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7/6/2011

Eating Disorders: Harm vs. Help

Stephanie Casey, MD, FRCPC

In your classrooms many students with both diagnosed and undiagnosed eating disorders go undetected.

IWK Health Centre Dalhousie Department of Psychiatry

Academy in School Mental Health

Academy in School Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

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

Goals for Today Achieve a realistic awareness of eating disorders. disorders Identify early warning signs. Discuss strategies to support students

Why is it so important to properly assess and diagnose eating disorders?

with eating disorders and their families. Academy in School Mental Health

Academy in School Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

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7/6/2011

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, either by medical complications or suicide Now estimated that 10-20 % occur in males and the rate appears to be increasing.

ANOREXIA BULIMIA

Academy in School Mental Health

Academy in School Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

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 Nervosa, Bulemia Nervosa, Eating Disorder Not Otherwise Specified (B.N. only determined to be a mental illness in 1979)

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

Academy in School Mental Health

Academy in School Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

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 consecutive menstrual cycles.

Academy in School Mental Health

Academy in School Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

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7/6/2011

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.

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

Academy in School Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Bulimia Nervosa (BN) Subtypes

Eating Disorder Not Otherwise Specified (EDNOS)

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.

Disorders of eating that do not meet the criteria for any specific Eating Disorder

Academy in School Mental Health

Academy in School Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

85% of patients assessed in specialty clinics (including g IWK Health Centre) are diagnosed with ED NOS

Being diagnosed ED NOS does not mean you are less ill than patients diagnosed with AN or BN!

Academy in School Mental Health

Academy in School Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

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7/6/2011

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.

Effects of Starvation on the Brain Low mood 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

Academy in School Mental Health

Academy in School Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Effects of Starvation on the Body Minnesota Semi-Starvation Experiment November 1944 – December 1945 Ancel Keys

Cardiovascular Bradycardia and hypotension Sudden death – arrythemia Mitrol valve prolapse Dermatological Dry skin Thinning g dry y hair Lanugo hair Starvation associated Puritis Gastrointestinal Constipation Hepatitis

Academy in School Mental Health

Academy in School Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Endocrine/Metabolic Amenorrhea Infertility Osteoporosis Cold intolerance Hypothyroidism Hypoglycemia yp g y Arrested growth Hematologic Pancytopenia Decreased ESR Neurologic Cerebral Atrophy Pulmonary Respiratory Failure

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 Sudden Death Cardiomyopathy

Endocrine Irregular menses

WHAT CAUSES AN EATING DISORDER? WE DON’T KNOW. KNOW

Metabolic Hypokalemia Dehydration Neprhropathy Metabolic alkalosis

Academy in School Mental Health

Academy in School Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

4


7/6/2011

What might place a child more at risk of developing an Eating Disorder?

We do know 75-80% start with a diet to lose weight. weight

GENETIC VULNERBILITY (the Emma story)

Academy in School Mental Health

Academy in School Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

What might place a child more at risk of developing and Eating Disorder? Individual characteristics, i.e.: gender anxious or obsessive temperament using any unhealthy weight control measures low self-esteem

What might place a child more at risk of developing an Eating Disorder? Family Influence encouragement of dieting over-focus on p physical y appearance pp negative attitudes about others who are overweight few structured meals

Academy in School Mental Health

Academy in School Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

What might place a child more at risk of developing an Eating Disorder?

Sport and School Influence

Peer Influence: friends who are dieting g

Teachers’ and coaches’ attitudes and beliefs can have a huge g influence f on students.

weight teasing competition with friends

Academy in School Mental Health

Academy in School Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

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7/6/2011

Media

Academy in School Mental Health

Academy in School Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Academy in School Mental Health

Academy in School Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Media Literacy

Media images and advertising help to create and p perpetuate p 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.

Teaching our Youth to Become Media Literate Become a critical consumer of advertising and media messages. Pay attention to images, messages or attitudes that give you self-doubt, or make you feel bad about 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 and self-esteem. 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

Academy in School Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

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7/6/2011

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 retouched and enhances in a way that supposedly makes the products being sold more appealing. When we spend money trying to make ourselves look like their images, they keep on g money. y making 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 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.

Identifying and Referring At Risk Students Rule of thumb: Treat any warning signs seriously. Early intervention may greatly improve the prognosis. Error on the side of caution.

