OCD, Eating Disorders & DID Interventions

Overview of Module

• This learning module aims to provide an understanding of interventions and methods for evaluating patient outcomes for Obsessive-Compulsive Disorder (OCD), eating disorders (Anorexia Nervosa & Bulimia Nervosa) and Dissociative Identity Disorder (DID)
• These disorders are defined according to the DSM 5.
• The module includes checkpoints, examples, and points for reflection to evaluate your learning

Class Objectives

• Identify how interventions designed to manage the physical consequences of compulsions are combined with medication and psychosocial interventions for individuals with OCD
• Compare and contrast the three domains of interventions—therapeutic relationship, physical health, and psychosocial—for anorexia and bulimia nervosa.
• Describe how each of the three domains must be included in a comprehensive care plan for individuals and families with eating disorders to achieve successful patient outcomes
• Describe how mindfulness and cognitive behavior therapy are embedded in nursing interventions for eating disorders.
• Compare and contrast the roles of pharmacological agents and psychotherapy in the treatment of DID
• Describe how pharmacological and psychotherapeutic interventions promote patient safety and well-being across the lifespan and throughout the trajectory of DID
• Critique how pharmacological and psychotherapeutic interventions are influenced by the Socio-Economic Determinants of Health (SEDoHs).

Obsessive-Compulsive Disorder (OCD) Interventions

Types of Interventions

• Interventions address two primary focus areas to:
  • Manage the physical consequences of compulsions
  • Address the psychosocial components of OCD

Maintaining Skin Integrity

• Use tepid water and mild soap
• Provide hand cream.
• Create a schedule for hand washing, for example:
  • After specific events
  • Time-limited handwashing

Exposure & Response Prevention

• Expose the patient to the situation or object that triggers their compulsions
• Help them refrain from the ritualistic behavior
• The goals are to:
  • Decrease stress related to the activity
  • Identify the real outcome of resisting the compulsion,.
• Start with short exposure times, gradually increasing duration.
• Observe the patient for signs of distress.
• Ask the patient about their feelings and urges, particularly regarding harm to self or others.
• The patient might feel uncomfortable, but shouldn't experience intense distress
• Reinforce that the patient was able to remain safe even when feeling uncomfortable

Thought Stopping

• Interrupt obsessive thoughts by saying "stop."
• The goal is to:
  • Interrupt the autonomic process associated with obsessive thinking
  • Control the downward spiral of obsessional thinking
  • Delay the compulsive response to allow for change
• Recognizing the thought is key to interrupting it

Relaxation Techniques

• Can decrease anxiety with the symptoms of OCD remaining the same
• Serve as a distraction, offering an alternative activity without eliminating compulsions
• Can improve sleep patterns, and help with insomnia
• Examples of relaxation techniques:
  • Deep breathing
  • Meditation
  • Listening to music
• Most relaxation activities have a rhythmical nature

Cognitive Restructuring

• Cognitive restructuring alters the individual's dysfunctional appraisal of situations and their perceptions of consequences
• It combines mindfulness and cognitive behavior therapy (CBT):
  • Mindfulness interrupts autonomic processes
  • CBT then tests distorted thoughts with reality and evidence
• Cognitive restructuring involves:
  • Cue cards
  • Pros and cons lists

Medications for OCD

• Common medications include:
  • TCAs like Clomipramine
  • SSRIs like Fluoxetine, Fluvoxamine, Paroxetine and Sertraline
• Antidepressants are typically prescribed in higher doses for OCD than for depression
• Drug interactions:
  • MAOIs can lead to hypertensive crisis and serotonin syndrome
• Educate patients and families about medications, including:
  • Time to work: Initial changes may take 4-6 weeks
  • Patients may experience side effects with no improvement during this period.
  • Effectiveness: Medication is only part of the solution, as behavioral therapy is also needed for lasting change.
• Side effects: Sedation, toxicity, and suicidality.

Social Domain Principles in Acute Care

• Clearly explain unit routines to decrease fear of the unknown.
• Do not initially prevent the patient from engaging in rituals
• Allow time to adjust without increasing anxiety
• Empathize with the need to perform rituals to foster a positive therapeutic relationship.
• Balance time between private and unit activities

Psychoeducation

• Educate patients and families, as knowledge is empowering.
• Cover diagnosis, rationale for interventions, importance of continued behavioral practice, and available resources

OCD Evaluation

• Consider the following points when evaluating patient progress:
  • Remission of presenting symptoms
  • Ability to complete activities of daily living
  • Participation in social activities
  • Lacking self-harm behaviors
  • Knowledge about the disease and treatment
  • Improved scores on rating scales

