Disorders of Neurovegetative Function: Feeding, Eating and Sleep–Wake Disorders

Session Information

• Session ID for Q2: SLK310Q2 (used for the remainder of Q2)

Chapter 8: Disorders of Neurovegetative Function

• Topic: Feeding, Eating and Sleep-Wake Disorders
• Module: SLK 310: Adult Psychopathology
• Lecturer: Dr Jolize Joubert van Appel

Learning Objectives

• Understand the scope and severity of feeding and eating disorders.
• Describe the clinical features and diagnostic criteria for:
  • Anorexia Nervosa
  • Bulimia Nervosa
  • Binge-Eating Disorder
• Explain the causes of eating disorders using the integrative model.
• Discuss different approaches to the management of eating disorders.

Neurovegetative Functions

• Definition: Functions directly related to the body and central to life (activities of survival), e.g., eating and sleeping.
• Impact: Persistent disturbances affect both physical and psychological health.

DSM-5-TR

• Feeding and Eating Disorders
• Sleep-Wake Disorders

DSM-5-TR Feeding & Eating Disorders

• Anorexia Nervosa
• Bulimia Nervosa
• Binge-Eating Disorder
• Pica
• Rumination Disorder
• Avoidant/Restrictive Food Intake Disorder

Anorexia Nervosa: Clinical Description & Diagnosis

• Restriction of food/energy intake leading to significantly low body weight.
• Intense fear of gaining weight, even at a significantly low weight.
• Persistent behavior that interferes with weight gain.
• Disturbance in how body weight/shape is viewed (e.g., self-evaluation relies excessively on body weight/shape).
• Lack of recognition of the seriousness of low body weight.
• Sub-types (specifiers):
  • Restricting type: Weight loss primarily through dieting, fasting, and/or exercising (no binge eating or purging behavior in the past 3 months).
  • Binge-eating/purging type: Recurrent episodes of binge-eating and purging behavior in the past 3 months.
• If bingeing is present, they usually binge on small amounts of food.
• Proud of their diets and their extraordinary control.
• Some develop intense interest in food (e.g., cooking).
• Often seen among models, ballet dancers, and gymnasts.
• Most have comorbid psychological disorders:
  • 71% experience depression at some point.
  • High rate of anxiety disorders & OCD.
  • Substance abuse is common.
  • 18 times more likely to die by suicide.

DSM-5-TR Criteria - Anorexia Nervosa

• A. Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health. Significantly low weight is defined as a weight that is less than minimally normal or, for children and adolescents, less than that minimally expected.
• B. Intense fear of gaining weight or of becoming fat, or persistent behaviour that interferes with weight gain, even though at a significantly low weight.
• C. Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.
• Specify type:
  • Restricting type: During the last three months, the individual has not engaged in recurrent episodes of binge eating or purging behaviour (i.e. self-induced vomiting or the misuse of laxatives, diuretics or enemas). This subtype describes presentations in which weight loss is accomplished primarily through dieting, fasting, and/or excessive exercise.
  • Binge-eating/purging type: During the last three months, the individual has engaged in recurrent episodes of binge eating or purging behaviour (i.e. self-induced vomiting or the misuse of laxatives, diuretics or enemas).

Bulimia Nervosa: Clinical Description & Diagnosis

• Recurrent episodes of binge eating, characterized by:
  • Eating, in a discrete period (2-hour), a significantly large amount of food
  • A sense of lack of control over eating (e.g., feeling that you cannot stop)
• Recurrent inappropriate compensatory behavior to prevent weight gain (e.g., self-induced vomiting, misuse of laxatives, fasting, excessive exercising).
• Binge eating & compensatory behavior both occur at least once/week for 3 months.
• Self-evaluation is unduly influenced by body shape/weight.
• Does not occur exclusively during episodes of anorexia nervosa.
• May be associated with guilt, shame, or regret.
• May hide behavior from family members.
• Foods consumed are often high in sugar, fat, or carbohydrates.
• Often abuse medications restricting diet.
• Most are within 10% of normal body weight.
• Most have comorbid psychological disorders:
  • Up to 80% experience an anxiety disorder at some point.
  • 50–70% met criteria for a mood disorder at some point.
  • Higher lifetime rates of substance abuse.
  • Shared phenomenology with borderline personality disorder.

DSM-5-TR Criteria - Bulimia Nervosa

• A. Recurrent episodes of binge eating. An episode of binge eating is characterised by both of the following:
  • Eating, in a discrete period of time (e.g. within any two-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances.
  • A sense of lack of control over eating during the episode (e.g. a feeling that one cannot stop eating or control what or how much one is eating).
• B. Recurrent inappropriate compensatory behaviour in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics or other medications; fasting; or excessive exercise.
• C. The binge eating and inappropriate compensatory behaviours both occur, on average, at least once a week for three months.
• D. Self-evaluation is unduly influenced by body shape and weight.
• E. The disturbance does not occur exclusively during episodes of anorexia nervosa.

