1/22/2020 1 Eating Disorders 101: Signs, Symptoms, Screening, and Referral Anna Bardone-Cone, PhD Bowman & Gordon Gray Distinguished Term Professor of Psychology, University of North Carolina at Chapel Hill; Director of Clinical Psychology Louise Metz, MD Internal Medicine Physician Mosaic Comprehensive Care Chapel Hill, NC 1 What is NCEED? • National Center of Excellence for Eating Disorders (NCEED) • Established thanks to a SAMHSA grant from the U.S. Dept. of Health and Human Services • Primary mission: education and training – Healthcare professionals – Public stakeholders • Web-based platform in development—sign up to stay informed! www.nceedus.org
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Eating Disorders 101: Signs, Symptoms, Screening, and Referral
Anna Bardone-Cone, PhDBowman & Gordon Gray Distinguished Term Professor of Psychology, University of North Carolina at Chapel Hill;Director of Clinical Psychology
Louise Metz, MDInternal Medicine PhysicianMosaic Comprehensive CareChapel Hill, NC
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What is NCEED? • National Center of Excellence for Eating
Disorders (NCEED)• Established thanks to a SAMHSA grant from
the U.S. Dept. of Health and Human Services • Primary mission: education and training
– Healthcare professionals– Public stakeholders
• Web-based platform in development—sign up to stay informed!
- absence of regular inappropriate compensatory behaviors
- 3+ of the following: eating more rapidly than normal; eating until uncomfortably full; eating large amounts when not hungry; eating alone because embarrassed; feeling disgusted with self, depressed, guilty after binge
- eating/feeding disturbance(e.g., lack of interest in food; food avoidance due to sensory characteristics) associated with 1+ of the following:- significant weight loss or failure to achieve expected weight gain (for
children)
- significant nutritional deficiency
- dependence on enteral feeding or oral nutritional supplements
- marked interference in psychosocial functioning
- unlike AN, no significant distress about weight/shape
- not explained by lack of available food or a culturally sanctioned practice
- Note: ARFID most commonly develops in infancy/childhood & can persist into adulthood
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Other Specified Feeding or Eating Disorder (OSFED)
Examples:• Atypical anorexia nervosa – all criteria but, despite
significant weight loss, not underweight
• Bulimia nervosa or binge eating disorder of low frequency (e.g., < 1x/wk) or limited duration (e.g., < 3 months)
• Purging disorder – recurrent purging behavior to influence weight/shape in the absence of binge eating
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Warning Signs and Symptoms • Preoccupation with food, eating, calories
– Often cooking/baking, but refusing to eat
– Watching cooking shows
– Counts calories obsessively
• Reluctance to eat with others– Frequently saying, “I’ve already eaten.”
– Bringing own food to meal outings
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Warning Signs and Symptoms • Food rituals
– Cutting food into small pieces
– Pushing food around the plate
– Excessive use of condiments
• Secretive behavior related to eating– Food missing
– Wrappers in car, bedroom
– Regularly using the bathroom shortly after eating (to vomit)
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Warning Signs and Symptoms
• Weight and shape concerns– Frequent self-weighing
– Wearing baggy clothes to hide shape
– Scrutinizing shape in mirror
– Body checking
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What Do EDs “Look Like”?• What: Eating pathology is a spectrum
• Who: Eating disorder stereotypes are misleading
• Eating disorders affect:
– males
– racial/ethnic minorities
– individuals with low SES – e.g., living with food insecurity
– sexual and gender minorities
“Marginalized Voices” from NEDA: https://youtu.be/OU768PVZvgY
Approaching a Patient – Do’s • Inform the patient of their symptoms and why
they concern you
• Provide information on harmful effects of eating disorders on physical health
• Inform them of available treatment options and that you are supportive
• Remind them of your confidentiality as their healthcare provider
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Approaching a Patient – Don’ts
• DO NOT approach the topic in an open area with others around
• DO NOT use language that blames or shames (instead, use non-judgmental language)
• DO NOT give simple solutions “you just need to eat”
• DO NOT make any appearance-based comments
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Treatment Options• Levels of care
• Inpatient (hospital-based; medically acute)
• Residential (less medically acute)
• Partial hospitalization/day treatment
• Intensive outpatient (3-7x/week)
• Outpatient (~1x/week)
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APA Level of Care Guidelines for Management of Eating disorders: Guidelines on NEDA website, Yager et al APA Practice Guidelines
Outpatient treatment: Team Approach
● Referral to outpatient eating disorders specialists
● Team members ○ Psychotherapist○ Registered dietitian○ Primary care provider ○ Psychiatrist
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Treatment Options: Team Approach
● Nutritional counseling: ○ Meal plans, use of food exchanges○ Intuitive eating○ Moderation/discontinuation of exercise
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Treatment Options: Team Approach● Psychotherapy:
○ Cognitive Behavioral Therapy (CBT): Identifying, challenging, and changing maladaptive thoughts that often influence emotions and behavior; identifying and modifying behavioral patterns
Commitment Therapy (ACT), Interpersonal Psychotherapy (IPT)○ Group therapy
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Treatment Options: Team Approach
● Medical provider: ○ Evaluation and management of medical
complications● Pharmacotherapy:
○ Limited pharmacologic agents for EDs○ Treatment for comorbid psychiatric
conditions
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Providing Referrals
• Work with local centers and providers when possible– www.findedhelp.com
• Consistent communication is key!
