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Welcome to PsychEd, the psychiatry podcast for medical learners by medical learners. This is the second episode of a two-part series on the topic of eating disorders. In part one, we discussed the diagnosis, initial assessment, predisposing factors, explanatory models, and medical complications of eating disorders.
In part two, we'll explore the treatment of eating disorders. The learning objectives for this episode are as follows. One, outline the management of eating disorders using a biopsychosocial framework.
Two, identify the indications for various levels of care. Three, understand the ethical and medical legal dilemmas that may arise in treatment of eating disorders. And four, consider the treatment of special populations.
Hi, podcast listeners, this is Dr. Lucy Chen. We're back for part two of our eating disorders episode with Dr. Randy Staab. And we still got Nikhita and Vanessa with us for this episode as well. So I guess just to segue into the next part of the interview where Dr. Staab, we're going to get into, I guess, the treatment of eating disorders.
Sure.
Maybe generally, can you give us a little bit of like, I guess, maybe a general approach to what eating disorders treatment looks like?
Sure. I mean, the treatment of eating disorders is complex and multifaceted, right? And it involves nutrition, psychotherapy, skills acquisition, education, medical monitoring, and definitely medications can play an important role as well.
But they're definitely not the main focus necessarily of treatment. I always tell patients that the most important medication that they can take is food, right? So having a balanced diet with a regular breakfast, regular lunch, regular dinner, regular snacks.
That's the most important thing that they can do is kind of establish a healthy meal plan with adequate calories and good nutrition, with good balance and variety is the most important step that they can do. And early diagnosis and intervention definitely enhances recovery. And treatment can often, often needs to be kind of longer term, as there's no sort of quick fixes often for eating disorder recovery, right?
These are sort of more, we kind of take more of a rehabilitation model. Looking at eating disorder recovery, kind of like substance abuse recovery, it does take time. And these are complex illnesses.
So, you know, longer term compassionate support throughout the treatment process is essential.
Yeah, thanks for that, Dr. Staab. And, you know, I guess in terms of treatment approaches, right? Like, I've done like a grand rounds on reviewing the nine international sort of evidence-based clinical treatment guidelines around the world.
So there's definitely several approaches. What's the approach that you typically tend to practice on your unit?
So we kind of take like the best practice guidelines, you know, from Europe, from the APA, from the American Psychiatric Association. There are some Canadian guidelines from BC, some provincial guidelines, and we kind of take, you know, bits and pieces from all of them. They're similar.
They're not identical, but there's mostly a lot of similarities between them. So, you know, the overarching themes are, you know, nutrition rehabilitation, right? Which for people with bleeding nervosa involves, you know, obviously, you know, proper breakfast, lunch, dinner, snacks involving adequate calories and good balance and variety.
And for anorexia nervosa, again, well-balanced meals. However, their calories do need to be increased to support weight gain. And the literature does support a more sort of rapid refeeding approach.
Not as conservative or slow that may have been advocated, let's say, you know, five or ten years ago in the nutrition rehabilitation with anorexia nervosa. So we are proceeding a bit more quickly than we would have, let's say, ten years ago in the field. People with anorexia nervosa, because they're underweight, their metabolisms often get revved up in treatment and they have a lot of repair work that their bodies need to do.
You know, they need to repair their heart and their kidney and their organs and their bones and their muscles. So they often need to go on higher calories than the average person would need. So we start off at a lower rate and then often we bring them up to at least about 2800 calories or 3000 calories by about three weeks.
If patients are not able to complete their meals in a program or in a residential setting or day hospital setting, then we do ask that they complete a liquid nutritional supplement to kind of make up for the calories. Because they're main, like I said before, their main treatment, their main food, their main medication, especially in the early days, is definitely food and nutrition.
I guess we often think in psychiatry of this biological, psychological, and social approach and thinking about those different aspects. So it sounds like the nutritional rehabilitation is really key from that biological perspective.
Very much so, yeah. So again, without the nutrition, you know, without the biology and nutrition, then the psychological and the social are probably not going to, you're not going to get very far, right? So people who have very poor nutrition who are underweight and malnourished do not respond well to antidepressants or other medications as well.
