1. Eating and Sleep Disorders
Chapter 8
Eating and Sleep Disorders

2. Outline Types of eating disorders Causes of eating disorders
Treatment of eating disorders
Sleep-Wake disorders
Treatment of sleep-wake disorders

3. Eating Disorders: An Overview
Two major types of DSM-5 eating disorders
Anorexia nervosa and bulimia nervosa
Severe disruptions in eating behavior
Weight and shape have disproportionate influence on self-concept
Extreme fear and apprehension about gaining weight
Strong sociocultural origins – Westernized views
Emphasis on thinness

4. Eating Disorders: An Overview
Additional DSM-5 eating disorder:
Binge eating disorder
Involves disordered eating behavior but may involve fewer cognitive distortions about weight and shape
Obesity – considered a symptom of some eating disorders but not a disorder in and of itself
A growing epidemic

5. Bulimia Nervosa Binge eating – hallmark of bulimia nervosa
Eating excess amounts of food in a discrete period of time
Eating is perceived as uncontrollable
Self-evaluation influenced by body shape and weight
May be associated with guilt, shame or regret
May hide behavior from family members
Foods consumed are often high in sugar, fat or carbohydrates

6. Bulimia Nervosa
Compensatory behaviors – designed to “make up for” binge eating
Purging (most common)
Self-induced vomiting (most common)
May also include use of diuretics or laxatives
Fasting or food restriction
Excessive exercise

7. Bulimia Nervosa Associated medical features
Most are within 10% of target body weight
Purging methods can result in severe medical problems
Salivary gland enlargement
Chubby facial appearance
Erosion of dental enamel
Electrolyte imbalance (i.e., sodium and potassium levels)
Kidney failure, cardiac arrhythmia, seizures
Intestinal problems
Severe constipation
Permanent colon damage

8. Bulimia Nervosa Associated psychological features
Most have comorbid psychological disorders
Anxiety (81%) and mood disorders (50-70%)
*Depression often follows bulimia (not depression first)
Substance abuse (37%)
Most are overly concerned with body shape
Fear of gaining weight

9. Bulimia Nervosa: Statistics
Majority are female – 90%+
Onset typically in adolescence
Lifetime prevalence is about 1.1% for females, 0.1% for males
6-7% of college women suffer from bulimia
Tends to be chronic if left untreated

10. Bulimia Nervosa: Treatment
Cognitive-behavioral therapy (CBT)
Basic components of CBT
Identifying maladaptive thinking patterns and behavioral habits, then gradual practice of new habits
Setting realistic goals
Using self-monitoring when eating
Modifying negative self-perception
Medical and drug treatments
Antidepressants
Can help reduce binging and purging behavior
Are not efficacious in the long-term

11. Anorexia Nervosa Extreme weight loss – hallmark of anorexia nervosa
Restriction of calorie intake below energy requirements
May also involve binging and purging
Defined as 15% below expected weight
*Average is about 25-30% by the time treatment is sought
Intense fear of weight gain and losing control over eating
People suffering from anorexia show a relentless pursuit of thinness
Instead of guilt, proud of both their diets and their extraordinary control
Often begins with dieting

12. Anorexia Nervosa DSM-5 subtypes of anorexia nervosa
Restricting type – limit caloric intake via diet and fasting
Binge-eating-purging type
Unlike bulimia nervosa, binging is typically on relatively small amounts of food and purge more consistently
*These subtypes refer only to the last 3 months
May reflect a certain phases of anorexia nervosa
e.g., 62% of the restricting type had begun binging and purging

13. Anorexia Nervosa Associated medical features
Cessation of menstruation (i.e., amenorrhea)
Dry skin, brittle hair or nails, sensitivity or intolerance of cold temperatures
Lanugo – softy, downy, fine white hair on the chest, back, arms, neck, and face
Due to severe weight loss and approaching emaciation
When too much weight is lost they no longer have enough body fat to heat the body; this develops to trap heat (like a blanket)
Similar concerns related to bulimia if purging by vomiting
Anorexia nervosa is one of the most deadly mental disorders
Starving body borrows energy from internal organs, leading to organ damage
Most serious consequence is cardiac damage which can lead to heart attack and death

