Multidisciplinary Approach to Eating Disorders on Campus: A Case Based DiscussionAmanda Bailey MSW LCSW Anne E. Kearney LCSW-RJennifer Thieben MS RPA-C Julie A. Doody RN MS

Objectives

• Define eating disorders according to DSM-IV.

Identify psychological and medical warning signs of students with eating disorders.

Discuss the multi disciplinary approach to treating eating disorder patients on a small college campus.

Discuss administrative challenges regarding diagnosis and treatment of eating disorder patients.

Goal

To provide participants with useful tools to identify and treat eating disorder patients on a college campus.

Characteristics

• Eating disorders are syndromes characterized by severe disturbances in eating behavior and by distress or excessive concern about body shape or weight.

• Presentation varies, but eating disorders often occur with severe medical or psychiatric co-morbidity.

Definitions

The criteria for diagnosing a student with an eating disorder is in accordance with the Diagnostic and Statistical Manual of Mental Health (DSM-IV):

• Anorexia Nervosa

• Bulimia Nervous

• Eating Disorder Not Otherwise Specified

Anorexia Nervosa

• Refusal to maintain body weight at or above a minimally normal weight for age and height: Weight loss leading to maintenance of body weight <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.

• Intense fear of gaining weight or becoming fat, even though under weight.

Anorexia Nervosa

• Disturbance in the way one's body weight or shape are experienced, undue influence of body weight or shape on self evaluation, or denial of the seriousness of the current low body weight.

• Amenorrhea (at least three consecutive cycles) in postmenarchal girls and women. Amenorrhea is defined as periods occurring only following hormone (e.g., estrogen) administration.

Anorexia Nervosa

Two subtypes:

Restricting type: During the current episode of anorexia nervosa, the person has not regularly engaged in binge-eating or purging behavior (self induced vomiting or misuse of laxatives, diuretics, or enemas).

Binge-eating–purging type: During the current episode of anorexia nervosa, the person has regularly engaged in binge-eating or purging behavior (self-induced vomiting or the misuse of laxatives, diuretics, or enemas).

Bulimia Nervosa

1. Recurrent episodes of binge eating are characterized by both:

• 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 during a similar period of time and under similar circumstances

• A sense of lack of control over eating during the episode, defined by a feeling that one cannot stop eating or control what or how much one is eating

Bulimia Nervosa

2. Recurrent inappropriate compensatory behavior to prevent weight gain

• Self-induced vomiting

• Misuse of laxatives, diuretics, enemas, or other medications

• Fasting

• Excessive exercise

Bulimia Nervosa

3. The binge eating and inappropriate compensatory behavior both occur, on average, at least twice a week for 3 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

Two subtypes:

Purging type: During the current episode of bulimia nervosa, the person has regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas.

Non-purging type: During the current episode of bulimia nervosa, the person has used inappropriate compensatory behavior but has not regularly engaged in self-induced vomiting or misused laxatives, diuretics, or enemas.

Eating Disorder Not Otherwise Specified

Includes disorders of eating that do not meet the criteria for any specific eating disorder:

1. For female patients, all of the criteria for anorexia nervosa are met except that the patient has regular menses.

2. All of the criteria for anorexia nervosa are met except that, despite significant weight loss, the patient's current weight is in the normal range.

Eating Disorder Otherwise Not Specified

3. All of the criteria for bulimia nervosa are met except that the binge eating and inappropriate compensatory mechanisms occur less than twice a week or for less than 3 months.

4. The patient has normal body weight and regularly uses inappropriate compensatory behavior after eating small amounts of food (e.g., self-induced vomiting after consuming two cookies).

