Within just six months of launching the new treatment program at Rogers Memorial Hospital, Dr. Tracey Cornella-Carlson is seeing more children and families enjoy a quality of life that seemed lost within the tight grip of an eating disorder.

Even as young as fourth grade, children are becoming concerned with calories and fat grams and subjected to emotional bullying about their appearance.

Cornella-Carlson said that parents come to Rogers Memorial Hospital, not just because they are worried about their child’s health, but because they feel that they have lost their child emotionally. The disorder affects the child’s ability to participate in day-to-day activities with their friends and families.

The new child and adolescent inpatient program was developed under her leadership to provide a safe, nurturing environment where children and teens could be treated for medical and emotional stability by a specialized team comprised of physicians, dietitians, therapists, nurses, and other trained professionals.

Inpatient environment addresses behaviors

The Rogers Memorial Hospital inpatient program was designed to provide medical, nutritional, and emotional stability as it affects the needs of children and young teens.

Cornella-Carlson says that many children and teens being treated for eating disorders on an outpatient basis find it hard to eat what they should. “They really try,” she said, “They promise that they’ll eat their snack, pack it, but then ‘forget’ to eat it or say that they just weren’t hungry.” The inpatient program guides patients while eating and addresses any related behaviors.

“Once their nutritional intake is increased, they have a better ability to understand their situation, that they are separate from their disorder and are able to express themselves in a healthier way,” Cornella-Carlson said.

Jessica Witt, clinical services manager for the program, explained how the treatment team at Rogers Memorial Hospital continually monitors patients to pinpoint their diagnosis and manage any other medical issues common to eating disorders. “Patients may have developed symptoms that affect their gastrointestinal system, bones, heart or limit their physical activity,” she said.

“We work to stop the behaviors and provide an environment where they can heal while they discover that they are separate from their disorder.” One of the key elements of the program, Witt added, was the group therapy component.

Complex and challenging disorder

Cornella-Carlson explained that certain characteristics of eating disorders make it especially complex to treat them in children. Individuals with eating disorders often suffer from obsessive-compulsive disorder or other anxiety disorders and are more likely to focus on a thought pattern that compares them to others in a negative light.

Group and cognitive behavioral therapy are used to help patients recognize and change the distorted thought patterns. In a group therapy setting, they are able to see how their behavior looks from the outside and begin to recognize it from the inside.

Cornella-Carlson said that patients with eating disorders are highly attuned to their environment and behaviors. They find it hard to relate to those who do not understand food or activity in the same ways.

As a result of their disorder, they tend to be withdrawn and avoid mealtime, a common social point for patients. They are often perfectionists and intellectualize certain aspects of treatment. An example might be a patient who wants to satisfy their sweet tooth with an apple, instead of ice cream.

Knowing they’re not alone

Within the specialized eating disorder program at Rogers Memorial Hospital, patients can be with others their age who have first-person experience with eating disorders and can support each other. Mealtimes are supervised by trained dietitians who observe which mealtime issues patients struggle with and also ensure that patients are eating the right amount of food.

Cornella-Carlson also said that a key element of the program, which admits patients from throughout the United States and Canada, is the education and involvement of the patient’s family. “They may bring food in so they can eat together, participate in the recovery process and improve communication,” she said.

Cornella-Carlson said that parents are relieved to see their son or daughter’s unique personality reemerge and interact with the family again. “So many parents say, ‘Thank you for bringing our child back.’”

When patients leave the program, they have a much better understanding of how they can control their behaviors in a healthy way, explained Cornella-Carlson. “We teach them skills and techniques that we hope will help them for the rest of their lives.”

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By Theodore E. Weltzin, MD
Medical director of Eating  Disorder Services at  Rogers Memorial Hospital

Overview

Eating disorders – including anorexia nervosa, bulimia nervosa and binge eating disorder – affect up to 5 million Americans every year. While eating disorders typically affect females, males make up as much as 25 percent the total population of people with eating disorders.

Because of the destructive nature of the psychological and physical problems often associated with eating disorders, these disorders represent some of the most difficult psychiatric illnesses to treat. Eating disorders can have a major impact on a person’s ability to function in the workplace and can be a challenge for employers who have an employee with an eating disorder.

