Multidisciplinary Approach to Eating Disorders on Campus: A Case Based Discussion

1. Multidisciplinary Approach to Eating Disorders on Campus: A Case Based Discussion Amanda Bailey MSW LCSW Anne E. Kearney LCSW-R Jennifer Thieben MS RPA-C Julie A. Doody RN MS

2. 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.

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

4. 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.

5. 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

6. 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.

7. 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.

8. 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).

9. 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

10. 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

11. 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.

12. 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.

13. Eating Disorder Not Otherwise Specified Includes disorders of eating that do not meet the criteria for any specific eating disorder: • 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.

14. 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.

15. 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

16. Cultural Influences • Celebrity, Diet and Health Industry Influences • Pro Ana, Pro Mia & Thinspiration Websites • Social Networking Websites

17. Points of Entry • Self Referral • Outside Referral • Athletics • Residence Life • Faculty • Health Clearance • Mandated Referral

18. 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

19. April- Assessment Case Presentation • Demographics • Presenting problem • History of presenting problem • Impressions at time of intake

20. 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

21. 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

22. 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

23. 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.

24. April Prognosis and Plan • Stage of change • Treatment • Intervention • Prognosis • Recommendation • Case management

25. Tammy-Assessment Case Presentation • Demographics • Presenting problem • History of presenting problem • Impressions at time of intake

26. 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

27. 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

28. Tammy Assessment (Labs & Tests) • Complete Blood Count – WBC 4.4, 13.4/38.4 • Comprehensive Metabolic Panel – Glucose51 • 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

29. 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

30. Tammy-Prognosis and Plan • Stage of change • Treatment • Recommendation • Case management

31. 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.

32. Jason- Assessment Case Presentation • Demographics • Presenting problem • Impressions at time of intake

33. 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”

34. 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

35. Jason Assessment (Labs & Tests) Complete Blood Count – WBC 5.6, Hct40,Hb 14 Comprehensive Metabolic Panel – WNL Potassium – 4.0 Urinalysis – Mod Protein , +Ketones, -Gluc, 1.030 Thyroid Function Tests - WNL EKG @ MD – Sinus Bradycardia

36. 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

37. Jason- Prognosis and Plan • Stage of change • Treatment • Outside Provider • Administrative • Case Management

38. Administrative Issues • Case Management • Coordination of care with outside providers • Communication • Memo of Understanding • Conditions and Parameters of the Agreement • Documentation

39. 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

40. 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?

41. 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

42. Discussion

43. Resources • Screening Tools • Memo of Understanding • Inter office referral form

44. 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.