Chapter 8 Eating and Sleep Disorders

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

Eating Disorders: An Overview (continued) Other Subtypes of DSM-IV-TR Eating Disorders Binge eating disorder Obesity – A Growing Epidemic

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

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

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

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

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

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

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

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

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

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

Bulimia and Anorexia: Facts and Statistics 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

Bulimia and Anorexia: Facts and Statistics (continued) 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

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

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

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

Figure 8.4 An integrative causal model of eating disorders Fig. 8.4, p. 315

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

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

Goals of Psychological Treatment of Anorexia Nervosa General Goals and Strategies Weight restoration First and easiest goal to achieve Psychoeducation

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

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

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

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

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

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

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

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

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

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

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

The Dyssomnias: Overview and Defining Features of Insomnia Insomnia and Primary Insomnia One of the most common sleep disorders Problems initiating, maintaining, and/or nonrestorative sleep Primary insomnia – Unrelated to any other condition (rare!)

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

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!)

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

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

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

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

The Dyssomnias: Overview of 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

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

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

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

Circadian Rhythm Sleep Disorders Circadian Rhythm Disorders Disturbed sleep (i.e., either insomnia or excessive sleepiness) Due to brain’s inability to synchronize day and night

Circadian Rhythm Sleep Disorders (continued) Nature of Circadian Rhythms and Body’s Biological Clock Circadian Rhythms – Do not follow a 24 hour clock Suprachiasmatic nucleus Brain’s biological clock, stimulates melatonin Types of Circadian Rhythm Disorders Jet lag type Shift work type

Medical Treatments Insomnia Benzodiazepines and over-the-counter sleep medications Prolonged use Can cause rebound insomnia, dependence Best as short-term solution

Medical Treatments (continued) Hypersomnia and Narcolepsy Stimulants (i.e., Ritalin) Cataplexy Usually treated with antidepressants

Medical Treatments Breathing-Related Sleep Disorders May include medications, weight loss, or mechanical devices Circadian Rhythm Sleep Disorders

Medical Treatments (continued) Phase delays Moving bedtime later (best approach) Phase advances Moving bedtime earlier (more difficult) Use of very bright light Trick the brain’s biological clock

Psychological Treatments Relaxation and Stress Reduction Reduces stress and assists with sleep Modify unrealistic expectations about sleep Stimulus Control Procedures Improved sleep hygiene – Bedroom is a place for sleep For children – Setting a regular bedtime routine

Psychological Treatments (continued) Combined Treatments Insomnia – Short-term medication plus psychotherapy Other Dyssomnias Little evidence for the efficacy of combined treatments

The Parasomnias: Nature and General Overview Nature of Parasomnias The problem is not with sleep itself Problem is abnormal events during sleep, or shortly after waking

The Parasomnias: Nature and General Overview (continued) Two Classes of Parasomnias Those that occur during REM (i.e., dream) sleep Those that occur during non-REM (i.e., non-dream) sleep

The Parasomnias: Overview of Nightmare Disorder Occurs during REM sleep Involves distressful and disturbing dreams Such dreams interfere with daily life functioning and interrupt sleep

The Parasomnias: Overview of Nightmare Disorder (continued) Facts and Associated Features Dreams often awaken the sleeper Problem is more common in children than adults Treatment May involve antidepressants and/or relaxation training

The Parasomnias: Overview of Sleep Terror Disorder Recurrent episodes of panic-like symptoms during non-REM sleep Often noted by a piercing scream

The Parasomnias: Overview of Sleep Terror Disorder (continued) Facts and Associated Features More common in children than adults Child cannot be easily awakened during the episode Child has little memory of it the next day

The Parasomnias: Overview of Sleep Terror Disorder (continued) Treatment -- A Wait-and-See Posture Scheduled awakenings prior to the sleep terror Severe Cases Antidepressants (i.e., imipramine) or benzodiazepines

The Parasomnias: Overview of Sleep Walking Disorder Sleep Walking Disorder – Somnambulism Occurs during non-REM sleep Usually during first few hours of deep sleep Person must leave the bed

The Parasomnias: Overview of Sleep Walking Disorder (continued) Facts and Associated Features Problem is more common in children than adults Problem usually resolves on its own without treatment Seems to run in families

The Parasomnias: Overview of Sleep Walking Disorder (continued) Related Conditions Nocturnal eating syndrome – Person eats while asleep

Summary of Eating and Sleep Disorders All Eating Disorders Share Gross deviations in eating behavior Fear or concern about weight, body size, appearance Heavily influenced by social, cultural, and psychological factors

Summary of Eating and Sleep Disorders (continued) All Sleep Disorders Share Interference with normal process of sleep Interference results in problems during waking Heaving influenced by psychological and behavioral factors Incidence of Eating and Sleep Disorders Is Increasing More Effective Treatments for Eating and Sleep Disorders Are Needed