Eating and Sleep-Wake Disorders

Eating and Sleep-Wake Disorders

Eating Disorders

• Bulimia Nervosa involves eating large amounts of food, typically junk food, beyond what most people would eat in similar circumstances.
• A key aspect of Bulimia Nervosa is the feeling of loss of control during the eating experience.
• Individuals with Bulimia Nervosa try to compensate for binge-eating and potential weight gain, primarily through purging techniques.
• The DSM 5 removed the distinction between purging (e.g., vomiting, laxatives) and non-purging types (e.g., exercise, fasting) because the non-purging type is rare.
• Anorexia Nervosa involves people successfully losing weight to a point that it endangers their lives.
• Individuals with Anorexia Nervosa have an intense fear of obesity and persistently seek thinness.
• The DSM 5 specifies that anorexics are those with a body weight 15% below ideal.
• Restricting Type Anorexia Nervosa involves limiting calorie intake through dieting.
• Purging Type Anorexia Nervosa involves the use of purging behaviors; unlike bulimia, anorexics binge on small amounts of food and purge more consistently.
• Anorexics generally suffer from a poor body image.
• Binge-Eating Disorder involves marked distress due to binge eating without extreme compensatory behaviors.
• Binge-Eating Disorder was studied in DSM –IV TR and became a full-fledged disorder in DSM V.

Causes and Treatments of Eating Disorders

• Anorexia and Bulimia are culturally specific psychological disorders, linked to the "glorification of slenderness" in society.
• Typical families of individuals with anorexia are successful, hard-driving, concerned with appearances, and eager to maintain harmony.
• Eating disorders seem to run in families; speculation suggests that emotional stability and poor impulse control are potential genetic predispositions.
• Young girls with eating disorders have a diminished sense of personal control and low self-esteem.
• Drug treatments are not effective for anorexia nervosa, but antidepressants may work for bulimia.
• Short Term CBT targets problem eating behaviors and attitudes about body weight and shape.
• The goal in anorexia is to restore the patient's weight to within a low-average range; inpatient treatment is recommended for refusal to eat.

Sleep-Wake Disorders

• Dyssomnias involve difficulties getting enough sleep, problems sleeping when desired, and complaints about sleep quality.
• Parasomnias involve abnormal behavioral or physiological events during sleep, such as nightmares and sleepwalking.
• Insomnia Disorder involves complaints such as difficulty initiating sleep, maintaining sleep, and non-restorative sleep.
• Hypersomnolence Disorder involves sleeping too much.
• Narcolepsy is a condition with an extreme tendency to fall asleep in relaxing surroundings.
• Cataplexy, a sudden loss of muscle tone, can occur in narcolepsy and is often triggered by strong emotions.
• Cataplexy results from a sudden onset of REM sleep.
• Sleep paralysis is a brief period of being unable to move or speak after awakening.
• Hypnogogic Hallucinations are vivid, terrifying experiences that begin at the start of sleep involving visual, tactile, auditory, and body movement sensations.
• Breathing-Related Sleep Disorders involve sleepiness or disruptive sleep due to physical problems with breathing.
• Breathing issues during sleep can range from labored breathing (hypoventilation) to stopped breathing (sleep apnea).
• Obstructive Sleep Apnea Hypopnea Syndrome occurs when airflow stops despite continued respiratory activity; associated with obesity.
• Central Sleep Apnea involves complete cessation of respiratory activities and is associated with central nervous system disorders.
• Sleep-related hypoventilation is a decrease in airflow without a complete pause in breathing.
• Circadian Rhythm Sleep Disorder is characterized by disturbed sleep (insomnia or excessive sleepiness) due to the brain's inability to synchronize sleep patterns with current day/night patterns. Types include:
  • Jet lag type: caused by rapidly crossing multiple timezones
  • Shift work type: associated with work schedules
  • Delayed sleep phase type: sleep is delayed later than normal bedtime
  • Advanced sleep-wake type: early to bed, early to rise
  • Irregular sleep-wake type: varied sleep cycles
  • Non-24-hour sleep-wake type: sleeping on 25 or 26-hour cycles and delaying sleep each day
• Melatonin contributes to setting our biological clocks and tells us to sleep.
• Phototherapy uses bright light to trick the brain into readjusting the biological clock
• Phase delays (moving bedtime later) and phase advances (moving bedtime earlier) are effective treatments.
• Sleep hygiene changes include avoiding caffeine/nicotine and following a specific bedtime.

Sexual Dysfunctions, Paraphilic Disorders, and Gender Dysphoria

Sexual Desire Disorders

• Male Hypoactive Sexual Desire Disorder involves little or no interest in sexual activity among men.
• Female Sexual Interest/Arousal Disorder is when there is little or no interest in sexual activity among women.

