UNIT 2 - Chapter 9: Eating Disorders and Seep-Wake Disorders

Treatment of Bulimia

Research evidence supports the benefits of CBT in treating THIS. A study showed that CBT resulted in the elimination of bingeing episodes in about 2 out of 3 eating disorder patients who present with bingeing as a core symptom. CBT is used to counter maladaptive beliefs about eating and body image. CBT therapists help with THIS challenge self defeating thoughts and beliefs, such as unrealistic, perfectionistic expectations regarding dieting and body weight. It also challenges tendencies to overemphasize appearance in determining self worth. Psychodynamic therapy may also be used to probe for psychological conflicts. Hospitalization may sometimes be helpful in breaking the binge-purge cycle in this, but it appears to be necessary only when eating behaviors are clearly out of control and outpatient treatment has failed. Interpersonal psychotherapy focuses on resolving interpersonal problems based on the belief that more effective interpersonal functioning will lead to the adoption of healthier food habits and attitudes. SSRI type antidepressant drugs have also demonstrated therapeutic benefits in treating THIS, but their effectiveness is limited.

Anorexia Nervosa DSM

Restricted energy intake resulting in significantly low body weight. Fear of weight gain, becoming fat, or behavior that prevents weight gain (despite significantly low weight). Disturbance in perception of body weight or shape, significant influence of body weight/shape on one's evaluation of themselves, or not recognizing the seriousness of their low body weight. Restricting type: Weigh loss in the past 3 months due to dieting, fasting, or exercise. Binge-Eating/Purging type: Regular episodes of binge eating or purging (vomiting, use of laxatives, diuretics, or enemas) in the past 3 months. Partial Remission: Low body weight criterion not met for extended period, but the following symptoms persist: fear of weight gain, behaviors that prevent weight gain, or disturbed perception undue influence of weight on self perception. Full Remission: Criteria for THIS have not been met for an extended period of time.

Neurobiology

Reward System (helps to identify and coordinate the emotional response to rewarding stimuli - we need to coordinate our response to evolutionary opportunities, like with food). 1. Food Experience - Pleasure associated with eating is lower among people with anorexia and higher among people with bulimia = dysregulation with reward system. 2. Satiety (how full you feel). - For people with anorexia, the key structures in the reward system are under activated, so they don't feel as hungry or appropriately hungry when they're in starved states. - For people with bulimia, overaction contributes to a sense of deprivation, even when they have just eaten. Cognitive Control System (this is involved in planning, inhibition, and decision making). - This system is hyperactive in people with anorexia and underactive in people with bulimia. - For people with anorexia, the need for control drives the restriction or the binge/purging. - For people with bulimia, the underactivation of this system contributes to excessive eating and a sense of dyscontrol in the binge eating session. Homeostatic System (driven by the hypothalamus and helps us maintain homeostasis - we want to be fed, not over full and not starving; regulates body weight and food intake, and coordinates the balance between energy consumption and bodily needs). - For anorexia, the balance is off and it favors starvation. - For bulimia, the balance is off and favors overeating. Neurochemical Adaptations - Serotonin and dopamine are involved in anorexia and bulimia. Over time, the experience of starvation or binge eating can change the way the dopamine system works, which inturn contributes to ongoing symptoms. - In anorexia, exposure to food restriction seems to sensitize the dopamine system, and that alters the functioning of the reward system. Rather than being bad, the state of starvation is linking to reward. There is a tendency to become "addicted" to the state of starvation.

Biological Factors in Anorexia and Bulimia

Scientists suspect that abnormalities in brain mechanisms controlling hunger and satiety are involved in bulimia, most probably involving the brain chemical serotonin. - Serotonin plays a key role in regulating mood and appetite, especially cravings for carbohydrates. Irregularities in the levels of serotonin or how it is used in the brain may contribute to binge eating episodes. Genetics appears to play an important role in the development of eating disorders. They tend to run in families. There is also evidence of genetic factors from an important early study of more than 2000 female twins. The investigators found a much higher concordance rate for bulimia, 23% vs 9% among MZ twins than among DZ twins. Consistent with the diathesis-stress model, a genetic predisposition affecting the regulation of neurotransmitter activity in the brain may interact with stress associated with social and family pressures to increase the risk of eating disorders.

Breathing Related Sleep Disorders

Sleep disorders in which sleep is repeatedly disrupted by difficulty breathing normally. These frequent disruptions of sleep result in insomnia or excessive daytime sleepiness. Lifetime Prevalence in Population: Varies with age, from 1% - 2% in children to more than 20% in older adults. Description: Sleep repeatedly interrupted due to difficulties breathing.

Function of Sleep

Sleep is transdiagnostic Implemented in many disorders, like manic episodes, bipolar disorder, etc. Circadian Rhythm: - Approximately 24 hours on average - The suprachiasmatic nucleus is a bundle of cells that's between the eyes and it's kind of like a complicated internal clock. - The circadian rhythm is mediated by the suprachiasmatic nucleus ro coordinating activity across multiple systems in the body - the temperature system, the metabolic system, the sleep system. Helps us and trains us to know when it's light outside and when it's not. Zeitgebers: - Zeitgebers are cues in the environment that trains the body to the external world. The most powerful one is light. - Light helps the circadian rhythm stay aligned with the environment. - Also include social interaction because it's cognitively arousing and it interferes with sleep. Circadian Misalignment: - Circadian misalignment can happen from being exposed to artificial light can confuse the circadian system and make it think that it's daytime, which makes you want to stay awake.

