Equine Therapy: Donkeys Have an Important Role

Donkeys have a special place in our history, carrying wounded soldiers in World War I and bearing miners’ tools underground in the gold rush.

But for all that laboring, the humble donkey has had little respect and understanding. Australian psychiatrist May Dodd may be the donkey’s best human friend.

Dr. Dodd  runs Victoria’s only donkey hospital and refuge, at her Diamond Creek property and in Tongala. In the days following the Black Saturday bushfires, Dr Dodd evacuated 91 donkeys, on cattle trucks, to safe ground near Echuca. She drove her donkey ambulance through police roadblocks into places such as Kinglake, Chum Creek and Dixons Creek, while the ground was still smouldering.The psychiatrist has cared for more than 300 donkeys in the past 13 years at her home on Ironbark Road, where she also runs her private medical practice full time. The last fire-affected donkey, Moomba, went back home to Humevale just a few months ago, still partially blind from burnt eyes.

Dr Dodd says donkeys and psychiatry may seem an odd match, but they complement each other.

”One is all about the mind and the other is mostly physical work, so it’s a great balance,” she says. ”I have this propensity to protect minority or marginalized groups. Mentally ill patients are often shunned and donkeys are also forgotten by society. But donkeys also have a calm tranquility about them which I, and my patients, enjoy.”

”Donkeys are more dog-like than horse-like; they are inquisitive, affectionate and like to follow you around for a pat.”

Her father was a horse jockey from age 10 in Newmarket, the headquarters of British racing, but Dr. Dodd was always terrified on a horse, preferring the donkey’s slower gait.

But no matter how often he put his only child on a horse, she was always terrified. Instead, she preferred a donkey’s slow plod.

Dr Dodd broke with the family horsing tradition when she completed her medical degree at the University of London.

Not long afterwards, in 1981, she responded to an advertisement calling for doctors to come to Australia. She was meant to work for just two months at the Plenty Valley Repatriation Psychiatric Hospital, but never left.

Dr Dodd sees about 26 patients a week in Diamond Creek, where she lives alone, and cares for the donkeys in her spare time. ”Initially I took a few donkeys on because I had the space” but she had a  difficult time turning any away.

She lends donkeys for work with troubled children and events like Remembrance Day.

The above is excerpted from:

A caring operation that’s run for donkeys’ years

Marika Dobbin

January 5, 2011

Lisa Kantor Responds to Dr. Oz’s Show on Eating Disorders

This article first appeared in the Bradenton Herald

Lisa S. Kantor: An Open Letter to Dr. Oz

By Lisa S. Kantor

Posted: 7:53pm on Mar 19, 2012; Modified: 7:58pm on Mar 19, 2012

LOS ANGELES, March 19, 2012 — /PRNewswire/ — Along with countless professionals and families dealing with the physical, emotional and financial consequences of eating disorders, I am deeply disturbed by the way your recent program, “Dying to Be Thin: Meet the Skinniest Women in America,” had the unintended effect of glamorizing the deadliest of all mental illnesses. Rather than documenting the tragedy associated with eating disorders and providing encouragement to sufferers to seek help, you perpetuated myths about the disease and provided harmful information to millions. I believe this show did more harm than good. As a physician, you have a responsibility to improve your coverage of eating disorders in future shows.

“Dying to Be Thin,” while tantalizing, serves to perpetuate one of the deadliest misconceptions about eating disorders. People with eating disorders are not necessarily “skinny” or “thin,” and certainly not everyone who dies from an eating disorder is underweight. In fact, many people die at a very normal weight, especially if they have bulimia. You mentioned on your show that the “more acute cases” were the “thinner” women. That myth is also dangerous to disseminate. Those who weigh less than others are not necessarily “more acute” than others at a “healthy weight.” That misconception has long created stigmas associated with eating disorder sufferers and has often led to under-treatment by physicians who think that because a woman is not thin, she is not as acute. Your focus on thinness did a grave disservice by failing to educate your audience scientifically about what eating disorders really look like.

In giving air time to the Pro-Ana movement, you referred to it as “a dangerous new trend that helps women be skinny at any cost.” The Pro-Ana movement is not new. Pro-Ana (and Pro-Mia) sites have been around since the dawn of the Internet. Far from being “trendy,” they are a very dangerous facet of an eating disorder underground that preys on the mentally ill. Had you consulted an eating disorders expert, you would never have offered your audience direct access to the websites and their images. Studies show that doing so causes harm. One study, on college-aged women (none of whom had eating disorders), discovered that after viewing pro-eating disorders websites, 84% reduced their calorie intake by more than 2,000 calories per week. Only 56% of the women realized they were eating less. Results of the study also indicated that the women exposed to the pro-eating disorders website had decreases in self-esteem and perceived attractiveness.

My days are spent in and out of federal courts battling insurance companies that deny benefits for seriously ill women and men who seek adequate treatment for their diseases – even though a federal law and many state laws mandate that insurers provide similar levels of treatment for mental illnesses as they provide for physical illnesses.  Shows such as the one you aired trivialize this disease and undermine the progress well-respected groups such as the International Association for Eating Disorders Professionals, the Eating Disorders Coalition, the National Eating Disorders Association, and the Binge Eating Disorder Association have achieved. Still, getting the national media to take eating disorders seriously without parading dangerously thin women across the television screen is about as difficult as getting an insurance company to pay for a therapeutic length of stay at a residential treatment facility.

It is hard for me to believe that either you or your staff did any legitimate research about eating disorders before planning the programs. Were you aware that professionals in the eating disorder field were in touch with producers at your show in recent months offering the benefits of their expertise free of charge should you plan to air segments about eating disorders? Those calls and e-mails appear to have been ignored.