So there's actually no FDA approved medications for the treatment of anorexia nervosa to date. However, medications can sometimes be helpful to treat the comorbid conditions that frequently go along with anorexia nervosa. So, you know, antidepressants or low doses of neuroleptics can help to treat, you know, comorbid depressions or anxiety disorders, PTSD, you know, panic disorder, generalized anxiety disorder, things like that.
But they tend not to work very well when people are really malnourished and underweight because the components, the building blocks for SSRIs to work comes from food, right? People need to have enough tryptophan in their diet and in their brains for those medications to actually work.
Dr. Staab, what about the use of, you know, sometimes atypical antipsychotics for weight gain or some of the obsessionality in anorexia?
So, yeah, we are, we are, we definitely use those quite a bit. You know, people with eating disorders often have a lot of anxiety around food and meals and social situations and gatherings and, you know, eating new foods and around body image and things like that. So we often use small doses of atypical neuroleptics.
So things like, you know, risperidone or Seroquel or Zyprexa can be used, you know, in the short term, kind of around meal times or in the evening to help with their sleep and their anxiety. And it can help with some of that very rigid kind of black and white, you know, distorted thinking that people with anorexia often have around food and eating and weight gain. And they often have a lot of like, you know, catastrophizing and black and white thoughts.
And it can kind of take the edge off a bit. So there's no sort of large scale double blind placebo controlled trials showing their effectiveness. But there are some smaller open trials demonstrating that they can be effective.
And we often use them quite frequently in combination with an SSRI as well. So I personally find them very helpful. I know many other, you know, internationally renowned treatment centers as well use them, you know, in Oxford and John Hopkins and Columbia and UCLA.
So there may not be it's kind of a new and emerging frontier in the field of eating disorders, particularly the anorexia nervosa. Yeah, for sure. And I think it's important to consider options because, you know, I feel like some of the cases can be so challenging with respect to changing those cognitive distortions around eating. It could be so stuck that we'll talk more about the psychological treatments.
But sometimes it's extremely challenging and it's nice to note there's options too.
Yeah. Sometimes when you're when you're interviewing, you know, when you're when you're speaking with clients with anorexia nervosa, you know, if someone comes in and they're, you know, 80 pounds and they're BMI of 14 and they're too scared to eat a sandwich because they're worried that if they eat a chicken sandwich or something, they're going to become obese. It almost feels like you're talking to someone who's delusional at times, right?
I mean, they're not they're not fixed firm beliefs and they can be modified and they can, you know, fluctuate depending on their mood and things like that. However, you know, low doses of antipsychotics can sometimes help to loosen up those those rigid thoughts and those distortions to make them a little bit more amenable to being a bit more flexible, trying some new foods, you know, hopefully tolerating a bit of the weight gain a little bit better. Many of those medications I just mentioned do have weight gain as a side effect, which can actually be helpful with someone like with anorexia nervosa who is needing to gain weight anyway.
Sometimes patients can be a bit resistant to that because obviously they have a lot of fears around weight gain. But when you kind of explain the pros and cons, the advantages and, you know, when they get some of the group input as well, people in a group therapy program can often give patients feedback about how helpful they are. They can help with anxiety.
They can kind of take the edge off. They can help with panic. Most patients, I would say, eventually come around to trying them.
That's so interesting. Maybe just to finish off biological treatments for anorexia nervosa. We talked about nutritional rehabilitation.
We talked about medications. And I guess obviously also just, you know, treating physical complications.
Yes, 100% for sure.
Yeah.
So again, people with eating disorders that we talked in the last episode often come with a lot of, you know, medical complications that need to be treated comorbidly with them. Right. So, you know, heart conditions or kidney problems or, you know, GI difficulties, constipation, those kind of go hand in hand with eating disorders.
And so we typically spend time treating those medical problems as well. Just in terms of Blemiam nervosa, so there aren't any, you know, medications per se that have been proven to treat anorexia nervosa. But Blemiam nervosa, SSRIs, higher doses of SSRIs definitely do help.
So in about 60% of cases or so, they can significantly reduce bingeing and purging and also help with some of the underlying psychopathology that goes along with Blemiam nervosa as well. So Prozac has the most evidence for it because it's been around, you know, since the late 80s. But other antidepressants as well also work quite well.