Parasomnias

Sleep-wake disorders involving abnormal behavior behavior or physiological events during sleep. For some people, sleep is interrupted by partial or incomplete arousals during sleep. During these partial arousals, a person may appear confused, detached, or disconnected from the environment. The sleeper may be unresponsive to attempts by other people to awaken them or comfort them. The sleeper typically gets up the next day without any memory of these episodes of partial arousal. Examples: Nightmare disorder, non-REM sleep arousal disorders, REM behavior disorder.

Sociocultural Factors of Anorexia and Bulimia

THESE theorists point to social pressures and expectations placed on young women in our society as contributing factors in eating disorders. In support of the THIS model, evidence shows that eating disorders are much less common in non-Western countries that do not associate thinness with female beauty. Eating disorders in developing countries may be linked to factors other than obsessive concerns about weight. Rates of disordered eating behaviors and eating disorders also vary in the US among ethnic groups, with higher rates found among Euro-American adolescents than among African American and other ethnic minority adolescents.

Binge Eating/Purging Type of Anorexia

THIS eating disorder is characterized by frequent episodes during the prior 3 month of binge eating or purging (such as by self induced vomiting or overuse of laxatives, diuretics, or enemas). People with this tend to have difficulties with impulse control, which may lead to problems with substance abuse. They tend to alternate between periods of rigid control and impulsive behavior.

Restrictive Type of Anorexia

THIS type of eating disorder does not have bingeing or purging episodes. People with this tend to rigidly, even obsessively, control their diet and appearance.

Risk Factors for Insomnia

Temperament: - Sleep Reactivity: the idea that some of us are more reactive to sleep related disruptions than others. -- Some people can sleep anywhere under any conditions with no problems. -- You want to have natural light so you can be alerted that it's daytime when you're asleep. Environment: - Poor sleeping conditions: you want to be in an environment that is ideally quiet, doesn't have too much light, and is a comfortable temperature. Genetic and Physiological: - Gender and genes (h^2 = 0.5). - Insomnia slightly favors women at 1.5 times more likely than men to develop insomnia. - Hormonal fluctuation influences sleep for women and can be related to sleep disruption. - Possibly women are a little more sleep reactive and a little more sensitive to disruption in the sleep schedule. Many overlapping and interacting genes seem to contribute to insomnia. We also know that about half of the variance is attributable to environmental factors. - One reason why psychosocial intervention is the first-line for insomnia.

Circadian Rhythm Sleep Wake Disorder

These disorders are characterized by a mismatch between the body's normal normal sleep-wake cycle and the demands of the environment. Lifetime Prevalence in Population: 1% or less in the general population, but more common in adolescents. Description: Disruption of the internal sleep-wake cycle due to time changes in sleep patterns. The disruption in normal sleep patterns can lead to insomnia or hypersomnolence and result in daytime sleepiness. Causes significant levels of distress or impairs a person's ability to function in social, occupational, or other roles. Treatment may include a program of gradual adjustments in the sleep schedule to allow a person's circadian system to become aligned with changes in the sleep-wake schedule.

Psychodynamic Perspective in Anorexia and Bulimia

These theorists suggest that girls with anorexia have difficulty separating from their families and consolidating separate, individuated identities. Perhaps anorexia represents a girls unconscious effort to remain a prepubescent child. By maintaining the veneer of childhood, pubescent girls may avoid dealing with adult issues such as increased independence and separation from their families, sexual maturation, and assumption of adult responsibilities.

Psychological Treatment of Sleep Wake Disorders

This has been limited to treatment of primary insomnia. Cognitive-behavioral techniques are short term in emphasis and focus on lowering bodily arousal, establishing regular sleep habits, and replacing anxiety producing thoughts with more adaptive thoughts (techniques are stimulus control, adopting a regular sleep-wake cycle, relaxation training, and rational restructuring). Stimulus control involves changing the environment associated with sleeping. This strengthens the connection between the bed and sleep by restricting the activities in bed as much as possible to sleeping. Adopting a regular sleep-wake cycle means going to bed and waking up at about the same time each day. Relaxation techniques used before bedtime help reduce the states of physiological arousal to a level conducive to sleep. Rational restructuring involves substituting rational alternatives for self defeating, maladaptive thoughts or beliefs.

