chapter 9 eating disorders

anorexia nervosa

an eating disorder characterized by low body weight, distorted self image, and intense fear of gaining weight and failure to recognize the risks of maintaining low body weight

subtypes of anorexia nervosa

• binge eating disorder

• restricting type

binge eating/purge

• frequent episodes during 3 month period of binge eating or purging

• tend to have impulse control issues and can may lead to substance abuse problems

restrictive type

• rigidly and obsessively control diet and appearance

medical complications of AN

• anemia

• dermatological problems

• cardiovascular complications

• gastrointestinal problems

• menstrual irregularities

• muscular weakness and abnormal growth of bones

• increased risk of death

• 1/5 made suicide attempt

• 8x more likely to commit

• 5-20% of cases end in suicide or death from malnutrition

bullimia nervosa

occurrence of frequent episodes of binge eating followed by compensatory behaviors such as self induced vomitting, laxative abuse, diuretics / enemas, excessive fasting / exercise

dsm for bullimia nervosa

binge eating and purging must occur at least once a week for three months

• typically maintain weight in normal range → doesnt gain due to purging

binges

• typically during unstructured afternoon or evening hours

• last from 30 to 60 minutes and involves consumption of “forbidden foods”

• generally sweet and rich in fat

• feel lack of control over binging, may consume as much as 5,000-10,000 calories

• typically affects women in late adolescence or early adulthoo

medical complications of BN

• repeated vomiting

• skin irritation around mouth

• blockage of salivary ducts

• decay of tooth enamel

• abdominal pain, disturbed menstrual functioning

• pancreatitis

• irregular bowl movements

• 25-35% have suicide attemps

sociocultural factors of AN and BN

• social pressures to be thin - body dissatisfaction

• diet culture

• more of a westernized disorder, places like africa fasting for religious reasons is more likely

• anorexia—higher levels in white

• bulimia - equal rates among ethnicies

psychosocial factors of AN and BN

bulimia is linked to problems in interpersonal relationships

• tend to be shy

• lower self esteem

negative emotions can lead to binge episodes

• bulimia is often accompanied by other disorders such as depression, ocd, and substance abuse disorders

bulimics are more likely to experience childhood abuse

anorexics may restrict to attempt to rellieve upsetting emotions by seeking control

learning perspectives of AN and BN

• weight phobia

• relief from anxiety acts as negative reinforcement

• high genetic risk

cognitive factors of AN and BN

• perfectionistic traits

• people with bulimia tend to think in black and white terms

  • harshly judge themselves for binge and purge episodes

  • blame themselves for negative events

• body dissatisfaction

psychodynamic perspectives of AN and BN

girls with anorexia have difficulty separating from their families and consolidating seperate individualized identities

• represents a girls unconscious effort to remain a child

family factors of AN and BN

• frequently develop against a backdrop of family conflicts

  • some adolescents refuse to eat to punish their parents for feelings of lonliness and alienation

• parents tend to be overprotective but less nurturing

• binge eating may be metaphoric effort to gain the nurturance and comfort through food that the daughter is lacking from family

• systems perspective

  • girls who develop anorexia may be seen as helping maintain the shaky balances and harmonies found in dysfunctional families by displacing attention from conflicts onto themselves

  • girl becomes identified patient, although it is actually the family unit that is dysfunctional

biological factors of AN and BN

• serotonin plays role in regulating mood and appetite

  • irregularities may contribute to binge eating episodes

  • antidepressants (that target serotonin) may help decrease binge eating episodes in bulimia

• genetics

  • diathesis stress model → genetic predisposition paired with outside stress

treatment for anorexia

hospitalization

• monitored refeeding regimen

• behavioral therapy

  • rewards made from adherence to the refeeding protocal

  • include privileges and social opportunities

  • therapy is recommended during and after hospitalization

treatment for bulimia

CBT

• used to counter maladaptive beliefs about eating and body image

• CBT resulted in the elimination of bingeing episodes in about 2/3 patients

• helps challenge self defeating thoughts such as unrealistic, perfectionistic expectations regarding dieting and body weight

• also challenges black and white thinking

exposure with response prevention

• behavioral technique

• patient is exposed to eating forbidden foods while the therapist stands by and prevents vomiting until the urge to purge has passed

Interpersonal Psychotherapy (IPT)