14. Anorexia Nervosa Associated psychological features
Most have comorbid psychological disorders
Depression (71%)
Anxiety disorders are also often present
OCD is especially common
Engage in ritualistic behaviors to rid themselves of thoughts focused on gaining weight
Substance abuse (27%)
Strong predictor of mortality, especially suicide
Often associated with a sense of control in one’s life
Most show marked disturbance in body image

15. Anorexia Nervosa: Statistics
Majority are female and white
From middle- to upper-middle-class families
Usually develops around early adolescence
Lifetime prevalence approximately 1%
Predominately occurs in Western cultures
But… now being seen more in Eastern cultures... perhaps due to increasing Western influence?
Develops in Eastern women after moving to Western countries
Rare in African-American women
More chronic and resistant to treatment than bulimia nervosa

16. Anorexia Nervosa: Treatment
General goals and strategies
Weight restoration
First and easiest goal to achieve
Psychoeducation
Behavioral and cognitive interventions
Target food, weight, body image, thought and emotion
Treatment often involves the family
Family functioning strong predictor of treatment outcome
Long-term prognosis for anorexia nervosa is poorer than for bulimia nervosa
Preventing eating disorders
Focuses on promoting body acceptance in adolescent girls

17. Causes of Bulimia and Anorexia
Media and cultural considerations
Being thin = success, happiness....really?
Cultural imperative for thinness
Translates into dieting
Standards of ideal body size
Change as much as fashion
Media standards of the ideal
Are difficult to achieve
Biological considerations
Relatives of those with eating disorders are 4-5 times more likely to develop an eating disorder

18. Causes of Bulimia and Anorexia
FIGURE 8.1  Male and female ratings of body size. (Based on Fallon & Rozin, 1985.)

19. Causes of Bulimia and Anorexia
Psychological and behavioral considerations
Low sense of personal control and self-confidence
Perfectionistic attitudes
Distorted body image
Preoccupation with food
Mood intolerance
Familial influences
“typical” family is successful, hard-driving, concerned about external appearances, and eager to maintain harmony (often deny/ignore conflicts or negative feelings)

20. Causes of Bulimia and Anorexia: An Integrative Model
FIGURE 8.3  An integrative causal model of eating disorders.

21. Binge-Eating Disorder
New disorder in the DSM-5
It was an “Appendix Disorder” in the DSM-IV-TR
Binge eating without associated compensatory behaviors
Occurs, on average, at least once a week for 3 months
Associated with distress and/or functional impairment (e.g., health risk, feelings of guilt)

22. Binge-Eating Disorder
Associated features
Many persons with binge-eating disorder are obese (but can also be average weight)
Some, but not all, have concerns about shape and weight
Often older than bulimics and anorexics
About 33% binge to alleviate “bad moods” or negative affect
More psychopathology vs. non-binging obese people
It may run in families (i.e., genetic influence)
High stress events can act as a trigger

23. Binge-Eating Disorder: Statistics
Affects about 2.8 million adults
More common among adults in the US than anorexia and bulimia combined
Affects women 2:1
Occurs at similar rates across race/ethnicity

24. Binge-Eating Disorder: Treatment
Cognitive-behavioral therapy (CBT)
Similar to that used for bulimia
Encourages individuals to regulate their eating habits
Setting realistic goals
Using self-monitoring when eating
Modifying negative self-perception
CBT may also help reduce the frequencies of eating binges
Interpersonal psychotherapy
Equally as effective as CBT, especially if binge eating related to social problems

25. Summary of Eating Disorders
All eating disorders share:
Gross deviations in eating behavior
Heavily influenced by social, cultural, and psychological factors
Most are driven by distorted thinking related to shape and weight

