Chapter 8
Eating and Sleep Disorders
Eating Disorders: An Overview
• Two Major Types of DSM-IV-TR Eating
Disorders
– Anorexia nervosa and bulimia nervosa
– Severe disruptions in eating behavior
– Extreme fear and apprehension about
gaining weight
– Strong sociocultural origins – Westernized
views
Eating Disorders: An Overview (continued)
• Other Subtypes of DSM-IV-TR Eating
Disorders
– Binge eating disorder
• Obesity – A Growing Epidemic
Bulimia Nervosa: Overview and Defining
Features
• Binge Eating – Hallmark of Bulimia
– Binge
• Eating excess amounts of food
– Eating is perceived as uncontrollable
Bulimia Nervosa: Overview and Defining
Features (continued)
• Compensatory Behaviors
– Purging
• Self-induced vomiting, diuretics,
laxatives
– Some exercise excessively, whereas
others fast
Bulimia Nervosa: Overview and Defining
Features (continued)
• DSM-IV-TR Subtypes of Bulimia
– Purging subtype – Most common subtype
– Nonpurging subtype – About one-third of
bulimics
Bulimia Nervosa: Associated Features
• Associated Medical Features
– Most are within 10% of target body weight
– Purging methods can result in severe
medical problems
• Erosion of dental enamel, electrolyte
imbalance
• Kidney failure, cardiac arrhythmia,
seizures, intestinal problems, permanent
colon damage
Bulimia Nervosa: Associated Features
(continued)
• Associated Psychological Features
– Most are over concerned with body shape
– Fear of gaining weight
– Most have comorbid psychological
disorders
Anorexia Nervosa: Overview and Defining
Features
• Successful Weight Loss – Hallmark of
Anorexia
– Defined as 15% below expected weight
– Intense fear of obesity and losing control
over eating
– Anorexics show a relentless pursuit of
thinness
– Often begins with dieting
Anorexia Nervosa: Overview and Defining
Features (continued)
• DSM-IV-TR Subtypes of Anorexia
– Restricting subtype – Limit caloric intake
via diet and fasting
– Binge-eating-purging subtype – About 50%
of anorexics
Anorexia Nervosa: Overview and Defining
Features (continued)
• Associated Features
– Most show marked disturbance in body
image
– Most are comorbid for other psychological
disorders
– Methods of weight loss have life
threatening consequences
Binge-Eating Disorder: Overview and
Defining Features
• Binge-Eating Disorder – Appendix of DSM-IVTR
– Experimental diagnostic category
– Engage in food binges without
compensatory behaviors
Binge-Eating Disorder: Overview and
Defining Features (continued)
• Associated Features
– Many persons with binge-eating disorder
are obese
– Concerns about shape and weight
– Often older than bulimics and anorexics
– More psychopathology vs. non-binging
obese people
Bulimia and Anorexia: Facts and Statistics
• Bulimia
– Majority are female
– Onset around 16 to 19 years of age
– Lifetime prevalence is about 1.1% for
females, 0.1% for males
– 6-8% of college women suffer from bulimia
– Tends to be chronic if left untreated
Bulimia and Anorexia: Facts and Statistics
(continued)
• Anorexia
– Majority are female and white
– From middle-to-upper middle class families
– Usually develops around age 13 or early
adolescence
– More chronic and resistant to treatment
than bulimia
• Both Bulimia and Anorexia Are Found in
Westernized Cultures
Causes of Bulimia and Anorexia: Toward an
Integrative Model
• Media and Cultural Considerations
– Being thin = Success, happiness....really?
