developing a multidisciplinary eating disorder treatment team in a university setting aimee daigle,...
TRANSCRIPT
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Developing a Multidisciplinary Developing a Multidisciplinary Eating Disorder Treatment Team Eating Disorder Treatment Team
in a University Settingin a University SettingAimee Daigle, FNP | Jennifer Gilkes, MDAimee Daigle, FNP | Jennifer Gilkes, MD
Vanessa Richard, RD, LDN | Rachel Stokes, PsyDVanessa Richard, RD, LDN | Rachel Stokes, PsyD
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Objectives
1. Define the role, function and value of a multidisciplinary eating disorder treatment team in a university setting.
2. Discuss “how-to” skills for developing and implementing an eating disorder treatment program within a university setting.
3. Identify the key components of a multidisciplinary eating disorder treatment team.
4. Discuss ways to increase treatment effectiveness and measure treatment outcomes.
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ROLE, FUNCTION, AND VALUEROLE, FUNCTION, AND VALUE
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Role, Function, and Value
• Evaluate and Assess– Students are often identified in various
departments on campus and referred to the treatment team• Administration• Faculty/Staff• Residential Life• Sorority/Fraternity
– Self-referrals
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Role, Function, and Value
• Provide Treatment and Referrals– Provide outpatient treatment services – Provide referrals for community care– Provide support for clients navigating the
university and/or healthcare system• Ex. withdrawing from classes, leaving housing,
enrollment, disability services, health insurance/reimbursement assistance
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Role, Function, and Value
• Financial Value of Treatment– Estimated Treatment Cost• 1 year of community outpatient treatment
– Out of Pocket: $7,000-10,000– With Insurance: $1,400-2,000
» Assuming 80% coverage
• 1 year of LSU Student Health Fees – $390 (Fall, Spring, Summer fees combined)
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HOW TO DEVELOP A TREATMENT HOW TO DEVELOP A TREATMENT TEAMTEAM
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“How-to” Skills
1. Solicit Administrative Support from Key Departments
• Ex. counseling center, medical clinic, health promotion
2. Determine which Treatment Components will be Provided
• Individual /Group Therapy• Nutrition Counseling• Medical Treatment• Psychiatric Treatment• Case Management• Exercise Monitoring
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“How-to” Skills
3. Find and Establish Working Relationships with Providers– Creating a working relationship between core
treatment providers is vital in successfully building a treatment team• Within a Student Health Center• Across campus• Community providers/resources
– Establish a strong, frequent communication pattern between providers
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“How-to” Skills
4. Schedule Time for Interdisciplinary Meetings– Treatment Team Meetings• Weekly consultation/review for providers participating
in the team• Weekly to biweekly phone /email consultation with
community providers• Documentation of review for charting purposes
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“How-to” Skills
4. Schedule Time for Interdisciplinary Meetings– Client Staffing Meetings• All providers and client in attendance• Held once per semester or as needed• Aids in multifaceted treatment planning• Provides continuity of care• Additional way to track progress• Gives the client a voice in treatment• Opportunity for family and/or partner to attend
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“How-to” Skills
5. Determine Types of Documentation – Treatment Contract– Evaluation/Assessment Forms– Staffing Reviews/Reports– Treatment Team Meeting Reviews– Assessment Measure– Treatment Plan
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“How-to” Skills
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“How-to” Skills
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“How-to” Skills
6. Create a Policies and Procedures Manual– Purpose:• Establishes the scope of practice of the treatment
program/boundaries• Rely on policies/procedures when higher level of care is
needed and/or noncompliance issues• Helpful for risk management purposes
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“How-to” Skills
