F.E.A.S.T's Around The Dinner Table forum

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Hendrixt
Hi Everybody

Our 14yrs old D has been AN since January - started refeeding in May, undergoing FBT as an outpatient under CAHMS in the UK - weight restored and eating well but only in the lower portions of her healthy weight range with a lot of ED behaviours to work through.

Just lately we have had a massive increase in anxiety which has led to a prolonged absence from school. The therapist has suggested we need to think about medication and we now have an appointment to see a psychiatrist tomorrow to discuss this.

Bearing in mind we are in the UK and under the CAHMS Community Eating Disorder service does anybody have any idea what might be suggested to us in terms of medication, and what should we be asking at the appointment

Thanks in advance.
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sandie
My experience is that you will be offered choice of fluoxetine (prozac) or sertraline- both Ssris. Fluoxetine is 1st choice. Sertraline has the edge if anxiety is significant but if off license. They will ask if anyone in family has benefitted from an ssri as evidence Of genetic link with benefit to one over the other. 

Psychiatrist wanted to to speak with D first before I joined meeting. I found it was important to give all history from my perspective as D had said she wasn’t anxious to psychiatrist when in fact this is a dominant issue for her.
I expect they will ask about depression, anxiety, sleep, self-harm etc. What I had not appreciated is that depression in young people manifests differently than in adults. 
Psychiatrist had also asked D when I wasn’t there about suicidal ideation. Don’t be afraid to ask about this as I was uncomfortable not knowing what my D had said. 

Likely at at first meeting you won’t be prescribed but will be sent away with information leaflets to consider. 

One important side effect they will discuss is that when starting an ssri, there can be an increase in suicidal thoughts for the first few weeks in young people so they need to be watched closely for this. I understand it’s to do with meds making the young person more motivated first before affecting mood, ie more inclined to act on thoughts they already have. 
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Ronson
Hi 

Like Sandie above we were offered fluoxetine. This was for body dysmorphia and anxiety.  I have to say it was good for my d.  I know not all have had great experiences but worked well for us. We do unfortunately have an appt to increase dose as school has led to additional anxieties more recently.


Anxiety can often increase as weight gets closer to its required level - maybe read some posts on extinction burst.  For some pushing through this time with weight gain has been enough.  But meds have helped us.

R
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sandie
Hi just to clarify we chose sertraline. I was already on this and had found almost immediate benefit and same when D started I noticed change in her within few hours. We also increased dose. 
And are also due to discuss starting on melatonin with psychiatrist offered due to significant sleep issues. 
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Fearfulparent
Hi , 

My daughter has been prescribed olanzapine due to her aggression and high distress . However , she doesn’t want to take it . She is 14 years old struggling with anorexia for more than 3 years , we managed to restored her weight last tread and she was discharged from the community service, but straight away relapsed last year in March since then we are battling this monster at home. I wishes she could take the olanzapine as it could help to decrease the voice in her head that telling her not to eat . 
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Ellesmum
We were prescribed fluoxetine for anxiety, we’ve gone from 10mg to 30mg  and melatonin for sleep. I asked for the melatonin and was immediately prescribed so don’t be afraid to ask if you feel it’s needed. 
Ellesmum
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Hendrixt
sandie wrote:
Hi just to clarify we chose sertraline. I was already on this and had found almost immediate benefit and same when D started I noticed change in her within few hours. We also increased dose. 
And are also due to discuss starting on melatonin with psychiatrist offered due to significant sleep issues. 


Thanks Sandie that's really helpful and will help us prepare for our appointment tomorrow. I didn't know anything at about medication. Amazing how the sertraline acted so quickly in your case. Setraline could be best for us as her anxiety is very high. I'll make some notes prior to the appointment to make sure we ask all the right questions. A bit scary that they can increase suicidal thoughts though!
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Hendrixt
Ronson wrote:
Hi 

Like Sandie above we were offered fluoxetine. This was for body dysmorphia and anxiety.  I have to say it was good for my d.  I know not all have had great experiences but worked well for us. We do unfortunately have an appt to increase dose as school has led to additional anxieties more recently.


