Download Multidisciplinary Management of Complicated Eating Disorder

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
–
–
–
–
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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:
–
–
–
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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:
–
–
–
–
–
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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:
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–
–
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–
–
–
–
–
–
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
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http://www.nih.gov/
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