Chapter 8:Eating and Sleep-Wake Disorders sodium and potassium levels.

It can result in serious

BULIMIA NERVOSA medical
complications if unattended, including cardiac
arrhythmia (disrupted heartbeat), seizures, and renal
(kidney) failure, all of which can be fatal.
- Intestinal problems resulting from laxative abuse are
also potentially serious; they can include severe
constipation or permanent colon damage.
- Marked calluses on their fingers or the backs of their
hands caused by the friction of contact with the teeth
and throat when repeatedly sticking their fingers
down their throat to stimulate the gag reflex.

Associated Psychological Disorders

- Individual with bulimia usually presents with
additional
psychological disorders, particularly anxiety and mood
disorders
- One prominent theory suggested that eating
disorders are simply a way of expressing depression.
- Out-of-control eating episodes But most evidence indicates that depression follows
- Bulimia nervosa is eating a larger amount of food bulimia and may be a reaction to it
typically, more junk food than fruits and vegetables- - bulimia seems strongly related to anxiety disorders
than and somewhat less so to mood and substance use
most people would eat under similar circumstances disorders. Underlying traits of emotional instability
- Just as important as the amount of food eaten is that and novelty seeking in these individuals may account
the eating is experienced as out of control for these patterns of comorbidity.
- Individual attempts to compensate for the binge - People with bulimia are ashamed of both their
eating and potential weight gain, almost always by eating
purging techniques. issues and their lack of control
- Techniques include self-induced vomiting - Kumakain nang marami tapos sinusuka
immediately Treatment
after eating ,using laxatives (drugs that - Cognitive-Behavioral Therapy-Enhanced (CBT-
relieveconstipation) and diuretics (drugs that result in E):
loss of fluids through greatly increased frequency of Teaching the patient the physical consequences
urination). ofbinge
- Bulimia nervosa was subtyped in DSM-IV-TR into eating and purging, as well as the ineffectiveness of
purging type (for example, vomiting, laxatives, or vomiting and laxative abuse for weight control.
diuretics) or nonpurging type (for example, exercise - CBT-E focuses on altering dysfunctional thoughts and
and/or fasting). attitudes about body shape, weight, and eating.
- People with eating disorders have a distorted sense Coping
of self strategies for resisting the impulse to binge and/or
Medical Consequences purge are also developed, including arranging
- Salivary gland enlargement caused by repeated activities so that the individual will not spend time
vomiting, which gives the face a chubby appearance. alone after eating during the early stages of treatment
- Repeated vomiting also may erode the dental - Family therapy directed at the painful conflicts
enamel on the inner surface of the front teeth as well present in families with an adolescent who has an
as tear the esophagus. eating disorder can be helpful
- Electrolyte imbalance - continued vomiting may - Integrating family and interpersonal strategies into
upset the chemical balance of bodily fluids, including CBT is a promising new direction
 course of the disorder but rather may reflect a certain
ANOREXIA NERVOSA phase or stage of anorexia
- Individuals with anorexia are never satisfied with
their
weight-loss. Staying the same weight from one day to
the next or gaining any weight is likely to cause
intense panic, anxiety, and depression. Only
continued weight loss every day for weeks on end is
satisfactory.
- Marked disturbance in body image.
- They may agree they are underweight and need to
gain a few pounds- but they do not really believe it
themselves
- Individuals with anorexia seldom seek treatment on
their own
Medical Consequences
- Amenorrhea - One common medical complication
of
anorexia nervosa is cessation of menstruation which
also occurs relatively often in bulimia
- Dry skin, brittle hair or nails, and sensitivity to or
intolerance of cold temperatures.
