Eating, Sleeping, and Elimination Disorders

Psychopathology and Diagnostic Reasoning- Week 6/ Module 2

Anorexia nervosa diagnostic hallmark

Restriction of energy intake leading to significantly low body weight, intense fear of gaining weight, and persistent behavior interfering with weight gain

Anorexia nervosa, DSM-5-TR Criterion A

Restriction of energy intake relative to requirements resulting in significantly low body weight for age, sex, developmental trajectory, and physical health

Anorexia nervosa, DSM-5-TR Criterion B

Intense fear of gaining weight or becoming fat, or persistent behavior that interferes with weight gain despite significantly low weight

Anorexia nervosa, DSM-5-TR Criterion C

Disturbance in self-perceived weight or shape, undue influence of weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of low body weight

Anorexia nervosa restricting type

During the previous 3 months, the individual has not regularly engaged in binge eating or purging behavior

Anorexia nervosa binge-eating/purging type

During the previous 3 months, the individual has regularly engaged in binge eating or purging behavior

Anorexia nervosa severity, adults

Mild BMI ≥17, moderate BMI 16–16.99, severe BMI 15–15.99, extreme BMI <15

Anorexia nervosa in children and adolescents

Severity may be based on BMI percentile rather than adult BMI cutoffs

Anorexia nervosa clinical red flags

Bradycardia, hypotension, hypothermia, electrolyte abnormalities, amenorrhea or menstrual dysfunction, lanugo, and syncope

Anorexia nervosa medical emergency

Severe bradycardia, hypotension, significant electrolyte abnormalities, cardiac instability, syncope, or severe malnutrition may require hospitalization

Bulimia nervosa diagnostic hallmark

Recurrent binge eating with recurrent inappropriate compensatory behaviors occurring at least weekly for 3 months

Bulimia nervosa binge episode

Eating an objectively large amount of food with a sense of lack of control over eating during the episode

Bulimia nervosa Criterion A

Recurrent binge-eating episodes characterized by objectively large food intake plus a sense of lack of control

Bulimia nervosa Criterion B

Recurrent inappropriate compensatory behaviors such as self-induced vomiting, fasting, or excessive exercise

Bulimia nervosa Criterion C

Binge eating and compensatory behaviors occur at least once weekly for 3 months

Bulimia nervosa Criterion D

Self-evaluation is unduly influenced by body shape and weight

Bulimia nervosa Criterion E

The disturbance does not occur exclusively during episodes of anorexia nervosa

Bulimia nervosa common physical findings

Dental enamel erosion, parotid enlargement, calluses on the dorsum of the hand, electrolyte abnormalities, and gastrointestinal complications

Russell sign

Calluses or abrasions on the dorsum of the hand caused by repeated self-induced vomiting

Bulimia nervosa electrolyte danger

Recurrent vomiting can cause hypokalemia and metabolic alkalosis, increasing risk of cardiac arrhythmias

Binge-eating disorder diagnostic hallmark

Recurrent binge eating without regular inappropriate compensatory behaviors

Binge-eating disorder binge frequency

Binge episodes occur at least once weekly for 3 months

Binge-eating disorder associated features

Rapid eating, eating until uncomfortably full, eating when not physically hungry, eating alone due to embarrassment, and subsequent guilt or disgust

Binge-eating disorder key distinction from bulimia nervosa

Binge-eating disorder lacks recurrent inappropriate compensatory behaviors

Binge-eating disorder severity

Mild 1–3 binge episodes weekly, moderate 4–7, severe 8–13, extreme 14 or more

Avoidant/restrictive food intake disorder, ARFID

Persistent failure to meet appropriate nutritional or energy needs without weight or shape disturbance

ARFID clinical consequences

Significant weight loss or failure to gain expected weight, nutritional deficiency, dependence on enteral feeding or supplements, or marked psychosocial interference

ARFID distinguishing feature

Food restriction is driven by sensory sensitivity, lack of interest in eating, or fear of aversive consequences rather than body-image concerns

Pica

Persistent eating of nonnutritive, nonfood substances for at least 1 month

Pica developmental requirement

Eating nonfood substances must be inappropriate to the developmental level and not part of a culturally supported practice

Pica substances

Examples include dirt, hair, paper, soap, cloth, chalk, or other nonfood materials

