Chapter 8 Eating and Sleep Disorders

1. Chapter 8 Eating and Sleep Disorders

2. Eating Disorders: An Overview • Two Major Types of DSM-IV-TR Eating Disorders • Anorexia nervosa and bulimia nervosa • Severe disruptions in eating behavior • Extreme fear and apprehension about gaining weight • Strong sociocultural origins – Westernized views

3. Eating Disorders: An Overview (continued) • Other Subtypes of DSM-IV-TR Eating Disorders • Binge eating disorder – Buffet diet! • Obesity – A Growing Epidemic – not yet a disorder but the side effects are diagnosed. Can be on Axis III

4. Bulimia Nervosa: Overview and Defining Features • Binge Eating – Hallmark of Bulimia • Binge • Eating excess amounts of food • Eating is perceived as uncontrollable

5. Bulimia Nervosa: Overview and Defining Features (continued) • Compensatory Behaviors • Purging • Self-induced vomiting, diuretics, laxatives • Some exercise excessively, whereas others fast

6. Bulimia Nervosa: Overview and Defining Features (continued) • DSM-IV-TR Subtypes of Bulimia • Purging subtype – Most common subtype • Nonpurging subtype – About one-third of bulimics

7. Bulimia Nervosa: Associated Features • Associated Medical Features • Most are within 10% of target body weight • Purging methods can result in severe medical problems • Erosion of dental enamel, electrolyte imbalance • Kidney failure, cardiac arrhythmia, seizures, intestinal problems, permanent colon damage

8. Bulimia Nervosa: Associated Features (continued) • Associated Psychological Features • Most are over concerned with body shape • Fear of gaining weight • Most have comorbid psychological disorders

9. Anorexia Nervosa: Overview and Defining Features • Successful Weight Loss – Hallmark of Anorexia • Defined as 15% below expected weight • Intense fear of obesity and losing control over eating • Anorexics show a relentless pursuit of thinness • Often begins with dieting

10. Anorexia Nervosa: Overview and Defining Features (continued) • DSM-IV-TR Subtypes of Anorexia • Restricting subtype – Limit caloric intake via diet and fasting • Binge-eating-purging subtype – About 50% of anorexics

11. Anorexia Nervosa: Overview and Defining Features (continued) • Associated Features • Most show marked disturbance in body image • Most are comorbid for other psychological disorders • Methods of weight loss have life threatening consequences

12. Binge-Eating Disorder: Overview and Defining Features • Binge-Eating Disorder – Appendix of DSM-IV-TR • Experimental diagnostic category • Engage in food binges without compensatory behaviors

13. Binge-Eating Disorder: Overview and Defining Features (continued) • Associated Features • Many persons with binge-eating disorder are obese • Concerns about shape and weight • Often older than bulimics and anorexics • More psychopathology vs. non-binging obese people

14. Bulimia and Anorexia: Facts and Statistics • Bulimia • Majority are female • Onset around 16 to 19 years of age • Lifetime prevalence is about 1.1% for females, 0.1% for males • 6-8% of college women suffer from bulimia • Tends to be chronic if left untreated

15. Bulimia and Anorexia: Facts and Statistics (continued) • Anorexia • Majority are female and white • From middle-to-upper middle class families • Usually develops around age 13 or early adolescence • More chronic and resistant to treatment than bulimia • Both Bulimia and Anorexia Are Found in Westernized Cultures

16. Causes of Bulimia and Anorexia: Toward an Integrative Model • Media and Cultural Considerations • Being thin = Success, happiness....really? • Cultural imperative for thinness • Translates into dieting • Gossip News and People magazine; Playboy model appearance

17. Causes of Bulimia and Anorexia: Toward an Integrative Model (continued) • Standards of ideal body size • Change as much as fashion: What is a size 00? • Media standards of the ideal • Are difficult to achieve • Biological Considerations • Can lead to neurobiological abnormalities

18. Causes of Bulimia and Anorexia: Toward an Integrative Model • Psychological and Behavioral Considerations • Low sense of personal control and self-confidence • Perfectionistic attitudes • Distorted body image • Preoccupation with food • Mood intolerance • An Integrative Model

19. Fig. 8.4, p. 315

20. Medical and Psychological Treatment of Bulimia Nervosa • Medical and Drug Treatments • Antidepressants • Can help reduce binging and purging behavior • Are not efficacious in the long-term

21. Medical and Psychological Treatment of Bulimia Nervosa (continued) • Psychosocial Treatments • Cognitive-behavior therapy (CBT) • Is the treatment of choice • Basic components of CBT • Interpersonal psychotherapy • Results in long-term gains similar to CBT

