Transcript Anxiety Disorders Eating Disorders Eileen Levy RN, MSN, PMHNP

Anxiety Disorders
Eating Disorders
Eileen Levy RN, MSN, PMHNP-BC
April 9, 2016
ANXIETY
• Anxiety is experienced by everyone!
• It’s the general state of apprehension and
foreboding
• It can evoke “fight or flight”
• Also can be positive, improvng one’s
performance
ANXIETY DISORDERS
• IS PERSISTENT, OCCURS TOO OFTEN, TOO
SEVERLY AND IS TRIGGERED VERY EASILY, LASTING
TOO LONG
• IMPACTS QUALITY OF LIFE
• Subjective sense of worry, apprehension, fear and
distress
• High levels of anxiety or excessive shyness in
children 6-8 years old may be an early indicator
of an anxiety disorder
GENERAL SYMPTOMS
• Overwhelming feelings of panic and fear
• Uncontrollable obsessive thoughts
• Painful intrusive memories, recurring
nightmares
• Nausea, sweating , muscle tension, other
physical reactions
• Dysfunction in school, job and relationships
•
•
•
•
•
•
•
•
•
Spectrum of Anxieties in Children and
Adolescents
Panic disorder
Generalized Anxiety Disorder
Specific Phobias
Social Phobia/Anxiety
Obsessive Compulsive Disorder
Post traumatic Stress Disorder
Acute Stress Disorder
Separation Anxiety Disorder/
Selective Mutism (specific social situations, >1
month)
Panic Disorder
• Severe, often spontaneous panic complicated with
anticipatory worry of having another and phobic
avoidance (situations where occurred or may be
anticipated
• At least 4 , duration 4 weeks in children: palpitations,
sweating, shaking, SOB, choking sensation, CP, N/V,
dizzy, chills/hot, numbness/tingling,
derealization/depersonalization, lose of control/going
crazy, fear dying
• Children/adolescents experience unrealistic worry, selfconsciousness and tension
• They will have recurrent panic attacks
Generalized Anxiety Disorder
• Excessive anxiety and worry about a number of
events or activities
• Difficult to control
• Occurs more days than not
• Six months or more
• Including at least 3: restlessness, easily fatigued,
difficulty concentrating, irritability, muscle
tension, sleep disturbance
• Children and adolescents usually anticipate the
worst
• They often c/o fatigue, tension, headaches and
nausea
Phobias: Specific, Social
• Marked fear, anxiety, or avoidance
• Fear of specific object, situation: heights,
animals, bugs, weather/natural environment,
social situations making child feel immediately
afraid, anxious
• Immediate fear, anxiety provoked by
exposure: crying, tantrums, hold on to parent
• Avoidance: steps taken to avoid
object/situation
• Duration : 4 weeks or longer
Obsessive Compulsive Disorder
• Unwanted images, thoughts, urges
• Physical acts felt necessary to avoid/reduce
distress associated with unwanted images etc.
• These experiences/behaviors cause significant
trouble with family, friends, school, work…
• Obsessive and /or compulsive behaviors
>1hr./daily or cause significant distress or
impairment
• Body Dysmorphia (body image), Trichotillomania
and Excoriation(skin picking) D/O: behavior
impairment and attempt to change
OCD in Youth
• May be aware that symptoms do not make sense and
are excessive(adolescents)
• Distressed when compulsive habits are prevented
(younger children)
• Most common obsessions concern dirt, contamination,
repeated doubts, arrangement of things, fearful
aggressive or murderous impulses, disturbing sexual
imagery
• Frequent compulsions are repetitive hand washing, use
of tissue to touch things, checking drawers, locks,
windows, doors, counting rituals, repeating actions,
requesting reassurance
Treatments
• Individual /play therapy
• Cognitive Behavior Therapy: focuses on changing
both behaviors and thinking patterns to change
feelings. A variety of CBT techniques are available
all of which are very specific and goal-directed.
• CBT is the blending of BT which is the changing
negative feelings by changing behaviors (ie
avoidance) and CT which works on changing
negative feelings by challenging beliefs to
become more realistic and rational.
• Visualizing , relaxation techniques, altering self
talk and challenging irrational beliefs
Medications
• FDA has approved several medications for
prescription to children and adolescents.
