American College Health Association Annual Meeting June 4, 2010

1. 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

2. Disclosure • We have no financial relationship with a commercial entity producing health-care related products and/or services

7. 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

8. Objectives • Define the three categories of eating disorders delineated in the diagnostic and statistical manual of mental disorders fourth edition (DSM-IV) • Review the history and physical examination findings presented by patients with eating disorders • Recognize the medical and psychological complications of eating disorders • Describe a multidisciplinary model that can be used to effectively manage eating disorder patients on university and college campuses • Discuss legal and ethical dimensions of challenging eating disorder cases on university and college campuses • Identify potential triggers necessitating the need for referral to a higher level of care

9. 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

10. The average American woman is 5’4” tall and weighs 140 pounds • The average American model is 5’11” tall and weighs 117 pounds

11. Americans spend more than $40 billion dollars a year on dieting and diet-related products

12. 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

13. 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%)

14. 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

15. 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

16. 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)

17. 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)

18. 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

19. 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)

20. Anorexia Nervosa • 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) • Intense fear of gaining weight or becoming fat, even though underweight • 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 • Amenorrhea (at least three consecutive cycles) in postmenarchal girls and women

21. Anorexia Nervosa • The DSM-IV specifies two subtypes: • Restricting Type: during the current episode of anorexia nervosa, the person has not regularly engaged in binge-eating 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, self-induced vomiting, or the misuse of laxatives, diuretics, or enemas)

22. Bulimia Nervosa • 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. • Recurrent inappropriate compensatory behavior to prevent weight gain, such as: self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; excessive exercise. • The binge eating and inappropriate compensatory behaviors occur, on average, at least twice a week for three months. • Self-evaluation is unduly influenced by body shape and weight • The disturbance does not occur exclusively during episodes of anorexia nervosa.

23. 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.

24. 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

25. DSM-V: Proposed Diagnostic Criteria for BED • Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: • 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 • 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) • The binge-eating episodes are associated with three or more of the following: • Eating much more rapidly than normal • Eating until feeling uncomfortable full • Eating large amounts of food when not feeling physically hungry • Eating alone because of being embarrassed by how much one is eating • Feeling disgusted with oneself, depressed, or very guilty after overeating

26. DSM-V: Proposed Diagnostic Criteria for BED Continued C. Marked distress regarding binge eating is present • 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

27. 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 • Do you make yourself Sick because you feel uncomfortably full? • Do you worry you have lost Control over how much you eat? • Have you recently lost more than One stone (14 pounds or 6.35 kg) in a three month period? • Do you believe yourself to be Fat when others say you are too thin? • Would you say that Food dominates your life?

28. Screening • the Eating disorder Screen for Primary care (ESP) • Are you satisfied with your eating patterns? (No is abnormal) • Do you ever eat in secret? (Yes is abnormal) • Does your weight affect the way you feel about yourself? (Yes is abnormal) • Have any members of your family suffered with an eating disorder? (Yes is abnormal) • 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

29. 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

30. 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 • Bradycardia • Tachycardia • Hypotension • Hypothermia • Orthostasis

31. 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

32. 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

33. Levels Usually Associated with Purging Mehler PS. Bulimia Nervosa. NEJM 2003; 349: 875-881

34. 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

35. 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

36. 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

37. 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

38. 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)

39. 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

40. 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: • Cardiovascular collapse • Rhabomyolysis • Seizures • Delirium

41. 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

42. 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

43. 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

44. 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: • Restoring the person to a healthy weight • Treating the psychological issues related to the eating disorder • Reducing or eliminating behaviors or thoughts that lead to disordered eating • 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

45. 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

46. 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

47. 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

48. Treatment: Bulimia Nervosa • Medication • Various classes of antidepressants have been demonstrated in short-term, double-blind, placebo-controlled 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)

49. 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

50. 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