Eating disorders in adults: what can we even do

[Celexa]

I have no pithy comments for this week's conversation starter. Just frustration and frequent helplessness. I do CL and so of course see adult eating disorder patients in the hospital who are extremely ill. The adult hospital is not equipped to take care of them. I have seen some very bad outcomes.

These diseases have a very high mortality rate, but I wish I knew what the mortality rate would be if they actually got quality care (inpatient OR outpatient). I'm sure it would still be high but surely it would be lower than it is.

Please weigh in with shared frustration, success stories, words of wisdom for both inpatient and outpatient treatment of severe eating disorders in adults, etc

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[nexus73]

Seems like if they have means family can get them into residential relatively quickly. if not and they aren’t eating they either accept TF, or decompensate to the point family consents to TF and they start putting on weight. Patients with ED probably generate the most ethics consults at our hospital.

 

[forchinet121]

I have no pithy comments for this week's conversation starter. Just frustration and frequent helplessness. I do CL and so of course see adult eating disorder patients in the hospital who are extremely ill. The adult hospital is not equipped to take care of them. I have seen some very bad outcomes.

These diseases have a very high mortality rate, but I wish I knew what the mortality rate would be if they actually got quality care (inpatient OR outpatient). I'm sure it would still be high but surely it would be lower than it is.

Please weigh in with shared frustration, success stories, words of wisdom for both inpatient and outpatient treatment of severe eating disorders in adults, etc

What do you do for them on CL?

 

[WisNeuro]

In an inpatient setting, it's pretty much just stabilization. I've done some OP treatment here, and as a problem-focused, short-term therapy person, this is one category of disorders that generally needs much longer term treatment to see appreciable change. NEDA is the national association, I believe that they have a listing of therapists that may be helpful.

 

[Candidate2017]

We need to accept we are physicians who practice medicine. And in medicine, some diseases have a higher rate of mortality, and patients sometimes die from their disease. Psychiatrists, as a whole, seem to poorly accept this fact. At some point, when a patient is extremely ill, treatment may be for palliative purposes only.

The 25% mortality rate in anorexia is considered high in our field, but it's quite low compared to many other diseases. Some oncologists specialize in cancers, for example glioblastomas, that practically have a 100% mortality rate. In my opinion, physicians who deal with death and dying on a daily basis are the ones who are most zen and least frustrated with the limitations of medicine. Arguably, psychiatry is the specialty that has the least exposure to dying patients. Hence, psychiatry tends to inculcate a childlike, narcissistic view of death, resulting in frustration and helplessness. As well as lengthy notes.

 

[shoomer]

Hence, psychiatry tends to inculcate a childlike, narcissistic view of death, resulting in frustration and helplessness.

I don't know, I think there should be some recognition of the fact that our exposure to death is often via self-destructive means as opposed to externally-imposed mortality such as an idiopathic malignancy. Maybe we could view chronic CHF or diabetic patients who don't adhere to treatment as slowly killing themselves, but I know plenty of internists disillusioned with treating those populations for that very reason.

I would also ask if it's not normal to examine our own feelings towards these cases, and if frustration isn't a perfectly acceptable response? And then sharing that frustration as an endeavor that may be informative and perhaps even therapeutic. Processing our work is important IMO.

I can fully understand and accept that there are some people who will die no matter what interventions take place, and some people will even get worse after attempted treatment due to human margins of error. But should we still not at least consider if improvement is possible?

 

[Celexa]

We need to accept we are physicians who practice medicine. And in medicine, some diseases have a higher rate of mortality, and patients sometimes die from their disease. Psychiatrists, as a whole, seem to poorly accept this fact. At some point, when a patient is extremely ill, treatment may be for palliative purposes only.

The 25% mortality rate in anorexia is considered high in our field, but it's quite low compared to many other diseases. Some oncologists specialize in cancers, for example glioblastomas, that practically have a 100% mortality rate. In my opinion, physicians who deal with death and dying on a daily basis are the ones who are most zen and least frustrated with the limitations of medicine. Arguably, psychiatry is the specialty that has the least exposure to dying patients. Hence, psychiatry tends to inculcate a childlike, narcissistic view of death, resulting in frustration and helplessness. As well as lengthy notes.

