7/6/2011
Eating Disorders: Harm vs. Help
Stephanie Casey, MD, FRCPC IWK Health Centre Dalhousie Department of Psychiatry
Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
In your classrooms l ss ms m many n st students d nts with both diagnosed and undiagnosed eating disorders go undetected.
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Eating Disorders are serious mental illnesses with devastating psychological and physical consequences. Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
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Goals for Today Achieve a realistic awareness of eating disorders. Identify early warning signs. Discuss strategies to support students with eating disorders and their families. Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
Why is it so important to properly assess and diagnose eating di d disorders? ? Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
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3rd most common chronic illness in adolescent females Incidence of up to 5% - 1% AN, 4% BN 80% onset before age 20 Rate dramatically increasing over past 3 decades Highest mortality rate of any psychiatric disorder, disorder either by medical complications or suicide Now estimated that 10-20 % occur in males and the rate appears to be increasing. Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
ANOREXIA BULIMIA
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Diagnostic and Statistical Manual of Mental Disorders CLASSIFICATION SYSTEM (published by American Psychiatric Association)
DSM ITM – 1952 – initial emphasis was to gather statistical information for research purposes. 60 disorders – 1 E.D. – Anorexia Nervosa DSM IVTM – 1994 – 200 disorders – Anorexia N Nervosa, Bulemia B l i Nervosa, N Eating E ti Di Disorder d Not Otherwise Specified (B.N. only determined to be a mental illness in 1979) Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
TM
Current Edition – 2000 – DSM-IV-TR (text revision) Binge Eating Disorder is a provisional disorder
DSM VTM – will be published in 2013 - still evolving
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Anorexia Nervosa (AN) A refusal to maintain body weight above 85% of that expected. Intense fear of gaining weight. Disturbance of the experience of one’s body weight or shape. Amenorrhea or the absence of three Amenorrhea, consecutive menstrual cycles.
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Anorexia Nervosa (AN) Subtypes Restricting Type – Person has not regularly engaged in binge eating or purging behaviour (ie. Self-induced vomiting or misuse of laxatives, diuretics). Binge Eating/ Purging Type – Person has regularly engaged in binge eating or purging behaviour.
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Bulimia Nervosa (BN) Recurrent episodes of binge eating Large amount of food Loss of control
Compensatory Behaviour Twice a week for three months Evaluate self by body image Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
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Bulimia Nervosa (BN) Subtypes Purging Type – Regularly engages in selfinduced vomiting or the misuse of laxatives/ diuretics. Non-purging Type – Uses other inappropriate compensatory behaviours such as fasting or excessive exercise. exercise
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Eating Disorder Not Otherwise Specified (EDNOS)
Disorders of eating that do not meet the criteria for any specific Eating Disorder
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85% of patients assessed in specialty clinics (including IWK Health Centre) are diagnosed with ED NOS
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Being g diagnosed g ED NOS does not mean you are less ill than patients diagnosed with AN or BN!
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Assessment
Most of the signs and symptoms seen in eating disorders are the effects of severe starvation, chaotic eating or purging on the brain and body. Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
Effects of Starvation on the Brain Low L w mood m Decreased motivation, decreased energy, lethargy Isolating, lack of interest in others Irritability Obsessive, stuck thinking Constant thinking about food Decreased memory and decreased concentration Behaviours such as cutting food into tiny pieces, small bite sizes, binging behaviours
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Minnesota Semi-Starvation Experiment November 1944 – December 1945 Ancel Keys
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Effects of Starvation on the Body Cardiovascular Bradycardia and hypotension Sudden death – arrythemia y Mitrol valve prolapse Dermatological Dry skin Thinning dry hair Lanugo hair Starvation associated Puritis Gastrointestinal Constipation Hepatitis
Endocrine/Metabolic Amenorrhea Infertility y Osteoporosis Cold intolerance Hypothyroidism Hypoglycemia Arrested growth Hematologic Pancytopenia Decreased ESR Neurologic Cerebral Atrophy Pulmonary Respiratory Failure
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Effects of Purging on the Body Gastrointestinal Dental Erosions Parotid Gland Swelling Esophageal Rapture GE Reflux Constipation Cathartic Colon Mallory Weiss Tear
Pulmonary Aspiratin pneumonitis
Cardiac Arrthythmias and dd D h Death Sudden Cardiomyopathy
Endocrine Irregular menses
Metabolic Hypokalemia Dehydration Neprhropathy Metabolic alkalosis
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WHAT CAUSES AN EATING DISORDER? WE DON’T KNOW.
