Feeding/Eating, Elimination, and Sleep-Wake Disorders

Pica diagnostic criteria

eating non-nutritive, nonfood substances for 1+ months and is inappropriate for their developmental level and is not a culturally or socially acceptable practice.

can occur at any age but is most common in women and pregnant women.

anorexia nervosa diagnostic criteria

restriction of energy intake that causes a significantly low body weight for their age, sex, developmental trajectory, and physical health.

must have:

• intense fear of gaining weight or enage in behavior that interferes with gaining weight

• a disturbance in the way they experience their weight or shape, or a lack of awareness of the seriousness of their weight

specifiers for anorexia

type (restricting or binge-eating/purging)

course (partial or full remission)

severity (determined but their BMI).

disorders comorbid with anxorexia

depression and anxiety (especially OCD)

there is evidence that anxiety often precedes the onset of anorexia.

Prognosis for anorexia

One of the most difficult disorders to treat because they don’t believe they have a problem.

Poorer than the prognosis for bulimia but there is evidence that long-term outcomes for the two disorders may be more similar than previously believed.

treatment goals for anorexia (initial goals then subsequent goals, 7 total)

1. (initial goals) restore the person to a healthy weight and address physical complications

2. increase their motivation to participate in treatment

3. provide them with education about healthy nutrition

4. help them identify and change beliefs, attitudes, and emotions contributing to the eating disorder

5. treat psychological conditions that are contributing to the eating disorder (e.g., low self-esteem, impulse control problems)

6. enlist family support and provide family therapy when appropriate

7. help them identify strategies for preventing relapse

treatments for anorexia (list the 3)

CBT for anorexia nervosa

enhanced CBT (CBT-E) for eating disorders

family-based treatment (FBT) for anorexia nervosa

CBT for anorexia nervosa

a post-hospitalization intervention based on the assumption that shape- and weight-related concerns engender dietary restriction and other extreme methods of weight control that maintain anorexia symptoms

it employs behavioral strategies to establish regular eating patterns and eliminate frequent body-checking and cognitive strategies to identify and replace problematic thinking and enhance motivation

CBT-E

transdiagnostic treatment that proposes that eating disorderes share the same core psychopathology (i.e., excessive value given to a physical appearance and weight)

it is a personalized and flexible treatment that focuses on the factors that are maintaining the patient’s symptoms

FBT for anorexia nervosa

an outpatient intervention for adolescents who are medically stable. consists of 3 phases:

1. parents take charge of the adolescent’s nutritional rehabilitation and weight restoration with the help of the therapist

2. control over eating is gradually returned to the adolescent

3. adolescent developmental issues are addressed and include establishing age-appropriate independence for the adolescent and healthy parent-child relationships

pharmacotherapy for anorexia

the antipsychotic olanzapine is useful for fostering initial weight gain

SSRI fluoxetine for improving weight maintenance

because of the inconsistent findings about the effectiveness of meds to treating anorexia, some experts recommend that meds only be used to treat comorbid symptoms such as anxiety and depression

bulimia nervosa diagnostic criteria and specifiers

recurrent episodes of binge eating that are accompanied by a sense of a lack of control, inappropriate conpensatory behavior to prevent weight gain, and self-evaluation that’s excessively influenced by body shape and weight

binge eating and compensatory behavior must occur at least 1x/week for 3+ months

specifiers are for course (partial or full remission) and severity (based on average number of episodes of compensatory behavior per week)

comorbidity with bulimia

depression and anxiety, with anxiety sometimes preceding the disorder

medical aspects of bulimia

usually within normal to overweight range

medical complications about usually the result of compensatory behavior (e.g., purging causing dental problems, acid reflux, dehydration that can result in electrolyte balance and heart arrhythmia and death

treatments for bulimia (list the 4 and their effectiveness)

nutritional rehabilitation + CBT

enhanced CBT (CBT-E) for eating disorders

interpersonal therapy (IPT)

family-based treatment (FBT) for bulimia

effectiveness: CBT, CBT-E, and IPT have comparable effects, but CBT and CBT-E are generally preferred because IPT takes longer to produce those effects

