10. Eating and sleeping disorders Flashcards
Eating as a mental disorder?
“Body image problems and eating disorders sit on a continuum which ranges from healthy body image and eating patterns through disordered eating and eating behaviours…to… diagnosable clinical eating disorders”.
the DSM 5 feeding and eating disorders
Pica Rumination disorder avoidant/restrictive food intake disorder anorexia nervosa blimia nervosa binge eating disorder unspecified feeding or eating disorder other specified feeding or eating disorder
How are feeding and eating disorders characterised in the DSM 5?
“Characterized by persistent disturbance of eating or eating-related behaviour that results in the altered consumption or absorption of food that significantly impairs physical health or psychosocial functioning”
Diagnostic criteria for ANOREXIA NERVOSA
Significantly low weight
Intense fear of gaining weight
Disturbance in experience of body weight or shape
Significantly low weight criteria of anorexia nervosa
– BMI below 18.5 – lower limit for normal weight
– BMI below 17 – ‘moderate to severe thinness’
– Rapid weight loss
– Percentage of ideal body weight for age, height, sex
– Threats to physical health
Extreme emaciation is not unusual
Most people with this diagnosis are 25-30%
below normal body weight
Defining Thinness
BMI – a popular indicator
• But only one metric – doesn’t capture other factors
elevant to health
– Waist size
– Fat, bone, muscle mass are not taken into account
• Other indices of health also need to be taken into account
Physical impact of low weight
• Amenorrhea
• Dry skin, brittle hair & nails
• Increased sensitivity to cold
• Lanugo: downy hair growth on face and limbs
• Dehydration
• Cardiovascular problems (e.g., low blood pressure, slowed pulse rate,
cardia arrythmia)
• Dizziness, episodes of fainting
• Low temperature – risk of hypothermia
• Extreme fatigue/physical exhaustion
• Osteopenia (low bone density) leading to osteoporosis/stress fractures
• If purging – electrolyte imbalance; dental problems; sensitized gag reflex
• Infertility, perinatal complications
Intense fear of gaining weight criteria for anorexia nervosa
• Intense fear of gaining weight, becoming fat,
OR
• Persistent behavior that interferes with weight gain, even though at a significantly low weight
• Often terror/panic at prospect of eating
• Not alleviated by weight loss and often becomes more intense with weight loss
Behaviours that interfere with weight gain in anorexia nervosa
– Restricting food intake – often drastically
– Excessive exercise
– Purging, even following very low intake
Disturbance in experience of body weight or shape criteria for anorexia nervosa
- Distorted body image
- Inaccurate perceptions of size/shape
- Weight/size the most important factor in self evaluation/sense of worth
- Poor recognition of low weight and seriousness of low weight
Poor recognition of low weight and seriousness of low weight
– Unable to recognise emaciation – perceive self as overweight
– Inability/refusal to acknowledge seriousness of low weight
Restricting type anorexia
During the episode of anorexia nervosa the person does not regularly engage in binge eating or purging behaviour. Low weight is maintained by extremely low food intake. May:
• Avoid food/eating altogether
• Eat certain foods only
• Have a very low calorie intake
Binge eating/purging type anorexia
During this episode of anorexia nervosa, the person has regularly engaged in binge eating or purging behaviour. Often alternating with periods of restricting. Purging may include: • Vomiting • Laxative use • Excessive exercise • Enemas
Associated features of anorexia nervosa
- Depressed mood
- Irritability
- Social withdrawal
- Insomnia
- Preoccupation with food and eating
- Inflexible thinking
- Food related obsessions – hoarding food, collecting recipes, cookbooks, pictures of food
- Compulsive eating rituals
- Common comorbidities include: Depression and OCD
Anorexia nervosa death rate
AN has highest death rate of all mental illness
– Partially due to medical factors
– Partially due to suicide
Course of AN
In longitudinal research
• ~20% remain significantly underweight
• ~5-20% estimated death rate
• Remainder are in healthy weight range
– While weight may be in normal range, preoccupation with diet, image, shape and weight often remain
