Chapter 8 - Bulimia Nervosa and Eating Disorders

• Test 2 is scheduled for Tuesday, March 18th.

• 65 multiple choice questions cover the material from February 11, Chapter 4 from the section on suicide to the end of Chapter 8 (feeding and sleep-wake disorders).

• Feeding & eating disorders, specifically anorexia, are being discussed

• Isabella Caro is mentioned in reference to anorexia

DSM 5 Criteria: Anorexia Nervosa

• Restriction of energy intake relative to requirements, leading to significantly low body weight in the context of age, sex, developmental trajectory and physical health are diagnostic criteria
• Significantly low weight is defined as a weight that is less than minimally normal, or for children and adolescents, less than minimally expected in the DSM 5 criteria
• Experiencing an intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain, even in a significantly low weight state should be considered
• Disturbance in experiencing one’s own body weight or shape with undue influence on self-evaluation is a sign of anorexia
• Be aware of any lack of recognition of the seriousness of current low body weight in people at risk

Subtypes of Anorexia Nervosa

• Anorexia Nervosa has two distinct subtypes: restrictive and binge-eating/purging
• Restrictive type is characterized by persistent and severe calorie restriction, fasting and/or excessive exercise
• Binge-eating/purging is characterized by regularly binging (eating large quantities of food) and purging behaviors (vomiting, laxatives, diuretics and/or excessive exercise; inappropriate compensatory behavior)
• In binge-eating/purging type, the main way of controlling weight is still through severely restricting calories
• Atypical Anorexia Nervosa meets the criteria for anorexia nervosa; however, weight is normal or above normal
• As many as 30% of the patients presenting with an eating disorder are Atypical Anorexia Nervosa

Anorexia Nervosa

• Preoccupation with food is often seen
• Sufferers may also experience depression, anxiety, sleep problems and/or self-harm

Medical complications of anorexia

• Medical complications may include low blood pressure (BP), heart rate and/or core body temperature as the person’s body begins to starve
• Accompanying signs of starvation may include dry skin and hair, brittle nails, lanugo (fine hair growth)
• Decreased estrogen, amenorrhea, osteoporosis and infertility are indicative
• Misuse of diuretics, vomiting or laxatives results in electrolyte imbalance and cardiovascular problems
• Cognitive impairment may present as reduction of brain mass and/or ventricles getting larger
• There is a high death rate overall which may be attributed to suicide and cardiovascular problems

Prognosis

• With longer duration of the disorder (5 years or more), treatment becomes lengthier and less successful which then lowers overall recovery rate
• Complete recovery rates depend on how early Anorexia Nervosa is diagnosed and addressed as this improves treatment outcomes

Bulimia Nervosa

• Bulimia Nervosa is characterized by a repeating cycle of binging and purging
• Binging is defined as eating an excessive amount of food in a short amount of time
• During binging, people tend to eat “forbidden foods” that are soft in texture
• Compulsive eating is often done alone and in secret as a “binge mode"
• Purging includes self-induced vomiting, misusing laxatives, diuretics, enemas, periods of fasting and/or excessive exercise
• Effectiveness of purging is dependent on the amount of food consumed, the duration of the binge and/or method of purging with estimated removal rates between 10-50%
• Binging is often triggered by feelings of being overwhelmed, to avoid feelings of anger, depression and/or anxiety
• A sense of having no control over eating, i.e., uncontrolled eating makes it difficult to stop
• Recurrent, inappropriate compensatory behaviors to prevent weight gain that occur at least once a week over a 3 month period
• Self-evaluation is unduly influenced by weight and/or body shape
• Severity is rated as mild, moderate, severe and/or extreme depending on the inappropriate compensatory behavior

Medical Complications of Bulimia

• Can occur through purging such as self-induced vomiting and/or the use of diuretics or laxatives
• Tooth decay and/or dental cavities may occur with chronic self-induced vomiting
• Damage to the esophagus, reversal in peristalsis and/or blockage of salivary ducts are related complications
• Other potential complications are pancreatitis, kidney damage and/or potassium deficiency
• Chronic laxative use can damage the nerves in the colon

Sleep Disorders

• Having sleep difficulties, provide your doctor/specialist with specific information.
• Diagnosing a sleep disorder involves questionnaires like a sleep diary, duration of the problem, family members diagnosed with sleep problems or the Epworth Sleepiness Scale.
• Diagnosing a sleep disorder involves Actigraphy.
• Sleep lab polysomnography examines electroencephalography (EEG), electromyography (EMG), and electrooculography (EOG).
• EEG, EMG, and EOG determine two distinct sleep states: NREM (N1, N2, N3) and REM (tonic and phasic).
• NREM and REM alternate with a cycle of about 90 minutes, indicative of an endogenous oscillator.
• Multiple Sleep Latency Test (MSLT) and Maintenance of Wakefulness Test (MWT) can be used to assess sleep.

