Outpatient with Underweight Symptoms (Trigger Warning)
Weight is a sensitive and complex topic, particularly when addressing low weight or disordered eating issues like anorexia nervosa (AN), which is one of the most severe psych-medical disorders. While psych providers don’t directly treat obesity or overweight, these issues may arise as side effects or be linked to disorders like stress-eating, requiring mindful consideration, especially in children –about weight gain in kids. AN, however, presents unique challenges due to its association with malnutrition, denial, and resistance to treatment, often necessitating specialized care or hospitalization. This disorder has the highest mortality rate among eating disorders, largely due to complications such as starvation, suicidal ideation, or cardiac issues, making early recognition and intervention a critical priority. It’s also a triggering word (TW)/topic so it’ll just be abbreviating it with AN. Quick facts:
- It mainly affects teenage girls (10:1 female to male ratio), common with sports involving smaller frames e.g. ballet, cheerleading, running, gymnastics.
- Psychodynamic theories include a struggle to gain control, strict parents, and parental enmeshments.
Differential Diagnosis: Medical conditions that may mimic an eating disorder include endocrine conditions (e.g. diabetes mellitus, hyperthyroidism), GI (e.g., malabsorption, IBS), genetic (Tuner syndrome, Gaucher disease), cancer, AIDS.
AN Case Study
SB, a 15-year-old female, is being evaluated for increased restrictive eating behaviors following two seizures in recent months, despite no prior seizure disorder diagnosis. She weighs 93 lbs at 4’11”, though her mother reports a recent 10-pound weight loss and suspects she may weigh less due to wearing baggy clothing. SB denies concerns about her weight, attributing her size to always being small, and claims she vomits due to nervousness about school and tests. Despite her denial of issues, her mother notes concerning symptoms, including thinning hair, poor sleep, depression, and a lack of menstruation. SB admits to eating minimally—often just a small snack daily—and is refusing treatment but has agreed to attend weekly appointments.
Plan of Care
- Assess the risk of harm: The risk of harm in this case is classified as severe, given the presence of multiple seizures, significant physical health issues (thinning hair, weight loss, vomiting, and amenorrhea), and the impact of depression and stress, with denial exacerbating the situation. The symptoms, coupled with the high risk of harm, warrant frequent follow-ups and proactive care to prevent further deterioration. There is a critical need to prioritize intervention before the situation progresses to hospitalization, as dismissing the severity based on functional status alone can lead to delayed treatment. This highlights the limitations of spectrum-based assessments and underscores the value of grading severity for more targeted care. Sidebar: some people may say that since she’s not in a hospital bed or still functioning it shouldn’t be severe, but I’m being overly cautious -let’s NOT wait until a person is in the hospital to prioritize.
- Provide clear and firm guidance: Since SB is refusing treatment, establish clear rules i.e. -if she loses more than 2 lbs per week or vomits, labs must be ordered to assess her condition. Emphasize to the parent that while education and monitoring can address the risks of seizures and cardiac complications, compliance from SB is crucial. If the patient was cooperative, labs should have been conducted during the initial visits to evaluate potential complications and ensure safety before initiating any medication. What to write on the prescription pad/order:
- DX F50.1; R 63.6 -EKG r/o arrhythmia, prolonged QTc, bradycardia
- DX F50.1; R 63.6 -CBC w/differential; CMP; TSH; Free T4; magnesium level; amylase; prealbumin; UA; lipid panel; phosphorus level
- Keep Educating/Monitoring: During the next visit, SB declined an SSRI but agreed to try olanzapine to address sleep and mood concerns. Moving forward, it is essential to provide ongoing education during each visit, emphasizing the risks associated with seizures and to the heart. Thankfully, SB has not experienced any additional weight loss since the last appointment, but continue highlighting the importance of monitoring and addressing this concern as part of her care plan.
The mother called in between sessions and reported that SB initially showed improvement in sleep and mood after starting olanzapine, but experienced another seizure, leading to hospitalization. Following evaluation, the neurologist discontinued olanzapine, prescribed seizure medications, and advised using low-dose melatonin for restlessness. Subsequently, the mother expressed concern about SB’s increasing depression, and her continued restrictive eating behaviors. Additional notes:
- Food is the best medicine: it became evident that fostering better eating habits was critical. Despite SB’s resistance to mental health treatment and psych medications, ensuring she consumed any food—healthy or not—was prioritized to avoid the weight loss risks exacerbated by mood instability.
- All hands on deck: the care team and the family should be stern about correcting the behaviors. Avoid jokes, mix messages, sarcasm, arguments, etc. Focus on goals and educating. Emphasized a unified, assertive approach to confront the serious consequences of her condition, including potential hospitalization and social setbacks.
- D/C from NP care (focus on the therapy): SB was adamant about not being on psych medications but I told the mother to call if she reconsiders. She only took meds the first week and the weekly follow-ups were mainly for educating/monitoring. She ultimately continued to adhere with therapy and was using an app Recovery Record, which really help SB improve the dietary intake with structured guidance.
A Reflection
- Gap in Care and the Importance of Early Intervention: This patient has been seeing the therapist for about a year but since her symptoms were getting worse, they wanted a psych eval when in actuality, she should’ve seen a provider way sooner. I noted this gap because technically I have to cover my bases but I usually chart how other staff members are involved. My only point is how there was a lapse of care or a seizure disorder could’ve been avoided and documenting the lack of formal treatment also has to be noted.
- Focus on Education and Monitoring: Follow-ups prioritized educating the patient about the severity of a seizure disorder, emphasizing risks like brain damage, driving restrictions, and the demands of care. Whether she took my prescribed medications or not wasn’t the issue. I knew she wasn’t understanding the gravity of the situation so the appointments turned into stern discussions to address the patient lack of understanding and to deter worsening issues.
- Consideration of Escalation: If educational and monitoring efforts fail, petitioning for higher-acuity treatment is a potential next step. I would’ve explain to parents that the petition may include something like a harm to self via an eating disorder even if the patient denies being suicidal. It’s controversial but it’s that serious.. This approach, while it’s the last resort, would prioritize life-saving measures, including inpatient lab monitoring and addressing harm risks associated with the eating disorder, even in the absence of explicit suicidality.
Lastly, it’s important NOT to override the neurologist’s expertise. Olanzapine has shown benefits for AN and, at a low dose like 2.5mg that I prescribed, can support mood and rest without significant risks, etc. it doesn’t matter…do NOT undermine the neurologist or risk another seizure. Prioritizing safety and avoiding further seizures is crucial. Advocating for teamwork and continuous education among healthcare providers is essential to minimize complications, even if it means thoughtfully challenging conventional practices within safe and informed boundaries.
Additional DSM-5 information and resources -PMHealth NP
