By Gerald Klee, MD
[Winter 2006; Vol. 32, No. 2; Pg 3-12]
The Center for Eating Disorders at Sheppard Pratt opened in January 2005. It is housed in the spacious old Victorian D Building which has been modernized to serve current needs. Board certified psychiatrists Harry Brandt, MD and Steven Crawford, MD are director and associate director of the program. They have been involved in the treatment of eating disorders for more than 15 years, first at Mercy Medical Center and later at St. Joseph Medical Center.
When I entered psychiatry over a half century
ago, eating disorders were poorly understood, despite their identification as
early as the 17th
Century. Things are changing. The frequency of eating disorders has increased as
has the awareness of these serious syndromes. The scientific and popular
literature on the subject is growing rapidly. There is no other set of
conditions in psychiatry that better illustrate the need for an in depth
Bio-Psycho-Social model. Comprehensive, multimodal treatment for patients with
severe eating disorders is absolutely essential.
On October 6th I attended an open house and was thrilled by what I saw and heard.
Drawing upon his extensive experience, Director Dr Harry Brandt lectured to a packed audience on the subject of eating disorders. I will summarize some of the highlights.
Eating Disorders include a wide range of conditions that involve an obsession with food, weight and appearance. This leads to adverse effects on health, relationships and on life’s activities.
The primary diagnostic conditions associated with Eating Disorders are Anorexia Nervosa, Bulimia Nervosa and Binge Eating Disorder. The latter is similar to bulimia nervosa, but without the compensatory purging behavior.
There is a tremendous amount of suffering with eating disorders. Patients who come to the hospital often don’t want to be there, are frequently brought in by parents, spouses or significant others, and fight efforts to stabilize them. The struggle to control weight can become epic and patients may purge or binge or both. A significant percentage of patients who are at a diminished weight develop major depression. Medical complications are complex and serious, affecting virtually every major organ system. Whereas the normal adult can call upon glycogen stores in times of food depletion, the patient with severe anorexia has used them up and can become hypoglycemic, particularly at night while sleeping. Blood sugar may need to be monitored to prevent cardiac arrhythmias; vascular collapse may occur. Patients abusing laxatives or diuretics are particularly at risk.
Eating
disorder patients often have significant comorbidities including mood disorders,
anxiety disorders, substance use disorders, and personality disorders.
This further complicates the care of these patients.
The morbidity of eating disorders is pronounced and the mortality of anorexia nervosa is the highest of any psychiatric illness. Further, suicide rates in eating disorders are very high.
The high morbidity and mortality rates explain the need for a multidimensional treatment program that includes inpatient facilities, day hospital programs and outpatient care. Dr Brandt said, “Relocating to Sheppard Pratt enabled us to expand the inpatient service to 22 beds and to serve a larger number of patients in both day hospital and intensive outpatient programming. We consistently have a waiting list for services. This expansion will allow us to be more effective while serving more patients.”
A
number of factors are considered in evaluating someone for inpatient care. The
chief ones are:
1. Failure of access to a well designed outpatient program
2. Severe metabolic abnormalities
3. Rapidly progressing weight loss that is not reversing on an outpatient basis
4. Ongoing, progressive bingeing and purging, with danger of electrolyte
imbalance
5. Suicidal risk or progressive depression
6. Limited family support or structure
Hospital based program components include:
22 inpatient beds in a specially designed and elegantly
appointed setting; a 12 hour a day, seven day a week Day Hospital program
housing up to 40 patients; a four hour, late day Intensive Outpatient Program;
traditional outpatient individual, group, pharmacological, and family therapy
services; and ongoing support groups.
Board certified psychiatrists coordinate a multi-disciplinary team of
professionals. Medical problems are closely monitored by a carefully selected
panel of consulting subspecialists.
Each person entering the program receives a complete assessment by a
psychiatrist. Additional information is gathered from a nutritional evaluation
by a registered dietitian. During this evaluation process, information about the
course and development of symptoms, underlying issues and related complications
is reviewed. Findings from the assessment are presented and a personalized
treatment plan is developed. When the eating disorder is life threatening or
there are serious medical complications, referral to the inpatient, day hospital
or intensive outpatient program is recommended.
Patients are engaged in multi-modality treatments that entail efforts to block the primary symptoms of the disorder while trying intensively to understand the meaning of the symptoms. Most patients are in a combination of various groups, individual therapy (including cognitive behavioral therapy), and nutritional counseling. Most are in family therapy as well. If indicated, medication is utilized.
The length of hospitalization can vary widely, but many patients are only inpatients for several days. They often then transfer into the partial hospitalization program for longer-term treatment.
Prognosis: The news on eating disorders isn’t all
bad. At least two-thirds of significantly ill patients can be helped
considerably with appropriate treatment, while some will remain chronically ill.
Teaching and Research: Drs. Brandt and Crawford have active ties to the University Of Maryland Department Of Psychiatry where they teach medical students and residents about eating disorders. They are also involved in an NIH-funded multicenter study of the genetics of eating disorders. Drawing on patients from eight cities in the U.S. as well as one in Canada and two in Europe, the study collects data on families in which two members meet strict eating disorder criteria. The plan is to eventually pool data from 400 families for genetic assessment. It has already been suggested from earlier human genome studies that some chromosomal abnormalities are linked to anorexia or bulimia. The findings also indicate that the traits of perfectionism and harm-avoidance and other early temperament factors may be the genetic underpinning of severe eating disorders.
Since the move to Sheppard Pratt, Dr Brandt also continues
in his role as Head of the Department of Psychiatry at St. Joseph Medical
Center.