You owe it to your many viewers to correct the harm your recent program caused. First, please remove all material from your website and blog that mentions the Pro-Ana movement. Second, work with some of the many excellent professionals at reputable facilities around the country to plan follow up segments to properly educate your audience about how people can recover from eating disorders and lead productive and fulfilled lives not centered on food. You have an opportunity to teach millions across the country, including other physicians who might watch your show, the real skinny about eating disorders. I hope you will do the right thing.

About Lisa S. Kantor

Lisa S. Kantor, a Los Angeles lawyer and member of the Board of Directors of the Eating Disorders Coalition, is the country’s premier legal advocate for patients with eating disorders who have been denied health insurance benefits for treatment.  In 2011, the 9th U.S. Circuit Court of Appeals ruled for her client in Harlick v. Blue Shield, creating one of the most influential decisions ever in mental health parity litigation and paving the way to making treatment and recovery for severe mental illnesses more attainable.  For more information, go to www.kantorlaw.net.

SOURCE Lisa S. Kantor

Ashley Judd Responds to Media Criticism About Her Appearance

Ashley Judd Slaps Media in the Face for Speculation Over Her ‘Puffy’ Appearance

THIS EDITORIAL first appeared at The Daily Beast at http://www.thedailybeast.com/articles/2012/04/09/ashley-judd-slaps-media-in-the-face-for-speculation-over-her-puffy-appearance.html

editorial@thedailybeast.com.

Ashley Judd’s ‘puffy’ appearance sparked a viral media frenzy. But, the actress writes, the conversation is really a misogynistic assault on all women.

The Conversation about women’s bodies exists largely outside of us, while it is also directed at (and marketed to) us, and used to define and control us. The Conversation about women happens everywhere, publicly and privately. We are described and detailed, our faces and bodies analyzed and picked apart, our worth ascertained and ascribed based on the reduction of personhood to simple physical objectification. Our voices, our personhood, our potential, and our accomplishments are regularly minimized and muted.

As an actor and woman who, at times, avails herself of the media, I am painfully aware of the conversation about women’s bodies, and it frequently migrates to my own body. I know this, even though my personal practice is to ignore what is written about me. I do not, for example, read interviews I do with news outlets. I hold that it is none of my business what people think of me. I arrived at this belief after first, when I began working as an actor 18 years ago, reading everything. I evolved into selecting only the “good” pieces to read. Over time, I matured into the understanding that good and bad are equally fanciful interpretations. I do not want to give my power, my self-esteem, or my autonomy, to any person, place, or thing outside myself. I thus abstain from all media about myself. The only thing that matters is how I feel about myself, my personal integrity, and my relationship with my Creator. Of course, it’s wonderful to be held in esteem and fond regard by family, friends, and community, but a central part of my spiritual practice is letting go of otheration. And casting one’s lot with the public is dangerous and self-destructive, and I value myself too much to do that.

 

However, the recent speculation and accusations in March feel different, and my colleagues and friends encouraged me to know what was being said. Consequently, I choose to address it because the conversation was pointedly nasty, gendered, and misogynistic and embodies what all girls and women in our culture, to a greater or lesser degree, endure every day, in ways both outrageous and subtle. The assault on our body image, the hypersexualization of girls and women and subsequent degradation of our sexuality as we walk through the decades, and the general incessant objectification is what this conversation allegedly about my face is really about.

A brief analysis demonstrates that the following “conclusions” were all made on the exact same day, March 20, about the exact same woman (me), looking the exact same way, based on the exact same television appearance. The following examples are real, and come from a variety of (so-called!) legitimate news outlets (such as HuffPo, MSNBC, etc.), tabloid press, and social media:

One: When I am sick for more than a month and on medication (multiple rounds of steroids), the accusation is that because my face looks puffy, I have “clearly had work done,” with otherwise credible reporters with great bravo “identifying” precisely the procedures I allegedly have had done.

Two: When my skin is nearly flawless, and at age 43, I do not yet have visible wrinkles that can be seen on television, I have had “work done,” with media outlets bolstered by consulting with plastic surgeons I have never met who “conclude” what procedures I have “clearly” had. (Notice that this is a “back-handed compliment,” too—I look so good! It simply cannot possibly be real!)

Three: When my 2012 face looks different than it did when I filmed Double Jeopardy in 1998, I am accused of having “messed up” my face (polite language here, the F word is being used more often), with a passionate lament that “Ashley has lost her familiar beauty audiences loved her for.”

Four: When I have gained weight, going from my usual size two/four to a six/eight after a lazy six months of not exercising, and that weight gain shows in my face and arms, I am a “cow” and a “pig” and I “better watch out” because my husband “is looking for his second wife.” (Did you catch how this one engenders competition and fear between women? How it also suggests that my husband values me based only on my physical appearance? Classic sexism. We won’t even address how extraordinary it is that a size eight would be heckled as “fat.”)

Ashley Judd on her new show “Missing”

Five: In perhaps the coup de grace, when I am acting in a dramatic scene in Missing—the plot stating I am emotionally distressed and have been awake and on the run for days—viewers remarks ranged from “What the f–k did she do to her face?” to cautionary gloating, “Ladies, look at the work!” Footage from “Missing” obviously dates prior to March, and the remarks about how I look while playing a character powerfully illustrate the contagious and vicious nature of the conversation. The accusations and lies, introduced to the public, now apply to me as a woman across space and time; to me as any woman and to me as every woman.

That women are joining in the ongoing disassembling of my appearance is salient. Patriarchy is not men. Patriarchy is a system in which both women and men participate. It privileges, inter alia, the interests of boys and men over the bodily integrity, autonomy, and dignity of girls and women. It is subtle, insidious, and never more dangerous than when women passionately deny that they themselves are engaging in it. This abnormal obsession with women’s faces and bodies has become so normal that we (I include myself at times—I absolutely fall for it still) have internalized patriarchy almost seamlessly. We are unable at times to identify ourselves as our own denigrating abusers, or as abusing other girls and women.

A case in point is that this conversation was initially promulgated largely by women; a sad and disturbing fact. (That they are professional friends of mine, and know my character and values, is an additional betrayal.)

