Eating and Sleeping Disorders
Eating Disorders
* 13.4% of girls and 7.1% of boys engage in disordered eating patterns.
* Paradox: As emphasis on thinness is increasing, so is the problem of obesity.
* 7 million women and 1 million men in the U.S. suffer from eating disorders.
* 15% of young women have “substantially disordered” eating attitudes and behaviors.
Factors Associated with Disordered Eating Patterns
* Being overweight
* Low self-esteem
* Depression
* Substance use
* Suicidal ideation
* More prevalent among females
* Least likely among African American females
Eating Disorders
Prevalence of Weight Concerns of Youth in Grades 5-12
Eating Disorders Anorexia Nervosa
* Anorexia Nervosa: Eating disorder characterized by:
o Refusal to maintain a body weight above the minimum normal weight for a person’s age and height.
o Intense fear of becoming obese that does not diminish with weight loss.
o Body image distortion
o In females, absence of at least 3 consecutive menstrual cycles otherwise expected to occur.
Anorexia Nervosa
* Subtypes:
o Restricting: Lose weight through dieting or exercising.
o Binge-Eating/Purging: Lose weight through use of self-induced vomiting, laxatives, or diuretics.
* Physical complications:
o Cardiac arrhythmia, low blood pressure, slow heart rate, weakened heart muscle
o Lethargy, dry skin, brittle hair, swollen parotid glands, hypothermia
o Males: Osteoporosis, substance use disorder, antisocial personality disorder
* Associated characteristics:
o Obsessive-compulsive behaviors and thoughts about food
* Associated characteristics:
o Personality disorders/characteristics:
+ Restricting: introversion, conformity, perfectionism, rigidity
+ Binge eating/purging: Extroverted, histrionic, emotionally volatile, impulse control problems, substance abuse
* Course and outcome: Highly variable
o Usually begins in adolescence
o Better outcome for binge-eating/purging
o More severe is associated with constricted/ overcontrolled profile
o ~ 44% recover completely, ~28% show some weight gain but remain underweight, poor outcome for ~ 24%
o Death: 5-20%, primarily from cardiac arrest or suicide
Eating Disorders Bulimia Nervosa
* Bulimia Nervosa: Eating disorder characterized by:
o Recurrent episodes of binge eating (rapid consumption of large quantities of food) at least twice a week for 3 months, during which the person loses control over eating and uses vomiting, laxatives, and excess exercise to control weight.
o More psychopathology than non-bulimics: Greater external locus of control, lower self-esteem and sense of personal effectiveness, negative self-image, although most are within normal weight range.
* More prevalent than anorexia
o Up to 3% of women suffer from bulimia, another 10% report some symptoms
o ~10% of bulimics are male
* Physical complications:
o Effects of vomiting: Erosion of tooth enamel, dehydration, swollen parotid glands, low potassium (can weaken heart and cause arrhythmia and cardiac arrest)
o Binge eating may cause stomach ruptures
o Gastrointestinal disturbances
* Related to:
o Coping responses to stress
o Mood disorders, especially seasonal affective disorder
o Also shares characteristics of borderline personality
* Course and outcome:
o Generally begins late adolescence/early adulthood
o Mixed, but better course than for anorexia
o Some bulimics continue to show disturbed eating patterns, low self-esteem, depressive disorder, but most recover either fully or partially.
o Poorer prognosis with associated history of substance use and longer duration before treatment.
Eating Disorders Binge-Eating Disorder (BED)
* Diagnostic category “provided for further study” in DSM-IV-TR:
o Binge Eating Disorder: Involves a large consumption of food over a short period of time at least twice weekly for 6 months
o Unlike bulimia, does not involve use of extreme behavioral attempts of vomiting, fasting, or excessive exercise as compensation for binge eating.
o Diagnosis: History of binge-eating episodes at least 2 days/week for 6 months
* Prevalence:
o Prevalence: 0.7-4% of population
o Females are 1.5 times as likely as males to have the disorder.
o Prevalent among white, African American, and American Indian women (possibly 10%), although white women are more likely to be seen for the disorder.
