Transcript Eating Disorders in Children & Adolescents

The Critical Role of Primary Care Providers in
the Evaluation, Management, and Referral of
Eating Disorders
February 26, 2007
Mary Tantillo PhD RN CS
Director, Eating Disorders Recovery Center of Western NY
Director, Eating Disorders Program, Unity Health System
Richard Kreipe MD
Medical Director, Eating Disorders Recovery Center of WNY
Director, Child and Adolescent Eating Disorder Program,
Golisano Children’s Hospital
Learning Objectives

Evaluate adolescents/young adults with eating
disorders as they present in Primary Care

Manage common health problems associated with
eating disorders (metabolism, heart, gyn, bones)

Avoid pitfalls commonly encountered when
interacting with patients/families with eating
disorders
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Enhance the effectiveness of referrals to
specialists
Overview
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Screening and assessment in primary care
Principles of early recognition and treatment
Management of Common Problems
– Malnutrition and Metabolism
– Cardiovascular
– Reproductive
– Musculoskeletal
Engaging Patients and Parents
Role play
Referral to EDRC
– Principles of comprehensive treatment
– Elements of treatment
Discussion
12 year old self-portrait
1) Library: 5 Minute Exercises,
Recipes for Health,
Calories Do Count,
Secrets of Staying Thin
2) Exercise rope
3) Clock always at mealtime
4) Plate with vegetables, fruit, no meat
or fat. Most food uneaten
5) Forbidden foods beyond arm’s
reach
6) Externally: Superwoman
7) Internally: An empty skeleton
DSM-PC
Wolraich ML, et al. The
Classification of Child and
Adolescent Mental Diagnoses
in Primary Care: Diagnostic
and Statistical Manual for
Primary Care (DSM-PC), Child
and Adolescent Version.
AAP, 1996
Variation
Problem
Disorder
V65.49 Dieting/Body Image Variation
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Dieting may occur if the child is overweight but it
should be a realistic program.
The child does not completely eliminate any food
group, but generally decreases intake of food,
especially of sweets and fats or is on an
appropriate diet.
The child favors a thin appearance but has a
realistic image.
The individual can stop dieting voluntarily.
DSM-PC, Child and Adolescent Version, AAP, 1996
V69.1 Dieting/Body Image Problem
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More intense dieting/food restrictions resulting in
weight loss or failure to gain weight as expected,
but not enough to qualify for A.N. or E.D. NOS
Obsessed with the pursuit of thinness and
develops systematic fears of gaining weight
Consistent disturbance in body perception and
starts to deny that weight loss or dieting is a
problem.
DSM-PC, Child and Adolescent Version, AAP, 1996
ANOREXIA NERVOSA
(pursuit of thinness)
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Insufficient energy intake
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Wasting of the body
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Delusion of being fat
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Obsession to be thinner
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Does not diminish with weight loss
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Denial
BULIMIA NERVOSA
(avoidance of obesity)
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Recurrent, secretive binge-eating
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Fear of not being able to stop eating
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Awareness that eating pattern is abnormal
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Depressed moods and self-deprecating thoughts
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Temporary relief via avoidance of weight gain by
–
–
–
–
Fasting
Self-induced vomiting
Catharsis or diuresis
Exercise
Guidelines for Adolescent Preventive Services (G.A.P.S.)
http://www.ama-assn.org/ama/pub/category/1980.html
Eating Disorders: Caveats in Primary Care
Negative
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“Classic” presentation less likely in younger
patients and/or shorter duration of illness
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No single “cause” to this final common pathway
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No diagnostic lab (blood, urine, ECG, imaging,
etc) studies
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Opinions are less important than facts
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Initial goal is not to diagnose an eating disorder,
but to determine the cause of weight loss
Eating Disorders: Caveats in Primary Care
Positive
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Physical findings are the result of weight control
habits
Mental status is part of the physical examination
Laboratory studies for baseline, or to reinforce
physical examination finding
Motivational interviewing avoids many pitfalls in
management
Parents are part of the solution to, not the cause
of, the eating disorder
Diagnostic Algorithm for Weight Loss
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Is weight loss intentional and/or desired?