6. Create a Policy and Procedures Manual– Essential Components • Establish the central goal of the treatment program• Identify core procedures to meet identified goals• Identify type of documentation and where
documentation will be stored (EMR vs. paper chart)– Helpful Hints • Consult with peer institutions with established teams• Adapt to meet the needs and constraints of your
resources
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“How-to” Skills
7. Designate Case Management Services– For individuals with complex needs– Can be provided by existing team members or
dedicated case manager– Examples:• Client is without health insurance• Referral to community providers or higher level of care• Intensive medical services
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“How-to” Skills
8. Advertise the Treatment Program– Freshman orientation– Campus-wide outreach– Brochures/literature stands – Student Health Center website
9. Develop Campus Wide Relationships– Communication with campus partners,
administrators, faculty and staff
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“How-to” Skills
10. Create a Referral Base– Self referrals– Parent, partner, family and friend referrals– Administrative referrals (mandated)• Expectations must be clear about ongoing
communication with administrative referrals• Ex-residence hall disturbances
– Faculty/Staff referrals
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“How-to” Skills
11. Define the Community Referral Process – Partial treatment by community provider– Referral for higher level of care or alternative
treatment• Outpatient Treatment Providers• Intensive Outpatient Program• Partial Hospitalization Program• Residential Treatment Program• Medical Stabilization/Inpatient Hospitalization
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KEY COMPONENTS OF A KEY COMPONENTS OF A TREATMENT TEAMTREATMENT TEAM
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Key Components of a Treatment Team
• Psychological Evaluation and Treatment• Nutritional Evaluation and Treatment• Medical Evaluation and Treatment• Psychiatric Evaluation and Treatment
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Psychological Evaluation and Treatment
• Evaluation• Severity of symptoms (outpatient vs. residential
treatment)• Emotional functioning and comorbidity
• Empirically Supported Treatment Approaches• Cognitive Behavioral Therapy• Interpersonal Therapy• Dialectical Behavior Therapy• Short-term Psychodynamic Therapy• Integrative Approaches
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Psychological Evaluation and Treatment
• Beginning Stage: Building trust, providing psychoeducation, and establishing treatment parameters
• Weekly /biweekly therapy• Building a positive therapeutic relationship• Assessing key features of the eating disorder and
individual needs• Providing education about the effects of disordered
eating patterns• Enhancing motivation for change
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Psychological Evaluation and Treatment
• Mid Stage: Changing beliefs related to food/weight/body and broadening the scope of therapy
• Identifying dysfunctional thoughts, schemes, and thinking patterns and developing cognitive restructuring skills• Developing a sense of self without the ED• Focus on interpersonal relationship patterns• Reframing relapses
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Psychological Evaluation and Treatment
• Ending Stage: Preventing relapse and preparing for termination
• Summarizing progress• Summarizing areas of continued vulnerability• Clarifying when to return to treatment
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Nutritional Evaluation and Treatment
• Role of the Registered Dietitian– Provide nutrition education and counseling• Bridges therapeutic and medical components
– Addresses the “surface” issues• Eating and exercise behaviors, symptom usage
• Expertise in disordered eating is preferred– Strong counseling skills– Often met with resistance
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Nutritional Evaluation and Treatment
• Appointment Frequency– Weekly to biweekly follow up • less frequent over time
• Primary Goals– Weight stabilization– Nutrition restoration– Reducing symptom usage– Improvement in relationship with food and body
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Nutritional Evaluation and Treatment