- The person eats only minimal amounts of food or - Lanugo - downy hair on the limbs and cheeks.
exercises vigorously to offset food intake so body - Cardiovascular problems, such as chronically low
weight sometimes drops dangerously. blood
Anorexia nervosa (which literally means a "nervous pressure and heart rate, can also result
loss - If vomiting is part of the anorexia, electrolyte
of appetite" -an incorrect definition because appetite imbalance and resulting cardiac and kidney problems
often remains healthy can result, as in bulimia
- People with anorexia are so successful at losing
weight Associated Psychological Disorders
that they put their lives in considerable danger. - Anxiety disorders and mood disorders are often
- People with anorexia are proud of both their diets present in individuals with anorexia, with rates of
and depression occurring at some point during their lives
their extraordinary control. - One anxiety disorder that seems to co-occur often
Clinical Description with anorexia is obsessive-compulsive disorder
- Many individuals with bulimia have a history of - Unpleasant thoughts are focused on gaining weight,
anorexia; that is, they once used fasting to reduce and individuals engage in a variety of behaviors, some
their bodyweight below desirable levels of them ritualistic, to rid themselves of such thoughts.
- people with anorexia have an intense fear of obesity - Bipolar disorder, Substance abuse
and relentlessly pursue thinness - Strong predictor of mortality, particularly by suicide.
Two subtypes of anorexia nervosa. Treatment
- Restricting type: individuals diet to limit calorie - Initial goal is to restore the patient's weight to a
intake point
- Binge-eating-purging type: They rely on purging. that is at least within the low-normal range. severe
Binge medical complications, particularly acute cardiac
eating-purging anorexics binge on relatively small failure, could occur if weight is not restored
amounts of food and purge more consistently, in immediately
some cases each time they eat. - Weight gain is very important, since starvation
- Subtyping may not be useful in predicting the future induces
loss of gray matter and hormonal dysregulation in the - Often found in weight-control programs.
brain changes that are reversible when normal weight - Obese individuals in weight-loss programs engage in
is binge eating
restored. - individuals with BED try dieting before bingeing, and
- CBT was found to be significantly better than half start with bingeing and then attempt to diet
continued nutritional counseling in preventing relapse - Those who begin bingeing first become more
after weight restoration severely
- CBT, family-based treatment, psychodynamic- affected by BED and are more likely to have additional
oriented disorders
therapies, and treatment as usual - Individuals with BED have some of the same
- A family focused approach can often be beneficial for concerns
a about shape and weight as people with anorexia and
number of reasons bulimia, which distinguishes them from individuals
who are obese without BED
BINGE-EATING DISORDER - avoidant/restrictive food intake disorder (ARFID)-
People with this problem limit their food intake not
because they are concerned about weight or body
shape but because they are simply not interested in
eating or food or because they avoid certain sensory
characteristics or consequences of food or eating. This
can lead to impaired growth in children and to
significant weight loss in adults
Treatment
- Adapting CBT for bulimia to obese binge eaters
were
quite successful
- IPT is every bit as effective as CBT for binge eating.
- It is also important to emphasize again that if an
obese
person is bingeing, standard weight-loss procedures
will be ineffective without treatment directed at
bingeing.
OBESITY
- Obesity is not formally considered an eating disorder
in the DSM. It is included in this chapter because
eating is often used as a maladaptive emotion
regulation strategy, while also being associated with
great emotion distress and significant physical and
other mental health problems. lt is often produced by
- Individuals may binge repeatedly and find it
the consumption of a greater number of calories than
distressing, but they do not attempt to purge the
are expended in energy
food.
- Diabesity: Obesity is comorbid with diabetes
-Individuals who experience marked distress because
of
Disordered Eating Patterns in Cases of Obesity
binge eating but do not engage in extreme
- Two forms of maladaptive eating:
compensatory behaviors
- Binge Eating
- BED is now included as a full-fledged disorder in
- Night Eating Syndrome: Individuals with night
DSM-5
eating
- Greater likelihood of occurring in males and a later
syndrome consume a third or more of their daily
age of onset
intake
after their evening meal and get out of bed at least toddlers on diets in the hope of preventing obesity at
once a later date
during the night to have a high-calorie snack. In the - Mothers who have anorexia restrict food intake in
morning, however, they are not hungry and do not not
usually eat breakfast. These individuals do not binge only themselves but also their children, sometimes to
during their night eating and seldom purge. the detriment of their children's health
- Nocturnal Eating Syndrome: They also may eat - Repeated cycles of "dieting" seems to produce stress
uncooked or other dangerous foods while asleep. related withdrawal symptoms in the brain, much like
Treatment other addictive substances, resulting in more eating
- Self-directed weight-loss program in individuals than would have occurred without dieting.
who buy a popular diet book. The most usual result is - Reverse anorexia nervosa - Men with this syndrome
that some individuals may lose some weight in the reported they were extremely concerned about
short term but almost always regain that weight looking
- Most popular diet programs, such as the Atkins small, even though they were muscular.