• Prozac(fluoxetine): ages 8 and older (MDD)
ages 7 and above(OCD)
• Zoloft (sertraline) :ages 6-17 (MDD, Panic
D/O, Social Phobia, OCD, PTSD, PMDD)
• Luvox(fluvoxamine): ages 8-17(OCD)
• Lexapro(escitalopram): ages 12-17 (MDD)
Medications /Anxiety Disorders
• Anafranil (clomipramine) : (OCD, enuresis,
impulsive behaviors): ages 10 and older
• CAREFULLY WEIGH THE RISKS AND BENEFITS
OF PHARMACOLOGICAL TREATMENTS VS.
NONTREATMENT WITH ANTIDEPRESSANTS .
• It is important to document this discussion
with parents in patient’s chart.
Black Box Warning
• 10/2004: FDA issued public warning about
increased risk of suicidal thoughts or behavior in
children and adolescents treated with SSRI
medications
• 2006: advisory committee to FDA recommended
extension of warning to include aduls to age 25
• More recently from comprehensive review
(including NIMH)of pediatric trials between 19882006 suggest benefits of antidepressant
medications likely outweigh risks to children and
adolescents with MDD and anxiety disorders.
FDA Review
• Found no completed suicides occurred among
2200 children treated with SSRI’s.
• 4% taking SSRI’s experienced SI or behaviors—
twice rate of placebo treated people in
study=black box warning
• Subsequent studies have shown when SSRI
scripts lessened, suicidal gestures, attempts, SI
increased
Monitoring
• Face to face regularly—weekly when initiating
treatment
• Use with caution , observe for activation of
known or unknown bipolar disorder and/or SI
• Inform parents/guardians of risk so they can help
observe child or adolescent patients
• Star low and go slow
• SSRI’s should not be stopped abruptly to prevent
‘d/c or withdrawal syndrome’: H/A, G/I, faintness,
strange sensations of vison /touch
SEROTONIN SYNDROME
• Group of adverse events with use of medications that
effect enhancement of central serotonin activity
• Use of SSRI with other serotonergic agents:
dextromethorphan, methadone, MDMA, ectasy,
triptans, St. Johns Wort, TCA (elavil, tofranil), Tramadol
• Triad of s/s: cognitive or MS changes—agitation,
confusion
• neuromuscular abnormalities-hyperflexia, spasms,
restlessness, rigidity, shivering , tremors
• Autonomic hyperactivity-diaphoresis, diarrhea, fever,
flushing, change in B/P, tachycardia, inc. respirations
• If temperature increases rapidly and note muscle
rigidity---go to ED: can decompensate in hours
• Unusual in children
PEDIATRIC AUTOIMMUNE
NEUROPSYCHIATRIC DISORDER
•
•
•
•
•
PANDA(ages 3-puberty)
OCD or tic d/o suddenly appear or worsen after a
Grp A Beta –hemolytic strep infection
after strep infection or scarlet fever
Dramatic s/s, “out of blue”
Motor or vocal tics, obsessions or compulsions,
moodiness, irritability, separation anxiety, panic
attacks
2-3 episodes with preceding strep infection
PANDA TREATMENT
• Antibiotic treatment of strep infection
• If throat culture negative, check for familial
carriers or occult strep infection (sinus, anus,
vagina, urethral opening of penis)
• Tell parents to sterilize or replace toothbrush
to prevent reinfection
• Prophyllatic antibiotics investigated by NIMH,
not yet recommended
EATING DISORDERS
• CAN DEVELOP DURING ANY STAGE OF LIFE, TYPICALLY
DURING TEENS OR YOUNG ADULTHOOD
• CHRONIC DIETING
• CONSTANT WEIGHT FLUCTUATIONS
• OBSESSION WITH CALORIES AND FAT CONTENTS OF
FOODS
• RITUALISTIC EATING PATTERNS
• FIXATION WITH FOOD, RECIPES, BUT NOT EAT IT
• ISOLATION
• DEPRESSION/LETHAGY
• SWITCHING BEWTEEN OVEREATING AND FASTING
BIOLOGICAL , PSYCHOLOGICAL,
ENVORONMENTAL FACTORS
• IRREGULAR HORMONE FUNCTIONS, GENETICS,
NUTRITIONAL DEFICIENCIES
• NEGATIVE BODY IMAGE, POOR SELF ESTEEM
• DYSFUNCTIONAL FAMILY DYNMAICS, CERTAIN PROFESSION
AND CAREERS, AESTHETICALLY ORIENTED SPORTS=LEAN
BODY MEANS ENHANCES PERFORMANCE
• FAMILY , CHILDHOOD TRAUMAS, CHILDHOOD SEXUAL
ABUSE
• CULTURE OR PEER PRESSURE, STRESSFUL SITUATIONS
(significant birthday, tests, grades) OR LIFE CHANGES(new
school, off handed remarks re: looks, weight)
ANOREXIA NERVOSA:WARNING SIGNS
• Is thin and continues to get thinner(15% OR MORE
LESS THAN MEDICALLY IDEAL WEIGHT)
• Diets even though not overweight, denies hunger
• Has a distorted body image—feels fat even though is
thin