I've got no trouble understanding patients die. I am in CL. Sometimes my job involves briefly morphing into a palliative care physician. Sometimes I do transplant evals in which we turn patients down for organs knowing that means their inevitable, imminent death.

With eating disorders I have been in the position of attempting to convince medical teams to please, please feed the patient with a Bmi of 14 and been unable to coordinate adult floors to feed over objection even for patients who clearly lack capacity. I have seen patients die from basic errors of medical care because they were on the adult side, that would not have happened if they were accross the street in the children's hospital instead. I have also been in many, many situations where every attempt to get a patient transferred to a facility most appropriate to treat them was thwarted by insurance and nothing else. So no, I don't accept that these patients all would have died anyway. Some of them are dying because they cannot access treatment. It's a willful misreading of my starting post to say, "you just have to get better at accepting they die because that is the inevitable trajectory of their disease".

To answer the question above about what we do on CL, some combination of psycho education and support for team and family, attempting to communicate how gravely ill the patient actually is, sometimes making medication adjustments or discontinuing meds that may be causing more harm than good, and often capacity evals end up needing to be done at some point as well.

 

[wolfvgang22]

We need to accept we are physicians who practice medicine. And in medicine, some diseases have a higher rate of mortality, and patients sometimes die from their disease. Psychiatrists, as a whole, seem to poorly accept this fact. At some point, when a patient is extremely ill, treatment may be for palliative purposes only.

The 25% mortality rate in anorexia is considered high in our field, but it's quite low compared to many other diseases. Some oncologists specialize in cancers, for example glioblastomas, that practically have a 100% mortality rate. In my opinion, physicians who deal with death and dying on a daily basis are the ones who are most zen and least frustrated with the limitations of medicine. Arguably, psychiatry is the specialty that has the least exposure to dying patients. Hence, psychiatry tends to inculcate a childlike, narcissistic view of death, resulting in frustration and helplessness. As well as lengthy notes.

This elicits a strong negative response from me. Because I'm not the one that has a problem with people having illness and sometimes dying. I agree that is part of life and happens. I only have a problem because others have a problem with coping with illness and death. These others include patient families (however estranged from the patient), our legal system, hospital administration, and state licensure boards to name a few. It is these people who put pressure on us, and we are already doing our very best and more than anyone else is able.

 

[Sushirolls]

Disagree @Celexa , I believe @Candidate2017 post nailed it.

Accept it.

Can't win them all.

You obviously outline how you are a seasoned C/L and now the ropes of ethics, insurance, hospital, admin, consulting teams, etc.

You can perhaps pull up your last 3 of theses cases and do your own M&M review with your team or the other C/L folks in your department. Perhaps there is more expedient way to integrate the courts for involuntary feeding if allowed in your state? Start with M&M but be prepared, acceptance is where its at.

In the outpatient I make it clear for the ED population I won't address it, provide links to referral options and rest is up to them. Even had one whose severity level to need residential was apparent, made it very clear with patient and family during the consult, they ignored it and opted not to continue with me. They wanted the magic pill, not in my possession.

*Candidate2017 other point about mortality I believe is part of the reason why our field has been pigeon holed on suicide. Can't stop that either but enough of the field said sure, we'll take on the blame as though it is a 'never ever event.'

 

[Ceke2002]

I have no pithy comments for this week's conversation starter. Just frustration and frequent helplessness. I do CL and so of course see adult eating disorder patients in the hospital who are extremely ill. The adult hospital is not equipped to take care of them. I have seen some very bad outcomes.

These diseases have a very high mortality rate, but I wish I knew what the mortality rate would be if they actually got quality care (inpatient OR outpatient). I'm sure it would still be high but surely it would be lower than it is.

