Feeding/Eating, Elimination, and Sleep-Wake Disorders

What sleep stages are NREM Sleep Arousal Disorders associated with?

Stage 3 or 4 (deep NREM sleep).
EPPP highlight: These occur early in the night (first third of sleep).

When during the night do NREM Sleep Arousal Disorders usually occur?

First third of a major sleep period.

What are the two types of NREM Sleep Arousal Disorders?

Sleepwalking (somnambulism)

• Sleep terrors

Describe sleepwalking (somnambulism).

- Getting out of bed and walking around while asleep.

• May involve eating or sexual behavior.

• Little or no memory afterward.

Describe sleep terrors.

Sudden arousal with a panicky scream.

• Intense fear and autonomic arousal (e.g., rapid heart rate, fast breathing).

• Person is unresponsive during the episode and has no memory afterward.
  EPPP highlight: Sleep terrors = NREM, amnesia afterward.

Are people easily awakened during NREM arousal episodes?

No. They are typically unresponsive and hard to awaken.

How does memory differ between NREM sleep disorders and nightmares?

- NREM disorders: little or no recall of the episode or dream imagery.

• Nightmare disorder: vivid recall of the dream.

At what ages are NREM Sleep Arousal Disorders most common?

Childhood; they often decrease with age.

When do nightmares typically occur?

During REM sleep, usually in the second half of the night.
EPPP highlight: REM = vivid recall, later in the night.

What are the key features of Nightmare Disorder?

- Repeated, vivid, well-remembered dreams.

• Often involve threats to survival, security, or physical integrity.

• Person awakens oriented and alert but may remain distressed.

Are people confused or disoriented upon waking from a nightmare?

No—they’re usually alert and oriented.

What autonomic signs are seen in sleep terrors?

Intense physical arousal—rapid heart rate (tachycardia), rapid breathing.

Mnemonic to remember NREM Sleep Arousal Disorders vs. Nightmare Disorder?

- NREM = Night starts, No recall, Not awake.

• Nightmares = Near morning, vivid Narratives, fully Noted.

How can you distinguish sleep terrors from nightmares for the EPPP?

Sleep terrors: NREM, early night, no memory, hard to wake.

• Nightmares: REM, late night, vivid recall, easy to wake.

What’s tachycardia?

Fast heart rate.

What is Narcolepsy characterized by?

An irresistible need to sleep, causing sudden sleep episodes or naps at least 3 times/week for 3 months or more.

What are the three criteria used to diagnose Narcolepsy (only one needed)?

• Cataplexy (sudden loss of muscle tone triggered by emotions)

• Hypocretin deficiency (low levels in the brain)

• Short REM latency (entering REM sleep in ≤15 minutes on polysomnography)

What is cataplexy?

Sudden loss of voluntary muscle control, often triggered by strong emotions like laughter, anger, or surprise.

“A CAT gets excited, then suddenly goes limp — that’s CAT-A-PLEX-Y!”

What is hypocretin (orexin)?

A neurotransmitter that regulates wake/sleep states; often deficient in narcolepsy.

What does short REM latency mean in Narcolepsy?

Entering REM sleep within 15 minutes of falling asleep during a sleep study (polysomnography).

What are hypnagogic hallucinations?

What are hypnagogic hallucinations?

What are hypnopompic hallucinations?

Vivid hallucinations when waking up from sleep.

What is sleep paralysis?

Temporary inability to move or speak when falling asleep or waking up.

Why might people with narcolepsy try to suppress emotions?

To prevent cataplexy episodes, which can be triggered by strong emotions.

What behavioral strategies help manage narcolepsy?

• Maintaining good sleep hygiene

• Keeping a consistent sleep schedule

• Taking scheduled daytime naps

• Staying active physically and mentally

What are first-line medications for improving alertness in narcolepsy?

Modafinil and armodafinil (increase dopamine levels).

Modafinil → “Mode on, feel in!”

• Think: MODE (like turning a switch ON) → you turn your alertness ON.

• “Feel in” → you’re able to stay IN the moment, awake and focused.
  → So Modafinil helps turn your “alertness mode on.” → first-line for alertness.

What are psychostimulant options for narcolepsy?

Amphetamines and methylphenidate, which increase dopamine, and to a lesser extent serotonin and norepinephrine.

What medications are used to treat cataplexy in narcolepsy?

• Antidepressants like venlafaxine (SNRI), fluoxetine (SSRI), and clomipramine (TCA)

• Sodium oxybate (improves deep sleep, reduces cataplexy and daytime sleepiness)

What is sodium oxybate, and how does it help narcolepsy?

A medication derived from GHB, taken at bedtime, that improves deep sleep and reduces cataplexy and daytime sleepiness.

Sodium Oxybate → “So damn extreme, I’m out — need OXYgen for BATE!”

→ So Sodium Oxybate is for severe or treatment-resistant narcolepsy.

What is polysomnography?

A sleep study that records brain waves, oxygen levels, heart rate, and breathing during sleep.

How does DSM-5-TR define Feeding and Eating Disorders?

As “a persistent disturbance of eating or eating-related behavior that results in altered consumption or absorption of food and that significantly impairs physical health or psychosocial functioning.”

What is Pica?

Persistent eating of non-nutritive, nonfood substances (e.g., paper, paint, coffee grounds) for at least one month, inappropriate to developmental level, not culturally sanctioned.

Who is most commonly affected by Pica?

Children (most common), but elevated rates in pregnant women.

What are possible complications of Pica?

Intestinal obstruction, lead poisoning, and other medical issues.

What are the key diagnostic criteria for Anorexia Nervosa?