Sexual Arousal Disorders

• Erectile Disorder involves a problem with becoming physically aroused, not with desire.
• Men with Erectile Disorder have an inability to become rigid for penetration.
• Women with Erectile Disorder have an inability to achieve sufficient lubrication.
• Erectile Dysfunction increases rapidly after age 60.
• Orgasm Disorders involve the inability to achieve orgasm despite adequate sexual desire and arousal.
• Delayed ejaculation is when males achieve orgasm only with great difficulty or not at all.
• Female orgasmic disorder is the term used for women with Orgasm Disorder.

Sexual Pain Disorders

• Genito-pelvic pain/penetration disorder affects only women, referring to difficulties with penetration or significant pain during intercourse.
• Vaginismus is the most common presentation of Genito-pelvic pain/penetration disorder, involving involuntary spasms of pelvic muscles in the outer third of the vagina.

Paraphilic Disorders

• Paraphilic Disorders are disorders of sexual arousal that cause distress or impairment to the individual, or cause harm or risk of harm to others.
• The DSM V does not consider a paraphilia a disorder unless it is associated with distress, impairment, or harm.

Specific Paraphilic Disorders

• Fetihistic Disorder involves a person being sexually attracted to non-living objects.
• Three classes of objects or activities in Fetihistic Disorder are inanimate objects, sources of specific tactile stimulation (e.g., rubber), and body parts (e.g., foot, buttocks).
• Voyeuristic Disorder is the practice of observing an unsuspecting individual undressing or naked to become aroused.
• Exhibitionistic Disorder involves achieving sexual arousal and gratification by exposing genitals to unsuspecting strangers.
• Transvestic Disorder is sexual arousal strongly associated with dressing in clothes of the opposite sex or cross-dressing.
• Sadism and Sexual Masochism Disorders are associated with inflicting pain or humiliation (sadism) or suffering pain or humiliation (masochism) to become sexually aroused; specifically associated with violence and injury.
• Hypoxiphilia is self-strangulation to reduce oxygen flow to the brain and enhance orgasm sensation.
• Sadistic Rape: Many rapists meet the criteria for Antisocial Personality Disorder

Gender Dysphoria

• Gender Dysphoria is present if physical sex (natal sex) is inconsistent with a person's sense of who they are (experienced gender).
• Transsexual man or transman is if natal sex is female, but the experienced gender is strongly male.
• Transwoman is if natal sex is male, but the experienced gender is strongly female.
• Post transition is what individuals are called if they have undergone sex reassignment surgery.
• Gender dysphoria can occur among individuals with Disorder of Sexual Development who are born with ambiguous genitals.

Assessing and Treating Paraphilic Disorders

• Covert sensitization involves patients associating sexually arousing images with reasons why the behavior is harmful or dangerous.
• Orgasmic Reconditioning is when patients are instructed to masturbate to their usual fantasies but to substitute more desirable ones before ejaculating.
• Cyproterone acetate, an antiandrogen, is the most popular drug used to treat Paraphilic Disorders.
• Cyproterone acetate chemically castrates, eliminating sexual desire and fantasy.

Substance-Related, Addictive and Impulse Control Disorder

• Substance-related and addictive disorders are associated with the abuse of drugs and other substances people take to alter the way they think, feel, and behave.
• Gambling disorder is a new addition to this category in the DSM V.
• Impulse Control Disorders represent problems that involve the inability to resist acting on a drive or temptation.
• Substance Use is ingesting psychoactive substances in moderate amounts that does not significantly interfere with social, educational, and occupational functioning.
• Intoxication refers to physiological reactions to ingested substances such as drunkenness or getting high.
• Substance Abuse is defined in terms of how significantly it interferes with a user's life.
• Substance Dependence is when a person is physiologically dependent on a drug, requires greater amounts for the same effect (tolerance), and experiences negative physical effects when not ingested (withdrawal).
• DSM IV considered substance abuse and substance use as 2 separate diagnosis. DSM V combined the two based on the research that they co-occur.
• Substance is a chemical compound that are ingested to alter mood or behavior.

Six categories of substances

• Depressants are substances that result in behavioral sedation and can induce relaxation.
  • Examples are alcohol, barbiturates, and benzodiazepines.
• Stimulants are substances that cause users to be more active and alert and can elevate mood.
  • Examples are amphetamines, cocaine, nicotine, and caffeine.
• Opiates produce analgesia (reducing pain temporarily) and euphoria.
  • Examples are heroin, opium, codeine, and morphine.
• Hallucinogens alter sensory perception and can produce delusions, paranoia, and hallucinations.
  • Examples are Cannabis and LSD.
• Other Drugs of Abuse do not fit neatly into other categories.
  • Example: Anabolic steroids and other over the counter medications.
• Gambling Disorder involves the individuals being unable to resist the urge to gamble, resulting in negative consequences.
• Intermittent Explosive Disorder: Clients act on aggressive impulses that result in serious assaults or destruction of property.
• Kleptomania: Recurrent failure to resist urges to steal things that are not needed for personal or monetary value
• Pyromania: Impulse-control disorder that involves having an irresistible urge to set fires.