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–
–
–
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Unrecognized illness
Increased energy needs due to exercise or growth
Efforts to “get in shape”
Energy restriction (intake) or output (exercise)
Excessive dieting or exercise
– Symptoms, signs, body image distortion
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Pursuit of thinness/avoidance of obesity major issue
– “Healthy” habits directed toward sport, dance, etc
– Unhealthy habits
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Determine level of care needed
– Outpatient / Intensive Outpatient
– Partial Hospitalization
– Inpatient / Residential
Principles of Motivational Interviewing
(Miller & Rollnick)
1.
Express empathy with patient’s perceptions
2.
Develop discrepancy between present behavior
& personal goals
3.
Avoid argumentation and defensiveness
4.
Redefine, rather than confront, resistance
5.
Support self-efficacy through autonomy support
Dr. Kreepie
Major Systems Affected
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Metabolic
– Hypometabolism
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Cardiovascular
– Functional compensation
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Reproductive
– Amenorrhea
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Musculoskeletal
– Osteoporosis
Keys, et al
The Biology of
Human Starvation
U Minnesota Press
1950
Bonus question:
What was Ancel
Keys’ claim to fame?
Affected Biological Systems
 Neurologic (CNS and PNS)
 Skin and Hair
 Cardiovascular
 Hematologic
 Hepatic
 GI: motility, absorption
 Endocrine (hypothalamic)
– Thyroid
– Growth hormone
– Adrenal
– Gonads
 Musculoskeletal
Kreipe RE. Assessment of Weight Loss in
the Adolescent. Ross Labs. Columbus,
OH 1988.
Drawing by C. Lyons, MD
Salivary gland enlargement
Parotid
Submandibular
Dental Enamel Erosion
www.maxillofacialcenter.com/bulimia.html
- Dentin (yellow) visible beneath
eroded enamel (white)
- Worse on lingual than buccal
surfaces
www.thejcdp.com/issue001/gandara/
introgan.htm
A: Less enamel loss on buccal
surfaces
B: Enamel sparing in gingival
crevices
Erosion of enamel (white) and dentin (yellow)
from persistent vomiting, resulting in tooth
decay, fracture, and loss
Malnutrition and Hypometabolism
Muscle
wasting
Lanugo
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 Energy intake results in wasting of lean (muscle) > fat
Metabolism occurs in the lean body mass>>>>>fat
Energy conservation:  BMR;  Temp.;  HR;  Peripheral
blood flow;  Physical activity
~70% of regained weight is lean body mass
Week 1:
•Wt 91#;
•S.G. 1.018;
•HR: 62 70;
•36.9°C
Weekly visits
Week 5:
•Wt 91#;
•S.G. 1.020;
•HR: 4482
•35.3°Cl
Recheck Wt.
(observed) and
physical exam
Cardiovascular: Physiologic v Pathologic
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Physiologic
– Bradycardia (low energy intake)
– Cold hands/feet (energy conservation)
– Slow capillary refill (low cardiac output)
– Acrocyanosis (deoxygenated hgb)
– Orthostatic pulse ∆ >25 BPM: (compensatory)
Pathologic
– ECG: Non-specific changes (voltage ↓, R QRS
axis, ST ↓, T flat or inverted, U waves)
– Echo: Normal contractility; C.O. ↓; effusion?