Binge-Eating Disorder: Clinical Description & Diagnosis

• New disorder in DSM-5.
• Recurrent episodes of binge eating, characterized by:
  • Eating, in a discrete period (2-hour), a significantly large amount of food.
  • A sense of lack of control over eating (e.g., feeling that you cannot stop).
• Binge-eating episodes are associated with three/more of the following:
  • Eating much more rapidly than normal.
  • Eating until feeling uncomfortably full.
  • Eating large amounts of food when not physically hungry.
  • Eating alone because of feeling embarrassed by how much one is eating.
  • Feeling disgusted with oneself, depressed, or very guilty afterward.
• Not associated with compensatory behaviors.
• Binge eating causes marked distress.
• Binge eating occurs at least once/week for 3 months.
• Binge eating should not better explained by another eating disorder.
• Excessive concern with weight or shape may or may not be present.
• 50% of patients attempt modified, weight-restricting diets before bingeing.
• Some binge to alleviate negative affect (bad moods).
• Greater occurrence in males.
• Better response to treatment than other eating disorders.
• Often seen in people who are involved in weight-control programs & candidates for bariatric surgery.

DSM-5-TR Criteria - Binge-Eating Disorder

• A. Recurrent episodes of binge eating. An episode of binge eating is characterised by both of the following:
  • Eating, in a discrete period of time (e.g. within any two-hour period), an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances.
  • A sense of lack of control over eating during the episode (e.g. a feeling that one cannot stop eating or control what or how much one is eating).
• B. The binge-eating episodes are associated with three (or more) of the following:
  • Eating much more rapidly than normal
  • Eating until feeling uncomfortably full
  • Eating large amounts of food when not feeling physically hungry
  • Eating alone because of feeling embarrassed by how much one is eating
  • Feeling disgusted with oneself, depressed or very guilty afterwards.
• C. Marked distress regarding binge eating is present.
• D. The binge eating occurs, on average, at least once a week for three months.
• E. The binge eating is not associated with the recurrent use of inappropriate compensatory behaviour as in bulimia nervosa and does not occur exclusively during the course of bulimia nervosa or anorexia nervosa.

Cultural Considerations

• Historically associated with Western cultures.
• Recent increase also noted in developing countries.
  • Industrialization and urbanization may play a role.
• In South Africa, similar presentations among different races.

Developmental Considerations

• Eating disorders and negative attitudes towards being overweight seen as early as 3 years of age.
• Eating disorders typically emerge in adolescence.
  • During puberty, boys develop muscle and lean tissue - closer to the “ideal Western body”.
  • During puberty, girls gain weight primarily in fat tissue - further away from the “ideal Western body”.
• Anorexia nervosa and bulimia nervosa thus more common in women.
• Generally, concerns about body image decrease with age, but eating disorders can occur in later years.

Causes of Eating Disorders: An Integrative Model

• Multiple interacting factors:
  • Biological Influences
    • Inherited vulnerability (unstable or excessive neurobiological response to stress associated with impulsive eating)
  • Psychological Influences
    • Anxiety focused on appearance and presentation to others
    • Distorted body image
  • Social Influences
    • Cultural pressures to be thin
    • Family interactions/pressures re social presentation

Integrative Model Details

• Share biological vulnerability with anxiety & mood disorders
  • Excessive neurobiological responsiveness to adverse life events
  • Negative emotions and ‘mood intolerance’ may trigger binge-eating
• Psychological influences
  • Anxiety focused on appearance and presentation
  • Distorted body image
  • Obsessive-compulsive trait → anorexia
  • Emotional responsivity & impulsive trait → bulimia
• Social & cultural pressure to be thin → severe dieting
• High-achieving families
  • Emphasize appearance & achievement
  • Perfectionistic tendencies
• Maladaptive eating behaviors (e.g., bingeing, purging, food restriction) temporarily reduce anxiety → vicious cycle.

Management of Eating Disorders

• Pharmacological Treatments
• Medical Treatments
• Psychological Treatments

General Considerations for Treatment

• Initial goal: treat physical complications & restore the patient’s weight.
  • Often involves inpatient treatment at a specialized unit.
• Weight loss programs offer some positive effect for binge-eating disorder.
• Promising results for e-health treatment.
• Tailored treatment, based on personal demographics and personal characteristics, may improve success.
• Long-term prognosis for anorexia is poorer than for bulimia.

Pharmacological Treatments

• Anti-depressant medication
  • Used to treat co-morbid depression, anxiety, and OCD.
  • May enhance the effect of psychological treatment somewhat.
  • SSRIs may help reduce bingeing and purging behavior.
  • Generally ineffective for anorexia nervosa.

Psychological Treatments

• Cognitive-behavioral therapy (CBT)
  • Focus on distorted evaluation of body weight/shape
  • Address maladaptive compensating behavior
  • Psychoeducation on the adverse effects of bingeing, purging, and dieting
  • Scheduled eating
  • Guided self-help programs based on CBT principles appears promising
• Interpersonal psychotherapy (IPT) / Family therapy
  • Address negative & dysfunctional communication regarding food and eating

Case Study

• Surviving an Eating Disorder