Eating Disorder Management Team Protocol and Procedures

Student Health and Counseling Services

Created Fall 2006 (last update Winter 2015) Table of Contents

I. Mission statement

II. Diagnostic Definitions of Eating Disorders Treated by EDMT

III. Treatment

a. Diagram: Eating Disorder Level of Care Chart

b. Overview of Services at the University of California, Davis

c. Services at Counseling Services in North Hall

d. Services at Student Health Wellness Center

IV. Collaboration and Treatment Coordination across Disciplines

a. Initial Appointment

b. Referrals

c. The Eating Disorder Management Team (EDMT)

d. Scope of EDMT Service

e. Confidentiality

V. Special populations

a. Medical Students

b. Graduate Students

c. Athletes

EDMT Protocol & Procedures (Cougevan) Page 2 of 9 Mission Statement

This manual is intended to be a guideline for the treatment of students at the University of

California, Davis who suffer from symptoms of disordered eating or eating disorders. This has been

developed by the Eating Disorder Management Team, so that successful collaboration and clinical

treatment can be provided. This manual exhibits an understanding that eating disorders are multi-

faceted, complex and potentially difficult disorders that require the support and knowledge of trained

professionals across various areas of expertise. It also reflects an expectation of the student’s

accountability and commitment toward treatment goals in order to start and continue treatment.

EDMT Protocol & Procedures (Cougevan) Page 3 of 9 Diagnostic Definitions of Eating Disorders Treated by EDMT

Diagnostic criteria for 307.1 Anorexia Nervosa A. Refusal to maintain body weight at or above a minimally normal weight for age and height (e.g., weight loss leading to maintenance of body weight less than 85% of that expected; or failure to make expected weight gain during period of growth, leading to body weight less than 85% of that expected). B. Intense fear of gaining weight or becoming fat, even though underweight. C. Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight. D. In postmenarcheal females, amenorrhea, i.e., the absence of at least three consecutive menstrual cycles. Restricting Type: during the current episode of Anorexia Nervosa, the person has not regularly engaged in binge-eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas) Binge-Eating/Purging Type: during the current episode of Anorexia Nervosa, the person has regularly engaged in binge-eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas)

Bulimia: Diagnostic criteria for 307.51 Bulimia Nervosa A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: (1) eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances (2) a sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating) B. Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise. C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for 3 months. D. Self-evaluation is unduly influenced by body shape and weight. E. The disturbance does not occur exclusively during episodes of Anorexia Nervosa. Purging Type: during the current episode of Bulimia Nervosa, the person has regularly engaged in self- induced vomiting or the misuse of laxatives, diuretics, or enemas Nonpurging Type: during the current episode of Bulimia Nervosa, the person has used other inappropriate compensatory behaviors, such as fasting or excessive exercise, but has not regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas

Binge Eating Disorder or 307.50 Eating Disorder NOS This is a category used for disorders of eating that do not meet the criteria for a specific eating disorder. Examples include: 1. For females, all criteria for Anorexia Nervosa are met except the individual has regular menses. 2. All of the criteria for Anorexia Nervosa are met except that despite significant weight loss, the individual’s current weight is in the normal range. 3. All of the criteria for Bulimia Nervosa are met except that the binge eating and inappropriate compensatory mechanisms occur at a frequency of less that 2x a week or for a duration of less than 3 months. 4. Regular use of inappropriate compensatory behavior by an individual of normal weight after eating small amounts of food (e.g., vomiting after consumption of 2 cookies). 5. Repeatedly chewing and spitting out, but not swallowing, large amounts of food. 6. Binge-eating disorder: recurrent episodes of binge eating in the absence of the regular use of inappropriate compensatory behaviors characteristic of Bulimia Nervosa.