Please weigh in with shared frustration, success stories, words of wisdom for both inpatient and outpatient treatment of severe eating disorders in adults, etc

For every one person from the eating disorder support community, that I knew, who died, I also know another 5 who recovered. I think as human beings we do have a tendency to focus more on perceived failures rather than actively acknowledging our successes. We are a notoriously difficult population to treat, and I honestly don't think anyone is going to find the holy grail of eating disorder treatment, because I don't think it exists. I would say just work with us as individuals, celebrate even the smallest of steps forward, and don't beat yourself up to much if some of us don't make it, because this is a real b!tch of a disease/disorder.

(from someone who developed Anorexia Nervosa at the age of 8, was actively and severely eating disordered for almost 25 years, and who is now pretty darn close to being 100% recovered. I'm one of the success stories.)

 

[justalittlestar]

For every one person from the eating disorder support community, that I knew, who died, I also know another 5 who recovered. I think as human beings we do have a tendency to focus more on perceived failures rather than actively acknowledging our successes. We are a notoriously difficult population to treat, and I honestly don't think anyone is going to find the holy grail of eating disorder treatment, because I don't think it exists. I would say just work with us as individuals, celebrate even the smallest of steps forward, and don't beat yourself up to much if some of us don't make it, because this is a real b!tch of a disease/disorder.

(from someone who developed Anorexia Nervosa at the age of 8, was actively and severely eating disordered for almost 25 years, and who is now pretty darn close to being 100% recovered. I'm one of the success stories.)

Thank you for your transparency!

Having had some short-term training in treating the younger and older ED population at a an all ages treatment facility I will say there is definitely a good deal of difficulty in treating eating disorders and there's no one right answer or one thing that works best as stated in your message. In my opinion, a step-wise approach seems the most efficient with focus on undoing harmful behaviors and things of that nature. I see no reason why the approach would vary across age groups. While some programming at the facility I worked was delineated by age groups most therapy sessions at the treatment facility intersected with all ages.

 

[Ceke2002]

Thank you for your transparency!

Having had some short-term training in treating the younger and older ED population at a an all ages treatment facility I will say there is definitely a good deal of difficulty in treating eating disorders and there's no one right answer or one thing that works best as stated in your message. In my opinion, a step-wise approach seems the most efficient with focus on undoing harmful behaviors and things of that nature. I see no reason why the approach would vary across age groups. While some programming at the facility I worked was delineated by age groups most therapy sessions at the treatment facility intersected with all ages.

The step wise approach actually sounds very similar to something we did in the ED support communities I used to be a part of, except we called it 'stasis' (if it's not the same, let me know).

For us being in 'stasis' was a type of 'pre-recovery', it meant committing to try and maintain whatever weight we were at, to stop trying to actively lose weight, and to start work on challenging harmful ideas or behaviours. So 'stasis' for me, which I did for a year before going into full weight and nutrition restoration mode, meant maintaining my weight at my then BMI of around 14.5, refraining from actively trying to lose weight (not easy), and each day I would pick one aspect of my eating disorder to challenge: that could mean anything from deciding to put one extra slice of tomato on my half a sandwich for lunch, not completing all the steps of my entire weighing ritual, walking into a grocery store and just buying a packaged food item without having to sit on the floor of the shop and then pull the entire stock level off the shelf in order to find the one that 'felt right', or just spending a day 'talking back' to my disordered thoughts & trying to challenge certain ideas I had objectively. To outsiders it might not have looked like I was making any progress at all, still emaciated and engaging in disordered behaviours after all, but that step by step, day by day approach was a huge deal for me and what eventually helped me accept the switch into attempting full recovery.

As for the 'step by step' or 'stasis' mode of recovery being useful across all age groups, I would agree with that. I've seen young teens successfully use this method, and I've also seen women and men in their 40s or older successfully use the same method. When I said 'treat patients as individuals' I was talking more from the theories of causation in therapy point of view and what then stems from that. I have seen therapists and psychiatrists who were so rigidly hung up in their 'one true theory' approach that it impacted their ability to engage in meaningful therapy with their patient. Like if I have anorexia nervosa and I go to you for therapy or support, and your pet theory is that I have anorexia nervosa because I'm scared of growing up, and I tell you "Nope, that doesn't match me at all, not even a tiny bit", and you continue to insist on approaching therapy/support from a point of view that I've just adamantly negated, then that's gonna be an issue going forward.

