498 mental health eating disorder

Instructions

• The learning module aims to guide understanding of interventions and evaluating patient outcomes for various disorders, defined in the DSM 5.
• Disorders covered include Obsessive Compulsive Disorder (OCD), eating disorders such as Anorexia Nervosa & Bulimia Nervosa, and Dissociative Identity Disorder (DID).
• Learning is evaluated through checkpoints, example questions, and points of reflection.
• Completing all questions is not required, but doing so helps in articulating nursing knowledge.
• Questions can be emailed to [email protected].

Class Objectives: OCD

• Identify how interventions to manage physical compulsions are combined with medication and psychosocial interventions.
• This combination is needed to create a comprehensive care plan for individuals with OCD.

Class Objectives: Eating Disorders

• Compare and contrast the three domains of interventions (therapeutic relationship, physical health, psychosocial) for anorexia nervosa and bulimia nervosa.
• Describe how each of the three domains must be included in a comprehensive care plan for eating disorder patients and their families.
• The three domains are necessary in order to achieve successful patient outcomes.
• Describe how mindfulness and cognitive behavior therapy are embedded in the nursing interventions for eating disorders.

Class Objectives: DID

• Compare and contrast the roles of pharmacological agents and psychotherapy in DID treatment.
• Describe how pharmacological and psychotherapeutic interventions promote patient safety and well-being across the lifespan and the trajectory of DID.
• Critique how pharmacological and psychotherapeutic interventions are influenced by the SEDoHs.

OCD Interventions

• OCD interventions address two primary areas of concern: the physical consequences of the compulsion and psychosocial components.

Physical Consequences Of The Compulsion

• A nursing intervention to address the physical consequences of compulsions is maintaining skin integrity.
• Skin integrity can be maintained by using tepid water and mild soap, providing hand cream, and creating a schedule for hand washing.
• Schedules for handwashing include after specific events and time-limited hand washing.

Exposure & Response Prevention

• Expose patients to the situation or object that triggers compulsions and have them refrain from the ritualistic behavior.
• Goals of exposure and response prevention are to decrease stress related to activity and identify the real outcome.
• Begin with a very short exposure time and gradually increase the length of time.
• Observe patients for signs of distress.
• Ask patients to identify how they are feeling and any urges for harm to themselves or others during the exposure.
• Acknowledge that discomfort during exposure is okay, but patients shouldn't feel intense distress.
• Vocalize that even though the patient felt uncomfortable, they were able to remain safe.

Thought Stopping

• Interrupt a thought by saying "stop."
• Thought stopping is used with obsessive thoughts.
• It interrupts the autonomic process and is associated with mindfulness.
• It controls the downward spiral of obsessional thinking and delays the response by creating an opportunity to change the response.
• The challenge is to recognize a thought in order to interrupt it.

Relaxation Techniques

• Relaxation techniques decrease anxiety, although symptoms of OCD remain the same.
• Distraction offers an alternative activity but does not eliminate existing compulsions.
• These activities can improve sleep patterns and can help with insomnia.
• Examples of relaxation activities are deep breathing, meditation, and listening to music.
• Most relaxation activities have a rhythmical nature.

Cognitive Restructuring

• Cognitive restructuring alters the individual’s dysfunctional appraisal of the situation and their perceptions of the consequences.
• This goal involves a combination of mindfulness and cognitive behavior therapy (CBT).
• Mindfulness interrupts autonomic processes.
• CBT tests distorted thoughts with reality/evidence.
• Cue cards and a pros and cons list are examples of cognitive restructing techniques.

Medications

• Common medications for OCD includes TCAs and SSRIs.
• Clomipramine is an example of a TCA.
• Fluoxetine, fluvoxamine, paroxetine, and sertraline are examples of SSRIs.
• Antidepressants are given in higher doses for OCD than when given for depression.
• Drug interactions include MAOIs.
• Adverse side effects of MAOIs include hypertensive crisis and serotonin syndrome.
• Educate patients and families about medications.
• It may take 4-6 weeks to see an initial change.
• Individuals may experience side effects with no improvement during this time.
• Medication is only part of the solution.
• Behavior therapy is needed for lasting change.
• Side effects of OCD medications include sedation, toxicity, and suicidality.

Social Domain

• Four principles for OCD patients in acute care are clearly explaining unit routines, initially not preventing patient from engaging in rituals, empathizing with the individual's need to perform rituals, and balancing time between private activities and unit activities.
• Explaining routines decreases fear of the unknown.
• Empathizing with the need to perform rituals contributes to a positive therapeutic relationship.

Psychoeducation

• Educate OCD patients and their families on the diagnosis, rationale for interventions, importance of continued behavioral practice, and additional resources.

OCD Evaluation

• Monitoring remission of presenting symptoms and ability to complete activities of daily living.
• Look for participation in social activities and absence of self-harm behaviors.
• Assess knowledge about the disease and treatment.
• Track improved scores on rating scales.

