East Coast Medical Director Dr. Molly McShane, MD, MPH is a board certified psychiatrist and practices psychotherapy and medication management for a range of psychiatric conditions including, but not limited to, depression, anxiety, trauma, ADHD, bipolar disorder, obsessive-compulsive disorder, PTSD, panic attacks, substance abuse and eating disorders. In part two of the series, Dr. McShane continues to share more important information on the biological basis of eating disorders.
Brain research has revealed that neurochemistry is disrupted in individuals with eating disorders. Serotonin and dopamine are neurotransmitters that are involved in complex signaling pathways. These pathways are dysregulated in eating disorders, mood and anxiety disorders. Dopamine is involved in functions related to reward, pleasure, movement, compulsion and perseveration. Serotonin is involved in functions related to mood, memory processing, cognition and sleep. Considerable evidence suggests that altered serotonin and dopamine functions contribute to dysregulation of appetite, mood, impulse control and temperament in individuals with eating disorders. Restriction causes reduced plasma levels of tryptophan, the precursor to serotonin, which modulates serotonin activity and therefore symptoms of anxiety and depression. In individuals without eating disorders, dopamine is associated with a positive reinforcement effect in feeding. In other words, eating feels good. In anorexia nervosa, dopamine dysregulation diminishes the reward effects of food, so that eating does not necessarily feel good. Data suggests low levels of dopamine receptors and weakened responsivity of dopamine is associated with increased eating and weight. We also know that appetite-regulating hormones, like leptin and ghrelin, may affect dopamine functioning. Leptin is an appetite suppressing chemical, and ghrelin stimulates the appetite. In patients with anorexia nervosa, ghrelin is abnormally low. In patients with binge eating, leptin is abnormally low. These findings help confirm that eating disorders are not due to “lack of will power”. There are chemical alterations in the brain that affect the development and persistence of eating disorder symptoms.
The more we as providers understand the biological basis of eating disorders, the better equipped we are to provide effective treatments. Based on new research in the field, novel medications are being studied that may help us better treat eating disorders. Psychiatric medications that target serotonin and dopamine pathways, such as SSRIs, can be very helpful in the treatment of eating disorders and co-morbid anxiety and mood disorders. Usually, the best treatment for eating disorders is a multidisciplinary approach involving a therapist specializing in eating disorders, a psychiatrist, nutritionist and primary care physician.
To read part one of the series, click here.
Clementine’s Chief Medical Officer Joel Jahraus, MD, FAED, CEDS and Medical Director Lauren Ozbolt, MD, CEDS oversee the psychiatric care and attending psychiatrists at all Clementine adolescent treatment program locations, an Oliver-Pyatt Centers sister program and Monte Nido affiliate. In their writing, they share the many challenges with eating disorder treatment and the broader implications for adolescents and young adults. They stress how accurate diagnosis and treatment necessitate the interaction of a multidisciplinary team including mental health, medical and nutrition.
“I have yet to see any problem, however complicated, which, when you looked at it the right way, didn’t become more complicated.” –Paul Anderson
To say eating disorders are multi-faceted illnesses would be a serious understatement, as any professional in the field would tell you. Not only do treatment teams have to find a balance between their different disciplines when addressing complicated medical and psychiatric issues, but they also face the added challenges of working with patients who are often unhappy about being in treatment, tend to have difficulty trusting treatment providers, may feel in denial of their condition or resistant to treatment, and on top of everything else may face legal or financial barriers to seeking proper treatment. All of these obstacles don’t even begin to cover the myriad of psychiatric and medical comorbidities that typically present in a patient with an eating disorder.
When unraveling an eating disorder medically, we are first encountered with the challenge of discerning whether or not symptoms such as dizziness, tremors, and heart palpitations are the result of malnutrition, dehydration, altered metabolism or from psychiatric manifestations such as anxiety. Additionally, we also come across co-morbid medical conditions such as hypothyroidism, anemia, and atypical chest pain (just to name a few) that can in turn cause psychiatric symptoms. When psychotropic medications are introduced into the equation, it is important for the team to be vigilant as they themselves can have side effects that can manifest as medical or psychiatric complications. This constant presentation of symptoms that compete for both medical and psychiatric care calls for effective and cohesive clinical integration when treating clients with eating disorders. The underlying illness, whether psychiatric or medical may be challenging to diagnose and one should not immediately rule out the other when complications arise. People with mental health issues often get physically ill; they are not mutually exclusive.
