Summer 2007

A Comprehensive Plan for Teen Eating Disorders

Charles Irwin, M.D.

The UCSF Division of Adolescent Medicine has established a research-based, multidisciplinary protocol to treat adolescents with eating disorders, says Charles Irwin, M.D., director of the division.

"One of the problems with eating disorders is that they don't have an established protocol for care the way, let's say, cancer is handled. So treatment is different every time," says Irwin. "We've been taking care of patients with eating disorders for more than 30 years. The difference is, after five years of development, we now have a research-based, more comprehensive protocol."

Irwin collaborated with nutritionist Andrea Garber, Ph.D., R.D., and psychiatrist Kim Norman, M.D., to create the protocol as part of a more comprehensive eating disorders program at the UCSF Teen Clinic. The program not only attends to teens' medical needs, but addresses nutritional and exercise concerns, as well as the underlying psychological issues driving the disorder.

Catching the Signs

Many teens come to the clinic not expressly because of eating disorders, but because they have one of the various health problems caused by eating disorders. Roughly 20 percent of the teens who come are ultimately diagnosed with either anorexia nervosa or bulimia nervosa.

The age of patients treated for eating disorders ranges from 12 to 21 years old, with one-third in the 18-to-21 range. Clinicians diagnose anorexia nervosa using the standard DSM-IV criteria: intense fear of becoming fat or gaining weight; refusal to maintain body weight appropriate for their height and age; disturbed body image and denial of seriousness of their low weight; and amenorrhea (absence of at least three consecutive menstrual cycles).

"It's gotten to the point where young people are struggling with weight all the time," says Irwin. "There are several different body types and very little tolerance for these different types.

"With so many pressures for adolescents to be thin, it doesn't seem like they can be comfortable with how they really are, he says. "Their intense fear of being fat leads to a starvation psychosis and obsession with food. They aren't capable of making rational decisions, and they think a piece of asparagus is a meal."

The new protocol, funded by the Department of Health and Human Services' Maternal and Child Health Bureau Training Program, is research-based. Garber, principal investigator, led a four-year study at the UCSF Pediatric Clinical Research Center of correlations between anorexia nervosa and depression. Twenty-five adolescent females, aged 13 to 20, were admitted to the hospital for anorexia nervosa, completed a survey on depression, and received a psychiatric consult to assess and treat depressive symptoms.

Sorting Out Causes

The results indicated that two separate groups were admitted into the hospital: those who predominantly had eating disorders and those who predominantly were depressed. Since loss of appetite is a hallmark symptom of depression, Garber says it's important for clinicians not to misdiagnose depression for anorexia nervosa.

"Although more research needs to be done to sort out anorexia, depression and obsessive-compulsive disorder in these patients, we know that psychiatric care plays a key role in treating eating disorders," says Garber, who was the primary author of the new protocol. "With this continuing study, our hope is to examine correlates between anorexia and other psychiatric disorders. We want to know if treating depression will help anorexia, and vice versa."

Under the new protocol, an initial patient visit entails a nurse taking height, weight and vital sign measurements, and a clinician analyzing medical history, asking screening questions, and conducting a physical exam and lab tests. A nutritionist evaluates body mass index and provides a nutrition consultation. A social worker helps connect patients with community resources. The team works together to develop a plan that designates supplementation regimens, meal planning, mental health therapy and community resources.

Maudsley Method

For nutrition counseling and therapy, Garber uses the Maudsley method, which was first developed at the Maudsley Hospital in London. This approach puts the parents in charge of their child's eating behavior.

"We provide the meal planning, and we ask the parents to be supportive and present the food as 'medicine,'" says Garber. "Then we work with the psychiatrist to bring this approach to family therapy. This collaboration is essential because anorexia is a psychiatric disease. Because of its acute medical needs, it's the most deadly of all psychiatric diseases."

Norman says that struggles with power and independence are the primary underlying emotions driving eating disorders, in addition to pressures from peers, family members and the media.

"Many teens feel like they are being held hostage by their parents — they are struggling with power and independence. So family counseling helps family members take a more appropriate stance," says Norman, founder and director of the UCSF Teen Psychiatric Clinic at the Langley Porter Psychiatric Institute.

Norman says starvation has profound psychological consequences, such as impairment of cognition and concentration, development of a more volatile and obsessive personality, and intense anxiety and depression. "These personality changes make it difficult to treat the patient because the personality changes mask the real person," says Norman. "Just as an alcoholic needs to be sober before psychiatric counseling, patients with eating disorders first need to be fed and medically stable."

Patients are transferred from the Teen Clinic to the hospital if they have severe complications from malnutrition, such as weight less than 75 percent of their age and height standard; bradycardia; hypothermia; systolic pressure less than 90 mmHg; acute electrolyte disturbances; and acute psychiatric emergencies, such as suicidal ideation or psychosis.

"There are two main things that kill these kids: cardiac problems and suicide," says Irwin. "Cardiac problems occur due to abnormalities in electrolytes and wasting of the heart. Secondly, about 10 percent of girls with anorexia commit suicide later in life — roughly 10 years later."

The typical inpatient stay is from two to four weeks, during which heart rate, electrolytes and weight are closely monitored. The patients are confined to bed, and not even bathroom visits are allowed, to ensure that patients are not inducing vomiting.

A continuous EKG and an echocardiogram are taken, CD4-CD8 counts are recorded and an anergy panel is taken for immune suppression assessment. There is also a bone density assessment, using dual-energy X-ray absorptiometry (DXA) for total body and lumbar bone density.

"The most disastrous long-term consequence of starvation during the growing years is that bone mineralization occurs during adolescence, and these are the bones you have for the rest of your life," says Irwin. "All of these girls have signature abnormalities in the bone scans.

"The question becomes: Do they recover following treatment? Often it depends on how many years they have been malnourished. So it's important to work with primary care physicians to diagnose and treat early."

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