CBT-E for bulimia

transdiagnostic intervention for eating disorders that is based on the assumption that these disorders share the same core psychopathology (excessive value given to physical appearance and weight)

FBT for bulimia

outpatient intervention for adolescents that involves 3 phases that are similar to those when treating anorexia, except some differences that are in bold:

1. parents take charge of the adolescent’s nutritional rehabilitation with the focus on disrupting their binging, purging, restrictive dieting, and other undesirable methods of weight control

2. control over eating is gradually returned to the adolescent

3. adolescent developmental issues are addressed and include establishing age-appropriate independence for the adolescent and healthy parent-child relationships

since symptoms are more egodystonic and they are more motivated to change than those with anorexia, the phases are slightly different because treatment is more collaborate with the adolescent and parent working together to alter undesirable food-related behaviors

pharmacological treatment for bulimia

antidepressants (especially fluoxetine) have been found effective for alleviate comorbid depression and reducing binge eating and purging in patients without depression

binge-eating (BED) disorder criteria

eating an amount of food that is larger than what most people would eat in a similar amount of time and in similar circumstances, plus a sense of lack of control over eating during episodes

must have:

• 3 out of 5 symptoms (eating more rapidly than usual, eating until uncomfortably full, eating large amounts when not feeling hungry, feeling alone due to embarrassment about binging, feeling disgusted, depressed, or guilty about binging)

• episodes occur at least 1x/week for 3 months

levels of severity and how severity is determined for binge-eating disorder

mild, moderate, severe, extreme

determined by the number of episodes in each week

rates of binge-eating disorder based on individual characteristics

2-3x more common in women than men

occurs in people who are normal, overweight, or obese

binge eating disorder vs bulimia

binge eating disorder (BED):

• do not engage in recurrent compensatory behaviors

• usually have a better response to treatment

• dieting often follows the onset of BED (after) whereas dieting usually precedes bulimia (before)

• similar comorbidity to bulimia and anorexia

2 evidence-based treatments for BED and which is more effective

Cognitive behavioral therapy-enhanced (CBT-E)

Interpersonal therapy (IPT)

some research suggests the CBT-E is more effective

general suggestion is that the focus is on binge-eating before or concurrently with weight loss when treating individuals with BED who are overweight or obese

psychopharmacology treatments for BED

SSRIs (fluoxetine, paroxetine, sertraline)

the anti-seizure medication topiramate

the CNS stimulant lisdexamfetamine

therapy vs meds for BED

medication alone is less effective than CBT

CBT + meds is no more effective than CBT alone

diagnostic criteria for enuresis

5+ years old or equivalent developmental level

voiding of urine into bed or clothing 2x/week for 3+ months, or causing significant distress or impaired functioning

always or usually involuntary, not due to substance use or medication condition

treatments for nocturnal enuresis

moisture alarm (aka bell-and-pad) which causes an alarm to ring when a child begins to urinate while sleeping

antidiuretic hormone desmopressin used also reduces or stops bedwetting in most cases, but it’s associated with a high risk for relapse when it’s discontinued

insomnia disorder criteria

1+ symptoms: difficulty initiating, maintaining, or early-morning wakening with an ability to return to sleep

3x/week for 3+ months

significant distress or impaired functioning

3 types of insomnia

sleep-onset (initial): difficulty initiating falling asleep

sleep maintenance (middle): frequent or extended awakening during the night

late insomnia: awakening in the early morning with an ability to return to sleep

most common type of insomnia

sleep maintenance (frequent or extended awakenings during the night)

polysomnography research on insomnia

when retrospective subjective reports of people with insomnia are compared to measures obtained during their sleep (polysomnography), subjective reports usually overestimated sleep latencies, overestimated time spent awake during the night, and underestimate total amount of sleep.

cognitive interventions for chronic insomnia (and which is gold-standard)

cognitive behavior therapy for insomnia (CBT-I)

and cognitive therapy for insomnia (CT-I)

CBT-I is usually considered first-line treatment

components of CBT-I

• stimulus control is used to strengthen the bedroom and bed as cues for sleep (e.g., going to bed only when tired and sleeping only in the bedroom)

• sleep restriction is used to improve sleep efficiency, which is the amount of time in bed that is spend sleeping. it involves restricting the amount of time in bed to the amount of time the person usually sleeps (as identified with a sleep diary) and then increase the amount of time in bed as sleep efficiency increases.

