Eating, Sex, Sleep

AN diagnostic criteria

• restriction of energy intake relative to requirements, leading to sig low body weight relative to development

• intense fear of gaining weight or becoming fat, or persistent behavior interfering with weight gain

• disturbance in experience of body shape or weight, undue influence of weight/shape on self-eval, persistent lack of recognition of seriousness of current body weight

AN specifications

• type: binge/purge or restrictive

• remission: partial (A not met, B/C still present) or full

• severity:

  • BMI for adults

  • BMI percentage for youth

associated features AN

• depressive signs/symptoms when seriously underweight

• obsessive-compulsive features

• inflexibility/desire for control (restrained emotional expression, limited social spontaneity, no eating in public)

• binge/purge: impulsivity, drug abuse

• excessive physical activity

• misuse of medication

development and course AN

• onset common in adolescence or adulthood

• younger may manifest atypical features

• older have longer duration

• period of changed eating behavior prior to full criteria met

• most remiss within 5y of presentation

• 5% mortality per decade

risk factors AN

• anxiety disorders or obsessional traits in childhood

• within thinness valuing culture

• genetics (first-degree relatives)

differentiation of AN

• body image disturbance and fear of gaining weight differentiates from medical conditions, MDD, SUD, ARFID, and schizophrenia

• social fears, obsessions, compulsions, and distortions centering around food/body shape differentiate from SAD, OCD, and body dysmorphia

• disturbed body weight differentiates from BN

BN diagnostic criteria

• recurrent episodes of binge eating

  • eating more food in 2h than normal

  • sense of lack of control over eating

• recurrent episodes of inappropriate compensatory behaviors to prevent weight gain

• both occur 1/w for 3mo

• unduly influenced self-evaluation

• does not only occur in AN episodes

BN or BED severity

• mild: 1-3 episodes/w

• moderate: 4-7 episodes/w

• severe: 8-13 episodes/w

• extreme: 14+ episodes/w

development and course BN

• onset common in adolescence or young adulthood

• onset can be precipitated by SLE

• symptoms can appear to diminish with/without treatment

risk factors BN

• weight concerns

• low self-esteem

• depressive symptoms

• SAD

• overanxious childhood disorder

• idealization of thin body ideal

• childhood sexual/physical abuse

• childhood obesity

• early pubertal maturation

• genetics

differentiating BN

• compensatory behaviors differentiate BED and atypical MDD

• can be comorbid with BPD

• must occur outside AN episode for at least 3mo

BN comorbidity

commonly comorbid with MDD, BD, SUD, GAD

BED diagnostic criteria

• recurrent episodes of binge eating characterized by overeating and lack of control

• episodes associated with 3+ of (rapid eating, uncomfortably full, large amounts when not hungry, alone over embarrassment, disgust/depression/guilt)

• distress

• once a week for 3mo

• no inappropriate compensatory behavior

BED associated features

• can occur at any weight

• greater functional impairment, lower quality of life, more subjective distress, and more psychiatric comorbidity than just obesity

BED development and course

• occurs at any age

• dieting often follows development

• those seeking treatment often older

BED differentiation

• BN has compensatory behavior

• can be comorbid with BD, BPD, MDD, anxiety disorders, SUD

pica diagnostic criteria

• persistent eating of nonnutritive, nonfood substances (1mo)

• eating inappropriate to developmental level

• eating not part of culturally supported or socially normative practice

rumination disorder diagnostic criteria

• repeated regurgitation of food (1mo) may be re-chewed, re-swallowed, or spit out

• not attributable to associated medical condition

• does not occur exclusively during AN, BN, BED, or ARFID

ARFID diagnostic criteria

• eating/feeding disturbance manifested by persistent failure to meet appropriate nutritional and/or energy requirements, 1+:

  • significant weight loss

  • significant nutritional deficiency

  • dependence on enteral feeding or oral nutritional supplements

  • interference with psychosocial functioning

• not attributable to associated medical condition

• does not occur exclusively during AN, BN

• not explained by lack of food

male ED presentation

• less weight and shape concern, drive for thinness, or body dissatisfaction

• more worry centered on muscularity and being large

• less likely to seek treatment, start it later than women

ED assessment (male EDs)

• assessments overly reliant on female ED symptoms

• Eating Disorder Examination commonly used, subscales dietary restraint and eating concern less relevant for men