So, you know, you could also try Zoloft or Celexa, you know, Effexor or, you know, Cipralex, Pristiqe can also be helpful to decrease impulsivity and decrease some of the bingeing and purging. So, again, sometimes patients with bulimia also can be reluctant to try a medication. They may be a bit guarded around that.
However, we still often use them to treat the comorbid conditions that are very common with anorexia nervosa.
Yeah. And then would you say, Dr. Staab, that like the doses for the treatment of bulimia nervosa, they're about equivalent or do we require higher doses?
Higher. So yeah, for sure, higher doses work better for bulimia. So for example, like Prozac around the 60 milligram range or Zoloft around 200 or, you know, Ciprolen 20, Selexa 40.
So definitely higher dosages work better than lower dosages. Kind of like what you think about kind of used to treat like OCD or something like that. Yeah, that's been demonstrated in many double-blind placebo controlled trials that higher dosages, you know, Prozac 60 milligrams works better than Prozac 20 milligrams works better than placebo.
So definitely if you're going to use these medications and higher dosages are the way to go.
And are we kind of, I guess, like mechanistically, is it more of like a serotonergic agent that's kind of helpful for the bingeing and the purging?
Yes, yes, we think so. Again, people who have failed, let's say a serotonergic agent. I have used Effexor or Cymbalta or Pristiqe, and depending on the person, I have had actually some good results with it.
So the most evidence-based for sure is like Prozac and Zoloft and the serotonergic ones. But again, if people have tried those and have not had a great response, you can try other antidepressants as well. Again, at higher dosages.
And now is probably also a good time to emphasize that bupropion is contraindicated in bulimia nervosa due to the risk.
And now is probably also a good time to emphasize that bupropion is contraindicated in bulimia nervosa due to the risk. For sure. Yeah. So 100% do not prescribe bupropion for either anorexia nervosa or bulimia nervosa.
It's contraindicated because it does increase the risk of seizures. And because bupropion sometimes causes a little bit of weight loss, sometimes these patients will do their research and actually go to their family doctor and say, Oh, I'm not willing to try any other antidepressants except for bupropion. So please prescribe bupropion.
Sometimes I've seen family doctors make the mistake of actually prescribing it. And then, you know, having to stop it later on because it is contraindicated. So it's definitely not allowed.
And I guess while we're on the topic of biological treatments for bulimia nervosa, what's the difference in the, you know, the refeeding process for bulimia nervosa compared to anorexia?
Right. Well, people with bulimia nervosa, by definition, usually are normal weight, right? They're usually normal weight or sometimes above average weight.
So we're just trying to get people on to a healthy meal plan, basically, you know, approximately 2000 calories per day, depending on your age and your height and different things like that. But, you know, in that ballpark range and just, you know, dividing it up between, you know, a proper breakfast, lunch, dinner and two snacks, including a good balance between protein and carbohydrates and vegetables and fruits and added fats and it includes some desserts in the meal plan. So with Blemiam Nervosa and Enderexnosa, the goal is to get exposure to some different treat foods or like typical sort of binge foods in quotations.
So get some exposure to those things that they learn how to eat, let's say, you know, one donut, right? And keep it down and not have that turn into eating, binging on 12 donuts, right? Or eating one small bag of chips and keeping it down or eating, you know, a portion of french fries.
In moderation, so we're trying to find that balance, that middle path, not the extremes of extreme under eating or over eating or binging, trying to find that middle ground somewhere in the middle.
Thanks so much for that. That overview of the differences there. Coming back to the biopsychosocial framework, what are some of the key tenets of the psychological approach or psychotherapeutic modalities that you might use in the treatment of eating disorders?
For both of them, for anorexia and for bulimia nervosa, the gold standard of treatment, the main evidence-based treatment would be CBT, cognitive behavior therapy. The evidence supporting cognitive behavior therapy for bulimia nervosa is actually very good. You're looking at doing thought records and challenging some of their cognitive distortions, working on exposure, working on modifying their perfectionism, working on problem-solving skills and coping skills, ingrated hierarchies and thought records, things like that.
There's very good evidence for CBT with bulimia nervosa. There is some decent evidence for anorexia nervosa, but it's not as robust. It's more in the relapse prevention once people are at a decent weight and are hopefully maintaining.