Males and Eating Disorders

The awareness of eating disorders in males is growing. The behavioral characteristics of anorexia, bulimia and binge eating disorder in men are similar to those of women. Like women, males with anorexia will develop symptoms of weight loss and fear of weight gain. With bulimia and binge eating disorder men and women both develop binge eating symptoms with or without compensatory behavior to purge food. Again, like women, males with eating disorders also are at increased risk for depression, anxiety disorders and alcohol and substance abuse.

However, important differences exist between males and females with eating disorders. Studies show that males are less likely to seek help for emotional problems in general, and this is true among those with an eating disorder. Because eating disorders are typically seen as “female problems,” males are often even more reluctant to seek help. Because of this, males will often struggle with their eating disorder for many years before seeking help. Delaying treatment can reduce treatment effectiveness and increase the risk of medical complications. Delays also increase the risk of depression and problems with school, work and relationships.

Males with eating disorders often do not want to lose weight or attain a lower body weight; they tend to focus on having a more muscular physical shape. Males with eating disorders typically become preoccupied with how muscular they are physically and a male’s eating disorder may begin with compulsive exercising in addition to dieting. Historically, males who participate in athletic activities with a high degree of emphasis on weight and shape (including wrestling and gymnastics) have an increased risk of developing eating disorders.

Eating and body image problems in males can occur which do not clearly fit into the category of eating disorders. Compulsive exercisers (in which exercise becomes like an addiction and can have a destructive effect on family, work and physical health) will often become anxious if they cannot exercise. They tend to feel frustrated and believe they have “not exercised enough” rather than a sense of well-being following exercise. This feeling prompts them to exercise rather than spend time with family or friends or have decreased work performance as a result of their need to exercise.

Eating Disorders in the Workplace

Over the last decade, employers have had an increased awareness of the cost of mental illness in the workplace; eating disorders are no exception. Depression and irritability, which often accompany eating disorders, can lead to increased conflict at work. Tardiness, sick days and decreased productivity due to employees engaging in abnormal eating behavior can also be a sign of ongoing eating disorder symptoms or relapse in an eating disorder.

Denial and concealment of eating disorders symptoms occurs almost universally. Since most people are uniquely aware about the eating habits of their coworkers, it is not uncommon for co-workers to make observations about someone’s weight or eating habits. Also, in the case of bulimia, employees may be caught by co-workers binge eating or purging while on the job. With improving employee assistance programs, it is not uncommon for employees to seek help from someone in the workplace as a first step in seeking recovery.

Directing an employee to an evaluation by a medical provider should be the first step to assure medical stability. The medical provider, often times in conjunction with a firm’s insurance plan, will then refer the patient to a psychotherapist who specializes in eating disorders.  This can be particularly difficult with male patients as fewer professionals have experience with male patients with eating disorders.

While the employer may not be included in the employee’s treatment, it is important to remember that medical monitoring is needed. This can reduce the chances of medical complications and injury while in the workplace. Psychiatric medications can have side effects that need to be taken into account to assure that this also does not impair safety in the workplace.

Eating Disorders, Depression and Anxiety

In addition to abnormal eating and weight, people with eating disorders have an increased risk of having other psychiatric illnesses. Depression occurs in up to 50 percent of people with eating disorders and appears to be strongly linked to the abnormal eating behavior. Depression is difficult to treat in someone with an eating disorder if his or her eating disorder is not treated at the same time. However, when the eating disorder is treated, about 75 percent of the time, depression symptoms improve as well.

Anxiety disorders also occur frequently in people with eating disorders. Anxiety about food and weight are characteristic of these illnesses, however, studies show that people with eating disorders have increased rates of anxiety disorders including social anxiety and obsessive compulsive disorder.  As opposed to depression, anxiety disorders frequently predate the onset of the eating disorder and in that sense may represent a trait for those who are at risk for developing an eating disorder.

Medical Problems and Eating Disorders

Because of the serious nutritional symptoms associated with eating disorders, several medical problems are associated with this group of illnesses. Malnutrition is the hallmark of anorexia and is associated with many physical and emotional problems, including weakness and fatigue, low body temperature, hypoglycemia, anemia, easy bruising, low blood pressure and dizziness, and problems with concentration and memory. The medical complications of anorexia often are severe and can be life threatening.