 

[clozareal]

You can perhaps pull up your last 3 of theses cases and do your own M&M review with your team or the other C/L folks in your department. Perhaps there is more expedient way to integrate the courts for involuntary feeding if allowed in your state? Start with M&M but be prepared, acceptance is where its at.

In the outpatient I make it clear for the ED population I won't address it, provide links to referral options and rest is up to them. Even had one whose severity level to need residential was apparent, made it very clear with patient and family during the consult, they ignored it and opted not to continue with me. They wanted the magic pill, not in my possession.

*Candidate2017 other point about mortality I believe is part of the reason why our field has been pigeon holed on suicide. Can't stop that either but enough of the field said sure, we'll take on the blame as though it is a 'never ever event.'

I like this article discussing involuntary treatment of anorexia:

https://jaapl.org/content/jaapl/45/4/419.full.pdf

 

[prominence]

For psychiatrists who work as part of a multidisciplinary treatment team within an eating disorders residential treatment program, I was curious about the following 3 questions:

1. What is the role of a psychiatrist in such a position? I believe that Vyvanse has an indication for Binge Eating Disorder but other than that, there are no other FDA approved medications for eating disorders to my knowledge. So does the psychiatrist in this setting assess and potentially treat co-morbid psychiatric disorders, such as mood, anxiety, substance use and personality disorders?

2. Is there specific criteria on how to differentiate the level of care as to which eating disorder patients need inpatient treatment vs. residential eating disorder treatment program?

3. What is the general range of how long insurance companies will pay for an eating disorders residential treatment program? Up to 1 month? 1-3 months? 3-6 months? Longer?

Would appreciate any helpful insights to my above questions. Thank you in advance.

 

[hamstergang]

For psychiatrists who work as part of a multidisciplinary treatment team within an eating disorders residential treatment program, I was curious about the following 3 questions:

1. What is the role of a psychiatrist in such a position? I believe that Vyvanse has an indication for Binge Eating Disorder but other than that, there are no other FDA approved medications for eating disorders to my knowledge. So does the psychiatrist in this setting assess and potentially treat co-morbid psychiatric disorders, such as mood, anxiety, substance use and personality disorders?

2. Is there specific criteria on how to differentiate the level of care as to which eating disorder patients need inpatient treatment vs. residential eating disorder treatment program?

3. What is the general range of how long insurance companies will pay for an eating disorders residential treatment program? Up to 1 month? 1-3 months? 3-6 months? Longer?

Would appreciate any helpful insights to my above questions. Thank you in advance.

1. Prozac is FDA-approved for Bulimia in adults as well. Generally as psychiatrists, we are treating comorbidities, but also there are times we try some of the medications that have been studied but not FDA-approved. For example, several RCTs of Zyprexa in Anorexia Nervosa showed some benefit to the rate of weight gain and some of the emotional and behavioral components, even if there was no additional weight gain overall relative to placebo. Outside of medications, we can assess the patients and bridge the psychological and medical components of their team/treatment.

2. Level of care is most determined by medical stability. Residential units may have cut offs for heart rate or blood pressure, as well as some labs.

 

[justalittlestar]

For psychiatrists who work as part of a multidisciplinary treatment team within an eating disorders residential treatment program, I was curious about the following 3 questions:

1. What is the role of a psychiatrist in such a position? I believe that Vyvanse has an indication for Binge Eating Disorder but other than that, there are no other FDA approved medications for eating disorders to my knowledge. So does the psychiatrist in this setting assess and potentially treat co-morbid psychiatric disorders, such as mood, anxiety, substance use and personality disorders?

2. Is there specific criteria on how to differentiate the level of care as to which eating disorder patients need inpatient treatment vs. residential eating disorder treatment program?

3. What is the general range of how long insurance companies will pay for an eating disorders residential treatment program? Up to 1 month? 1-3 months? 3-6 months? Longer?

Would appreciate any helpful insights to my above questions. Thank you in advance.