(carbohydrate restriction), Ornish (fat restriction), -Many of these men avoided beaches, locker rooms,
Zone and other places where their bodies might be seen.
(macronutrients balance), and Weight Watchers -These men also were prone to using anabolic
(calorie androgenic steroids to bulk up, risking both the
restriction) diets. medical and the psychological consequences of taking
- The most successful programs are professionally steroids.
directed behavior modification programs. The - Strong genetic contribution to body size; that is,
combination of restricted calorie intake, increased some of us are born to be heavier than others, and we
physical activity, and behavior therapy tends to lead are all
to more weight loss than any of these components on shaped differently.
their own - Cultural standards are often experienced as peer
- Tthe FDA has only a few approved drugs approved pressure and are more influential than reason and
for this purpose, such as lorcaserin (Belviq) and fact.
phentermine /topiramate (Osymia). Dietary Restraint
- Bariatric Surgery: Surgical Approach to extreme - Dieting is one factor that can contribute to eating
obesity. This surgery is reserved only for the most disorders and, along with dissatisfaction with one's
severely obese individuals for whom the obesity is an body, is a primary risk factor for later eating disorders
imminent health risk because the surgery is Family Influences
permanent. - Possible significance of family interaction patterns in
cases of eating disorders.
CAUSES OF EATING DISORDERS - “Typical" family of someone with anorexia is
SOCIAL DIMENSIONS successful, hard-driving, concerned about external
- Being seen as thin is more important than being appearances, and eager to maintain harmony
healthy - Mothers of girls with disordered eating seemed to
- Self-worth, happiness, and success are largely act as "society's messengers" in wanting their
determined by body measurements and percentage daughters to be thin, at least initially
of body fat, factors that have little or no correlation
with personal happiness and success in the long run. BIOLOGICAL DIMENSIONS
- Conflict between reality and fashion seems most - Eating disorders run in families and thus seem to
closely related to the current epidemic of eating have a genetic component
disorders. - This biological vulnerability might then interact with
- "Failure to thrive" syndrome, in which growth and social
development are severely stunted because of and psychological factors to produce an eating
inadequate nutrition. In each case, the parents had disorder.
put their young, healthy, but somewhat chubby - Hypothalamus and the major neurotransmitter
systems including norepinephrine, dopamine, and,
particularly, serotonin-that pass through it to emotions as factors driving eating disorders
determine whether something is malfunctioning when SLEEP-WAKE DISORDERS: THE MAJOR
eating disorders occur DYSSOMNIAS
- Low levels of serotonergic activity, the system most - For many, sleep is energizing, both mentally and
often associated with eating disorders are associated physically. Unfortunately, most people do not get
with impulsivity generally and binge eating specifically enough sleep
- Strong associations between ovarian hormones and - Chronotype: Your chronotype (i.e., whether you are
dysregulated or impulsive eating in women prone to a
bingeeating episodes morning or evening type) is regulated by both your
- Emotional eating behavior (eating to relieve stress or circadian clock and genetic variations in the clock
anxiety) and binge-eating frequencies peaked in the genes
postovulatory phases of the menstrual cycle for all and the environment
women whether they binged or not during other - Social Jetlag: Switching your schedule because of
phases of their cycle. social factors is similar to changing time zones when
- reduced levels of leptin, a hormone acting in the you travel
hypothalamus to produce feelings of fullness (and - Sleep-wake disorders are divided into two major
therefore keep people from overeating) might be categories: dyssomnias and parasomnias
associated with excessive efforts to keep weight down - Dyssomnias: Involve difficulties in getting enough
and therefore lead to increases in the reinforcing sleep, problems with sleeping when you want to (not
value of food and possibly binge eating. being able to fall asleep until 2 a.m. when you have a
9 a.m. class), and complaints about the quality of
PSYCHOLOGICAL DIMENSIONS sleep, such as not feeling refreshed even though you
- Young women with eating disorders have a have slept the whole night
diminished - Parasomnias: characterized by abnormal behavioral
sense of personal control and confidence in their own or
abilities and talents physiological events that occur during sleep, such as
- Perfectionism is directed to distorted perception of nightmares and sleepwalking.