EDMT Protocol & Procedures (Cougevan) Page 4 of 9 Eating Disorder Treatment – Level of Care Chart

Level of Care Appropriate for Possibly appropriate Refer out for Refer out for both Inpatient treatment by for treatment by psychological tx psychological and Hospitalization SHCS – routine SHCS depending on SHS continues medical treatment – Judicial Affairs monitoring progress routine intensive outpatient possibly encourages monitoring or residential. treatment Level 1 Level 2 Level 3 Level 4 Level 5 Weight (%IBW) Normal range 95% and higher 85% and higher 84% - 75% 75% and below Symp./Appearance Normal Range Swollen facial Dry skin Amenorrhea Amenorrhea features (purge) Swollen salivary Lanugo Lanugo Scars on hands glands Emaciation Emaciation Hair loss Yellow/dry skin Yellow/dry skin Amenorrhea Lethargy Lethargy Cold Intolerance Cold Intolerance Abnormal labs/EKG Anemic Behaviors Purges<3 weekly, Purges 3-4 weekly, Purges 4+ Purges 6+, almost Purges after every up to 2x day no more than 3x day weekly, (or 4x daily meal. Requires day 1x a week) Caloric intake at supervised meals Blood in vomit- unhealthy lvl. moves to lvl 4. Supervision needed Mild restriction of Moderate restriction after meals. Severe restriction calories, still of cal, strict rules Moderate restric under 500 calories. receiving around food. of cal w/ nutrition. increased ‘fear of Severe restriction – fat’ denial of hunger Psych. Present. No SI/P or SIV Comorbid disorder Comorbid Suicidal plan – no Suicidal intent/plan No comorbid D/O 3- hours/day disorder that intent No ability to control Insight & able to compulsive requires session Preoccupied thoughts control urges increase w/compulsive/obses 4-8 hrs sive thoughts compulsive Motivation Good, cooperative Fair, cooperative Fair to poor Poor. Routinely no- Poor to absent. Resistance shows. Nutrition Follows meal plan Shows progress with Fluctuates in Poor compliance No compliance with consistently meal plan progress with meal plan meal plan Impairment with Self- Able to exercise Able to exercise for Some structure Impairment, can’t Complete Care and Exercise for fitness and fitness and control needed to gain weight by self; impairment, can’t eat Control control compulsive urges. prevent from structure required to or gain weight by compulsive urges. compulsive prevent compulsive self; structure exercise. exercise. required to prevent compulsive exercise. Medical Monitoring Medical f/u 6 to 8 Medical 6wks Medical weekly Seen on an ER basis Seen on an ER basis Outcome and wks (if stable) Nutrition 2-3 wks Nutrition only. only. Actions Taken Nutrition f/u weekly- if Insurance Insurance dependent. every 3 weeks requires this dependent. Official letter sent to level, needs Official letter sent to student. Stable after 6 outside RD student. Possible JA months at same involvement – weight/lack of medical WD. symptoms. This level of care chart (devised from APA & AMA guidelines) is used as an outline to determine the best treatment plan of action for each individual. It is recognized that a student can be at many different levels on the chart, depending on their current behaviors/motivation/symptoms and level of compliance with nutrition. When a student is at different levels, the Eating Disorder Management Team will take an average, and then use clinical judgment to determine best course of treatment action.

EDMT Protocol & Procedures (Cougevan) Page 5 of 9 Practice Guidelines for the Treatment of Patients with Eating Disorders, July 2006, American Psychiatric Association.

Resources on the U.C. Davis Campus A student can begin the process of recovery in many different ways. The campus units available to provide help, coordinate their efforts to provide comprehensive services. You can seek help at the location where you feel most comfortable. All services are confidential. You can change your behavior and these University Resources have staff available to help you.

1. Campus Resources: Student Health & Counseling Services (SHCS) The House Residence Halls Intercollegiate, Intramural, and Club Athletics Women's Resource and Research Center

2. CS at North Hall Offers the Following Confidential Services: Individual evaluation Brief individual psychotherapy Brief psycho-educational groups Long-term group psychotherapy Referral for long-term individual psychotherapy and individual inpatient treatment programs Consultation to faculty, staff and students Educational programs and general campus outreach presentations Referral and coordination of treatment with health providers at Student Health Services

Students may access services by scheduling an ED intake appointment from 8:00 am to 4:30 pm, Monday - Friday at CS, 219 North Hall, 752-0871.