That the conversation about my face was initially promulgated largely by women is a sad and disturbing fact.

News outlets with whom I do serious work, such as publishing op-eds about preventing HIV, empowering poor youth worldwide, and conflict mineral mining in Democratic Republic of Congo, all ran this “story” without checking with my office first for verification, or offering me the dignity of the opportunity to comment. It’s an indictment of them that they would even consider the content printable, and that they, too, without using time-honored journalistic standards, would perpetuate with un-edifying delight such blatantly gendered, ageist, and mean-spirited content.

Ashley Judd responds to her critics on ‘Nightly News.’

I hope the sharing of my thoughts can generate a new conversation: Why was a puffy face cause for such a conversation in the first place? How, and why, did people participate? If not in the conversation about me, in parallel ones about women in your sphere? What is the gloating about? What is the condemnation about? What is the self-righteous alleged “all knowing” stance of the media about? How does this symbolize constraints on girls and women, and encroach on our right to be simply as we are, at any given moment? How can we as individuals in our private lives make adjustments that support us in shedding unconscious actions, internalized beliefs, and fears about our worthiness, that perpetuate such meanness? What can we do as families, as groups of friends? Is what girls and women can do different from what boys and men can do? What does this have to do with how women are treated in the workplace?

I ask especially how we can leverage strong female-to-female alliances to confront and change that there is no winning here as women. It doesn’t actually matter if we are aging naturally, or resorting to surgical assistance. We experience brutal criticism. The dialogue is constructed so that our bodies are a source of speculation, ridicule, and invalidation, as if they belong to others—and in my case, to the actual public. (I am also aware that inevitably some will comment that because I am a creative person, I have abdicated my right to a distinction between my public and private selves, an additional, albeit related, track of highly distorted thinking that will have to be addressed at another time).

If this conversation about me is going to be had, I will do my part to insist that it is a feminist one, because it has been misogynistic from the start. Who makes the fantastic leap from being sick, or gaining some weight over the winter, to a conclusion of plastic surgery? Our culture, that’s who. The insanity has to stop, because as focused on me as it appears to have been, it is about all girls and women. In fact, it’s about boys and men, too, who are equally objectified and ridiculed, according to heteronormative definitions of masculinity that deny the full and dynamic range of their personhood. It affects each and every one of us, in multiple and nefarious ways: our self-image, how we show up in our relationships and at work, our sense of our worth, value, and potential as human beings. Join in—and help change—the Conversation.

  • Ashley Judd is a prolific actress, who will next be seen in ABC’s new midseason show, Missing. Judd most recently appeared in Dolphin Tale alongside Morgan Freeman, Harry Connick Jr. and Kris Kristofferson.
  • Judd is also on the board of directors for PSI (Population Services International), which she joined in 2004 after serving as Global Ambassador for PSI’s HIV education and prevention program, YouthAIDS since 2002.  Judd has visited PSI programs in Thailand, Cambodia, Madagascar, Kenya, South Africa, Guatemala, Honduras, Nicaragua, El Salvador, India, Rwanda and the Democratic Republic of Congo. In her work, she witnesses the lives of the exploited and poor to help educated the world about the reality of global poverty and bring solutions to the devastating effects of social injustice and gender inequality.
  • Judd was the subject of three award-winning documentaries aired in more than 150 countries worldwide on VH1, The Discovery Channel and The National Geographic Channel.  In her role as PSI board member, Judd has graced the covers of countless magazines and been the subject of newspaper and television interviews bringing vital awareness to issues closest to her heart, gender inequality and poverty alleviation.
  • Judd has visited legislators on Capitol Hill, addressed the General Assembly of the UN on the scourge human trafficking, spoke at the National Press Club, testified before the Senate Foreign Relations Committee for the protection of vulnerable women from violence, sexual abuse and HIV and, most recently served as an expert panelist at Clinton Global Initiative to discuss the issue of safe water and the empowerment of girls in the developing world.
  • Recently, Judd has come on board as a spokesperson for organizations Defenders for Wildlife and The Sierra Club providing her time and voice to advocate against practices of aerial wolf hunting (Defenders for Wildlife) and mountaintop removal coal mining (The Sierra Club).
  • She resides in Tennessee and Scotland with her husband, the international racing star Dario Franchitti.  They have 8 beloved pets and enjoy a quiet, rural life.

Eating Disorders, Dieting, Can Reduce Serotonin and Social Decision-Making

New research by scientists at the University of Cambridge suggests that the neurotransmitter serotonin, which acts as a chemical messenger between nerve cells, plays a critical role in regulating emotions such as aggression during social decision-making.

Serotonin has long been associated with social behavior, but its precise involvement in impulsive aggression has been controversial. Though many have hypothesised the link between serotonin and impulsivity, this is one of the first studies to show a causal link between the two. The research also provides insight into clinical disorders characterized by low serotonin levels, such as depression and obsessive   compulsive disorder (OCD), and may help explain some of the social difficulties associated with these disorders.

These findings highlight why some of us may become combative or aggressive when we haven’t eaten.The only way to build serotonin in the brain is by consuming tryptophan in our diet, through foods such as poultry or chocolate. Serotonin levels are lower when a person has not eaten.  Since serotonin levels naturally decline when we don’t eat,  the researchers took advantage of this effect in designing their experiment.

  • The researchers were able reduce brain serotonin levels in healthy volunteers for a short time by manipulating their diet.
  • They used a situation known as the ‘Ultimatum Game’ to investigate how individuals with low serotonin react to what they perceive as unfair behaviour. In this game one player proposes a way to split a sum of money with a partner. If the partner accepts, both players are paid accordingly. But if he rejects the offer, neither player is paid.
  • Normally, people tend to reject about half of all offers less than 20-30% of the total stake, despite the fact that this means they receive nothing – but rejection rates increased to more than 80% after serotonin reductions.
  • Other measures showed that the volunteers with serotonin depletion were not simply depressed or hypersensitive to lost rewards.