– Depending on level of starvation, may have long term physical complaints (e.g. osteoporosis)
Bulimia nervosa diagnostic criteria
recurrent episodes of binge eating
compensatory behaviours to prevent weight gain
self-evaluation is unduly influenced by shape and weight
Define Binge eating
- Eating, in a discrete period, an amount that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances (usually less than 2 hours)
- Associated with a sense of lack of control
Binge eating as a criterion for Bulimia Nervosa
- Typically involves foods that are usually avoided by the person
- Sense of uncontrollability – unable to stop once started
- May describe dissociation during or after
- Often triggered by stressors – interpersonal conflict, boredom, negative feelings about self
- May describe a general state of negative affect/dysphoria
- Typically followed by intense dysphoria, disgust, shame
Compensatory Strategies (Purging) as a criteria for BN
Attempts to purge the foods consumed from the body
– Self-induced vomiting (most common)
– Laxative/diuretic use
– Exercise
– Fasting
– Enemas
– In those with diabetes, omitting or reducing insulin
Physical implications of Bulimia
• Physical complications are secondary to purging pattern
Depend on the nature of purging
– Fluid and electrolyte imbalances (cardiac arrhythmia, renal failure)
– Erosion of dental enamel
– Enlargement of salivary glands
– Sensitive gag reflex
– Callusing on fingers and back of hand from contact with teeth and throat to stimulate gag reflex
– Intestinal problems (e.g., colon damage) if laxative abuse
– Can become dependent on laxatives to stimulate bowel movements
– Rare but potentially fatal complications include esophageal tears and gastric rupture
Self-evaluation unduly influenced by shape and weight as a criteria for BN
- Often high dissatisfaction with weight and shape
- Self-worth tied to weight and diet
- Seek to lose weight/avoid gaining weight
- Comparisons to others resulting in negative selfevaluation
Associated features of BN
- Of normal weight or overweight
- May engage in dieting/restriction of food intake between binges
- Typically deeply ashamed of pattern
- Binge eating often occurs in secrecy
- Depression is often comorbid
The co-existence of symptoms of AN and BN
Often not seen in “pure” form – symptoms of both AN and BN typically co-exist
– 50% of persons with Anorexia engage in bingeing and
purging
– Many people with bulimia have a history of anorexia
– Diagnostic flux – high rates of movement between diagnoses
• Longstanding criticism of the classification of eating disorders is the high rate of use of DSM Unspecified/Not otherwise specified categories
Binge eating disorder
BED involves recurrent episodes of binge eating without compensatory behaviour
– Large amount of food in 2 hrs
– Loss of control over eating
– 3 or more associated symptoms – rapid eating, disgust, embarrassment, secrecy
– Marked distress
– Occurs once a week or more for 3 or more months
Should DSM-5 have included obesity?
- Does obesity cause subjective distress / impairment?
- Is the involvement of biological factors sufficient reason NOT to include it? [Arguments against its inclusion include the potency of “biological” factors]
- If not as an eating disorder, then as an addictive disorder (Moreno & Tandon, 2011)
The effect of including obesity as a mental illness in the DSM-5?
what is the effect of including obesity in DSM on our conceptualization of mental illness? Would it mean that the number of people diagnosed would conflict with rarity notions of “abnormal” behaviour?
Are eating disorder concepts too narrow?
- Are there other ways distortions in body image can unduly influence our behaviour?
- Should behaviours other than eating be considered here?
- How else might distorted body image show up in behaviour?
Prevalence of eating disorders
– Highest rates are in young women
– AN and BN each occur in approximately 1% of the population
• AN 0.5-1%, BN 1-1.5%
– Cohort effects – the lifetime prevalence of BN is much higher in women born after 1960 than those before 1950
– ? Role of change in cultural standards
AN as a culturally specific disorder?
– Highest prevalence in Western industrialised countires
– Previously thought to occur in Western/first world countries only
– Some evidence occurring in other countries such as Japan (unsystematic interviews with health workers).