• Loses or thinning hair, c/o bloating, nauseated eating
normal or less than normal quantities, amennorhea
• Talks excessively about food, cooking, dieting
• Exercises excessively , even when tired or injured
• Overemphasizes her importance of her body image to
her self worth
• Views weight loss as an accomplishment vs. an
affliction: therefore limited motivation to change
ANOREXIA NERVOSA
•
•
•
•
•
•
•
•
•
Severe/selective restriction of intake
Rigorous self denial
Wish to punish herself
Irritability, mood lability, decreased concentration,
decreased libido, obsessive features
Perfectionistic demands of self, anxious, restrained in
character, focuses intensely on details
Increase in exercise, purging , laxative and or diuretic
abuse
Substance abuse
Self injury
Serious , can be life threatening
BULEMIA NERVOSA
• Repeated cycle of out-of-control eating
followed by some form of purging
• Serious, can be life threatening
• Purging: self induced vomiting, excessive use
of laxatives or diuretics, obsessive exercising
• Preoccupied with shape, weight, body image
as a source of self esteem
• Often feel out of control in other areas of their
lives in addition to food
• May spend money excessively, abuse
substances, engage in chaotic relationships
•
•
•
•
•
•
•
•
•
•
•
•
BULEMIA NERVOSA: WARNING SIGNS
Engages in binge eating and cannot stop
Overeats in response to emotional stress
Guilt and shame felt about eating
Obsessively concerned about weight, body image,
shape
Often fails at adherence to diets
Uses bathroom frequently after meals
Feels out of control
Frequent fluctuations in weight
Menstrual irregularities
Swollen glands
Impulsively act on thoughts and feelings, moody and
depressed presentations
MAY BE AT NORMAL WEIGHT AND HEIGHT
BINGE EATING DOSORDER
• Referred to compulsive overeating
• Episodes of uncontrolled eating or bingeing
followed by feelings of guilt and depression
• Binge is defined as a large consumption of food ,
sometimes with a pressured , “frenzied’ feeling
• Often continues to eat after feeling “full’
• DOES NOT INVOLVE PURGING, EXCESSIVE
EXERCISE OR OTHER COMPENSATORY
BEHAVIORS
• Can lead to obesity, high cholesterol, diabetes
heart disease , depression
BINGE EATING DISORDER :
WARNING SIGNS
•
•
•
•
Eats large amounts and may not be hungry
Eats more rapidly than normal
Eats til uncomfortably full
Often eats alone: feeling shame or
embarrassment
• Has feelings of disgust, depression or guilt
after eating
• Hx. marked weight fluctuations
• Very unhappy with body image and may avoid
activities, even pleasurable ones
• Eating disorders are not just fads
• Extremely serious and can be life threatening
• Have the highest mortality rate of any
psychiatric disorder
• Cripple body and the mind
• Patients are intensely self critical, experience
profound body dissatisfaction and anxiety
• Cannot “be fixed”
• Lack self awareness/prevents recognition they
are in danger
• Many are openly protective of disorder
BODY IMAGE
• Four out of five 10 year olds are afraid of being
FAT
• 80% of women are dissatisfied with their bodies
• Average female in US is 5’4” , 140lbs
• Idealized average model, famous role model is
5’11” and weighs 117lbs. or comparable
• Thinness represents power, “being cool”, a
measure of self worth, even a measure of fitness
or wellness in todays society
BODY IMAGE
• Begins to form a an early age
• Influenced by our parents, caregivers, peers,
idols, life experiences
• Development of self esteem, a strong identity,
capacity for pleasure
• Ability to connect emotionally to one’s self
and others
• ALL CONNECTED TO A POSITIVE BODY IMAGE
• Each one of us from an early age has a picture
of ourselves in our mind’s eye
• THAT IMAGE AND OUR BELIEF OF HOW
OTHERS PERCEIVE US CREATES OUR
BODY IMAGE
BODY IMAGE DISTURBANCE
• Unable to accept a compliment
• Moods are overly affected by how she thinks she
looks
• Constantly compares herself to others
• Calls herself “fat”, “ugly, “gross”
• Seeks constant reassurance that her looks are
acceptable
• Identifies being thin to beautiful, successful,
happy, in control
• Compartmentalizes her body into part..Thighs,
stomach, butt, hips, etc
• Doesn’t feel connected to her body as a whole