Other psychotherapeutic modalities that are commonly used are IPT. Interpersonal therapy also has good evidence for bulimia nervosa. DBT is emerging as a new frontier for both anorexia and bulimia nervosa as well.
Particularly, the DBT skills. I find those to be very helpful. When people come into treatment, we're asking them to engage in a very scary process.
The process of eating normally, stopping the cycle of bingeing and purging, stopping excessive exercise, stopping laxatives, stopping diet pills. We're asking them to give up their crutch or their old coping mechanisms. DBT skills and CBT skills are really helpful to try and fill the void that's left behind when the eating disorder symptoms are no longer there.
A lot of focus is done on mindfulness skills or relaxation skills, distress tolerance skills, interpersonal affective skills, emotion regulation skills. I find the DBT skills are amazing and the patients often really take to them as well. Even though DBT was initially developed for borderline personality disorder, it's been adapted for eating disorders and for substance abuse and depression anxiety as well.
Often, in reality, people often don't just stick to a very pure, let's say, CBT model or just a pure DBT model. We often use an eclectic mix of different therapies. In our program at Credit Valley Hospital, we have a strong dose of CBT.
Every meal that's eaten and every meal supervision is getting exposure and working on coping skills. But then we have specific CBT group. We have DBT groups.
We have distress tolerance groups and emotion regulation skill groups. So often it's kind of an eclectic mix of many different types of therapies kind of rolled into one. And people still do also some psychodynamic psychotherapy as well.
I was just going to say family therapy. You often do family therapy as well, especially for younger adolescents or for younger adults who are still living at home, let's say, or marital or couples counseling for adults who are living with a partner. For younger adolescents, let's say, you know, a little over the age of 18, family-based treatment actually is the number one.
Evidence-based treatment, even more so than CBT. So yeah, that's the way to go for like younger adolescents where parents basically kind of are in the driver's seat and are prescribing, you know, the doctor prescribed the dietitian and doctor prescribed the meal plan. And it's up to the parents to kind of like be meal supervisors and kind of almost be like the nursing staff that we have here in our program in terms of monitoring patients, you know, not allowing them to go to the bathroom for an hour after meals to prevent purging and, you know, having contingency management and getting on top of other symptoms like laxatives and exercise and things like that.
I guess I wanted to ask quickly, Dr. Staab, it's so interesting, this Maudsley based approach, you know, usually used in the children, adolescent population. I also wonder, is it sometimes used almost in an adult sort of setting when, you know, the patient, you know, maybe doesn't have as much capacity to manage themselves like this family therapy approach, I feel like can also be used in so many adult contexts as well.
Yeah, and it can, it has, there's some preliminary data showing that it can help with, let's say, you know, younger adults, let's say under the age of 25 who are still living at home, who may be, may be still a bit regressed or maybe a bit immature, that it can actually be helpful for that. It's still again, it's in its early days. So still, you know, the primary modality would still be, you know, individual or group CBT.
But I have seen it done. We don't typically do that here in our program. But I have seen it done at other centres.
For, let's say, adolescents who start off in FBT, you know, just because they turn 18, you don't flick a light switch and then all of a sudden they're a different person. And then you switch to CVT, you know, you can still continue on with modality therapy, especially if they're living at home and they're quite financially and emotionally dependent still on their, on their parents. So it can sometimes be done, you know, 18, 19, 20.
I think depending on the person, yes.
And Dr. Straub, I'm wondering what's the role of allied health in supporting these patients?
If they're real, like if they're, you know, going into DT or having withdrawal or they're getting drunk every night or they're abusing cocaine, they may need to kind of go to a detox or like a higher level of care for substance abuse addictions first, before they come into our eating disorders treatment program. But we, yeah, we're very adept at treating, you know, run of the mill depression, anxiety, general anxiety disorder, panic disorder, OCD, PTSD, you know, concurrently with our program. The main focus is always obviously going to be the eating disorder.
But we do a lot of work on the comorbidities as well.
And I guess following up on that, comorbidities are probably one of the determinants of this. But would you be able to walk us through what the various levels of care are that are available for treatment?