Your first question you pretty much answered, yes, the psych doc I worked with pretty much treated comorbities and at times mirtazipine was tried for appetite. Lots of med management and also some checking of vitals since patients can experience different types of medical conditions from not eating as you might imagine

 

[clausewitz2]

The step wise approach actually sounds very similar to something we did in the ED support communities I used to be a part of, except we called it 'stasis' (if it's not the same, let me know).

For us being in 'stasis' was a type of 'pre-recovery', it meant committing to try and maintain whatever weight we were at, to stop trying to actively lose weight, and to start work on challenging harmful ideas or behaviours. So 'stasis' for me, which I did for a year before going into full weight and nutrition restoration mode, meant maintaining my weight at my then BMI of around 14.5, refraining from actively trying to lose weight (not easy), and each day I would pick one aspect of my eating disorder to challenge: that could mean anything from deciding to put one extra slice of tomato on my half a sandwich for lunch, not completing all the steps of my entire weighing ritual, walking into a grocery store and just buying a packaged food item without having to sit on the floor of the shop and then pull the entire stock level off the shelf in order to find the one that 'felt right', or just spending a day 'talking back' to my disordered thoughts & trying to challenge certain ideas I had objectively. To outsiders it might not have looked like I was making any progress at all, still emaciated and engaging in disordered behaviours after all, but that step by step, day by day approach was a huge deal for me and what eventually helped me accept the switch into attempting full recovery.

As for the 'step by step' or 'stasis' mode of recovery being useful across all age groups, I would agree with that. I've seen young teens successfully use this method, and I've also seen women and men in their 40s or older successfully use the same method. When I said 'treat patients as individuals' I was talking more from the theories of causation in therapy point of view and what then stems from that. I have seen therapists and psychiatrists who were so rigidly hung up in their 'one true theory' approach that it impacted their ability to engage in meaningful therapy with their patient. Like if I have anorexia nervosa and I go to you for therapy or support, and your pet theory is that I have anorexia nervosa because I'm scared of growing up, and I tell you "Nope, that doesn't match me at all, not even a tiny bit", and you continue to insist on approaching therapy/support from a point of view that I've just adamantly negated, then that's gonna be an issue going forward.

ED is not my area of expertise, so this is quite interesting. This is very much the kind of approach we'd be encouraging someone with OCD to pursue, in the sense that any simplification of a ritual or small, deliberate step towards the possibility of a feared outcome is a win. It builds the sense of confidence and self-efficacy that you are, in fact, capable of doing this thing that seems utterly impossible at the outset, and each time you do this is a time you are embracing distress that you'd rather not have because the alternative is continuing to surrender control of your life to Something Else (ED/OCD).

I recognize I am not the first person to note similarities between OCD and anorexia and the co-morbidity rate is quite high (20-40% depending on the study).

 

[Merovinge]

For psychiatrists who work as part of a multidisciplinary treatment team within an eating disorders residential treatment program, I was curious about the following 3 questions:

1. What is the role of a psychiatrist in such a position? I believe that Vyvanse has an indication for Binge Eating Disorder but other than that, there are no other FDA approved medications for eating disorders to my knowledge. So does the psychiatrist in this setting assess and potentially treat co-morbid psychiatric disorders, such as mood, anxiety, substance use and personality disorders?

2. Is there specific criteria on how to differentiate the level of care as to which eating disorder patients need inpatient treatment vs. residential eating disorder treatment program?

3. What is the general range of how long insurance companies will pay for an eating disorders residential treatment program? Up to 1 month? 1-3 months? 3-6 months? Longer?

Would appreciate any helpful insights to my above questions. Thank you in advance.

Vyvanse is usually utter garbage for BED, daytime suppression of appetite usually just leads to more binge/restrict cycles. BED is best treated with regular/consistent food intake as well as some stimulus control depending on any level of food addiction that is part of it (and of course addressing the void that binge eating is being used to fill). Zyprexa/Remeron are big players for treatment (although many patients are not good candidates for appetite stimulating medication depending on where they are at in recovery) as well as GI medications (zofran, Reglan, etc) to help support stomach symptoms during the reintroduction of normal food intake.

Attached are the specific LoC guidelines.

Insurance coverage depends on the insurer, progress made, amount of weight to restore, comorbidity etc. Hard to generalize but often times aiming to be at a month with step-down to PHP after.