It is clear that there are a multitude of considerations to make when first meeting a client and as promised, the problem is only more complicated when we hone in on any one aspect of the illness. When it comes to evaluation and treatment planning, once again, clinical integration is key. There are several general considerations that we recommend taking into account when first meeting a patient:
Be suspicious: patients may make evaluation more difficult, either by being unwilling to give a full history, unable to give an accurate description of symptoms or too frightened to allow a full physical exam.
Remember that patients with mental illness develop medical problems too.
Be alert for presentations, which make medical illness more likely, but don’t stop considering a medical illness just because they don’t initially fit.
Look for symptoms that make medical illness more likely.
Do not assume a certain symptom “must” be of psychological origin.
Be holistic: note the patient’s feelings and functioning within the current context as well as what happened in the past.
Above all, it is important to be aware of the limitations placed on a patient’s capacity for recovery when looking at a complex illness through a narrow lens. It is crucial that clinicians are acutely aware of the urgency of the patient’s needs, whether medical or psychiatric, and appropriately empathize with the individual to reassure them that you understand their concerns. They need to know that you will you will work to help them feel better whatever the cause. Integration of the various disciplines involved in the care and treatment of eating disorders takes collaboration. With balance, careful consideration of contributing factors and regular communication, eating disorder providers can successfully help treat their patients in a holistic and effective way.
To learn more, join Dr. Jahraus and Dr. Ozbolt in Portland, Oregon at the Riverplace Hotel on November 10th. RSVP to Professional Relations Manager Lindsey Riley (firstname.lastname@example.org).
Join us in reading inspirational and informative articles we have cultivated from across the web. If you have found an article you feel is inspirational, explores current research, or is a knowledgeable piece of literature and would like to share with us please send an e-mail here.
Anxiety, Fears, and Things That Go Bump in the Night Psychology Today
How Weight Information Can Increase Overeating/Binge Eating Dr. Stacey Rosenfeld
Yoga May Be Good for the Brain The NY Times
If We Treated Ourselves The Way We Treat Our Children Kantor & Kantor Law
How Anorexia Causes a ‘Starved Brain’ Dr. Jen Gaudiani
Understanding Anorexia Nervosa in Males Psychology Today
Head Nurse Quality Assurance Chrissy Stockert, RN shares the importance of educating and empowering our clients, particularly our adolescent clients, to understand and communicate their own medical health and history.
“Why don’t you tell me what medications you should be taking right now?” is a phrase I love to use. As a nurse, the answer I fear the most is “I don’t know.” When our clients first admit to treatment they can present with multiple medical complications at once. It is not uncommon to treat dehydration, abdominal pain, low blood pressure, and electrolyte abnormalities, among other things simultaneously. Once our patients begin to hydrate and nourish themselves those problems tend to resolve. As that happens, my work shifts and I get to do what I am so passionate about – educate, educate, educate. My goal is to prepare our clients so that “I don’t know” is not their response when asked about medical understanding and / or history.
One of the things I love about my job is that I have time to sit with our clients. I am able to have conversations and run groups with each one of them, so we can talk about how they are feeling, medical questions they have, medications they are taking and how these medications are affecting their bodies, what their labs look like and what it means, tests they’ve had and what the results mean, etc. I am able to teach them how they are ultimately responsible for knowing “all things medical” about themselves. This is such an important lesson because it can give our adolescent girls a feeling of empowerment. They are able to take the information I give them, process what it means, and use it as a tool to help them fight against their eating disorder.
One of the big differences between the medical treatment of adolescents and adults is the incredible way parents are involved when their adolescent child is admitted into treatment. With our adolescent clients, though, what this often translates to is “I don’t need to know, my mom knows all of it.” I love having the opportunity to redirect that thinking so our clients, though young, can truly be their own best advocate.
As a client begins to transition to a lower level of care, I try to work with her to create a realistic “medical” plan to follow. We try to look at realistic factors, like school, when we figure out what time she will take her medications. We look at her bone strength to figure out what kind of movement she can be involved in. And once we finish, rather than having the same conversation with her parents, one of my favorite things is when I sit down together with the client and her parents, and she is able to carefully, and correctly, explain her plan.
