Transcript Management in the Case of a Severely Anorexic College Student
Andra Prum, DO, FAAFP & Leslie Parsons, DO, FAPA Assistant Medical Directors Florida State University, University Health Services
Objectives
To describe the case of a severely anorexic college student in crisis.
To discuss the factors surrounding the initial plan of care for an acutely ill anorexic patient in crisis using the bio-psycho-social model of care management.
To identify resources in the geographic southeast United States for acute care inpatient management of the college student with severe disordered eating.
History of Present Illness
CC: “Wellness Check up. No concerns” HPI: 19 y/o female patient who is here for an “eating disorder issue”. The pt. notes she was initially told she needed to lose weight to improve her skills in softball two years ago which drove her to poor eating habits and excessive working out.
History of Present Illness
Referred by the recreation center on campus Eats only 2 meals/day No red meat Doesn’t like how she looks but is afraid to gain weight Exercising 1 ½ - 2 hours a day twice weekly to get rid of skin fold on abdomen Recent binging, self-induced vomiting, calorie restriction, skipping meals Worry about school and parents “hounding” her about her health
History of Present Illness (cont.)
She was identified by a trainer at the gym who contacted our Health Promotions Director of the situation who subsequently initiated an “intervention”. Pt. was then seen by Leslie Parsons, DO, Director of Psychiatry, and was diagnosed with severe anorexia (BMI 15.4). Pt. was then referred to our FSU medical clinic for lab work and evaluation today.
History of Present Illness (cont. )
Pt. notes she has been experiencing dizziness, occasional syncopal episodes, fatigue, diffuse abdominal discomfort, and h/o bulimia. Notes losing 120 lbs in past 2 years. Has been seen by a Hematologist due to chronic low white blood cell count. Pt. denies dyspnea, chest pain, cough or wheeze, palpitations, irregular heart beats, extremity swelling, nausea / vomiting, backache, joint or skeletal pain/swelling at this time. Denies suicidal ideation or homicidal ideation.
Past History
Medical History: Iron deficiency anemia B12 deficiency “Passed out” twice, once after working out and smoking marijuana “Bone marrow test” related to persistent anemia Was told that she was on the verge of needing a blood transfusion approximately 9 months prior Allergies: Penicillin, pollen Meds: Pt. denies Surgical History: Surgical repair of arm fracture/ dislocation in 2003.
Past Psychiatric History
Never before seen a psychiatrist Never before been in counseling or psychotherapy Never before been hospitalized for psychiatric reasons Never before been in an eating disorders program
Family History
Mother described as a “worrier” with a history of an eating disorder Another family member had postpartum depression Two family members reportedly died suddenly “out of nowhere” while otherwise healthy Cancer runs in the family Aunt with drug addiction Sister with heart murmur
Social History
Father retired marine Younger sister was focus of family’s attention due to various rebellious behaviors Told by high school softball coach that if she wanted to “start”, she would need to lose weight (she weighed 225 pounds at the time) Concerned about grades due to wanting to become a physician Not currently sexually active Drinks Caffeinated tea daily
Substance Abuse History
Denied using any alcohol or illicit drugs since coming to FSU Acknowledged drinking “a lot” and smoking marijuana beginning at the age of 16.
Denied any history of blackouts but stated that she drank to intoxication and/or vomiting
Physical Examination
VITALS: LMP: 9/2011 (6 months ago) T: 96.8 P: 48 R: 12 BP: 86/64 Ht: 70 inches Wt: 107 BMI: 15.4
Overall Appearance: Alert, emaciated, cachectic appearing pale female NAD Skin: sullen, appearance pale HEENT: oropharynx clear, dry lips, gingivitis Neck: Neck supple, without masses or thyroidomegaly Chest: lungs clear to auscultation, chest wall non-tender Heart: Bradycardic, 2/6 syst murmur appreciated.
Abdomen: scaphoid, + mild diffuse tenderness no rebound no guarding with skin sag on abdomen due to severe cachexia Spine/Extrem: diffuse muscle atrophy noted upper and lower extremities, no edema.
Neuro: Grossly normal neurologic exam
Physical Examination/ Mental Status
Psych: alert, oriented, cognitive function intact, cooperative with exam, poor eye contact, poor eye contact, speech diminished output, volume, mood depressed, judgment and insight poor, no auditory or visual hallucinations, speech clear, thought content without suicidal ideation.
Diagnostic Testing
Laboratory testing:
CBC with differential Comprehensive metabolic panel Nutrition Panel: Magnesium, Phosphate, Calcium, B12 level, Folate Thyroid Panel EKG DEXA, if associated with Female Athletic Triad: Disordered eating Amenorrhea Osteoporosis
Diagnostic Testing
L= Low , H=High CBC: WBC: 1.6 k/mm3 (L), Hg: 7.5 g/dl (L), Hct: 22% (L), MCV: 97 FL Comprehensive Metabolic panel: Glu: 85 mg/dl, BUN: 27mg/dl (H), Cr:1.03 mg/dl (H), K: 5.2 mmol/L (H), Ca: 8.8mg/dl (L), Pro: 5.7 g/dl (L), Alb: 4.0 , AST: 228 U/L (H), ALT : 282 U/L (H)
Diagnostic Testing
L= Low , H=High Nutrition panel: Mg: 2.1mg/dl, PO4: 3.3 mg/dl, Folic Acid: 17.5 ng/ml B12: >1500 PG/ml Thyroid: TSH: 3.14 mlU/L, Free T4: 0.62 ng/dl Urine Drug screen: neg.