Sleep Disorders Types:

• Dyssomnias are disorders of getting to sleep, staying asleep, or excessive sleepiness - insomnia, hypersomnolence, and narcolepsy
• Parasomnias are disorders that intrude into or occur during sleep - REM sleep behavior disorder, night terrors, and nightmares.
• Circadian rhythms disorders include ASPS, DSPS, and CR sleep-wake disorder.
• Breathing-related sleep disorders include obstructive sleep apnea.
• Insomnia, sleep-disordered breathing, and restless leg syndrome are the most prevalent disorders.

Sleep Disorders: Insomnia

• About 1/3 of adults report occasional insomnia and approximately 10% report chronic insomnia
• Insomnia is higher among the elderly, shift workers, those who have suffered a loss, and among lower SES; also higher among women, substance and alcohol users, underlying disorders (pain, medical, or psychological conditions).
• Cultural differences occur in prevalence rates and definition of insomnia.
• Categories of insomnia include acute (aka transient, lasting up to 4 weeks) and chronic (aka primary; > 4 weeks).

Sleep Disorders - DSM 5 Criteria for Insomnia:

• A predominant complaint of dissatisfaction with sleep quality or quantity.
• This can manifest as difficulty falling asleep (sleep-onset), maintaining sleep (sleep maintenance insomnia), or waking early with an inability to fall back to sleep
• Difficulty falling asleep can also be an inability to sleep even when presented with an adequate opportunity to sleep.
• Sleep disturbance occurs at least 3 times per week, for a minimum of 3 months.
• Causes significant distress or impairment in social, occupational, educational, academic, behavioral, or other important areas of functioning.
• Insomnia cannot be explained by another sleep disorder, substance use, or another medical or psychiatric condition.
• Coexisting mental disorders or medication conditions should not adequately explain the insomnia.

Sleep Disorders - Consequences of Insomnia:

• Includes fatigue, malaise, low energy/motivation, cognitive and memory impairment, difficulty concentrating and remembering.
• Diminished quality of life, increased likelihood of accidents, and increased risk of developing psychological disorders; headaches, GI problems, chronic pain, hypertension, type 2 diabetes, decreased immune function, etc.
• Sleep-onset insomnia can be secondary to circadian disorder misalignment of the sleep-wake cycle and temperature cycle (delayed).

Sleep Disorders - Insomnia Treatment

• Treatment identifies factors that precipitate or perpetuate the insomnia.
• Insomnia often begins with transient insomnia, which then continues.
• Diagnosis is usually based on a patients subjective reporting.
• Medication or Referral to a specialist

Sleep Disorders - Insomnia Medications:

• Most sleep medications act on the GABA-benzodiazepine receptor and increase the action of GABA.
• Action of GABA causes increased sedation, sleepiness, and muscle relaxation.
• Acton of GABA causes impaired memory, performance, and increased risk of injury (falling).
• Action of GABA causes potential for tolerance, rebound insomnia when stopped.
• Physical and psychological dependence can develop on medications.
• Double-blind, placebo-controlled studies have shown that the effectiveness of sleep medication shows a very small difference in TST, but no recollection of waking during the night.
• Ramelteon is a melatonin agonist, orexin (hypocretin) dual orexin receptor antagonist.
• Over the counter antihistamines and herbal remedies such as melatonin may be used as treatments.

Sleep Disorders - Insomnia - Non-Medical Treatments - Sleep Hygiene

• Regular bedtimes and wake times should be adhered to.
• Try not to nap, but if you need a nap, keep it short and early in the afternoon.
• Avoid stimulating activities before bed.
• Avoid alcohol, caffeine, and smoking.
• Maintain a cool, quiet, dark bedroom

Sleep Disorders - Insomnia - Behavioural Treatments

• Stimulus control strengthens the association between the bedroom and sleep.
• Relaxation techniques should be used such as progressive muscle relaxation, biofeedback, and meditation.
• Temporal control should be used, maintain wake times and eliminate naps.
• Sleep restriction to increase sleep efficiency (TST/time in bed x 100).
• Cognitive behavioral therapy should be used to addresses unrealistic expectations/maladaptive thoughts about sleep and the consequences of insomnia.

Sleep Disorders: Narcolepsy

• Narcolepsy is rare but present in 0.001% to 0.05% of the population worldwide and in Canada it is present in 0.02% to 0.04% of the population.
• Time of onset is typically during adolescence and adulthood
• Narcolepsy was first described in the 1880's.
• In the 1950s, narcolepsy encompassed four symptoms: daytime sleepiness (“sleep attacks"), cataplexy, sleep paralysis, and hypnogogic images