22. Goals of Psychological Treatment of Anorexia Nervosa • General Goals and Strategies • Weight restoration • First and easiest goal to achieve • Psycho-education

23. Goals of Psychological Treatment of Anorexia Nervosa (continued) • Behavioral, and cognitive interventions • Target food, weight, body image, thought and emotion • Treatment often involves the family • Long-term prognosis for anorexia is poorer than for bulimia

24. Medical and Psychological Treatment of Binge Eating Disorder • Medical Treatment • Sibutramine (Meridia) • Psychological Treatment • CBT • Similar to that used for bulimia • Appears efficacious

25. Medical and Psychological Treatment of Binge Eating Disorder (continued) • Interpersonal psychotherapy • Equally as effective as CBT • Self-help techniques • Also appear effective

26. p. 342

27. Obesity: Background and Overview • Not a formal DSM disorder • Statistics • In 2000, 20% of adults in the United States were obese • Mortality rates • Are close to those associated with smoking

28. Obesity: Background and Overview (continued) • Increasing more rapidly • For teens and young children • Obesity • Is growing rapidly in developing nations

29. Obesity and Disordered Eating Patterns • Obesity and Night Eating Syndrome • Occurs in 7-15% of treatment seekers • Occurs in 27% of individuals seeking bariatric surgery • Patients are wide awake and do not binge eat

30. Obesity and Disordered Eating Patterns (continued) • Causes • Obesity is related to technological advancement • Genetics account for about 30% of obesity cases • Biological and psychosocial factors contribute as well

31. Obesity Treatment • Treatment • Moderate success with adults • Greater success with children and adolescents • Treatment Progression -- From least-to-most intrusive options

32. Obesity Treatment (continued) • First step • Self-directed weight loss programs • Second step • Commercial self-help programs • Third step • Behavior modification programs • Last step • Bariatric surgery

33. p. 342

34. Binge Eating Disorder-DSM-5 A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: 1. eating, in a discrete period of time (for example, within any 2-hour period), an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances 2. a sense of lack of control over eating during the episode (for example, a feeling that one cannot stop eating or control what or how much one is eating) B. The binge-eating episodes are associated with three (or more) of the following: 1. eating much more rapidly than normal 2. eating until feeling uncomfortably full 3. eating large amounts of food when not feeling physically hungry 4. eating alone because of feeling embarrassed by how much one is eating 5. feeling disgusted with oneself, depressed, or very guilty afterwards • Marked distress regarding binge eating is present. • The binge eating occurs, on average, at least once a week for three months. E. The binge eating is not associated with the recurrent use of inappropriate compensatory behavior (for example, purging) and does not occur exclusively during the course Anorexia Nervosa, Bulimia Nervosa, or Avoidant/Restrictive Food Intake Disorder.

35. Anorexia Nervosa- DSM-5 A. Restriction of energy intake relative to requirements leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health. Significantly low weight is defined as a weight that is less than minimally normal, or, for children and adolescents, less than that minimally expected. (*Rewording of DSM-IV criterion to focus on behavior, not refusal to maintain body weight) B. Intense fear of gaining weight or becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight. (*Addition of behavioral clause, as many deny fear) C.  Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight. (*Criterion D – Amenorrhea – deleted; many exhibit some menstrual activity, does not apply to pre-menarchal females, post-menarchal females, those taking modern oral contraceptives, and males) Specify current type: (*Due to cross-over complication in current episode sub-typing in the DSM-IV, current types are now specified “during the last three months”) Restricting Type: during the last three months, the person has not engaged in recurrent episodes of binge eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas) Binge-Eating/Purging Type: during the last three months, the person has engaged in  recurrent episodes of binge eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas)

36. Bulimia Nervosa-DSM-5 A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: 1. Eating, in a discrete period of time (for example, within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances. 2. A sense of lack of control over eating during the episode (for example, a feeling that one cannot stop eating or control what or how much one is eating). B. Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications, fasting; or excessive exercise. C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months. (*change from twice/week for past two months) D. Self-evaluation is unduly influenced by body shape and weight. E. The disturbance does not occur exclusively during episodes of anorexia nervosa. (*Removal of purging/non-purging subtype)