26. Sleep-Wake Disorders: An Overview
Two major types of sleep disorders
Dyssomnias
Difficulties in amount, quality, or timing of sleep
Insomnia Disorder
Hypersomnolence Disorders
Narcolepsy
Circadian Rhythm Sleep-Wake Disorder
Parasomnias
Abnormal behavioral and physiological events during sleep or shortly after waking
Nightmare Disorder
Non-REM Sleep Arousal Disorders
REM Sleep Behavior Disorder

27. The Importance of Sleep
We spend about one-third of our lives asleep
Most people do not get enough sleep
28% of people in the U.S. report feeling excessively sleepy during the day
Sleep deprivation affects all aspects of daily functioning – energy, mood, memory, concentration, attention
Just a few hours of sleep deprivation decreases immune functioning
Sleep problems interact in important ways with psychological factors
REM sleep disturbance is related to depression
Insufficient sleep can stimulate overeating
Anxiety can negatively affect sleep patterns
Also relationships with bipolar and schizophrenia

28. Insomnia Disorder
Problems initiating/maintaining sleep (e.g., trouble falling asleep, waking during night, waking too early in the morning)
Occurs at least 3 nights per week and is present for at least 3 months
Occurs despite adequate opportunity for sleep
Only diagnosed as a sleep disorder if it is not better explained by a different condition (e.g., generalized anxiety disorder, substance abuse)
Microsleeps – due to sleep deprivation; eventually may fall asleep for several seconds

29. DSM-5 Criteria: Insomnia Disorder

30. Insomnia Disorder Statistics Associated features
One of the most common sleep disorders
Affects females twice as often as males
Often associated with psychological and medical problems, and environmental changes
E.g., depression, anxiety, substance abuse; physical pain, respiratory problems; changes in light, noise, temperature
35% of adults report daytime sleepiness
Sleep problems increase as adults get older
Associated features
Unrealistic expectations about sleep
e.g., “must get 8 hours of sleep” – thoughts can disrupt sleeping
Believe lack of sleep will be more disruptive than it usually is

31. Integrative model of Insomnia Disorder

32. Hypersomnolence Disorder
Excessive sleepiness despite a main sleep period lasting at least 7 hours and at least one of the following:
Recurrent periods of sleep or lapses into sleep within the same day
A prolonged main sleep episode of more than 9 hours per day that is non-restorative (i.e., unrefreshing)
Difficulty being awake after abrupt awakening
Occurs at least 3 times per week, for at least 3 months
Only diagnosed if other conditions don’t adequately explain hypersomnia, which should be the primary complaint

33. DSM-5 Criteria: Hypersomnolence Disorder

34. Hypersomnolence Disorder
Statistics
Often associated with psychological and medical problems
Not much is known about causes
Associated features
Complain of sleepiness throughout the day
Able to sleep through the night
Thinking about the disruptiveness of sleeping too much can interfere with other facets of life

35. Narcolepsy
Recurrent intense need for sleep, lapses into sleep, or napping (“sleep attacks”) within the same day, at least 3 times per week or the past 3 months
Experience episodes of cataplexy
Typically brief episodes of sudden loss of muscle tone with maintained consciousness (due to a sudden onset of REM sleep)
Can range from slight weakness in the facial muscles to complete physical collapse
Often precipitated by strong emotion
Hypocretin deficiency
A neuropeptide that regulates arousal, wakefulness, and appetite
Enter REM sleep abnormally fast (<15 min) during nocturnal sleep

36. DSM-5 Criteria: Narcolepsy

37. Narcolepsy Statistics Associated features
Very rare – affects about 0.03% to 0.16% of the population
Equally distributed between males and females
Onset during adolescence
Associated features
Sleep paralysis – a brief period after awakening when they can’t move or speak (very frightening)
Hypnagogic hallucinations – vivid and often terrifying experiences that begin at the start of sleep and are said to be unbelievably realistic
Include not only visual, but also touch, hearing, and sensation of body movement
Can also experience microsleeps