* Associated characteristics/risk factors:
o Overweight with history of weight fluctuation
o Prevalence: 2-5%
o Adverse childhood experiences, parental depression, vulnerability to obesity, repeated negative comments re weight and body
o Binges preceded by poor mood, low alertness, feelings of poor eating control, cravings for sweets.
o Complications: High blood pressure, high cholesterol, diabetes, and depression
* Comorbid features:
o Major depressive disorder
o Obsessive-compulsive personality disorder
o Avoidant personality disorder
* Course and outcome:
o Begins in late adolescence/early adulthood
o Positive course compared with other eating disorders: Most recover within 5 years
o Weight remains high (over time, ~1/3 meet criteria for obesity)
Eating Disorders Eating Disorder Not Otherwise Specified
* Eating Disorder Not Otherwise Specified: Eating disorders not meeting criteria for anorexia or bulimia nervosa:
o Individuals with binge-eating disorder
o Female who meets criteria for anorexia but has regular menses
o Individual who has lost significant weight but is in normal weight range
Eating Disorders Hyperphagia
* Hyperphagia: Excessive hunger and overly large amounts of food ingestion.
Eating Disorders Rumination
* Rumination: An eating disorder characterized by having the contents of the stomach drawn back up into the mouth, chewed for a second time, and swallowed again. This regurgitation appears effortless, may be preceded by a belching sensation, and typically does not involve retching or nausea. In rumination, the regurgitant does not taste sour or bitter. The behavior must exist for at least 1 month, with evidence of normal functioning prior to onset.
Eating Disorders Pica
* Pica: An appetite for non-foods (e.g., coal, soil, chalk, paper etc.) or an abnormal appetite for some things that may be considered foods, such as food ingredients (e.g., flour, raw potato, starch). In order for these actions to be considered pica, they must persist for more than one month, at an age where eating dirt, clay, etc., is considered developmentally inappropriate.
* Geophagia: Eating of dirt or clay.
Do You Have an Eating Disorder?
Overview of Major Risk Factors for Eating Disorders
Hunger and Satiety
* Ig Nobel awards celebrate the sillier side of science
* The Ig Nobel for nutrition went to a concept that sounds like a restaurant marketing ploy: a bottomless bowl of soup.
* Cornell University professor Brian Wansink used bowls rigged with tubes that slowly and imperceptibly refilled them with creamy tomato soup to see if test subjects ate more than they would with a regular bowl.
* "We found that people eating from the refillable soup bowls ended up eating 73 percent more soup, but they never rated themselves as any more full," said Wansink, a professor of consumer behavior and applied economics. "They thought 'How can I be full when the bowl has so much left in it?' "
* His conclusion: "We as Americans judge satiety with our eyes, not with our stomachs.“
* CNN.Com 10-7-07
* Societal influences:
o Mass media portray ideal female body as 5’7” 110 lbs; actual average is 5’4” 162 lbs
o Sociocultural demand for thinness
o Peer influences
o Criticisms by family members about weight
o Dating
* Body dissatisfaction:
o Males see their bodies as smaller than what they believe is preferred; females see their bodies as larger than what they believe is preferred
o Most dissatisfaction parallels low self-esteem
* Certain predisposition and characteristics lead some people to interpret images of thinness as evidence of their own inadequacy.
* Exposure to ultra-thin ideal by media can lead to:
o Internalization of that image and eating patterns intended to bring about that ideal
o Negative affect, which triggers dieting
o Social comparison, which leads to disordered eating to meet external standards of comparison.
* Top figure
o Body image ratings of women who score high on measure of distorted eating behaviors.
* Bottom Figure
o Body image ratings of women who score low on measure of distorted eating behaviors.
Route to Eating Disorders Eating Disorders
Etiology
* Family and peer influences
o Psychodynamic (for anorexia):
+ Fear of maturation:
# Growing up and separating from family
# Developing own identity
# Fulfills unconscious desire to remain a child
o Family systems: Problematic family communication patterns result in anorexia
o Socialization agents (peers and family)
o Relationship problems and role models
Eating Disorders
Etiology
* Cultural factors:
o Culture-bound (Western cultures) and other societies influenced by Western culture.
o Many African Americans seem insulated from thinness standard, but equally as likely to have binge-eating disorder.
o Internalization of U.S. societal values regarding attractiveness affects self-esteem and body dissatisfaction.