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Medical Evaluation and Treatment
• Role of Medical Clinician– Assess and treat any medical complications that
result from eating disorder– May or may not be first point of contact– Educate medical staff on early recognition
of/screening for EDs– Liaison between medical clinic, treatment team
and involved outside providers (if indicated)– Educate the patient/client
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Medical Evaluation and Treatment
• Initial History and Physical– Schedule adequate time—trust, rapport building– Establish documentation/templates— to assure
comprehensive exam, “queue questions” for essential information
– Rule out other physical causes for symptoms• GI disorders, infectious/autoimmune disease, primary endocrine
disorders, neurological disorder/disease– Determine physical impact/severity of disorder to date– Determine necessitation for immediate medical
intervention/hospitalization for medical stabilization– Establish if specialty referrals are indicated– Develop medical goals, treatment plan, follow-up schedule– Educate patient regarding medical needs/complications
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Medical Evaluation and Treatment• Eating Disorder History
• Age of onset, longevity of ED• Weight history --loss/change/amount• “Typical day”—eating habits, hydration, exercise, caffeine
use, supplements, alcohol/tobacco use, sleep, bowel habits/patterns
• Compensatory behavior history--such as restriction, binge, purge, laxatives, diet pills, supplements, substance use/abuse, exercise
• Family history and psychosocial history—FMH EDs, substance abuse, support systems
• Medical /surgical /psychiatric history—medications, hospitalizations/dates
• Known medical co morbidities
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Medical Evaluation and TreatmentReview of Systems
General -fatigue, malaise
Neuro/Psychological -seizures -decreased LOC/memory/concentration -fainting/syncope -anxiety/depression/insomnia -suicidal ideation
HEENT -oral/dental concerns/hoarseness -swollen glands
Respiratory/Cardiovascular -SOB/activity intolerance -CP/palpitations -swelling
G/I -epigastric/abdominal pain/reflux -bloating/fullness -vomiting/hematemesis -constipation/diarrhea -rectal bleeding/hemorrhoids
Endocrine -menstrual irregularities -libido changes
Musculoskeletal/Dermatological -back/limb pain -bruising -slow healing -hair loss/lanugo
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Medical Evaluation and TreatmentPhysical Exam
Weight/BMI -assure accuracy/consistency -consider patient concerns
Vitals -bradycardia -orthostatic changes HR/BP
Temperature -hypothermia
HEENT -cachexia/facial wasting -hoarseness -dental/oral erosions -stomatitis -inflamed/infected salivary glands
Cardiovascular -murmur -MVP -poor perfusion
Gastrointestinal -decreased bowel sounds/tenderness -hemorrhoids
Musculoskeletal/Dermatological -bruising/skin discoloration -muscle wasting -lanugo (downy hair) -”Russell Sign”
Neurological/Psychological -flat affect -anxious/depressed affect -decreased LOC
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Medical Evaluation and Treatment LABS /Findings Other TestsCBC-anemia, pancytopenia,leukopenia
Metabolic Profile/Magnesium/Phos-hyper/hypoglycemia, hypokalemia, hypophophatemia, hyponatremia
Thyroid function studies-normal to low TSH, low T4
Estrogen/Testosterone-low estrogen/testosterone
Vitamin D-hypovitaminosis D
U/A-low SG
DEXA SCAN-decreased bone mineral density-indicated for longstanding ED or amenorrhea > 6 months
EKG (ECHO if indicated)-arrhythmias-prolonged QT interval-bradycardia
MRI/CT-neuro symptoms
Amylase, lipase, FSH/LH, fasting insulinGTT, 24 Urine CC
Note:-lipids elevated in malnutrition-use care in discussing with patient
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Medical Evaluation and Treatment• Medically Unstable/Requiring Immediate Hospitalization
– Establish guidelines/criteria for your institution– Key indications
– Cardiac problems/compromise– Unstable/abnormal symptomatic vitals signs
» CP, HR < 40, abnormal EKG/arrhythmias of concern– Symptomatic/marked electrolyte imbalances/lab abnormalities
» Hypokalemia, hypophosphatemia, marked hypoglycemia– GI bleed, obstruction, other GI concerns– Renal/hepatic compromise– EKG abnormalities– Dehydration– Severe malnutrition– Altered mental status– Suicidality– < 70% IBW, low BMI
– Use good clinical judgment (safety/do parents need to be contacted?)