5. Repeatedly chewing and spitting out, but not swallowing, large amounts of food.

Background: Facts and Stats

Lifetime Prevalence Estimates – 1% AN, 1-3% B

Epidemiology – ACHA 2009 Health Assessment

1.1% = ED Effects Academic Performance

6.6% Females, 4.0% Males with BMI <18.5 (Underweight)

Rx for Anorexia – Males 0.6%, Females 1.0%, Total 0.9%

Rx for Bulimia – Males 0.5%, Females 1.0%, Total 0.9%

Male Patients- Nationally 10:1, 25% 2007 Harvard

Mortality Data: AN 5% per decade, Bulimia - Low

Cultural Influences

Celebrity, Diet and Health Industry Influences

Pro Ana, Pro Mia & Thinspiration Websites

Social Networking Websites

Points of Entry

• Self Referral

• Outside Referral

• Athletics

• Residence Life

• Faculty

• Health Clearance

• Mandated Referral

Stages of Change: Readiness

1. Pre contemplation- Not ready for change

2. Contemplation- Thinking about change

3. Preparation- Getting ready to take action

4. Action- Recently started to change overt behaviors

5. Maintenance- has overtly changed behavior

April- Assessment

Case Presentation

• Demographics

• Presenting problem

• History of presenting problem

• Impressions at time of intake

April Assessment (History)

Past Medical History – Entrance PE WNL. Height 65”, 96/48. Hb 12.4.

Family History - Denies

Psychiatric History – Admitted to Inpatient facility 4 yrs prior to Treat Bulimia, Prozac in past.

Social History – Oldest, Single Parent Family

ROS – Hair loss, swollen glands, acne, delayed thought process, fatigue and insomnia

April Assessment (PE) Vital Signs: 64.75 “, 129#, 100/70, 68, BMI 20

Accurate Weight with Urinalysis

General Appearance – Well nourished, good color, blunted affect

HEENT – MM Moist, Pale Conjunctiva, (-) Pharyngeal erythema/swelling, Dentition WNL

Cardiopulmonary – RRR (-) M, R, G

Abdominal – Soft, NT, (-) HSM (-)masses

Skin – Mild decomposition with chest and facial acne

Neuromuscular – Strength intact, (-) Tremor

Breast & GU - Deferred

April Assessment (Labs & Tests)

Complete Blood Count – WNL, 12.2/36.6

Comprehensive Metabolic Panel – Glucose 60,

Na 141, K 4.6

Albumin 4.2

Urinalysis – Tr. Protein , -Ketones, -Gluc, 1.005

Thyroid Function Tests - WNL

April Medical Follow - Up

Patient requests Wellbutrin - Denied.

Patient required to have bi-weekly weight checks with a urinalysis.

Continue College Counseling Center including referral to Psychiatrist.

April Prognosis and Plan

Stage of change

Treatment

Intervention

Prognosis

Recommendation

Case management

Tammy-Assessment

Case Presentation

Demographics

Presenting problem

History of presenting problem

Impressions at time of intake

Tammy Assessment (History)

Past Medical History – Entrance PE WNL. 63”, 120#, 92/60, P62

Family History - Denies

Psychiatric History - Denies

Social History – Arrived at School under stress. Reluctantly enters PA school under pressure from parents.

ROS – Depression, Rapid Weight loss, Constipation, Lethargy, Hair Loss, Amenorrhea

Tammy Assessment (PE)

Vital Signs: 63”, 90#, 92/74, P76 BMI 15.5

Accurate Weight with Urinalysis

General Appearance – Sallow, Flat affect, No eye contact

HEENT – MM Dry, Red conjunctiva, Parotid enlargement

Cardiopulmonary – RRR, EKG Pending

Abdominal – Scaphoid, BS Sluggish, -masses/bowel loops

Skin – Poor Turgor, Lanugo

Neuromuscular – Atrophy

Breast & GU - Deferred

Tammy Assessment (Labs & Tests)

Complete Blood Count – WBC 4.4, 13.4/38.4

Comprehensive Metabolic Panel – Glucose 51

Mg, PO4, Zn, Albumin - WNL

Urinalysis – Tr. Protein , -Ketones, -Gluc, 1.020

Thyroid Function Tests - TSH, Free T4 (WNL)

EKG @ MD – Sinus Bradycardia

DEXA Scan – Abnormal

Vitamin D - Deficient , PTH <2

Referring Specialist Rx

Referred to Local Specialist and EKG

No exercise except yoga

Celexa 20 mg day

Demands weight gain 1- 2 week and weekly counseling sessions

Tammy-Prognosis and Plan

Stage of change

Treatment

Recommendation

Case management

Acute EmergencyRefeeding Syndrome

Life-threatening constellation of multi-organ abnormalities.