– Dysrhythmia: Ventricular tachyarrhythmia
– Surveillance depends on findings and symptoms
Edema
Slow Capillary Refill
Acrocyanosis
Carotenemia
Livedo Reticularis
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Bluish discoloration of skin
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Reticular (“lacy”) pattern
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Asymptomatic, but often
associated with low core
temperature and metabolism
www.pediatrics.wisc.edu/education/
derm/tutc/69.html
Cardiovascular Changes
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Symptoms respond to adequate nutrition
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Adequate energy intake needed to gain weight
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Moderate exercise, after intake exceeds output
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Limiting exercise is possible, but difficult
Gynecologic Status
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Amenorrhea and infertility are related
to weight and exercise
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Menstrual weight: 90% ABW for height
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Prolonged amenorrhea does not
preclude childbearing
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With adequate weight gain, fertility
should return to normal, but ovulation
weight may exceed menstrual weight
Gynecologic Changes
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Birth control pills preclude using menses
as sign of physical health recovery
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Birth control pills and other hormonal
therapy results in withdrawal bleeding,
NOT menses
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Progesterone challenge does NOT “kick
start” normal menstrual periods
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Return of menses related to gain of lean,
as well as fat, body mass
Musculoskeletal Status
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Reduced skeletal muscle mass
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Causes of osteopenia/osteoporosis
– Low weight
– Ineffective load-bearing exercise
– Low estrogen
– High cortisol
N=48 with AN
RCT: E/P vs Placebo
F-U: 1.5 years
Results
1) HRT does not prevent
bone loss overall
2) If <70% ABW, BMD :
E/P +4.0%
Pla -20.1%
3) If >70% ABW, BMD  :
E/P +2.2%
Pla +4.3%
4) Resumption of menses
leads to normalized BMD
Estrogen/Progestin
Placebo
Klibanski et al. JCEM 1995;80:898-904
Annual BMD ∆ Relative to Menses and Wt Gain
 Resumed menses & Improved weight: Spine ↑
3.1%; Hip ↑ 1.8%
 No menses and No weight gain: Spine ↓ 2.6%;
Hip ↓ 2.4%
 Resumed menses: Spine* ↑ 2.7%; Hip N.S. ↑
 Improved weight: Spine ↓ 0.2%; Hip* ↑ 0.15%
 Lean body mass: Stronger determinant of BMD
than either weight ↑ or fat mass ↑
 On OCP: No BMD ↑ at any site, despite a mean
11.7% weight increase
Miller et al. Determinants of skeletal loss and
recovery in A.N. J Clin Endo Metab 2006;91:2931
Treatment Of Osteopenia / porosis
Prevention is the only cure!
 Weight gain and resuming menses is the
MOST effective method of increasing BMD
 Calcium and vitamin D supplementation (if
low dairy intake)
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Hormone therapy: NO evidence of
effectiveness in improving BMD
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Bisphosphonates, DHEA, IGF-I?
What Do I Do Until “Treatment Begins”?
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Don’t waste time on “why”
Focus on symptoms, signs and health
Use motivational interviewing techniques
Plan to gradually improve weight control habits
Enlist support from family
Regular health check visits
Plan follow-up visit(s) after treatment begins to
reinforce importance and acknowledge challenge
Stages of Change
Precontemplation
 Contemplation
 Preparing for Action
 Action
 Maintenance
 Termination
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(Prochaska, Norcross, & Diclemente, 1994)
Support for Change in Primary Care
Provide information about
–Illness
–Recovery process
–How we get in our own way
 Therapeutic relationship (alliance)
 Awareness of influence of language, environment
and social norms
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(Prochaska, Norcross, & DiClemente, 1994)
Principles of Motivational Interviewing
(Miller & Rollnick)
1.
Express empathy with adolescent’s perceptions
2.
Develop discrepancy between present behavior
& personal goals
3.
Avoid argumentation and defensiveness
4.
Redefine, rather than confront, resistance
5.
Support self-efficacy through autonomy support
Engaging Patients In Treatment

Symptoms/Signs related to weight control
habits: “What your body is telling me”
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Focus on health, rather than weight
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Nurturant-authoritative approach
– Acknowledge conflict explicitly
– Emphasis on will-power, self-determination
– Avoid blame, fault, guilt
– Consultant, advisor, health expert
(after Levenkron S: Treating and Overcoming AN, 1990)
Engaging Parents in Treatment
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Developmental framework (child  adult)
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Discuss blame, fault, guilt openly
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Realignment of roles in family
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Positive framing of family attributes
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Future orientation
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Authority to treat, and empowerment of,
professionals comes from parents
Problems Addressed In
Mental Health Treatment
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Low Self-esteem
Distorted body-image
Dysfunctional coping behaviors and habits
Depression
– SSRIs only for BN or weight recovered AN
Ineffective communication
Conflict resolution
Lack of assertiveness
Post-trauma recovery (sexual abuse, etc)
PCP Approach for Patients with
Eating Disorders
Validation
 Direct/specific questions
 Don’t assume, clarify
 Anticipate cognitive distortions and reasoning errors
 Be genuine/real (not opaque/distant)
 Use warmth, humor, consistency and persuasiveness
 Educate
 Team approach and good communication decreases
splitting
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Role Play
Referral to, and Collaboration with,
Mental Health Care Providers (1 of 4)
Be confident about the referral with the patient
and family
 Emphasize the need for consultation for you, the
patient, and the family
 Reinforce the patient is not “crazy.”
