Eating And Weight Related Disorders: Case Presentations of Multidisciplinary Care. Renee Gibbs, PhD Central Arkansas VA Healthcare System

Transcription

1 Eating And Weight Related Disorders: Case Presentations of Multidisciplinary Care Renee Gibbs, PhD Central Arkansas VA Healthcare System

2 DISCLOSURES No disclosures of conflict of interest to report 2

3 OVERVIEW Two case presentations illustrate complete course of outpatient treatment from multidisciplinary perspective Case 1: Recovery story of 21 year old female Veteran with severe bulimia including esophageal tears, and recent history of depression and PTSD due to military sexual trauma (MST) Case 2: Treatment story of a 24 year old female Active Duty Service member with recent history of anorexia and remote history of binge eating disorder 3

4 THE TREATMENT TEAM MODEL 4

5 INITIAL PROCESS FOR PATIENT 5

6 EATING DISORDER TREATMENT Case Discussions *All names and some details have been changed to protect identities 6

7 CASE 1: MS. TRISTAN Relevant case details 21 year old, African-American female OEF/OIF/OND Veteran, non-combat MST while overseas at age 18, perpetrated by higher- ranking, older male officer History of severe bulimia subsequent to rape, with esophogeal tears and nutritional deficiencies; associated restrictive eating patterns and dietary rules Suffered from PTSD due to MST, with pervasive avoidance of emotionally intimate relationships and recurrent depressive episodes 7

8 DISCUSSION POINT What is the first thing you would you do if a patient reported eating disorder behaviors? 8

9 WHAT WOULD YOU DO? 9

10 TREATMENT CONSIDERATIONS Referred for brief course of DBT (Dialectical Behavior Therapy) coping skills and evidence based trauma processing, no prior eating disorder assessment Assessment indicated bulimia; records review revealed prior inpatient treatment for eating disorder while in service Severity of symptoms and medical assessment/labs indicated need for higher level of care 10

11 HIGHER LEVEL OF CARE: REFERRING FOR INPATIENT Researched several inpatient hospitals to locate a facility that met Veteran s treatment needs VA pays Medicaid rate, many inpatient facilities will not accept this rate Referral required Chief of Staff approval (medical documentation of clinical need and failure in outpatient treatment) Process from initial assessment to inpatient care required four months Collaborated with inpatient treatment team during 30 day stay 11

12 REFERRAL INSTRUCTIONS: YOU DO NOT HAVE TO REINVENT THE WHEEL Generate a Chief of Staff Referral Consult This may be called Choice Care or NVCC (Non VA Choice Care) Document (in the consult) patient s critical medical needs, outpatient treatment failure, increase in psychiatric concerns and/or worsening of eating disorder behaviors (use American Psychiatric Association guidelines as a guide) Document treatment team meeting discussions pertinent to level of care decisions 12

13 REFERRAL INSTRUCTIONS CONTINUED Cite dates and note titles (in the consult) that capture critical lab values, worsening of symptoms, compromised medical or psych status See chart linked below for inpatient hospitalization criteria guidelines Assoc-Guidelines-Chart.pdf 13

14 WHAT CONSTITUTES COMPROMISED MEDICAL STATUS? 14

15 MINI INTENSIVE OUTPATIENT PROGRAMMING AFTER INPATIENT TREATMENT Veteran seen twice weekly for psychotherapy to reinforce inpatient learning and progress Registered dietitian joins team and sees Ms. Tristan weekly to reinforce nutrition education and meal planning Increased visits with primary care to monitor labs and medical followup; primary care physician joins eating disorders treatment team Veteran maintains progress and achieves one year abstinence from binge/purge behaviors Veteran is finally able to complete Cognitive Processing Therapy (CPT) and functioning improves 15

16 DISCUSSION POINT: SEXUAL TRAUMA & EATING DISORDERS How would her sexual trauma history influence your approach to this case? Let s discuss. 16

17 SEXUAL TRAUMA & EATING DISORDERS What we know (Mitchell et al., 2012): Rates of concurrent interpersonal trauma and eating disorders were high in a 2012 study with a sample of 2,382 men and 3,310 women. More than 40% of women with Bulimia Nervosa and 35% of women with Binge Eating Disorder (BED) reported sexual assault trauma. Nearly 60% of men reported being beaten or stalked by a romantic partner. 17

18 WHY CBT-E? Cognitive Behavioral Therapy (CBT) in general is based on two interconnected premises: Cognitive processes play important role in maintenance of psychopathology Treatment should address maladaptive cognitive processes and behavior change for recovery CBT is evidence based treatment of choice in VA for several conditions: depression, anxiety, insomnia, substance use disorders, PTSD, etc. 18

19 WHY CBT-E? Cognitive Behavior Therapy Enhanced (CBT-E) for eating disorders is the only therapy to date with established evidence base for transdiagnostic patients Includes anorexia, bulimia, BED, and subclinical disordered eating Effective for patients with co-occurring disorders Can be adapted for outpatients, intensive outpatient programming (IOP), and inpatient treatment Similar to other CBT modalities, but with real time food recording procedures Solid evidence base 19

