Q&A: Treating patients with eating disorders ‘takes a lot of tolerance and patience’
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According to researchers, eating disorders — which affect more than 1 in 10 Americans — pose “a serious threat” to patients’ health and well-being, but many primary care physicians find it challenging to identify these disorders.
The last week of February is National Eating Disorders Week. To mark the occasion, Healio Primary Care spoke with Melinda Green, PhD, MS, director of the Cornell College Eating Disorder Institute, and Kasey Goodpaster, PhD, a psychologist with the Bariatric & Metabolic Institute at Cleveland Clinic, to get their insight on diagnosing and treating eating disorders. – by Janel Miller
Q: The authors of a 2019 meta-analysis concluded that the tool known as Sick, Control, One, Fat and Food, or SCOFF, is a “simple and useful” screening tool for young women at risk for anorexia nervosa and bulimia nervosa. However, the authors found there was insufficient evidence to support the tool’s use in primary care to screen for other eating disorders, such as binge eating disorder and night eating syndrome. What diagnostic tools for eating disorders can you recommend to PCPs?
Green: I like to use the Questionnaire for Eating Disorder Diagnoses that was described by Mintz and colleagues in the Journal of Counseling Psychology in 1997. This test does a really nice job of getting to some of the more nuanced eating disorder behaviors like patients who chew and then spit out their food or engage in maladaptive exercise as a purge method. There is also the Eating Disorder Examination described by Christopher G. Fairburn and others in Cognitive Behavior Therapy and Eating Disorders in 2008. If you have adequate time to conduct a diagnostic clinical interview with the patient, use Fairburn’s interview format. If you don’t have that amount of time, use its questionnaire version. This tool gets to the heart of eating disorders’ diagnostic criteria.
Goodpaster: For binge eating disorder and night eating syndrome, I would recommend supplementing SCOFF with other questions. Start with a broad question, framed in a curious and nonjudgmental manner, such as, “How would you describe your relationship with food?” Then follow up with specific questions. For binge eating disorder, this could be, “Do you have times in which you eat an unusually large amount of food in a short period of time, and feel like you just can’t stop eating? Like you’re a car without brakes, you want to stop eating but can’t?” For night eating syndrome, specific questions could be, “How often do you eat another meal’s equivalent (at least 25% of your daily calories) after dinner and before bed? What about eating in the middle of the night?”
Q: Research suggests PCPs do not always immediately recognize the symptoms of eating disorders, hindering timely treatment. What are some signs — both subtle and not so subtle—that could possibly suggest that a patient has an eating disorder?
Goodpaster: Patients struggling with eating disorders rarely present to their PCP complaining specifically about their eating. PCPs should be on the lookout for other signs such as significant weight loss or gain, fatigue, irregular menses, gastrointestinal issues, very poor body image, frequent weighing, and psychological distress, particularly related to control and perfectionism. In addition, never assume that a BMI in the “normal” range rules out an ED, nor that a high BMI necessarily means one is binge eating.
Green: Patients with eating disorders often show hallmark features of energy conversation and negative energy balance including increased vagal tone, decreased QRS voltage on ECG, orthostatic hypotension, bradycardia, decreased estrogen levels, and hypoglycemia. With regard to psychological risk factors, patients with eating disorder often have very high personal standards, tend to be a bit oriented toward perfectionism, are more likely to struggle with low self-esteem. Be especially mindful that persons with eating disorder symptoms may be especially mindful of weight and some may have a history (current or past) of being in larger bodies. Be careful not to equate weight with health in their presence as this can reinforce some negative stereotypes.
Q: A 2017 review of the literature found that family-based treatment is an effective intervention for adolescents with anorexia nervosa and bulimia nervosa. What can you tell us about family-based interventions and why they are effective for this population?
Green: The family-based intervention consists of bringing the patient’s family together and training them on how to best support that patient and encourage the patient to eat in a healthful way without being overly controlling or judgmental. Training family members to support the patient to make good food-related choices despite very high anxiety levels is an essential component of treatment. Some of the helpful things family members can be trained to say are: “We know this is anxiety-provoking when you try new foods ” or “We know it is terrifying for you to eat some days,” and then adding “We’re so proud that you’re choosing to continue therapy.” Family-based interventions also train family members to avoid critical statements that can elevate anxiety, such as “If you don’t do this, we’re going take you back to the hospital” or “You won’t survive if you don’t do this.”
