Feeding/Eating, Elimination, and Sleep-Wake Disorders

Question 1

Feeding and Eating Disorders:

Answer 1

Feeding and Eating Disorders: The DSM-5 describes the disorders in this category as involving “a persistent disturbance of eating or eating-related behavior that results in the altered consumption or absorption of food and that significantly impairs physical health or psychosocial functioning” (p. 329).

1. Pica: Pica involves persistent eating of non-nutritive, nonfood substances (e.g., paper, paint, coffee grounds) for at least one month that’s inappropriate for the person’s developmental level and is not a culturally or socially acceptable practice. Pica can occur at any age, but it’s most common among children and has an elevated rate among pregnant women. It can lead to intestinal obstruction, lead poisoning, and other medical complications.
2. Anorexia Nervosa: This disorder involves a restriction of energy intake that causes a significantly low body weight for the person’s age, sex, developmental trajectory, and physical health. For the diagnosis, the person must have (a) an intense fear of gaining weight or becoming fat or engage in behavior that interferes with weight gain and (b) a disturbance in the way he/she experiences his/her weight or shape, self-evaluations that are unduly influenced by weight and shape, or a lack of awareness of the seriousness of his/her low weight. Specifiers are used to indicate type (restricting or binge-eating/purging), course (in partial remission or full remission), and severity, which is determined by the person’s current body mass index. Anorexia nervosa often co-occurs with depression or an anxiety disorder (especially obsessive-compulsive disorder), and there’s evidence that anxiety often precedes the onset of anorexia (Kaye, Bulik, Thornton, Barbarich, & Masters, 2004). Medical complications are usually the direct result of malnutrition and extreme weight loss, affect nearly all of the major organ systems, and can lead to death (Mehler & Brown, 2015).

Anorexia nervosa is a life-threatening disease that often involves frequent relapses before a stable pattern of eating and weight maintenance is attained. It’s also one of the most difficult disorders to treat because people with this disorder often deny they have an eating problem and resist treatment. The prognosis for anorexia is generally considered to be poorer than the prognosis for bulimia nervosa, but there’s some evidence that long-term outcomes for the two disorders may be more similar than previously believed: For example, Eddy and colleagues (2017) assessed the long-term outcomes for patients with anorexia or bulimia and found that 31.4% of those with anorexia and 68.2% of those with bulimia had recovered at the 9-year follow-up but that 62.8% of patients with anorexia and 68.2% of patients with bulimia had recovered at the 22-year follow-up.

The initial treatment goals for anorexia are to restore the person to a healthy weight and address physical complications. Subsequent goals include (a) increasing the person’s motivation to participate in treatment; (b) providing the person with education about healthy nutrition; (c) helping the person identify and change beliefs, attitudes, and emotions that are contributing to the eating disorder; (d) treating psychological conditions that are contributing to the eating disorder (e.g., low self-esteem, impulse control problems); (e) enlisting family support and providing family therapy when appropriate; and (f) helping the person identify strategies for preventing relapse (American Psychiatric Association, 2006). Treatments that have some research support include enhanced cognitive-behavior therapy for eating disorders (Fairburn, 2008) and family-based treatment for anorexia nervosa (Locke, LeGrange, Agras, & Dare, 2001): Enhanced cognitive-behavior therapy for eating disorders (CBT-E) focuses on four core eating disorder maintaining mechanisms: clinical perfectionism, core low self-esteem, intense mood states, and interpersonal difficulties. Family-based treatment (FBT) for anorexia is an outpatient intervention for adolescents who are medically stable and involves three phases: full parental control, gradual return of control to the adolescent, and establishing an age-appropriate level of independence for the adolescent and healthy family relationships. With regard to pharmacotherapy, the research has provided inconsistent results. For example, some (but not all) studies have found the antipsychotic olanzapine to be useful for fostering initial weight gain and the SSRI fluoxetine for improving weight maintenance (Blanchet et al., 2019). Because of the inconsistent findings about the effectiveness of these and other medications for treating anorexia, some experts recommend they be used only to treat comorbid symptoms such as depression and anxiety.

3. Bulimia Nervosa: This disorder involves recurrent episodes of binge eating that are accompanied by a sense of a lack of control, inappropriate compensatory behavior to prevent weight gain (e.g., self-induced vomiting, excessive exercise), and self-evaluation that’s excessively influenced by body shape and weight. For the diagnosis, binge eating and compensatory behavior must occur at least once a week for three months or more. Specifiers are used to indicate course (in partial or full remission) and severity, which is based on average number of episodes of inappropriate compensatory behavior per week. Like anorexia nervosa, bulimia nervosa frequently co-occurs with depression or anxiety, with anxiety sometimes preceding the eating disorder. Most people with this disorder are within the normal weight range or overweight, and medical complications are usually the result of compensatory behavior. For example, purging can cause dental erosion, caries, and other dental problems; gastroesophageal reflux, and dehydration, which causes an electrolyte imbalance that can result in heart arrhythmias and death (Mehler & Rylander, 2015).

