Anxiety Disorders Eating Disorders Eileen Levy RN MSN

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Anxiety Disorders Eating Disorders Eileen Levy RN, MSN, PMHNP-BC April 9, 2016

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

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

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 •

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

• • • 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

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, self -consciousness and tension • They will have recurrent panic attacks

Generalized Anxiety Disorder • Excessive anxiety and worry about a number of events or

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,

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

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 >1 hr. /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

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

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. •

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

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

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.

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 ,

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

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

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

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

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

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

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

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

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

• • • 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

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

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

• 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

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” , 140 lbs • Idealized average model, famous role model is 5’ 11” and weighs 117 lbs. 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

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

• 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

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 •

• 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,

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

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

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

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

Once an eating disorder is recognized, it can be treated SUCCESSFULLY

Treatment Healing • Is done by parents and professionals • Each has different roles

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

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

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

• 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

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 ,

• 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

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

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

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.