• Eating Disorder Assessment for Men assesses male-specific symptoms, needs more research

factors enhancing ED treatment outcomes for men

• improving interpersonal interactions

• therapist characteristics and therapeutic relationship quality

• collaborative treatment approach

• male-only treatment groups

pediatric ED presentation

• atypical

• commonly presented as growth stunting

• less likely to have body image concerns

considerations for pediatric EDs

• higher screening because of atypical presentation, evaluate high-risk behaviors

• lower treatment threshold

treatment for pediatric EDs

• family based treatment highly recommended, largest evidence base

• takes biological and genetic contributions into account, caregivers viewed as allies

• 3 phases: physical recovery, behavioral recovery, psychological recovery

• no pharmacotherapy researched for children/adolescents

CBT-E

• focuses on underlying processes of EDs, can be used for any

• stages: intensive initial (formulate underlying factors), taking stock, main body of treatment, focus shift to future/final stage

• CBT guided self help effective

• very effective in BN and BED, moderately effective in AN

IPT for EDs

• focuses on IP functioning in relation to ED

• initial phase (diagnosis, sick role, IP inventory, formulation)

• intermediate phase (strategies shaped by main problem area)

• termination phase

• works for BN and BED, not AN

interpersonal problem areas in EDs

• IP deficits (social isolation or chronically unfulfilling relationships)

• IP role disputes (conflicts with important other)

• role transitions

• grief

pharmacotherapy for EDs

• antidepressants work for BN, better than antiepileptics

• antidepressants work for BED behavior, weight management medication works for weight loss, stimulants work for both

• no significant effective medication for AN

compulsory treatment for EDs

• patient-therapist relationship remains same

• initial problems more severe and duration of stay longer, but weight at discharge similar

• usually feel bad at start but better by the end

• long term effects not extensively studied

AN treatment resistance and motivation

• resistant to treatment because of egosyntonic symptomatology

• resistance significant hinderance to treatment

• recommended use of socratic questioning (questioning to synthesize information and allow patient to come to conclusions alone)

factors to be considered in sexual dysfunctions

• partner factors

• relationship factors

• individual vulnerability factors

• cultural/religious factors

• medical factors

sexual dysfunction specifications

• lifelong or acquired

• generalized or situational

• mild moderate or severe (distress)

delayed ejaculation diagnostic criteria

• delay, infrequency, or absence of ejaculation in 75-100% of partnered sexual activity

• 6mo duration

• significant distress

• not better explained by another disorder

delayed ejaculation associated features

• prolonged thrusting to point of discomfort/exhaustion

• avoiding sexual activity

• feeling less sexually attractive

delayed ejaculation prevalence

• least common male sexual complaint

• more common in asian populations

delayed ejaculation differential diagnosis

• medical conditions differentiated by problem explanation

• substance use

erectile disorder diagnostic criteria

• difficulty obtaining or maintaining erection, or decrease in erectile rigidity in 75-100% of any sexual activity

• 6mo duration

• significant distress

• not better explained by another disorder/stressor

erectile disorder associated features

• low self-esteem, confidence, sense of masculinity

• depressed affect

• fear/avoidance of sexual encounters

• decreased sexual satisfaction and reduced sexual desire

erectile disorder development and course

• if after first sexual attempt , associated with negative/uncomfortable experience (pressured, unknown partner, drugs)

• if acquired, associated with biological factors, likely to be persistent

• if lifelong, associated with psychological factors

erectile disorder differential diagnosis

• can be comorbid with MDD

• substance use

• can coexist with premature ejaculation or hypoactive sexual desire disorder

male/female hypoactive sexual desire disorder diagnostic criteria

• persistently/recurrent deficient/absent sexual thoughts/fantasies/desire

• 6mo duration

• significant distress

• not better explained by another disorder/stressor

male hypoactive sexual desire disorder associated features

• erectile/ejaculatory concerns

• decreased/absent initiation of sexual activity

male hypoactive sexual desire disorder risk factors

• past history of psychiatric symptoms

• alcohol

• being gay

• endocrine disorders

male hypoactive sexual desire disorder differential diagnosis

• substance use

• other medical condition

• IP factors

• can occur with other sexual dysfunction

premature ejaculation diagnostic criteria

• persistent/recurrent pattern of ejaculation approx 1min after penetration, before individual wishes, during 75-100% of partnered sexual activity