People with bulimia can have several of the physical symptoms of malnutrition. In addition, binge eating and purging can cause electrolyte disturbances, such as low potassium which can result in cardiac failure; gastrointestinal problems, including esophageal tears and bleeding, gastritis and esophageal reflux; severe dental problems, as a result of gastric acids effects on teeth; and a variety of digestive problems, including cramps, bloating, constipation, diarrhea and increased risk of seizures. It is important to emphasize that eating disorders can be medically dangerous and that medical problems can result in death.

Treatment of Eating Disorders

The treatment of eating disorders typically involves a team of professionals, including a therapist, dietitian and medical doctor. Those suspected of having an eating disorder should be evaluated by a medical professional. Some patients will need hospitalization to treat acute malnutrition and dehydration, in addition to other medical problems. A comprehensive assessment will also consider suicide risk and other self-destructive behaviors, including substance abuse. At times, psychiatric hospitalization for depression and suicide may be required.

After a thorough medical evaluation, working with a therapist who specializes in treating eating disorders is essential. Therapists should focus on examining the causes of the eating disorder, looking at how stress affects these symptoms, and how often the eating disorder becomes a dysfunctional coping mechanism for dealing with stress. Patients with eating disorders usually need to work long-term with a dietitian. Because medical insurance often does not cover dietary services or more than one dietary consultation, employers can have a positive impact on treatment if they can influence their insurance carrier or managed care company to see this service as integral to an employee’s recovery. A dietitian needs to be involved in determining normal body weight, helping the patient develop a health meal plan, monitoring compliance with the meal plan, and helping identify obstacles to recovery.

Summary

An increased awareness of eating disorders and their treatment can help employers to help their employees receive effective treatment that can lead to recovery from these illnesses. For a majority of patients, treatment will greatly reduce medical and psychiatric risk for other problems, decrease risk in the work-place, and improve employee productivity.

OBJECTIVES & STUDY DESIGN

The objective of this outcome study was to evaluate the effectiveness of a multidisciplinary partial program to decrease symptoms severity and improve weight in adolescents and young adults diagnosed with eating disorders. Study participants were 26 adolescents and young adults admitted for treatment in the eating
disorder services partial hospitalization program at Rogers Memorial Hospital-Milwaukee who gave their voluntary consent to participate in Rogers Memorial outcome studies. In addition, another three clients left treatment against medical advice and four were transferred to a higher level of treatment.

Key Findings

The results for weight gain show that study participants overall gained an average of 10 pounds during the 5 weeks of treatment. The average weight at admission was 110 pounds and at discharge was 120 pounds. When only the clients diagnosed with Anorexia Nervosa were taken into consideration, the weight gain increase from a mean of 102 pounds at admission to 117 pounds at discharge.
Eating disordered symptoms and behaviors were measured with the EDI-3 and EDE-Q.

Both instruments show reductions that were statistically significant from admission and discharge.  At admission the EDI-3 mean score was 145 and the EDE-Q mean score was 3.6; at discharge the EDI-3 was reduced to 119 and the EDE-Q was reduced to 1.7. All changes were statistically significant.
Co-morbid symptoms are an important contributor to patients’ well being and effective treatment programs should address these symptoms. The results show depression severity as measured on the BDI was reduced from a mean score of 22 at admission to 10 at discharge; the results of the STAI were reduced from 101 at admission to 39 at discharge. All changes were statistically significant.

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A substantial number of those diagnosed with anorexia or bulimia present with at least two co-morbid psychiatric illnesses at admission to treatment (Bean et al., 2005; Blinder, Cumella & Sanathara, 2006). The presence of anxiety disorders, including obsessive-compulsive disorder (OCD) , have been consistently found in patients who were already being treated for eating disorders in an outpatient or an inpatient setting (e.g., Bean, 2006; Kaye, Bulik, Thorton, Barbarich, & Masters, 2004; Rabe-Jablonska, 2003). Findings indicate that OCD is present in a low of 10% (Lucka, 2006; Rabe-Jablonska, 1996), a median of 20-37%, (e.g., Bean, 2006; Rubenstein, Pigott, L’Heureux, Hill & Murphy, 1992; Thiel, Broocks, Ohlmeier, Jacoby & Schussler, 1995) and a high of 56% (Blinder, Cumella & Sanathara, 2006) of all eating disorder patients. Both conditions have a peak age of onset during adolescent years and interestingly,  OCD prevalence is increased in both anorexic and bulimic eating disorder subgroups. OCD was found to be two times more common in patients with a diagnosis of anorexia (Blinder, Cumella & Sanathara, 2006; Lucka, 2006) compared to bulimia.