These results suggest that serotonin plays a role in social decision making.

  • Normally, serotonin keeps aggressive social responses in check.
  • Changes in diet and stress cause fluctuations in serotonin levels, and this study suggests that the fluctuations in serotonin affect every day decision-making
  • This study suggests that patients with depression and anxiety disorders may benefit from therapies that teach them strategies for regulating emotions during decision making, particularly in social scenarios.

This research was  funded by the Wellcome Trust and the Medical Research Council.

Someday Melissa: Judy Avrin’s Tribute to Her Daughter

ANDREW AVRIN sits on a beige couch in a nondescript room, a fruit still-life partly visible on the wall behind him, twisting his fingers while, off-camera, an unseen interviewer prompts him to talk about his sister, Melissa, who died at the age of 19 after a long battle with bulimia.

“There was no food in the house,” he says, looking off to the side as his eyes fill. “If I went out with friends, I could not bring leftovers home because they would be gone by the next morning.”

Once, he explains, in the middle of a bitterly cold night, he looked out the window and saw Melissa on the curb, going through the garbage. “I went outside and I yelled her name,” he recounts in the interview, his voice breaking. “Just the way she looked back at me — it was so empty, vacant. It was a deer in the headlights, but that doesn’t even explain it.”

It is a hard scene for anyone to watch, but even more so for the film’s producer — Judy Avrin, Melissa’s mother, who decided to make a documentary about her daughter’s life and, ultimately, her death.

People deal with grief in their own ways, and those who have been spared the loss of a daughter or a son can only imagine how they would choose to try to cope. For Ms. Avrin, coping meant confronting her anguish and trying to make something good come out of it.

The idea for a film didn’t occur to her immediately. In the weeks following Melissa’s death, Ms. Avrin mostly avoided her daughter’s bedroom, and tried to resume some semblance of normalcy, going back to work three days a week as the coordinator for a consortium of academic libraries in New Jersey. But one day she sat down to read Melissa’s leather-bound journal.

Someday …

I’ll eat breakfast.

I’ll keep a job for more than 3 weeks.

I’ll have a boyfriend for more than 10 days.

I’ll love someone.

I’ll travel wherever I want.

I’ll make my family proud.

I’ll make a movie that changes lives.

The film, called “Someday Melissa” and now in the editing stages, has become for Ms. Avrin salve, distraction and cause — a way to get the word out to other families grappling with eating disorders that they are not alone; to sound the alarm that eating disorders have the highest mortality rate of any mental illness; to help make sense of the senseless event that was losing her teenage daughter.

“I kept saying, ‘This is an amazing way for me to channel my grief,’ ” Ms. Avrin said. “But it also allowed me to put off grieving.”

Ms. Avrin, 56, got the idea for the film from one of Melissa’s therapists, Danna Markson, who introduced her to Jeffrey Cobelli, 27, a filmmaker. Over the last several months of working on the project, Ms. Avrin has come to know more than she ever intended to about eating disorders — how their seriousness has been underestimated, their treatment underinsured, their deaths underreported.

The process hasn’t been easy, and some, like her ex-husband, initially questioned the impulse to do it at all. Melissa’s best friend since first grade, Nicole Kendrick, who also suffers from an eating disorder, said she was incredulous when she first learned that Ms. Avrin was making the film. “I thought she was crazy,” Ms. Kendrick said. “I guess I didn’t realize how deep a mother’s love can run.”

But Ms. Avrin said that making the film has been easier than doing nothing at all. “I’ve never once thought this was more than I could bear,” she said, in an interview at her home in Totowa, N.J. “If anything, the more I continue, the more I know it’s the right thing to do.”

The difficulty of reliving her daughter’s decline has been mitigated by the public response. “Sometimes I think: ‘I’m a suburban mom. Who am I to think I could make a difference in the world?’ ” Ms. Avrin said. “But then I read the messages that keep coming in from people I know and people I don’t know who say Melissa’s story has motivated them to fight one more day.”

On Melissa’s Facebook page and on the film’s Web site — somedaymelissa.com — Ms. Avrin continues to get feedback. “Thank you,” says one entry posted on the Web site’s guestbook page. “This could save one person’s life. That life may be mine.”

Ms. Avrin and Mr. Cobelli have interviewed Melissa’s family members, doctors and friends, along with prominent experts in the field, like Dr. Thomas R. Insel, the director of the National Institute of Mental Health; and Dr. B. Timothy Walsh, the founding director of the Eating Disorders Research Unit at the New York State Psychiatric Institute, and Dr. Evelyn Attia, the director of the Columbia Center for Eating Disorders, both at Columbia University Medical Center.

“I get a lot of requests, but there was something about this one I thought was particularly striking,” said Dr. Insel of the mental health institute. “I wanted to hear more of the story.”

“It was such an extraordinary expression of love,” he said, “a powerful way of honoring and remembering the daughter she lost.”

Although those closest to Melissa agreed to be interviewed for the film, participating wasn’t easy. William Avrin, Melissa’s father, said that he might have preferred to keep his experience to himself and that he was in no hurry to revisit his memories of Melissa. “I have a hole in my heart and it will be there forever,” he said in a telephone interview. “I don’t really try to describe what it’s like to lose a child.”

But he felt he had to do it for the film. “Clearly, Judy’s a champion of this project,” he said. “I’m a little bit more personal and inward. I’m still struggling with the whole thing. This is her way of dealing with it, and I respect that.”

In the documentary interview, filmed at his home in Hamburg, N.J., Mr. Avrin visibly struggles to describe what it was like to be thousands of miles away in Japan on business when he found out his daughter had died. At first he appears almost devoid of emotion, delivering his words in flat, deliberative sentences as he sits in a blue button-down shirt in front of his fireplace mantel. But then you can see tears trickling down into his salt-and-pepper mustache. “What was I thinking?” he says, repeating the question. “I was thinking my daughter is dead. That’s not supposed to happen. I couldn’t believe it. I didn’t — didn’t know what to think. I was in shock.”