EKG: Sinus Bradycardia Rate 37, otherwise WNL DEXA: ordered.
Urine preg: negative
Assessment
Assessment Anorexia Nervosa Symptomatic Bradycardia Prerenal azotemia- Dehydration Anemia- Normocytic Leukopenia (chronic)
Acute Management Plan
Our patient was sent to the local emergency room via ambulance for symptomatic bradycardia, dehydration, severe neutropenia and anorexia nervosa for further diagnostic testing and treatment.
Dr. Parsons contacted patient’s family (as agreed to by patient) and they will be driving to town to meet patient in hospital.
Management
Based on findings, we determined that the patient needed inpatient medical stabilization Patient was admitted to local hospital where she was given IV fluids, cardiac and lab work monitoring
Management
We encouraged the patient’s mother to try to find an inpatient eating disorders treatment program that could address patient’s poor medical condition as well as provide the needed intensive psychotherapy.
Pressure continued to be placed by the attending physician to discharge as the patient was considered “medically stable”.
We tried to have another local hospital with a psychiatric inpatient unit admit patient temporarily while waiting for transfer to an eating disorders program.
Inpatient psychiatric unit stated that the patient was too “unstable medically” to be on their unit.
Management
Management
Patient continued to eat a minimal number of calories during her hospital stay She was admitted on a Baker Act and had a police officer with her 1:1, hence, she was unable to purge Patient’s mother was also with her most of the time Patient’s mother and I called several different inpatient eating disorder programs with various levels of reciprocal communication
Management
Ultimately, patient was discharged home to her mother’s care with the plan to admit her to an inpatient eating disorders program as soon as possible Patient’s mother called to let me know that she had been admitted We assisted patient in getting a medical withdrawal from her classes We have not heard from the patient or her mother since then
Definition: Anorexia Nervosa
DSM IV criteria for Anorexia: Refusal to maintain body weight at or above a minimally normal weight for age and height (<85%), along with: an intense fear of gaining weight even though underweight; a disturbance in the way in which one’s body weight is experienced; and, absence of at least 3 consecutive menstrual cycles Specify type: Restricting type Binge-eating and purging type
Likely Risk Factors for Anorexia Nervosa Female Incidence peaks in adolescence Family history of eating disorders Dieting and psychiatric comorbidity Perfectionism and negative self-evaluation Genetic risk factors (chromosomes 1,3and 4) Leslie Parsons, DO, SCHA, Sandestin, April 2013
Possible Risk Factors for Anorexia Nervosa
Perinatal factors such as cephalohematoma, very preterm birth and small for gestational age Diabetes type 1 Eating alone Less than 5 family meals weekly Birth in March - June Leslie Parsons, DO, SCHA, Sandestin, April 2013
Early Warning Signs of Anorexia Nervosa
Excessive dieting Failure to gain weight during puberty Isolation from peers and family Excessive exercising Focus on weight and body Leslie Parsons, DO, SCHA, Sandestin, April 2013
Anorexia Nervosa is associated with an increased risk of death from medical complications and suicide.
THE SEVERITY OF AN ALCOHOL USE DISORDER PREDICTS MORTALITY.
Leslie Parsons, DO, SCHA, Sandestin, April 2013
Psychiatric Comorbidity
Bulimia nervosa Major depression Dysthymia Substance use disorder Other associated conditions: Obsessive-compulsive disorder Social Phobia Simple Phobia Avoidant Personality Disorder Dependent Personality Disorder Borderline Personality Disorder Histrionic Personality Disorder Leslie Parsons, DO, SCHA, Sandestin, April 2013
Outpatient Management
Outpatient Treatments at University setting:
Outpatient management for less severe pts. (weekly weight checks and lab testing until improvement).
Nutrition consultation.
Psychiatric consultation to determine severity of anorexia/bulimia. Psychological Consultation.
Nutritional Management
Relapse and rehospitalization rates are lower for patients who achieve their target body weight prior to discharge. However, the optimal length of stay or optimal setting for weight restoration is still unknown
Nutritional Management
Weight gain goals of 0.5 – 1 lb/week are reasonable in an outpatient setting; up to 2 lbs/week in a residential or inpatient setting.
Along with weight gain, treatment efforts focus on modifying thoughts and beliefs about food, weight, self-concept, and control, as well as developing relapse-prevention strategies.
Psychosocial Management
Psychosocial treatments such as psychoeducation, family therapy etc. are the mainstays of treatment for anorexia nervosa. However, there is little research to support their efficacy.
