OCD and Eating Disorders: Interventions

OCD and Eating Disorders: An Overview of Interventions

• This module provides an overview of interventions and patient outcome evaluations for Obsessive-Compulsive Disorder (OCD), eating disorders, and Dissociative Identity Disorder (DID), as defined by the DSM 5.

Instructions and Evaluation Methods

• Learning can be evaluated through checkpoints, example questions with detailed answers, and points for reflection.
• Answering all questions is not mandatory.
• Questions can be directed to [email protected].

Class Objectives

• Understand how interventions to manage physical compulsions are combined with medication and psychosocial interventions for individuals experiencing OCD.
• Compare the three domains of interventions of therapeutic relationship, physical health, and psychosocial aspects for anorexia nervosa and bulimia nervosa.
• Describe how the three domains are used in comprehensive care plans for individuals and families dealing with eating disorders to ensure successful patient outcomes.
• Outline how mindfulness and cognitive behaviour therapy (CBT) are integrated into nursing interventions for eating disorders.
• Examine the roles of pharmacological agents and psychotherapy in DID treatment.
• Explain how pharmacological and psychotherapeutic interventions enhance patient safety and well-being throughout the lifespan and the course of DID.
• Critically assess how pharmacological and psychotherapeutic interventions are affected by the SEDoHs.

OCD Interventions

• OCD interventions focus on the physical consequences of compulsions and the psychosocial components of the disorder.

Managing Physical Consequences of Compulsions

• Tepid water should be used to maintain skin integrity.
• Mild soap is recommended for cleaning.
• Hand cream should be provided.
• A structured hand washing schedule should be agreed upon.

Exposure and Response Prevention

• Patients should be exposed to situations or objects that trigger compulsions.
• Patients should aim to refrain from ritualistic behaviours.
• This aims to reduce stress related to the activity and identify realistic outcomes.
• Start with short exposure times, gradually increasing the duration.
• Closely monitor the patient for distress signs.
• Ask about feelings and urges during exposure.
• It's important to acknowledge that discomfort is normal, but intense distress should be avoided.
• Reinforce that the patient remained safe even they felt uneasy.

Thought Stopping Technique

• Interrupt obsessive thoughts by verbally saying "stop".
• Works to interrupt the autonomic process; it is associated with mindfulness.
• Patients can take control of the obsessional thinking and delay the response or create an opportunity to change it.
• The method's success lies in recognizing the thought to enable interruption.

Relaxation Techniques

• Decrease anxiety without changing the OCD symptoms.
• Promotes distraction by finding alternative activities without removing any existing compulsions.
• May include improve sleep patterns and remedy insomnia.
• Examples of activities include deep breathing, meditation and listening to music.
• Most activities incorporate rhythmic actions.

Cognitive Restructuring

• Aims to change a patient’s dysfunctional view of the condition and related outcomes.
• Therapy is rooted in both CBT and mindfulness.
• Use of CBT tests can examine distorted thoughts from the patient's reality.
• Tools might use cue cards, and pros and cons lists for identifying and addressing cognitive distortions.

OCD Medications

• Common medications used for OCD treatment:
  • TCA: Clomipramine.
  • SSRIs: Fluoxetine, Fluvoxamine, Paroxetine, and Sertraline.
• Antidepressants are used in more concentrated doses compared to regular antidepressant prescriptions.
• MAOIs may cause hypertensive crisis and Serotonin syndrome.
• It may take 4-6 weeks before a patient sees results.
• Behavioral therapy is also important for sustained change.
• Side effects can include toxicity, sedation, and suicidal tendencies.

Evaluating OCD Patients

• Assess remission of symptoms, the ability to perform daily tasks, participation in social activities, absence of self-harm behaviours, and knowledge of their condition.
• Improved rating scales should be used to track a patient's progression.

Psychosocial Social Domain

• Address fear of the unknown by explaining unit habits.
• To reduce anxiety, don't inhibit the need for rituals.
• By empathizing with an individual's need to perform rituals, this can contribute to a positive therapeutic relationship.
• Balance time between private and group activities.