Upon returning from Japan, Mr. Avrin decided not to view his daughter’s body. “Judy thought it would be better if I didn’t,” he said, “that I’d remember her like the last time that I saw her.”

Melissa died on May 6, 2009. Cause of death: heart attack due to complications from an eating disorder. Just a few days before, Melissa learned she had been admitted to Emerson College. The official letter of acceptance arrived a week after she died and sits unopened.

Melissa’s brother, Andrew, who is completing his Master of Science degree in engineering, said he believes the documentary has become essential to his mother’s emotional resilience. “It’s the only way she knows how to move forward,” he said.

At the same time, Andrew said he worried that the documentary would ultimately prove to be just a Band-Aid, postponing the heartbreak that is bound to rear its head when the film is completed. “The trick becomes moving forward with life but not letting everything this project is fill the void completely,” he said, “so the second this project finishes, you don’t crash.”

To be sure, Ms. Avrin doesn’t always hold it together. She did not conduct the interviews with her ex-husband or with her son (her collaborator, Mr. Cobelli, did). “We would have just sat there and cried,” she said.

In the interviews she did do, there have been times when she has broken down during or afterward. In concluding her discussion with Dr. Leslie Sanders, one of Melissa’s doctors, for example, Ms. Avrin starts to cry, and the cameras keep rolling. “I still remember being in your office and — I think her potassium was off — and you said, ‘I’ll be your quarterback,’ ” Ms. Avrin tells Dr. Sanders. “I didn’t know who to turn to next and I felt like I was in such good hands with you.”

Dr. Sanders responds: “I think what I remember about that first visit is just being struck at how little her life had become — I think at that point she was barely in school — and how much she was struggling, not just physically, I think physically was the least of it, but just emotionally and how we needed to do something intensive, and quickly, to get her life back.”

BORN Dec. 21, 1989, Melissa seemed in her early years to be a happy little girl. Her family lived in Wayne, N.J., and then in Pine Brook, N.J., spending two years in Coral Gables, Fla., in between, where Mr. Avrin was transferred for his work with a specialty chemical company. Melissa did well in school — producing A’s and short stories.

But at age 13, thing started to change. Melissa’s mood darkened; she didn’t want to go to school or do extracurricular activities. She developed stomach problems and constipation. Ms. Avrin took her to a pediatric gastroenterologist who said Melissa probably had an eating disorder. “I reacted the way most parents do: ‘That’s not possible,’ ” Ms. Avrin said. “We didn’t go back to him.”

In the early stages, the Avrins did not really see what was going on, in part because Melissa wasn’t visibly underweight, in part because they didn’t want to. But clues started to show up that were too stark to ignore — logs of cookie dough that disappeared from the freezer along with whole boxes of cookies from the cabinet. Empty pizza boxes. “I found containers with chewed and spit-out food and I’d never heard of that before,” Ms. Avrin tells Dr. Sanders during their filmed interview. “Is that very common?”

Ms. Avrin wrapped the fridge in locks and chains, hid her purse and made sure never to leave money lying around. “It didn’t have to be good junk food — if she wanted to go on a binge, it could be a dozen eggs,” Ms. Avrin said of Melissa. “Anything that wasn’t nailed down, she would eat.”

Ms. Kendrick, in her own interview for the film, alternates between smiling recollections of her childhood friend and sad eyes as she recalls Melissa’s downward spiral. “People who knew her in the last two years never really saw who she really was,” she says. “She was so energetic and funny and just ridiculous but not, like, in an obnoxious way. And then, as she started to worry about what other people thought, that’s when it started to be in more of an attention-getting way. When things got really bad, that kind of all just slowly disappeared and it just became very monotone — down. And we didn’t really see that energetic, fun Melissa anymore.”

Eventually, Melissa was sent away for professional help against her will and thus began a series of programs over the next few years that had varying degrees of success. It wasn’t until Melissa’s third round of in-patient treatment — when she and other young women testified about their eating disorders in front of their families — that her father began to fully understand. “I really said, ‘Wow this is almost like heroin addiction,’ ” he says in his film interview. “They need to purge because it makes them feel high and it’s something they need to do. I never appreciated that.”

In the course of making the film, Ms. Avrin has become something of a public service announcement on eating disorders. She was a featured speaker last October at the first walk to raise money for the National Eating Disorders Association. At its benefit dinner in March in New York, the evening opened with a clip from Ms. Avrin’s film. She is due to be in Washington in late April to lobby Congress as part of an Eating Disorders Coalition.

She said she is happy to play the role of advocate, to help try to remove the stigma that still cloaks eating disorders and keeps people from acknowledging the disease as the cause of death in obituaries. “I want it to come out of the shadows,” Ms. Avrin said. “I want people to talk about it, for people to get treatment faster, to reach doctors on the front lines. I want parents to open their eyes and not be swayed by being glad that their kid fits into size 4 jeans — to stop focusing on looks.”

Ms. Avrin is aiming to finish her documentary project by June, in time for summer film festival deadlines, and she said she is determined to get theatrical distribution. It would seem the ultimate act of acceptance. Yet in her film interview with Dr. Sanders, Ms. Avrin sounds like a mother still wrestling with remnants of denial.

“I’ve always been the glass half-full — I’ve always been an optimist,” she says, reaching under her eyeglasses to wipe away tears. “I always believed that she really would be somebody who could recover, even though, looking back, I realized the odds were stacked against her because of the level of her illness.”

“But I never lost hope and, you know,” she adds, “I still believe that she could have beaten it.”