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9 Truths About Eating DisordersTruth 1: Many people with eating disorders look healthy, yet may be extremely ill.
Truth 2: Families are not to blame, and can be the patients’ and providers’ best allies in treatment.
Truth 3: An eating disorder diagnosis is a health crisis that disrupts personal and family functioning.
Truth 4: Eating disorders are not choices, but serious biologically influenced illnesses.
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9 Truths About Eating DisordersTruth 5: Eating disorders affect people of all genders, ages, races, ethnicities, body shapes and weights, sexual orientations, and socioeconomic statuses.
Truth 6: Eating disorders carry an increased risk for suicide and medical complications.
Truth 7: Genes and environment play important roles in the development of eating disorders.
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9 Truths About Eating DisordersTruth 8: Genes alone do not predict who will develop eating disorders.
Truth 9: Full recovery for an eating disorder is possible. Early detection and intervention are important.
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References• American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders 5th ed. Washington, DC:
American Psychiatric Association; 2013• Balantekin KN, Birch LL, Savage JS. Eating in the absence of hunger during childhood predicts self-reported
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Eat Disord. 2017;50(9):1031-1040. doi: 10.1002/eat.22735• Bulik CM, Sullivan PF, Kendler KS. Genetic and environmental contributions to obesity and binge eating. Int J Eat
Disord. 2003;33(3):293-298. doi:10.1002/eat.10140• Eating disorders: A Guide to Medical Care. AED Report 2016. 3rd edition.• Fairburn CG, Doll HA, Welch SL, Hay PJ, Davies BA, O’Connor ME. Risk factors for binge eating disorder: a
community-based, case-control study. Arch Gen Psych. 1998;55(5):425-432. doi: 10.1001/archpsyc.55.5.425• Garber, AK. Moving beyond “skinniness”: Presentation weight is not sufficient to assess malnutrition in patients
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• Graham et al. J Am Coll Health. A screening tool for detecting eating disorder risk and diagnostic symptoms among college-age women. 2019 May-Jun;67(4):357-366. doi: 10.1080/07448481.2018.1483936. Epub 2018 Oct 9.
• Grilo CM, Masheb RM. Childhood psychological, physical, and sexual maltreatment in outpatients with binge eating disorder: frequency and associations with gender, obesity, and eating-related psychopathology. Obes Res. 2001;9(5):320-325. doi: 10.1038/oby.2001.40
• Harrington et al. Initial Evaluation and Treatment of Anorexia nervosa and Bulimia nervosa. Am Fam Physician. 2015. Jan 1;91(1):46-52.
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References• Hilbert A, Pike KM, Goldschmidt AB, et al. Risk factors across the eating disorders. Psychiatry Res. 2014;220(1-
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• Schaumberg K, Welch E, Breithaupt MA, et al. The science behind the Academy for Eating Disorders’ Nine Truths About Eating Disorders. Eur Eat Disord Rev. 2017;25(6):432-450. doi: 10.1002/erv.2553
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