37. Feeding or Eating Conditions Not Elsewhere Classified – DSM-5 • Originally termed Eating Disorder NOS • Atypical Anorexia Nervosa - All criteria for AN are met, except that, despite significant weight loss, the individual’s weight is within or above the normal range. • Subthreshold Bulimia Nervosa (low frequency or limited duration) - All criteria for BN are met, except that the binge eating and inappropriate compensatory behaviors occur, on average, less than once a week and/or for less than for 3 months. • Subthreshold Binge Eating Disorder (low frequency or limited duration) -All criteria for BED are met, except that the binge eating occurs, on average, less than once a week and/or for less than for 3 months. • Purging Disorder - Recurrent purging behavior to influence weight or shape (self-induced vomiting, misuse of laxatives, diuretics, or other medications), in the absence of binge eating. Self-evaluation unduly influenced by body shape or weight or there is an intense fear of gaining weight or becoming fat. • Night Eating Syndrome - Recurrent episodes of night eating, as manifested by eating after awakening from sleep or excessive food consumption after the evening meal. There is awareness and recall of the eating. The night eating is not better accounted for by external influences such as changes in the individual’s sleep/wake cycle or by local social norms. The night eating is associated with significant distress and/or impairment in functioning. The disordered pattern of eating is not better accounted for by Binge Eating Disorder, another psychiatric disorder, substance abuse or dependence, a general medical disorder, or an effect of medication. • Other Feeding or Eating Condition Not Elsewhere Classified - Residual category for clinically significant problems meeting the definition of a Feeding or Eating Disorder but not satisfying the criteria for any other Disorder or Condition.

38. Sleep Disorders: An Overview • Two Major Types of DSM-IV-TR Sleep Disorders • Dyssomnias • Difficulties in amount, quality, or timing of sleep • Parasomnias • Abnormal behavioral and physiological events during sleep

39. Sleep Disorders: An Overview (continued) • Assessment of Disordered Sleep: Polysomnographic (PSG) Evaluation • Electroencephalograph (EEG) – Brain wave activity • Electrooculograph (EOG) – Eye movements • Electromyography (EMG) – Muscle movements • Detailed history, assessment of sleep hygiene and sleep efficiency

40. The Dyssomnias: Overview and Defining Features of Insomnia • Insomnia and Primary Insomnia • One of the most common sleep disorders • Problems initiating, maintaining, and/or non-restorative sleep • Primary insomnia – Unrelated to any other condition (rare!) • Mental health disorders can underlie sleep problems (e. g. depression, anxiety)

41. The Dyssomnias: Overview and Defining Features of Insomnia (continued) • Facts and Statistics • Often associated with medical and/or psychological conditions • Affects females twice as often as males • Associated Features • Unrealistic expectations about sleep • Believe lack of sleep will be more disruptive than it usually is

42. The Dyssomnias: Overview and Defining Features of Hypersomnia • Hypersomnia and Primary Hypersomnia • Sleeping too much or excessive sleep • Experience excessive sleepiness as a problem • Primary hypersomnia – Unrelated to any other condition (rare!)

43. The Dyssomnias: Overview and Defining Features of Hypersomnia (continued) • Facts and Statistics • About 39% have a family history of hypersomnia • Often associated with medical and/or psychological conditions • Associated Features • Complain of sleepiness throughout the day • Able to sleep through the night

44. The Dyssomnias: Overview and Defining Features of Narcolepsy • Narcolepsy -- Daytime sleepiness and cataplexy • Cataplexic attacks • REM sleep, precipitated by strong emotion

45. The Dyssomnias: Overview and Defining Features of Narcolepsy (continued) • Facts and Statistics – Rare Condition • Affects about .03% to .16% of the population • Equally distributed between males and females • Onset during adolescence • Typically improves over time

46. The Dyssomnias: Overview and Defining Features of Narcolepsy (continued) • Associated Features • Cataplexy, sleep paralysis, and hypnagogic hallucinations • Daytime sleepiness does not remit without treatment

47. The Dyssomnias: Overview of Breathing-Related Sleep Disorders • Breathing-Related Sleep Disorders • Sleepiness during the day and/or disrupted sleep at night • Sleep apnea • Restricted air flow and/or brief cessations of breathing

48. The Dyssomnias: Overview of Breathing-Related Sleep Disorders (continued) • Subtypes of Sleep Apnea • Obstructive sleep apnea (OSA) • Airflow stops, but respiratory system works • Central sleep apnea (CSA) • Respiratory systems stops for brief periods • Mixed sleep apnea • Combination of OSA and CSA

49. The Dyssomnias: Facts and Features Associated With Breathing-Related Sleep Disorders • Facts and Statistics • Occurs in 1-2% of population • More common in males • Associated with obesity and increasing age

50. The Dyssomnias: Facts and Features Associated With Breathing-Related Sleep Disorders (continued) • Associated Features • Persons are usually minimally aware of apnea problem • Often snore, sweat during sleep, wake frequently • May have morning headaches • May experience episodes of falling asleep during the day