Rapport key to treating teen eating disorders

The world of adolescent girls can be tumultuous, and puberty can trigger a healthy weight gain. But the pressure to measure up to willowy supermodel proportions remains unrelenting. Many teens end up dancing around the edges of potentially deadly eating disorders such as anorexia nervosa or bulimia.

An August 2004 University of Toronto study on eating disorders found that between 1994 and 1999, the incidence of eating disorders in B.C. was the highest in Canada at 15.9 per 100,000 women. Alberta and Saskatchewan had the lowest incidence at 8.6 per 100,000. Although the numbers don't break down by age, experts say the average onset is between 14 and 16. They also say these numbers are conservative, as eating disorders are widely underreported.

Fortunately, a vigilant family doctor can spot the first signs of such disorders before they become much more difficult to manage. In fact, the general practitioner or pediatrician is crucial because families often turn to them first for help, says Dr. Ron Manley, clinical director of the B.C. Children's Hospital Eating Disorders Clinic for Children and Adolescents, which deals with the more extreme cases of disordered eating.

"GPs or pediatricians are the entry point into the process," Manley said in a telephone interview with the Georgia Straight. "And early detection and referral, before the disorder is entrenched or intertwined with the patient's sense of who they are, can make the difference between a successful outcome or not." As can the doctor-patient relationship itself.

Throughout her career as a Lower Mainland family physician, Dr. Joan Fujiwara, who now works out of the Surrey Youth Clinic at Surrey Memorial Hospital and in the South Fraser Eating Disorder program, has made a point of establishing good relationships with adolescents. At a time when many teenagers stop going to the doctor, Fujiwara encourages them to come and see her on their own-and keeps open a crucial window into their world and the often subtle early signs of eating disorders.

"Some of the initial signals," said Fujiwara by phone, "are common to lots of teenage girls. Concern about weight, their appearance, and dieting-these are not unusual." Such behaviours should be looked at in conjunction with other less obvious risk factors, said Fujiwara, such as whether or not there is a family history of eating disorders, whether or not the parents or siblings make adverse remarks about eating or weight, and whether or not obesity tends to run in the family.

If all the signs point to an eating disorder, the GP can take the first step in the long process of treatment, but it should not leave a heavy footprint, Manley emphasized. "The confrontational approach that was once used in treating these patients has been replaced by a much more collaborative model, in which patients are more involved in their own care."

Up until about the mid-'90s, being diagnosed with an eating disorder was a little like receiving a prison sentence. You could expect enforced bed rest, tube feeding, isolation from family, and only one way to earn back privileges: gain weight. You had no control over what happened to you and no voice in your treatment. The word parentectomy, referring to the notion that a separation from parents was needed for treatment to proceed, actually made its way into the precollaboration literature.

Although well-meaning, such coercive methods were so traumatic they discouraged patients from seeking treatment again.

Today things couldn't be more different. Even in an intensive treatment program like the one at Children's, patients are not forced to rest, tube feed, or be isolated from family. "There's an increased emphasis on the rights of children and adolescents to have input into their own care," said Manley. Consequently, they can interact with family, eat in the dining room, and exercise, beginning with supervised eating and a fitness-for-fun program that emphasizes reconnecting with the body. When ready, patients can assume higher levels of responsibility: eating unsupervised with friends or cardiovascular or strength training. The point is the patients decide, in collaboration with the health-care team, if and when they are ready for more responsibility.

The approach is more about a philosophy than the bits and pieces of a program, Manley observed. "We know more about motivation now, that it's a function not just of the patient, but of the interaction between patient and caregiver. That's why rapport is so important. We also understand that the motivation to change varies and that treatment must be oriented to the stage the patient is in. If someone is at the precontemplation stage, where they are saying to themselves, 'I don't need to change,' you can't treat them as if they are in the 'action' stage. It's counterproductive."

Manley cites the example of a young girl in the early stages of an eating disorder who comes in with her parents for an assessment. She may be angry; almost certainly she'll be ambivalent about getting treatment. "At this precontemplative stage, we'll concentrate on developing a relationship, acknowledging her voice. We won't push anything. Our main goal is to resolve her ambivalence about getting help and to reinforce that this is a place they can come back to for treatment when they are ready."

For general practitioners, the collaborative approach can take some adjusting to, pointed out Fujiwara. "We are used to being prescriptive. We learn to take action, to fix the problem, and as quickly as possible." But given what's at stake, the long slow approach is well worth learning.