Here is a list of some things I like all of our ladies to know when they discharge from treatment:
• What medications they take, the dose of the medication, and what time they take it
• What tests were completed and what the results were
• What abnormal labs they have had and what we did to resolve the abnormality
• How their vitals have been while in treatment (were they low and now have normalized? Are they still low? Etc.)
For more information about Oliver-Pyatt Centers and newly expanding Clementine, please call 866.511.HEAL (4325), visit our website, subscribe to our blog, and connect with us on Facebook, LinkedIn, Twitter, and Instagram.
Medical Director Dr. Joel Jahraus, MD, FAED, CEDS shares his insight and knowledge regarding diabulimia, a contemporary term for individuals with both Type I diabetes and an eating disorder where the individual purges by withholding his or her insulin.
1. How would you define diabulimia?
Diabulimia is a contemporary term for individuals with Type 1 diabetes and an eating disorder where the individual purges by withholding his or her insulin, thereby, making food ingested ineffective for use by the body. This action results in weight loss and severe systemic complications, including diabetic ketoacidosis which is potentially lethal.
2. Do you consider diabulimia to be a real diagnosis, or just a way to describe a variation of bulimia (since it is not specifically in the DSM 5)?
It is a contemporary word that bridges the terminology between diabetes and bulimia, but is not stated specifically as diabulimia as a mental health diagnosis in the DSM V.
3. How common is this type of eating disorder? Especially for women?
I co-chaired an international consensus panel on this evolving illness in 2009 in Minneapolis, MN. In doing that literature search we found it exists in the following percentages among different age populations:
2% of preteen girls
11-15% of midteen girls
30-39% of late teen girls
4. What are the top signs of this eating disorder?
The typical presentation is similar to other eating disorder patients with body image issues, and other mental health concerns. However, the difference is these individuals “purge” by withholding their insulin. Insulin is important in effectively utilizing calories ingested for health. Without insulin the body does not utilize these calories and the individual loses weight; the net impact is similar to anorexia or bulimia. However, the typical complications of diabetes are then much accelerated and the mortality or death rate from premature death increases dramatically:
Mortality rates (Nielson 2002):
Type 1 DM: 2.5%
Anorexia nervosa: 6.5%
Combined Type 1 DM and Anorexia nervosa: 34.8%
We are pleased to share with you an overview of the general medical complications of eating disorders from Medical Director Dr. Joel Jahraus, MD, FAED, CEDS. We hope this post informs and educates on the co-occurring medical issues that are commonly associated with eating disorders.
While eating disorders are mental health diagnoses, they are far from pure mental health illnesses. There is likely no other mental health illness with the complexity of medical complications found in eating disorders. Anorexia nervosa has the highest death rate of any mental health illness and while suicide is certainly a serious problem with these illnesses, the majority of individuals that die of their illness die from multi-organ failure and heart complications in particular. Yet, no body system or organ is untouched by eating disorders.
The good news is that most of the medical complications are reversible with normalization of nutrition and weight, assuming they are discovered early enough and acted on by both the medical professional and the individual. That can be particularly challenging given the lack of education about eating disorders in medical schools and residencies. Furthermore, some clinicians may feel uncomfortable confronting an individual about a potential eating disorder given their perception of stigmatization and the patient’s potential anger about being confronted. Nevertheless, appropriate questions are absolutely necessary where there is evidence of an eating disorder and aggressive medical monitoring is imperative. Children and adolescents in particular are at risk given their limited physiologic reserve and risk of disruption of normal growth and physical maturation if the eating disorder persists.
In addition to the severity of the eating disorder on one’s medical status, refeeding can be just as complicated. A physically compromised body is fraught with refeeding perils and risk of worsening if aggressive monitoring and careful refeeding is not completed. The heart, in particular, may be compromised from longstanding malnutrition, both functionally and anatomically. It is often in a weakened state both from the pumping capacity but also electrically with a risk of irregular heart rhythms that can lead to sudden death. In addition, one cannot fully predict the risk due to severely malnourished states occurring in individuals of normal body weight whether over time or from rapid weight loss. Convincing patients of the medical risks and even convincing parents at times can be particularly challenging as they struggle to understand the altered physiology and risks of refeeding.