20 CBT-E IN A NUTSHELL Stage 1: Engagement and joint formulation, education and introduction to weekly weighing and patterned eating. Approximately eight sessions. Stage 2: Therapist and patient build alliance, identify barriers, modify formulation and plan Stage 3. Two sessions. Stage 3: Main core of treatment. Goal to address mechanism maintaining disordered eating eight sessions. Stage 4: Final stage. Two goals: Ensure changes made are maintained in following months & to minimize relapse. Decrease frequency of visits to bi weekly or every three weeks. Fairburn, C.G. (2008). Cognitive Behavior Therapy and Eating Disorders. New York: Guilford Press. 20

21 CASE 3: MS. HARTFORD Relevant case details 24 year old, Caucasian female Active Duty Service member local military base Never married, reports very few relationships with friends or family Recent weight of 106 lbs., with a body mass index (BMI) of 16; treatment mandated by mental health command Self-reported history of binge eating disorder in childhood; dropped weight via restriction at basic training Presents with lack of insight and frequent use of calorie counting apps 21

22 MULTIDISCIPLINARY ROUNDTABLE Psychologist: CBT-E interventions and Attempts at Engagement Patient would not agree to plan of healthy weight restoration; denied need for weight gain Denied connections of emotions or mood to eating or restricting, or history of trauma, depression, or anxiety Results of objective assessment inventories (EDE-Q and EAT-26) revealed nothing of use extreme minimization 22

23 MULTIDISCIPLINARY ROUNDTABLE Dietitian: Motivational Interviewing and Nutrition Counseling Patient contracts to discontinue use of calorie tracking devices; does not follow through Patient refuses to eat more than 1200 kcal per day despite 2000 kcal energy requirements Patient engages in food exposure exercises in session with dietitian, however will not reintroduce feared foods, including complex carbohydrates, healthy fats, or fruit 23

24 MULTIDISCIPLINARY ROUNDTABLE Psychiatrist: Medication Management Intervention Reports history of OCD and asks for medication; however improvement in heightened obsessionality and ritualized behaviors not evident after several months Primary Care: No Patient Participation Patient does not attend appointments or respond to attempts to reschedule Unable to determine medical stability for outpatient treatment until emergency situation arose 24

25 MULTIDISCIPLINARY ROUNDTABLE Higher Level of Care: Determination of Medical Instability Patient reports to nutrition appointment after having gained 13 lbs. in two days after dangerous binge behaviors (admits she is attempting to avoid inpatient treatment for anorexia) Patient exhibits medical signs of refeeding syndrome, including edema, erratic heart rate, and electrolyte imbalance Mental health command agrees with treatment team to refer for higher level of care Patient leaves against medical advice; subsequently discharged medically from military service 25

26 DISCUSSION POINT: WHAT ABOUT PREGNANCY? What if this young service member was pregnant? How would this affect your treatment approach? 26

27 EATING DISORDERS & PREGNANCY What we know: Risks for the Pregnant Person: Poor nutrition, dehydration, cardiac irregularities, gestational diabetes, severe depression during pregnancy, premature birth, labor complications, difficulties nursing, and postpartum depression. 27

28 PREGNANCY RISKS CONTINUED Risks for the Baby: Poor development, premature birth, low birth weight, respiratory distress, feeding difficulties, and other perinatal complications. Anorexia nervosa: Individuals can be underweight and may not gain enough weight during pregnancy. Baby could have abnormally low birth weight and related health problems. Bulimia nervosa: Purging can cause dehydration, chemical imbalances, or even cardiac irregularities. Pregnancy heightens these health risks. Binge eating disorder: Binge eating is often correlated with weight gain. May lead to a greater risk of developing high blood pressure and gestational diabetes. 28

29 DISCUSSION POINT Could Military service requirements play a role? What are your thoughts? 29

30 MILITARY SERVICE & WEIGHT Veterans and Active Duty Service Members specifically have been shown to be at unique risk for eating disorders related to an emphasis on body shape and weight (Bodell et al., 2014). Veterans and Active Duty Service Members use of diet pills, extreme dieting, and fluid manipulation to make measurements. For active duty, how does a clinician balance fitness for duty requirements and treatment adherence? 30

31 CASE DISCUSSION Q&A: Don t hold back! 31

32 REFERENCES Bodell, L., Forney, K.J., Keel, P., Gutierrez, P., & Joiner, T.E. (2014). Consequences of making weight: A review of eating disorder symptoms and diagnoses in the United States Military. Clinical Psychology Science and Practice, 21, Fairburn, C.G. (2008). Cognitive Behavior Therapy and Eating Disorders. New York: Guilford Press. Linehan, M.M. (2015). DBT Skills Training Handouts and Worksheets. New York: Guilford Press Mitchell, K.S., Mazzeo, S.E., Schlesinger, M.R., Brewerton, T.D., & Smith, B.N. (2012). Comorbidity of partial and subthreshold PTSD among men and women with eating disorders in the National Comorbidity Survey- Replication study. International Journal of Eating Disorders, 45, Safer, D.L., Telch, C.F., & Chen, E.Y. (2009). Dialectical Behavior Therapy for Binge Eating and Bulimia. New York: Guilford Press. 32