EATING DISORDERS: PART 2
Eating disorders (ED) are associated with significant comorbid psychopathology and the most extensive medical complications of any psychiatric disorder. Disordered behaviors that present across diagnoses (eg, restriction, binge eating, compensatory behaviors) are linked with acute medical risks that often require careful medical monitoring and clinical intervention. Yet, individuals with EDs frequently express hesitancy towards recovery and have great difficulty controlling their ED symptoms.
EDs are typically chronic and follow a treatment-refractory trajectory. Existing research indicates that even the most effective evidence-based outpatient treatment yields recovery for only around one-half of patients.1-3 In our clinic, we often encounter patients like “Hayley,” “Georgia,” and “Michael” (see Case Vignettes) for whom outpatient treatment has been unsuccessful. Like many other eating disorder treatment programs, our program seeks to optimize recovery by providing more intensive treatment with stepped levels of care.
Hayley is a 24-year-old graduate student and a competitive runner who competes regularly. She has a diagnosis of anorexia nervosa, restricting type (AN-R), which developed when she was 20 after a period of binging. Two years ago, Hayley began working with a multidisciplinary outpatient team, but she has continued to lose weight. She attributes the weight loss to her unwillingness to eat the large amount of food it would take to offset the calories she burns while running and training. She initially presented to her primary care physician feeling weak then was admitted to an inpatient eating disorders unit for bradycardia. Upon discharge from the hospital she was referred to a partial hospitalization treatment program.
Most research explores the efficacy of treatment at the outpatient level; little is known about the comparative value of the higher levels of care for patients with EDs.4 However, these approaches are important alternatives for treatment-refractory EDs because they provide the more intensive treatment and meal support that many severely ill patients need.1,2 Common reasons for needing higher levels of care include substantial weight loss that might be life threatening; difficulty eating enough food to gain weight; severe binge/purge behaviors; incapacitating ED symptoms; comorbid substance abuse; and anxiety, depression, obsessive compulsive disorder, or suicidal intent.
It is not unusual that such behaviors result in medical instability with symptoms of cardiovascular compromise, electrolyte disturbances, or hypoglycemia. It is important to note that some individuals have a lack of insight about their behaviors or are not motivated to engage in treatment. Because of these factors, the mortality rate for anorexia nervosa and bulimia nervosa can be 5% or higher.5,6 Higher levels of care provide a structured and protective environment that can be essential for these serious, life-threatening disorders.
Georgia, aged 17 years, has bulimia nervosa (BN) with comorbid major depressive disorder, panic attacks, and a history of sexual trauma. She has been engaging in polysubstance abuse, including alcohol, marijuana, prescription painkillers, and cocaine, since the age of 12. She has been hospitalized several times for suicide attempts and accidental drug overdoses. She binges and purges daily and states that she is only able to reduce these behaviors when using substances. Her outpatient therapist feels overwhelmed by all of Georgia’s comorbidities and is not sure how to help her reduce these self-destructive behaviors, so she refers Georgia to a PHP program.
Dr Anderson is Associate Clinical Professor Director of Training, Ms Simpson is Milieu Therapist, and
Dr Kaye is Professor and Founder and Executive Director, Eating Disorders Program, Department of Psychiatry, University of California, San Diego, CA. The authors report no conflicts of interest concerning the subject matter of this article.
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