Differences in Body Image and Weight Concerns Among African American and White Females
Eating Disorders Other Etiological Factors
* Personality characteristics and negative emotional moods
* Sexual abuse
* Low self-esteem and feelings of helplessness
* Passivity, dependence, nonassertivness
* Anorexia: Perfectionism, obedience, academic and athletic success, model children
* Bulimia: Perfectionism, seasonal affective disorder
* Genetic factors: First-degree relatives
Eating Disorders Treatment
* Prevention programs:
o Goals of school-based intervention program:
+ Develop positive attitude toward one’s body
+ Become aware of societal messages re being female
+ Develop healthier eating/exercise habits
+ Increase comfort in expressing feelings
+ Develop healthy strategies to deal with stress
+ Increase assertiveness skills
o Teach females to examine consequences of gender messages
o Institutional awareness of the problem is critical
* Anorexia nervosa:
o Inpatient/outpatient depends on weight and health of individual
o Initial goal: Restore weight with psychological support
+ Nutritional/physical rehabilitation
+ Identify/understand dysfunctional attitudes
+ Improve interpersonal/social functioning
+ Address comorbid psychopathology/psychological conflicts
* Anorexia nervosa:
o Family therapy: Parents involved in meal planning, reduce criticism (understanding seriousness of anorexia), negotiate new relationship patterns, move toward separation and individuation.
* Bulimia nervosa:
o Identify conditions contributing to purging
o Identify physical conditions resulting from purging
o Normalize eating pattern and eliminate binge-purge cycle
* Bulimia nervosa:
o Cognitive-behavioral therapy and use of antidepressants:
+ Encourage eating 3 or more balanced meals a day
+ Reduce rigid food rules and body image concerns
+ Develop cognitive and behavioral strategies
* Binge-Eating Disorder
o Similar to treatments for bulimia with fewer physical complications
o Because most are overweight, therapy programs try to help individual lose weight
o Three phases:
+ Determine underlying cognitive factors
+ Use cognitive strategies to change distorted beliefs about eating
+ Relapse prevention strategies
Primary Sleep Disorders
* Most adults require 8 hours of sleep to function optimally.
* Insufficient sleep results in lapses in attention, vigilance, and deterioration of performance.
* Five stages of sleep:
o Stage 1 (5%): Transition from wakefulness to sleep
o Stage 2 sleep (50%)
o Stages 3-4 (10-20%): Deepest level
o Rapid eye movement (REM-20-25%): Dream sleep
Primary Sleep Disorders Dyssomnias
* Most problems are either inability to initiate or maintain sleep at night or excessive daytime sleepiness.
* Dyssomnias: Difficulties in getting to sleep, maintaining sleep, or complaints of excessive sleepiness during the day.
Primary Sleep Disorders Primary Insomnia
* Primary Insomnia: Characterized by difficulty getting to sleep, maintaining sleep, or having nonrestorative sleep for at least one month, causing clinically significant distress in social, occupational, or other areas of functioning.
o Causative factors: caffeine, alcohol, heavy meals, exercising 2 hours before bedtime, stress, intrusive/ uncontrollable cognitive activity, altered sleep habits
o Highest rate: 52% of older adults
* Many people with primary insomnia have undiagnosed sleep Apnea or Restless Leg Syndrome.
* RLS (which is also sometimes referred to as Jimmy Legs, spare legs or "the kicks") may be described as uncontrollable urges to move the limbs in order to stop uncomfortable, painful or odd sensations in the body, most commonly in the legs. Moving the affected body part eliminates the sensation, providing temporary relief. The sensations and need to move may return immediately after ceasing movement, or at a later time. RLS may start at any age, including early childhood, and is a progressive disease for a certain percentage of sufferers, although it has been known for the symptoms to disappear permanently in some sufferers.
Primary Sleep Disorders Primary Hypersomnia
* Primary Hypersomnia: Characterized by excessive daytime sleepiness or prolonged nighttime sleep for at least one month, causing significant distress or impairment in social, occupational, or other important areas of functioning.
o Compelling need to nap during the day that provides no relief from sleepiness.
o Results in problems with driving, work performance, or social functioning.