Anxiety can often increase as weight gets closer to its required level - maybe read some posts on extinction burst.  For some pushing through this time with weight gain has been enough.  But meds have helped us.

R


Hi Ronson - thanks for the advice. Glad it worked well for you. Must say I'm a bit nervous as I don't know much about anti-depressants. I've read a lot of stuff about extenction bursts - I can recognise that in our D's behaviour. We're just keeping feeding her. She's at 104% height for weight but we continue to push for more
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sandie
Yes it does need to be taken seriously and I would definitely recommend removing any medication lying around etc. 
I found some paracetamol tablets in Ds room shortly after she started. I don’t think she took any but did have thoughts of self-harm. It was a big shock. I understand this risk wears off after 2 or 3 weeks. 
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Hendrixt
Rose123 wrote:
Hi , 

My daughter has been prescribed olanzapine due to her aggression and high distress . However , she doesn’t want to take it . She is 14 years old struggling with anorexia for more than 3 years , we managed to restored her weight last tread and she was discharged from the community service, but straight away relapsed last year in March since then we are battling this monster at home. I wishes she could take the olanzapine as it could help to decrease the voice in her head that telling her not to eat . 


Hi Rose - you must have been gutted when she relapsed after all the hard work of refeeding. We are constantly watching out for re-lapse and dreading that it might happen. It's a shame she won't take the Olanzapine. Can you not get back onto CAHMs books? 
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Hendrixt
Ellesmum wrote:
We were prescribed fluoxetine for anxiety, we’ve gone from 10mg to 30mg  and melatonin for sleep. I asked for the melatonin and was immediately prescribed so don’t be afraid to ask if you feel it’s needed. 


Thanks Ellesmum - it is mainly anxiety that is the problem. She has low moods but can quickly come out of them. She sleeps with mum and doesn't have much of a problem with sleep. CAHMs suggested considering meds as a result of a lot of anxiety over school and she has now stopped going in all together. 
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Hendrixt
sandie wrote:
Yes it does need to be taken seriously and I would definitely recommend removing any medication lying around etc. 
I found some paracetamol tablets in Ds room shortly after she started. I don’t think she took any but did have thoughts of self-harm. It was a big shock. I understand this risk wears off after 2 or 3 weeks. 


OMG that's really scary - thanks for the warning
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ValentinaGermania
Rose123 wrote:
Hi , 

My daughter has been prescribed olanzapine due to her aggression and high distress . However , she doesn’t want to take it . She is 14 years old struggling with anorexia for more than 3 years , we managed to restored her weight last tread and she was discharged from the community service, but straight away relapsed last year in March since then we are battling this monster at home. I wishes she could take the olanzapine as it could help to decrease the voice in her head that telling her not to eat . 


Can´t you just mix it into her food? A 14 year old should not be allowed to refuse important meds...
Keep feeding. There is light at the end of the tunnel.
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ValentinaGermania
Hendrixt wrote:


OMG that's really scary - thanks for the warning


I think you should not overreact on that, even without these psychopharmacal meds you should not have any meds or chemicals or sharps lying around with an AN patient and I am sure you are aware of that already.
Keep feeding. There is light at the end of the tunnel.
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Hendrixt
tina72 wrote:


I think you should not overreact on that, even without these psychopharmacal meds you should not have any meds or chemicals or sharps lying around with an AN patient and I am sure you are aware of that already.


Very good advice Tina
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melstevUK
Hi Tina,

"Can´t you just mix it into her food? A 14 year old should not be allowed to refuse important meds..."

I am a bit uncomfortable with that suggestion Tina!  I don't know what the legal ramifications are but I suspect it could be interpreted as child abuse in the UK.   I don't think any clinicians would agree with that approach either.  Something feels unethical about it.  

I am willing to stand corrected by others, however.
 