Sleep Cycle

When an individual first falls asleep, they go immediately into stage one sleep. - Called N1 because it's non-REM sleep. Sleep cycle lasts about 90 minutes and it changes over the night - you get longer REM stages as the night progresses. Sleep Cycle: stage 1 - stage 2 - stage 3 - REM - repeat. - Each cycle lasts about 90 minutes. - You will often wake up 90 minutes after you've gone to sleep because you're coming out of REM and going back into the next sleep stage. Sleep Cycle: 1. Stage 1 (light sleep) - This stage lasts between 1 minutes and 5 minutes. We don't spend very much time in this stage. - The body is slowly relaxing and it's the interim between sleep and consciousness. - If someone interrupts you during this stage, you wake up really easily. 2. Stage 2 (HR slows, brain does less complex tasks, the body relaxes) - Heart rate slows, the brain does less complex tasks. - You spend about half of your time in stage 2 and it gets longer across the course of the night. - People spend about 10-25 minutes in this stage, and it gets longer across the night. - Sleep spindles - There is some evidence that there is dreaming in stage 2. 3. Stage 3 (delta stage, begin deep sleep) - This stage is very important. - Deep sleep and the delta wave stage. Delta waves are slow brainwaves. - The restorative stage of sleep - linked to immune system health, creativity, physical and psychological health. We think it's related to recovery and growth. - Will typically last between 20 and 40 minutes and they get shorter as the night goes on. 4. REM (muscle atonia) - This is the stage where most people dream and remember their dreams. We don't know why we dream. - Muscle atonia - paralysis while you sleep. Important so that you don't act out your dreams. - You spend about a quarter of the night in REM sleep and it gets longer as the night goes on. You don't want to shorten stage 3 or REM because it can have negative impacts.

Biological Treatment of Sleep Wake Disorders

When used for short term treatment of insomnia, sleep medications generally reduce the time it takes to get to sleep, increase total length of sleep, and reduce nightly awakenings. - Primarily work by increasing the activity of GABA. - Medications tend to suppress REM sleep, which may interfere with some of the restorative functions of sleep. Can also lead to a "hangover" the following day and rebound insomnia. - Medications can also lead to tolerance. Users can also become psychologically dependent on sleeping pills (assume they can't sleep without it). Antianxiety drugs of the benzodiazepine family and tricyclic antidepressants are also used to treat deep sleep disorders, such as sleep terrors and sleepwalking. Stimulant drugs are often used to enhance wakefulness in people with narcolepsy and to combat daytime sleepiness in people suffering from hypersomnolence. The first-line treatment for sleep apnea is use of mechanical devices that help maintain breathing during sleep.

Biological Model ED

h^2 = 0.4-0.6 - About 50% of diseased risk attributable to genes. - Anorexia Nervosa - genes involved in the functioning of the metabolic system. Anorexia is more biologically based. - Anorexia has a shared genetic liability with anorexia and OCD. There's also some genetic overlap with schizophrenia, suggesting that their might be neurodevelopmental issues at play here. Anxiety and depression could also be comorbid with this. Bulimia is more influenced by social and cultural factors.

Psychosocial Factors of Anorexia and Bulimia

A pattern of overly restricted dieting is common to women with bulimia and anorexia. Women with eating disorders typically adopt very rigid dietary rules and practices about what they can eat, how much they can eat, and how often they can eat. It's important to recognize that eating disorders involve deeper emotional issues involving feelings of insecurity, body, dissatisfaction, and use of food for emotional gratification. Bulimia is also linked to problems in interpersonal relationships. Women with it tend to be shy and have few if any close friends. Enhancing the social skills of women with bulimia may increase the quality of their relationships and perhaps reduce their tendencies to use food in maladaptive ways.

Cataplexy

A physical condition triggered by a strong emotional reaction that involves loss of muscle tone and voluntary muscle control, which may result in a person slumping or collapsing to the floor. Narcolepsy is often associated with this. Triggered by strong emotional reactions such as joy, crying, anger, sudden terror, or intense laughter.

Narcolepsy

A sleep disorder characterized by sudden, irresistible episodes of sleep or sudden sleep attacks or naps occurring at least 3 times a week over 3 months. Lifetime Prevalence in Population: 0.05% (1 in 2000) Description: Sudden attacks of sleep during the day. During a sleep attack, a person suddenly falls asleep without warning and remains asleep (REM) for about 15 minutes.

Dyssomnia

A sleep disorder in which one has difficulty falling asleep, staying asleep, or isn't tired even though they have slept. Examples: narcolepsy, insomnia, hyper somnolence disorder, circadian rhythm disorders, apenas.

Insomnia Disorder

A sleep-wake disorder characterized by chronic or persistent THIS not caused by another psychological or physical disorder or by the effects of drugs or medications. Lifetime Prevalence in Population: 6% to 10% Description: Persistent difficulty falling asleep, remaining asleep, or getting enough restful sleep. Diagnosis requires that the problem has been present for at least 3 months and that it occurs at least 3 nights per week.

Nightmare Disorder

A sleep-wake disorder characterized by recurrent awakenings due to frightening and well remembered nightmares. Lifetime Prevalence in Population: Unknown Description: Repeated awakenings due to nightmares. THESE are lengthy, story like dreams in which the dreamer attempts to avoid imminent threats or physical danger. The dreamer may suddenly awaken during the nightmare, but have trouble getting back to sleep because of lingering feelings of fear resulting from the terrifying dream. THIS or the disruption of sleep they cause lead to significant personal distress or interfere with important areas of daily functioning. Generally occurs during REM sleep.