At Risk patient is <70 % Ideal Body weight with weight loss>10% within 2 – 3 month period

Onset when carbohydrates are re-introduced after 24 - 72 hrs of starvation

Mandates Immediate Admission.

Jason- Assessment

Case Presentation

• Demographics

• Presenting problem

• Impressions at time of intake

Jason Assessment (History)

Past Medical History – Entrance PE WNL (June).

159#, No Height

Family History – Older Sister with ED

Psychiatric History - Denies

Social History – XC

ROS – “Vomited Blood”

Jason Assessment (PE)

Vital Signs: 74”, 149#, 100/60, P45 BMI 19

Accurate Weight with Urinalysis

General Appearance – Sunken eyes, dry lips, very nervous

HEENT – MM dry, Enamel erosion molars, Parotid tender

Cardiopulmonary – Bradycardia, EKG Pending

Abdominal – Scaphoid, BS Active , Guaiac (-)

Skin – No Russell’s Sign

Neuromuscular – DTR’s WNL, Emaciated

Jason Assessment (Labs & Tests)

Complete Blood Count – WBC 5.6, Hct 40, Hb 14

Comprehensive Metabolic Panel – WNL

Potassium – 4.0

Urinalysis – Mod Protein , +Ketones, -Gluc, 1.030

Thyroid Function Tests - WNL

EKG @ MD – Sinus Bradycardia

Jason Referrals & Follow-Up

Referred to Local Specialist, Nutritionist & College Counseling Center

Continued to Run on XC Team – Limit 150#

Meds: MVI, Refuses other

Weekly weights, K q2 weeks, CBC monthly

Jason- Prognosis and Plan

Stage of change

Treatment - Outside Provider - Administrative- Case Management

Administrative Issues

Case Management

Coordination of care with outside providers

Communication

Memo of Understanding

Conditions and Parameters of the Agreement

Documentation

Legal and Ethical Obligations

• Obligation to protect client/patient confidentiality• Obligation to serve students’ best interest; protect human life, and in higher ed …“in loco parentis”• Obligation to promote the general welfare of students in the larger living community• Obligation to our institutions (protection from liability, etc.)

• Policy and procedures

Utilizing the Director

• Someone who can step back and observe “from the balcony”

• What role does fear plays in informing treatment or

overshadowing care?

• Role of MI vs. controlling a controller

• When can we take a risk-reduction model?

• Where do we draw the line?

Community Standards & Code of Conduct

• Role of the SOC committee• VP or Dean can REQUIRE a medical assessment (on/off campus)• VP or Dean can inform parents (FERPA)• Institution can REQUIRE treatment and

minimal health indicators• Institution can implement a mandatory

medical withdrawal

Discussion

Resources

Screening Tools

Memo of Understanding

Inter office referral form

References

American College Health Association.(2009). American College Health Association- National College Health Assessment II: Reference Group Executive Summary Fall 2009. Linthicum, MD: American College Health Association; 2009.

Clarke, C. (2010). Men with eating disorders are a growing population. College Health in Action, 50, 14.

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed.,text rev.). Washington, DC: Author.

Jonathan T., Sheen P. (2008).Refeeding Syndrome: Recognition is the key to prevention and management. Journal of the American Dietic Association, 108, 2105-2108.

Walsh, B. (2003). Eating Disorders. In Harrison’s Principles of Internal Medicine. Retrieved September 9, 2010, http://www.accessmedicine.com/content.aspx?aID=2865564.

William, P., & Motsinger, C. (2008). Treating eating disorders in primary care. American Family Physician, 77, 187-195.