Sleep Disorders & Eating Disorders

Question 1

Define the term “eating disorder”

Answer 1

a mental disorder defined by abnormal eating habits that negatively affect a person’s physical and/or mental health

Question 2

1. In which gender is anorexia nervosa more common?
2. What is the average age of onset of anorexia nervosa?
3. Name some values which the onset of anorexia nervosa is thought to be related to

Answer 2

1. female (10:1)
2. 15-16; onset is rare over 30
3. westernised values of individualism and the idealisation of thinness and beauty

Question 3

1. Describe some precipitating factors for anorexia nervosa
2. Name some predisposing factors for anorexia nervosa
3. Name some perpetuating factors for anorexia nervosa

Answer 3

1. life stressors - exams; changing schools; family problems
2. family hx of mood/eating disorder or substance abuse
   poor self esteem; extreme perfectionism
   premorbid anxiety and depressive disorder
   childhood abuse
   personality disorder
   occupational/recreational pressure to be thin
   family environment characterised by overprotection, rigidity and lack of conflict resolution
   criticism about weight or feeding behaviours
3. starvation leads to neuroendocrine disturbances which perpetuate anorexia

Question 4

1. What is believed to be involved in not eating in the initial phases of anorexia?
2. How is abstinence from eating maintained in later stages of the disease?

Answer 4

1. altered reward processing is thought to play a role in the heightened saliency of not eating by modulating emotional distress
2. non-eating as a method of modulating emotional distress becomes habitual and thus refractory to change
   anorexia becomes part of the individual’s identity; change in values regarding life and death

Question 5

1. Name the 5 clinical features within the ICD-10 classification of anorexia nervosa
2. name some other clinical features of anorexia nervosa

Answer 5

1. • body weight <15% below standard weight/BMI <17.5
   • self induced weight loss
   • distortion of body image
   • morbid fear of fatness
   • amenorrhoea in women
2. previous hx of faddish eating
   patient eats little yet is obsessed by food
   excessive exercose
   reluctant to seek medical help; frequently deny there is a problem
   sometimes irritable and hostile

Question 6

Name some physical conseuqnces of anorexia nervosa affecting the following systems:

1. metabolic
2. endocrine
3. cardiovascular
4. gastrointestinal
5. renal
6. haematological
7. musculoskeletal

Answer 6

1. dehydration; hypoglycaemia; vitamin deficiencies; hypokalaemia
2. decreased gonadotrophins, oestrogen and testosterone
   increased GH and cortisol
3. arrythmias; hypotension, bradycardia, heart failure
4. constipation; peptic ulceration; acute pancreatitis
5. renal calculi; renal failure
6. iron deficiency anaemia; leucopenia; thrombocytopenia
7. osteoporosis; muscle cramps

Question 7

What examinations/measurements are important to carry out in the rapid risk assessment of anorexia nervosa? (5)

Answer 7

1. BMI
2. BP (lying and standing)
3. pulse
4. muscle strength
5. full physical examination for signs of infection and nutritional deficiency

Question 8

What psychological therapies are useful in the management of anorexia nervosa:

1. in patients under 18
2. in patients over 18

Answer 8

1. anorexia nervosa focussed family therapy
   CBD/adolescent focussed psychotherapy
2. CBD-EDT
   ED focussed psychodynamic therapy
   Maudsley anorexia nervosa treatment for adults

Question 9

When is hospital admission indicated in patients with anorexia nervosa?

Answer 9

• sever weight loss

- accompanied by marked cardiovascular and/or electrolyte and vitamin disturbances

Question 10

Why is compulsory admission for anorexia nervosa controversial? (2)

Answer 10

• patients cognitive ability may otherwise be fully intact therefore deemed to have capacity
• may undermine the therapeutic relationship and further alienate the patient

Question 11

1. Which guidelines govern the management of severely unwell patients with anorexia nervosa?
2. What are the general recommendations of these guidelines?

Answer 11

1. MARSIPAN guidelines (management of really sick patients with anorexia nervosa)
2. Most adults with severe anorexia nervosa should be treated on specialist eating disorders units
   Adult patients with anorexia nervosa being admitted to hospital are high risk - underfeeding and refeeding syndromes; behavioural problems

Question 12

1. Describe the prognosis of anorexia nervosa

2. Name factors associated with poor outcomes of anorexia nervosa (7)

Answer 12

1. 50% make a complete recovery
   20% experience chronic, severe illness
   30% make a partial recovery but retain abnormal eating habits and sometimes become bullimic
2. • long initial illness
   • severe weight loss
   • older age at onset
   • bullimic behaviour
   • personal difficulties
   • difficulties in relationships
   • male gender

Question 13

1. What is bullimia nervosa?

2. How does bullimia differ from binge-purge anorexia?

Answer 13

1. eating disorder characterised by episodes of uncontrolled, excessive eating (binges) accompanied by behaviours to avoid the fattening effects of periodic binges
2. patients with bullimia tend to be of normal/higher than normal body weight, and do not have the characteristic long term weight suppression of those with anorexia

