Transcript Multidisciplinary Approach to Eating Disorders on Campus

Multidisciplinary
Approach to Eating
Disorders on Campus: A
Case Based Discussion
Amanda Bailey MSW LCSW
Jennifer Thieben MS RPA-C
Anne E. Kearney LCSW-R
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 Emergency
Refeeding 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 AssociationNational 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, 21052108.

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.