Neurodevelopmental Disorders

• Neurodevelopmental Disorders show themselves early in life and often persist as a person grows older.
• Neurodevelopmental disorders are presumed to be neurologically based.
• Attention-Deficit and Disruptive Behavioral Disorders - Pattern of inattention, such as being disorganized or forgetful, about school or work-related tasks, or of hyperactivity and impulsivity
  • Symptoms include Inattention and Hyperactivity/Impulsivity
  • ADHD and learning disabilities may share a common cause.
• Conduct Disorder is a repetitive and persistent pattern of behavior in which the basic rights of others or major-age-appropriate societal norms or rules are violated. Two Subtypes:
  • Childhood-onset: onset is prior to age 10
  • Adolescent-onset: absence of symptom prior to age 10).
• DSM V adds a subtype “with callous-unemotional presentation to show that client presents in a way that shows characteristics similar to adults with psychopathy.
• Oppositional Defiant Disorder is a pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness, lasting at least six months.
• Language disorder: A child's delay in using spoken and written language, characterized by small vocabulary, incorrect sentences, or difficulty understanding words/sentences.

Communication and Learning Disorders

• Social Communication Disorder is difficulty with the practical use of language despite adequate vocabulary, leading to inappropriate conversational interactions.
• Speech sound disorder is when correct speech develops slowly for the patient's age/dialect.
• Childhood-onset fluency disorder (stuttering) is when the normal fluency of speech is frequently disrupted.
• Specific Learning Disability is a significant discrepancy between a person's academic achievement and what would be expected from someone of the same age Clinicians can use specifiers such as disorders of reading, written expression, or mathematics to highlight specific problems for remediation
  • Disorders of reading can manifest as:
    • problems with word recognition (dyslexia)
    • fluency
    • comprehension
• Historically, a specific learning disorder is defined as two standard deviations between achievement and IQ.
• Autism Spectrum Disorder is a neurodevelopmental disorder that affects how one perceives/socializes with others.
  • DSM V combines most disorders previously under the umbrella term “pervasive developmental disorders (e.g. autistic, Asperger’s, childhood disintegrative) into one category
    • Rett Disorder is classified under ASD
• Two major characteristics of ASD:
  • Impairments in social communication/interaction
  • Restricted, repetitive patterns of behavior, interests, activities.
• DSM V recognizes that impairments are present in early childhood and that they limit daily functioning
• DSM V introduced 3 levels of severity:
  • Level 1: Requiring Support
  • Level 2: Requiring Substantial Support
  • Level 3: Requiring Very Substantial Support

Intellectual Disability

• Intellectual Disability (Intellectual Development Disorder): A disorder evident in childhood as significantly below-average intellectual and adaptive functioning
  • Difficulties in 3 domains:
    • Conceptual
    • Social
    • Practical
  • Those with severe forms of ID may never learn speech for communication.
• The DSM V criteria for ID no longer include numeric cut-offs for IQ scores, which were present in previous versions
  • Previously classified as four levels of ID:
    • Mild
    • Moderate
    • Severe
    • Profound
• Classification of levels of support needed is intermittent, limited, extensive, and pervasive
• Down Syndrome is most common chromosomal form of ID: Caused by the presence of an extra 21st chromosome

Motor and Feeding Disorders

• Developmental Coordination Disorder: Patient is slow to develop motor coordination; some also have attention-deficit/hyperactivity disorder or learning disorders
• Stereotypic Movement Disorder patients repeatedly rock, bang their heads, bite themselves, or pick at their own the skin or body orifices.
• Tourette’s disorder Multiple vocal and motor tics occur frequently throughout the day in these patients.
• Persistent (chronic) motor or vocal tic disorder A patient has either motor or vocal tics, but not both
• Provisional tic disorder Tics occur for no longer than 1 year
• Other or unspecified tic disorder Use one of these categories for tics that do not meet the criteria for any of the preceding
• Disorders of Eating, Sleeping, and Elimination
  • Pica: The patient eats material that is not food
  • Rumination disorder: There is persistent regurgitation and chewing of food already eaten
  • Encopresis: At age 4 years or later, the patient repeatedly passes feces into clothing or onto the floor.
• Enuresis: At age 5 years or later, there is repeated voiding of urine (it can be voluntary or involuntary) into bedding or clothing.
• Disruptive mood dysregulation disorder: A child's mood is persistently negative between severe temper outbursts