• 6mo duration

• significant distress

• not better explained by another disorder/stressor

premature ejaculation risk factors

• anxiety disorders, especially SAD

• moderate genetic contribution

female orgasmic disorder diagnostic criteria

• delay, infrequency, absence, or reduced intensity of orgam is 75-100% of any sexual activity

• 6mo duration

• significant distress

• not explained by another disorder/stressor

female orgasmic disorder associated features

• no association with personality, psychopathology, sexual satisfaction

• difficulty communicating about sexual issues

female orgasmic disorder risk factors

• wide range of psychological factors

• relationship problems, physical health, sociocultural factors

• medical conditions and medications

• genetic contribution

female orgasmic disorder differential diagnosis

• substance use

• medical condition

• IP factors

• may occur in association with other sexual dysfunctions

female sexual interest/arousal disorder diagnostic criteria

• lack of/significantly reduced sexual interest/arousal, manifested by 3+, absent or reduced:

  • interest in sexual activity

  • sexual/erotic thoughts/fantasies

  • initiation of sexual activity, unreceptive to initiation

  • sexual excitement/pleasure

  • sexual interest/arousal in response to cues

  • genital/non-genital sensations

• 6mo duration

• significant distress

• not better explained by other disorder/stressor

female sexual interest/arousal disorder associated features

• problems experiencing orgasm

• pain during sexual activity

• infrequent sexual activity

• relationship difficulties

• mood disorders

• poor sexual techniques

• lack of information about sexuality

female sexual interest/arousal disorder risk factors

• negative cognitions/attitudes about sexuality

• history of mental disorders

• difference in propensity for sexual excitation and inhibition

• relationship difficulties

• developmental history

• genetics

female sexual interest/arousal differential diagnosis

• nonsexual mental disorder

• substance use

• medical condition

• IP factors

• inadequate/absent sexual stimuli

• can coexist with other sexual dysfunctions

genito-pelvic pain/penetration disorder diagnostic criteria

• persistent/recurrent difficulties with 1+

  • vaginal penetration during intercourse

  • vulvovaginal/pelvic pain during vaginal penetration attempts

  • fear/anxiety about pain anticipating, during, or because of penetration

  • tensing/tightening of pelvic floor during attempted vaginal penetration

• 6mo duration

• significant distress

• not better explained by another disorder/stressor

genito-pelvic pain/penetration disorder associated features

• other sexual dysfunctions

• avoidance of sexual situations

• avoidance of gynecological exams

• relationship problems

genito-pelvic pain/penetration disorder risk factors

• sexual/physical abuse

• vaginal infection history

• pain during tampon insertion

• inadequate sexual education

genito-pelvic pain/penetration disorder differential diagnosis

• often comorbid with other medical condition

• inadequate sexual stimuli

biopsychosocial model of sex

biological, psychological, and social aspects each contribute to sexual health

sexual response cycle

sexual response is: excitement, plateau, orgasm, then resolution

psychosomatic circle of sex

• tactile stimuli → spinal cord and limbic system → physical response and arousal → awareness of response → cognition → limbic system and spinal cord → orgasm

• cycle can be broken at any point

push-pull model of incentive-motivation

desire is result of being confronted with sexual stimuli (pull factor) and thoughts of sexual stimuli (push factor)

incentive motivational model

you feel desire because you’re having sex

circular model for women

• desire for women is very complex

• includes “spontaneous innate desire” (Freudian)

information processing model

• explains spontaneous innate desire as being aroused through stimulus without being aware

• process works the same for men and women, but men have more stimuli in the world so more easily turned on

diagnosis for sexual dysfunction

• history of desire, arousal, orgasm, pain, muscle tension, and satisfaction

• qualities of complaint

• physical exam

• additional assessments if needed

vasocongestion

erectile structures throughout body expand and enlarge in excitement phase

male indicators of excitement

• penile erection (might not be full, easily lost)