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Medical Evaluation and Treatment
• Key Reminders– Eating disorders affect every system in the body– Weight is NOT the only clinical marker of an ED– An ED can occur with NO obvious physical signs or symptoms– Underweight, normal, and overweight patients can still have
nutritional deficiencies– Labs are generally normal, don’t be fooled—however, abnormal labs
can assist with residential admission criteria– Medical consequences of EDs can go unrecognized even by
experienced clinicians– Medications should be targeted on treatment of comorbid conditions– Medications should NOT be used as a substitute for
nutritional/behavioral recovery– Keep medical visits to the minimum required to reduce blame of
symptoms on a physical cause if ruled out
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Medical Evaluation and Treatment
• Useful Links for Medical Providers
– Diagnosis of Eating Disorders in Primary Carehttp://www.aafp.org/afp/2003/0115/p297.html
– Clinical Report—Identification and management of Eating Disorders in Children and Adolescents—American Academy of Pediatricshttp://pediatrics.aappublications.org/content/126/6/1240.full.pdf+html
– Critical Points for Early Recognition and Medical Risk management in the Care of Individuals with Eating Disordershttp://www.aedweb.org/AM/Template.cfm?Section=Medical_Care_Standards&Template=/CM/ContentDisplay.cfm&ContentID=2413
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Psychiatry and College EDTT• First Evaluation– Establish therapeutic alliance– Diagnose and treat co-occurring illness– Make predictions about illness– Psycho-education– Determine best treatment setting
• Subsequent Appointments– Monitor response to medication– Monitor eating disorder symptoms and behaviors– Collaborate with other providers– Assess/monitor psychiatric status and safety
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Therapeutic Alliance for Eating Disorders
• Reduces drop out risk • The clinician should:– Be curious– Welcome the client– Give assurance/support– Praise/validate (hard work and courage)
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Determine Appropriate Treatment Setting
• Anorexia– Outpatient– Intensive outpatient (part-day outpatient care)– Partial hospitalization (full-day outpatient care)– Residential treatment center– Inpatient hospitalization (either on a medical unit
for acute stability of physical concerns or on a psychiatric ward)
• Bulimia, Binge Eating and EDNOS– Outpatient treatment services
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Co-occurring Illnesses in Eating Disorders
• Diagnose and treat co-occurring illness– Many with bulimia or anorexia suffer from clinical
depression, anxiety, obsessive-compulsive disorder, substance abuse, and other psychiatric illnesses
– Bulimia is associated with Diabetes I – Binge eating disorder is associated with Diabetes II
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Psychiatric Evaluation and Treatment
• Make predictions about illness– Poor Outcomes: Anorexia
• Very low BMI• Family conflict or dysfunction• Long duration of illness• Comorbid psychiatric or personality disorders• Vomiting or laxative abuse
– Good Outcomes: Anorexia• Absence of severe weight loss• Absence of serious medical complications• Good social support• Absence of drug abuse
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Psychotropic Medication
• SSRI’s– Fluoxetine
• Serotonin-norepinephrine re-uptake inhibitors– Venlafaxine– Desvenlafaxine– Duloxetine
• Bupropion (FDA black box warning for use in ED due to increased risks of seizures)
• TCA’s and MAOI’s (generally avoided)• Mood Stabilizers
– Anti-seizure meds– Second Generation Antipsychotics– Lithium (generally avoided in bulimia)
• Benzodiazepines (generally avoided)
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FDA Approved Medications for Anorexia
• There are NONE!– Use medication with caution for comorbid
conditions such as depressive or obsessive–compulsive features• Depression, anxiety and obsessions may resolve with
weight gain alone• Students with anorexia may be more sensitive to side
effects
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Psychiatric Evaluation and Treatment