Eating Disorders: Everybody Knows Somebody

February 5, 2012, Mark Baldwin, The Republic, Columbus, IN

Although we don’t exactly shout it from the rooftop, my family never has hidden the experience of our middle daughter’s struggle with anorexia nervosa, the eating disorder that leads some people — and especially smart and pretty young women — to starve themselves.

Very often, the conversation produces a flash of understanding.

There was the baseball executive. The City Council member back in Wisconsin. The fellow parishioner. The neighbor. The casual professional acquaintance.

All had firsthand experiences with eating disorders.

Surprised? You shouldn’t be.

After all, the theme of National Eating Disorders Awareness Week, to be held Feb. 26 to March 3, is “Everybody Knows Somebody.”

Lynn Grefe, president of the National Eating Disorders Association, pegs the number of Americans battling a form of the illness — anorexia or one of its evil cousins, bulimia or binge eating disorder — at 24 million, a figure that dwarfs the number of those suffering from, for example, Alzheimer’s disease, estimated at about 5.4 million in 2011.

Some estimates put the eating disorders number as high as 30 million.

“The piece that’s missing is ‘eating disorders not otherwise specified,’” Grefe says. “That’s probably where most people are.”

To put it simply, that means sufferers are prone to bouncing pinball-fashion from anorexia to bingeing to bulimia.

Here’s one more fact to make you shiver: The mortality rate for eating disorders is higher than for any other mental illness, with death typically resulting from medical complications or suicide. And anorexic patients remain at higher risk for premature death for years after treatment.

One key to reducing the awful toll is to raise public awareness. Ignorance of eating disorders, their warning signs and their long-term effects is widespread. Teachers, coaches, physicians and plenty of others who ought to know, don’t

And that brings me to Daughter No. 3, a clever and articulate lass named Jane, who was required by circumstances beyond her control to transfer to Columbus North High School before her senior year. With the change of schools, of course, came the requirement that she produce a senior project.

Almost on the fly, Jane decided to draw a positive result from the experience of her sister’s illness and make eating disorder awareness the focus of her project.

One result of her work will be on display at 6:30 p.m. Feb. 16 at Bartholomew County Public Library, where Jane will screen a documentary called “Someday Melissa,” the story of Melissa Avrin, a New Jersey woman who died three years ago at 19 after a grueling battle with bulimia. The movie was produced by Melissa’s mom, who resolved to make something good come out of her daughter’s death.

The documentary will be followed by a question-and-answer session with a representative of the Coalition for Overcoming Problem Eating at Indiana University in Bloomington.

I suppose I shouldn’t be surprised by Jane’s choice of topic. The two sisters are best friends — except, of course, when they’re mortal enemies. They’re very different, but their bond is unbreakable.

Her sister’s ordeal has been a significant influence on Jane’s teenage years. Like alcoholism, eating disorders distort family routines nearly beyond recognition as the illness exerts a centripetal force that draws all things to it.

Life in a household struggling with an eating disorder can be isolating. After all, who else understands that for the sufferer, “dinner” can be a few strands of chicken breast and a lettuce leaf?

Let me rephrase that. It was isolating — until it became clear just how many families out there have dealt with the same thing.

That’s why I’m writing today. If an eating disorder has wrapped itself around someone you love — or if you simply want to learn more — head to the library on the 16th.

A six-week hospital stay provided Daughter No. 2 some valuable tools for coping with her illness, though eating remains a high-anxiety endeavor. A sharp, sympathetic therapist in Bloomington has made a difference. Still, you can’t wave a magic wand to make an eating disorder vanish.

If you know what I mean, we should talk.

Mark Baldwin is editor of The Republic, Columbus Indiana which is where this post was published.  You can reach Mr. Baldwin at 379-5665 or by email at mbaldwin@therepublic.com. Follow him on Twitter @MarkFBaldwin.

Eating Disorders: Low Levels of BDNF Suggests Biological Etiology

Eating disorders are frequently seen as psychological or societal diseases, but do they have an underlying biological cause? A new study shows that the levels of a brain protein differ between healthy and anorexic women.

Anorexia is a serious and potentially fatal eating disorder most commonly affecting women. Scientists do not yet understand the physical causes of anorexia, though some studies suggest a link to low levels of a brain protein called BDNF. BDNF stands for brain derived neurotrophic factor. This molecule, found in the brain’s fear hub could have a significant impact on the study of several anxiety disorders including Post Traumatic Stress Disorder, as well as on anorexia and bulimia.

Now, a study recommended by psychiatrist Cindy Bulik,  founder and director of the  UNC Eating Disorders Program shows that BDNF levels are higher in women who have recovered from anorexia. This suggests that low BDNF levels may be reversible.

Researchers at Chiba University in Japan found that anorexic women had lower levels of BDNF in their blood than healthy women or those who had recovered from anorexia. Women with low BDNF also had the lowest self-image, suffered from anxiety and depression, and performed poorly on certain tests of cognitive ability.

Further study is needed to determine what role BDNF plays in anorexia, and if it can be used to predict the risk of developing it, but Bulik forecasts that “…BDNF may emerge as a useful biomarker of [anorexia] and of recovery from [anorexia].

Family Focused Therapy Improves Mood Symptoms in Children & Adolescents At Risk for Bipolar Disorder

A study published in the February 2013 issue of the Journal of the American Academy of Child and Adolescent Psychiatry (JAACAP) found that children and adolescents with major depression or subthreshold forms of bipolar disorder — and who had at least one first-degree relative with bipolar disorder — responded better to a 12-session family-focused treatment than to a briefer educational treatment.

The study, led by David J. Miklowitz, Ph.D., of the UCLA School of Medicine, and Kiki D. Chang, M.D., of Stanford University School of Medicine, identified 40 youth (average age 12 years) who were at risk for developing bipolar disorder.