We hope you enjoy the third post in our four part series on the treatment of co-occurring and eating disorders at Oliver-Pyatt Centers. Thank you to Medical Director Dr. Joel Jahraus, MD, FAED, CEDS who speaks to the increased medical complications for those individuals struggling with co-occurring and eating disorders.
The medical impact of eating disorders has been well-documented. In essence, every organ system in the body is impacted by poor nutrition over time and the subsequent metabolic changes that occur in the body of an individual with chronic malnutrition, irrespective of actual weight numbers. Other eating disorder behaviors including vomiting, bingeing, and over the counter substance abuse like ipecac, diuretics, diet pills, and laxatives, add additional layers of medical complications.
Yet, the individual with comorbid alcohol or drug abuse and an eating disorder is at particular risk of medical morbidity and even death due to body organ failure or the lethal interaction of alcohol and drugs with medications used to treat eating disorders. All organs are impacted, but in particular the brain, heart, liver, and pancreas are impacted by both eating disorders and alcohol or drugs. Nutritional and vitamin deficiencies from both illnesses result in a dangerous situation with refeeding. Thiamine (Vitamin B1) in particular needs to be given urgently, before any refeeding starts in the individual with chronic malnutrition and alcoholism or there is a risk of Wernicke-Korsakoff Syndrome with a 10-20% mortality rate. The heart is also impacted by the potential for alcoholic or drug cardiomyopathy while the eating disorder may negatively impact the heart through malnutrition with regression in heart size and structure and diminished cardiac output as well as arrthythmias due to conduction disturbances. The liver and pancreas damage from alcohol and drugs is well-known which compounds the issue of malnutrition and subsequent refeeding on both organs with development of hepatic dysfunction and pancreatitis. Another potentially lethal issue is the interaction of alcohol with some of the medications used to treat eating disorders. In particular, benzodiazepine effects on respiratory suppression are additive with those of alcohol and not an uncommon cause of death in these individuals with dual diagnosis illness.
We are so pleased to share a guest post from our esteemed colleague, Edward P. Tyson, MD. We were impressed and inspired by the original posting of this article on the Gurze – Salucore Eating Disorders Resource Catalogue website. We think it is extremely relevant and important for all physicians to understand how to assess and treat individuals struggling with an eating disorders and hope your find the following post helpful. To connect with Dr. Tyson, please visit his website. For more information from the Gurze – Salucore Eating Disorders Resource Catalogue website, please visit here.
The most important things physicians need to know have to do not with technical aspects of assessing or treating physical aspects of an illness, although those are important. It is about the physician first addressing his or her own attitudes about eating disorders and those who have those illnesses.
1. Physicians are lucky to have people with eating disorders as their patients. People who suffer from eating disorders are a special group. Almost without exception, they are empathic, creative, intuitive, hard working, and usually gifted in at least one of the following (and quite often in all 3): academics, creative expression, and athletic endeavors. When these sufferers are free of their illness, they are incredible people to know and be around. And their recovery encompasses all the reasons why, hopefully, most doctors go into that profession.
2. Don’t be afraid of an eating disorder. It is an illness, with signs and symptoms and causes, and really good treatment. What other illness would a physician feel so inadequate about and also not seek the advice of colleagues or the literature? Sadly that happens so frequently and it is the topic of sufferers, family members, and professionals in the eating disorder field. Please do not be one of those people we talk about like that. Get educated or get help, but do not ignore, dismiss, or fail your professional responsibility.
3. Eating disorders will test one’s ability to be humble. These are some of the most complicated illnesses there are, as they involve both complex medical and psychiatric issues. In addition, there are not that many medical experts around, so, yes, most doctors will feel like they are in unchartered territory. And you will make mistakes; we all do. But learn from them and approach the problem in the way that patients expect of physicians—with a cool head and keen mind, unfettered from a sensitive ego.
4. You will likely need help at some point. A physician cannot know all details about every illness, especially ones as complex as eating disorders. As with any illness one encounters as a physician, the professional approach is to determine what the best assessments and treatments are. Again, be humble enough to ask for or seek advice. One can seek opinions of experts in the field in any number of ways—a phone call (a so-called “sidewalk consult”), go to the literature, use the AED medical guide, or any number of texts on the subject (consider the books by Mehler & Andersen, and Birmingham & Treasure, or, maybe even my chapter in the book by Maine, McGilley & Bunnell).