Believe you can and you're halfway there.
Theodore Roosevelt.
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ValentinaGermania
I understand your concerns but here in Germany a 14 year old is not allowed to refuse meds. When the parents agree that she has to take them and give them to her in other ways that is o.k. Maybe different rules and laws in different countries.
If it was cancer and chemotherapy meds, would it be seen the same in UK? Would she be allowed to die because she does not want to take them? Unbelievable here...
A lot of patients only refuse to take those meds because they read on some bad internet sites (you know what I mean) that they will gain weight taking these meds.

And a lot of professionals think the same about sneaking in fats and calories here, they say it is "unethical" and you should be "honest" with your child and we all know that in some cases with AN it is your only chance to get the food in when you do that...

But if that is really illegal in UK I will for sure delete my post. I do not want to suggest to do something illegal there.
Keep feeding. There is light at the end of the tunnel.
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melstevUK
I will have to check with psychiatrists I know Tina. Certainly life saving medication such as antibiotics would be given if child was too ill to realise they were needed but there is still a lot of anti-medication feeling in the UK for mental health conditions that I imagine support would favour the child rather than the parents in this instance .
No, I don't want you to retract your statement if this is permissible in Germany. Exploring attitudes and legislation within different countries is of interest and useful. 
I will email a psychiatrist I know and ask him for his comments.
Believe you can and you're halfway there.
Theodore Roosevelt.
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melstevUK
Hi Tina and any interested others.  A reply to my question about giving medication against the will of a child/young person.  This is the position in Scotland and I imagine guidelines in England will be the same, according to a reply I received from an ed psychiatrist I know:

"In Scotland children from the age of 12 can give consent if it is thought they are capable of that. If she is making a capable decision to refuse the medication - and a doctor should assess that - then she can refuse to take it. 
The mental welfare commission has a covert medication guideline that is quite helpful. People should only be given covert medication if it is absolutely necessary, they are incapable of properly consenting and there is legal authority from the mental health or adults with incapacity act. 
Even if she took it, she is likely to have side effects and will know that she has been given it. That’s not likely to have a good impact on her family relationships. If medication is given covertly, it also needs to be checked with pharmacy that mixing with food will not affect the absorption of the drug. All in all - no, I wouldn’t think they should be administering medication in this way. "

So I think,Rose123, that you should just keep trying to persuade your d that she would benefit from taking the medication because it is likely to alleviate her suffering.  She is probably scared that it will 'make her' give up the anorexia and she probably does not feel ready to do that.
Perhaps you can help her to see that she would probably feel calmer and that it is often taken at night time so she is likely to have better sleep.  Maybe you can 'sell' the idea of Olanzapine in this way instead.  These aggressive behaviours are very distressing and hard to deal with.  Just keep 'chipping away' at her. 

 

Believe you can and you're halfway there.
Theodore Roosevelt.
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Hendrixt
melstevUK wrote:
Hi Tina and any interested others.  A reply to my question about giving medication against the will of a child/young person.  This is the position in Scotland and I imagine guidelines in England will be the same, according to a reply I received from an ed psychiatrist I know:

"In Scotland children from the age of 12 can give consent if it is thought they are capable of that. If she is making a capable decision to refuse the medication - and a doctor should assess that - then she can refuse to take it. 
The mental welfare commission has a covert medication guideline that is quite helpful. People should only be given covert medication if it is absolutely necessary, they are incapable of properly consenting and there is legal authority from the mental health or adults with incapacity act. 
Even if she took it, she is likely to have side effects and will know that she has been given it. That’s not likely to have a good impact on her family relationships. If medication is given covertly, it also needs to be checked with pharmacy that mixing with food will not affect the absorption of the drug. All in all - no, I wouldn’t think they should be administering medication in this way. "

So I think,Rose123, that you should just keep trying to persuade your d that she would benefit from taking the medication because it is likely to alleviate her suffering.  She is probably scared that it will 'make her' give up the anorexia and she probably does not feel ready to do that.
Perhaps you can help her to see that she would probably feel calmer and that it is often taken at night time so she is likely to have better sleep.  Maybe you can 'sell' the idea of Olanzapine in this way instead.  These aggressive behaviours are very distressing and hard to deal with.  Just keep 'chipping away' at her. 