Sure. So, you know, going maybe from the highest level of care would be inpatient treatment program, right? Where you're in a hospital and you have 24-hour nursing care and access to, you know, other specialists and emergency treatment if needed, you know, IVs and other fancy medical paraphernalia.
And then, you know, the step down would be a residential treatment program where, again, you're still having some 24-hour care, but it's not as highly specialized or it's not as, you know, as an acute facility. They may have more staffing with PSWs or things like that. And then going down to like a day treatment program or partial hospitalization program, which is usually at least about, you know, six to ten hours per day involving, you know, meal supervisions, group therapy and individual therapy.
And it can be anywhere, you know, from four to seven days per week. And then going down to like more of an intensive outpatient program, which may be typically around the range of three hours per day, again, five to seven days per week. And then outpatient programming could be, you know, seeing a therapist once a week or a dietitian, social worker, attending an outpatient group, you know, maybe an outpatient CBT or DBT skills group.
And then eventually a community support group or, you know, a drop in or things like that. So at Credit Valley Hospital, we have a, we go from a very high level of care. We have, you know, inpatient treatment.
We have day hospital treatment. We have a transition program, which would be considered to be like an intensive outpatient program. And then we have some outpatient groups and follow up with psychiatric, with psychiatry and with our case managers as well.
Yeah. So again, depending on people's levels of severity when they present to us, typically inpatient care is reserved for people with anorexia nervosa who are quite underweight and medically compromised. Usually, typically a ballpark would be like under a VMI of 16.5, let's say, or who people who have, you know, low potassium or QT prolongation, or they're having fainting spells, dizzy spells, seizures, things that require a higher level of care, low blood sugars or severe hypoglycemia.
And then a day hospital, you know, residential treatment again would be for people who maybe don't require an intensive hospital based program, but still require kind of like round the clock treatment because they have such severe symptoms that they may be engaging a lot of bingeing and purging at night. And they require like more intensive guidance and supervision. And then they program would be for people who have, let's say, less severe anorex nervosa, typically, let's say above a BMI of 17, who are able to commit to come to a program daily, who are a bit more motivated and who maybe don't require as frequent blood work or medical monitoring.
And then an intensive outpatient program. So our transition program would be for people who kind of graduate from our day program. And they're typically within a normal weight range.
So above a BMI of 19, between 19 and 20, who their symptoms are quite minimal. So usually less than, let's say, once or twice a month. They can be followed in our intensive outpatient program.
And then for people who are not as severe, could perhaps benefit from just, let's say, a once a week group or once a week individual support. So, yeah, so, you know, a gold standard of treatment would involve all these different levels of care and kind of meeting patients where they're at in terms of what they need. Sometimes, though, having said that, though, so you can have all these wonderful steps of care.
But sometimes people with eating disorders, with anorexia and bulimia, because of the high levels of denial and resistance, may not always access these. Right. So even though someone may require inpatient treatment, they may not be ready to engage in such a high level of care that requires so much change.
And they may only be ready to engage in, let's say, a once a week group or a motivation group or an education group or something very minimal, just to kind of get their foot in the door and kind of see what it's like. And because they can be, you know, a bit guarded and suspicious about making changes and not 100 percent gung-ho.
Thank you for that. That's a really helpful overview. And yeah, ideally, I mean, the severity would match up with kind of their level of motivation and readiness to change.
It often wouldn't be the case. Is there any kind of a harm reduction approach that you can take with patients who have very severe and during eating disorders, but perhaps the idea of full recovery is not something that's palatable to them?
Yeah. So again, you know, that would be, let's say, for a more chronic patient. So if someone has, let's say, come into a typical, you know, a classical kind of standard program numerous times, you know, and how many times is maybe up for debate, but at least three to five times where they've been into a regular standard inpatient or behavioral sort of day treatment program and have not done well or have not completed or they've relapsed, then you might look at more taking a more of a harm reduction approach.
At Credit Valley Hospital, our inpatient program and day hospital program, we don't take so much of a harm reduction. We our goal in our program is more of a full recovery. Our goal is to, you know, completely weight restore and stop, you know, symptom abstinence, basically.
