Management in the Case of a Severely Anorexic College Student

1. 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

3. 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.

4. 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.

5. 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

6. 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.

7. History of Present Illness (cont. ) • Pt. notes she has been experiencing dizziness, occasional syncopalepisodes, 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.

8. 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.

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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.

15. 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

16. Diagnostic TestingL= 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)

17. Diagnostic TestingL= 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

18. Assessment • Assessment • Anorexia Nervosa • Symptomatic Bradycardia • Prerenal azotemia- Dehydration • Anemia- Normocytic • Leukopenia (chronic)

19. 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.

20. 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

21. 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.

22. Management

23. 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

24. 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

25. 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

26. 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

27. Possible Risk Factors for Anorexia Nervosa Leslie Parsons, DO, SCHA, Sandestin, April 2013 • 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

28. Early Warning Signs of Anorexia Nervosa Leslie Parsons, DO, SCHA, Sandestin, April 2013 Excessive dieting Failure to gain weight during puberty Isolation from peers and family Excessive exercising Focus on weight and body

29. Anorexia Nervosa is associated with an increased risk of death from medical complications andsuicide.THE SEVERITY OF AN ALCOHOL USE DISORDER PREDICTS MORTALITY. Leslie Parsons, DO, SCHA, Sandestin, April 2013

30. Psychiatric Comorbidity Leslie Parsons, DO, SCHA, Sandestin, April 2013 • 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

32. 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.

33. Nutritional Management • Relapse and rehospitalizationrates 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

34. 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.

35. 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

36. 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.

37. 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.

38. 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.

39. 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

40. 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

41. A Sampling of Inpatient/Residential Eating Disorder Programs in the Southeast United States

42. Evidenced Based Recommendations 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.

43. 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.

44. 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.

45. 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. • BulikCM, 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. Accessed June 28, 2007.

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47. Any Questions?