That’s very interesting Melstev.  I wonder if you could ask your psychiatrist friend another question for me, as, the way things are going with our D, she may well refuse to take the tablets.

The way I read it; the advice is that from 12 years onwards she is able to give consent, and presumably withhold it, as long as she is capable, and that level of capability is assessed by a doctor.  It’s probably a similar case in England. 

As we know many AN patients are anosognosic, that is the case with our D, who is weight restored but has never accepted that she is poorly and often says she wishes she was ‘doing the healthy eating again’ and that she was back to the way she used to be prior to refeeding; ‘nice and slim’. Is that not a case for regarding the child as being incapable of either giving consent or withholding consent to any aspect of treatment including medication. 

Another aspect of treatment is the nutrition (considered as ‘medicine’ by many experts) provided to children with anorexia, in which some parents covertly add high fat and calorific content to meals.  

I applied the principle of my D having a lack of capability, due to anosognosia, when I decided to add high-fat components to food by stealth during refeeding. As Tina says, some therapists feel that this is ‘unethical’ and that the child has a right to know what is in their food.  Also, of course there is the potential of this practice damaging the relationship, and trust, with the child, but that I think is a slightly separate issue .

We were criticised by our therapist for adding cream and full fat butter etc to food without informing our D. 

This is how I argued our case back. The scenario (if you want to be ‘ethical’) is that, during refeeding, you inform your child that you are putting high levels of fat and calorific components into their food. Therefore you place your child in the position where they have the opportunity to give consent or withhold consent to receiving the food, (the treatment/medicine) based on knowing what is in it. There is a reasonable chance that a child with anorexia will not consent to accepting food which has been loaded up with fat and high calorific content, maybe not in every case.

However, the nature of the disorder means that the child is not capable of giving informed consent in this matter, and furthermore if the child is anosognosic he/she will not even consider herself to be ill and therefore in need of the high-fat/calorific content. Therefore I have never felt that, as a parent, I have acted in an unethical way when I have added content by stealth to food, although I do recognise there is a risk that if it is discovered, my D could consider it a breach of trust, thereby damaging the relationship, but I feel this is a risk worth taking when you are trying to save your child’s life  

Anyway I have ended up rambling and going off subject. I would be interested in the psychiatrist view on what I have said about consent and covert administration of medication.

I am not advocating that medication should be given by stealth in the UK  as I think Childrens Services may consider this worthy of an investigation into child neglect or abuse. Just imagine if the child had an allergic reaction or a bad side-effect and ended up in A & E and you had to explain that you have been putting medication into their food by stealth. It is possible that staff  would consider this a safeguarding issue and make a referral to social services. 

However, if I was in another country where this was allowed, I’m pretty sure I would be doing it with a child who needs medication but is refusing to take it. Maybe we will move to Germany with Tina 😂

 

 

 

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deenl
Don't move to The Netherlands so. 12 is the age of consent here too. My son refused meds and an NG, neither of which can be placed without the consent of both the patient and parents unless a court order has been obtained. 

Warm wishes 

D
2015 12yo son restricting but no body image issues, no fat phobia; lost weight IP! Oct 2015 home, stable but no progress. Medical hosp to kick start recovery Feb 2016. Slowly and cautiously gaining weight at home and seeing signs of our real kid.

May 2017 Hovering around WR. Mood great, mostly. Building up hour by hour at school after 18 months at home. Summer 2017 Happy, first trip away in years, food variety, begin socialising. Sept 2017, back to school FT first time in 2 years. [thumb] 2018 growing so fast hard to keep pace with weight
  • Swedish proverb: Love me when I least deserve it because that's when I need it most.
  • We are what we repeatedly do. Excellence Recovery, then, is not an act but a habit. Aristotle.
  • If the plan doesn't work, change the plan but never the goal.
  • We cannot control the wind but we can direct the sail.
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ValentinaGermania
melstevUK wrote:

"In Scotland children from the age of 12 can give consent if it is thought they are capable of that. If she is making a capable decision to refuse the medication - and a doctor should assess that - then she can refuse to take it. "



So this is really the tricky point with that question - is an AN patient capable to make this decision?
If she would refuse the meds because she would be scared of the realistic side effects I would say - yes.
If she would refuse the meds because she would be scared of weight gain because of that (and that is only with some meds a side effect and not with all patients or all professionals would want them to take it) I would say - no.