Who is most at risk of eating disorders?
young females from high SES groups
age and gender as risk factors of eating disorders
- Women are more likely to be affected by ED’s but men may also experience them
- Both AN and BN typically have onset in adolescence and early adulthood
- Weight and dieting (and the presence of EDs) decreases as adolescent girls become women (esp. following marriage & parenthood)
- Men become more concerned with weight with age
Eating disorders in men
• Eating disorders do occur in men
• Rates are lower (~0.3%)
• Often documented in subgroups including
– wrestlers (pressure to “make weight”)
– Athletes (AFL player case examples)
– Dancers
• Age of onset of eating disorders in men & women similar
Cultural factors that cause eating disorders
– Value placed on thinness
– Reinforcing centrality of appearance in acceptance
– Those who participate in sports/activities with a strong focus on weight, appearance are at higher risk
– E.g. ballet, athletics, gymnastics, ice-skating, modelling
other sociocultural factors of eating disorders
• Acceptance (or promotion) of dietary restraint – in family, workplace, social groups, online groups
• Role modelling
• In many families, direct messages about appearance and weight
may be shared
Role modelling as a cause of eating disorders
observations of relatives engaging in dieting, negative self-evaluation, disordered eating (Lieberman, Gauvin, Bukowski, & White, 2001; Pike & Rodin, 1991)
Psychological aetiologies for eating disorders
• Thin ideal internalisation
• Perfectionism, emotional constraint, rigidity represent risk factors for
AN
• Poor interoceptive awareness – difficulty tuning into bodily signals
• Anxiety associated appearance of self to others
• Distorted perception of body size/weight
• High level of dissatisfaction with body
• Self worth tied to appearance, weight, body shape and size
Thin ideation internalisation
the degree to which identifies with cultural value of thinness – how much do you believe thin = attractive
Perfectionism, emotional constraint, rigidity as a risk factors for AN
– During periods of stress, people with these personality characteristics tend to seek structure, and increase rigidity which may be applied to eating/food
– Perfectionism tends to increase sense of inadequacy and failure
A sense of control as a cause of eating disorders
- Some theories emphasise the role of control in Anorexia
- Many patients report a sense of satisfaction or pride in controlling food intake and hunger – mastery over the body
- Others report regulating their intake allows a sense of control and order where they had previously felt out of control/ had no say
biological causes of eating disorders
- Possible genetic component though complex to interpret…
- Body’s attempt to maintain “set point”
- Starvation syndrome
Set point theory of eating disorders
- The body seeks to maintain a homeostasis
- It compensates for changes in consumption and exercise to maintain the set point
- Periods of starvation increase likelihood of bingeing
- The increase in hunger can trigger off a cascade of negative cognitions for those with AN, increasing sense of lack of control
starvation in eating disorders
Many of the symptoms of anorexia may actually be attributable to starvation
1950 Minnesota Starvation Experiment
– 36 Healthy men
– 6 months of semi-starvation
– Drastic changes in behaviour during starvation period and throughout re-feeding
starvation syndrome - food related symptoms
- Preoccupation with food – thoughts, conversation, day dreams
- Vicarious pleasure watching other people eat or just from smelling the food
- Hoarding of food related items – cookbooks, menu
- Rituals around food and eating
Starvation syndrome - psychological symptoms
- Depression, irritability
- Social withdrawal, isolation
- Impaired concentration, alertness comprehension, and judgement during semi-starvation
Starvation syndrome - physiological symptoms
Dizziness, headaches, hypersensitivity to noise and light, reduced
strength, poor motor control, edema, hair loss, decreased tolerance
for cold temperatures, visual disturbances, auditory disturbances
and paraesthesias (abnormal tingling in hands or feet)
re-feeding problems as a result of eating disorders
- During re-feeding, many had problems with binge-eating (persistent for months)
- Reported a sense of intense uncontrollable hunger even after eating a considerable amount of food
- For most, symptoms resolved after re-feeding and weight restoration
- Initially, weight was slightly higher than original, but returned to normal after several months
Inpatient treatment for anorexia
Inpatient admission may be necessary in severe cases of anorexia
to establish safe weight gain
How is weight restoration achieved for anorexia patients
– Inpatient treatment
– Nasogastric tube feeding
– Supervised meals
– Strict meal expectations
What is the first priority of anorexia treatment?