– Cultural imperative for thinness
• Translates into dieting
Causes of Bulimia and Anorexia: Toward an
Integrative Model (continued)
– Standards of ideal body size
• Change as much as fashion
– Media standards of the ideal
• Are difficult to achieve
• Biological Considerations
– Can lead to neurobiological abnormalities
Causes of Bulimia and Anorexia: Toward an
Integrative Model
• Psychological and Behavioral Considerations
– Low sense of personal control and selfconfidence
– Perfectionistic attitudes
– Distorted body image
– Preoccupation with food
– Mood intolerance
• An Integrative Model
Fig. 8.4, p. 315
Medical and Psychological Treatment of
Bulimia Nervosa
• Medical and Drug Treatments
– Antidepressants
• Can help reduce binging and purging
behavior
• Are not efficacious in the long-term
Medical and Psychological Treatment of
Bulimia Nervosa (continued)
• Psychosocial Treatments
– Cognitive-behavior therapy (CBT)
• Is the treatment of choice
• Basic components of CBT
– Interpersonal psychotherapy
• Results in long-term gains similar to
CBT
Goals of Psychological Treatment of
Anorexia Nervosa
• General Goals and Strategies
– Weight restoration
• First and easiest goal to achieve
– Psychoeducation
Goals of Psychological Treatment of
Anorexia Nervosa (continued)
– Behavioral, and cognitive interventions
• Target food, weight, body image, thought
and emotion
– Treatment often involves the family
– Long-term prognosis for anorexia is poorer
than for bulimia
Medical and Psychological Treatment of
Binge Eating Disorder
• Medical Treatment
– Sibutramine (Meridia)
• Psychological Treatment
– CBT
• Similar to that used for bulimia
• Appears efficacious
Medical and Psychological Treatment of
Binge Eating Disorder (continued)
– Interpersonal psychotherapy
• Equally as effective as CBT
– Self-help techniques
• Also appear effective
Obesity: Background and Overview
• Not a formal DSM disorder
• Statistics
– In 2000, 20% of adults in the United States
were obese
– Mortality rates
• Are close to those associated with
smoking
Obesity: Background and Overview
(continued)
– Increasing more rapidly
• For teens and young children
– Obesity
• Is growing rapidly in developing nations
Obesity and Disordered Eating Patterns
• Obesity and Night Eating Syndrome
– Occurs in 7-15% of treatment seekers
– Occurs in 27% of individuals seeking
bariatric surgery
– Patients are wide awake and do not binge
eat
Obesity and Disordered Eating Patterns
(continued)
• Causes
– Obesity is related to technological
advancement
– Genetics account for about 30% of obesity
cases
– Biological and psychosocial factors
contribute as well
Obesity Treatment
• Treatment
– Moderate success with adults
– Greater success with children and
adolescents
• Treatment Progression -- From least-to-most
intrusive options
Obesity Treatment (continued)
• First step
– Self-directed weight loss programs
• Second step
– Commercial self-help programs
• Third step
– Behavior modification programs
• Last step
– Bariatric surgery
Sleep Disorders: An Overview
• Two Major Types of DSM-IV-TR Sleep
Disorders
– Dyssomnias
• Difficulties in amount, quality, or timing of
sleep
– Parasomnias
• Abnormal behavioral and physiological
events during sleep
Sleep Disorders: An Overview (continued)
• Assessment of Disordered Sleep:
Polysomnographic (PSG) Evaluation
– Electroencephalograph (EEG) – Brain
wave activity
– Electrooculograph (EOG) – Eye
movements
– Electromyography (EMG) – Muscle
movements
– Detailed history, assessment of sleep
hygiene and sleep efficiency
The Dyssomnias: Overview and Defining
Features of Insomnia
• Insomnia and Primary Insomnia
– One of the most common sleep disorders
– Problems initiating, maintaining, and/or
nonrestorative sleep
– Primary insomnia – Unrelated to any other
condition (rare!)
The Dyssomnias: Overview and Defining
Features of Insomnia (continued)
• Facts and Statistics
– Often associated with medical and/or
psychological conditions
– Affects females twice as often as males
• Associated Features
– Unrealistic expectations about sleep
– Believe lack of sleep will be more
disruptive than it usually is
The Dyssomnias: Overview and Defining
Features of Hypersomnia
• Hypersomnia and Primary Hypersomnia
– Sleeping too much or excessive sleep
– Experience excessive sleepiness as a
problem
– Primary hypersomnia – Unrelated to any
other condition (rare!)
The Dyssomnias: Overview and Defining
Features of Hypersomnia (continued)
• Facts and Statistics
– About 39% have a family history of
hypersomnia
– Often associated with medical and/or
psychological conditions
• Associated Features
– Complain of sleepiness throughout the day
– Able to sleep through the night
The Dyssomnias: Overview and Defining
Features of Narcolepsy
• Narcolepsy -- Daytime sleepiness and
cataplexy
– Cataplexic attacks
• REM sleep, precipitated by strong
emotion
The Dyssomnias: Overview and Defining
Features of Narcolepsy (continued)
• Facts and Statistics – Rare Condition
– Affects about .03% to .16% of the
population
– Equally distributed between males and
females
– Onset during adolescence
– Typically improves over time
The Dyssomnias: Overview and Defining
Features of Narcolepsy (continued)
• Associated Features
– Cataplexy, sleep paralysis, and hypnagogic
hallucinations
