Outpatient with Underweight Symptoms
Another sensitive topic that’s not easy to discuss, is a person dealing with too little or excessive weight. Psych providers don’t directly treat obesity or overweight, but of course, it can be a part of the side effects or a disorder (like stress-eating) so we have to be mindful of weight issues. About weight gain in kids. However, being intentionally underweight or having symptoms of anorexia nervosa (AN) is the most serious. see DSM-5 for eating disorders and resources. It’s also a trigger word/topic so I’ll just be abbreviating it with AN.
Typically these patients are either treated in a specialized facility or hospitalized, depending on the severity. This is related to the seriousness of malnutrition that requires a higher acuity of care. We, psych providers, want to avoid complications but you can easily get a patient with AN in your office though it’s rare. Thus, I’ll give you a case study that’s far from the textbooks.
In most Western societies, the issue is usually being overweight and you can assess or modify the medications, lifestyle, eating habits, etc. AN, however, is trickier and more concerning, in which the patient is usually in denial or not cooperative. But it has the highest mortality rate with disordered eating –Very Well Mind so it’s a serious priority. This is mainly related to starvation, SI, or heart issues.
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 is a 15y/o female and being seen for increased restrictive eating, she had 2 seizures in the last recent months and has never been diagnosed with a seizure disorder. She’s in the office with her mother and she denies weight issues, insists that she has always been small, the mother reports how she still vomits but SB expressed it’s due to being nervous about school and taking tests. SB is 93lbs and 4’11 but her mother reports that she lost 10 pounds in the last few months, she’s also wearing baggy clothes so she may weigh less than 93 lbs but her BMI is still okay. SB reports depression and poor sleep, and her hair is thinning but still intact. She doesn’t remember her last cycle. SB denies any issues and says she only eats until she’s full, which is only a bag of chips or something simple for the day. SB overall denies everything and is refusing treatment but agreed to do weekly appointments.
Plan of Care
- Assess the risk of harm: I would classify the risk and the disorder as severe; she had multiple seizures, her hair is thinning, significant weight loss, vomiting episodes, lacking her menses, and depression/stress is a factor but the main issue is the DENIAL. I honestly wish DSM can get away from “spectrums” and focus on grades or assigning a level of severity. According to the daughter’s symptoms, she may not even be diagnosed with an eating disorder if this was telehealth and the mother wasn’t involved. The risk of harm is high, especially since she’s already had a few seizures and this warrants frequent follow-ups. Side-note; 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.
- EDUCATE with tough love: since SB is refusing treatment she’s given an ultimatum that if she loses more than 2lbs/week and/or vomits, we need to get labs. Express to the mother that we can only monitor and educate about the seizure and cardiac risks. SB may not cooperate but if she was compliant, labs should be ordered on the initial visits for the sake of possible complications and before starting medications. 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: the next visit SB refused an SSRI but agreed to try olanzapine for sleep/mood so with every visit keep educating and focus on the seizure risks and weight. She has not lost any weight since the last visit.
The mother called and reports SB has been sleeping well and improving since starting the olanzapine but had another seizure and was hospitalized…After a few weeks, the neurologist d/c the olanzapine and reported how she can only have a low dose of melatonin and was started on seizure medications. The mother called again and express how SB is getting more depressed and concerned about her only eating junk food and still restricting her intake.
- Food is the best medicine: I have some parents that report how the child isn’t eating super healthy or eating just crap and losing weight because they won’t eat the “family” prepared meals… but any food, even junk food, is better than nothing. SB continues to refuse additional mental treatment plus her seizure medications can also negatively affect her mood so as the saying goes let them eat cake. We are also heading in this gray zone because as the teen refuses care, my options are more limited so let the teen eat ANYTHING.
- All hands on deck: SB clearly wants to be in control like most teenagers and I completely sympathize but her condition is serious and she needs to improve her eating habits. We don’t have many weight-gain programs
besides fast foodand with limited time, I needed the mother and everyone to get on the same page. I told the mother this is our last-ditch effort and start being harsh about the reality. No more being nice, constantly arguing/refusing, and having everything her way..etc. Talk about the reality of being hospitalized and losing friends and losing parts of her high school years and I also convinced the therapist to also be harsh. - D/C from NP care (focus on the therapy): SB was adamant about not being on any 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 just for educating/monitoring. She continued to do therapy and adhere to the seizure medications and has started gaining weight. The therapist has been using an app (I believe) Recovery Record, which really helped SB have that control but also improved her eating habits by linking/tracking them with the clinician.
Last Key Points
- 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 that could’ve been avoided and documenting the family refusal for labs and formal treatment also has to be noted.
- Continue the follow-ups to simply educate/monitor. SB like most typical teens doesn’t like being told what to do but the focus was educating about a seizure disorder. That was the gist of the appointments. She already had >3 seizures in the last few months. 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 tough love. Plus these talking points may deter worsening the eating disorder. Telling someone you can’t drive for at least a year, the side-effects of the antiepileptics are serious, and seizures can cause brain damage…etc. is definitely a wake-up call. Sidenote: this isn’t “up-coding” I’m treating this as monitoring a crisis situation and documenting it as a 99214 due to the complexity.
- If none of the above work then petitioning would’ve been the last resort. The person will get a higher acuity of treatment and labs/EKG can be more monitored. At a certain level, life-saving measures are truly involved and it wouldn’t be appropriate for outpatient. I sometimes explain to parents that the petition will have to be written as something like harm to self via an eating disorder even if the patient denies being suicidal. It’s controversial but it’s that serious.
Lastly, you don’t want to usurp the neurologist. Olanzapine has been studied with AN and was found to be helpful and at a low dose (2.5mg I prescribed), it shouldn’t have been a problem to help with her mood and rest. I’m not sure how melatonin affects seizures or brain activity, especially at a certain dose but it doesn’t matter…You don’t want to undermine the neurologist or risk another seizure.
Not saying other services and providers can’t be wrong but proceed with caution, collaborate, and continue to educate as needed. I usually work with a physician so again, work as a team to focus on avoiding the complications even if you have to push the boundaries.