3. Student Health Services Offers the Following Confidential Services: Medical examination and assessment of health status and physical risks due to an eating disorder. Nutritional assessment and recommendations / meal plan by a registered dietician. Psychiatric consultation and medication evaluation. On going routine medical monitoring, if the eating disorder can be managed at an outpatient level (above 85% IBW) . On going nutritional counseling, if the needs for appointments fall within the scope that can be provided on campus (every 2 to 3 weeks). Referral and coordination of treatment with CS staff, who provide psychological assessment and intervention. Educational programs, peer education and referrals provided by Health Education & Promotion.

Students may access services by making an appointment at Student Health Services, 752-2349.

EDMT Protocol & Procedures (Cougevan) Page 6 of 9 Communication and Collaboration Across Disciplines

Initial Appointment If the initial appointment is with CS, the attending therapist will conduct an intake/psychological assessment, firstly, to determine if the student has an eating disorder according to DSM-IV (V) criteria; and secondly, ascertain whether the student’s condition is amenable for outpatient treatment at SHCS. If both conditions are met, and the student elects the option to receive care on campus, he/she will be automatically referred to the EDMT and given details regarding the potential outpatient services offered. If the student’s eating disorder is non-diagnosable or a diagnosis of Eating Disorder NOS, then the clinical decision to be followed by the EDMT will be up to the primary care provider based on the student’s needs. The intake form that a student signs to consent to treatment at CS contains information about the communication that occurs between SHS and CS staff members as well as the open-access chart. This will be explained to the student on intake. If the student needs more intensive treatment, or the student elects to receive off campus care, the therapist should make a referral to an off campus eating disorder treatment facility or make a referral to a community provider that specializes in eating disorder treatment. Once a referral has been made, a Release of Information can be filled out so that communication can take place between SHCS and the outside provider (if the student is on SHIP/GSHIP insurance, no ROI is needed, if it is an outside insurance provider then a referral is needed). If the initial appointment is with Health Services, the attending medical provider will be responsible for obtaining the appropriate release of information and making the proper referral(s).

Referral to the EDMT

Any student who is seen at CS and meets diagnostic criteria for an eating disorder must be referred for a medical evaluation at SHS. Any student who is seen at SHS and meets diagnostic criteria for an eating disorder can be referred for a psychological evaluation at CS and must be referred to the registered dietician at SHS for a nutritional evaluation. When a student has been referred to the EDMT, the following appointments must be scheduled if they have not already been: 1. Medical evaluation - SHS 2. Nutrition evaluation – SHS 3. Counseling evaluation – CS 4. Psychiatric evaluation (if applicable)

Referral to Off Campus Eating Disorder Treatment Facility Off Campus referral to the appropriate off campus eating disorder treatment service or other appropriate level of medical or psychological care is indicated when the student: 1. Fails to comply with established treatment goals (evidenced by 2 or more appointment failures without justifiable cause, or lack of motivation toward working on established treatment goals) 2. Fails to make adequate progress toward treatment goals 3. Is medically unstable (including a body weight <85% of ideal body weight, hypotension, cardiac signs or symptoms, or significantly abnormal lab tests) 4. Shows evidence of psychological risk to themselves 5. Requests off campus treatment

EDMT Protocol & Procedures (Cougevan) Page 7 of 9 Students meeting criteria for an eating disorder, with SHIP insurance, may be offered the option of referral to an off campus eating disorder treatment service for psychological services but SHS will remain their primary medical treatment provider. CS will continue to be available to them for group therapy and crisis intervention as needed. Students meeting criteria for an eating disorder, WITHOUT SHIP insurance, will be referred to their primary medical provider for medical treatment. SHS will remain available for medical emergencies and minimal medical support. CS will continue to be available to them for short-term individual therapy, group therapy and crisis intervention as needed.

Composition of the Eating Disorder Management Team (EDMT) The EDMT is an ongoing team collaboration between CS and SHS. It consists of members from the following departments and disciplines: Student Health (physicians, nurse practitioners, psychiatrists, registered dietician); CS North Hall (staff psychologists, eating disorder post-doctoral fellow and pre- doctoral intern). These individuals will serve as direct treatment providers, or consultants, in the management of each case. Each discipline will maintain clinical records for treatment encounters. Individual therapists or consultants may attend meetings as clinically necessary provided that appropriate releases are signed. - The EDMT will meet on a bi-weekly basis. The meetings will be chaired by a CS therapist and will follow a structured meeting format that ensures that critical cases are given consultation priority. An EDMT administrative note will be documented for each reviewed case. If needed, a follow up Health-E-Message communication will be sent to the treating providers.