Primary Sleep Disorders Narcolepsy
* Narcolepsy: Characterized by overwhelming need for daytime sleep even when adequate sleep occurs at night; daily for at least 3 months, together with at least 2 of the following:
o Irresistible drowsiness/falling asleep without warning
o Cataplexy
o Sleep paralysis during wakefulness
o Hypnogogic hallucinations before falling asleep
Primary Sleep Disorders Breathing-Related Sleep Disorder
* Breathing-Related Sleep Disorder: Excessive sleepiness caused by sleep disruption through abnormalities of breathing during sleep
o Obstructive Sleep Apnea: Upper-airway obstruction during sleep
+ Undiagnosed in ~75% of treatable cases
+ Disruptive snoring, breathing pauses, gasping, excessive daytime sleepiness
+ Obstruction of airway prevents breathing during sleep
o Central sleep apnea syndrome
o Central alveolar hypoventilation syndrome
Primary Sleep Disorders Circadian Rhythm Sleep Disorder
* Circadian Rhythm Sleep Disorder: Pattern of recurrent sleep disruption caused by disruption of the biological sleep-wake cycle or mismatch between internal “clock” for sleeping and waking and environmental demands.
o Jet lag, shift work
o Associated with major disasters (e.g., Exxon Valdez oil spill)
Primary Sleep Disorders Dyssomnias Not Otherwise Specified
* Dyssomnias Not Otherwise Specified: Do not meet criteria for specific dyssomnia, but produce significant impairment:
o Insomnia caused by environmental factors
o Excessive sleepiness caused by sleep deprivation
o Restless leg syndrome
o Periodic limb movement disorder
Primary Sleep Disorders Parasomnias
* Parasomnias: Activation of physiological systems at inappropriate times during the sleep-wake cycle.
* Generally involve activation of the autonomic nervous system, including cognitive processes during sleep or sleep-wake transitions.
Primary Sleep Disorders Parasomnias
* Nightmare disorder: Nightmares several times/week during REM sleep.
o 3% of preschoolers and school-aged children
* Sleep Terror Disorder: Vivid nightmares during first third of deep sleep (non-REM); child screams with terror, is not fully aroused, and does not remember what happened.
o ~6% of children, disappears in adolescence
o In adults age 20-30 it has a chronic course
* Sleepwalking Disorder: Motor activity ranging from sitting up to getting out of bed and walking about while still asleep.
o ~2% of school-aged children sleepwalk at least a few nights a week
o Up to 30% of children sleepwalk at least once
o 1-5% of children have sleepwalking disorder
o Tends to disappear in adolescence; in adults it will have a chronic waxing/waning course.
* Parasomnias Not Otherwise Specified:
o REM sleep behavior disorder: Violent motor behavior during REM sleep
o Sleep paralysis/inability to move during transition from wakefulness and sleep
Primary Sleep Disorders Etiology and Treatment of Dyssomnias
* Etiology: Subclinical anxiety and depression, environmental changes, health and behavioral habits; for some etiology is unknown but may include:
o Cognitions or intrusive, uncontrollable thoughts
o Personality and psychological adjustment problems
o Lifestyle factors
o Nocturnal activities that interfere with sleep
* Treatment for specific disorders:
o Excessive sleepiness (narcolepsy or hypersomnia): Stimulants, though more success with hypersomnia than narcolepsy.
o Insomnia: Sleep pills, which tend to become ineffective over the long-term.
o Sleep apnea: Avoid medications, alcohol and other substances; lose weight if overweight; sleep on side rather than back; pressure mask during sleep may also help with moderate and severe apnea.
* Treatment for RLS and PLMD: Behavioral treatment, medications for RLS
* Treatment for sleep disorders generally:
o Relaxation/focusing procedures
o Changing mental state prior to bedtime
o Slow deep breaths
o Eliminate distractions
o Avoid daytime naps, caffeine late in day, heavy meals/exercise/alcohol/nicotine 2 hours before bedtime.
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