• Why medications may not work with this population– Anorexia as a self perpetuating illness:• Severe weight loss • Leads to loss of white and grey matter of the brain• Decreased neurotransmitters and proteins• Decreased metabolic rate• Abnormalities in cognitive dysfunction• GI abnormalities that lead to early fullness, decreased
gastric motility, constipation, and abdominal distention
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Psychiatric Evaluation and Treatment
• FDA approved medications for Bulimia, Binge Eating and EDNOS– Fluoxetine (60mg) is FDA approved for Bulimia
Nervosa– No medications are FDA approved for Binge Eating
Disorder or EDNOS
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TREATMENT EFFECTIVENESS AND TREATMENT EFFECTIVENESS AND OUTCOME MEASUREMENT OUTCOME MEASUREMENT
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Treatment Effectiveness and Outcome Measurement
• Objective Measures– Physical
• Vitals• Labs• Weight/BMI
– Psychological and Behavioral Measures• Nutrition Analysis of Food Intake• Psychological Measures
– Eating Disorder Inventory – 3 (EDI-3);– Eating Disorders Examination (EDE);– Eating Disorders Examination-Questionnaire (EDE-Q)
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Treatment Effectiveness and Outcome Measurement
• Subjective Measures– Client self-report and food journals– Provider report and observation– Treatment team meetings– Client staffing meetings
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Treatment Effectiveness and Outcome Measurement
LSU DataFemale 96%Male 4%
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Treatment Effectiveness and Outcome Measurement
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Treatment Effectiveness and Outcome Measurement
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Treatment Effectiveness and Outcome Measurement
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Treatment Effectiveness and Outcome Measurement
Initial EDI-3 Assessment (M=46.74, SD=10.69) and Final EDI-3 Assessment (M=36.06, SD=9.47); t(31)=5.47, p <.001
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ChallengesAdministrative Challenges• Gaining administrative support• Limited sessions or services
through the team• Limited community referral
options• Cohesiveness within the
treatment team• Communication with
community providers• Confidentiality vs. university
notification • Record keeping• Absent treatment team
member
Client Challenges• Clients with limited
resources needing a higher level of care– Lacking insurance, family
support, financial resources
• Clients noncompliant with recommendations
• Autonomy vs. communication with family members– Family out of town– Family involvement
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Conclusion
• Recovery from an eating disorder is life changing for the student
• Participation in an interdisciplinary treatment program offers– Increased graduation rates– Increased treatment compliance – Provides a support system– Reduced burnout for clinicians
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Helpful Websites• National Eating Disorders Association
www.nationaleatingdisorders.org• National Institute of Mental Health
www.nimh.nih.gov/health/topics/eating-disorders/index.shtml• Academy for Eating Disorders
www.aedweb.org• International Association of Eating Disorder Professionals
www.iadep.com• GURZE Books
www.gurze.com• Something Fishy-Website on Eating Disorders
www.something-fishy.org
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ReferencesAcademy for Eating Disorders: Clinical Practice Recommendations for Residential and Inpatient Eating Disorder Programs (2012).
American College Health Association, National College Health Assessment: Reference Group Data Report. 2011, American College Health Association: Linthicum, MD. Bachner-Melman, R., Zohar, A, Ebstein, R, et.al. 2006. How Anorexic-like are the Symptom and Personality Profiles of Aesthetic Athletes? Medicine & Science in Sports & Exercise 38 No 4. 628-636. Cafri, G., Olivardia, R and J.K. Thompson, Symptom characteristics and psychiatric comorbidity among males with muscle dysmorphia. Comprehensive psychiatry, 2008. 49(4): p. 374-379. Carlat, D.J., Camargo. Review of Bulimia Nervosa in Males. American Journal of Psychiatry, 154, 1997. Crow, S.J., Peterson, C.B., Swanson, S.A., Raymond, N.C., Specker, S., Eckert, E.D., Mitchell, J.E. (2009) Increased mortality in bulimia nervosa and other eating disorders. American Journal of Psychiatry 166, 1342-1346.