The treatment of bulimia nervosa consists of nutritional rehabilitation plus cognitive behavior therapy (CBT) or interpersonal therapy (IPT). CBT and IPT are both evidence-based treatments for bulimia, but CBT is generally preferred because IPT takes longer to produce beneficial effects comparable to those produced by CBT. SSRIs and tricyclic antidepressants are sometimes used in conjunction with therapy and have been found useful not only for alleviating comorbid depression but also for reducing binge eating and purging in patients without depression (American Psychiatric Association, 2006). While studies have consistently found CBT plus an antidepressant to be superior to an antidepressant alone, studies comparing CBT alone to CBT plus an antidepressant have produced inconsistent results: Some studies indicate that the combined treatment is most effective; others indicate that the combined treatment is no more effective than CBT alone (e.g., Goldbloom et al., 1997; Wilson & Fairburn, 2007). In addition, there’s evidence that the effects vary, depending on the outcome measure. For example, Hall, Friedman, and Leach (2008) found that, in terms of full remission of binge and purge episodes, the combined treatment was most effective followed by, in order, CBT alone and antidepressant alone. In contrast, CBT alone had the lowest rate of early dropout from treatment followed by, in order, the combined treatment and antidepressant alone.

The enhanced version of cognitive behavior therapy (CBT-E) has been found to be the most effective version of CBT for patients with bulimia. It’s a transdiagnostic intervention for eating disorders that’s based on the assumption that these disorders share the same core psychopathology – i.e., excessive value given to physical appearance and weight. CBT-E consists of four stages (Murphy, Straebler, Cooper, & Fairburn, 2010): Stage 1 includes engaging the patient in treatment; jointly creating a formulation of the patient’s eating problem that identifies the processes that are maintaining the problem; establishing self-monitoring of eating and relevant behaviors, thoughts, feelings, and events; providing education about weight and eating; and establishing a pattern of regular eating. Stage 2 is a brief transitional stage that involves reviewing the patient’s progress, identifying any new problems and barriers to change, and revising the formulation if necessary. Stage 3 includes addressing the patient’s overevaluation of shape and weight and exploring its origins; identifying events that trigger undesirable eating; and addressing clinical perfectionism, low self-esteem, and interpersonal problems. Stage 4 consists of helping the patient identify ways to maintain progress and reduce the risk for relapse.

Several studies have evaluated the effectiveness of telepsychology for individuals with bulimia. These studies have generally found that telepsychology and comparable face-to-face interventions produce positive results but differ in terms of some outcomes. For example, Mitchell and colleagues (2008) compared manual-based CBT that was delivered face-to-face or via telepsychology. They found that the two modes of delivery were equivalent in terms of acceptability to clients and retention of clients in treatment. However, they also found that rates of abstinence from binge eating and purging were slightly (non-significantly) higher for face-to-face CBT and that face-to-face CBT produced significantly greater reductions in eating-disordered cognitions.

Finally, compared to individuals with anorexia, those with bulimia are more distressed by their symptoms and tend to be more motivated to change their eating behaviors. The benefits of motivation – and, more specifically, autonomous motivation – on treatment outcomes for individuals with bulimia and other eating disorders has been confirmed by several studies. For example, Sansfacon, Gauvin, Fletcher, and Cottier (2018) compared the effects of autonomous (intrinsic) and controlled (extrinsic) motivation for reducing symptoms in adults who had received a diagnosis of bulimia nervosa, anorexia nervosa, or other specified feeding or eating disorder. They found that higher levels of autonomous motivation (but not controlled motivation) predicted a greater reduction in overall symptoms and a lower risk for dropping out of treatment.

4. Binge-Eating Disorder: The diagnosis of binge-eating disorder (BED) requires recurrent episodes of binge eating that involve eating an amount of food that is larger than what most people would eat during a similar period of time and in similar circumstances plus a sense of a lack of control over eating during episodes. For the diagnosis, the person must also (a) have at least three of five characteristics symptoms (eating more rapidly than usual; eating until uncomfortably full; eating large amounts when not feeling hungry; feeling alone due to embarrassment about one’s binge eating; feeling disgusted, depressed, or very guilty about one’s binge eating); and (b) have had episodes that occurred, on average, at least once a week for three months. Symptom severity (mild, moderate, severe, extreme) is determined by the number of episodes each week. BED is two to three times more common in women than in men and occurs in people who are normal weight, overweight, or obese. In contrast to people with bulimia nervosa, those with BED do not engage in recurrent inappropriate compensatory behaviors and usually have a better response to treatment. In addition, dieting often follows the onset of BED, while dysfunctional dieting often precedes bulimia nervosa. BED is associated with significant psychiatric comorbidity that is comparable to the comorbidity associated with bulimia nervosa and anorexia nervosa.

Cognitive-behavior therapy-enhanced (CBT-E) and interpersonal therapy (IPT) are evidence-based treatments for BED. However, while both treatments produce a significant reduction in binge eating, some studies have found CBT-E to be more effective (e.g., Fairburn et al., 2015). A number of studies have evaluated medications for treating BED, including SSRIs (fluoxetine, paroxetine, sertraline), the anti-seizure medication topiramate, and the CNS stimulant lisdexamfetamine. Most studies have found that medication alone is less effective than CBT and that combining CBT with medication is no more effective than CBT alone (e.g., Grilo, 2017). Note that experts generally recommend focusing on binge-eating before or concurrently with weight loss when treating individuals with BED who are overweight or obese (e.g., Frutchey & Carels, 2014).