Question 14

Name the DSM-IV diagnostic criteria for bulimia nervosa (4)

Answer 14

• recurrent episodes of binge eating
• recurrent inappropriate compensatory behaviour to prevent weight gain
• episodes of binge eating and compensatory behaviour at least twice a week for 3 months
• self evaluation is unduly influenced by body shape and weight

Question 15

Describe features of the 2 types of bulimia nervosa:

1. purge type
2. non-purge type

Answer 15

1. regular engagement in self induced vomiting/use of laxatives etc.
2. regular engagement in compensatory behaviours such as fasting and regular exercise but no engagement in self induced vomiting/use of laxatives etc.

Question 16

Name complications of bulimia nervosa

Answer 16

• dehydration, electrolyte abnormalities, arrythmias and renal failure secondary to purging behaviours
• dental erosion, parotid gland enlargement, oesophageal inflammation and aspiration pneumonia
• russell sign - callosities, scarring and abrasions on the dorsal surface of the index and ling finger that form as a result of repeated self induced vomiting
• drug side effects and overdose

Question 17

How is bulimia nervosa managed:

1. psychologically
2. pharmacologically

Answer 17

1. individual CBT

2. SSRIs (usually higher doses required)

Question 18

1. What is sleep?

2. Describe the 4 stages of sleep

Answer 18

1. a readily reversible state of reduced responsiveness to, and interaction with the environment
2. N1 - light sleep
   N2 - muscle activity decreases and conscious awareness of the external environment disappears
   N3 - slow delta waves
   R - rem sleep; atonia, beta waves and increased parasympathric activity

Question 19

What is important to ask about when a patient presents with disturbed sleep?

Answer 19

• usual daily routine - waking time, daily activities, daily naps, bedtime routine
• description of sleep - episodes of waking, quality and satisfaction with sleep, dreams/nightmares
• daytime somnolence
• other medical/psych conditions and medication
• family hx
• drug and alcohol hx

Question 20

What is meant by:

1. primary sleep disorder
2. secondary sleep disorder

Answer 20

1. a sleep disorder not attributable to another medical or psychiatric disorder
2. sleep disorders related to other medical psychiatric disorder

Question 21

1. What is the definition of insomnia?

2. Name 2 groups of people in which insomnia is more common?

Answer 21

1. Persistent difficulty (3 days/week for at least 1 month) in initiating or maintaining sleep (that causes significant distress or daytime effects)
2. women and the elderly

Question 22

describe sleep hygiene advice which is given in the management of insomnia

Answer 22

• have a strict routine involving regular and adequate sleep times
• have a relaxing bedtime routine that allows you to relax before bedtime
• avoid caffeine containing drinsk after 4pm; refrain from smoking at least 1 hour before bed
• avoid other activities while in bed
• If sleep does not occur, get up and go to another room, without turning lights on, returning to bed only when sleepy
• Regular exercise
• Eat an adequate evening meal (but not too late)

Question 23

1. What is hypersomnia?
2. What are the 2 sub classifications of hypersomnia?
3. What scale is used to diagnosed hypersomnia?

Answer 23

1. excessive daytime sleepiness, sleep attacks or sleep drunkness
2. narcolepsy and hypersomnolence disorder
3. epworth sleepiness scale

Question 24

1. What is hypersomnolence disorder?

2. At what age does this disorder particularly start?

Answer 24

1. patients experience significant episodes of sleepiness, even after having ≥7 hours of quality sleep
2. adolescence/young adulthood

Question 25

1. What are the tetrad of symptoms of narcolepsy?

2. When is the peak onset?

Answer 25

1. excessive sleepiness
   cataplexy
   sleep paralysis
   hypnagogic hallucinations
2. adolescence/young adulthood

Question 26

Describe the following sleep disorders

1. delayed sleep-wake phase disorder
2. advanced sleep-wake phase disorder
3. irregular sleep-wake rhythm disorder

Answer 26

1. late appearance of sleep, with no difficulty maintaining sleep. common in adolescents and young adults and does not tend to present to medical attention
2. complaints of early sleep onset and early morning waking
3. sleep occurrence and waking behaviour are very variable, leading to considerable disturbance of normal sleep-wake cycle and complaints of insomnia; most commonly occurs secondary to other conditions such as neurodegenerative disorders, head injury, neurodevelopment disorders and hypothalamic tumours

Question 27

1. What are parasomnias?
2. Name the 3 N-REM related parasomnias
3. Name the 2 REM related parasomnias

Answer 27

1. undesirable physical and/or experimental phenomena accompanying sleep
2. sleep waking; sleep terrors; sleep related eating disorder
3. sleep paralysis; nightmare disorder