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ReferencesEating disorders on the college campus: A national survey of programs and resources. February 2013. National Eating Disorders Association website. Retrieved May 10, 2013, from http://www.nationaleatingdisorders.org/sites/default/files/CollegeSurvey/CollegiateSurveyProject.pdf Fairburn, C.G. (2008). Cognitive Behavior Therapy and Eating Disorders. New York: Guildford Press
Garner, D.M., & Garfinkel, P.E. (1997). Handbook of treatment for eating disorders (2nd ed.). New York: Guilford Press
Hudson, J.I., et al., The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biological Psychiatry, 2007. 61(3): p. 348-358. Javaras KN, Pope HG, Lalonde JK, Roberts JL, Nillni YI, Laird NM, Bulik CM, Crow SJ, McElroy SL, Walsh BT, Tsuang MT, Rosenthal NR, Hudson JI. Co-occurrence of binge eating disorder with psychiatric and medical disorders. J Clin Psychiatry. 2008. 69(2): p.266-73. McFarland, M.B. and P.L. Kaminski, Men, muscles, and mood: The relationship between self-concept, dysphoria, and body image disturbances. Eating behaviors, 2009. 10(1): p. 68-70.
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ReferencesMellin, L., McNutt, S., Hu, Y., Schreiber, G.B., Crawford, P., & Obarzanek, E. (1991). A longitudinal study of the dietary practices of black and white girls 9 and 10 years old at enrollment: The NHLBI growth and health study. Journal of Adolescent Health, 23-37. Merikangas KR, He J, Burstein M, Swanson SA, Avenevoli S, Cui L, Benjet C, Georgiades K, Swendsen J. Lifetime prevalence of mental disorders in U.S. adolescents: Results from the National Comorbidity Study-Adolescent Supplement (NCS-A). J Am Acad Child Adolesc Psychiatry. 2010 Oct;49(10):980-989. National Institute of Mental Health (NIMH) guide: Eating Disorders. (2011). Retrieved May 10,2013 from http://www.nimh.nih.gov/health/publications/eating-disorders/index.shtml Nelson, D. L., Castonguay, L. G. and Locke, B. D. (2011), Challenging Stereotypes of Eating and Body Image Concerns Among College Students: Implications for Diagnosis and Treatment of Diverse Populations. Jnl of College Counseling, 14: 158–172. Noordenbox, Greta. Treatment of Patients with Chronic Eating Disorders. International Journal of Eating Disorders, Volume 10: 15-29, 2002. Olivardia, R., et al., Biceps and Body Image: The Relationship Between Muscularity and Self-Esteem, Depression, and Eating Disorder Symptoms. Psychology of Men & Masculinity, 2004. 5(2): p. 112. Fine, Sari. A team approach to eating disorders treatment. June 2008. Retrieved May 10, 2013, from http://www.eatingdisordersblogs.com/treatment_notes/2008/06/a-team-approach.html Sullivan, Patrick. F., Mortality in Anorexia Nervosa. American Journal of Psychiatry, 152 (7), July 1995, 1073-1074.
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ReferencesShisslak, C.M., Crago, M., & Estes, L.S. (1995). The spectrum of eating disturbances. International Journal of Eating Disorders, 18 (3), 209219. Statistics: Eating Disorders and Their Precursors. National Eating Disorders Association website. Retrieved January 10, 2013, from http://www.nationaleatingdisorders.org/uploads/statistics_tmp.pdf Sundgot-Borgen J, Torstveit MK. (2004). Prevalence of eating disorders in elite athletes is higher than in the general population. Clin J Sport Med., Jan;14(1):25-32. The Renfrew Center Foundation for Eating Disorders, “Eating Disorders 101 Guide: A Summary of Issues, Statistics and Resources,” 2003. U.S. Department of Health and Human Services, Office on Women’s Health. About Eating Disorders. (2010, September 22). Retrieved May 10, 2013 from http://www.womenshealth.gov Zivin, K., et al., Persistence of mental health problems and needs in a college student population. Journal of affective disorders, 2009. 117(3): p. 180-185. Zucker NL, Womble LG, Williamson DA, et al. Protective factors for eating disorders in female college athletes. Eat Disorders 1999; 7: 207-218.