• Restriction of energy intake → significantly low body weight

• Intense fear of gaining weight or becoming fat, or behaviors preventing weight gain

• Disturbance in self-perception of weight/shape or denial of low weight seriousness

What are the two types of Anorexia Nervosa?

A: Restricting type and Binge-eating/Purging type.

What specifiers exist for Anorexia Nervosa?

Type, course (in partial or full remission), and severity (based on BMI).

What psychological conditions often co-occur with Anorexia Nervosa?

Depression and anxiety disorders, especially OCD. Anxiety often precedes anorexia.

What are medical complications of Anorexia Nervosa?

Multi-organ damage, malnutrition, extreme weight loss, potentially fatal outcomes.

Why is Anorexia Nervosa hard to treat?

Patients often deny having a problem and resist treatment.

What are initial treatment goals for Anorexia Nervosa?

Restore healthy weight, treat physical complications.

What are further treatment goals for Anorexia Nervosa?

• Increase motivation for treatment

• Provide nutrition education

• Change distorted beliefs and attitudes

• Treat comorbid conditions

• Involve family support and therapy

• Develop relapse prevention strategies

What psychological treatments have research support for Anorexia Nervosa?

• CBT for anorexia nervosa

• CBT-E (enhanced CBT) for eating disorders

• Family-Based Treatment (FBT) for adolescents

How does CBT for Anorexia Nervosa work?

Targets body image and weight-related beliefs, regularizes eating patterns, reduces body-checking.

What is CBT-E?

A transdiagnostic treatment assuming all eating disorders share core psychopathology (overvaluation of shape/weight); tailored and flexible.

What is FBT for Anorexia Nervosa?

A three-phase outpatient therapy for adolescents:

1. Parents manage weight restoration

2. Gradual return of control to adolescent

3. Address developmental issues and healthy independence

Are medications effective for treating Anorexia Nervosa directly?

Results are mixed; meds like olanzapine may help initial weight gain, fluoxetine may help weight maintenance, but generally used for comorbid symptoms.

What characterizes Bulimia Nervosa?

• Recurrent binge eating with lack of control

• Inappropriate compensatory behaviors (vomiting, exercise)

• Self-evaluation heavily influenced by body shape/weight

How often must binge and compensatory behaviors occur for a diagnosis of Bulimia Nervosa?

At least once a week for 3 months or more.

What specifiers are used for Bulimia Nervosa?

Course (in partial or full remission) and severity (based on weekly compensatory episodes).

Do people with Bulimia Nervosa usually have low body weight?

No. They’re usually within normal weight range or overweight.

What are medical complications of Bulimia Nervosa?

Dental problems, reflux, dehydration, electrolyte imbalance → risk of heart arrhythmias and death.

What psychological conditions often co-occur with Bulimia Nervosa?

Depression and anxiety, sometimes preceding bulimia.

What are primary treatments for Bulimia Nervosa?

Nutritional rehabilitation + CBT, CBT-E, IPT, or FBT.

How does CBT-E differ for Bulimia Nervosa?

Same transdiagnostic approach, tailored to reduce overvaluation of weight/shape.

How does FBT for Bulimia Nervosa differ from Anorexia?

More collaborative; aims to disrupt binging/purging quickly. Symptoms often ego-dystonic, so patients are motivated for change.

What pharmacotherapy is used for Bulimia Nervosa?

Antidepressants, especially fluoxetine, helpful for comorbid depression and reducing binges/purges.

What defines Binge-Eating Disorder?

Recurrent episodes of eating excessively large amounts of food + lack of control, without compensatory behaviors.

What additional symptoms are part of BED diagnosis (need 3 or more)?

• Eating more rapidly than normal

• Eating until uncomfortably full

• Eating when not hungry

• Eating alone due to embarrassment

• Feeling disgusted, depressed, or guilty after bingeing

How often must binge episodes occur for BED diagnosis?

At least once/week for 3 months.

How does BED differ from Bulimia Nervosa?

No regular compensatory behaviors. Dieting often follows onset of BED, but precedes bulimia.

Who is more likely to be diagnosed with BED?

Women 2–3 times more than men; occurs across normal, overweight, and obese ranges.

What comorbidity rates exist for BED?

Comparable to bulimia and anorexia.

What are effective treatments for BED?

CBT-E and IPT; CBT-E sometimes found more effective.

Are medications effective for BED?

Medication alone < effective than CBT. Combining CBT with meds not significantly better than CBT alone.

What meds have been studied for BED?

SSRIs (fluoxetine, paroxetine, sertraline), topiramate (anti-seizure), and lisdexamfetamine (CNS stimulant).

What treatment focus is recommended for BED in overweight/obese individuals?

Address binge eating before or alongside weight loss interventions.

What is Enuresis?

Repeated involuntary or intentional urination in bed or clothes, at least 2x/week for 3 months or causing distress/impairment.

What age is required for Enuresis diagnosis?

At least age 5 or equivalent developmental level.

What are the subtypes of Enuresis?

Nocturnal only, diurnal only, nocturnal and diurnal.

What is first-line treatment for nocturnal enuresis?

Moisture alarm (bell-and-pad).

What medication helps enuresis, and what’s a caution?

Desmopressin (an antidiuretic hormone) reduces bedwetting but has high relapse risk if discontinued.

→ DESMOpressin = “DAMP? NO!” pressin’ the pee off!

• DESMO sounds like “DAMP NO!” → think of stopping damp (wet) sheets.

• pressin’ = pressing down urine production.

• “DESMOpressin presses the pee off to keep the bed DRY!”