Readiness to change, as determined by standardized instruments, has been the most effective measure by which to predict clinical incomes
Psychosocial Management
Provide patients and their families with education on the nature, course, and treatment of eating disorders. When treating children and adolescents, caregivers and family members should be included in the treatment process to share information, provide guidance on behavioral management (i.e., meal planning, limit-setting), and facilitate communication.
Family member participation in support groups should also be encouraged.
Pharmacological Management
There are no FDA medications to treat anorexia nervosa.
Antidepressant medications may help with maintaining weight after the patient has gained weight and has had some improvement in psychological symptoms.
Antidepressant medications for the treatment of anorexia nervosa have limited effectiveness and should not be the sole treatment modality.
Pharmacological Management
Preliminary studies using the atypical antipsychotic olanzapine (Zyprexa) have demonstrated positive results.
Psychotropic medications may be effective as an adjunctive therapy when treating comorbid disorders, such as depression and anxiety.
Estrogen may help increase bone density in a subset of women with body weight less than 70% of ideal weight.
Anorexia Nervosa: Status Determination
Medical Status determination: Level 1: Outpatient: Level 2: Intensive Outpatient Level 3: Full Day Outpatient Levels 1-3: Medically stable to the extent that more extensive monitoring, as defined in Levels 4 and 5, is not required Level 4: Residential Treatment Center: Medically stable (not requiring IV fluids, NG tube feedings, or multiple daily laboratory tests) Weight: Generally < 85% percentage healthy body weight Motivation: Fair to poor Level 5: Inpatient Hospitalization
Anorexia Nervosa: Status Determination
Level 5: Inpatient Hospitalization Adults: heart rate < 40 beats per minute; blood pressure < 90/60 mm Hg; glucose < 60 mg/dL (3.33 mmol/L); potassium < 3 mEq/L (3 mmol/L); electrolyte imbalance; temperature < 97.0°F (36.1°C); dehydration; hepatic, renal or cardiovascular organ compromise; poorly controlled diabetes SUICIDALITY: If suicidality present then inpatient monitoring and treatment may be needed depending on the level of risk.
WEIGHT: Generally < 85% with acute weight decline with food refusal. Motivation to recover: poor to very poor
A Sampling of Inpatient/Residential Eating Disorder Programs in the Southeast United States
Evidenced Based Recommendations
Clinical recommendations Evidence Rating
Interpersonal or cognitive behavior therapy should be offered to patients with bulimia nervosa and binge-eating disorder.
A
References
AFP Journal A self help program may be considered as the first step in the treatment of bulimia nervosa and binge-eating disorder.
Most patients with anorexia nervosa should be treated as outpatients in a tertiary care setting by a multidisciplinary team.
B C AFP Journal AFP Journal A trial of an antidepressant may be offered as a primary therapy or in combination with psychotherapy in patients with bulimia nervosa B AFP Journal A= Consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, see http://www.aafp.org/afpsort.xml
.
Prognosis
27 to 50 percent of persons with anorexia nervosa will not show evidence of a clinical eating disorder within 10 years of follow-up after receiving treatment in a tertiary care setting.
The remaining persons will not improve, maintain a subclinical eating disorder, or meet criteria for another eating disorder. Standardized mortality ratios (SMRs) are elevated for patients with anorexia nervosa, ranging from 1.36 for females 20 years following treatment to 30.5 for females less than one year following treatment.
Conclusion
Anorexia Nervosa is a potentially life threatening disorder that involves complex psychosocial issues. Many patients can effectively be treated in the outpatient setting by a healthcare team that includes: physician (both primary care and psychiatrist) , nutritionist, and a therapist. Patients may require inpatient care if they are suicidal or have life threatening medical complications such as: bradycardia, hypothermia, severe electrolyte disturbances, end organ compromise, or weight below 85 percent of healthy body weight. Along with weight gain, treatment efforts focus on modifying thoughts and beliefs about food, weight, self-concept, and control, as well as developing relapse-prevention strategies.
References
Berkman ND, Lohr KN, Bulik CM. Outcomes of eating disorders: a systematic review of the literature. Int J Eat Disord. 2007;40(4):293–309.
Bulik CM, Berkman ND, Brownley KA, Sedway JA, Lohr KN. Anorexia nervosa treatment: a systematic review of randomized controlled trials. Int J Eat Disord. 2007;40(4):310–320.
Diagnostic and Statistical Manual of Mental Disorders. 4th ed. rev. Washington, DC: American Psychiatric Association; 2000:594–595.
Sullivan PF, Bulik CM, Fear JL, Pickering A. Outcome of anorexia nervosa: a case-control study. Am J Psychiatry. 1998;155(7):939–946 Williams PM, Goodie J, Motsinger CD. Treating Eating Disorders in Primary Care. Am Fam Physician, Jan 15 2008; 77(2): 187-195.
Yager J, Devlin MJ, Halmi KA, et al., for the Work Group on Eating Disorders. Practice Guideline for the Treatment of Patients with Eating Disorders. 3rd ed. Washington, DC: American Psychiatric Association; 2006. http://www.psych.org/psych_pract/treatg/pg/EatingDisorder-s3ePG_04-28 06.pdf
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