Management in the Case of a Severely Anorexic College Student

Report
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
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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:
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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
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“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
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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
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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:
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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
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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
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Bulimia nervosa
Major depression
Dysthymia
Substance use disorder
Other associated conditions:
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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
References
Interpersonal or cognitive behavior therapy should A
be offered to patients with bulimia nervosa and
binge-eating disorder.
AFP Journal
A self help program may be considered as the first
step in the treatment of bulimia nervosa and
binge-eating disorder.
B
AFP Journal
Most patients with anorexia nervosa should be
treated as outpatients in a tertiary care setting by a
multidisciplinary team.
C
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 patientoriented 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_04-2806.pdf. Accessed June 28, 2007.
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