 

[comp1]

Definitely second the comments above about anorexia and suicidality being quite different from deaths from oncologic issues. Yes, patients kill themselves indirectly through poor diets and smoking, but the direct causation is just not there. Not once has a physician been sued because they told a patient to stop smoking, the person kept smoking and then the patient developed lung cancer. It's very different emotionally and in many places legally when someone does it to themselves in real time. There is an assumption, legally and ethically, that the person lacked the capacity to do that in our field, whereas it's quite the opposite with smoking. This ends up putting the blame, rightly or wrongly, on the physicians since we are supposedly experts. In regards to the OP in specific, wouldn't the vast majority of states grant conservatorship to family or the state when someone had a BMI of 14? I guess this wouldn't help if you genuinely had no resources and your hospital didn't know how to treat starvation, but hopefully that's a relatively rare situation. I fortunately work with a population that has vanishingly small amounts of restrictive eating disorders, so I'm not very familiar.

 

[Candidate2017]

I can fully understand and accept that there are some people who will die no matter what interventions take place, and some people will even get worse after attempted treatment due to human margins of error. But should we still not at least consider if improvement is possible?

Some of them are dying because they cannot access treatment.

We can always improve outcomes/increase access. Or more precisely, SOCIETY can always do so. The question is what is society willing to give in exchange for incremental improvement. Is society willing to spend more money as well as restrict civil liberties? I'd wager anorexic death rates were much lower generations ago when the bar for forced treatment was low and done merely upon family request or doctor's orders.

The transition to shared decision making (including 3rd party payors), in my opinion, is largely what leads to frustration. I doubt trauma surgeons are frustrated because they generally… do things they deem need to be done, rather than haggle with utilization review, fill out prior auths, do motivational interviewing ("What are your thoughts about me stopping your arterial bleed?"), etc.

This is the environment in which we operate. The original question posed was "What can we even do?" My answer is, "Not much more as an individual psychiatrist, given societal restraints."

There is an assumption, legally and ethically, that the person lacked the capacity to do that in our field, whereas it's quite the opposite with smoking.

It's the opposite. Psychiatric patients are presumed to have capacity unless proven otherwise in court, despite the fact serious psychiatric issues affect thought processes, insight and judgment. There are reams of mental health laws dictating how we do treatment. No other specialty contends with onerous requirements.

For every one person from the eating disorder support community, that I knew, who died, I also know another 5 who recovered. I think as human beings we do have a tendency to focus more on perceived failures rather than actively acknowledging our successes.

Exactly. Many psychiatrists don't fully appreciate patients that stabilize and do well. These boring refills patients are our success stories.

Again, 25% mortality rate means 75% survival rate, which is pretty good. And I dare say we can achieve near 100% survival rate if society locked up and tube fed every anorexic indefinitely, as well as provided funding.

 

[Sushirolls]

The surgeons don't get the push back because hospitals still get financial windfall from them with facility fees. Writing off some cases here there because the surgeon proceeded out of medical necessity adds to the numeric list of "charity care" the hospital did to further justify their supposed non-profit status; or they simply pass the bill on to the patient and use collections agencies to claw what they can.

But should the day emerge where the finances behind surgical procedures tips lower, or even lower on the facility fee side of things, you bet Insurance and Hospital Admin will be up in their faces saying you didn't get the auth first to do this surgery... do not proceed.

Every state has different laws, and in some states the guardianship has no teeth... they can't force the person do anything. They are merely the paper tiger who holds the check book, signs documents, collects the SSD checks, etc. Other states they are 'god' and can dictate treatment at all levels.

 

[mistafab]

1. What is the role of a psychiatrist in such a position?

Depends on lots of factors. In certain settings, like c&l for instance, the psychiatrist may have far more knowledge about the medical management than the primary team. Unless they’ve seen it before, internists may be clueless about what refeeding syndrome might be like in this pop. They may not be monitoring the night bradycardia. They may not know the frequency of lyte monitoring/repletion. They might say they do but then you’ll see infrequent monitoring just because the patient has been there a long time, not realizing how quick they can get arrhythmias.

