Comprehensive Notes on Eating, Sleep-Wake, Sexual, Gender Identity, Substance-Related, and Impulse-Control Disorders

Chapter 8: Eating and Sleep-Wake Disorders

Overview of Eating Disorders

• Two major DSM-5 eating disorders: anorexia nervosa and bulimia nervosa.

• Key features:

  • Severe disruptions in eating behavior.

  • Weight and shape disproportionately impact self-concept.

  • Extreme fear of gaining weight.

  • Strong sociocultural origins, with Western culture emphasizing thinness.

• Additional DSM-5 disorder: binge eating disorder: involves binge eating without compensatory behaviors.

• Obesity is considered a symptom in some disorders but not a DSM diagnosis itself; it is a growing epidemic worldwide.

Bulimia Nervosa

• Binge Eating: hallmark feature involving uncontrollable consumption of large food amounts, often high in sugar, fat, or carbohydrates.

• Binge episodes are associated with guilt, shame, or regret and may be hidden from family.

• Compensatory behaviors are used to "make up" for binges:

  • Most common: purging (self-induced vomiting, diuretics, laxatives).

  • Also includes excessive exercise and fasting.

• Medical complications:

  • Often maintain weight within 10% of normal.

  • Severe medical issues from purging: dental erosion, electrolyte imbalance, kidney failure, cardiac arrhythmias, seizures, intestinal and colon damage.

• Psychological features:

  • Strong fear of weight gain.

  • Overconcern with body shape.

  • Common comorbid psychological disorders.

Anorexia Nervosa

• Hallmark: extreme weight loss, defined as 15% below expected weight due to calorie restriction.

• May include binging and purging.

• Intense fear of weight gain and losing control over eating, with a relentless pursuit of thinness.

• Often begins with dieting.

• Associated features:

  • Marked disturbance in body image.

  • Common comorbid psychological disorders.

  • Most deadly mental disorder: can cause grave organ damage, especially to the heart, potentially leading to heart attacks and death.

• Two subtypes:

  • Restricting type: weight loss primarily through dieting, fasting, or excessive exercise without binging or purging.

  • Binge-eating/purging type: involves recurrent episodes of binge eating or purging behavior.

Binge Eating Disorder

• New DSM-5 disorder, involving recurrent binge eating without compensatory behaviors.

• Many individuals are obese; some have concerns about shape and weight.

• Often older than bulimia or anorexia patients.

• Higher levels of psychopathology compared to obese individuals without binge eating.

Causes of Eating Disorders

• Socio-cultural influences: media portrayals linking thinness to success and happiness, cultural emphasis on dieting, and changing ideals of body size.

• Biological factors: partial genetic contributions and serotonin deficits related to bingeing.

• Psychological factors: low personal control and self-confidence, perfectionism, distorted body image, preoccupation with food, and mood intolerance.

• Integrative models consider dietary restraint, family influences, and combined biological and psychological dimensions.

Treatment of Eating Disorders

• Bulimia Nervosa:

  • Cognitive-behavioral therapy (CBT) is treatment of choice; focuses on modifying maladaptive thoughts and behaviors related to eating and body image.

  • Antidepressants may reduce binging and purging, but often not effective long-term alone.

• Binge Eating Disorder:

  • CBT is effective, similar to bulimia treatment.

  • Interpersonal psychotherapy also effective.

  • Self-help techniques show promise.

  • Medication previously used for obesity is no longer recommended.

• Anorexia Nervosa:

  • Goals include weight restoration, psychoeducation, behavioral and cognitive interventions targeting food, weight, body image, and emotions.

  • Family-based treatment is common.

  • Prognosis is generally poorer than bulimia.

Obesity

• Defined as body mass index (BMI) ≥ 30.

• Not a DSM disorder, but often a consequence of disordered eating.

• Prevalence is increasing globally, including among children and adolescents.

• Related to lifestyle, technology reducing physical activity, genetic factors (~30%), and psychosocial contributors.

• Associated with mortality rates close to smoking.

• Disordered eating patterns common, such as night eating syndrome (eating ≥ 1/3 daily calories after dinner, awake during night eating episodes, no binging, often skipping breakfast).

Treatment of Obesity

• Moderate success in adults; more success with children and adolescents.