Eating Disorder Interventions

• The the types of interventions for eating disorders include therapeutic relationship, physical health, psychosocial, and prevention strategies.

Therapeutic Relationship

• The nature of the therapeutic relationship is to support the goals of therapy and clarify the boundaries related to roles.
• Therapeutic relationships can be difficult to develop with eating disorder patients.
• Anorexia patients tend to be suspicious and mistrustful, while bulimia patients have an intense need to be liked and please others.
• Patients can be impatient and irritable due to starvation, guilt, shame, and embarrassment about their eating and/or underlying separation issues.
• A nursing approach to eating disorder patients includes being firm and accepting, providing a rationale for interventions to build trust, and using a non-reactive approach to avoid power struggles.

Anorexia Nervosa: Physical Health

• Refeeding is the most important intervention during initial stages of treatment.
• There will be resistance and refusal to eat.
• The goal is to gain 1-2 pounds per week.
• It is recommended to start with 1500 calories and increase to 3500 calories.
• Several meals per day.
• Behavioral plan includes both positive and negative reinforcement.
• Monitor meals and bathroom use.
• Record "ins and outs" in oral form, tube feeds, and IV.
• Work on cognitive distortions that include beliefs about their body and food.
• The behavior plan's structure consists of expectations rather than a list of punishments.
• All staff need to be consistent with the agreed upon plan.
• May include nasogastric tube feeds and intravenous replacement of electrolytes.
• Decreased electrolytes can result from using diuretics and vomiting.
• Decreased calcium results from large intake of fiber which decreases calcium absorption.
• Patients are hyperkinetic and may be hyperactive and experience abnormal muscle spasms.
• Patients may sleep very little and wake up in an energized state.
• Promotion of sleep requires developing a sleep hygiene routine in order to conserve energy and reduce caloric expenditure.
• Exercise is not permitted during the refeeding phase.
• Monitor patients closely for attempts to exercise in their rooms.

Anorexia Nervosa: Medications

• Fluoxetine (Prozac) is the only approved drug in Canada for the treatment of anorexia nervosa, and must be taken in the morning.
• Antipsychotics such as chlorpromazine (Thorazine) are typical antipsychotics and are used for delusions and over activity.
• Olanzapine (Zyprexa) is an atypical antipsychotic used to improve mood, decrease obsessional thinking, and side effect is weight gain.
• Some medications can cause many of the symptoms an individual with anorexia nervosa already experiences, i.e. nausea, vomiting, diarrhea, loss of appetite, weight loss.

Anorexia Nervosa: Psychosocial

• Three components of psychosocial interventions are addressing interoceptive awareness, helping patients understand feelings, and psychoeducation.
• The goal is to help patients acknowledge visceral cues and emotions related to food.
• Journaling can help identify the emotion behind the somatic concern.
• For example, "I'm fat," can be connected to anger, loneliness, or guilt.
• Distinguish between body image distortion and reality by asking what triggers the distortion in terms of emotions and specific situation.
• The underlying principle is to develop an accurate perception of what is going on.

Psychosocial Interventions: Helping Patients Understand Feelings

• Helping patients understand feelings attempts to decrease avoidance of conflict.
• One technique it to name the feelings when patients want to state thoughts instead of feelings.
• For example, use “I feel lonely” rather than "I'm too thin.”
• Restructure cognitive distortions by distinguishing fears from reality.
• Challenge patients to see the world differently and use CBT techniques.

Anorexia Nervosa: Psychoeducation

• Assess knowledge, clarify facts, and provide SMART goals.
• SMART goals should be as small as possible to limit the chance of failure and set patients up for succes.
• Encourage a balanced lifestyle with activity, rest, healthy relationships, and developing interests.

Bulimia Nervosa: Physical Health

• Monitor meals and bathroom visits, record intake and output, and encourage regular sleep.
• Patients may be overcommitted and have difficulties saying no.
• Worry about fulfilling their commitments can interfere with sleep and be a trigger to binge eating.
• Develop and practice using relaxation strategies.

Bulimia Nervosa: Medications

• Fluoxetine (Prozac) is the only approved drug in Canada for the treatment of bulimia nervosa.
• Take in the morning and monitor for cheeking and purging after drug administration.
• Tricyclic antidepressants have some evidence that they reduce binge-eating and purging, but toxicity can be lethal.
• Wellbutrin increases risk of seizures and is not generally used.
• Some medications can cause many of the symptoms an individual with anorexia nervosa is already experiencing, i.e. nausea, vomiting, diarrhea, loss of appetite, weight loss.

Bulimia Nervosa: Psychosocial Interventions

• The three components of psychosocial interventions are behavioral strategies, group interventions, and psychoeducation.
• Behavioral strategies are intended to achieve cue elimination and self-monitoring through journaling of binges and purges, precipitating emotions, and environmental cues.
• Identify healthy responses, for example: distraction, postponing a binge, and modify responses for specific scenarios and track successes.
• Group interventions aims to increases interpersonal learning opportunities and are primarily used after symptoms subside to process inadequacy, low self-esteem, lack of assertiveness, and opportunity to receive feedback about distorted beliefs.
• Groups with rigid rules can be counterproductive, as those with bulimia tend to be rigid and abstain in ways that lead to binge eating.
• Nutrition should be about moderation.

