Transition Issues for Patients With Eating Disorders

January 29, 2016

Strategies to decrease the chances that individuals will fall through the cracks in the college years.

Eating disorders affect individuals of all socioeconomic and ethnic backgrounds and are increasingly common in males. The age of onset is typically in the adolescent years, although the diagnosis may be made across the lifespan, and the course of illness often stretches well into adulthood. According to the most recent survey from the American College Health Association, 1.2% of students report eating disorder symptoms that have an adverse effect on academic performance.1

Anorexia nervosa is characterized by inadequate nutrition intake, which results in low weight, distorted perception of weight and shape, and intense fear of weight gain. Patients typically have difficulty understanding the gravity of their illness, and as a result, treatment can be difficult. Bulimia nervosa generally presents as episodic binge eating (consuming large amounts of food, feeling loss of control) followed by compensatory mechanisms such as vomiting, fasting, or compulsive exercising. These episodes occur at least weekly for a period of 3 months. Binge eating disorder was recently incorporated into DSM-5; similar to bulimia nervosa, the diagnosis is made in individuals who experience binge eating episodes (also weekly for 3 months) that are not followed by compensatory purging behaviors. Avoidant restrictive food intake disorder is another recent inclusion in DSM-5; it most accurately describes patients who are not taking in enough nutrition but do not seem to experience any difficulties with body image distortion or concerns about shape or weight. These individuals typically describe restrictive eating that stems from abdominal pain, texture concerns, or fear of choking or vomiting.

[[{"type":"media","view_mode":"media_crop","fid":"45066","attributes":{"alt":"© Photographee.eu/shutterstock.com","class":"media-image media-image-right","id":"media_crop_1752600252257","media_crop_h":"212","media_crop_image_style":"-1","media_crop_instance":"5101","media_crop_rotate":"0","media_crop_scale_h":"118","media_crop_scale_w":"175","media_crop_w":"314","media_crop_x":"2","media_crop_y":"0","style":"float: right;","title":"© Photographee.eu/shutterstock.com","typeof":"foaf:Image"}}]]Malnutrition affects every organ system in the body, leading to significant medical concerns and high risk of death, usually due to sudden cardiac arrest. In fact, anorexia nervosa has the highest mortality of any psychiatric illness other than substance use disorders; 50% of those who succumb die by suicide.2 Psychiatric comorbidity is quite common in this population and needs to be addressed quickly and aggressively. More than 50% of patients with eating disorders describe co-occurring mood, anxiety, substance use, or personality disorders that may have a profound effect on the recovery process.

Malnutrition itself may also be associated with heightened anxiety, obsessive thoughts, and food-related rituals as well as troubles with focus and concentration that need to be evaluated carefully to avoid misdiagnosis. Sleep problems, anergia, anhedonia, and fatigue may closely resemble the neurovegetative symptoms of depression. Careful diagnosis is essential to ensure that patients receive adequate treatment; renourishment is the first line of defense, particularly in those who have never previously experienced mood or anxiety symptoms before the change in eating and activity patterns.

Treatment and management

At baseline, eating disorders can be extremely difficult to treat, and some patients experience a chronic, relapsing and remitting course. The ego-syntonic nature of anorexia nervosa makes treating the illness particularly challenging.

A multidisciplinary approach is the standard of care in treating eating disorders: a medical provider, a dietitian, and a psychotherapist provide the backbone of the treatment team. If possible, team members should have experience in treating eating disorders. It is also important that all members have clearly defined roles and communicate often to minimize splitting and ensure that all team members are “on the same page” and present a united front. A psychiatrist may be necessary if psychotropic medications are used.

Approximately 50% of adolescents with eating disorders treated in medical settings receive psychotropic medication3; however, no medications have been approved for the treatment of eating disorders in children or adolescents. Fluoxetine at 60 mg/d is indicated for bulimia nervosa in adults, and lisdexamfetamine is approved for binge eating disorder in individuals over the age of 18. Studies have looked at the SSRIs, atypical antipsychotics, and mood stabilizers such as topiramate, but there is no compelling evidence to support their use.4

Psychopharmacological interventions in this population should target comorbid mood and anxiety disorders that may interfere with recovery. Keep in mind that optimizing nutrition is the most important initial step. Indeed, malnourished individuals are at higher risk for adverse effects, and medications tend to work better when the patient has had a period of normal and regular meals and snacks.