5. You will not be able to successfully separate out the physical from the psychiatric. Both must be treated at the same time. It is no longer appropriate to say, as a physician, that these are psychiatric illnesses. Nor is it permissible for psychiatrists to say that they are not the ones to deal with the medical. Again, if you do not know, do not reject the patient—instead, call in a consultant and work with that other physician.
The same applies to medical and psychiatric hospitals. Eating disorder patients should never be placed in a medical “no-mans land” where they are ping-ponged back and forth from one to the other, each claiming they cannot treat an eating disorder. These hospitals, by the way, do not have a sign outside saying, “WE TREAT EVERYTHING…except eating disorders.”
6. Keep checking every organ system every time. Use screening tools and a consistent pattern to the history and physical to make it easier, faster, and more likely not to miss something important. Use a BMI graph in those who have restricted to predict how serious the decline is, as the more dramatic the drop or angle of decline on the graph, the more likely that cardiovascular complications are present. A dramatic drop of the BMI can be very alarming and convincing to family members and to patients (see example). As I say often in those cases, “Imagine you’re flying Southwest Airlines and this is how the plane is going down. What would you want the pilot to do about now?” The answer is universally: “Pull up”…How soon? “Now!”
7. While they are complex, eating disorder’s medical complications follow specific, predictable physiological patterns resulting from the ED behaviors. However, physicians must consider the specific circumstances of that individual patient and what behaviors and conditions can predict certain medical (or psychiatric) complications. If they are purging, for example, they could have bleeding, electrolyte and dehydration issues, and signs and symptoms consistent with those conditions. Always consider cardiac complications, and in those who are restricting, screen for Refeeding Syndrome. Those who restrict should have signs of hypometabolism, with low body temperature, bradycardia, capillary refill delay, acrocyanosis, and such.
8. Check lab values frequently, including electrolytes and especially phosphorus and magnesium in those at risk of Refeeding Syndrome. Purgers are at risk of bleeding, so the CBC needs to be followed. The AED medical guide provides a good summary of labs needed.
9. Remember that many of the psychological issues may be a result of medical issues and vice versa. What one may think is anxiety or panic could easily be hypoglycemia. What may appear to be depression, bipolar disorder, or personality disorder may actually be malnutrition, brain starvation, and such. And the medical issues will tend to worsen what psychiatric issues are present.
10. Athletes can get eating disorders, too. Don’t assume because the patient is a high performing athlete, that physical findings that would be considered abnormal in others is due just to the patient being an “athlete.” A common mistake is to assume that one’s bardycardia (slow heart rate) is due to being a fit athlete. However, if the resting heart rate is below 50, evaluate if hypometabolism and energy conservation are ongoing, and not due from a fit heart but one that is losing its exercise capacity.
Do not be surprised how many calories it takes to refeed someone who has been malnourished, especially one who was exercising heavily with their eating disorder. It can be enormous calories and the patient may only then slowly gain weight at first. This is because the metabolism has to be reversed and turned from hypometabolic to hypermetabolic and that requires enormous calories, fat, protein, and carbohydrates. It is not uncommon for someone at a very low weight to be eating 5,000 calories per day at a treatment center and very slowly gaining at a rate of 1 or 2 pounds a week after a few weeks of no weight gain or even weight loss.
If a physician were to follow just the above, he or she would know more about eating disorders than 95% of other physicians. We are not looking just for experts; we’re looking for volunteers to care for these deserving patients.
The International Association for Eating Disorder Professionals (iaedp) is hosting the annual Symposium 2014 this week through March 2nd. The iaedp Symposium’s program is created by and for professionals who work in therapeutic settings with patients. This continuing education is essential in providing the most effective treatment to our clients and fosters collaboration and friendship among clinicians, whether developing new connections or meeting as old friends.
We are very excited to be a part of this event, and learn and grow from all of you. As a sneak peek into the events and presentations that are scheduled, we are honored to share an excerpt from Carolyn Costin and Joan Borysenko’s presentation on March 1st.