• sleep hygiene training consists of providing education about behaviors that facilitate and interfere with sleep (e.g., creating a comfortable bedroom, limiting coffee consumption before bedtime, getting out of bed when unable to fall asleep for 20 minutes)

• relaxation training involves teaching the use of meditation, PMR, and/or other techniques that facilitate a relaxed state.

• cognitive restructuring consists of strategies designed to identify and replace negative thoughts and beliefs that contribute to insomnia

CT-I

Harvey’s (2005) cognitive model of insomnia and focuses on reversing cognitive processes that occur at night and during the day

• sleep-related worry and rumination that cause arousal and distress (e.g., “if i don’t fall asleep, tomorrow will be a horrible day)

• selective attention and monitoring for sleep-related threats (e.g., monitoring for fatigue and concentration problems during the day)

• unhelpful beliefs about sleep (faulty assumptions about normal sleep and the consequences of inadequate sleep)

• misperceptions about sleep and daytime defecits )e.g., discrepancies between subjective and objective reports of time awake and time aleep)

• sleep-related safety behaviors which are counterproductive coping strategies used to increase control over sleep but actually worsen insomnia by preventing disconfirmation of unhelpful beliefs (e.g., avoiding conversations about sleep, canceling evening social activities, frequently checking the time while trying to fall asleep, exercising or drinking alcohol before bedtime to promote sleep, trying to suppress disturbing thoughts and images at bedtime).

narcolepsy criteria

attacks of an irrepressible need to sleep that causes sleep or daytime naps, often triggered by a strong emotion, so people with this disorder may attempt to control therapy emotions to prevent sleep episodes.

3x/week for 3+months

must have 1+ episode of:

• cataplexy - loss of muscle tone

• hypocretin deficiency

• REM latency of 15 minutes or less as determined by polysomnography

treatment of narcolepsy

behavioral strategies:

• establishing good sleep habits

• daytime naps

• staying active

medications are used to improve alertness and reduce cataplexy:

• alertness

  • modafinil and its newer form armodafinal (increase dopamine levels)

  • amphetamines and other psychostimulants (e.g., methylphenidate) (increase dopamine levels and, to a lesser degree, serotonin and norepinephrine levels)

• cataplexy

  • antidepressant (e.g., venlafaxine, fluoxetine, and comipramine)

  • sodium oxybate (for patients who do not respond to other treatments. it’s a derivative of a natural chemical in the brain and is taken at bedtime to improve deep sleep at night and reduce cataplexy and daytime sleepiness

non-rapid eye movement sleep arousal disorders (list)

sleep walking

sleep terrors

sleep walking

getting out of bed during sleep about walking about. may include sleep-related eating or sexual behavior.

when do sleepwalking and sleep talking usually occur

during stage 3 or 4 sleep in the first third of a major sleep period

most common in childhood and decrease in frequency with age

sleep terror

abrupt arousal from sleep that usually starts with a panicky scream and is accompanied by tense fear and autonomic arousal (e.g., tachycardia, rapid breathing).

unresponsive to attempts to awaken or comfort him/her during a sleepwalking or sleep terror episode and, on awakening, has little or no memory of dream imagery and cannot recall the episode

nightmare disorder criteria

repeated occurrences of extended, extremely dysphoric, and well-remembered dreams that usually involves efforts to avoid threats to survival, security, or physical integrity

when awakened, are usually oriented and alert by may continue to experience a dysphoric mood

when do nightmares usually occur

during REM sleep in the 2nd half of a major sleep period

hypnopompic hallucinations and when do they occur

common in narcolepsy

vivid hallucinations

occur just after awakening