More on treatment >

Coupled with renourishment, outpatient psychotherapy is a mainstay of treatment. For children and adolescents with anorexia nervosa, family-based treatment is the gold standard; however, adolescent-focused therapy and systemic family therapy are also effective. For those with bulimia nervosa or binge eating disorder, individual cognitive behavioral therapy and interpersonal therapy are the most typical approaches, but family-based therapy is effective in children and adolescents with bulimia nervosa as well. Dialectical behavioral therapy, acceptance and commitment therapy, and cognitive remediation therapy are all being investigated.5,6

For patients who find it difficult to modify disordered eating behavior with outpatient therapy, increasing the level of care may be necessary. Those with unstable vital signs, very low weight, or electrolyte abnormalities may need an inpatient medical stay, while those with safety concerns, uncontrolled binge eating, purging, or acute food refusal may need an inpatient psychiatric admission. Partial hospital programs, intensive outpatient programs, and residential treatment centers that focus on eating disorders are available to increase support if necessary. Unfortunately, progress made in highly structured programs may be difficult to sustain once the patient returns to the home environment. Stressful situations and other dynamics with family and friends may make it challenging for the individual to resist urges to fall back into old patterns and preferred, maladaptive coping strategies.

Challenges in the transitional-age youth

Parents have a great deal of influence on the treatment of their minor children; they ultimately make treatment decisions and transport young patients to and from therapy. They may also oversee meals and snacks, restrict bathroom use after meals, enforce activity restriction, and deny the child permission to participate in school outings or events that may make it difficult to ensure adequate rest and nutrition for recovery. Treatment approaches such as family-based therapy depend on the fact that parents make the decisions that are in the patient’s best interest and take control of planning, preparing, and plating all meals and snacks.

In the transitional-age youth population, treatment decisions are complicated by the fact that 18-year-old patients are legally able to make such decisions, and they may exclude parents and caregivers from the treatment process. Despite this, parents and guardians often have much more input and influence than they might think. The vast majority of transitional-age youths continue to rely on parents for financial and emotional support; many live with their parents and are covered by their parents’ insurance. While it may seem drastic, parents do have the ability to make continued financial support and housing contingent on their adult child’s active participation in treatment.

Family-based therapy is currently being adapted for use in young adults (acknowledging an age-appropriate desire for separation and individuation by giving them slightly more independence and autonomy than is normal for phase I of traditional family-based therapy). Parents can be instrumental in motivating their young adult to receive treatment.

For those transitional-age youths who do not have insurance or who are covered by government payers, treatment can be severely limited. This is further complicated by the fact that many treatment centers are costly and may not be covered by a full range of health insurance companies. For this reason, it is especially pressing that we continue to refine evidence-based treatments that can be delivered in an outpatient setting.

The early adult years are often marked by great change and opportunity, which can be incredibly exciting but which also represent a significant stress for many young patients. Some enter the workforce, while others pursue higher education at local community colleges. Still others attend 4-year universities, some choosing to travel significant distances from their families. For those who have previously suffered from disordered eating, it is essential that families and treatment teams anticipate this vulnerable time and make plans to closely monitor and aggressively treat any signs of relapse.

Some previously healthy youths may experience the first onset of symptoms during this transition. Increased autonomy, decreased parental oversight, higher workload at school or at work, and pressures to conform to the thin ideal to be attractive to peers may all be at play. Those leaving home for the first time may also be challenged by managing roommates, housework, and finances and keeping up regular cooking, sleeping, and cleaning schedules. Balancing work, studies, and fun may also be a new experience-and one that may require the youth to experience some natural consequences. The Table lists triggers associated with increased stress during the transition to college.