• structured form of psychodynamic therapy

• helpful in treating bulimia and cases that fail to respond to CBT

• focuses on resolving interpersonal problems based on belief that more effective interpersonal functioning will lead to adoption of healthier food habits

SSRIs

• help with regulating appetite — does not work well with anorexia

binge eating disorder

repeated binge eating episodes but with no purging behavior

• occur around once a week for 3 months

• episodes are characterized by lack of control over eating and consuming far greater amts of food a person typically eats

BED prevelance rates

• 1.25% of women

• .42% of men

• tend to be older

BED features

patients with BED tend to be more depressed, have more difficulty regulating their emotions, and have more disturbed eating behaviors

• BED is linked to obesity

• linked to history to depression

• linked to unsuccessful attempts in losing weight

may fall in broader range of compulsive disorders

• such as gambling and substance use disorders

BED treatment

• CBT

• SSRIs

• stimulant medication (for ADHD)

sleep wake disorders

sleep-wake disorders: persistent or recurrent sleep problems that cause distress or impaired functioning

• frequently occur together with other psychological disorders and medical conditions

sleep centers

research center where participant spends a few nights and are wired

to devices to get physiological symptoms recorded

• polysomnographic recording (PSG)

• combined with obtained medical and psychological evals, subjective reports, and sleep diaries

insomnia disorder

chronic or persistent insomnia not caused by other psychological

disorders or medications

• problem must be present for at least three months and occurs at least 3 nights a week

features of insomnia disorder

• sleep deprivation

  • physixal health problems;poorer immune system functioning

• cognitive

  • concentration

  • reaction speed

  • problem solving abilities

• usually paired with depression or anxiety

  • performance anxiety

  • stress about sleep

• classical conditioning

  • after pairing a few anxious sleepless nights with stimuli associated with the bedroom, simply entering the room may be sufficient to elicit bodily arousal that impairs sleep onset

hypersomnolence disorder

Pattern of excessive sleepiness during daytime hours occurring at least three days a week for at least three months

• some may sleep 9+ hours a night and feel not refreshed, or some may nap repeatedly throughout the day when they need to stay awake

• prevelence: 1.5% of gen pop

treatment of hypersomnolence disorder

stimulant meds

cause of HD

GABA (increasing acts as natural sleeping pill)

narcolepsy

irresistible need to sleep or sudden sleep attacks that occur at least three times a week over a three month period

• during a sleep attack, the person falls asleep without warning and remains asleep for about 15 minutes

• narcoleptic attacks are associated with an almost immediate transition from wakefulness to REM sleep

narcolepsy / hypocretin deficiency syndrome

• Involves deficiency in brain of hypocretin (orexin) produced by hypothalamus

• suspect that it is a type of autoimmune disease in which the body kills the hypocretin producing neurons

cataplexy

medical condition in which a person experiences a loss of muscle tone

• associated with narcolepsy

• also involves deficiency of chemical hypocretin

• triggered by strong emotions

sleep paralysis

temporary state following awakening in which they feel incapable of

moving or talking

hypnagogic hallucinations

frightening hallucinations occurring just before the onset of sleep or shortly upon awakening

• often associated with sleep paralysis

breathing related sleep disorders

repeated disruptions of sleep due to respiratory problems

• 4 subtypes of the disorder

obstructive sleep apnea hypopnea syndrome

involves episodes of sleep of snorting or gasping for breath, pauses of breath, or abnormally shallow breathing

• not as severe as full apnea

obstructive sleep apnea

• accompanied by loud snoring, and occurs when airways become narrowed or blocked during sleep

• leads to excessive daytime sleepiness, fatigue, and complaints of unrefreshing sleep

• commonly occurs among middle aged or older adults and affects racial minorities more than whites

• common among obese people

• caused by structural defect

  • in cases of complete obstruction, the sleeper may literally stop breathing or periods of 15 to 90 seconds as many as 500 times during the night

• impaired quality of life

  • higher levels of depression

  • linked to health problems such as hypertension and other cardiovascular problems, as well as diabetes