body image, a powerful engine to drive eating - Polysomnograph: an overnight electronic
disorder behavior is in place evaluation of sleep patterns.
- Women with eating disorders are intensely - Sleep efficiency (SE): the percentage of time
preoccupied with how they appear to others. actually
- They also perceive themselves as frauds, considering spent asleep, not just lying in bed trying to sleep. SE is
false any impressions they make of being adequate, calculated by dividing the amount of time sleeping by
self the amount of time in bed.
sufficient, or worthwhile. In this sense, they feel like
impostors in their social groups and experience INSOMNIA DISORDER
heightened levels of social anxiety
- Patients has difficulty tolerating any negative
emotion
(mood intolerance) and may binge or engage in other
behaviors, such as self-induced vomiting or intense
exercise, in an attempt to regulate their mood (reduce
their anxiety or distress by doing something they
think
will help them avoid being fat)
- Intense negative affect after overeating and seemed
threatened by food cues, which could lead to the
extreme food restriction or intense exercise
- Intense emotions triggered by food cues and fear of
becoming fat and faulty attempts to regulate these
 - Other sleep disorders, such as sleep apnea (a
disorder
that involves obstructed nighttime breathing) or
periodic limb movement disorder (excessive jerky leg
movements) can cause interrupted sleep and may
seem similar to insomnia
- People with insomnia may have unrealistic
expectations about how much sleep they need ("I
need a full 8 hours") and about how disruptive
disturbed sleep will be ("l won't be able to think or do
my job if I sleep for only 5 hours")
- It is important to recognize the role of cognition in
insomnia; our thoughts alone may disrupt our sleep.
- ls poor sleeping a learned behavior? It is generally
accepted that people suffering from sleep problems
associate the bedroom and bed with the frustration
and
anxiety that go with insomnia.
- Predisposing conditions : they may not, by
themselves, always cause problems, but they may
combine with other factors to interfere with sleep.
Example, a person may be a light sleeper (easily
aroused at night) or have a family history of insomnia,
narcolepsy, or obstructed breathing
- Sleep stress: Includes a number of events that can
negatively affect sleep. For example, poor bedtime
- Most common sleep- wake disorders habits (such as having too much alcohol or caffeine)
- After being awake for one or two nights, a person - Rebound insomnia: Where sleep problems
begins having microsleeps that last approximately 15 reappear,
seconds or shorter sometimes worse- may occur when the medication is
- Fatal familial insomnia (a degenerative brain withdrawn. This rebound leads people to think they
disorder), total lack of sleep eventually leads to death still
- People are considered to have insomnia if they have have a sleep problem, readminister the medicine, and
trouble falling asleep at night (difficulty initiating go through the cycle repeatedly. In other words,
sleep), if they wake up frequently or too early and taking sleep aids can perpetuate sleep problems.
can't go back to sleep (difficulty maintaining sleep), or - A person who hasn't had enough sleep can make up
even if they sleep a reasonable number of hours but for this loss by napping during the day. Unfortunately,
are still not rested the next day (nonrestorative sleep). naps that alleviate fatigue during the day can also
- Women report insomnia twice as often as men. disrupt sleep that night
Causes
- Insomnia accompanies many medical and HYPERSOMNOLENCE DISORDERS
psychological disorders, including pain and physical
discomfort, physical inactivity during the day, and
respiratory problems
- People with insomnia seem to have higher body
temperatures than good sleepers
- Other factors that can interfere with sleeping are
drug
use and a variety of environmental influences such as
changes in light, noise, or temperature.