Connections and complications

Anxiety and eating disorders could represent a different presentation or expression of a common neuro-biological abnormality or risk factor. The expression of this biological vulnerability could relate to the magnitude of the vulnerability and/or unique environmental experiences, as well as other factors. Additionally, data suggests that patients with co-occurring eating and anxiety disorders may have a more severe and/or more treatment resistant eating disorder. Thus, the relationship between eating disorder and OCD might be of immense clinical relevance with regard to prognosis and treatment.
Patients with both eating and anxiety disorders may have more severe eating disorder symptoms. Studies have shown that subjects with anxiety and eating disorder co-morbidity have a longer history of eating disorder and that subjects who suffer from OCD are likely to have developed an eating disorder at an earlier age. (Milos et al. 2002) Other treatment teams have reported that no matter whether the eating disorder or OCD came first, OCD symptoms have a significant effect on treating the eating disorder. (Fisher et al., 2002). Eating disorder patients with co-morbid OCD exhibited a higher score in the Eating Disorder Inventory (EDI) than eating disorder patients without a co-morbid OCD. They found that eating disordered patients with and without a lifetime diagnosis of OCD scored highest on the subscales of drive for thinness, body dissatisfaction, and ineffectiveness. (Lennkh et al. 1998) Another study noted that similar subscales of the EDI – drive for thinness, body dissatisfaction, and perfectionism differed significantly between an eating disorder group and a control psychiatric group (Cassady et. al., 1999).  The eating disorder group scored higher in all three scales.  Furthermore, between three percent and 13% of adults and children diagnosed with anorexia and OCD also met the DSM-IV-TR criteria for depression, with females sustaining a higher rate of incidence than males (Rabe-Jablonska, 1996; Lucka, 2006; Noshirvani et al.1991).

Aversion to change

Increased anxiety with change may reduce the efficacy of eating disorders treatment. In patients with co-morbid anorexia nervosa and OCD, introducing new foods and reinforcing typical eating patterns were much more difficult compared to patients with anorexia nervosa alone. Generalized anxiety disorder has been identified as being most strongly associated with anorexia nervosa in patients requiring hospitalization for their eating disorders (Godart et al., 2005; Lucka, 2006).  While there are few studies available focusing on the impact of known treatment modalities for anxiety disorders on the course and treatment of eating disorders, effectively addressing co-morbid OCD and other anxiety symptoms should improve treatment efficacy and outcome for eating disorder patients. A follow-up study found that patients whose eating disorders were most improved at the 30-month follow-up also showed the highest reduction of obsessions and compulsions (Thiel et al., 1998).

Treatment can be challenging

Effectively addressing anxiety disorder symptoms in eating disorder patients can be challenging. As compared to depression, the treatment of anxiety disorders, (particularly in children, adolescents and young adults) relies less on pharmacotherapy and more on psychotherapy. Antidepressant medications, often used for the treatment of anxiety disorders, are associated with an increase risk of treatment emergent suicidal symptoms in this age group.  Studies suggest that behavior therapy including exposure with ritual prevention is as effective for OCD (if not more effective) as compared to pharmacotherapy. Skilled behavior therapists are not often available and the time required to develop the skills to be an effective behavior therapist are often prohibitive for most clinicians. These factors, as well as the combination of eating and anxiety disorders, represent a unique challenge to the patient families and clinicians.

At Rogers Memorial Hospital we have developed a specific residential program that uses evidence-based treatment for both eating disorders and anxiety disorders. Preliminary results have been quite encouraging as we have found a significant reduction in both anxiety and eating disorders symptoms (Riemann et al, 2006).  Furthermore, while analyzing length of stay, this modality may actually reduce time needed for treatment.  Results are preliminary but encouraging and support further development of specific eating disorder treatments that address co-morbid anxiety disorders.