• scrotal skin tightening

• testicles rise and englarge

female indicators of excitement

• erection and enlargement of clitoris

• vaginal lubrication

• vagina becomes wider and longer

• breasts, nipples, areolas enlarge

plateau phase

arousal levels off, continues with no increase

plateau in women

• walls of outer 1/3 of vagina engorge and thicken

• walls of inner 2/3 vagina expand

• clitoris engorges and retracts closer to body and under clitoral hood

orgasm

• climax of sexual arousal

• highly variable between and within people

factors influencing intensity and duration of orgasm

• length of arousal prior to orgasm

• length of time since previous orgasm

• alcohol or drug use

• feelings of comfort/intimacy with partner

resolution

completion of cycle, body returns to sexually non-aroused state

EPOR model criticisms

• number of stages, omitting desire

• female sexual response seen as more complex than model suggests

• generalizes the differences between men and women

effects of feedback

• paying attention to sexual response has slightly beneficial effect on voluntary production of response

• visual feedback has enhancing effect for strong erotic stimulus, opposite for weak stimulus

effects of performance demand

• normal not adversely affected by demand for response, dysfunctional are

• better to focus attention on self if partner not aroused (both normal and dysfunctional)

• better to focus attention on partner if partner is aroused (only normal, reverse for dysfunctional)

sexual arousal cognitive model

• 2 components, automatic and attentional processing

• initially automatic sexual appraisal of stimulus, depends on implicit sexual memory

• attentional component attributes sexual meaning and processes original stimulus response

sexual content induced delay

completing a task is delayed when erotic element is present for men and women

physiological response to information processing

enhanced tendon reflex reflects early motor preparation for motivated action

effect of distraction by nonsexual stimuli on sexual response

• when sexual stimulus is visual, no effect on men but inhibiting effect on women

• when sexual stimulus is auditory, inhibiting effect on men and women

misinformation on sexual response

• if given placebo pill said to enhance, arousal reported as minimized

• if pill said to decrease, arousal is reported as enhanced

dual control model

in some circumstances appraisal of sexual stimulus directly leads to arousal, in others the arousal sequence is inhibited

anxiety and sexual response

• inducing anxiety can enhance sexual response

• arousal enhances focus on information processing, response depends on what focus is on

sexual satisfaction and quality of life

• intrapersonal SS significant predictor of QOL for men and women, stronger for men

• interpersonal SS significant predictor of QOL for women

• men more likely to associate low SS with low QOL

female orgasm determinants

• self-determining attitude toward sexuality

• sexual experience with steady partner

• happy relationship

• oral or manual sex

• sexual self-esteem

• sexual skills, position, duration

poor female orgasm determinants

• social background

• physical exercise

• psychological symptoms

• smoking

• moderate alcohol use

factors preventing female orgasm achievement

• fatigue/stress

• difficulty concentrating

• unskillful partner

• partner too fast

• bad relationship quality

alcohol and sexual response

• enhances sexual pleasure or reduces inhibition

• associated with increased subjective arousal but decreased vaginal blood flow

alcohol myopia

as result of alcohol, attention focused on positive sexually arousing/rewarding aspects of situation and away from negative consequences and associated inhibition of arousal

alcoholism and sexual response

• complex relationship

• long-term toxic effects of alcohol on nervous and endocrine systems

drugs and sexual response

• opiates consistently associated with reduced sexual interest and response

• cocaine has positive effects with early use, negative with chronic use

• marijuana sexually enhancing, but not through desire or response, but more relaxation and being in tune with partner

• unclear effects of amphetamines

learning disabilities and sexuality

• more likely to manifest sexuality inappropriately, because of self-fulfilling prophecy since they are believed to show inappropriate sexual behavior

• somewhat less sexually active

• more prone to get involved in sexual offences (naivety)

abuse characteristics increasing risk of sexual dysfunction

• repeated abuse

• abuse including multiple abusers

• longer duration

• including threat or force

• abuser being father

• penetrative CSA

CSA and type of sexual dysfunction

• can lead to any disorder

• majority have more than one dysfunction

• more report arousal difficulties

CSA and cognitive associations with sex

• lower positive implicit association with sexual stimuli, associated with lower SS

• tendency toward threatening interpretation of sex

• report more fear, anger, disgust during sexual arousal

CSA and sexual self-schema

• less positive emotion words used describing sexual self-schema

• positive emotion words associated with better sexual function

CSA and SNS activation

• increased SNS activity starts earlier in life for CSA

• SNS increases during sexual arousal, but decreases for CSA, impairing sexual function

CSA and body image/esteem

• report lower overall body esteem, linked to poorer sexual function

• sexual attractiveness explains most variance in excitation in women with CSA