REM Sleep Behavior Disorder

A sleep-wake disorder characterized by repeated episodes of acting out one's dreams during THIS sleep in the form of vocalizing parts of the dream or thrashing about. Lifetime Prevalence in Population: 0.38% - 0.5% Description: Vocalizing or thrashing about during REM sleep. During THIS sleep, muscle paralysis is absent or incomplete and a person may suddenly kick or flail the arms during THIS sleep, potentially causing injuries to the self or the person's bed partner.

Sleep Terrors

A sleep-wake disorder characterized by repeated episodes of terror induced arousals that usually begin with a panicky scream. Lifetime Prevalence in Population: Unknown Description: Repeated experiences of sleep terrors resulting in sudden arousals. The child (most cases involve children) may be sitting up, appearing frightened and showing signs of extreme arousal - profuse sweating with rapid heartbeat and respiration. After a few minutes, the child falls back into a deep sleep and upon awakening in the morning remembers nothing of the experience. Occurs during deep, non-REM sleep.

Sleepwalking

A sleep-wake disorder involving repeated episodes in which people walk around the house while remaining asleep. Lifetime Prevalence in Population: Estimated 1% - 5% in children. Description: Repeated episodes of sleepwalking. During these episodes, a person is partially awake and can perform motor responses. These motor behaviors are performed without conscious awareness and the person typically does not remember the incident upon fully awakening the following morning. This tends to occur during the deeper, non-REM stages of sleep.

Body Mass Index

A standard measure that takes both body weight and height into account.

Obstructive Sleep Apnea Hypopnea Syndrome

A subtype of breathing-related sleep disorders. It typically involves repeated episodes during sleep of snorting or gasping for breath, pauses of breath, or abnormally shallow breathing. Occurs most commonly among middle age and older adults and affects racial minorities more often than whites. THIS is also a health concern because it is linked to increased risk of serious health problems, such as hypertension and other cardiovascular problems, as well as diabetes. Repeated lapses of oxygen during episodes of THIS may lead to subtle forms of brain damage that affect psychological functioning, including thinking ability.

Sleep Paralysis

A temporary state of muscle paralysis upon awakening in which they feel incapable of moving or talking. People with narcolepsy may also experience this.

Sleep Architecture

Actigraphy: - This tells you when you were asleep and when you were moving around in your sleep. It tells you things like sleep efficiency (are you laying in bed for longer than you're sleeping). - If you're a healthy sleeper, you should fall asleep within about 20 minutes of laying down and wake up without an alarm clock. Polysomnography: - Can see how long you are in REM sleep, muscle activity, eye movement, heart activity.

Anorexia Nervosa

An eating disorder characterized by maintenance of an abnormally low body weight, a distorted body image, and intense fears of gaining weight. Lifetime Prevalence in Population: 0.9% or 9 in 1000 women; about 0.3%, or 3 in 1000 in men. Description: Self starvation, resulting in abnormally low body weight for one's age, gender, height, and physical health and developmental level. Associated Features: - Strong fears of gaining weight or becoming fat. - Distorted self image (perceiving oneself as fat despite extreme thinness). - Two general subtypes: binge eating/purging type and restricting type. - Potentially serious, even fatal, medical complications. - Typically affects young, European American women. Criterion: Significantly low body weight. 1. Restricting Type - These individuals severely limit their caloric intake and they may exercise excessively to offset any potential weight gain from the food that they have eaten. - One side effect is the growth of fine hair that grows on the persons back or face (called lanugo) = points to the fact that the body is trying to survive and as the individual engages in prolonged starvation, their metabolic and temperature systems start to become dysfunctional, and so their cold. The body grows this hair in an attempt to maintain body warmth. 2. Binge-Eating/Purging Type - Binge eating is defined by the APA and in the DSM as eating an excessive amount of food in a discrete time period. - Excessive refers to the idea that a normal person (someone who doesn't have this type of abnormal clinical presentation) would definitely not consume in the same time period. - As for discrete time period, the DSM specifically says "for example, within a two hour period." - Purging is getting rid of any food eaten by vomiting, laxatives, or other methods. 3. Fear of weight gain. 4. Disturbed body image. - Some people may look in the mirror and see a distortion with their bodies and some may not. - Disturbances in the way people look at themselves and feel about themselves. - People with anorexia often don't see themselves as sick.

Treatment of Binge Eating Disorder

CBT has become the treatment of choice for THIS disorder. Antidepressants, especially SSRIs, may also be used to reduce binge-eating episodes by helping to normalize serotonin levels in the brain. CBT showed even better results than antidepressant medication at a follow up evaluation.