 NARCOLEPSY

- Insomnia disorder involves not getting enough sleep

(the prefix in means "lacking" or "without"), and
hypersomnolence disorders involve sleeping too
much
(hyper means "in great amount" or "abnormal
excess")
- Many people who sleep all night find themselves - Disorder that affects the brain's ability to control
falling asleep several times the next day sleep
- People with hypersomnolence sleep through the wake cycles. People with narcolepsy may feel rested
night after waking, but then feel very sleepy throughout
(sometimes longer than is typical) but still complain of much of the day. Daytime Sleepiness
being excessively tired throughout the day - Cataplexy: a sudden loss of muscle tone. Cataplexy
- Sleep apnea: Breathing-related sleep disorder. occurs while the person is awake and can range from
People slight weakness in the facial muscles to complete
with this problem have difficulty breathing at night. physical collapse
They often snore loudly, pause between breaths, and - Cataplexy lasts from several seconds to several
wake in the morning with a dry mouth and headache. minutes; it is usually preceded by strong emotion such
as anger or happiness. Imagine that while arguing
with a friend, you collapse to the floor in a sound
sleep
- Two other characteristics of Narcolepsy:
Sleep paralysis: a brief period after awakening when
they can't move or speak that is often frightening to
those who go through it
Hypnagogic hallucinations: vivid and often terrifying
experiences that begin at the start of sleep and are
said to be unbelievably realistic because they include
not only visual aspects but also touch, hearing, and
even the
sensation of body movement. Examples of hypnagogic
hallucinationsinclude the vivid illusion of being caught
in a fire or flying through the air.
- Sleep paralysis and hypnagogic hallucinations may
serve a role in explaining a phenomenon- unidentified
flying object (UFO) or alien abduction experiences
- Isolated Sleep Paralysis: Sleep paralysis commonly
co
occurs with anxiety disorders
- It appears that there is a significant loss of a certain
type of nerve cell (hypocretin neurons) in those with
1. Obstructive Sleep Apnea Hypopnea Syndrome
narcolepsy.
- Occurs when airflow stops despite continued activity
by the respiratory system
BREATHING-RELATED SLEEP DISORDERS
- Reported snoring at night
- Sleepiness during the day or disrupted sleep at night
- Obstructive sleep apnea is most common in males.
has a physical origin problems with breathing while
2. Central Sleep Apnea
asleep
- involves the complete cessation of respiratory
- People whose breathing is interrupted during their
activity for brief periods and is often associated with
sleep often experience numerous brief arousals
certain central nervous system disorders, such as
throughout the night and do not feel rested even after
cerebral vascular disease, head trauma, and
8 or 9 hours asleep
degenerative disorders
- Hypoventilation: breathing is constricted a great
- Those with central sleep apnea wake up frequently
deal and may be labored
during the night, but they tend not to report excessive
- Sleep Apnea: There may be short periods (10 to 30
daytime sleepiness and often are not aware of having
seconds) when they stop breathing altogether
a serious breathing problem.
- Signs that a person has breathing difficulties are
3. Sleep-Related Hypoventilation
heavy
sweating during the night, morning headaches, and
episodes of falling asleep during the day (sleep
attacks)
with no resulting feeling of being rested

Three types of Apnea

- - Decrease in airflow without a complete pause in

breathing. This tends to cause an increase in carbon Jet lag type: Caused by rapidly crossing multiple time
dioxide (CO) levels because insufficient air is zones. People with jet lag usually report difficulty
exchanged going to sleep at the proper time and feeling fatigued
with the environment. during the day. Traveling more than two time zones
westward usually affects people the most. Traveling
CIRCADIAN RHYTHM SLEEP DISORDER eastward and/or less than three time zones are
usually tolerated better
Shift work type: sleep problems are associated with
work schedules
- Many people-such as hospital employees, police, or
emergency personnel-work at night or must work
irregular hours; as a result, they may have problems
sleeping or experience excessive sleepiness during
waking hours.