Bulimia Nervosa: Psychoeducation

• SMART goals focused on setting healthy boundaries and limits, nutritional concepts, learn about misconceptions about food and the binge-purge cycle, and distorted thinking and consider changing thinking patterns from either/or to both/and.
• Teach about the physical harm, damage to physical systems, signs of increased risk for suicide and self-harm, and resources for education and supports.

Eating Disorders: Evaluation

• Treatment outcomes for both anorexia and bulimia exist on a continuum.
• Discharge when the individual has attained 85% of ideal weight.
• Treatment is considered successful when the individual has attained 90% of ideal weight and maintained this for 1 year.
• Monitor if thoughts about body image, weight, and food are more closely aligned to reality and improved scores on rating scales.

Prevention Strategies for Parents & Children

• Parents should receive education on real vs ideal weight, ways to increase self-esteem, media, signs and symptoms of OCD and eating disorders, interventions for obesity, and supervision of eating and exercise.
• Children & adolescents should receive education on peer pressure, pubescent changes, strategies for obesity, how to develop and improve self-esteem, media and body image traps, and managing problems through coping strategies, stress reduction, and creative problem solving

Dissociative Identity Disorder (DID): Pharmacology

• Medications do not decrease the frequency of dissociation.
• Usually prescribed to decrease symptoms that lead to extreme distress and a dissociative episode, such as anxiety, depression, panic, difficulty falling asleep, nightmares, and increased arousal symptoms.
• Early intervention promotes the best outcomes across the lifespan.
• Counsel individuals to resolve trauma prior to another trauma occurring.
• Identify maladaptive coping skills and develop healthy adaptable coping mechanisms.
• SSRIs are considered first line medications and are the only approved medication for treatment of PTSD in Canada.
• SSRIs are frequently used in all age groups.
• For DID, medications are sometimes used for "off-label" indications.
• Off-label medications include antipsychotics, benzodiazepines, clonidine (Catapres), guanfacine (Tenex), and propranolol. Treat any other co-morbid or concurrent conditions
• Common mental co-morbid health conditions
• Bi-polar and psychotic disorders
• Common co-morbid physical health conditions such as arrhythmias and diabetes mellitus.

DID Pharmacology: Across the Lifespan

• The use of medication has become more frequent for Children and Adolescents
• Early intervention is critical.
• Relieving even one symptom has a significant positive impact on overall functioning.
• Dependent on the parent's, child's, and adolescent's beliefs and values of pharmacological interventions
• SSRIs are the most researched medications in children and adolescents.
• For older adults, use caution as medications are metabolized in the liver.
• There is increase risk for drug to drug interactions and decreased liver functioning.
• SSRIs: addresses anxiety, depression, labile affect, obsessional thinking, compulsive behavior.
• Side effects include suicidal ideation and behavior. In general antidepressants increase an individual's energy level before it improves their mood so a thorough risk assessment is required
• medications approved by health canada include citalopram and sertraline
• additional medication prescribed include fluoxetine and paroxetine which also stabilizes blood sugar

DID - Other Medications

• Antipsychotics address agitation, dissociation, hypervigilance, paranoia, or brief psychotic reactions- off label use
• Common medication used include risperidone, olanzapine and quetiapine
• Benzodiazepines are intended for short term management only for anxiety and hypervigilance
• Medications include lorazepam, alprazolam and diazepam for management
• Clonidine is used to reduced anxiety and arousal and improve concentration, mood and behavioural impulsivity.
• Guanfacine is used to reduced nightmares
• Propranolol is used to reduce arousal symptoms

DID: Goal Setting

• Goals will differ based on the setting in which care is provided.
• Acute care goals focus on stabilization, maintaining personal safety, and participating in unit activities.
• Community care goals focus on long term therapy, integrating identities, decreasing the frequency of dissociation, and maintaining personal safety.

DID: Psychotherapeutic interventions

• Provide a safe environment
  • Establish a trusting rapport by accepting the patient's feelings
  • Identify nursing interventions to help the patient remain safe
  • How often you will see the patient ( rounds and 1:1)
  • who the patient will approach if they dont felt safe
  • Locate patient room close to the nursing desk
  • Consider what in the environment could be dangerous
  • Decrease stimuli
• Identify stressors that could contribute to increased fear and anxiety
  • Consider what is happening in the milieu
• Keep a neutral approach when the patient dissociates
  • Provide support and encouragement
  • Gather assessment data to support patients safety

DID: Desired Patient Outcomes

• Acknowledge and discuss feelings of anxiety and fear.
• Identify ways to manage anxiety/fear effectively.
• Demonstrate problem-solving skills and use resources effectively.