They might not know to make sure the patient isn’t told their weight/ get the weight making sure the pt can’t see it. May not know about how/when to check weight to make sure patients aren’t water loading. They may have never used reglan for malnourished gastroparesis, but run into a wall where someone is very noxious after every meal despite their best efforts. They may have never managed the constipation in this group (2nd to gastroparesis, as well as post-laxative abuse). They may not know they need to assess capacity - often these folks are allowed to rot for months in severely malnourished states because they seem superficially competent. Many of these folks get very sick and become delirious at very low bmi.

Not many people treat EDs. Honestly I’m glad they have specialized centers because it is a unique and difficult area of medicine. People can really cause harm in these patients if they make small mistakes. Half the job on C&L when I got brought in a case is getting the primary team to take it serious. You might get the consult for “depression” then walk in and see a bmi of 12-13. It’s quite scary. Therapists or other docs may be calling these things primary psych (personality, depression, etc) but these things often resolve when they achieve normal weight.

Edit: another important point - by the time an ED patient is inpatient, they’ve likely been at an ED center several times before. They know the game/ tips of the trade. The ED has hijacked a smart, hardworking person’s brain and is careening towards a slow, methodical, and complex suicide. They are often deceptive, professional saboteurs. A hapless physician might be passively helping them navigate the waters towards self destruction - puzzled as to why the weight has not gone up.

 

[forchinet121]

Depends on lots of factors. In certain settings, like c&l for instance, the psychiatrist may have far more knowledge about the medical management than the primary team. Unless they’ve seen it before, internists may be clueless about what refeeding syndrome might be like in this pop. They may not be monitoring the night bradycardia. They may not know the frequency of lyte monitoring/repletion. They might say they do but then you’ll see infrequent monitoring just because the patient has been there a long time, not realizing how quick they can get arrhythmias.

They might not know to make sure the patient isn’t told their weight/ get the weight making sure the pt can’t see it. May not know about how/when to check weight to make sure patients aren’t water loading. They may have never used reglan for malnourished gastroparesis, but run into a wall where someone is very noxious after every meal despite their best efforts. They may have never managed the constipation in this group (2nd to gastroparesis, as well as post-laxative abuse). They may not know they need to assess capacity - often these folks are allowed to rot for months in severely malnourished states because they seem superficially competent. Many of these folks get very sick and become delirious at very low bmi.

Not many people treat EDs. Honestly I’m glad they have specialized centers because it is a unique and difficult area of medicine. People can really cause harm in these patients if they make small mistakes. Half the job on C&L when I got brought in a case is getting the primary team to take it serious. You might get the consult for “depression” then walk in and see a bmi of 12-13. It’s quite scary. Therapists or other docs may be calling these things primary psych (personality, depression, etc) but these things often resolve when they achieve normal weight.

Edit: another important point - by the time an ED patient is inpatient, they’ve likely been at an ED center several times before. They know the game/ tips of the trade. The ED has hijacked a smart, hardworking person’s brain and is careening towards a slow, methodical, and complex suicide. They are often deceptive, professional saboteurs. A hapless physician might be passively helping them navigate the waters towards self destruction - puzzled as to why the weight has not gone up.

I would venture the majority of psychiatrists would have no clue about what you’re talking about to be honest especially the medical side of things

 

[annoyedpsychiatrist]

Vyvanse is usually utter garbage for BED, daytime suppression of appetite usually just leads to more binge/restrict cycles.

yes and with time, the appetite effect isnt quite as apparent. Though i have a few people on it for BED who swear by it, and theyre both high functioning/reliable so who knows. I dont use it routinely for BED but have a few on it for that. In most people i would agree, what I would typically see is at night they just end up rebounding

 

[Merovinge]

yes and with time, the appetite effect isnt quite as apparent. Though i have a few people on it for BED who swear by it, and theyre both high functioning/reliable so who knows. I dont use it routinely for BED but have a few on it for that. In most people i would agree, what I would typically see is at night they just end up rebounding

There are probably some cases of compulsive binge eating that is not formed as maladaptive coping skill in an otherwise higher functioning person where if you can just get the impulses down during the day they can use executive control in the evening and push through to make it work (but would fall apart during the day if they needed to suppress the compulsions all day) where it makes sense. I don't disagree with it in that setting but it's an unusual medication where despite having FDA approval it can be expected to worsen the pathology in a significant percentage of cases.