I am honored to present a Keynote lecture at the 2014 IAEDP Symposium this Saturday, March 1st with Joan Borysenko. Our title, “From Buddha to Brain Scans: The Integration of Science, Psychotherapy, and Spirituality” stems from our mutual interest in these areas as well as our own personal transformations from illness to well-being. As neuroscience continues to validate ancient wisdom, Joan and I feel it is important to promote what used to be thought of as “fluffy” or “alternative” into the foreground as viable treatments and healing modalities. Our goal is to help inspire clinicians to educate themselves on how to help their clients train their brains to change their lives. The morning keynote will be followed by an afternoon session where both Joan and I will go into further detail and provide experiential exercises.
– Carolyn Costin, MFT, MA, MEd, CEDS / Founder and Chief Clinical Officer, Monte Nido & Affiliates
We look forward to connecting with you all. To meet with us at the Symposium, please call Ibbits Newhall at 914.912.7561 or e-mail us at email@example.com. See you there!
We are pleased to announce Medical Director Dr. Joel Jahraus, M.D., FAED, CEDS will be speaking at an upcoming professional training, sponsored by the Eating Disorders Coalition of Miami and IAEDP in Miami on Friday, March 7, 2014. Dr. Joel Jahraus, a board certified physician for over 30 years, is well-known and respected for his specialization in the medical management of clients with eating disorders and a recognized expert on diabetes and the medical complications of eating disorders.
Dr. Jahraus’s presentation entitled “Beyond the Emotional Aspects of Eating Disorders: Complications, Co-Morbidities, and Communication within the Healthcare System,” will provide attendees an overview of the basic psychological processes impacted by eating disorders, understand the interplay of common comorbid medical conditions with eating disorders, and understand how to communicate effectively with health care providers outside of the primary treatment team, with insurance companies, and the media.
Providing an excerpt from his upcoming talk, Dr. Jahraus comments on the different components of the eating disorder as well as the challenges that may arise. “Eating disorders cross the line between mental and medical health more than any other illness, so it is imperative to understand the interplay between these two areas of care [… ] The challenging nature of treating eating disorder patients that do not always want treatment or are fearful of treatment can present unique challenges of communication among the local team, referral providers, and others involved in care including the patient and family. Splitting is problematic and must be avoided.” Additionally, Dr. Jahraus will speak to the importance of addressing and treating comorbid conditions complicating the treatment of eating disorders, such as gluten enteropathy.
The event will be held on March 7, 2014 from 8:00AM – 12:00PM at the University of Miami, Hurricane 100 Room, The Bank United Center, 1245 Dauer Drive, Coral Gables, FL. This event is worth 4 CEU’s. Click here to receive a discounted price for registration, or register at the door.
On Friday, January 17th our Medical Director Dr. Joel Jahraus, MD, FAED, CEDS and Founder / Executive Director Dr. Wendy Oliver-Pyatt, MD, FAED, CEDS will be presenting on “Eating Disorder Treatment: Doing What Works,” an educational event co-sponsored with the Atlanta Center for Eating Disorders (ACE).
Through this medically-based talk, participants will learn effective nuts-and-bolts practice techniques for managing resistance, sustaining motivation for complete and sustainable recovery, and working with parents and families in restarting a stalled healing process; identify psychiatric illnesses frequently overlooked and/or undertreated in patients with eating disorders; gain knowledge of the application of self-psychology as a foundation for understanding the psychodynamics in treatment-resistant eating disorders; describe three functions of exposure therapy in eating disorder treatment; and understand the multisystem impact of eating disorders, the interface of medical complications and eating disorder symptoms, and how to address them with basic treatment protocols.
Dr. Jahraus notes, “No other primary mental health issues cross the line between mental health and medical as eating disorders do. Every organ system in the body can be adversely impacted by an eating disorder, some changes being reversible and some not.” Joel’s presentation will delve deeper into “The Medical Complications of Eating Disorders,” and Dr. Oliver-Pyatt will discuss “Navigating the Undercurrent: Multimodal Treatment of the Resistant Eating Disordered Patient.”
Do not miss these presentations, along with a discussion of “The Clinician’s Toolkit: Seasoned Therapists Share Their Favorite Techniques,” presented by Linda Buchanan, PhD; Rick Kilmer, PhD; and the ACE Staff. RSVP by January 13th to Colleen Stephens. Villa Christina Restaurant at Perimeter Summit, 400 Summit Boulevard, Atlanta, Georgia.