SAMPLE:

  • The participants had diagnoses of any of the following:
    • major depressive disorder
    • cyclothymic disorder
    • bipolar disorder, not otherwise specified (NOS) (brief and recurrent episodes of mania or hypomania that did not meet full diagnostic criteria for bipolar disorder)
  • All participants had at least one first-degree relative (usually a parent) with bipolar I or II disorder.
  • Of the 40 participants, 60% were taking psychiatric medications upon entry, and continued taking recommended medications throughout the study.
  • Half of the participants were recruited and treated at the University of Colorado, Boulder, and half at Stanford University.

STUDY DESIGN:

The investigators randomly assigned the 40 participants to:

  • family-focused treatment, high-risk version (FFT-HR), consisting of 12 family sessions over 4 months of psychoeducation (learning strategies to manage mood swings), communication skills training, or problem-solving skills training

or

  • 1-2 family informational sessions (educational control, or EC).

 

FINDINGS:

  • Participants in the FFT-HR condition recovered from their initial depressive symptoms in an average of 9 weeks, compared to 21 weeks in the EC condition.
  • Participants who received FFT-HR also had more weeks in full remission from mood symptoms over the study year.
  • Improvements in mania symptoms on the Young Mania Rating Scale were greater in the FFT-HR group as well.
  • The study participants who lived in families that were rated high in expressed emotion, a measure of critical comments or emotional overprotectiveness in parents, took almost twice as long to recover from their mood symptoms as those in families rated low in expressed emotion.
  • A secondary analysis indicated that youth from high expressed emotion families who were treated with FFT-HR spent more weeks in remission over the year than those treated with EC.

Dr. Miklowitz cautioned that the length of follow-up (1 year) was too short to determine whether these children would develop full bipolar disorder. “Nonetheless,” he said, “catching bipolar disorder at its earliest stages, stabilizing symptoms that have already developed, and helping the family to cope effectively with the child’s mood swings may have downstream effects that improve the long-term outcomes of high-risk children.”

Bipolar Disorder and Borderline Personality: Similar and Different

Bipolar disorder and borderline personality disorders are both characterized by unstable moods and impulsive actions, but they are different diagnoses, and have different recommended treatments.

Bipolar disorder and borderline personality disorder often get confused with each other.  I often see patients who tell me a family member has been diagnosed with bipolar disorder, and when we review the DSM criteria for bipolar disorder and borderline personality disorder, it appears that borderline personality disorder better explains their family member.

Now, a study from Rhode Island Hospital may explain why this confusion sometimes occurs:

A widely-used screening tool for the diagnosis of bipolar disorder may actually be identifying borderline personality disorder.

In the article that appears online in the Journal of Clinical Psychiatry, the researchers question the effectiveness of the Mood Disorder Questionnaire (MDQ). The MDQ is the most widely-used and studied screening tool for bipolar disorder. It is a brief questionnaire that assesses whether a patient displays some of the characteristic behaviors of bipolar disorder.
The study consisted of the following:

  • The research team interviewed nearly 500 patients using the Structured Clinical Interview for Diagnostic Statistical Manual IV (DSM-IV) and the Structured Interview for DSM-IV for personality disorders.
  • The patients were also asked to complete the MDQ.

After scoring, the researchers found that:

  • Patients with a positive indication for bipolar disorder using the MDQ were as likely to be diagnosed with borderline personality disorder as bipolar disorder when using the structured clinical interview.
  • Borderline personality disorder was four times more frequently diagnosed in the group who screened positive on the MDQ.

While only a qualified clinician can make a diagnosis bipolar disorder or borderline personality disorder, there are some differences that clinicians use to make this determination:

  • Persons with bipolar disorder will have episodes of depression, and episodes of euphoria or irritability, and even periods of normal mood in between. There are other associated symptoms that go along with the mood changes, such as low energy, and behavioral changes.
  • People with bipolar disorder will cycle between these mood states over months to even years. Rarely, the mood states change more rapidly. But in borderline personality disorder, the shifts in mood are far more rapid—even several times a day.
  • People with borderline personality disorder are more affected by what is happening in their life at any moment, and how they feel about it, and they react to it. They are particularly sensitive to abandonment, or fears of abandonment.
  • The ups and downs in borderline personality disorder are not all-encompassing mood shifts of mania and depression. Instead, they have specific feelings that fluctuate: fear, anger, sadness, disgust, love, in a sort of all-or-nothing, black and white way.

Childhood Bipolar Disorder is NOT Bipolar

Childhood Bipolar Disorder is not Bipolar? DSM-V and the new Temper Dysregulation Disorder with Dysphoria

Written by Nestor Lopez-Duran PhD on Wednesday, February 10.2010 from childpsych.org

Today the American Psychiatric Association released a draft of the major changes that are expected in the new version of the Diagnostic and Statistical Manual of Mental Disorder – 5th Edition (DSM-V). While most people in the field will be underwhelmed by the relatively minor changes,  there are a few areas where the DSM-V will likely make some drastic changes.  Today most of the news coverage was focused on the proposed changes to the Autism diagnosis, which has raised some heated debate in the autism community. However, there is another major change that has received little, if any, attention: the clarification that a syndrome that in recent years has been labeled childhood bipolar disorder is actually NOT bipolar disorder. Instead, a new disorder category was created: Temper Dysregulation Disorder with Dysphoria (TDD).

Let me start by explaining that the creation of TDD does NOT deny the existence of classic bipolar disorder in childhood. That is, although extremely rare, bipolar disorder can occur in children and adolescents, and it looks very much like adult bipolar.  Instead, TDD was created to capture a valid syndrome with characteristics and outcomes that are different than those of bipolar disorder. The available scientific data supports the position that the TDD syndrome is NOT simply the manifestation of bipolar disorder in childhood. This means that thousands of children that have been diagnosed with childhood bipolar disorder may not have bipolar and instead have a completely different syndrome now called Temper Dysregulation Disorder with Dysphoria.

So what is TDD?

Here is the proposed criteria for TDD:

A. The disorder is characterized by severe recurrent temper outbursts in response to common stressors.

1.  The temper outbursts are manifest verbally and/or behaviorally, such as in the form of verbal rages, or physical aggression towards people or property.