38. Circadian Rhythm Sleep-Wake Disorder
Disturbed sleep (e.g., either insomnia or excessive sleepiness) leading to distress and/or functional impairment (e.g. significantly decreased productivity at work) due to an alteration of the circadian system or to a misalignment between the endogenous circadian rhythm and the sleep—wake schedule required by the individual’s environment
Due to brain’s inability to synchronize day and night

39. DSM-5 Criteria: Circadian Rhythm Sleep-Wake Disorder

40. Circadian Rhythm Sleep-Wake Disorder
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
Examples of circadian rhythm sleep-wake disorders
Shift work type – job leads to irregular hours
Familial type – associated with family history of dysregulated rhythms

41. Medical Treatments for Dyssomnias
Insomnia
Benzodiazepines and over-the-counter sleep medications
Prolonged use can cause dependence and rebound insomnia – when sleep problems reappear (often worse) when medication is withdrawn
Best as short-term solution
Hypersomnia and narcolepsy
Stimulants (i.e., Ritalin)
Cataplexy usually treated with antidepressants

42. Medical Treatments for Dyssomnias
Circadian rhythm sleep-wake disorders
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

43. Psychological Treatments for Dyssomnias
Cognitive behavioral therapy for insomnia
Psychoeducation about sleep
Changing beliefs about sleep
Relaxation and stress reduction
Extensive monitoring using sleep diary
Practicing better sleep-related habits
i.e., improved sleep hygiene
See Table 8.4 (p. 318)

44. Nightmare Disorder
Repeated episodes of extended, extremely dysphoric and well-remembered dreams (REM sleep)
On awakening from the dysphoric dreams, the person rapidly becomes oriented and alert
The nightmares cause significant distress and/or impairment in daily life
The nightmare symptoms are not better explained by other conditions

45. DSM-5 Criteria: Nightmare Disorder

46. Nightmare Disorder Statistics Treatment
10%-50% of children and 1% of adults have nightmares regularly
Occurs during REM sleep
Involves distressful and disturbing dreams
Will often awaken the sleeper
Such dreams interfere with daily life functioning and interrupt sleep
Treatment
May involve antidepressants and/or relaxation training

47. Non-REM Sleep Arousal Disorder
Recurrent episodes of incomplete awakening from sleep accompanied by either:
Sleepwalking (somnambulism)
Leaving the bed during non-REM sleep; not acting out a dream
Sleep terrors
Recurrent episodes of panic-like symptoms during non-REM sleep
No or little dream imagery is recalled
Amnesia for the episodes is present
The sleep arousal symptoms are not better explained by other conditions

48. DSM-5 Criteria: Non-REM Sleep Arousal Disorders

49. Sleep Terrors Statistics Associated features
6% of children and <1% of adults have sleep terrors
Associated features
Often noted by a piercing scream
Child cannot be easily awakened during the episode
Child has little memory of it the next day
Treatment – a wait-and-see posture
Scheduled awakenings prior to the sleep terror
Severe cases
Antidepressants (i.e., Imipramine) or benzodiazepines

50. Sleep Walking Statistics Facts and associated features
More common in children (15-30%) than adults (<1%)
Facts and associated features
Seems to run in families
Waking a sleepwalker is difficult and they typically do not recall the experience, BUT it is not dangerous to awaken them
Problem usually resolves on its own without treatment
Related conditions
Nocturnal eating syndrome – Person eats while asleep

51. REM Sleep Behavior Disorder
New diagnosis in DSM-5
Repeated episodes of arousal during sleep associated with vocalization and/or complex motor behaviors
Causes impairment or distress
Often, major problem is injury to self or sleeping partner

52. DSM-5 Criteria: REM Sleep Behavior Disorder

53. Summary of Sleep Disorders
All sleep disorders share:
Interference with normal process of sleep
Interference results in problems during waking
Heavily influenced by psychological and behavioral factors