- Unfortunately, the problems of working (and thus
staying awake) at unusual times can go beyond sleep
and may contribute to cardiovasculardisease, ulcers,
and breast cancer in women
Delayed sleep phase type: Extreme night owls,
people who stay up late and sleep late. There is a later
than normal bedtime.
- The difficulty has to do with how our biological Advanced sleep phase type: people are "early to bed
clocks and early to rise:' Here, sleep is advanced or earlier
adjust to this change in time. than
- This disorder is characterized by disturbed sleep normal bedtime.
(either insomnia or excessive sleepiness during the Irregular sleep-wake type: people who experience
day) brought on by the brain's inability to synchronize highly varied sleep cycles)
its sleep patterns with the current patterns of day and Non-24-hour sleep wake type: for example, sleeping
night. on a 25- or 26-hour cycle with later and later bedtimes
- Circadian (from circa meaning "about" and dian ultimately going throughout the day
meaning "day"): Rhythms don't exactly match our - Hormone melatonin contributes to the setting of
24-hour day our
- Our biological clock is in the suprachiasmatic biological clocks that tell us when to sleep
nucleus in the hypothalamus. Connected to the - This hormone is produced by the pineal gland in the
suprachiasmatic center of the brain. Melatonin has been nicknamed
nucleus is a pathway that comes from our eyes the
- Some people have trouble sleeping when they want "Dracula hormone" because its production is
to stimulated by darkness and ceases in daylight.
because of problems with their circadian rhythms. The - When our eyes see that it is night time, this
causes may be outside the person (for information is passed on to the pineal gland, which, in
example,crossing turn, begins producing melatonin
several time zones in a short amount of time) or PARASOMNIAS AND THEIR TREATMENT
internal. - Parasomnias are not problems with sleep itself but
- Not being synchronized with the normal wake and abnormal events that occur either during sleep or
sleep cycles causes people's sleep to be interrupted during that twilight time between sleeping and waking
when they do try to sleep during the day.
Nightmares Disorder
Several Types Of Circadian Rhythm Sleep
Disorders: - Occur during REM or dream sleep
- Nightmares are defined as disturbing dreams that the event. This rare problem can cause relationship
awaken the sleeper; bad dreams are those that do not problems and, in extreme cases, legal problems when
awaken the person experiencing them cases occur without consent or with minors
- Nightmares are thought to be influenced by genetics,
trauma, and medication use and are associated with
some psychological disorders (such as substance
abuse, anxiety, borderline personality disorder, and
schizophrenia
spectrum disorders)
- treatment of nightmares suggests that both
psychological intervention (such as cognitive-
behavioral therapy) and pharmacological treatment
(such as prazosin) can help reduce these unpleasant
sleep events

Disorder of arousal
- Includes a number of motor movements and
behaviors
during NREM sleep such as sleepwalking, sleep
terrors, and incomplete awakening
- Sleep terrors: most commonly afflict children,
usually
begin with a piercing scream. The child is extremely
upset, often sweating, and frequently has a rapid
heartbeat. During sleep terrors, children can not be
easily awakened and comforted, as they can during a
nightmare. Children do not remember sleep terrors,
despite their often dramatic effect on the observer
Sleepwalking
- (also called somnambulism) occurs during NREM
sleep
- This means that when people walk in their sleep,
they are probably not acting out a dream. This
parasomnia typically occurs during the first few hours
while a person is in the deep stages of sleep.
- Sleepwalking occurs during the deepest stages of
sleep, waking someone during an episode is difficult; if
people are wakened, they typically will not remember
what has happened.
- Factors such as extreme fatigue, previous sleep
deprivation, the use of sedative or hypnotic drugs,
and
stress have been implicated
- Sleepwalking episodes have been associated with
violent behavior, including homicide and suicide
- Nocturnal eating syndrome: is when individuals rise
from their beds and eat while they are still asleep
- Sexsomnia; acting out sexual behaviors such as
masturbation and sexual intercourse with no memory
of