Terry Schwartz, MD
Clinical director UCSD Eating Disorder Adult and Adolescent Programs, Assistant clinical professor UCSD School of Medicine, Dept. of Psychiatry
Dr. Schwartz has disclosed that she has no relevant financial or other interests in any commercial companies pertaining to this educational activity.
TCPR: Can you explain the factors determining whether to hospitalize somebody with an eating disorder? Dr. Schwartz: There are two types of hospitalizations to consider. One is in a medical unit with psychiatric support, and the other is in a psychiatric unit, preferably a specialized eating disorder unit that has medical services available if necessary. The type we choose has to do with the patient’s degree of medical instability, starting with vital signs. If a patient’s pulse gets very low, below 40 or 50, blood pressure falls, or if he or she is significantly orthostatic or has low electrolytes, we tend to consider a medical unit. Similarly, if there is evidence of liver, kidney, or cardiac problems, a medical unit is more appropriate. Some limited measures can be taken in urgent care or the ER, such as replacing potassium. Also, we consider hospitalization in patients with anorexia nervosa when they have had acute weight loss and they are refusing food, due to the risk of re-feeding syndrome. If you have a patient who has been eating very low calories a day for a period of weeks, you have to carefully titrate their calories up to avoid this syndrome, which can be dangerous and lead to death. That is something that should be monitored in a hospital setting. We consider psychiatric hospitalization if patients’ psychiatric co-morbidity is severe and they are medically stable, or if we feel they require a lower level of care but are unable to provide themselves with meals. However, a specialized psychiatric unit for eating disorders is preferred, as most general psychiatric units are not able to provide the type of meal support and monitoring required. A specialized psychiatric unit is also appropriate if patients purge after every meal, or they are taking laxatives or drugs or alcohol, or they have expressed suicidality with intention. Occasionally people are hospitalized if they are from rural areas and it is not possible for them to participate in an outpatient setting. The lack of specialists in some rural areas is a real problem.
TCPR: When, in the course of the illness, is hospitalization necessary? Dr. Schwartz:Sometimes people initially present to an emergency room or their primary care doctor before they’ve ever been diagnosed with an eating disorder. I have had people seek help for fatigue, and then they’re found to have a hematocrit of 20 or something, and their weight is dangerously low. So the medical abnormality can come at any point during the disease.
TCPR: In those patients who have never been diagnosed, is that because psychiatric care is not available? Or do they refuse psychiatric care? Dr. Schwartz: One critical feature of eating disorders is the ego-syntonic nature of the disease and the subsequent denial. Often, people with anorexia nervosa are simply not upset by it. It’s something that they find to be helpful, that helps them feel like they are stronger people, helps manage anxiety, and gives them some kind of success in their own minds in terms of accomplishing something that most people cannot accomplish, albeit to an extent that is potentially deadly. As a result of their perception of the physical and psychological advantages of their low weight, they don’t present for treatment because they don’t see the problems. Often a parent, friend, or spouse will insist that somebody with anorexia nervosa come for treatment. Sometimes parents don’t recognize it, either. We have had parents say, “She was a little chubby and we noticed that she was losing weight. We thought it was a good thing and she looked great.” But then she went to the doctor, who found that she fell off her growth curve, and the doctor noticed that the weight loss was enough to be concerning.
TCPR: Is there anything we can do to help patients recognize the damage that they are doing to their bodies? Dr. Schwartz: Getting patients with anorexia nervosa to recognize the damage that they are doing to their bodies is extremely difficult. They have a strangely laissez-faire attitude, despite often being very bright. One way that we actually get adolescents to engage in treatment is through the parents. Even with adults, if they are receiving financial or other forms of support from parents or a husband or somebody, it is just critical to bring in family members. It’s usually the family member who can put in contingencies that can help motivate the patient in recovery. Keep in mind that when patients are starving, it is very important to get them to want to recover because when they eat their anxiety level is intolerable. It is just too painful. I have had people tell me they just can’t bear it. So they need a lot of support to get there.
TCPR: Is it possible that we are looking here at something like a delusional or psychotic process? Dr. Schwartz: There are some symptoms similar to psychosis, more in the range of what you might see with body dysmorphic disorder, where people are not psychotic in other areas of their life. It is really about weight, body image, what they eat, and the impact it is going to have on their body. They also have a devastating level of anxiety about overeating and gaining weight, when in fact they should be more devastated about their body weight being so low. I would say that the belief system is on the line between severe distortion and an actual delusion. Some patients actually have some level of insight.
TCPR: Is there any role for antipsychotic medication? Dr. Schwartz: Prior to the appearance of atypical antipsychotics, the typical antipsychotics really did not provide much help or success in restoring weight. There are some positive case series with the atypicals, but that may be due to their role in handling the affective, emotional, and anxiety symptoms that accompany or facilitate the eating disorder symptoms.
