EATING

DISORDERS Client SB

AND
TRAUMA
Presentation by Riley Maloney
Why SB?
Many types of trauma that can be
Trauma Response
associated with eating disorders & Onset of EDs
including:
• -neglect
• sexual assault
• sexual harassment
• physical abuse and assault
• emotional abuse
• emotional and physical neglect The prevalence of BN, AN, and OSFED “rates were
(including food deprivation) significantly higher only in subjects with histories of
• teasing, and bullying (Mitchell). rape with PTSD compared with subjects with histories
of rape without PTSD. These results suggest that it is
PTSD, rather than an abuse history per se, that best
forecasts the emergence of EDs (Brewerton).
Sack M, Boroske-Leiner K, Lahmann C.
 Client Profile

• 18-year-old cis gendered, bisexual, female using she/her pronouns

• Client legal initials are SB but prefers SH and to use mother’s maiden name

• Freshman at Berkley school of Music (taking semester off for treatment)

• Recording artist, records and uploads her own music; enjoys singing and playing guitar

• Lives with mother, father is deceased

• Insurance: PPO Blue Cross Blue Shield

 Background Information

• Restrictive patterns began in 2015

• Eating patterns escalated in 2018 after father sexuality assaulted client
• At this time client was recommended IDP but declined
• Client’s father successfully completed suicide in 2018, further complicating trauma and exacerbating
restrictive eating patterns
• Client was recommended residential at this time but declined
• Completed 6 weeks at east metro IDP -> step down to IOP but was not there long
• After graduating high school, eating became a lot worse. Client noted functional impairments and
needing help regulating eating patterns as reason for dropping out of college to enter SLP IDP
• ◦18lb lost in last 9 months
 Diagnosis & ED
Behaviors

Client original diagnosis on 9/23/2020 was other specified feeding or eating disorder (F50.89)

At time of discharge to Como IDP:

Primary Diagnosis: Anorexia Nervosa, restricting type (severe) (F50.01)

Behaviors:
• Rigid Food Rules/rituals
• Fixation on weigh, size, shape
• Restricting
• Trauma-related fear of foods—more foods seem to be added to list every week
 Restriction
Eating
Disorder
Avoidance and frustration around food

Behaviors
Small portions, inconsistency, lack of
variety
Specific food/nutrient restriction (i.e no
red meat unless it’s McDonald’s Burgers)

Denies: compensatory behaviors,

binge/purge, over exercise

Food Rules and

Rituals
Safe Foods:
- Dilly bars, chocolate, slim jims,
pretzels, strawberries
Fear foods:
- pasta, pizza, food priorly prepared
by father, breakfast foods
 Client reports body dissatisfaction as a 10/10.
Client reported body checking, mirror
avoidance, and fear of wearing certain “tight”.
When client discussed GWR with RD, she
resisted for several weeks, stating “150lbs is a
Fixation on fine weight to be”. RD and therapist worked to
explore this fixation in sessions during 7 weeks
Body weight at SLP.

and Size
 Weight History

• Admin weight: 140lbs

- Lowest weight: 138lbs - Highest weight: 165lbs

Ht: 5’11 Ht: 5’11
Age: 16 Age: 18
BMI: 18.8 BMI: 23
Weight Progress
 Vitamin D deficient  Client prescribed supplement, 2,000
IU/day
History of anemia
GI Distress
High Cholesterol

Nutritional
Implications Feeling cold when others are not
Cramping in lower abdomen “all the time”
& Medical Difficulty remembering things
Fatigue and dizziness
information Most recent vitals all normal; high cholesterol was
detected in last blood draw
 Current Medications

• Risperdone, .5mg
• Lorazapem, 50mg
• Vitamin D supplement, 2000 IU
• Pristiq, 0.5mg
Medications • Clonazepam 0.5mg
• Prazosin 1mg
Prior treatment
 Behavioral Health
• Other behavioral health diagnoses:
– OCD in July 2020
– Depression since age 12 (April 2012)
– PTSD from events in 2018
– Past hx of passive thoughts of self-injury and
suicidality
• On 11/03 Client was rushed to ER for suicidal thoughts.
Client voluntarily checked themselves into facility

– Anxiety since young age, has past of separation

anxiety from mom; social anxiety since 2012
 PES Statement

• Disordered eating pattern related to history or trauma, need for control, body image
distress as evidenced by client’s report of restriction and recent weight loss.
• Client meets criteria for OSFED at admission to SLP on 9/23.
• Upon leaving to Como, diagnosis changed to AN restrictive subtype

Inadequate intake related to history of trauma need for control, body image distress
as evidenced by recent increase in restriction and recent weight loss.
 .

Admitted 9/30/2020
Treatment team:
Family Therapist: Emileah Most
Therapist: Angela Schaeppi-Lauer, LPC
Dietitian: Jessica Lind, MS RD
Psychiatrist: Susan Swigart, MD
Yoga instructor: Sandra Barry
Physician assistant: Melanie Dolezal, PA
Initial Assessment
Ht: 5’10’’ Wt: 140 BMI: 19.2
Goal Weight Range (GWR): 155-165lbs

Caloric Needs based off Harrison Benedict Equation: 2390 kcal/day (177cm
x13.5kcal/cm); + 500kcal/day for 1lb a week restortatiom; =2890kcal/day
+1000kcal/day for 2lb a week restoration= 3890kcal

Initial estimated provided needs: 3075kcal/day

Estimated needs at week 4 of treatment: 3450kcal/day

 Diet History
Typical Day
24 hour recall
• B- (10am) 1 or 2 ice cream bars and
a slim jim • B- 1 dilly bar, 2 slim jims,
• L- skips lemonade
• S- 2pm pizza rolls OR chips OR baked • S- none
potato • L- none
• D- entrée and a side (chicken and • S- pretzels with strawberries,
rice OR steak mashed potatoes/
corn) caramel
• S- ice cream chocolate, cake, • D- 1 slice pizza
cookies, brownies • S- none
• Beverages- lemonade, water, coke,
 What is a tally? What is a
“choice”?