• Stepwise approach:

  1. Self-directed weight loss programs.

  2. Commercial self-help programs.

  3. Behavior modification programs.

  4. Bariatric surgery (in extreme cases).

Sleep-Wake Disorders: Overview

• Two major types:

  • Dyssomnias: difficulties in amount, quality, or timing of sleep.

  • Parasomnias: abnormal behaviors or physiological events during sleep or upon waking.

• Sleep is critical for immune function, daily mood, memory, attention, and concentration.

• Sleep deprivation can induce depression symptoms in non-depressed people, but may have antidepressant effects in people with depression.

• Assessment includes polysomnographic (PSG) evaluation (EEG, EOG, EMG) and detailed sleep history.

Dyssomnias: Specific Disorders

Insomnia Disorder

• Most common sleep disorder; includes trouble falling asleep, maintaining sleep, or early awakening.

• Symptoms must persist at least 3 nights per week for 3 months and cause significant distress or impairment.

• Often comorbid with medical/psychological conditions; twice as frequent in females.

• Unrealistic expectations about sleep and perceived sleep disruption exaggerate distress.

Hypersomnolence Disorder

• Characterized by excessive sleepiness despite at least 7 hours of main sleep.

• Symptoms: recurrent daytime sleep episodes, non-restorative prolonged sleep, difficulty waking fully.

• Diagnosed only if not better explained by other conditions.

• Commonly associated with medical and mental disorders.

Narcolepsy

• Recurrent intense need for sleep or lapses into sleep, with at least one symptom among cataplexy, hypocretin deficiency, or abnormally fast REM onset (<15 min).

• Rare condition (0.03%-0.16%), equal sex distribution, onset during adolescence, often improves over time.

• Associated symptoms: cataplexy (brief muscle tone loss triggered by emotions), sleep paralysis, hypnagogic hallucinations.

• Daytime sleepiness requires treatment and does not remit spontaneously.

Breathing-Related Sleep Disorders

• Includes:

  • Obstructive sleep apnea hypopnea: airflow stops but respiratory effort continues.

  • Central sleep apnea: pauses in respiratory effort.

  • Sleep-related hypoventilation: decreased breathing associated with elevated CO2.

• Obstructive sleep apnea affects 10-20% of the population, more common in males, those obese, and older adults.

• Symptoms: snoring, sweating during sleep, frequent awakenings, morning headaches, daytime sleepiness.

Circadian Rhythm Sleep-Wake Disorder

• Chronic or recurrent pattern of sleep disruption resulting from misalignment between biological circadian rhythm and environment or social schedule.

• Causes insomnia, excessive sleepiness, and significant distress or impairment.

• Examples: shift work type, familial type.

• Suprachiasmatic nucleus (brain's biological clock) regulates melatonin and circadian rhythms, which do not strictly follow 24-hour cycles.

Medical Treatments for Sleep Disorders

• Insomnia: benzodiazepines and OTC sleep medications (best for short-term use due to dependence and rebound insomnia risk).

• Hypersomnia and Narcolepsy: stimulants (e.g., Ritalin) and antidepressants for cataplexy.

• Breathing-related disorders: medications, weight loss, mechanical devices (e.g., CPAP).

• Circadian rhythm disorders: phase delay (shift bedtime later), phase advance (earlier bedtime, harder), and bright light therapy to reset clock.

Psychological Treatments for Sleep Disorders

• Cognitive Behavioral Therapy for Insomnia (CBT-I): psychoeducation, changing maladaptive beliefs, sleep diaries, improving sleep-related habits.

• Relaxation and stress reduction to reduce anxiety and unrealistic sleep expectations.

• Stimulus control: using bedroom only for sleep; regular bedtime routines, especially for children.

Parasomnias

• Abnormal events during sleep or upon waking, divided into those occurring during:

  • REM sleep (dream-related)

  • Non-REM sleep (non-dream related)

Non-REM Sleep Arousal Disorder

• Includes recurrent episodes of:

  • Sleep terrors: panic-like symptoms, predominantly in children, little memory, hard to awaken.

  • Sleepwalking (somnambulism): occurs early in sleep, person leaves bed, usually resolves spontaneously in children.

• Causes distress or impairment when severe; treatments include scheduled awakenings prior to episodes.

Nightmare Disorder

• Repeated intense dysphoric dreams during second half of sleep leading to distress and impairment.

• More common in children (10%-50%) than adults (~1%).

• Treated with antidepressants and/or relaxation training.