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We do know 75-80% start with a diet to lose weight.
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What might place a child more at risk of developing an Eating Disorder?
GENETIC VULNERBILITY (the Emma story)
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What might place a child more at risk of developing and Eating Disorder? characteristics i.e.: ie: Individual characteristics, gender anxious or obsessive temperament using any unhealthy weight control measures low self-esteem
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What might place a child more at risk of developing an Eating Disorder? Family Influence encouragement of dieting over-focus on physical appearance negative attitudes about others who are overweight few structured meals
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What might place a child more at risk of developing an Eating Disorder? Peer Influence: friends who are dieting weight teasing competition with friends
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Sport and School Influence
Teachers’ and coaches’ attitudes and beliefs can have a huge influence on students.
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Media
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Media Literacy
Media images and advertising help to create and perpetuate social and cultural definitions of beauty and attractiveness which provide the context in which we learn to place value on appearance and the size and shape of our body.
Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
Teaching our Youth to Become Media Literate Become a critical consumer of advertising and media messages. Pay attention to images, messages or attitudes h give i you self-doubt, lf d b or make k you f d about b that feell b bad your body. Voice your opinion and protest the negative images and messages you see by writing letters to advertisers, television stations and movie studios. Encourage the media and advertisers to present more diverse and real images of people that promote positive messages of beauty, health fb t h lth and d self-esteem. lf t Remember that the primary goal of the fashion, cosmetic, diet, fitness and plastic surgery industries is to make money, not to help you to reach your fullest potential and be the best person that you can possibly be. Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
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Teaching our Youth to Become Media Literate Remind yourself that the print ads you see in magazines are all photographed with special lighting and then digitally h d and d enhances h i a way that h supposedly dl makes k the h retouched in products being sold more appealing. When we spend money trying to make ourselves look like their images, they keep on making money. Question the motives of these companies and their advertisers, and make sure the hard-earned money you spend reflects the person you are, not the person that the media and advertisers want you to be. be Be a role-model to yourself and others. Develop your own style and celebrate who you are. Break free from the way our society and culture expects you to look.
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Identifying and Referring At Risk Students f thumb: Rule of Treat any warning signs seriously. Early intervention may greatly improve the prognosis. Error on the side of caution. Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
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What Should Educators Do? Keep clear records. There is a good chance parents w will react negatively students and p g y to any y suggestion there is an eating disorder. Your notes should focus on specific observed behaviours. Consult with other professionals (i.e. other teachers, school guidance counsellor, ) administrator). Do not be afraid to breech student’s confidentiality. These illnesses can be fatal! Develop ongoing support strategies. Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
Support Strategies
The challenge for the classroom teacher is to provide a supportive and safe learning environment that does not contribute to the students’ obsessive attention to food, weight gain or body image. image
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Build a Support Network at Your School “Case Manager” Communicate regularly with the youths medical treatment team. Communicate with parents. Ensure restrictions, restrictions supports needed are communicated to appropriate staff.
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A Word of Prevention The research shows that providing presentations to students about eating disorders – presentations that inform them about the behaviours, signs, symptoms, health consequences, etc. are ineffective in preventing eating disorders and may actually backfire by glamorizing eating disorders and teaching g students harmful weight g loss “tricks” such as purging and severely restricting food intake, which they may I turn eperiment with.
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7/6/2011
It is useful to provide some education about eating disorders, but it is unnecessary (and potentially harmful) to go into great detail. The goal in teaching/presenting on eating disorders should be tto PREVENT e eating tin dis disorders. rders T To prevent eating disorders, eating disorders curriculum should focus on some of the following: 1. Teach children the health hazards of dieting. Dieting is a risk factor for the development of an eating disorder, therefore preventing students from dieting is key in preventing eating disorders.
Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
2. Teach children respect and tolerance for diversity of body sizes. Establish a zero tolerance policy on teasing about body size. 3. Help children identify the conditions in their lives that contribute to their eating g and body y image m g struggles gg and assist them in finding their own solutions. 4. Teach children to listen to their bodies; to eat when they are hungry, stop when they are full, and to eat the foods that nourish them and give them energy. 5. Teach children to be critical viewers of the media so that they are better able to resist harmful media messages. 6. Teach children to respect and honor their bodies by not using diet pills pills, steroids steroids, or metabolife and teach them why these substances are harmful.
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7/6/2011
One last note: Having someone who has had an eating disorder come and speak can be very powerful powerful. However it is important that the speaker not talk about their behaviours (as they might teach the students weight loss “tricks�), numbers, calories, their weight(s), etc. (as some students might fixate on the numbers and p them as their goal g weight/calorie g intake,, etc.). ) adopt The speaker should instead focus on feelings, the experiences that lead up to the development of the disorder and the consequences. Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
Helpful things to remember when talking to youth suffering with an eating disorder.
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QUESTIONS
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The patient views herself and all things food and exercise related thru a lens tainted by the eating disorder. When it comes to food, eating, and weight you are not dealing with a patient that is rational. rational
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7/6/2011
COGNITIVE DISTORTIONS d ab ut refusing refusin to t eat Patient feels good about because she does it well despite the fact significant weight loss can be life threatening. To deadly disease, tto h her it’s T us it’s it’ a d dl di it’ a perfectly healthy diet.
Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
COGNITIVE DISTORTIONS Th patient p ti nt views vi s th r nts and nd th The the p parents the treatment team as the enemy, even though we are trying to help them fight their disease. We are forcing them to do the one thing they are trying to avoid, avoid eating. eating
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COGNITIVE DISTORTIONS
No matter how emaciated the patient becomes, she looks in the mirror and sees “FAT”.
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HEALTHY = FAT
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7/6/2011
AVOID GETTING CAUGHT UP IN AN “ANOREXIC ANOREXIC DEBATE DEBATE” Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
Remember the patient has an inner critic with “rules” (as many as 220) and our job is to help them fight to challenge the eating di d rule. disorder l
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7/6/2011
Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
10 THINGS NOT TO SAY You don’t look so bad to me. Wow, you look so healthy. You look like a refugee, AIDS patient, cancer sufferer. You re just doing this for attention attention. You’re But you’re such a pretty girl, you don’t need to do this. Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
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10 THINGS NOT TO SAY I wish I could have anorexia for a day. I have an eating disorder too – I eat all the time. If you think you’re fat, you must think I m obese.. am If you don’t eat that you’ll get the tube. Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
10 THINGS NOT TO SAY Why don’t you just eat! (Let me get a pen and write that down. I have never heard such good advice)
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7/6/2011
Don’t talk about weight or appearance at all. No calories, No numbers.
Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
10 THINGS TO SAY/DO What can I do to support you? Listen and try to understand. Be caring and concerned. You are thinking so much more clearly. clearly It’s so good to see your sense of humour. Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
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10 THINGS TO SAY/DO 6. Your concentration has really improved. 7. I know it’s hard but “Food is your medicine”. 8. It’s so nice to see more of your personality coming thru. y 9. You think y you are in control,, but it’s your eating disorder that’s fully in charge. 10. Remind the patient she is not alone. Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
Eating Disorder Patients… dis rder as their default mode m de of f Use the disorder coping in a maladaptive way. Lie about eating disorder behaviours. This is done out of shame, guilt, and fear and is a symptom of nott necessarily t f the th disorder, di d il character.
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QUESTIONS
“CHILDREN DO WELL IF THEY CAN. IF THEY CAN’T, WE AS ADULTS NEED TO FIGURE OUT HOW WE CAN HELP” (Ross Greene)
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