Psychoeducation

• Educating the patient and family can involve interventions, a diagnosis, additional resources, and importance of continued behavioral practice.

Eating Disorder Interventions: Types of Intervention

• Interventions span therapeutic relationships, physical health, psychosocial aspects, and prevention strategies for eating disorders.

The Therapeutic Relationship

• Promotes the goals of treatment and clarifies role boundaries.
• Suspicion and distrust may be present in patients experiencing anorexia.
• Intense need to be liked and please others may be present in patients experiencing bulimia.
• Patients may be impatient/irritable stemming from starvation in anorexia or guilt/shame in bulimia.
• The nursing approach involves a firm, accepting attitude and providing a rationale for interventions.
• Taking a non-reactive approach can minimize power struggles.

Anorexia Nervosa: Refeeding

• The primary intervention during the initial treatment phases.
• Nurses may find pushback or unwillingness to eat.
• Patients should try to gain 1-2 pounds weekly; and may want to start at 1500 calories/day and raising the initial consumption to 3500 calories/day.
• There may be few different meals everyday.
• A behavioral plan can include bathroom and meal habits.
• Cognitive distortions should be addressed involving beliefs about food and their body.
• Expectations should govern behavioral plans as opposed to punishments.
• Medical staff NEED to work together for consistent care.
• Nasogastric tube feedings may be necessary alongside intravenous electrolyte replacement.
• Potassium deficiency comes from diuretic and vomiting abuse.
• Calcium deficiency can happen from too much fiber intake, which reduces absorption.

Promoting Sleep

• Patients experiencing anorexia may be hyperactive with uncontrolled muscle spasms.
• They may receive low amounts of sleep, but wake up with high energy.
• Establish a sleep pattern in order to help patients conserve their energy and reduce calorie expenditure Patients may require bedrest.
• During refeeding periods, working out is not allowed.
• Nurses should monitor the patients, noting that patients may work out while in bed.

Anorexia Nervosa Medications

• Fluoxetine (Prozac) is the only FDA approved for anorexia in Canada.

  • Should be taken in morning to negate insomnia.

• Antipsychotics:

  • Chlorpromazine (Thorazine):
    • A typical antipsychotic.
    • Can be used in cases of delusions and over activity.
  • Olanzapine (Zyprexa):
    • An atypical antipsychotic.
    • Can be used to boost mood, reduce thinking that is obsessional.
    • May increase weight gain.

• Some medications can aggravate the symptoms of anorexia, such as nausea, diarrhea, vomiting, appetite loss and weight loss, it is vital to also treat co-morbid conditions together.

Nursing Goals when promoting physical wellness for anorexia patients.

• Identify goal to increase physical health. Identify the role of medication.

Anorexia Nervosa: Psychosocial Intervention

• Addressing interoceptive awareness.
• Helping patients’ understanding of patients own feelings.
• Providing psychoeducation.

Addressing Interoceptive Awareness

• Helps people realize cues about food and associated emotions.
• Journaling
• Emotions behind physical symptoms can be found.
• Distortions of body should be distinguished reality.
  • One can ask about triggers, that cause distortion.
• The primary aim is to create reliable idea of the nature of patient's current state.

Helping Patients Understand Feelings

• A focus on minimizing disputes.
• Determine feeling of patient.
• Thoughts can be shared instead emotions.
• Cognitive reframing
  • Differentiate fears that are irrational from what is true
  • A challenge for how patients view the world.
  • Use CBT techniques
  • Address distorted thinking

Psychoeducation

• Assessment of prior knowledge
  • What patient does not know.
  • For example: roles of fats
• Making goals that are SMART
  • Simple goals can mitigate frustrations.
  • Support a patient's path towards success.
• Lifestyle balance
  • Exercise and Relax
  • Strong Relationships
  • Create interests

Evaluating Wellness

• Assessing the effectiveness of bulimia and anorexia interventions.