A tally is a serving of an element in a meal such as 1 grain, 2 proteins,

1 fat, etc. The elements are grains, fat, fruit, vegetable, protein, and
dessert.

Often time in adult programming we use this model of meal plan to

meet client’s energy needs

A “choice” is often used in adolescent care since it is simpler to

measure. Choices are also portions of different elements.
 What is a tally? What is a
“choice”?
3 choice breakfasts:
• Fruit smoothie (1 cup fresh/frozen fruit, ½ cup juice/milk, ½ cup yogurt)
• English muffin with spread (butter or nut butter) + fruit or glass of milk
• ½ bagel with cream cheese + glass of milk or piece of fruit
4 choice breakfasts:
• 2 slices toast with butter and jam/jelly
• 2 Pop-Tarts or frozen waffles with butter and syrup
• Medium bagel with cream cheese/butter/nut butter on both halves
• Yogurt parfait (1 container flavored yogurt, ~ ¼ cup granola, ~ 1 cup fruit)
5 choice breakfasts:
• 2 frozen waffles with butter/nut butter and syrup
• Bakery muffin/scone/croissant/cinnamon roll/donut + milk
 SLP Meal Plan
P M V D FR F O

B
5 choices + 12 oz beverage
S
Snack List B + Beverage
L
Entrée and 2 sides +12 oz beverage
S
Snack List B + Beverage
D
Entrée and 2 sides + 12 oz beverage +dessert
S
Snack List B
 Session Assessment
Summary

• Client had strong urges

￭ Client would use essential oils to ease fullness and GI distress after meals
￭ Client never reported acting on urges during programming (i.e restriction through lying about food consumed, purging)
• Client rated Body Image (BI) as huge factor of dissatisfaction and struggle
⚬ Mirror avoidance, body checking, loose baggy clothing
⚬ Dissatisfaction 10/10—working toward exploring how to improve with therapist and RD
• Trauma foods: Breakfast foods, sandwiches, foods prepared by dad, meats, phallic shaped foods
• Motivation to get back to school and perform
⚬ I want to leave MN” “I miss my friends”
• Client could not give full control to RD or Therapist
⚬ Client had therapist in past, good relationship with them
 Nutrition Goals
LONG TERMS GOALS
• W E I G H T R E S T O R AT I O N T O 1 5 5 - 1 6 5 L B S
• E AT 5 - 6 T I M E S P E R D AY
• I N C O R P O R AT I N G VA R I E T Y I N T O M E A L S &
SNACKS
• BECOME INDEPENDENT WITH FOOD--
MAKING FOOD, BUYING FOOD, ETC
• B E H E A LT H Y, S A F E , " B E W H O I WA N T T O
BE".
Discharge Summary
◦ C L I E N T d i s c h a r g e d o n 11 / 1 0 f r o m S L P a f t e r 7
weeks of treatment

◦ D i s c h a r g e d t o s a m e L O C , d i ff e r e n t l o c a ti o n
◦SLP IDP --> COMO IDP

◦Gained 3.5 lbs during stay

◦ W i l l c o n ti n u e w i t h s a m e m e a l p l a n
◦Client reported the use of symptoms
c o n s i s t e n t l y t h r o u g h o u t ti m e a t S L P
Future of Client
• Continuation of family therapy is essential
• Client needs to be ready to change
• Still needs to work on trauma in order to completely
recover form ED
⚬ Several foods still associated with father
• Hope is that client will receive better support as a result
of transitioning from young adult --> adult group
• Telehealth
• Rapport
•
•
Collaboration WHAT DID I LEARN?
Meal Plan set up (tallies vs entrée/side)
• Medical information, lab values
• How to ask for help
• Dealing with client

The Emily Program has one of the most efficient,

compassionate, and collaborative teams I’ve ever seen
in ED care. TEP truly is a family and I am so grateful
to have had the chance to intern here.
References:

Mitchell KS, Mazzeo SE, Schlesinger MR, Brewerton TD, Smith BN.
Comorbidity of partial and subthreshold PTSD among men and
women with eating disorders in the National Comorbidity Survey-
Replication Study. The International Journal of Eating Disorders.
2012;45(3):307-315. doi:10.1002/eat.20965.

Brewerton, Timothy D. Eating disorders, trauma, and comorbidity:

focus on PTSD. The Journal of Treatment & Prevention. 2007;15(4):
285-304. doi:10.1080/10640260701454311

Sack M, Boroske-Leiner K, Lahmann C.  Association of nonsexual

and sexual traumatizations with body image and psychosomatic
symptoms in psychosomatic outpatients.  Gen Hosp Psychiatry.
2010 May-Jun; 32(3):315-20