C-L Psychiatrists Help Distinguish Medical, Psychiatric Issues in Patients With Eating Disorders

Patients with eating disorders challenge inpatient teams with medical, psychological, and ethical complexities. Consultation-liaison (C-L) psychiatrists are often asked to decide who should lead the treatment team when a patient presents with severe medical and psychiatric problems and how to prioritize interventions.

This column will address two clinical issues commonly confronting C-L psychiatrists collaborating with other physicians in the treatment of eating disorders: How to deal with diagnostic “gray areas” between psychiatric and medical illnesses and how to effectively manage treatment team dynamics.

Case Study

Sarah is a 30-year-old woman with a history of posttraumatic stress disorder secondary to sexual trauma in adolescence and anorexia nervosa in high school requiring a year of treatment in an intensive outpatient program. Over the past year, Sarah’s family became worried when she dropped from 125 to 105 pounds with symptoms of fatigue, abdominal tenderness, diarrhea, and nausea. Sarah was diagnosed with Crohn’s disease after colonoscopy. Despite treatment with budesonide and mesalamine and eventually infliximab, she continued to complain of nausea and vomiting. She avoided food, saying it caused her pain.

Sarah was admitted to the hospital for failure to thrive; she had experienced a 25-lb weight loss (from an initial body mass index of 19 kg/m2 to a BMI of 15 kg/m2). She also had vitamin B1 and B12 deficiency and a decline in physical functioning. Though she had symptoms of a Crohn’s flare, her colonoscopy results suggested she was responding to treatment. Given her history of an eating disorder, C-L psychiatry was consulted to assess Sarah for current symptoms of an eating disorder.

During psychiatric examination, Sarah acknowledged her weight loss was medically risky, yet she said she was “finally happy” with her appearance. While initially sad about her diagnosis of Crohn’s disease, she could now justify skipping meals. Due to pressure from her family and doctors to eat, she began purging through vomiting for the last six months.

The C-L psychiatry team diagnosed Sarah with anorexia nervosa binge/purging type. While hospitalized, Sarah often refused oral intake, complaining of nausea, abdominal pain, and anxiety. Her family supported this refusal, accusing the medical team of being unsympathetic to Sarah’s pain. The medical team began avoiding family encounters. When Sarah felt pressured to eat, she refused to talk to her team. Given her progressive weight loss, the medical team proceeded with placement of a nasogastric tube for re-feeding. After 10 days of enteral feeding, she began to ask for oral nutrition. Once medically stable, she was transferred to an eating disorders inpatient unit.

Sarah’s case highlights important clinical issues that commonly arise at the interface of medical and psychiatric care.

Treatment Planning in the Face of Diagnostic Uncertainty

The first goal of an inpatient medical admission for patients with compromised nutritional status and problematic eating behaviors should be medical stabilization aimed at achieving adequate levels of nutrition. This is necessary for transition to less-intensive levels of care. C-L psychiatrists working with patients with diagnosed eating disorders in medical settings should prioritize nutritional intake as the primary “medicine.” In Sarah’s case, treatment focused on her vitamin deficiencies and metabolic abnormalities through collaboration with her nutritionist.

For patients with eating disorders, uncertainties may exist around which medical problems result from disordered eating behaviors and which result from other primary medical diagnoses. Sarah refused tube feeds based on symptoms she attributed to Crohn’s disease; patients with comorbid gastroparesis and restrictive eating might experience discomfort when eating. But patients with eating disorders can find creative reasons for refusing food. It can be difficult determining which of these issues is related to an eating disorder, to psychological responses to somatic discomfort stemming from anxiety and hypersensitivity, and/or to medical conditions.

Regardless, medical teams are obliged to provide nutrition, the primary goal of medical stabilization. Psychiatric teams can educate others with regard to psychological aspects of refeeding. Individuals with an eating disorder may find that a malnourished state can dull negative, unwanted emotions such as intense anxiety or depression. With refeeding, they may re-experience these emotions with greater intensity. The treatment team can help by proactively identifying their emotions and discussing coping strategies to help the patient tolerate distress that naturally ensues.

Once stabilized, more detailed assessments for psychiatric comorbidities, the utility of psychotropic medications, and ongoing treatment planning become prominent concerns.

Team Dynamics

Explicitly addressing interpersonal and group dynamics that unfold among treatment teams, patients, and families is important. Teams sometimes experience significant frustration when patients resist refeeding efforts. Patients sometimes feel misunderstood and victimized. Families may supportively mediate, sometimes enable, or sometimes act punitively with respect to patients. Disputes may arise within teams and/or within families.

The psychiatric treatment team needs to appraise each of the patient’s symptoms and the functions they may be serving for the patient and communicate these perspectives to medical teams. For example, some patients justify and take pride in their maladaptive eating behaviors because they are a form of psychological control and security. The thinking of some patients with eating disorders can border on the dangerously delusional, causing them to resist all attempts at refeeding, often with skilled deception.

The following recommendations can facilitate collaborative, patient-centered approaches for individuals with eating disorders:

• Identify the members of the treatment team. This includes the patient, primary medical team, pertinent specialists, nutritionists, nursing staff, and anyone in regular contact with the patient, including family members.

• Clearly delineate the shared goals, roles, and responsibilities of each team member early to prevent the treatment plan from being derailed by strong patient pushback. Plan regular treatment team meetings.

• Consider how the patient’s family and friends affect the patient’s treatment. Identify opportunities for psychoeducation about the eating disorder and how friends and family can support the patient during medical interventions. Meeting with the patient and family regularly can help align efforts.

• Disposition planning should start early and focus on appropriate subsequent levels of care, potentially including an eating disorders inpatient unit, intensive outpatient program, or partial hospitalization program.

In summary, Sarah’s case highlights the important roles of C-L psychiatrists in consultations for individuals with eating disorders. C-L psychiatrists can offer invaluable guidance for treatment planning even in the context of diagnostic uncertainty and expertise in working with members of the treatment team in complex medical and psychosocial circumstances. ■