So in some cases, for example when they are sectioned, it must work against the will of the patient when it is clear that they are not capable to make a healthy decision. I think all parents should ask that key question first. If the patient is not capable to decide not to eat or not to be in IP then he should also not be capable to decide to refuse meds.

I wonder if that is only the case with mental diseases or can a child of age 12 also refuse to get for example vaccination in NL, Deenl? It is discussed here at the moment to make the measles vaccination a law in Germany...

In some rare cases the system here seems to be easier... here you are in charge as a parent up to the day before they turn 18.
Keep feeding. There is light at the end of the tunnel.
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teecee

Hi Hendrixt
How did you get on with the meds?? 

I can say from personal experience that Sertraline helps massively. The effects are immediate which was weird for me as I’ve never been keen on taking pills. I don’t take them anymore as they were brilliant at doing the job. 

What I would say is stick with it as initially I had symptoms such as a dry throat and I mean like I’ve never had before....drinking gallons of water! Plus sickly feelings amongst others but they all disappeared after a couple of weeks. The benefits far outweigh the negatives. 


I was worried about the side effects (bizzarely on the long list it mentioned AN as a side effect!) especially suicidal thoughts but I had none. 

my D had those though and I was given great advice by the GP...to not shy away from asking if she got seriously low mood and I was concerned. She was honest when she was and wasn’t to me at those times. 

we had a lock put on a cupboard to store all sharps meds cleaning stuff etc and we hid the key. 


I hope things are manageable for you at this time. You WILL get through this. Nothing lasts forever....even the bad times. 

xx

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Hendrixt
teecee wrote:

Hi Hendrixt
How did you get on with the meds?? 

I can say from personal experience that Sertraline helps massively. The effects are immediate which was weird for me as I’ve never been keen on taking pills. I don’t take them anymore as they were brilliant at doing the job. 

What I would say is stick with it as initially I had symptoms such as a dry throat and I mean like I’ve never had before....drinking gallons of water! Plus sickly feelings amongst others but they all disappeared after a couple of weeks. The benefits far outweigh the negatives. 


I was worried about the side effects (bizzarely on the long list it mentioned AN as a side effect!) especially suicidal thoughts but I had none. 

my D had those though and I was given great advice by the GP...to not shy away from asking if she got seriously low mood and I was concerned. She was honest when she was and wasn’t to me at those times. 

we had a lock put on a cupboard to store all sharps meds cleaning stuff etc and we hid the key. 


I hope things are manageable for you at this time. You WILL get through this. Nothing lasts forever....even the bad times. 

xx



Hi Teecee,
She has been prescribed sertraline - hope the effects are as quick as you describe. Thanks for the heads up re side-effects. 


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melstevUK
Hi Tina,

My sympathies lie with your way of thinking and in all honesty I would take the same line as the 'food is your medicine': and say that the meds are necessary in the same way.

Ironically I could not get my d to eat but when it comes to meds she trusted me implicitly and took fluoxetine with no problem because she knew my history with depression and how much SSRIs keep me well. Now she takes sertraline as and when she needs it. 

There is a huge anti medication lobby in the UK and a lot of people including psychiatrists who think that talking therapies can solve everything .I am not with that group but they are powerful and this is why at present the law favours the child I believe and the right to refuse. 
I don't have the energy to fight this viewpoint I am afraid. But it is very different to my own pragmatic stance. If medication alleviates suffering, then we should use it 
Believe you can and you're halfway there.
Theodore Roosevelt.
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