Scope of EDMT Service The purpose of the EDMT is to facilitate multidisciplinary collaboration for the assessment, education, and management of students with eating disorders. The EDMT offers non-intensive outpatient treatment of eating disorders. Students referred to the EDMT must be medically stable (see above criteria) and not at immediate psychological risk to themselves. CS will provide individual therapy at the rate of no more than two hours per week for a maximum of 10 sessions per academic year, as well as a potential unlimited group therapy at the rate of no more than two hours per week. Routine periodic outpatient medical and nutritional follow-up will be provided at SHS both if the student is in treatment at CS and if they have been referred out to an outside provider for psychotherapy in the community. Students must be referred to the appropriate type and level of care off campus whenever they become medically or psychologically unstable, or fail to make satisfactory progress. The degree of suitability for treatment is determined by the Eating Disorder Level of Care Chart (pg. 5). The duration of EDMT service may vary according to individual needs. However, due to the chronic remitting and relapsing nature of these diagnoses, some students may need treatment throughout their status as UCD student, as long as they remain medically stable, defined progress is being achieved, and they remain compliant to the established treatment plans. Since students can only receive care on campus while actively enrolled, treatment plans must include referral to an appropriate source of care during non-enrolled periods, such as during academic breaks, or before graduation. The alternate off campus care plan must be established well in advance of the non-enrolled status. If non-enrollment occurs without prior notice, the student should receive a telephone call followed by a certified letter from the treating therapist outlining the recommended care.

Confidentiality Confidentiality is strictly maintained. Open communication and shared files exists only within Student Health and Counseling Services, between treatment providers. The Team may also collaborate with additional campus departments (example: University Administration, Academic Advising, Housing, etc.),

EDMT Protocol & Procedures (Cougevan) Page 8 of 9 or off campus Providers in order to facilitate appropriate intervention. In such cases, additional releases would be required prior to this communication, unless a life-threatening situation exists.

EDMT Routine Follow-Up Care After all initial appointments for medical, nutrition, and therapist evaluations have been completed, the student will be expected to continue regular follow-up as established by their team: 1. Therapist: 4-8 times per month as determined by the treatment plan 2. Medical: 1-2 times per month or as determined by need (Level 1= every 6 to 8 weeks) 3. Nutrition: 1-2 times per month or as determined by need 4. Psychiatrist: determined by need

Suspensions and Medical Leaves Recommendations to change (usually limit) a student’s academic and/or activity level may be initiated by any member on the EDMT. The decision to hospitalize a student for medical complications should be made by the SHS Medical Consultant. The decision to refer for possible hospitalization for psychological complications should be made by a CS Therapist. For hospitalizations and limitations on physical or academic activity, the appropriate University staff will be notified as indicated with the appropriate release of information completed (e.g., academic advisor; athletic trainer, coach). Intercollegiate athletes who are non-compliant to scheduled appointments (minimum of two appointment failures without justifiable cause) will be suspended from athletic participation until determined by the EDMT.

Special Populations on Campus Medical Students Students pursuing their M.D. at UC Davis are able to obtain longer-term services through an arrangement between SHCS and the medical program. Medical students who require or request psychological services for an eating disorder are seen by dedicated staff for the Med Center, who will often arrange to meet with them during times that are more convenient for a medical student’s schedule (after hours). Other services received are at the clinical advice of the Director of CS.

Graduate Students Due to the sometimes longer-term requirements and time-commitment of graduate programs on campus, it is often advisable for graduate students to be referred out to specialists in the community, rather than seen for a limited time at CS. Long-term group therapy is available at CS.

Intercollegiate Athletes Intercollegiate Athletes can be required by coaches to seek treatment for an eating disorder, or at least be evaluated for health concerns – if they want to perform athletically. Their athletic participation can be limited by a medical member of the EDMT if it is determined that their weight or their lab-work suggests a possible health risk. Athletes are eligible for CS services, and there are specific groups at CS that are offered only to the athlete population.

EDMT Protocol & Procedures (Cougevan) Page 9 of 9