  • repeated lapses of oxygen may lead to subtle forms of brain damage affecting psychological functioning including thinking ability

central sleep apnea

breathing problems are less dependent of respiratory resistance and may

involve heart related problems or chronic use of opioid drugs

sleep realted hypoventilation

characterized by breathing problems that often trace to lung diseases or

neuromuscular problems that affect lung functioning

circadian rhythm sleep-wake disorders

persistent disruption of a person’s natural sleep-wake cycle

circadian rhythm sleep-wake disorders features

• can lead to insomnia or hypersomnolence and result in daytime sleepiness

• causes significant levels of distress or impairs a person’s ability to function in social, occupational, or other roles

• jet lag does not count— it is temporary

  • frequent time changes or frequent changes of work shifts can induce more persistent or recurrent problems resulting in diagnosis

circadian rhythm sleep-wake disorders treatment

program of gradual adjustments in the sleep schedule to allow a person’s

circadian system to become aligned with changes in the sleep wake schedule

parasomnias

abnormal behavior patterns associated with partial or incomplete

arousals

• Category of sleep wake disorders that is divided into disorders associated with REM sleep and those with non-REM sleep

• occurs within the boundaries of sleep and wakefulness

sleep terrors

repeated episodes of terror-induced arousals that usually begin with a panicky scream

• most cases involve children

• child may be frightened, profusely sweating with a rapid heartbeat, and may start talking incoherently

• child falls back into deep sleep and upon awakening in the morning remembers nothing of the experience

• occur during non-REM sleep

• most young children outgrow it by adolescence

prevalence and frequency

• more boys than girls; adults even

• in adults, frequency and intensity of episodes wax and wane over time

• 37% in 18 month olds, 20% in 30 month olds; 2% of adults

cause remains mystery, but genetic contribution is suspected

sleepwalking

people who are sleeping and have repeated episodes in walking

around the house while asleep

• during episodes, person is partially awake and can perform complex motor responses

• performed without conscious awareness; person does not typically remember the incident upon fully awaking

• tend to have blank stares on their face; unresponsive to others and difficult to awaken

• accidents occur occasionally

prevelence and cause of sleepwalking

• 1-5% of children

• 10-30% of children experience one episode

• adults, unknown

• 4% adults report one episode/ occasional episodes

• non-REM

• unknown cause

  • suspected genetic contribution and unspecified environmental factors

  • use of certain sleep medications carry risk of rare, unusual behaviors such as driving while sleepwalking or using a stove

    • eszopiclone (Lunesta)

    • zolpidem (Ambien

rapid eye movement sleep behavior disorder

characterized by repeated episodes of acting out one’s dreams during REM sleep in the form of vocalizing or thrashing about while dreaming

• usually muscle activity is blocked during REM sleep, however in RBD muscle paralysis is either absent or incomplete

prevalence of REMSBD

• 0.5% of adult population

• occurs most often among older adults

• generally result of neurodegenerative disorders such as Parkinson’s

  • also may be caused by withdrawal from alcohol

  • PTSD patients who take anti-depressants have higher risk

• medication is used to help control symptoms

nightmare disorder

recurrent episodes of disturbing and well-remembered

nightmares during REM sleep

nightmare disorder features

• nightmares are lengthy, story like dreams in which the dreamer attempts to avoid imminent threats or physical danger, such as being chased, attacked, or injured

• person usually recalls the nightmare vividly upon awakening

• emotional effects include fear, anger, sadness, frustration, guilt, disgust, or confusion

prevelence of nightmare disorder

• 4% of adults

• associated with traumatic experiences

• periods of REM sleep tend to become longer and dreams during REM become more intense

biological treatment approaches to sleep wake disorders

anti-anxiety drugs are often used to treat insomnia

• benzodiazepines (valium and ativan)

• zolpidem (Ambien) effective in reducing length of time it takes people with insomnia to fall asleep

• works by increasing the activity of GAVA

• anti-anxiety and tricyclic antidepressants are also used to treat deep sleep disorders such as sleep terrors and sleepwalking

• stimulant medications can be used to enhance wakefulness in people with narcolepsy and hypersomnolence

• medical device, a mask, used for sleep apnea

psychological approaches to treating sleep wake disorders

• CBT can help with lowering bodily arousal, establishing regular sleep habits, and replacing anxiety producing thoughts with more adaptive thoughts → first line treatment for insomnia

• rational restructuring: substituting rational alternatives for self defeating, maladaptive thoughts → thought of bad nights sleep leads to reducing chances in falling asleep because of increased anxiety

• stimulus control involves changing sleep enviornment