TCPR: What happens inside a psychiatric unit like yours, that specializes in eating disorders? Dr. Schwartz: First of all, we have a very specialized team. It is probably one of the most integrated treatment approaches that I have seen anywhere in psychiatry. We have a psychiatrist specialized in eating disorder treatment, and an internist with expertise in nutrition and in managing the unique medical risks. We have therapists with specialized training, and psychologists who are experienced in the techniques that have been either shown to help or are promising to help with eating disorders. Generally all specialized units also have a dietician who works with the internist and/or the psychiatrist to help in the re-feeding process and also works with patients to challenge them a little bit with foods, and make sure they get adequate nutrition. It’s also important that the nurses and the psych techs be trained as well. All of these people may be eating meals with these patients, and there are a lot of discussions that are not appropriate at meals or even in between meals. Moreover, people with eating disorders have all kinds of sneaky and ritualistic behaviors around food, so we train staff to be able to recognize them. We have people who hide food in their sleeves or hide it under the table. Some have specific behaviors like cutting the food into little pieces and eating really slowly. Others will find ways to purge food, so supervision is necessary. There are some behavioral modifications that we put into place that help normalize their eating behaviors.
TCPR: Can you describe your psychotherapeutic approach to treating an eating disorder? Dr. Schwartz: Particularly for adolescents, there has been a lot of research recently into the Maudsley Model, which has been shown to have better results than other family therapies and individual therapy. This model was developed in England and has been studied primarily in adolescents with anorexia nervosa. The treatment is family-based and focuses on training the parents in specific techniques that are very useful in re-feeding their kids. The therapy starts off with what people call “the funeral session.” It helps families realize the severity of the disease, and recognize that even though patients are supposed to be going through the process of separation and individuation, they first need to be able to feed themselves, and if they can’t, the parents have to step in and take over.
TCPR: It must be difficult for patients to hand over power to their parents? Dr. Schwartz: It is. Patients generally do not like it, but at the same time the recovery rates are much better with this approach. Even though starving actually helps reduce the anorexic’s anxiety and helps her feel better, if she is trying to individuate and exert her independence like that, it is severely pathological. After they are re-fed, then they can do the work of separating in other healthy ways. But neuroplasticity is so reduced in someone with anorexia when they are in the starvation state that therapy is not as effective. They become much more rigid and inflexible in their thinking.
TCPR: What else are we learning about the biology of eating disorders? Dr. Schwartz: At this point we cannot predict who is going to get anorexia nervosa with brain scans, although we can certainly identify temperamentally and historically who might be at risk. One marker is on the receptor level. Some people with anorexia have increased 5-HT1a binding potential and lower 5-HT2a binding potential, and that imbalance actually makes them predisposed to being more anxious, more perfectionistic (Kaye WH et al, Nat Rev Neurosci 2009;10(8):573–584). Interestingly, food produces anxiety in people with anorexia nervosa. For most people food produces a pleasure response due to increased dopamine in the nucleus accumbens. For patients with anorexia nervosa the increase in dopamine is felt as anxiety, so they actually get aversive reactions to food (Bailer UF et al, Int J Eat Disord 2012;45(2):263–271). This is made even stronger by the higher cortical regions telling them that being thin is better. And so it abnormally overpowers the hunger that someone without an eating disorder who is starving would feel.
TCPR: When treating a patient in an inpatient setting, how do you know that a patient is safe enough to go home? Dr. Schwartz: Unfortunately, managed care often dictates when patients leave the hospital, and they sometimes have different criteria than our internists, pediatricians, or psychiatrists. In general, to leave an inpatient level of care I would expect patients to be able to pick out their own meals in a weight-restoring direction, and demonstrate fewer of the compulsive, ritualistic behaviors around food. Many times we step them down to day treatment, which is a more cost-effective treatment when patients are a little bit more stable psychiatrically and medically. They still have most of their meals monitored and given to them on site and they participate in a structured day treatment. The question basically comes down to: do we think that they can manage at that level of care? We take into account vital signs, of course, but also weight. When they are below 80% of expected weight, it is often extremely hard for people to put on weight in an outpatient setting. Also, we consider the associated compulsive exercise and purging behaviors and any other psychiatric co-morbidity, and make sure these are under control.
TCPR: What are some good resources to find centers that might take patients? Where can patients be referred on a national basis? Dr. Schwartz:EDreferrals.com and the NEDA website (bit.ly/d13iNf) are good educational sites, with links to providers and treatment centers nationwide. Our department’s website at http://eatingdisorders.ucsd.edu also contains a list of helpful resources for professionals and patients.