Obtaining a normal weight. While a person is significantly underweight, psychological interventions are likely to have limited effect
Once a normal weight is obtained - what does treatment for anorexia then focus on?
Once ‘normal weight’ is obtained, treatments can focus on other aspects of presentation (e.g., self-worth)
aims of psychological treatment approaches for anorexia
• enhance self-esteem, tying this to internal rather than external
evaluations
• provide education about “normal body weight” & address
maladaptive cognitions regarding loss of control
• may involve family therapy (Durand & Barlow, 2000)
Maudsley Family Based Treatment for anorexia
gold standard intervention in adolescents
– Goal is weight restoration and re-establishment of feeding
– Involves parents taking responsibility for feeding
– Externalises the anorexia emphasising that the adolescent is not to blame
– Age appropriate autonomy is returned to adolescent as eating and
weight improv
Psychological treatments for bulimia
BN may be more amenable to successful psychological treatment than AN
CBT as treatment for bulimia
CBT, aimed at:
1. education and behavioural strategies to normalise eating
patterns;
2. addressing cognitions;
3. Relapse management and realistic future weight /shape preparation.
Effectiveness of CBT as treatment for bulimia
Effective for 70-80% of people (stopping binge-purge) & can be used with various formats – individual, group, self-directed.
Interpersonal Therapy as treatment for BN
focuses on improving personal relationships, rather than eating behaviours specifically;
• Initially studied as a placebo
• But in follow-up analyses showed promise…
Medications as treatments for eating disorders
- Antidepressants often prescribed to address concomitant depressive symptoms in both AN and BN
- Other medications may be prescribed to target comorbid symptoms
- No medication to treat the eating disorder itself
Why study sleep?
- Sleep is unavoidable
- Sleep problems are common
- Sleep a strong predictor of functioning and wellbeing
- A major psychological/behavioural state
- Changes in sleep are often associated with other mental disorders
Normal sleep
- Normal range 7-9 hours per night (but longer or shorter are OK too)
- Variation is normal (and adaptive)
- Waking up feeling refreshed
- Average time to fall asleep is 20-30 minutes
- Needs change across lifespan
- Time spent in different phases of sleep changes with age
Two broad categories of sleep disorders are DSM 5
Parasomnias
Dyssomnias
Parasomnias
abnormal events that occur during sleep (e.g. nightmares; sleep walking)
Dyssomnias
disturbance in amount, quality or timing of sleep
Types of dyssomias
insomnia hyper-somnolence disorder narcolepsy breathing related sleep disorders circaddian rhythm sleep disorder
types of parasomnias
Non REM sleep arousal disorder
nightmare disorder
REM sleep behaviour disorder
Substance/medication induced sleep disorder
Insomnia
Difficulty initiating or maintaining sleep OR poor quality of sleep
At least 3 nights per week for at least 3 months
Results of insomnia
Causes significant distress or impairment in social, occupational or other important areas of functioning
causes of insonia
Sleep onset often delayed due to worry, rumination, arousal
Hypersomnolence
• Excessive daytime sleepiness despite good quality night time sleep
• Recurrent lapses into sleep during the day
• Difficulty becoming and staying fully awake
• Prolonged periods of sleep and naps that are not restorative
• Unintentional sleep during periods of low stimulation (movies, lectures, driving)
• “sleep drunkenness” often described during sleep wake transition
• Day time functioning impaired: poor concentration, reduced work
outcomes, difficulty maintaining commitments
how is Hypersomnolenced diagnosed?
