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Chapter 8

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Chapter 8 – Eating & Sleep Disorders DIAGNOSIS: Death rate for eating disorders is highest for any psychological disorder, including depression. 20% of people w/anorexia nervosa die as a result of the disorder; slightly more than 5% w/in 10 years. As many as half those deaths are suicides. 90% of severe cases are young females, usually from upper-middle-class or upper- class socioeconomic groups, who live in a socially competitive environment. Criteria for Bulimia: A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: (1) Eating, in a discrete period of time (eg, within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances. (2) A sense of lack of control over eating during the episode (eg, a feeling that one cannot stop eating or control what or how much one is eating). B. Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, enemas or other medications; fasting or excessive exercise. C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for 3 months. D. Self-evaluation is unduly influenced by body shape and weight. E. The disturbance does not occur exclusively during episodes of anorexia nervosa. Specify type: • Purging type: During the current episode of bulimia nervosa, the person has regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics or enemas. • Nonpurging type: During the current episode of bulimia nervosa, the person has used inappropriate compensatory behaviors, such as fasting or excessive exercise, but has not regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics or enemas. Most bulimics are w/in 10% of their normal weight. Criteria for Anorexia Nervosa: A. A refusal to maintain body weight at or above a minimally normal weight for age and height (e.g. weight loss leading to a maintenance of body weight less than 85% of that expected, or failure to make expected weight gain during period of growth, leading to body weight less than 85% of that expected). B. Intense fear of gaining weight or becoming fat, even though underweight. C. Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight. Specify type: Restricting Type: During the current episode of Anorexia Nervosa, the person has not regularly engaged in binge-eating or purging behavior (i.e. self-induced vomiting or the misuse of laxatives, diuretics or enemas) Binge-Eating/Purging Type: During the current episode of Anorexia Nervosa, the person has regularly engaged in binge-eating or purging behavior (i.e. self induced vomiting or the misuse of laxatives, diuretics or enemas). Diagnostic Criteria for Binge Eating Disorder A. Recurrent episodes of binge eating. An episode is characterized by: 1. Eating a larger amount of food than normal during a short period of time (within any two hour period) 2. Lack of control over eating during the binge episode (i.e. the feeling that one cannot stop eating). B. Binge eating episodes are associated with three or more of the following: 1. Eating until feeling uncomfortably full 2. Eating large amounts of food when not physically hungry 3. Eating much more rapidly than normal 4. Eating alone because you are embarrassed by how much you're eating 5. Feeling disgusted, depressed, or guilty after overeating C. Marked distress regarding binge eating is present D. Binge eating occurs, on average, at least 2 days a week for six months E. The binge eating is not associated with the regular use of inappropriate compensatory behavior (i.e. purging, excessive exercise, etc.) and does not occur exclusively during the course of bulimia nervosa or anorexia nervosa. CAUSES: Social—eating disorders are the most culturally specific psychological disorders identified. Over-emphasis on thinness, especially in the past few decades. Study of Miss Americas and Playboy centerfolds shows the trend toward the ideal of thinness. (Most meet one of the criteria for anorexia—15% or more below normal body weight.) Treatments Drug treatments have not been shown effective for anorexia nervosa. Some evidence that Prozac may help prevent relapse, after weight has been restored. Bulimia can be helped by tricyclic antidepressants and Prozac (ssri). Improvement measured by reduction in frequency of binge eating and percentage of patients who stop binge eating and purging. Useful for short-term but long-lasting effects. Psychological treatments Bulimia Treatment of choice for bulimia is short-term cognitive behavior therapy targeting problem eating behavior and associated attitudes about the overriding importance and significance of body weight and shape. CBT for Bulimia: -Teach physical consequences of binge eating and purging, ineffectiveness of vomiting and laxative abuse, and adverse effects of dieting. -Small amounts of food 5-6 times/day, at no more than 3-hour intervals, to eliminate the alternating overeating and restriction that are the hallmarks of bulimia. -Alter dysfunctional thinking and attitudes about body shape and weight and eating. -Coping strategies for resisting the urge to binge and purge; arranging activities to be with other people after eating, at the beginning stages. CBT is most effective treatment we know, and works fastest. But IPT, which concentrates on interpersonal conflicts, not eating behaviors, has a slower but equaling good outcome over time (by 1 year). Not everyone responds to CBT. Some of those may respond better to IPT or medication. BED: Anti-binge CBT has also been adapted for BED patients, with good success. IPT has been shown equally effective as CBT for BED (in contrast to bulimia). Self-help groups are just as effective, and less costly. Anorexia Nervosa: Most important initial goal is to restore weight to at least w/in low-normal range. If below 70% of average or if lost very rapidly, inpatient hospital treatment used, because of very severe medical complications possible from such extreme weight- loss (esp. acute cardiac failure). (See Table 8.1 on page 319 for strategies to attain weight gain.) Without a shift in attitudes about body shape and interpersonal disruptions in her life, will almost always relapse. For restricting anorexics, focus is on anxiety about becoming obese and losing control of eating, as well as undue emphasis on thinness as a determinant of self- worth, happiness, and success. Similar CBT treatment to that for bulimics. Epworth Sleepiness Scale The Epworth Sleepiness Scale is used to determine the level of daytime sleepiness. Use the following scale to choose the most appropriate number for each situation: 0 = would never doze or sleep. 