• Always fears being fat, even if slim
• Is ashamed of herself and her body
• Strives to create that “perfect image”
RISK FACTORS FOR
CHILDHOOD/ADOLESCENT
EATING DISORDERS
• Family history
• Adverse parenting (little contact, high
expectations, parental discord)
• Family dieting
• Early menarche
• Sexual abuse
• Critical comments about weight, eating, shape by
family members and others
TIPS FOR CHILDREN/ADOLESCENTS
•
•
•
•
•
No food is “good” or “bad”
Eat when you’re hungry, stop when you’re full
Stay fit with sports, dance, karate, playing
All bodies are different
Teasing hurts, don’t tease a person about their
weigh or body
• Fat isn’t bad, as thin isn’t good
• If you’re unhappy with your body, talk to an adult
you trust. They can give you support and
information
TIPS for PARENTS
• Encourage healthy eating and exercise
• Examine own beliefs and behaviors about
weight, body image…consider your child’s
interpretation of your beliefs
• Allow your child to determine when they are
full
• Talk about the acceptability of all body types
• Discuss dangers of dieting
• Tell your child you love them for who she is
inside, not just how they look
PARENTS SHOULD AVOID
•
•
•
•
Labeling foods good and bad
Using food as a reward or a punishment
Encouraging your child to diet
Commenting on weight or body types of
anyone…you, your child or others
• Teasing or allowing your child to tease anyone
because of their appearance, including size
• Assuming a large person wants or needs to lose
weight
Once an eating disorder is
recognized, it can be treated
SUCCESSFULLY
Treatment
Healing
• Is done by parents and professionals
• Each has different roles , recovery is the
responsibility of the patient
• Remember how one approaches treatment for
an eating disorder makes a difference
• Encourage the person to talk to a clinician or
counselor
• It is a family disorder , needing all to take part
and stay with treatment until disorder is under
control
• Be aware that the person may be in denial, afraid,
ashamed resistive
The eating disorder
can ofen become a
way to help manage
painful feelings
PARENTS:
‘WHAT NOT TO DO’
•
•
•
•
Never plead, bribe, beg, threaten, manipulate
Avoid power struggles
Don’t criticize or shame
Don’t ignore the problem or warning signs of an
eating disorder
• Don’t try to control
• Don’t waste time reassuring her she isn’t fat
• Don’t get involved in endless conversations about
weight, food, calories
• Don’t give advice unless requested
• Don’t get too frustrated if she isn’t ready to
listen to your advice
• Don’t say “you’re too thin” or “it’s good
you’ve gained some weight”
• Keep family’s normal schedule, don’t let her
decide what, when and where family will
eat..this may keep her from recognizing
something is seriously wrong/unhealthy
• Don’t ignore stolen or missing food
• Don’t ignore evidence of purging
PARENTS:
WHAT IS GOOD TO DO
• Be kind—stay calm and when not frustrated or
emotional
• Stay positive: address evidence you have
heard or seen suggesting disordered eating
and broach topics like health, relationships,
mood rather than appearance, weight
• Be realistic: identify positives for change and
negative consequences for remaining
unchanged
• Be helpful..investigate clinical resources
• Be supportive and caring , encouraging
professional help.
• Don’t nag, but don’t give up
• Be patient
• Resist guilt…..
DO YOUR BEST
BE AS GENTLE AS YOU CAN WITH YOURSELF
TREATMENT OPTIONS
• Medical monitoring..electrolytes, BMI,
consultation/recommendations
• Nutritionist counseling..guidance for normal
eating
• Medications to treat comorbid anxiety, mood
issues or in reducing binge eating and purging
behaviors
• Self help groups
THERAPY
• There are different forms of psychotherapy
that can be helpful in addressing underlying causes
of eating disorders.
• Individual outpatient, may include CBT
• Family Outpatient
• Group
• Day treatment
• Intensive Outpatient
• Residential
Therapy is fundamental in eating
disorder treatment because it affords
the person the ability to address and
heal from life’s events and learn
healthier coping skills and ways to
express emotions, communicate and
develop and maintain healthy
relationships.