Diagnosed via sleep study followed by a multiple sleep latency test (MSLT)
“sleep drunkenness”
– Impaired alertness, poor motor control, memory deficits, disorientation
– May engage in automatic behaviours with no recall
Narcolepsy
• Irresistible sleep attacks in the day
• Accompanied by
– brief episodes of sudden loss of muscle tone (cataplexy)
OR
– Evidence of REM sleep latency of 8 minutes or less on MSLT and 2 or more sleep onset REM periods
OR
– Hypocretin deficiency in cerebrospinal fluid
Breathing-related sleep disorders
- Sleep disruption, leading to excessive sleepiness judged due to a breathing condition
- (e.g. Sleep apnoea)
Circadian rhythm sleep-wake disorder
- Persistent pattern of sleep disruption leading to excessive sleepiness/insomnia due to mismatch between environment and internal clock
- Causing impairment or distress
- Typically in people working night shifts, adolescents
- (e.g. DSM-5 subtypes: DSP, ASP, non-24 sleep-wake type)
Examples of parasomnias
- Nightmare
- NREM Sleep arousal disorders
- REM Sleep Behaviour Disorder
NREM Sleep arousal disorders
sleep terror
sleep walking
nightmare
freq. awakening by terrifying dreams (REM)
sleep terrors
abrupt awakening, typically screaming (cf nightmare disorder) + unable to recall dream & intense autonomic arousal may be disoriented for some time (SWS)
sleepwalking
involves walking whilst in unresponsive state with inability to recall event (SWS)
REM Sleep Behaviour Disorder
- episodes of arousal during sleep associated with vocalization and/or complex motor behaviors
- During REM sleep – often in later part of the night
What affects sleep onset and quality?
- Stress and anxiety
- Worry/rumination
- Pain
- Medical conditions
- Alcohol and substances, including caffeine
- Medications
- Breathing conditions
- Teeth grinding
- Sleep walking/parasomnias
- Environmental factors – sound, light, temperature
Insomnia Treatment - Aims
- Stabilise sleep
- Break habits
- Reduce arousal
- Change beliefs
Insomnia treatments involve…
A combination of multiple components
Psychological and behavioural interventions have been demonstrated to be effective treatment options for the management of insomnia
Pharmacological treatments of sleep disorders
- Benzodiazepines are frequently taken to induce sleep (e.g. temazepam, diazepam, stillnox, serepax)
• Some antidepressants
• Melatonin is often prescribed for children/adolescents with sleep problems
Why are Benzodiazepines not recommended?
– Changes in sleep quality/time in different sleep phases
– Rapidly developing tolerance
– Reliance on medication to sleep
– Risk of interaction effects with other medications, substances or alcohol
Antidepressants as treatment for sleep disorders
some antidepressants have a sedating effect when taken at night (e.g. mirtazapine, amitriptyline, valdoxan)
Melatonin as treatment for sleep disorders
Melatonin is often prescribed for children/adolescents
with sleep problems
CBT as treatment of insomnia
- Sleep hygiene education
- Stimulus control therapy
- Sleep restriction therapy
- Relaxation training
- Cognitive therapy
Sleep hygine
Tips to support sleep & promote sleep quality
• Reduce caffeine (particularly after 3pm)
• Reduce nicotine (particularly in few hours before bed)
• Reduce alcohol
• Remove TVs and devices from bedroom
• Remove clocks from bedroom, avoid clock watching
• Reduce exposure to blue light in hours before bed
• Exercise each day
• Create comfortable sleep environment – dark, cool temperature, quiet
Stimulus Control Therapy as treatment for sleep disorders
Insomnia viewed as a conditioned response to temporal (bedtime) & environmental (bed & bedroom) cues associated with sleep. Aim is to reassociate bedroom environment with rapid sleep onset.
What are the methods of Stimulus Control Therapy as treatment for sleep disorders
- Go to bed only when sleepy
- Get out of bed if you can’t sleep
- Use the bed & bedroom only for sleep
- Regular rise time in morning (regardless of sleep duration)
- Avoid daytime naps
Sleep restriction therapy as a treatment for sleep disorders
- Determine set sleep times based on when typically sleeping
- Curtail actual amount of time in bed to sleep time only
- Aim is to improve sleep efficiency
- Complementary to Stimulus Control Therapy
Relaxation therapy as a treatment for insomnia
Aimed at reducing somatic tension (e.g. progressive muscle relaxation) or intrusive thoughts (e.g. imagery, meditation)
Cognitive therapy as a treatment for insomnia
Psychological methods aimed at challenging and changing misconceptions about insomnia and perceived daytime consequences
