks more eroded, and erosion like this comes from gastric acid being in contact with your teeth. I have a number of patients in my practice with this experience. Some have GERD. Some have an eating disorder, and some have both. Tell me about what your experience has been so we can pick the right plan to help your teeth. Our plan really depends on what has been happening for you. I want to make sure I am doing the best thing for you, and I know how important your teeth are to you.” Engaging with Patients in the Dental Office 2) Patients minimize symptoms – aim high and seek clarification “When you say you vomit twice/day, do you mean twice in one episode or two separate episodes of vomiting in the day?” “When you said you took a few laxatives, how many exactly is that? More than 20 per day? 10 per day? 5 per day?” When in doubt…. Remember: I’ll have to talk to the team. (Faggiano & Tantillo, 2005) Discussion Western New York Comprehensive Care Center for Eating Disorders www.NYEatingDisorders.org UNITY HEALTH SYSTEM EATING DISORDERS PROGRAM Intake coordinator (Erica Thomas MS Ed) 368-3709 [email protected] Program Director (Mary Tantillo PhD RN CS) 368-6550 x8590 [email protected] GOLISANO CHILDREN’S HOSPITAL Child and Adolescent Eating Disorder Program Intake coordinator (Teri Litteer MS NP): 275-1521 [email protected] Program Director (Richard Kreipe MD): 275-7844 [email protected] American Psychiatric Assoc. Practice Guideline for the Treatment of Eating Disorders (3rd ed, 2006) • • Amenorrhea not essential to diagnosis of A.N. “Atypical” A.N. may have better prognosis (willingness to change?) Assess motivational stage, interpersonal attachment, overall attachment to life. Essential features of treatment for A.N. related to intensity, not medication NG tube feedings for A.N. of value Family therapy (separated or conjoint) and psycho-education important Osteoporosis: Nutritional rehabilitation assuring sufficient protein, carbohydrates, fats, calcium, and vitamin D Bulimia: DBT>CBT>NT>Support. Fluoxetine even for patients who “fail” CBT