2.  The reaction is grossly out of proportion in intensity or duration to the situation or provocation.

3.  The responses are inconsistent with developmental level.

BFrequency: The temper outbursts occur, on average, three or more times per week.

CMood between temper outbursts:

1.  Nearly every day, the mood between temper outbursts is persistently negative (irritable, angry, and/or sad).

2.  The negative mood is observable by others (e.g., parents, teachers, peers).

DDuration: Criteria A-C have been present for at least 12 months.  Throughout that time, the person has never been without the symptoms of Criteria A-C for more than 3 months at a time.

E. The temper outbursts and/or negative mood are present in at least two settings (at home, at school, or with peers) and must be severe in at least in one setting.

F.  Chronological age is at least 6 years (or equivalent developmental level).

G. The onset is before age 10 years.

H. In the past year, there has never been a distinct period lasting more than one day during which abnormally elevated or expansive mood was present most of the day for most days, and the abnormally elevated or expansive mood was accompanied by the onset, or worsening, of three of the “B” criteria of mania (i.e., grandiosity or inflated self esteem, decreased need for sleep, pressured speech, flight of ideas, distractibility, increase in goal directed activity, or excessive involvement in activities with a high potential for painful consequences; see pp. XX). Abnormally elevated mood should be differentiated from developmentally appropriate mood elevation, such as occurs in the context of a highly positive event or its anticipation.

I.  The behaviors do not occur exclusively during the course of a Psychotic or Mood Disorder (e.g., Major Depressive Disorder, Dysthymic Disorder, Bipolar Disorder) and are not better accounted for by another mental disorder (e.g., Pervasive Developmental Disorder, post-traumatic stress disorder, separation anxiety disorder). (Note: This diagnosis can co-exist with Oppositional Defiant Disorder, ADHD, Conduct Disorder, and Substance Use Disorders.) The symptoms are not due to the direct physiological effects of a drug of abuse, or to a general medical or neurological condition.

The syndrome captured by section A-C (frequent and intense temper outbursts, happening several times per week in the context of negative emotionality) is the core of the symptoms that has been incorrectly interpreted as indicative of childhood bipolar disorder.  Section H is very interesting. It states that this diagnosis is not appropriate if the person has experienced classic mania (e.g., bnormally elevated or expansive mood), as in such a case the diagnosis of bipolar is likely more accurate.

So why did the DSM-V decide that this syndrome is not simply bipolar disorder of childhood?

1. Lack of continuity to bipolar.

If TDD is simply the expression of bipolar disorder during childhood, then children diagnosed with this condition would eventually develop symptoms of classic bipolar disorder as they reach adulthood. The data do not support this hypothesis. That is, children who display the TDD syndrome in childhood (and are often incorrectly diagnosed as bipolar) are not more likely to develop classic bipolar disorder later in life as their peers (see Brotman et al., 2006; Leibenluft et al, 2006; Stringaris et al, 2009).  Instead, these children are more likely to develop depression, not bipolar!

2. Different Biological Markets.

Youth who are diagnosed with classic bipolar differ significantly from those who have a TDD-like syndrome (see Brotman et al, 2010; Guyer et al, 2007; Rich et al, 2008).  If TDD is simply bipolar, then the biomarkers of TDD should be similar to those of bipolar, but this is not the case.

3. Different Demographic Factors.

If TDD is simply bipolar, then the gender distribution of TDD should be similar to that of bipolar. This does not appear to be the case. Specifically, there is no gender differences in the rate of classic bipolar; male and females are equally likely to develop the condition. However, the TDD-like syndrome is disproportionately observed in boys rather than girls.

4. A need for a new category that would impact treatment and research.

In theory, the presence of TDD will educate clinicians, researchers, and the public that this syndrome is not simply a version of bipolar disorder. This would facilitate research on the causes, features, and treatments for this condition. This has major implications for treatment. For example, the standard treatment for bipolar disorder does NOT seem to work in children that have the TDD syndrome (Dickstein et al, 2009). By explicitly stating that TDD is not bipolar, researchers would be less likely to approach the search for treatments from a “bipolar framework”, which would potentially facilitate the discovery of more effective interventions.

I am actually glad about this change as it will have a clear impact on clinical practice and research that will most likely benefit the children affected with this condition.

References:

Brotman MA, Schmajuk M, Rich BA, Dickstein DP, Guyer AE, Costello EJ, Egger HL, Angold A, Pine DS, & Leibenluft E (2006). Prevalence, clinical correlates, and longitudinal course of severe mood dysregulation in children. Biological psychiatry, 60 (9), 991-7 PMID: 17056393

Dickstein DP, Towbin KE, Van Der Veen JW, Rich BA, Brotman MA, Knopf L, Onelio L, Pine DS, Leibenluft E (2009): Randomized double-blind placebo-controlled trial of lithium in youth with severe mood dysregulation. J Child Adolesc Psychopharm 19: 61-73

Guyer AE, McClure EB, Adler AD, Brotman MA, Rich BA, Kimes AS, Pine DS, Ernst M, Leibenluft E (2007): Specificity of face emotion labeling deficits in childhood psychopathology. Journal of Child Psychiatry and Psychology, 48:863-71

Leibenluft E, Charney DS, Towbin KE, Bhangoo RK, Pine DS (2003): Defining clinical phenotypes of juvenile mania. Am J Psychiatry 160: 430-437

Rich BA, Grimley ME, Schmajuk M, Blair KS, Blair RJR, Leibenluft E (2008): Face emotion labeling deficits in children with bipolar disorder and severe mood dysregulation. Development and Psychopathology 20: 529-546

Stringaris A, Cohen P, Pine DS, Leibenluft E (2009): Adult outcomes of adolescent irritabilty: A 20-year community follow-up. Am J Psychiatry 166: 1048-54