Eating Disorders Interventions

• Focuses on Anorexia and Bulimia Nervosa
• Eating disorder interventions occur according to four categories:
  • Therapeutic Relationship
  • Physical Health
  • Psychosocial
  • Prevention Strategies

Therapeutic Relationship

• The therapeutic relationship should:
  • Support the goals of therapy
  • Clarify the boundaries related to patient and provider roles
• Developing this relationship is difficult because:
  • Patients with anorexia tend to be suspicious and mistrustful.
  • Patients with bulimia have an intense need to be liked and please others
  • Patients can be impatient and irritable due to starvation or underlying issues.
  • Shame and embarrassment about eating disorders or separation issues can become significant development barriers
• Approach through:
  • Being firm and accepting
  • Providing a rationale for interventions to build trust
  • Using a non-reactive approach to avoid power struggles

Anorexia Nervosa: Physical Health

• Refeeding:
  • The most important intervention during the initial stages of treatment
  • Resistance and refusal to eat is often encountered by the nurse
  • The goal is for the patient to gain 1-2 pounds per week.
  • Begin with 1500 calories, increasing to 3500 calories
  • Several meals per day are to be provided
• Behavioral plans for refeeding should include:
  • Positive and negative reinforcement
  • Monitoring meals and bathroom use
  • Recording "ins and outs" (oral, tube feeds, IV)
  • Working on cognitive distortions about body image and food.
  • Structuring the behavior plan as expectations rather than punishments
  • Consistency among all staff members
• Refeeding may require:
  • Nasogastric tube feeds
  • Intravenous replacement of electrolytes
    • Decreased potassium from using diuretics or vomiting
    • Decreased calcium from large fiber intake, which reduces calcium absorption

Anorexia Nervosa: Promotion of Sleep

• Patients with anorexia nervosa can experience:
  • Hyperactivity
  • Uncontrolled muscle spasms
  • Sleep very little and wake up in an energized state, so encourage the development of a sleep hygiene routine to:
    • Conserve energy
    • Reduce caloric expenditure
• Bed rest is often required
• Monitor the patient for exercise during the refeeding phase, as patients may try to exercise in their rooms through:
  • Running in place
  • Running while lying in bed
  • Calisthenics

Anorexia Nervosa: Medications

• SSRIs:
  • Fluoxetine (Prozac) is the only approved drug in Canada
  • Take in the morning because it can cause insomnia
• Antipsychotics:
  • Chlorpromazine (Thorazine), a typical antipsychotic, is used for delusions and overactivity.
  • Olanzapine (Zyprexa), an atypical antipsychotic, improves mood, decreases obsessional thinking, and has a side effect of weight gain
• Address co-morbid and concurrent diagnoses
  • Some medications may worsen the anorexia by causing nausea, vomiting, diarrhea, loss of appetite, and/or weight loss

Anorexia Nervosa: Psychosocial

• Focus on three components:
  • Addressing interoceptive awareness
  • Helping patients understand feelings
  • Psychoeducation

Anorexia Nervosa: Addressing Interoceptive Awareness

• The goal is to help patients acknowledge visceral cues and emotions related to food through:
  • Journaling to identify emotions behind somatic concerns. Recognize connections between visceral feelings and emotional states, e.g., "I'm fat" connected to anger, loneliness, or guilt
  • Distinguishing between body image distortion and reality by asking what triggers the distortion.
• Develop an correct perception of current status

Anorexia Nervosa: Helping Patients Understand Feelings

• The goal is to decrease avoidance of conflict through:
  • Naming feelings instead of stating thoughts
  • Restructuring of cognitive distortions
    • Distinguish fears from reality
    • Challenge the patient to see the world differently
    • Use CBT techniques
• Example:
  • Patient: "I've gained 2 pounds, so I'll be up by 100 pounds soon."
  • Nurse: "You have never gained 100 pounds, but I understand that gaining even 2 pounds is scary."

Anorexia Nervosa: Psychoeducation

• Include:
  • Assessment of knowledge
    • Clarifying prior knowledge
      • Example: role of fats
  • SMART goals
    • Small goals to limit chance of failure
    • Set the patient up for success
  • Balanced lifestyle through:
    • Activity and rest
    • Healthy relationships
    • Developing interests

Bulimia Nervosa: Physical Health

• Monitor meals and bathroom visits
• Record intake and output
• Encourage regular sleep to manage over commitment.
• Worry about personal commitments from being committed to others can interfere with sleep and be a trigger to binge
• Practice relaxation strategies

Bulimia Nervosa: Medication

• SSRIs:
  • Fluoxetine (Prozac) is approved in Canada
  • Take in the morning because it can cause insomnia
  • Monitor for cheeking and purging after drug administration
• Tri-cyclic antidepressants:
  • Provide some evidence that these medications reduce binge-eating and purging
  • Toxicity can be lethal requiring a risk assessment
• Wellbutrin:
  • Increases the risk of seizures, so is not generally used
• Address co-morbid and concurrent diagnoses
  • Some medications can cause symptoms of anorexia nervosa i.e. nausea, appetite loss