More on challenges >

Transitional-age youths who are attending college may have some additional stresses, but there are also some additional safeguards in place. Large parties, binge drinking, and Greek life may make it difficult to regulate eating, sleeping, and study patterns. Alcohol consumption can lower inhibitions and may make binge eating and purging more common. Buffet-style cafeterias may offer numerous options but may also promote binge eating and may be overwhelming for those struggling with urges to restrict their eating. Cafeterias that post nutritional information may inadvertently be a trigger for patients who are prone to calorie counting. Nevertheless, faculty, university administrators, residence advisors, and peers provide an additional layer of monitoring and supervision that may be protective in this population.

While there are many potential pitfalls for patients in transition, families can protect transitional-age youths by thoughtfully planning out the process well in advance of the matriculation date. Psychiatrists should talk with patients and their families in the early high school years to be sure that they understand their options. Patients may choose to go directly into the workforce or military, or they may choose to attend junior college before transitioning to a 4-year college. These “alternative” paths afford young people the opportunity to practice taking on increased independence while under the watchful eye of parents and treatment providers. However, many students want to “stay in step” with their peers and may resist accommodations that are intended to provide support. Parents may also worry about stressing their child by advocating for an “alternative” route.

Patients who are planning to attend college should consider distance from home, proximity to a major medical center, rural versus urban environment, and availability of subspecialty services on campus as they contemplate their options. College counseling centers may place limits on the number of sessions or may have a policy of referring patients who need ongoing care to community providers. Treatment options need to be easily accessible for a busy college student in order to be realistic. Most universities have multidisciplinary eating disorder treatment teams that can assess students at risk and can provide options for the initial treatment plan, but it is important to keep in mind that these may vary in availability and in sophistication.

Parents and students often inquire about how much information the university needs to know about a previous diagnosis. In most cases, it is usually better for universities to be aware of a student’s medical needs so that they can support the student and keep a watchful eye on him or her. Families need to know that accessing accommodations and medical support will not appear on a college transcript, and that fears that accepting help will prevent the student from attaining future professional goals are unfounded. Students should sign a release of information form allowing previous providers to adequately communicate pertinent history and treatment; this will also allow the university to inform parents if there is concern about the student’s health or safety. All involved should agree on a relapse prevention plan and clear parameters that would necessitate that the student take a medical leave to focus on recovery.7

Conclusions

Eating disorders commonly present in childhood and adolescence but frequently remain problematic into adulthood. Thoughtful planning by parents, transitional-age youths, and treatment-team providers will allow patients to transition smoothly from pediatric to adult systems of care, decreasing the chances that individuals will fall through the cracks and optimizing the successful pursuit of developmentally appropriate tasks.

Disclosures:

Dr Derenne is Clinical Associate Professor of Psychiatry and Behavioral Sciences at Stanford University School of Medicine Division of Child and Adolescent Psychiatry, Comprehensive Care Unit for Eating Disorders, Stanford, CA. She reports no conflicts of interest concerning the subject matter of this article.

References:

1. American College Health Association. National College Health Assessment II: Spring 2014. http://www.acha-ncha.org/docs/ACHA-NCHA-II_ReferenceGroup_ExecutiveSummary_Spring2014.pdf. Accessed November 20, 2015.

2. Birmingham CL, Su J, Hlynsky JA, et al. The mortality rate from anorexia nervosa. Int J Eat Disord. 2005;38:143-146.

3. Golden NH, Attia E. Psychopharmacology of eating disorders in children and adolescents. Pediatr Clin North Am. 2011;58:121-138.

4. Crow SJ, Mitchell JE, Roerig JD, Steffen K. What potential role is there for medication treatment in anorexia nervosa? Int J Eat Disord. 2009;42:1-8.

5. Lock J. An update on evidence-based psychosocial treatments for eating disorders in children and adolescents. J Clin Child Adolesc Psychol. 2015;44: 707-721.

6. Lock J, La Via MC, American Academy of Child and Adolescent Psychiatry (AACAP) Committee on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with eating disorders. J Am Acad Child Adolesc Psychiatry. 2015;54:412-425.

7. Derenne J. Successfully launching adolescents with eating disorders to college: the child and adolescent psychiatrist’s perspective. J Am Acad Child Adolesc Psychiatry. 2013;52:559-561.