Recovery Evaluation

• Healing is a process.
• Release at 85% of ideal weight, and deemed successful at 90% after a year.
• A more realistic view of weight and body image.
• Increased rating scale scores.

Bulimia Nervosa: Physical Health

• Monitor patient during meals and bathroom visits.
• Monitor output/input.
• Encourage the use of a regular sleeping schedules and relaxation due to patient's need to people please and inability to commitments.

Bulimia Nervosa medications

• SSRI, Fluoxetine (Prozac).
  • Only FDA approved bulimia treatment in Canada. Should be taken mornings in order to reduce sleep problems.

Tricylic Antidepressants.

- Can lessen purging, should assess to identify risk.

Wellburin

- Higher Seizure chance. Seldom is ever employed.

Addressing Co-Morbid Conditions

- Some prescriptions might trigger additional symptoms, that an anorexia patient may get (appetite loss, throwing up, etc.)

Bulimia Nervosa Psychosocial Interventions

• Consists of:
  • Behavioral Approaches.
  • Groups Involvement.
  • Patient guidance.

Behavioral Tactic

• Cue Removal and Self Monitoring
  • Recording actions.
  • Determining moods/actions.
  • Environmental cues involved.
  • Pinpointing reactions that are better. For eg: delaying actions etc.
  • Adjusting for individual settings.
  • Monitoring growth.

Timing of groups should be considered.

• Groups with rigid rules can be counterproductive.
• Primarily used after symptoms subside to process inadequacy.

Bulimia Nervosa-Patient Guidance

• Learn about healthy habits.
• Understand ideas behind nutrition.
• Unnatural thought patterns can be harmful.
• Self-harm.
  • Threats towards mental health.

Prevention Strategies

• Teaching Parents.

  • Explaining real vs ideal weight.
  • Giving methods to growing personal views.
  • Reduce influences from harassment.
  • Discuss common signs from eating issues.

• Education children and young adults.

• Talking about peer pressure and changes during puberty can help to manage obesity.

• Creating a positive view and identity of one's self.

• Support the ability to tackle health problems and thoughts

Dissociative Identity Disorder Interventions

• Medications typically manage symptoms that would increase episodes or distress.

  • Ex: A patient feeling panic, anxiety, sleep problems or higher agitation.
  • Symptoms of stress

• Early steps will lead to increased best potential of handling stress better.

  • Determine if the source began before recent shock/trauma
  • Use coping skills/reactions that are safer.

SSRIs

• Can lessen the severity of:
  • Dysregulation that is serotonergic

Side Effects

• Higher thoughts of actions from impulses. Assess risk potential.

• Additional medicines that can be supplied include:

  • Health Canada approved:
    • Sertaline (Zoloft), Citalopram. Additional Medicines (off-label use only):
    • Paroxetine and Also Fluoxetine(Prozac):
      • Can normalize glycemic levels. Monitor sugars of body.

Managing Emotions during DID episode.

• Try anti-psychotic drugs to assist/handle:

  • Uneasiness
  • Outbursts from impulsivity
  • Paranoid thoughts.

• Benzodiazepines:

  • Best for management that quick.
  • Can address nervousness and alertness with constant overreactions.

• Clondine and Qunfacine

• Used to manage impulses with conduct from patient.

• Lessen stress and reactions.

• Propranolol

• Reduces triggers from hyper reaction.

• The best approach will be to create a safety environment.

• Help build relationships.

• Identify the interventions needed.

Objectives to achieve for patients with DID.

• Differ on environment.
• Stabilize mental state.
• Help be safe.
• Engage in activities.

General Goals

• Help create thoughts of dealing with anxiety.
• Identify ways for control.
• Exhibit skills for problems.
• Employ assistance effectively.

Explore interventions for Obsessive-Compulsive Disorder (OCD) and eating disorders, as defined by the DSM 5. Understand managing compulsions with medication and psychosocial approaches for OCD. Compare therapeutic relationship, physical health, and psychosocial interventions for anorexia and bulimia.