REM Sleep Behavior Disorder

• Repeated episodes of arousal from REM sleep with vocalization or complex motor behaviors causing distress or injury.

• Occurs more often during later portions of sleep.

• Patient is fully alert upon awakening and not confused.

• Associated with synucleinopathies (e.g., Parkinson’s disease).

Summary of Eating and Sleep Disorders

• Eating disorders: characterized by gross deviations in eating, influenced by social, cultural, and psychological factors; driven largely by distorted body image and weight concerns.

• Sleep disorders: interfere with normal sleep, causing impairment during wakefulness; influenced by psychological and behavioral factors.

• Both categories show increasing incidence and require improved treatments.

Chapter 9: Sexual Disorders, Paraphilic Disorders, and Gender Dysphoria

Normal Sexuality and Sexual Dysfunctions

• “Normal” sexual behaviors are influenced by socio-cultural factors and gender attitudes; variations exist in sexual behavior and orientation.

• The sexual response cycle includes phases: desire, arousal, plateau, orgasm, resolution.

• Sexual dysfunctions involve problems in desire, arousal, orgasm, or pain, lasting at least 6 months and causing significant distress or impairment.

Common Sexual Dysfunctions

Assessment of Sexual Behavior

• Comprehensive clinical interview exploring sexual history, lifestyle, and contributing factors.

• Medical examination to rule out physiological causes.

• Psychophysiological evaluation using erotic stimuli:

  • Males: penile strain gauge to measure erections.

  • Females: vaginal photoplethysmograph to assess blood flow/arousal.

Causes of Sexual Dysfunction

• Biological: physical diseases, medications, substance use (alcohol, drugs), antihypertensive medicines.

• Psychological: anxiety, negative cognitions about sex, avoidance of sexual cues, distraction.

• Social and Cultural: erotophobia (negative sexual attitudes), trauma, poor interpersonal communication.

• Interactions among these factors are common.

Treatment of Sexual Dysfunction

• Education can be significantly helpful.

• Masters and Johnson psychosocial interventions: focus on sexual response education, sensate focus, nondemand pleasuring to reduce performance anxiety.

• Additional therapies:

  • Squeeze technique for premature ejaculation.

  • Masturbatory training for female orgasmic disorder.

  • Use of vaginal dilators for vaginismus.

  • Exposure to erotic material for low desire.

• Medical treatments primarily available for erectile dysfunction (e.g., Viagra, penile injections, implants, vascular surgery, vacuum devices).

• Limited medical treatments for female dysfunctions.

Paraphilic Disorders

• Characterized by sexual attraction/arousal focused on inappropriate people, objects, or situations.

• High comorbidity with anxiety, mood, and substance use disorders.

• Manifest as fantasies, urges, or behaviors; considered disordered only if causing distress/impairment or involving nonconsenting persons.

• DSM-5 Paraphilias include:

  • Fetishistic disorder: sexual focus on nonliving objects or nongenital body parts.

  • Voyeuristic disorder: observing unsuspecting others naked or engaged in sexual activity.

  • Exhibitionistic disorder: exposing genitals to strangers.

  • Frotteuristic disorder: rubbing against nonconsenting persons.

  • Transvestic disorder: sexual arousal from cross-dressing.

  • Sexual sadism disorder: inflicting pain/humiliation for arousal.

  • Sexual masochism disorder: receiving pain/humiliation for arousal.

  • Pedophilic disorder: sexual attraction to prepubescent children.

Causes and Treatment of Paraphilic Disorders

• Causes:

  • Difficulty with normal relationships and typical sexual experiences.

  • Early chance sexual associations reinforced by masturbation.

  • High sex drive; suppression efforts may worsen symptoms.

• Treatment:

  • Psychosocial behavioral interventions: covert sensitization (imagining negative consequences), orgasmic reconditioning, family/marital therapy, relapse prevention.

  • Approximately 75%-95% improvement in treated cases; poorer outcomes in rapists or multiple paraphilias.

  • Drug treatments (chemical castration) like cyproterone acetate or medroxyprogesterone acetate reduce testosterone and sexual urges, often used for dangerous offenders but relapse common after cessation.

Gender Dysphoria

• Marked incongruence between experienced/expressed gender and assigned gender lasting at least 6 months.

• Associated with distress or impairment in social, school, or other functioning areas.