Pica clinical complications

Intestinal obstruction, poisoning, infection, nutritional deficiency, and heavy-metal toxicity depending on the substance consumed

Rumination disorder

Repeated regurgitation of food for at least 1 month, with food potentially being rechewed, reswallowed, or spit out

Rumination disorder distinguishing feature

Regurgitation is not better explained by a gastrointestinal or medical condition and is not exclusively associated with another eating disorder

Rumination disorder vs vomiting

Rumination typically involves effortless regurgitation of recently ingested food without the characteristic retching of vomiting

Anorexia nervosa vs ARFID

Anorexia involves weight or shape disturbance, whereas ARFID does not involve body-image concerns

Bulimia nervosa vs binge-eating disorder

Both involve recurrent binge eating, but bulimia includes recurrent compensatory behaviors while binge-eating disorder does not

First-line psychotherapy for anorexia nervosa

Eating-disorder-focused psychotherapy with nutritional rehabilitation is central, with family-based treatment particularly important for adolescents

First-line treatment for bulimia nervosa

Cognitive behavioral therapy specifically adapted for bulimia nervosa is a first-line psychotherapy

Bulimia nervosa pharmacologic treatment

Fluoxetine has the strongest evidence and is FDA-approved for bulimia nervosa

Eating disorder treatment priority

Medical stabilization and nutritional rehabilitation take priority when significant malnutrition or medical instability is present

Refeeding syndrome

Potentially life-threatening metabolic disturbance after nutritional restoration, characterized especially by hypophosphatemia and shifts in electrolytes

Refeeding syndrome risk

Severe malnutrition followed by rapid nutritional rehabilitation increases risk

Eating disorder assessment priority

Assess weight trajectory, dietary restriction, bingeing, compensatory behaviors, exercise, vital signs, electrolytes, suicidality, substance use, and medical complications

Eating disorders and suicide risk

Anorexia nervosa, bulimia nervosa, and binge-eating disorder can be associated with elevated psychiatric comorbidity and suicide risk, requiring direct suicide assessment

Amenorrhea and anorexia nervosa

Amenorrhea is common but is no longer required for the DSM-5-TR diagnosis of anorexia nervosa

Eating disorder diagnosis and BMI

BMI helps characterize severity and medical risk but does not independently determine whether an eating disorder is present

Anorexia nervosa at normal or higher weight

Atypical anorexia nervosa can involve all major anorexia features without significantly low body weight

Night eating syndrome vs binge eating

Night eating involves recurrent evening hyperphagia or waking to eat with awareness and is distinct from binge-eating disorder

Most important diagnostic distinction in eating disorders

Determine whether restriction, binge eating, compensatory behaviors, body-image disturbance, or nonfood ingestion is the primary pattern

Enuresis

Repeated voiding of urine into bed or clothes, occurring at least twice weekly for at least 3 months or causing clinically significant distress or impairment

Enuresis minimum age

The child must be at least 5 years old chronologically or developmentally

Enuresis diagnostic requirement

The behavior must not be attributable to a substance, medication, or another medical condition

Enuresis nocturnal type

Urination occurs only during nighttime sleep

Enuresis diurnal type

Urination occurs during waking hours

Enuresis nocturnal and diurnal type

Urination occurs during both nighttime sleep and waking hours

Primary enuresis

The child has never achieved sustained urinary continence

Secondary enuresis

Enuresis develops after a period of established urinary continence, typically after at least 6 months of dryness

Secondary enuresis clinical evaluation

Assess for psychosocial stressors, constipation, urinary tract infection, diabetes mellitus, sleep disorders, and other medical causes

First-line behavioral treatment for enuresis

Enuresis alarm is the preferred long-term behavioral intervention

Desmopressin for enuresis

An effective medication for nocturnal enuresis that decreases nighttime urine production

Major safety concern with desmopressin

Hyponatremia and water intoxication, particularly if excessive fluid intake occurs

Desmopressin counseling

Restrict evening fluid intake and follow prescribed dosing to reduce hyponatremia risk

Enuresis and constipation

Constipation can contribute to urinary symptoms and should be assessed and treated when present

Encopresis

Repeated passage of feces into inappropriate places, such as clothing or the floor

Encopresis minimum age

The individual must be at least 4 years old chronologically or developmentally

Encopresis frequency requirement

At least one such event occurs for at least 3 months

Encopresis diagnostic requirement

The behavior must not be attributable to a substance or another medical condition except through a mechanism involving constipation