Elimination Disorders: The elimination disorders include enuresis, which involves repeated voiding of urine into the bed or clothing, with urination either occurring two or more times a week for at least three consecutive months or causing significant distress or impaired functioning. Urination is always or usually involuntary and is not due to substance use or a medical condition. For the diagnosis, the person must be at least five years old or the equivalent developmental level. A specifier is used to identify the subtype as nocturnal only, diurnal only, or nocturnal and diurnal. The most common treatment for nocturnal enuresis is the moisture alarm (also known as the bell-and-pad), which causes a bell to ring when a child begins to urinate while sleeping. The antidiuretic hormone desmopressin used alone also reduces or stops bedwetting in many cases, but it’s associated with a high risk for relapse when it’s discontinued (Houts, 2010).

Sleep-Wake Disorders: The DSM-5 describes these disorders as involving “dissatisfaction regarding the quality, timing, and amount of sleep … [with] resulting daytime distress and impairment” (p. 361).

1. Insomnia Disorder: Insomnia disorder is characterized by dissatisfaction with sleep quality or quantity that’s associated with one or more of three symptoms: difficulty initiating sleep; difficulty maintaining sleep; early-morning awakening with an inability to return to sleep. For the diagnosis, the sleep disturbance must occur at least three nights a week, have been present for at least three months, occur despite sufficient opportunities for sleep, and cause significant distress or impaired functioning. There are three types of insomnia: sleep-onset (initial) insomnia that involves difficulty initially falling asleep, sleep maintenance (middle) insomnia that involves frequent or extended awakening during the night, and late insomnia that involves awakening in the early morning with an inability to return to sleep. Sleep maintenance insomnia is the most common single type, but the combination of the three types is most common overall. When retrospective subjective reports of people with this disorder about their sleep are compared to objective measures obtained during their sleep (e.g., polysomnography), subjective reports usually overestimate sleep latencies, overestimate time spent awake during the night, and underestimate total amount of sleep time.

The nonpharmacological treatment-of-choice for this disorder is a multi-component cognitive-behavioral intervention that incorporates stimulus control or sleep restriction with sleep-hygiene education, relaxation training, and/or cognitive therapy (Morin, Davidson, & Beaulieu-Bonneau, 2017). Stimulus control involves strengthening the bedroom and bed as cues for sleep (e.g., by going to bed only when tired and sleeping only in the bedroom), while sleep restriction involves restricting the time that’s allotted for sleep each night so that time spent in bed matches sleep requirements.

2. Narcolepsy: Narcolepsy involves attacks of an irrepressible need to sleep that causes sleep or daytime naps at least three times a week for three months or more. The diagnosis requires episodes of cataplexy (loss of muscle tone), hypocretin deficiency, or a rapid eye movement latency of 15 minutes or less as determined by nocturnal sleep polysomnography. Many people with narcolepsy have hypnagogic or hypnopompic hallucinations (vivid hallucinations just before falling asleep or just after awakening, respectively) and/or experience sleep paralysis when falling asleep or awakening. Cataplexy is often triggered by a strong emotion, so people with this disorder may attempt to control their emotions to prevent sleep episodes.

The treatment of narcolepsy involves a combination of behavioral strategies and medication. Behavioral strategies include establishing good sleep habits, taking daytime naps, and staying active. Medications are used to improve alertness and reduce cataplexy: Medications for alertness include modafinil and its newer form armodafinil, which increase dopamine levels, and amphetamines and other psychostimulants (e.g., methylphenidate), which increase dopamine levels and, to a lesser degree, serotonin and norepinephrine levels. The primary medication for cataplexy is an antidepressant (e.g., venlafaxine, fluoxetine, and clomipramine). In addition, sodium oxybate is useful 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 (National Sleep Foundation, 2018).

3. Non-Rapid Eye Movement Sleep Arousal Disorders: The non-rapid eye movement sleep arousal disorders include sleepwalking and sleep terrors, which involve recurrent episodes of incomplete awakening from sleep that usually occur during Stage 3 or 4 sleep in the first third of a major sleep period. Sleepwalking involves getting out of bed during sleep and walking about and may include sleep-related eating or sexual behavior, while episodes of sleep terror involve an abrupt arousal from sleep that usually starts with a panicky scream and is accompanied by intense fear and autonomic arousal (e.g., tachycardia, rapid breathing). The person is 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. Sleepwalking and sleep terrors occur most often in childhood and decrease in frequency with increasing age.
4. Nightmare Disorder: As described in the DSM-5, nightmare disorder involves “repeated occurrences of extended, extremely dysphoric, and well-remembered dreams that usually involve efforts to avoid threats to survival, security, or physical integrity” (p. 404). Nightmares usually occur during rapid eye movement (REM) sleep in the second half of a major sleep period. When awakened during a nightmare, the person is usually oriented and alert but may continue to experience a dysphoric mood.