– Daytime sleepiness does not remit without
treatment
The Dyssomnias: Overview of BreathingRelated Sleep Disorders
• Breathing-Related Sleep Disorders
– Sleepiness during the day and/or disrupted
sleep at night
– Sleep apnea
• Restricted air flow and/or brief
cessations of breathing
The Dyssomnias: Overview of BreathingRelated Sleep Disorders (continued)
• Subtypes of Sleep Apnea
– Obstructive sleep apnea (OSA)
• Airflow stops, but respiratory system
works
– Central sleep apnea (CSA)
• Respiratory systems stops for brief
periods
– Mixed sleep apnea
• Combination of OSA and CSA
The Dyssomnias:
Facts and Features Associated With BreathingRelated Sleep Disorders
• Facts and Statistics
– Occurs in 1-2% of population
– More common in males
– Associated with obesity and increasing age
The Dyssomnias:
Facts and Features Associated With
Breathing-Related Sleep Disorders
(continued)
• Associated Features
– Persons are usually minimally aware of
apnea problem
– Often snore, sweat during sleep, wake
frequently
– May have morning headaches
– May experience episodes of falling asleep
during the day
Circadian Rhythm Sleep Disorders
• Circadian Rhythm Disorders
– Disturbed sleep (i.e., either insomnia or
excessive sleepiness)
– Due to brain’s inability to synchronize day
and night
Circadian Rhythm Sleep Disorders
(continued)
• Nature of Circadian Rhythms and Body’s
Biological Clock
– Circadian Rhythms – Do not follow a 24
hour clock
– Suprachiasmatic nucleus
• Brain’s biological clock, stimulates
melatonin
• Types of Circadian Rhythm Disorders
– Jet lag type
– Shift work type
Medical Treatments
• Insomnia
– Benzodiazepines and over-the-counter
sleep medications
– Prolonged use
• Can cause rebound insomnia,
dependence
– Best as short-term solution
Medical Treatments (continued)
• Hypersomnia and Narcolepsy
– Stimulants (i.e., Ritalin)
– Cataplexy
• Usually treated with antidepressants
Medical Treatments
• Breathing-Related Sleep Disorders
– May include medications, weight loss, or
mechanical devices
• Circadian Rhythm Sleep Disorders
Medical Treatments (continued)
• Phase delays
– Moving bedtime later (best approach)
• Phase advances
– Moving bedtime earlier (more difficult)
• Use of very bright light
– Trick the brain’s biological clock
Psychological Treatments
• Relaxation and Stress Reduction
– Reduces stress and assists with sleep
– Modify unrealistic expectations about sleep
• Stimulus Control Procedures
– Improved sleep hygiene – Bedroom is a
place for sleep
– For children – Setting a regular bedtime
routine
Psychological Treatments (continued)
• Combined Treatments
– Insomnia – Short-term medication plus
psychotherapy
– Other Dyssomnias
• Little evidence for the efficacy of
combined treatments
The Parasomnias: Nature and General
Overview
• Nature of Parasomnias
– The problem is not with sleep itself
– Problem is abnormal events during sleep,
or shortly after waking
The Parasomnias: Nature and General
Overview (continued)
• Two Classes of Parasomnias
– Those that occur during REM (i.e., dream)
sleep
– Those that occur during non-REM (i.e.,
non-dream) sleep
The Parasomnias: Overview of Nightmare
Disorder
• Nightmare Disorder
– Occurs during REM sleep
– Involves distressful and disturbing dreams
– Such dreams interfere with daily life
functioning and interrupt sleep
The Parasomnias: Overview of Nightmare
Disorder (continued)
• Facts and Associated Features
– Dreams often awaken the sleeper
– Problem is more common in children than
adults
• Treatment
– May involve antidepressants and/or
relaxation training
The Parasomnias: Overview of Sleep Terror
Disorder
• Sleep Terror Disorder
– Recurrent episodes of panic-like symptoms
during non-REM sleep
– Often noted by a piercing scream
The Parasomnias: Overview of Sleep Terror
Disorder (continued)
• Facts and Associated Features
– More common in children than adults
– Child cannot be easily awakened during
the episode
– Child has little memory of it the next day
The Parasomnias: Overview of Sleep Terror
Disorder (continued)
• Treatment -- A Wait-and-See Posture
– Scheduled awakenings prior to the sleep
terror
– Severe Cases
• Antidepressants (i.e., imipramine) or
benzodiazepines
The Parasomnias: Overview of Sleep
Walking Disorder
• Sleep Walking Disorder – Somnambulism
– Occurs during non-REM sleep
– Usually during first few hours of deep sleep
– Person must leave the bed
The Parasomnias: Overview of Sleep
Walking Disorder (continued)
• Facts and Associated Features
– Problem is more common in children than
adults
– Problem usually resolves on its own
without treatment
– Seems to run in families
The Parasomnias: Overview of Sleep
Walking Disorder (continued)
• Related Conditions
– Nocturnal eating syndrome – Person eats
while asleep
Summary of Eating and Sleep Disorders
• All Eating Disorders Share
– Gross deviations in eating behavior
– Fear or concern about weight, body size,
appearance
– Heavily influenced by social, cultural, and
psychological factors
Summary of Eating and Sleep Disorders
(continued)
• All Sleep Disorders Share
– Interference with normal process of sleep
– Interference results in problems during
waking
– Heaving influenced by psychological and
behavioral factors
• Incidence of Eating and Sleep Disorders Is
Increasing
• More Effective Treatments for Eating and
Sleep Disorders Are Needed