Developing a Multidisciplinary Developing a Multidisciplinary Eating Disorder Treatment Team Eating Disorder Treatment Team

in a University Settingin a University SettingAimee Daigle, FNP | Jennifer Gilkes, MDAimee Daigle, FNP | Jennifer Gilkes, MD

Vanessa Richard, RD, LDN | Rachel Stokes, PsyDVanessa 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 VALUEROLE, 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• 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 HOW TO DEVELOP A TREATMENT TEAMTEAM

“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

• 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• 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• Outpatient Treatment Providers• Intensive Outpatient Program• Partial Hospitalization Program• Residential Treatment Program• Medical Stabilization/Inpatient Hospitalization

KEY COMPONENTS OF A KEY COMPONENTS OF A TREATMENT TEAMTREATMENT TEAM

Key Components of a Treatment Team

• 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• 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

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 TreatmentReview 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 TreatmentPhysical 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 Other TestsCBC-anemia, pancytopenia,leukopenia

Metabolic Profile/Magnesium/Phos-hyper/hypoglycemia, hypokalemia, hypophophatemia, hyponatremia

Thyroid function studies-normal to low TSH, low T4

Estrogen/Testosterone-low estrogen/testosterone

Vitamin D-hypovitaminosis D

U/A-low SG

DEXA SCAN-decreased bone mineral density-indicated for longstanding ED or amenorrhea > 6 months

EKG (ECHO if indicated)-arrhythmias-prolonged QT interval-bradycardia

MRI/CT-neuro symptoms

Amylase, lipase, FSH/LH, fasting insulinGTT, 24 Urine CC

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– 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 Carehttp://www.aafp.org/afp/2003/0115/p297.html

– Clinical Report—Identification and management of Eating Disorders in Children and Adolescents—American Academy of Pediatricshttp://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 Disordershttp://www.aedweb.org/AM/Template.cfm?Section=Medical_Care_Standards&Template=/CM/ContentDisplay.cfm&ContentID=2413

Psychiatry and College EDTT• First Evaluation– Establish therapeutic alliance– Diagnose and treat co-occurring illness– Make predictions about illness– Psycho-education– Determine best treatment setting

• Subsequent Appointments– 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– 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

• Very low BMI• Family conflict or dysfunction• Long duration of illness• Comorbid psychiatric or personality disorders• Vomiting or laxative abuse

– Good Outcomes: Anorexia• 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:• 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 TREATMENT EFFECTIVENESS AND OUTCOME MEASUREMENT 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 DataFemale 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

ChallengesAdministrative 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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