The Center for Eating Disorders at Sheppard Pratt
As the country experiences an epidemic of obesity, a group of clinicians struggle to treat those who almost delusionally view themselves as fat when, in fact, they are severely thin. This body image distortion is well known; less well appreciated, says Harry Brandt, M.D., is the fact that six to nine percent of patients with anorexia die of their disease, making it the psychiatric illness of greatest lethality. Dr. Brandt is director of Sheppard Pratt’s newly opened program to treat the full spectrum of eating disorders, which includes anorexia nervosa, bulimia nervosa, and binge eating disorder.
Formerly the head of a Baltimore area general hospital eating disorders unit, Dr. Brandt has supervised the care of 400 to 500 inpatients a year and some 45,000 outpatients enrolled at a stepped program of 12 hour partial hospitalization, an intensive four-hour program, and traditional outpatient care. Dr. Brandt pioneered this step approach. When he was director of the eating disorders program at NIH, patients stayed six months. Later, moving to a private hospital setting, he saw the length of stay drop to 40 days. Now, in the era of managed care, the average inpatient length of stay is eight days. But his step program is innovative and effective. For example, says Dr. Brandt, patients are returned much more quickly to their families. When such short term interventions result in relapse, issues can be dealt with quickly and directly. This is preferable to isolating the patient for weeks and months in the hospital and only then making the discharged patient adjust to home life. And while the patient population has historically been primarily female, with the incidence of females to males being 8.5 to one, there is a growing trend among males to be diagnosed with the disorder, likely attributable to the intense media focus on the ideal male body image. The age spread among the patients is now large, ranging from 12 to the 50’s and 60’s. Dr. Brandt anticipates that the trend for even younger patients to be diagnosed with the disorder will continue.
There is a tremendous amount of suffering with eating disorders, Dr. Brandt comments. From the outset, patients who come to the hospital don’t want to be there, are frequently brought in by parents, spouses or significant others, and fight stabilizing efforts. The struggle to control weight can become epic and patients may purge or binge or both. Over 85% of patients below goal weight develop a major depression. Medical complications are significant, including osteoporosis, kidney failure from dehydration, and muscle wasting. Patients abuse laxatives, diuretics, and alcohol. Whereas the normal adult can call upon glycogen stores in times of food depletion, the patient with severe anorexia has used up such stores and can become hypoglycemic, particularly at night while sleeping. Blood sugar may need to be monitored to prevent cardiac arrhythmias and vascular collapse may occur.
To deal with all these complexities requires an expert team. Steven Crawford, M.D., the Center’s associate director, coordinates inpatient and outpatient programs. Kim Anderson, Ph.D., plans the cognitive and behavior therapies that are the mainstay of treatment. Deborah Kaufman, RDLD, is the lead dietician. And Jill Midthune, M.D., assists with general treatment efforts. Dr. Midthune, in fact, was a former University of Maryland Fellow in eating disorders before she joined the staff. Dr. Brandt himself has active ties to the University and teaches all medical students and residents about the subject of eating disorders. He is also involved in an NIH-funded multicenter study of the genetics of the disease. Drawing on patients from eight cities in the U.S. as well as one in Canada, and two in Europe, the study collects data on families in which two members have restrictive eating disorders. It is hoped that in time, data from 400 families will be pooled for genetic assessment. It has already been suggested from earlier human genome studies that some abnormality in chromosomes one and 10 may be linked to anorexia or bulimia. But even more interesting are the findings that the traits of perfectionism and harm-avoidance are chromosomally linked.
These traits, while not in the language of DSM IV, appear to be enduring psychological characteristics seen very early among patients with eating disorders. Harm-avoidance refers, for example, to the exaggerated and dire consequences a patient with anorexia would suffer if she ate a small piece of forbidden meat. Perfectionism refers to the more traditional obsessive or compulsively driven behavior seen among patients with eating disturbances. The core of all these traits is, of course, anxiety, and the anxiety disorders themselves are four times more co-morbid with eating disorder patients than with other psychiatric illnesses.
Once every two years, associate director Dr. Crawford organizes an international symposium on eating disorders in Baltimore that draws 500 attendees from around the world. Dr. Brandt looks forward to Sheppard Pratt’s participation in the next such meeting. In the meantime, the Center for Eating Disorders at Sheppard Pratt begins operations January 1, 2005. Questions about this program can be directed to 410-938-5252.