1 = slight chance of dozing or sleeping 2 = moderate chance of dozing or sleeping 3 = high chance of dozing or sleeping Print out this test, fill in your answers and see where you stand. Chance of Dozing or Situation Sleeping Sitting and reading ____ Watching TV ____ Sitting inactive in a public place ____ Being a passenger in a motor vehicle ____ for an hour or more Lying down in the afternoon ____ Sitting and talking to someone ____ Sitting quietly after lunch (no alcohol) ____ Stopped for a few minutes in traffic ____ while driving Total score (add the scores up) ____ (This is your Epworth score) A score of 10 or more is considered sleepy. A score of 18 or more is very sleepy (usually associated w/sleep disorder. If you score 10 or more on this test, you should consider whether you are obtaining adequate sleep, need to improve your sleep hygiene and/or need to see a sleep specialist. These issues should be discussed with your personal physician. Scores of 17 (+/- 2 points) are associated with Narcolepsy and Central Nervous System Hypersomnolence. Scores of 11 (+/- 2 points) are associated with obstructive sleep apnea. Scores of 9 (+/- 2 points) are associated with periodic limb movements in sleep. Scores of 6 (+/- 2 points) are associated with primary snoring. Scores of 2 (+/- 2 points) are associated with insomnia. Sleep deprivation leads to: Car crashes Poor memory Lack of physical coordination Poor health Loss of productivity on the job Doctors making errors (especially during internship, when they are very sleep- deprived) Engineers making errors Considered a major health crisis Dyssomnias & Parasomnias DYSSOMNIAS: Diagnostic criteria for Primary Insomnia: A. The predominant complaint is difficulty initiating or maintaining sleep, or nonrestorative sleep, for at least 1 month. B. The sleep disturbance (or associated daytime fatigue) causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. C. The sleep disturbance does not occur exclusively during the course of narcolepsy, breathing-related sleep disorder, circadian rhythm sleep disorder, or a parasomnia. D. The disturbance does not occur exclusively during the course of another mental disorder (e.g., major depressive disorder, generalized anxiety disorder, a delirium). E. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition. Can insomnia be a CAUSE (rather than just a symptom) of psychological disorders? Patients with persistent and untreated insomnia are at between 2 and 10 times the risk for new onset or recurrent episodes of major depression. There is also good evidence that insomnia is a risk factor for the development and/or recurrence of anxiety disorders and substance abuse. TABLE 1 Common Causes of Insomnia Medical causes Psychologic causes Nonprescription drugs Depression Caffeine Anxiety "Diet pills" (e.g., those including Life stressors pseudoephedrine, Bedtime worrying phenylpropanolamine) Conditioning (associating the bed with Nicotine wakefulness) Prescription drugs Mania or hypomania Methylphenidate (Ritalin) Environmental causes Theophylline Bedroom too hot or too cold Albuterol (Ventolin) Noise Quinidine (Cardioquin) Eating, exercise, caffeine or alcohol use Pemoline (Cylert) before bedtime Dextroamphetamine (Dexedrine) Jet lag Pseudoephedrine (Novafed) Shift work Phenylephrine (Neo-Synephrine) Daytime napping Phenylpropanolamine (Entex) Selective serotonin reuptake inhibitors Medical conditions Primary sleep disorders (sleep apnea, periodic limb movement disorder, nocturnal myoclonus, restless legs syndrome) Pain from any source or cause Drug or alcohol intoxication or withdrawal Thyrotoxicosis Dyspnea from any cause Treatment Initially, it is important not to compensate for the sleep loss by napping, staying in bed late, lying in bed not sleeping, etc, it is usually self-correcting within a short period of time. If it continues, there are a number of strategies that can be used: Medication Benzodiazepines are prescribed to induce sleep. The are CNS depressants, have the effect of sedative/hypnotic. Problems: Morning sleepiness (depending on half-life) Side effects Tolerance Dependency Rebound insomnia Also nonbenzodiazepines, Zolpidem (such as Ambien) that have similar sedative/hypnotic effects, with less of the muscle-relaxant effect. Medications are suggested for short-term use only (not more than 4 weeks). What about alcohol? Will bring on sleep, but interfere with sleep later in the night. The effect of ethanol on sleep can take several forms. These include: 1. Altering the time to fall asleep 2. Disrupting the sequence of sleep 3. Altering the total time of sleep 4. Diminishing the duration of particular types or stages of sleep. Though it is true that drinking before bedtime may cause one to fall asleep sooner, it disrupts the second half of sleep. The person may have fitful sleep by awakening from dreams and having trouble returning to sleep. It is interesting that even if ethanol is drunk earlier in the day and has cleared the system, it still has the potential to disrupt sleep later in the night. This would suggest that ethanol acts on brain systems, which are still disrupted at a later, time. Neurotransmitters (NTs) serotonin and norepinephrine are important in the regulation of sleep. Serotonin seems primarily associated with sleep onset and with regulation of SWS, while norepinephrine seems to regulate REM and arousal. Since it known that ethanol affects both serotonin and norepinephrine, possible mechanisms for the effects of ethanol on sleep are via ethanol’s action on these NTs. Insomnia affects a higher percentage than found in the population at large. As a person consumes an excess amount of alcohol, the sedative properties of the substance lower significantly, and the alcohol no longer enables one to fall asleep quicker. In fact, consuming too much alcohol makes it increasingly difficult to fall asleep. Once sleep finally sets in for an alcoholic, the time spent in both SWS and REM modes is reduced
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