Academy in School Mental Health

Academy in School Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

What Should Educators Do? Keep clear records. There is a good chance students and parents will react negatively to any 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.

Support Strategies

The challenge for the classroom teacher is to provide a supportive p pp and safe f learning g environment that does not contribute to the students’ obsessive attention to food, weight gain or body image.

Academy in School Mental Health

Academy in School Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Build a Support Network at Your School “Case Manager” Communicate regularly with the youths medical treatment team. Communicate with parents. Ensure restrictions, supports needed are communicated to appropriate staff.

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 students harmful weight loss “tricks” such as purging and severely restricting food intake, which they may I turn eperiment with.

Academy in School Mental Health

Academy in School Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

7


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 to PREVENT eating disorders. To prevent eating disorders, eating disorders curriculum should focus on some of the following: 1 T 1. Teach h children hild the th health h lth hazards h d off dieting. Dieting is a risk factor for the development of an eating disorder, therefore preventing students from dieting is key in preventing eating disorders.

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 and body image struggles 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, steroids, or metabolife and teach them why these substances are harmful.

Academy in School Mental Health

Academy in School Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

One last note: Having someone who has had an eating disorder come and speak can be very powerful. However it is important that the speaker not talk about their behaviours (as they might teach the students weight l loss “tricks”), “ k ) numbers, calories, l their h weight(s), h ( ) etc. (as some students might fixate on the numbers and adopt them as their goal weight/calorie intake, etc.). The speaker should instead focus on feelings, the experiences that lead up to the development of the disorder and the consequences.

Helpful things to remember when talking to youth suffering y ff g with an eating g disorder.

Academy in School Mental Health

Academy in School Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

QUESTIONS

The patient views herself and all things food and exercise related thru a lens f tainted by the eating disorder. When it comes to food, eating, and weight you are not dealing with a patient that is rational.

Academy in School Mental Health

Academy in School Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

8


7/6/2011

COGNITIVE DISTORTIONS Patient feels good about refusing to eat because she does it well despite the fact significant weight loss can be life threatening. To us it’s a deadly disease, to her it’s a perfectly healthy diet.

COGNITIVE DISTORTIONS The patient views the parents and 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, eating.

Academy in School Mental Health

Academy in School Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

COGNITIVE DISTORTIONS

No matter how emaciated the patient becomes, she looks in the mirror and sees “FAT”.

HEALTHY = FAT

Academy in School Mental Health

Academy in School Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

AVOID GETTING C GHT UP CAUGHT P IN N AN N “ANOREXIC DEBATE”

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 disorder rule.

Academy in School Mental Health

Academy in School Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

9


7/6/2011

10 THINGS NOT TO SAY You don’t look so bad to me. Wow, you look so healthy. You look like a refugee, refugee AIDS patient, patient cancer sufferer. You’re just doing this for attention. But you’re such a pretty girl, you don’t need to do this.

Academyin School Mental Health

Academy in School Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

10 THINGS NOT TO SAY

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 am obese.

Why don’t you just eat! (Let me get a pen and write that down. down I have never heard such good advice)

If you don’t eat that you’ll get the tube. Academy in School Mental Health

Academy in School Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

10 THINGS TO SAY/DO What can I do to support you?

Don’t talk about weight or appearance at all. all No calories, No numbers.

Listen and try to understand. Be caring and concerned. You are thinking so much more clearly. It’s so good to see your sense of humour.

Academy in School Mental Health

Academy in School Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

10


7/6/2011

10 THINGS TO SAY/DO

Eating Disorder Patients…

6. Your concentration has really improved. 7. I know it’s hard but “Food is your medicine”. 8. It It’ss so nice to see more of your personality coming thru. 9. You think you are in control, but it’s your eating disorder that’s fully in charge. 10. Remind the patient she is not alone.

Use the disorder as their default mode of coping in a maladaptive way. Lie about eating disorder behaviours. This is done out of shame, guilt, and fear and is a symptom of the disorder, not necessarily character.

Academy in School Mental Health

Academy in School Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

Presented by: Sun Life Financial Chair in Adolescent Mental Health

QUESTIONS

“CHILDREN DO WELL IF THEY CAN. IF THEY CAN’T, WE AS ADULTS NEED TO FIGURE OUT HOW WE CAN HELP” (Ross Greene)

Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health

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