Encopresis with constipation and overflow incontinence

Fecal soiling occurs because retained stool causes overflow leakage

Encopresis without constipation and overflow incontinence

Fecal soiling occurs without evidence of constipation or overflow leakage

Most common mechanism of encopresis

Chronic constipation with stool retention and subsequent overflow soiling

Encopresis assessment

Assess stool frequency, consistency, painful defecation, stool withholding, abdominal symptoms, toileting history, diet, and psychosocial stressors

First-line treatment for encopresis with constipation

Disimpaction followed by maintenance stool-softening therapy and regular toileting

Behavioral treatment for encopresis

Establish scheduled toilet sitting, reinforce successful toileting, and avoid punishment or shaming

Enuresis versus encopresis

Enuresis involves inappropriate urination, whereas encopresis involves inappropriate defecation

Elimination disorder differential diagnosis

Rule out medical causes such as urinary infection, diabetes, neurologic disease, gastrointestinal disease, constipation, and medication effects

Elimination disorder psychosocial assessment

Evaluate family stress, developmental history, trauma, school functioning, and behavioral responses without assuming intentional misconduct

Sleep-wake disorders core assessment

Assess sleep schedule, sleep onset, awakenings, total sleep time, daytime impairment, substances, medications, medical conditions, psychiatric symptoms, and sleep environment

Insomnia disorder diagnostic hallmark

Persistent difficulty initiating sleep, maintaining sleep, or early-morning awakening with inability to return to sleep

Insomnia disorder daytime requirement

Sleep difficulty causes clinically significant distress or impairment in daytime functioning

Insomnia disorder frequency and duration

Symptoms occur at least 3 nights per week for at least 3 months

Insomnia disorder opportunity requirement

Sleep difficulty occurs despite adequate opportunity and circumstances for sleep

Insomnia disorder key diagnostic distinction

Insomnia can be diagnosed as a disorder even when another medical or psychiatric condition is also present if it warrants independent clinical attention

First-line treatment for chronic insomnia

Cognitive behavioral therapy for insomnia, CBT-I

CBT-I stimulus control for insomnia

Associate the bed and bedroom with sleep by going to bed only when sleepy and leaving bed when unable to sleep

CBT-I sleep restriction

Limit time in bed to approximate actual sleep time, then gradually increase time as sleep efficiency improves

CBT-I cognitive therapy for insomnia

Identifies and modifies maladaptive beliefs and anxiety-provoking thoughts about sleep

CBT-I sleep hygiene

Supports healthy sleep behaviors but should not be used as the sole treatment for chronic insomnia; used as an educational foundation

Chronic insomnia pharmacotherapy

Medication may be considered when CBT-I is unavailable, insufficient, or as an adjunct based on clinical circumstances

Circadian rhythm sleep-wake disorder

Persistent disruption of the sleep-wake schedule caused by misalignment between the individual's circadian rhythm and required schedule

Delayed sleep-wake phase disorder

Major sleep period is delayed relative to desired or required times, causing difficulty falling asleep and waking at conventional times

Delayed sleep-wake phase disorder hallmark

Sleep quality and duration are generally normal when the person is allowed to follow the preferred delayed schedule

Advanced sleep-wake phase disorder

Major sleep period occurs substantially earlier than desired, causing early sleep onset and early awakening

Non-24-hour sleep-wake disorder

Circadian rhythm progressively shifts (+1-2 hours per day) because the internal rhythm is not synchronized with the 24-hour day

Irregular sleep-wake rhythm disorder

Multiple irregular sleep periods occur throughout the 24-hour period with reduced organization of the sleep-wake cycle

Shift work type circadian disorder

Sleep disturbance and excessive sleepiness occur because work schedules overlap the individual's usual sleep period

Jet lag type circadian disorder

Temporary circadian disruption occurs after rapid travel across multiple time zones

Circadian rhythm disorder treatment principle

Align the circadian rhythm using appropriately timed light exposure, sleep scheduling, behavioral interventions, and sometimes melatonin

Narcolepsy

Disorder characterized by recurrent irresistible need to sleep, with characteristic REM-related symptoms and excessive daytime sleepiness

Narcolepsy type 1

Narcolepsy associated with cataplexy and typically hypocretin or orexin deficiency