 Focus on the interplay between mind and body
 Educate the patient/family re: a mental health
evaluation—worries, sadness, anxiety, fears,
conflict, alternative coping
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Referral to, and Collaboration with,
Mental Health Care Providers (2 of 4)
Externalize the illness.
 Use an empowering and non-blaming/nonshaming approach with the family.
 Decrease isolation and refer families to Eating
Disorders Network Support Meetings
 Encourage parents to work as a team and remain
unified
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Referral to, and Collaboration with,
Mental Health Care Providers (3 of 4)
Say why you have chosen a particular therapist
or consultant.
 Frame therapist as a specialist who is helpful
 Negotiate the kind of collaborative relationship
and communication you would like to have on
the treatment team.
 Specify roles and responsibilities (weekly
weigh-ins, lab work, lunch supervision, etc.).

Referral to, and Collaboration with, Mental
Health Care Providers:
It’s All about Relationships (4 of 4)
 Avoid
Splitting.
 Do not make changes in treatment plan without
discussing them with team: unified front.=
 Do not assume therapy is failing if the patient
complains about the therapist.
 Communication is essential (schedule calls)
 Use case review to provide concrete examples of
management challenges and helpful strategies
Referral to and Collaboration with Mental
Health Care Providers
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Help parents get respite and support for
themselves.
Monitor for strain on all family members, e.g.,
siblings.
Validate the burden incurred by the illness.
Encourage family to connect in ways that don’t
involve eating disorder.
Engaging with Patients in the Dental Office
Be empathic and non-judgmental and adopt a
more normalizing attitude during history taking.
“I noticed today that your enamel looks more eroded, and
erosion like this comes from gastric acid being in contact
with your teeth. I have a number of patients in my practice
with this experience. Some have GERD. Some have an
eating disorder, and some have both. Tell me about what
your experience has been so we can pick the right plan to
help your teeth. Our plan really depends on what has been
happening for you. I want to make sure I am doing the best
thing for you, and I know how important your teeth are to
you.”
Engaging with Patients in the Dental Office
2) Patients minimize symptoms – aim high and
seek clarification
“When you say you vomit twice/day, do you
mean twice in one episode or two separate
episodes of vomiting in the day?”
“When you said you took a few laxatives, how
many exactly is that? More than 20 per day?
10 per day? 5 per day?”
When in doubt….
Remember:
I’ll have to talk to the team.
(Faggiano & Tantillo, 2005)
Discussion
Western New York
Comprehensive Care Center for Eating Disorders
www.NYEatingDisorders.org
UNITY HEALTH SYSTEM
EATING DISORDERS PROGRAM
Intake coordinator (Erica Thomas MS Ed)
368-3709
[email protected]
Program Director (Mary Tantillo PhD RN CS)
368-6550 x8590
[email protected]
GOLISANO CHILDREN’S HOSPITAL
Child and Adolescent Eating Disorder
Program
Intake coordinator (Teri Litteer MS NP): 275-1521
[email protected]
Program Director (Richard Kreipe MD): 275-7844
[email protected]
American Psychiatric Assoc. Practice Guideline for
the Treatment of Eating Disorders (3rd ed, 2006)
•
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Amenorrhea not essential to diagnosis of A.N.
“Atypical” A.N. may have better prognosis
(willingness to change?)
Assess motivational stage, interpersonal
attachment, overall attachment to life.
Essential features of treatment for A.N. related
to intensity, not medication
NG tube feedings for A.N. of value
Family therapy (separated or conjoint) and
psycho-education important
Osteoporosis: Nutritional rehabilitation
assuring sufficient protein, carbohydrates,
fats, calcium, and vitamin D
Bulimia: DBT>CBT>NT>Support. Fluoxetine
even for patients who “fail” CBT