• Diagnostic features differ for children (specified behaviors such as preference for cross-gender roles, toys, clothes) and adolescents/adults (desire to be rid of primary or secondary sex traits, desire to be treated as other gender).

• Causes unknown; gender identity develops between 18 months and 3 years.

• Not a disorder unless causing significant distress or impairment.

• Treatment can include sex reassignment surgery after psychological and social stability, with 75% satisfaction reported; female-to-male transitions show better adjustment.

• Controversy exists around psychological interventions for children and treatment of intersexuality.

Summary

• Sexual dysfunctions are common and involve difficulties in desire, arousal, orgasm, and/or pain.

• Paraphilic disorders represent inappropriate sexual attractions causing impairment or distress.

• Treatments combining psychosocial and medical approaches are generally effective.

• Gender dysphoria involves distress related to a mismatch of gender identity and sex assigned at birth.

Chapter 10: Substance-Related, Addictive, and Impulse-Control Disorders

Perspectives on Substance Use Disorders

• Substance use: moderate consumption without significant interference.

• Substance intoxication: physiological reaction to substance (e.g., being drunk).

• Substance abuse: use causing danger or impairment (impacting work or relationships).

• Substance dependence: characterized by tolerance (need more for effect) and withdrawal symptoms; drug-seeking behavior.

Five Main Categories of Substances

DSM-5 Substance Use Disorder Criteria

• Pattern of substance use leading to clinically significant distress or impairment demonstrated by at least 2 symptoms within 12 months, including:

  • Using larger amounts or longer than intended.

  • Persistent desire or unsuccessful attempts to cut down/control use.

  • Excessive time spent obtaining, using or recovering.

  • Craving or strong urge to use.

  • Failure to fulfill major role obligations.

  • Continuing use despite social/interpersonal problems.

  • Reduction of important activities.

  • Use in physically hazardous situations.

  • Use despite physical/psychological problems caused or worsened by substance.

  • Tolerance and withdrawal symptoms.

• Severity: mild (2-3 symptoms), moderate (4-5), severe (6+).

Depressants: Alcohol and Sedatives

• Alcohol acts mainly on GABA neurotransmitter enhancing inhibition.

• Chronic use -> intoxication, withdrawal, brain damage (dementia, Wernicke’s disease), fetal alcohol syndrome (prenatal exposure causing developmental problems).

• 23% of Americans report binge drinking; males use and abuse more than females.

• Sedative, hypnotic, anxiolytic drugs act similarly to alcohol (also via GABA system), have similar abuse criteria.

Stimulants

• Increase alertness and energy; examples: amphetamines, cocaine, nicotine, caffeine.

• Amphetamines: elation, vigor, reduced fatigue by increasing norepinephrine and dopamine; followed by fatigue/depression.

• Cocaine blocks dopamine reuptake; highly addictive with slow development.

• Nicotine highly addictive, stimulates nicotinic acetylcholine receptors; used to self-regulate mood.

• Caffeine widely used; blocks adenosine reuptake; intoxication symptoms include restlessness, nervousness, insomnia, muscle twitching, tachycardia.

Opioids

• Derived from opium poppy; natural and synthetic substances providing analgesia (pain relief).

• Activate enkephalins and endorphins; low doses cause euphoria, drowsiness, slowed breathing; high doses can be fatal.

• Withdrawal symptoms severe and long-lasting; high HIV risk from needle sharing.

Hallucinogens

• Alter perception, cause hallucinations and paranoia; examples: marijuana (THC) and LSD.

• Marijuana impair motivation; withdrawal rare.

• LSD effects more intense; tolerance rapid; withdrawal rare but can cause psychosis.

Other Drugs of Abuse

• Inhalants: volatile solvents inhaled, causing rapid intoxication similar to alcohol, with rapid absorption and common withdrawal.

• Anabolic steroids: derived from testosterone; used medically and for muscle mass; no euphoria but cause mood and physical problems.

• Designer drugs: substances like ecstasy targeting recreational effects with altered sensory perception; tolerance and dependence possible.

Causes of Substance-Related Disorders

• Genetics: family, twin, and adoption studies show genetic risk components; multiple genes involved.

• Neurobiology: drugs affect brain’s pleasure pathway involving dopamine; GABA modulates reward system; substances inhibit anxiety neurotransmitters.