Etiology for Insomnia

Cognitive Factors - Dysfunctional Beliefs - Metaworry ("I have to stop thinking"). - We're tired, we aren't' thinking straight, feeling stressful and frustrated. - Worried you can't sleep, have problematic thought patterns. This is going to drive emotion and arousal, which is going to disrupt sleep. This then leads to daytime tiredness. Homeostatic Dysregulation: - Homeostatic drive is the need to over time. Napping is the behavior that interrupts it. If you're sleep reactive or if you have insomnia, napping is a bad idea because you're interrupting this basic drive. Circadian Misalignment - The most important zeitgebers, in terms of circadian alignments, is lights. -- When you're missing this cue or you're being exposed to things like social activity or late night exercise, or anything that can disrupt the circadian rhythm is going to contribute to insomnia. Inhibitory Factors: Conditioning - In the case of sleep, we want bed que to predict sleep; the bed should mean sleep. - If you practice bed means no sleep, that is the essence of inhibitory conditioning. - If you have insomnia, you shouldn't lay in bed for more than 20 minutes when it's not bedtime because you're training your body to not sleep in bed. Dysfunctional beliefs lead to homeostatic dysregulation, circadian misalignment, and inhibitory factors (conditioning), and then these lead to insomnia.

Family Factors in Anorexia and Bulimia

Eating disorders frequently develop against a backdrop THESE. Some suggest that some adolescents refuse to eat to punish their parents for feelings of loneliness and alienation they experience in the home. Young women with eating disorders often come from dysfunctional family backgrounds characterized by high levels of family conflict and by parents who tend to be overprotective on the one hand but less nurturing and supportive on the other.

Family Based Therapy ED

Empower Parents: - Empower the parents to step back into the parenting role. Therapist will have an in session meal and will work with the parents. They'll tell them the postures, words, and expectations that they should have to encourage the child to eat a healthy portion and encourage the child to say how they are feeling about eating. Have the child talk about these feelings and tell them that they still expect them to eat a healthy portion of food. - Goal is to normalize eating. - This works best with a child that hasn't been engaging in these behaviors for a very long time. Interpersonal Issues: - Focus on the developmental conflict that should be worked on - how to deal with negative feelings, how to resolve conflict, how to assert yourself and ask for what you need - because a lot of this has been left behind as the family has revolved around the pathological eating.

Empirically Supported Treatment for Insomnia

First line for insomnia is psychosocial interventions. 1. Sleep hygiene/stimulus control. - Establish a bedtime routine; develop regular bedtime and wake time; eliminate caffeine 6 hours before bed; limit use of alcohol and tobacco; try drinking milk before bed; get out of bed if you can't get/return to sleep within 15 minutes; do not exercise in the hours before bedtime; control sleeping environment (temperature, noise, light); take a warm bath an hour before bed; increase exposure to bright light during the day. 2. Relaxation - Physical arousal - some people can't sleep because they're keyed up. They have muscle tension. People like this should be taught relaxation techniques. -- Progressive Muscle Relaxation (start with you feet and contract the muscles in your feet and then relax. Progress through your body all the way up to your head and hold whatever muscle group for a few seconds. This helps let any tension go). -- Deep breathing techniques. - Cognitive arousal - people worry when they're trying to go to sleep and think about sleep. -- Count backwards as a distraction from worrying. 3. Sleep Restriction - Sleep efficiency: The proportion of time that one is in bed relative to when on is sleeping in bed. If you have 100% sleep efficiency, then you fall asleep immediately, you sleep 8 hours, and then you get up. - Sleep diary: writing about your sleep journey each night and then engage in a sleep restriction. You induce a state of partial sleep deprivation, and you do it for a few days. This can help to reset the circadian rhythm. -- Helps establish a consistent bedtime and a consistent rise time. 4. Cognitive Therapy - Use this to target problematic or dysfunctional beliefs. - Most common one is cognitive restructuring. -- Catch, check, and change dysfunctional thoughts that may be identified during the night (saying "I'm gonna feel tired tomorrow, but I'm going to be able to function" instead of saying "I'm never going to be able to function tomorrow"). - Paradoxical Intention -- Typically used for people that are experiencing sleep performance anxiety (having thoughts about needing to sleep causes arousal). -- Set a paradoxical intention - tell the client to stay awake as long as you can. This helps to take the emphasis off of going to sleep as fast as you can.

Hypnagogic Hallucinations

Frightening hallucinations occurring at the threshold between wakefulness and sleep onset or shortly upon awakening. People with narcolepsy may also experience this.

Learning Perspective of Anorexia and Bulimia

From this perspective, we can conceptualize eating disorders as a type of weight phobia. In this model, relief from anxiety acts as negative reinforcement. Women with bulimia tend to have been slightly overweight before they developed bulimia, and the binge-purge cycle usually begins after a period of strict dieting to lose weight. In a typical scenario, the rigid dietary controls fail, leading to a loss of inhibitions (disinhibition), which prompts a binge-eating episode. The binge eating induces fear of weight gain, which in turn prompts self-induced vomiting or excessive exercise. Some people with bulimia even resort to vomiting after every meal. Purging is negatively reinforced because it produces relief, or at least partial relief, from anxiety over gaining weight. As in anorexia, food-rejecting behavior (and purging in cases of the binge-eating/purging subtype) is negatively reinforced by relief from anxiety about weight gain. Dietary restraint appears to play a more prominent role in bulimia nervosa for women at high genetic risk of the disorder (Racine et al., 2011). This again illustrates the need to examine interactions of psychosocial factors (dietary restraint) and genetic factors in the development of psychological disorders.