But we do have people, you know, we refer, let's say to Toronto General Hospital. They have a med act team, like an sort of community treatment team, or they might come in for a short stay, or let's say instead of getting fully weight restored to a BMI of 19 or 20, they may just come in and contract to have a goal of, let's say, gaining 10 pounds, just to reduce their symptoms, to improve their medical status. But their goal may not be to achieve a full recovery.
Obviously, when people go for a full recovery, their outcomes are better and their chances of success are better. If you, if the closer people can get to like a BMI of 19 to 20, the better their prognosis and their better their overall quality of life and long term trajectory is. But sometimes people need to take things in smaller steps in a more gradual approach.
If there is someone who is kind of an imminent medical danger and unwilling to engage in treatment, I suppose that's kind of an ethical dilemma. And there's different laws that vary from region to region. Are people certified kind of under them?
Yeah, so rarely, rarely that happens. So, you know, in Ontario, if people, you know, to be certified is they have to be quite extreme. So, you know, for someone to be certified and then to put in voluntarily against their will, we're looking at people who are quite very, very ill, like we're talking, you know, people under BMI of like 11.5 or something in that ballpark range, people who have been losing weight very quickly, people who have really severe low potassium below 2.5 and they're refusing to get help, people who have like really severe cardiac arrhythmias or, you know, seizures, they can then be certified and treated against their will often with tube feeding.
But often it's just kind of short term to get them out of an imminent sort of crisis, medical crisis, and then they can sign themselves out against medical advice. So it's just kind of like, like, let's say an alcoholic or a drug addict who is in a very bad state. They're having seizures, they're going through duties or something, and they refuse to stay in hospital.
You often just treat them, you know, medically with Valium and get them stabilized. And then they have the opportunity to sign themselves out once they're more medically stabilized. So it's more just like a crisis intervention.
You know, if some people come in and they're very debilitated and they have ongoing chronically low blood sugars that put them at risk of seizures and passing out, they may need to stay in hospital for some two feedings sometimes for about a month to get them more boosted, to get their blood sugars more stabilized. But you wouldn't keep someone in hospital, you know, until they're BMI of 19 and they're fully weight restored. It's just more of like a crisis short-term sort of intervention.
And I'd imagine that might be traumatic for somebody.
It can, because when you look at that, like, obviously, I've done that. You know, I do that, you know, not frequently, but I would say, I don't know, you know, on average, maybe I do that four or five times a year, right? We see like 300 new consults a year and I'm doing that maybe four or five times a year.
So it's only it's run rarely and it's not done easily because once you do that, you can really jeopardize your treatment alliance with that person, right? Once I've certified someone and declared them incompetent and force fed them against their will for a week, they may not be so inclined to book appointments with me in the future or follow up with me again. And they may then say to help with Credit Valley, I'm never going back there ever again.
Or, you know, it can be quite damaging to your treat your therapeutic alliance. But sometimes it needs to be done because if not, they're going to die, right? So if someone is an imminent risk of death, then you have to do it.
Yeah. And I also think about kind of the children and adolescent population, right? And the considerations of are a little bit different with that.
So good point, Lucy. So for people who are under 17 or 16, that is done, you know, whatever you want to call it, more coercive treatment is done much more frequently. So because again, you know, parents are the boss, so to speak, in younger children and adolescents.
It's up to the parents to decide how long they're going to stay in hospital, when they're going to come out, things like that. But once people are kind of, you know, 16, 17, 18 years old, it's difficult to keep them in hospital against their will, especially for long periods of time.
You know, how, what about treatment for men? And I guess like how is that, I guess, how common do you see that? And is there a way that you kind of approach treatment that might be different for men with eating disorders compared to females?
Yeah, so we don't see that many men again. So for you, you know, if we see 300 patients a year, I'd say maybe like less than 5% of those are men. So even though 10% of eating disorders are men, we're seeing probably more like less than 5%.
And the amount, the amount of men coming into our inpatient or day hospital program is way, you know, much, much, much less. In terms of the actual disorder, it's actually very similar. Like a lot of their, you know, disturbed thinking and behaviors are very, very similar to females.
There can be more stigma for males to come into a treatment program, which is predominantly, you know, 95% female. They may feel a little bit awkward and like they don't fit in. But once they're there, I have to say, and they're talking to people and they realize that people have the same fears of fatness and body misdistortions and drive for thinness and underlying low self-esteem and perfectionism and depression, anxiety.