Bulimia Nervosa: Psychosocial Interventions

• Employ three components:
  • Behavioral strategies
  • Group interventions
  • Psychoeducation

Bulimia Nervosa: Behavioral Strategies

• Cue elimination and self-monitoring through:
  • Journaling
    • Binges and purges
    • Precipitating emotions
    • Environmental cues
    • Identify healthy responses
    • For example: distraction, postponing a binge or purge
  • Modify responses for specific scenarios
  • Track successes

Bulimia Nervosa: Group Interventions

• Primarily used after symptoms subside to process:
  • Inadequacy
  • Low self-esteem
  • Lack of assertiveness
  • Opportunity to receive feedback about distorted beliefs
• Timing should be considered, as rigid rules can be counterproductive.
• Individuals with bulimia tend to be rigid and abstain in ways that lead to binge-eating, so moderation is healthier.

Bulimia Nervosa: Psychoeducation

• SMART goals: Learn to set healthy boundaries and limits.
• Nutritional concepts: Learn to address misconceptions about food and the binge-purge cycle
• Distorted thinking: Changing thinking patterns from either/or to both/and
• Discuss physical damage, as well as increased risk for suicide and self-harm
• Provide resources for education and supports

Eating Disorders: Evaluation

• Treatment outcomes exist on a continuum:

• Discharge with 85% of ideal body weight

• Treatment considered successful at 90% of ideal weight for 1 year

  • Thoughts about body image, weight, and food are more closely aligned to reality
  • Improved scores on rating scales

Eating Disorders: Prevention Strategies for Parents & Children

• For Parents: Provide education about:
  • Real vs. ideal weight
  • Ways to increase self-esteem
    • Reduce the influence of teasing and bullying
  • Media influence
  • Signs and symptoms of OCD and eating disorders
  • Interventions for obesity
  • Supervision of eating and exercise
• For Children/Adolescents: Provide education about:
  • Peer pressure
  • Pubescent changes
  • Strategies for obesity
  • Self-esteem enhancement
  • Media body image traps and inactivity
  • Managing Problems
    • Coping strategies
    • Stress reduction
    • Creative problem solving

Dissociative Identity Disorder (DID): Interventions

Pharmacology

• Medications do not decrease the frequency of dissociation
• Medications most often prescribed to treat Anxiety, Depression, Panic, Difficulty falling asleep, Nightmares, Increased arousal symptoms
• Early intervention promotes the best outcomes
  • Resolve trauma before another occurs
  • Identify maladaptive coping skills
• SSRIs:
  • the only approved medication for PTSD in Canada
  • Frequently used in all age groups
• In children/adolescents:
  • Use of medications has become more frequent.
  • Early intervention is critical.
  • Relieving even one symptom can have a positive impact.
  • Dependent on the parent’s/child’s/adolescent’s beliefs
• In older adults:
• Proceed w/ caution due to liver metabolization
• Increased drug interactions and decreased liver functioning

Medications

• SSRIs*
• Treat anxiety, depression, labile affect, obsessional thinking, and compulsive behavior
• Requires a thorough risk assessment
• SSRIs approved by Health Canada:
  • Citalopram
  • Sertraline
• Also requires close monitoring of blood sugars when increasing/decreasing dose
• Antipsychotics*
• Address agitation, dissociation, hypervigilance, paranoia, and brief psychotic reactions
• Common antipsychotics:
  • Risperidone
  • Olanzapine
  • Quetiapine
• Benzodiazepines*
• Short term management of anxiety and hypervigilance. -Lorazepam -Alprazolam -Diazepam
• Other off-label medications:*
  • Clonidine
    • Anxiolytic, improves concentration/mood, decreases impulsivity
  • Guanfacine
    • Reduces nightmares Propranolol
    • Reduces arousal symptoms

Psychotherapeutic Interventions

• Provide the patient a safe environment to:
  • Establish a trust by accepting the patient’s feelings
  • Provide nursing interventions to help the patient remain safe
  • Provide consistent contact via rounds and 1:1s
  • Locate patient room close to the nursing desk
  • Decrease environmental stimuli
• Identify stressors that could contribute to increased fear/anxiety
• Keep a neutral approach when the patient dissociates
  • Provide support and encouragement
• Gather assessment data to support patient safety

Goal Setting

• Goals differ based on the level of care:
  • Acute: Stabilization & maintenance of personal safety -Community: Long term therapy, integration of identities, decrease dissociation, maintain safety
• Therapy:
  • Acknowledge and discuss feelings