Psychoeducation ED Treatment

If it's something that you've never struggled with, then there can be this perspective of "stop doing that", but it is not an issue of self control. Explain how the person got there and what things led to the problem. There is a lot of nonresponse to treatment and many individuals will need to be in an institutional setting to normalize their eating, in the context of anorexia, more than one time, so this tends to be a long term struggle. - Best thing to do is prevent it.

Medical Complications of Bulimia

Many medical complications stem from repeated vomiting: skin irritation around the mouth due to frequent contact with stomach acid, blockage of salivary ducts, decay of tooth enamel, and dental cavities. Cycles of bingeing and vomiting may cause abdominal pain, hiatal hernia, and other abdominal complaints, as well as disturbed menstrual functioning. Stress on the pancreas may produce pancreatitis. Excessive use of laxatives may cause bloody diarrhea and laxative dependency so the person cannot have normal bowel movements without laxatives. Repeated vomiting or abuse of laxatives can lead to potassium deficiency, producing muscular weakness, cardiac irregularities, and even sudden death. Vomiting: - Gating mechanism at the bottom of esophagus, and when you're constantly vomiting, it stops working. It will then allow stomach acid to back up into the esophagus, which can result in heart burn, indigestion, and increased risk of cancer. - Acid also causes enlargement of the salivary glands (chipmunk cheeks) because of exposure to the acid. - Esophagus can tear which can result in vomiting blood or internal bleeding. - Dangerous changes in the body's electrolytes. Laxatives: - Hemorrhoids, rectal prolapse, dependence on laxatives to defecate normally.

Medication for Insomnia

Medications: 1. Benzodiazepines: An example of this is Xanax. It targets GABA (brains inhibitory NT). It has a fairly serious risk profile in terms of dependence rates because of tolerance. Over time, you need more of the drug to get the same effect in terms of sleep. There's some data that benzodiazepines might reduce that slow wave delta sleep. - Shouldn't be used in the long term. - These won't solve the problem since much of the etiologic factors are behavioral, so if you're taking this medication you're still practicing your bad sleep habits. 2. OTCs: These can include Tylenol PM, melatonin, lavender, or even CBD. - These can work if you're having trouble sleeping. For many of these OTCs, the safety profile is pretty good and you can take them over the short term. - Melatonin doesn't help with sleep maintenance - a lot of the time people will take it and still wake up during the night. There does tend to be daytime sleepiness. 3. "Z" meds: Sedative/hypnotics (e.g., Ambien, Sonata). - These medications can work and will help an individual to sleep and make them feel more rested, so they're effective. - There is data to suggest that z meds influence sleep architecture. These are better for short-term use only. Prolonged use: 1. Disrupts sleep architecture - We spend a daily predictable amount of time in a given sleep cycle (about 90 minutes), and there is a progression toward the lengthening of REM across the night. Taking medications can mess up the cycle (making certain phases longer or shorter than they should be) which has impacts on physical and psychological health. - Normalcy of sleep architecture is important for health. 2. Rebound insomnia - When insomnia comes back upon discontinuation. When you've been on a sleep related medication for a prolonged period of time, you can have a rebounding or recurrence or return of the sleep related problems. -- May be because the brain changes back to how it was before you were on medication. May also be because you haven't learned the coping skills that can help you effectively deal with the sleep problem. - This is a side effect of all the psychotropic medications. 3. Dependence - You begin to really need the medication in order to be able to sleep.

Emotional Factors of Anorexia and Bulimia

People with anorexia nervosa may restrict their food intake in a misguided attempt to relieve upsetting THIS by seeking mastery or control over their bodies Young women with bulimia nervosa often have more THIS problems and lower self-esteem than other dieters. Negative THESE states such as anxiety and depression can trigger episodes of binge eating. Bulimia nervosa is often accompanied by other diagnosable disorders, such as depression, obsessive-compulsive disorder, and substance-related disorders. This suggests that some forms of binge eating represent attempts at coping with THIS distress. Unfortunately, cycles of bingeing and purging exacerbate THESE problems rather than relieve them. Women with bulimia are also more likely than other women to have experienced childhood sexual and physical abuse. In some cases, bulimia nervosa may develop as an ineffective means of coping with abuse. Binge eating may represent an attempt to manage or soothe negative feelings, as evidence links negative THIS states to binge-eating episodes.

Cognitive Factors in Anorexia and Bulimia

Perfectionism and overconcern about making mistakes figure prominently in many cases of eating disorders. People with eating disorders tend to impose perfectionistic pressures on themselves to achieve a "perfect body" and get down on themselves whenever they fail to meet their impossibly high standards. They also tend to have a strong need for control, which takes the form of extreme dieting. This gives them a sense of control and independence that they feel is lacking in other areas of their lives. People who struggle with bulimia tend to think in dichotomous or "black or white" terms. Thus, they expect to adhere perfectly to their rigid dietary rules and judge themselves as complete failures when they deviate even slightly. They also judge themselves harshly for episodes of binge eating and purging. They may also hold exaggerated beliefs about the negative consequences of gaining weight, which further contributes to disordered eating. Investigators find that women with eating disorders tend to heap blame on themselves for negative events in general, and self-blame most probably contributes to maintaining their disordered eating behavior. Body dissatisfaction is also an important factor in eating disorders. Body dissatisfaction may lead to maladaptive attempts—through self-starvation and purging—to attain a desired body weight or shape. Women with eating disorders tend to be extremely concerned about their body weight and shape. Excessive weight-related concerns even affect many young children and may possibly set the stage for development of eating disorders in adolescence or early adulthood.