They often fit in very well. Often male patients, not always, but sometimes male patients are not as averse to gaining weight, but they want it to be muscle. They want it to be, you know, muscle in their shoulders, on their chest and to keep a very trim, you know, waist with a six pack abdomen.
I guess like, yeah, we talked about the kind of the child and adolescent population and the treatment approach using the Maudsley approach. You know, adult populations, more so kind of individualistic or group-based CBT. I guess other populations, I'm just wondering, maybe like elderly population, other maybe, I guess, different other considerations of certain populations with eating disorders.
Yeah, I mean, we don't see like tons of elderly people. Usually eating disorders start more in the, you know, teenage years and early 20s. That's not to say that older people can't develop eating disorders, but it is more rare, you know, above the age of 50.
So some of the treatment considerations would be like for some of the more really chronic older, you know, when I'm saying older, like older for eating disorders is like above the age of 40, right? Which is obviously not older in the general population.
But if someone's had, you know, someone has been sick for over 20 or 30 years, they're often going to be quite debilitated, quite run down, you know, have multiple system damage and organ failure and they're going to be quite fragile.
They're going to be medically quite debilitated. So those considerations would be, you know, often with chronic pain, they have osteoporosis, they have compression fractures, they have hip fractures, they have heart failure, they have, you know, a whole bunch of other medical problems, which can be quite disturbing.
Yeah. The population, yeah, the medical. And then I guess for, and we talked about kind of, you know, the preponderance, like the ratio between females and males for eating disorders is around 10 to 1 for anorexia.
So they're not as this is not everyone, but some male patients are not as disturbed by a number on the scale going up, but they may be more disturbed by, let's say, their belt size increasing or their jeans not fitting their waist in particular. But actually, you know, surprisingly, they actually fit in very well to a typical traditional sort of eating disorders program.
There's there aren't any like specialized male eating disorder programs in Ontario, you know, in the States, United States, they do have some that are specifically just meant for males.
With males, there is a higher rate of people who are homosexual or bisexual. So there may be some more sexuality issues or conflicts around that as compared to female patients with eating disorders.
Yeah, and I guess one of the other categories or kind of subpopulation talk about it, I guess, like our LGBTQ and like trans individuals eating disorders, is that is that sort of is is that a population that's more at risk or how often do you see this within the scope of your programming?
They are. From what I've read, they are said to be more at risk for a whole host of psychiatric disorders, depression, anxiety, and eating disorders. And I think, again, along with that, there may be more some gender dysphoria that goes along with it.
So we have seen several patients who are transgender and who many of them have been experienced are really terrible sexual abuse histories and may feel sort of an aversion to female characteristics like, you know, breast tissue or thighs or our hips or things like that.
And so in the weight gain process, they may have some more anxiety or distress around sort of their feeling disgendered or that they're in the wrong body. But we have definitely seen patients who have completed our program and have gone on to have surgeries and take hormones, male hormones or female hormones, and actually done quite well and have made a full recovery.
Yeah, but that's so great just to even have that context, lots of special considerations and different things you might consider when working with these types of patients.
And with these different populations, one of the things that can be quite helpful is in the community, there are some resources and support. So, for example, here in Toronto, places such as Sheena's Place offer kind of support groups for folks outside of the more traditional medical model of treatment.
Great, yeah, no, Sheena's Place is wonderful, right? There's also Body Brave and Hamilton. Yeah, I love Sheena's Place and Body Brave, they're amazing.
They have some different sort of like different types of groups sometimes, like belly dancing groups and yoga therapy groups and art therapy groups and a lot of other wonderful, you know, music therapy and some sort of non-conventional sort of modalities or approaches to treatment, which is great.
Yeah, and speaking of kind of like non-conventional, there's also more novel interventions being explored. Did you have any thoughts on, I think, some studies underway about repetitive transcranomagnetic stimulation or brain stimulation even being used?
Sure, yeah. I was actually part of a working group looking at deep brain stimulation at the University of UHN, and they did have some preliminary data, again, very small sample sizes, for very chronic, intractable people with eating disorders. There's still some discussion about where is the best place in the brain to stimulate, right?
