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Addressing eating disorders earlier

March 25, 2013
by Gary A. Enos, Editor
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While eating disorders often begin manifesting in adolescence, formal treatment for many individuals frequently doesn’t occur until life-threatening circumstances compel action much later. A child and adolescent psychiatrist at Rogers Memorial Hospital in Wisconsin says that early and aggressive treatment often can make a huge difference in reducing the severe damage that can be caused by an eating disorder.

“We increasingly have become able to identify these problems earlier; there is more education in the school system,” says Tracey Cornella-Carlson, MD, medical director of Rogers Memorial’s child and adolescent eating disorder services.

Rogers offers adolescent eating disorder services that are somewhat uncommon in their intensity—it operates a specialized inpatient eating disorders unit for youths and also offers residential services for adolescent females and males (the young males are treated in the same program with adults, while the young females have their own separate residential program).

On the inpatient unit, youths are medically supervised and receive a broad-based menu of services that include cognitive-behavioral therapy, nutritional guidance, experiential therapies and family education.

Presenting issues

Body image issues are typically present in young people who are being treated for an eating disorder. Whether it’s the overweight male who has become a victim of bullying because of his size, or the young female taking extreme measures to become thinner, “Diet and weight loss become a way for them to gain control,” says Cornella-Carlson, one of three board-certified psychiatrists overseeing eating disorder programs at Rogers. She adds, “Eating disorder behaviors numb emotions.”

Perfectionism also is commonly seen in this population, and treatment at Rogers seeks to challenge that tendency directly. “We might tell a patient that she cannot make her bed in the next three days,” Cornella-Carlson says.

Comorbid mental health disorders also present frequently in the young population with eating disorders. Depression and anxiety are common and in many cases could be driving the eating disorder, Cornella-Carlson indicates.

Treatment team approach

Rogers staff believes numerous areas of expertise must be pooled in treatment because of the complex nature of an eating disorder and the high level of morbidity and mortality associated with the illness. According to a Rogers news release issued in February, the death rate from anorexia for young women ages 15 to 21 is 12 times higher than the death rate from all other causes.

Cornella-Carlson says primary care physicians often refer patients to Rogers’ higher-intensity units for treatment, while in other cases patients in Rogers’ outpatient programs will prove to need a higher level of service. Once in treatment, they will receive assistance from a broad-based treatment team that includes psychiatrists, therapists, experiential therapists and dietitians.

According to the Rogers news release, “The staff works with each patient to achieve nutritional stability, identify and correct errors in thinking, and address obstacles to recovery.” In addition, medication treatments often constitute an important element for individuals with comorbid depression or anxiety, Cornella-Carlson says.

Among the therapeutic techniques that have become more common in the treatment of eating disorders in recent years is Dialectical Behavior Therapy (DBT), which has traditionally been used in the treatment of borderline personality disorder and substance addictions. Distress tolerance tools have proven very useful in the treatment of eating disorders, Cornella-Carlson explains.

“A lot of the patients struggle with impulsivity—they need to stay in the moment,” she says. “We work on them riding the wave, and tolerating being in their own skin.”

Numerous experiential therapies offered as part of Rogers’ treatment program include art therapy and fitness work. Hands-on therapies are important in this population in order to convey that the body does not function merely with respect to its outward appearance to others.

A ropes course that is used in the program assists in team building. “The person will have to trust others,” Cornella-Carlson explains, “just as they need to trust others in the recovery process. For example, they’ll be working with a dietitian and they’re afraid to gain weight. They will have to understand that we’re not wanting to make them fat, but are focusing on their health.”

Financial challenges

Identifying an eating disorder early and therefore being in a position to treat it effectively has become even more important in an environment of tighter insurance coverage for treatment. Cornella-Carlson says families now bear more out-of-pocket costs for residential treatment than they did half a dozen years ago.

While at that time a typical residential stay ranged from 60 to 90 days, the program now typically sees a 30-to-60 day range, she says.

“Treatment has to be aggressive and effective,” Cornella-Carlson says. And this can pose challenges in that engaging the patient in treatment often takes time, and it is also critical early on to identify comorbid conditions that might be affecting the individual patient.

For many families, eating disorders treatment becomes very costly because problems can linger for years. “We like to catch it early,” Cornella-Carlson says.