Sleep Wake Disorders

Persistent or recurrent sleep related problems that cause distress or impaired functioning in social, occupational, or other roles. Frequently occur together with other psychological disorders such as depression and with medical conditions such as cardiovascular problems. There are different types: insomnia disorder, hypersomnolence disorder, narcolepsy, breathing related sleep disorders, circadian rhythm sleep wake disorders, and parasomnias.

Hypersomnolence Disorder

Persistent pattern of excessive sleepiness during the day occurring at least 3 days a week for a period of at least 3 months. Lifetime Prevalence in Population: 1.5% Description: Persistent pattern of excessive daytime sleepiness. People with this may sleep 9 or more hours a night but still not feel refreshed upon awakening. May have repeated episodes during the day of feeling an irresistible need to sleep, or napping repeatedly or falling asleep when they need to remain awake.

Statistics for Anorexia and Bulimia

Prevalence 1-2%. 10:1 females - Maybe because women are socialized to be skinny and men are not (even though men can also develop eating disorders). - Drive for muscularity and low body fat. Onset: Adolescence to young adult (college age). - May be because college students have more freedom than they would at home. Generally episodic. - Disorder can be chronic, but symptoms come and go. - There are times when people with these disorders are eating normally. Culture, race/ethnicity. - White, affluent women are more likely to seek treatment for eating disorders. This does not mean they are most likely to have them. Also doesn't mean that prevalence rates are lower for other groups. - Anorexia and bulimia can be found across cultures, but are most common in wealthy, industrialized countries.

Eating Disorder

Psychological disorders characterized by disturbed patterns of eating and maladaptive ways of controlling body weight. Often occur together with other psychological disorders, such as depression, anxiety disorders, and substance abuse disorders.

Bulimia Nervosa DSM

Recurrent binge-eating episodes, as defined by: - Eating an amount of food that is larger than most people would eat in a discrete time period (for example, 2 hours). - Lack of control during the episode. Recurrent, compensatory behaviors to prevent weight gain (for example, vomiting, laxatives, fasting, exercise). Both binge-eating and compensatory behaviors occur weekly for 3 months. Self evaluation significantly affected by body shape and weight. These problems are not occurring during an episode of anorexia. Partial Remission: Full criteria for THIS were met in the past, and some symptoms remain. Full Remission: Full criteria for THIS were met in the past, and no symptoms are present for an extended time period. Severity: - Mild: 1-3 compensatory behaviors per week. - Moderate: 4-7 compensatory behaviors per week. - Severe: 8-13 compensatory behaviors per week. - Extreme: 14 or more compensatory behaviors per week.

Bulimia Nervosa

An eating disorder characterized by recurrent binge eating followed by self induced purging, accompanied by overconcern with body weight and shape. People with this use inappropriate ways to compensate for overeating to prevent weight gain. Lifetime Prevalence in Population: 0.9% to 1.5% in women; 0.1% to 0.5% in men. Description: Recurrent episodes of binge eating followed by purging. Associated Features: - Weight is usually maintained within a normal range. - Overconcern about body shape and weight. - Binge/purge episodes may result in serious medical complications. - Typically affects young European American women. Defining feature is the occurrence of frequent episodes of binge eating, followed by compensatory behaviors such as self induced vomiting; abuse of laxatives, diuretics, or enemas; or fasting or excessive exercise. Other common features: Feels of lack of control over eating during binge eating episodes, excessive fear of gaining weight, excessive emphasis on body shape and body weight on self image. A DSM diagnosis requires that THESE episodes and the accompanying compensatory behaviors occur at an average frequency of at least once a week for 3 months. At the heart of THIS is recurrent binge eating episodes (2 hours). - Context can shift. - Often a preference for food that's avoidant (like high calorie food that the person would normally see as off limits). - Average size of a THIS in this clinical context is more than 2800 calories, episode lasts less than an hour, and that the pace of eating increases across the episode.

Binge Eating Disorder

An eating disorder characterized by recurrent eating binges without subsequent purging. Lifetime Prevalence in Population: 3.5% in women; 2% in men. Description: Recurrent obsessive eating without compensatory purging. Associated Features: Individuals with binge eating disorder are frequently described as compulsive overeaters. Typically affects obese women who are older than those affected by anorexia or bulimia. Characterized by a lack of control over eating and by consuming far greater amounts of food than people typically eat in the same span of time. During a binge, a person may eat much more quickly than usual and continue eating despite feeling uncomfortably full. The person may binge alone because of embarrassment over excessive eating in front of others. Afterward, they may feel disgusted with themselves, be depressed, or be plagued by feelings of guilt.