There's a lot of work being done around the insula, so it's still kind of in its infancy. We're not exactly sure, but it's a bit of a shot in the dark, but for some, again, a minority of people who've had chronic treatment resistant eating disorders, there may be some hope on the horizon with things like deep brain stimulation, RTMS. Again, I'm not an expert in that, but I've heard there's some good success with patients with bulimia nervosa and with comorbid PTSD as well, that there's been apparently some good success with that, which is a lot less invasive, obviously, than deep brain stimulation, which involves neurosurgery.
And then there's other things, again, that are sort of in the experimental phases, looking at some psychedelic assisted psychotherapy with things like ketamine or MDMA. And again, those are not things that we're doing here in Credit Valley Hospital. But again, you hear these things at conferences and you see some presentation, again, very small sample sizes.
It's experimental and it would be considered for people who have failed conventional treatment numerous times. It would not be sort of the first line treatment, right? So people who have had multiple attempts at like traditional inpatient day hospital residential treatment, multiple attempts at CBT, different medication trials, DBT, IPT, you know, the works and nothing has worked.
These may be some newer avenues to explore.
Very interesting for sure.
Yeah.
I guess we also that this has been a really great overview of all the different treatment considerations and approaches and to manage eating disorders. We did have a question from a listener, which may help kind of tie things together as well. They were wondering, they say they have a 23 year old daughter who was recently diagnosed with anorexia, depression, anxiety and OCD.
And she says that her eating disorder and extreme weight loss is not about body image. They managed to refeed her at home and they're waiting for ongoing treatment. The waiting lists are quite long.
And they're basically their mother is wondering, are the treatment protocols different from anorexia where body image and maintaining weight loss are the focus? They also noted she's struggling to complete university but insists on living in her university hometown. And they want to know really like what can parents of somebody who is in their 20s and kind of has autonomy, what can they do to support her without kind of walking on eggshells?
Yeah, I guess, you know, one thing we always like to leave with the audience are, I guess, if you have any kind of, I guess, words of wisdom that you'd like to impart on learners or, you know, honestly, our listener population is quite vast as well. We've got, you know, a variety of social workers, psychologists, you know, mostly medical students, people in the medical field. I guess any tips you'd like to impart on learners?
Sure. I think I think one thing might be just, you know, most people listening to this podcast are not going to become psychiatrists or necessarily eating disorder specialists. But I think just in the medical field in general, just be careful.
You know, if you're seeing, you know, typically, you know, a younger woman who's had, you know, weight fluctuations, she's presenting with some maybe some odd symptoms or, you know, concerns around their eating habits. Be a bit careful about what you say sometimes, because I have seen patients sometimes react negatively to some comments they receive from their doctors. Right.
So, you know, let's say if somebody has lost 20 pounds and then they see their doctor and their doctor's like, wow, good for you. Keep up the good work. Keep going.
Right. And then meanwhile, like, you know, 20 pounds later, they have anorexia nervosa. So just be careful sometimes about, you know, I think we're so obsessed, I think, in our culture with, you know, getting more activity and eating a low fat diet and not having junk food and eating more fruits and vegetables.
That's all great for sure. Right. For probably the vast majority of Canadians.
But just be careful for some of the vulnerable people that who may take that message too far and too extreme, that for some people actually applauding weight loss and diets. And, you know, increasing their activity is actually not helpful. It may actually be harmful.
Yeah.
Thanks so much for that, Dr. Staab. I think that's such an important message to give in this climate where I think there's, you know, there's like a movement or there's a lot of like this health obsessed culture. Yes.
It's a tricky landscape to navigate and that's an important message to deliver.
This brings us to the end of part two of our Eating Disorders episode series. PsychEd is a resident-driven initiative led by residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association.
The views endorsed in this episode are not intended to represent the views of either organization. This episode was produced and hosted by Dr. Lucy Chen, Dr. Vanessa Aversa, and Dr. Nikhita Singhal. The audio editing and show notes were completed by Dr. Vanessa Aversa.
Our theme song is Working Solutions by Olive Musique. A special thanks to the incredible guest, Dr. Randy Staab, for serving as our expert for this episode. You can contact us at psychedpodcast@gmail.com or visit us at psychedpodcast.org.
Thank you so much for listening.