 

[Jules A]

Not many people treat EDs. Honestly I’m glad they have specialized centers because it is a unique and difficult area of medicine. People can really cause harm in these patients if they make small mistakes. Half the job on C&L when I got brought in a case is getting the primary team to take it serious. You might get the consult for “depression” then walk in and see a bmi of 12-13. It’s quite scary. Therapists or other docs may be calling these things primary psych (personality, depression, etc) but these things often resolve when they achieve normal weight.

Edit: another important point - by the time an ED patient is inpatient, they’ve likely been at an ED center several times before. They know the game/ tips of the trade. The ED has hijacked a smart, hardworking person’s brain and is careening towards a slow, methodical, and complex suicide. They are often deceptive, professional saboteurs. A hapless physician might be passively helping them navigate the waters towards self destruction - puzzled as to why the weight has not gone up.

I moonlight on an inpatient ED unit and agree. It is not uncommon to get patients with severe anorexia that has gone unrecognized by family, pcps and general psych. These patients generally need an eating disorder center which are available as RTCs, PHP, OP in most decent size cities. Inpatient units can be harder to find but generally take patients from across the country and offer longer stays than we customarily see in mental health. When CL sees them inpatient ED is generally the recommendation. Obviously these patients are medically fragile and the refeeding process itself is complicated. The APA recently published an updated practice guideline for the treatment of patients with eating disorders 4th ed which is a good resource although I believe a specialized treatment team is required for most of these patients.

 

[Ceke2002]

ED is not my area of expertise, so this is quite interesting. This is very much the kind of approach we'd be encouraging someone with OCD to pursue, in the sense that any simplification of a ritual or small, deliberate step towards the possibility of a feared outcome is a win. It builds the sense of confidence and self-efficacy that you are, in fact, capable of doing this thing that seems utterly impossible at the outset, and each time you do this is a time you are embracing distress that you'd rather not have because the alternative is continuing to surrender control of your life to Something Else (ED/OCD).

I recognize I am not the first person to note similarities between OCD and anorexia and the co-morbidity rate is quite high (20-40% depending on the study).

Not surprising at all that is something that is recommended for OCD as well, there is definitely a fairly significant crossover with OCD and Eating Disorders (in my experience at least). My eating disorder actually initially developed out of childhood OCD, and a lot of folks I've know over the years have also had a diagnosis of both OCD and an eating disorder. Even in those of us who perhaps didn't meet diagnostic criteria for OCD we still tended to have a lot of ritualistic behaviour around things like food and weight.

In my opinion the comparison and/or relationship between EDs and OCD is also and important one to take into consideration, especially when treating the chronically eating disordered population. Unless there's an OCD therapy I don't know about, I would assume that you don't just use the 'stop it' comedy skit version of therapy on them; I think it's the same with a lot of chronically eating disordered patients, like unless our lives are in immediate danger then just throwing us in at the deep end with things like weight and nutrition restoration, and metaphorically shouting, "Swim", is probably more likely to send us running in the complete opposite direction of recovery & straight back to our disorder.

 

[clausewitz2]

There are probably some cases of compulsive binge eating that is not formed as maladaptive coping skill in an otherwise higher functioning person where if you can just get the impulses down during the day they can use executive control in the evening and push through to make it work (but would fall apart during the day if they needed to suppress the compulsions all day) where it makes sense. I don't disagree with it in that setting but it's an unusual medication where despite having FDA approval it can be expected to worsen the pathology in a significant percentage of cases.

I treated a medical sub-specialty fellow with Vyvanse for compulsive binging in just this way. We ultimately actually settled on a shorter acting stimulant because he ended up to the point he was okay while he was at work but the real trick was helping him get through the late afternoon/early evening without going to the grocery store, buying three packages of Oreos, and eating them in half an hour.