Goodpaster: Adolescents [with eating disorders] need a great deal of support and stability in their home environment in order to facilitate change. Family-based interventions empower families to create and implement solutions that will work in their unique circumstances. Because adolescents are practicing eating behaviors at home from early on in treatment, family-based interventions reduce the oftentimes steep learning curve of applying what is learned in an inpatient or residential setting to the natural home environment.
Q: Findings have shown that the “time-consuming” or “complex” nature of screening for eating disorders, as well as patients’ “lack of motivation and adherence” to treatment, can frustrate PCPs and often make them feel resentment toward patients with eating disorders. How can these negative feelings be overcome?
Goodpaster: It is important for PCPs to be cognizant of and challenge internalized bias, because even if expressed subtly, bias can be easily sensed by patients who are dealing with their own self-stigma and have likely had many other negative interactions in health care. Recognizing that they are likely to be a critical first point of contact and may need to fill the gap until patients are able to receive specialized eating disorder treatment, PCPs should specifically seek out additional training, while also knowing the bounds of their competence and building a referral network in the community. Bearing in mind the transtheoretical stage of change model can also be helpful. For example, facilitating patients’ movement from “precontemplation” (not considering making a change) to “contemplation” (considering pros and cons of change) is itself great progress. This mindset allows PCPs to reframe success and feel they are making a difference in what may be an arduous treatment process.
Green: Treating patients with eating disorders takes a lot of tolerance and patience. It is important that all members of the treatment team recognize that these are often long-term disorders which require an ongoing relationship with the patient which is characterized by patience and acceptance. It is also important to recognize that eating disorders often involve high levels of comorbid anxiety and patients may sometimes be very reluctant to engage in any behaviors which may result in weight gain. Interventions that involve patience, understanding and creativity toward behavioral goals which increase energy input without spiking anxiety to extremely high levels are essential during this time.
Q: Though the occurrence of eating disorders in males is rising, there is still a paucity of research in this area, according to researchers. What are some of the most important things PCPs need to know about eating disorders in male patients?
Goodpaster: PCPs should know that males are less likely to disclose eating disorder symptoms and more likely to delay help-seeking due to stigma and not knowing that their behaviors are “bad enough” to be considered an eating disorder. Thus, they are likely to present later in the disease trajectory. PCPs should also be aware that body dissatisfaction is more often related to the desire for a muscular appearance than thinness. Excessive exercise is also a red flag.
Green: There are certain groups of men at greater risk for eating disorders. For example, men with a history of being overweight, sexual minority men, and men who have participated in sports which emphasize weight may be at increased risk. Research indicates body image disturbances in men in America are more likely to include a focus on lean muscle mass as opposed to extreme thinness. This sometimes makes men more likely to struggle with muscle dysmorphia (body dysmorphic disorder) as opposed to an eating disorder.
References:
American Psychiatric Association. DSM – 5 Feeding and Eating Disorders. https://appi.org/Products/dsm. Accessed Feb. 24, 2020.
Fairburn CG. Eating Disorders Examination. Cognitive Behavior Therapy and Eating Disorders. Guilford Press, New York, 2008.
Johns G, et al. BJPsych Open. 2019;doi:10.1192/bjo.2019.48.
Kutz AM, et al. J Gen Intern Med. 2019;doi:10.1007/s11606-019.05478-6.
Lazare K, et al. Eat Disord. 2019;doi:10.1080/10640266.2019.1605778.
Mintz LB, et al. J Couns Psychol. 1997;doi:10.1037/0022-0167.44.2.132.
National Eating Disorders Association. Eating disorders activists receive trailblazing congressional support. https://www.nationaleatingdisorders.org/united-states-senate-officially-declares-feb-26-%E2%80%93-mar-4-national-eating-disorders-awareness-week-us. Accessed Feb. 24, 2020.
National Eating Disorders Association. Announcing National Eating Disorders Awareness Week 2020! https://www.nationaleatingdisorders.org/blog/announcing-national-eating-disorders-awareness-week-2020. Accessed Feb. 27, 2020.
Nicholls D, et al. BJPsych Advances. 2015;doi:10.1192/apt.bp.114.014068.
Reinecke RD. Adolesc Health Med Ther. 2017;doi:10.2147/AHMT.S115775.
Sangha S, et al. Am J Mens Health. 2019;doi:10.1177/1557988319857424.
Disclosures: Goodpaster and Green report no relevant financial disclosures.