Psychosocial Model Bulimia

Internalized Thin Ideal: - In order to be beautiful, one has to be slender; to be beautiful, I have to be skinny. - There are many sources of reinforcing the thin ideal - can range from a parent commenting on normal fluctuation of body fat; it can come from the cultural representations of women from very early on where girls get messages that equate beauty and thinness; bullying, particularly as girls are slower to shed baby fat and peers pointing that out. There is a vulnerability here. Body Dissatisfaction: - Thinking about your body in a negative way and thinking that a certain part of the body is too large. - The internet can play a role into this. Dieting/Negative Affect: - One attempts to take in fewer calores than one is expending. Can be done through calorie restriction and exercise. - Girls learn about dieting at a young age. - If you're dissatisfied with how you look/how your body looks, then that leads to efforts for one to change ones body or dieting. - Dieting and negative affect have a bidirectional relationship - if you diet and restrict your calories, it can influence negative affect; you can feel tired, grumpy, irritable, etc. Then failures in the diet creates negative affect. Binge eating compensatory weight control: - Individual reaches a breaking point after an effort to control and diet. - One gets so hungry that they reach a breaking point and will indulge in what they were restricting access to = binge eating episode begins. -- This is negatively reinforced because it gets rid of the yucky feelings that were felt before. During the episode, there's a sense of relief which will then lead to shame and guilt. Then as the episode is ending, the sense of shame and guilt and self disgust is pressing almost immediately.

Medical Complications of Anorexia

Losses of as much as 35% of body weight may occur, and anemia may develop. Females suffering from anorexia are likely to encounter dermatological problems such as dry, cracking skin; fine, downy hair; even a yellowish discoloration of the skin that may persist for years after weight is regained. Cardiovascular complications include heart irregularities, low blood pressure, and associated dizziness upon standing, sometimes causing blackouts. Decreased food ingestion can cause gastrointestinal problems such as constipation, abdominal pain, and obstruction or paralysis of the bowels or intestines. There is an increased risk of death, which is pegged at 5% to 20% of cases of anorexia nervosa, due to either suicide or to malnutrition due to starvation. - Women with it are eight times more likely to commit suicide. Cardiovascular Level: Thinning and weakening of the heart muscle. This can show up as dizziness, fatigue, racing heart upon exertion. Stomach/Gastrol Intestinal System: Bloating, constipation, trouble swallowing, abnormal liver functioning (body trying to retain as many calories as it can). Muscular/Skeletal: Thinning of the bones (osteoporosis). This can result in spinal compression, increase risk of fractures, rounded posture, losing height. Prolonged starvation can cause one's period to stop. THIS effects the entire body. People with THIS are 5x more likely to die from their symptoms/starvation and 18x more likely to die by suicide. Ethical Considerations: Force feeding with nasogastric tube (feeding tube) - can be inserted to help an individual get back to a healthy weight.

Psychosocial Model Anorexia

Low BMI: - Some of the people that have anorexia are naturally thin and have low BMI and biological influences. - Is a predictor for anorexia. Interpersonal Problems: - Early on, there seems to be troubles around eating. Kids may only like a certain food or they were really picky or something like that. There tends to be tensions with parents, siblings, or peers that likely is influenced by a broad based propensity towards negative affect. Negative Affectivity: - The tendency to experience frequent and strong states like sadness, anxiety, irritability, etc, stress reactivity and stress generation. - Basically generating stress in the environment.

Enhanced CBT ED

This is for adults who have suffered for a longer period with eating disorder symptoms. Apply the same type of cognitive behavioral tactics that are used in many other disorders - identifying distortions around body dissatisfaction, behaviorally prevent things like body checking. A common technique is that you cannot weigh yourself except for with a therapist in a therapeutic setting so that they can identify the thoughts that emerge from that experience and challenge them. CBT divides itself across 4 stages - start well (1 - motivate the client to engage in treatment and initiate early change. Clients agree to self monitor, eat on a regular schedule, and only weight themselves in-session; education, regular eating pattern, in-session weighing, self monitoring, engage significant others), review and plan (2 - building on stage 1 gains, a personalized treatment plan is developed; review progress, identify treatment barriers, personalize stage 3 treatment.), target transdiagnostic factors (3 - a variety of cognitive and behavioral treatment methods - for example, challenging thoughts about feeling fat, exposing oneself to triggers of problematic eating - are used to target client specific factors influencing their symptoms; over-evaluation of body weight, eating, and one's control over these factors, perfectionism, low self esteem, model intolerance, and interpersonal difficulties), end well (4 - reduce relapse risk by helping form realistic expectations about recurrence of problematic thoughts and behaviors, devise a plan to deal with high risk situations and set backs; maintain treatment gains, minimize risk of relapse).

Treatment of Anorexia

Treatment of THIS may involve hospitalization, especially in cases in which weight loss becomes severe or body weight falls rapidly. In the hospital, patients are usually laced on a closely monitored refeeding regimen. Behavioral therapy is commonly used, with rewards made contingent on adherence to the refeeding protocol. Commonly used reinforces include ward privileges and social opportunities. Relapses are common, and upward of 50% of inpatients treated for THIS are rehospitalized within a year of discharge. Psychodynamic therapy may also be used to probe for psychological conflicts. Use of antidepressants and other drugs in treating THIS has yielded either poor or mixed results, with many patients showing a lack of response.