• Psychological:

  • Positive reinforcement (euphoria) and negative reinforcement (withdrawal relief) maintain use.

  • Substance use as coping with negative affect.

  • Cognitive expectancy effects influence use; cravings triggered by cues.

• Social and Cultural: exposure (media, family, peers) is necessary; cultural norms shape presentation and acceptance.

Treatment of Substance-Related Disorders

• Biological interventions:

  • Agonist substitution: safe drugs chemically similar to abused substances (e.g., methadone, nicotine replacement).

  • Antagonistic treatments: block effects (e.g., naltrexone).

  • Aversive treatments: induce unpleasant reactions (e.g., antabuse).

  • Biological treatments alone are often ineffective but useful for withdrawal support.

• Psychosocial treatments:

  • Inpatient and outpatient care, no effectiveness difference.

  • Support groups (Alcoholics Anonymous, Narcotics Anonymous).

  • Component treatments combining psychotherapy, aversion therapy, contingency management, community reinforcement, relapse prevention.

  • Prevention efforts increasingly focus on law enforcement rather than only education.

Gambling Disorder

• Included in addictive disorders in DSM-5.

• Persistent problematic gambling causing distress or impairment; four or more symptoms within 12 months (e.g., increasing stakes, irritability when stopping, preoccupation, gambling when distressed, lying, jeopardizing life opportunities, reliance on others for money).

• Treatment similar to substance abuse therapies; motivation critical; high dropout rate.

• Research on integrated CBT treatments ongoing.

Impulse-Control Disorders

• Characterized by:

  • Impairment in social or occupational functioning.

  • Tension or anxiety before the act.

  • Relief or gratification after the act.

• Includes:

  • Intermittent Explosive Disorder: recurrent aggressive outbursts causing injury or property damage; rare with few controlled treatments.

  • Kleptomania: urge to steal unnecessary items; highly comorbid with mood and substance disorders.

  • Pyromania: urge to set fires; rare diagnosis among arsonists; treatment focuses on urge identification and incompatible behaviors.

Summary of Non-Substance Addiction-Related Disorders

• Involve impulsive, self-destructive behaviors impacting functioning.

• Research and treatment data remain limited.

Exam 3 Possible Discussion Questions

1. List the five substance categories and their CNS effects with examples:

   • Depressants (e.g., alcohol) – cause sedation.

   • Stimulants (e.g., cocaine) – increase alertness and mood.

   • Opiates (e.g., heroin) – analgesia and euphoria.

   • Hallucinogens (e.g., LSD) – alter sensory perception.

   • Other drugs (e.g., inhalants) – varied effects.

2. Describe the five phases of the human sexual response cycle and differentiate sexual dysfunctions from paraphilic disorders:

   • Phases: desire, arousal, plateau, orgasm, resolution.

   • Sexual dysfunctions involve impairments in these phases causing distress.

   • Paraphilic disorders involve atypical sexual interests or arousals often focused on inappropriate targets.

3. Define paraphilia; list and define four paraphilic disorders with examples:

   • Paraphilia: sexual arousal from atypical objects or situations causing distress or involving nonconsenting persons.

   • Examples:

     • Fetishistic disorder – attraction to nonliving objects (e.g., shoes).

     • Voyeuristic disorder – observing unsuspecting people.

     • Exhibitionistic disorder – exposing genitals.

     • Pedophilic disorder – attraction to prepubescent children.

4. Define and compare/contrast:

   • Fetishistic disorder vs. Transvestic disorder: Both involve sexual arousal linked to objects or clothing; fetishism is attraction to objects/nongenital body parts, while transvestic involves cross-dressing.

   • Transvestic disorder vs. Gender Dysphoria: Transvestic disorder is sexual arousal tied to cross-dressing without identity conflict; gender dysphoria involves distress due to incongruence between gender identity and biological sex.

5. Describe bulimia nervosa and anorexia nervosa; list two anorexia subtypes; primary difference:

   • Bulimia nervosa: recurrent binge eating with compensatory behaviors; weight often normal or slightly elevated.

   • Anorexia nervosa: intense fear of weight gain with significant weight loss.

   • Subtypes of anorexia:

     • Restricting type – weight loss mainly via dieting and fasting.

     • Binge-eating/purging type – includes bingeing or purging episodes.

   • Primary difference: Anorexia involves extreme weight loss; bulimia involves normal weight with binge/purge cycles.